Open Abdomen Management With Human Acellular Dermal Matrix in Liver Transplant Recipients
ABSTRACT Abdominal wall closure after liver transplantation is not always feasible and may result in increased intra-abdominal pressure along with associated complications. Various temporary closure techniques as well as open wound management have been used to address this complex problem. The aim of this series was to describe an approach to definitive wound closure of the open abdomen in liver transplant patients.
We performed a retrospective review of all liver transplant patients at our institution from September 2005 to November 2007. The management of the open abdomen in 10 liver transplant patients was reviewed, and a novel approach described to manage these defects.
Ten patients with open wounds were closed during the study period using human acellular dermal matrix (HADM). There were 7 men and 3 women of median age 55 years. Average size of HADM was 235 cm(2). The median follow-up is 10 months with no incidence of evisceration or hernia. In 1 patient, the graft failed along the lateral side due to infection; it dislodged during vacuum-assisted closure dressing change in another patient at 5 months after closure. Fascial closure was not possible due to organ edema (n = 3), a large liver (n = 4) or wound infection with dehiscence (n = 3).
HADM can be used for primary wound closure in both clean and contaminated wounds as an alternative to an open abdomen post-liver transplantation.
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ABSTRACT: Mesh implantation during abdominal wall reconstruction decreases rates of ventral hernia recurrence and has become the dominant method of repair. The authors provide a comprehensive comparison of surgical outcomes and complications by location of mesh placement following ventral hernia repair with onlay, interposition, retrorectus, or underlay mesh. A systematic search of the English literature published from 1996 to 2012 in the PubMed, MEDLINE, and Cochrane library databases was conducted to identify patients who underwent abdominal wall reconstruction using either prosthetic or biological mesh for ventral hernia repair. Demographic information was obtained from each study. Sixty-two relevant articles were included with 5824 patients treated with mesh repair of a ventral hernia between 1996 and 2012. Mesh position included onlay (19.6 percent), underlay (60.7 percent), interposition (6.4 percent), and retrorectus (12.4 percent). Prosthetic mesh was used in 80 percent of repairs and biological mesh in 20 percent. The weighted mean incidences of early events were as follows: wound complications, 19 percent; wound infections, 8 percent; seroma or hematoma formation, 11 percent; and reoperation, 10 percent. The weighted mean incidences of late complications included 8 percent for hernia recurrence and 2 percent for mesh explantation. Recurrence rates were highest for onlay (17 percent) or interposition (17 percent) reinforcement. The infection rate was also highest in the interposition cohort (25 percent). Seroma rates were lowest following a retrorectus repair (4 percent). Mesh reinforcement of a ventral hernia repair is safe and efficacious, but the location of the reinforcement appears to influence outcomes. Underlay or retrorectus mesh placement is associated with lower recurrence rates.Plastic and Reconstructive Surgery 11/2013; 132(5):1295-304. DOI:10.1097/PRS.0b013e3182a4c393 · 3.33 Impact Factor
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ABSTRACT: The use of human acellular dermis (hAD) to close open abdomen in the treatment process of severe peritonitis might be an alternative to standard care. This paper describes an investigation of the effects of fluids simulating an open abdomen environment on the biomechanical properties of Epiflex(R) a cell-free human dermis transplant. hAD was incubated in Ringers solution, blood, urine, upper gastrointestinal (upper GI) secretion and a peritonitis-like bacterial solution in-vitro for 3 weeks. At day 0, 7, 14 and 21 breaking strength was measured, tensile strength was calculated and standard fluorescence microscopy was performed. hAD incubated in all five of the five fluids showed a decrease in mean breaking strength at day 21 when compared to day 0. However, upper GI secretion was the only incubation fluid that significantly reduced the mechanical strength of Epiflex after 21days of incubation when compared to incubation in Ringer's solution. hAD may be a suitable material for closure of the open abdomen in the absence of upper GI leakage and pancreatic fistulae.BMC Surgery 01/2014; 14(1):7. DOI:10.1186/1471-2482-14-7 · 1.24 Impact Factor
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ABSTRACT: Abdominal closure is a complex surgical problem in intestinal transplant recipients with loss of abdominal domain, as graft exposure results in profound morbidity. Although intraoperative coverage techniques have been described, this is the first report of preoperative abdominal wall augmentation using tissue expanders in patients awaiting intestinal transplantation. We report on five patients who received a total of twelve tissue expanders as a means to increase abdominal surface area. Each patient had a compromised abdominal wall (multiple prior operations, enterocutaneous fistulae, subcutaneous abscesses, stomas) with loss of domain and was identified as high risk for an open abdomen post-transplant. Cross-sectional imaging and dimensional analysis were performed to quantify the effect of the expanders on total abdominal and intraperitoneal cavity volumes. The overall mean increase in total abdominal volume was 958 cm(3) with a mean expander volume of 896.5 cc. Two expanders were removed in the first patient due to infection, but after protocol modification, there were no further infections. Three patients eventually underwent small bowel transplantation with complete graft coverage. In our preliminary experience, abdominal tissue expander placement is a safe, feasible, and well-tolerated method to increase subcutaneous domain and facilitate graft coverage in patients undergoing intestinal transplantation.Transplant International 08/2013; 26(12). DOI:10.1111/tri.12187 · 3.16 Impact Factor