A Single Center Experience of Abdominal Wall Graft Rejection After Combined Intestinal and Abdominal Wall Transplantation

Abstract

We report our outcomes following combined intestinal and abdominal wall transplantation, focusing on the presentation and treatment of acute rejection of the abdominal wall vascularized composite allograft (VCA). Retrospective analysis of all patients with combined intestinal/VCA transplantation was undertaken. Graft abnormalities were documented photographically and biopsies taken, with histological classification of rejection according to Banff 2007 guidelines. We have performed five combined intestinal and abdominal wall transplants to date. Two patients developed erythematous, maculopapular to papular eruptions confined to the VCA, histologically confirmed as grade II/III rejection, yet with normal bowel on endoscopy. Both patients' rashes resolved within 72 h of increasing immunosuppressive treatment. One patient later developed a recurrence of the rash, confirmed as skin rejection, but did not immediately seek medical attention. Treatment was therefore delayed, and mild intestinal rejection developed. We describe the rash associated with VCA rejection, and propose that while the skin of an abdominal wall VCA may reject independently of the intestinal allograft, delay in treatment of rejection episodes may result in rejection of the intestinal graft.

Skype clinics after intestinal transplantation – follow‐up beyond post codes

“…Patients knew that they had to contact the Oxford Transplant Centre immediately if symptoms like diarrhea, abdominal pain, sickness, or febrile temperatures occurred. Patients who had received an abdominal wall graft in addition to their ITX were particularly trained in monitoring the abdominal wall graft's skin as an essential procedure to detect rejection at an early stage before it reaches the intestinal graft .…”

Functional Abdominal Wall Reconstruction Using an Innervated Abdominal Wall Vascularized Composite Tissue Allograft: A Cadaveric Study and Review of the Literature

“…Overall 21 AW-VCAs have been reported in the peer-reviewed literature, and none have attempted neurotization of the alloflap. [9][10][11][12]14 This body of literature represents three academic groups from the University of Miami (n ¼ 14), University of Bologna (n ¼ 3), and the University of Oxford (n ¼ 4).…”

“…14 The 21 AW-VCAs that have been performed worldwide provided deinnervated, vascularized, myofasciocutaneous coverage over solid organ allografts. [9][10][11][12][13][14][15] While coverage of the intestinal graft is of paramount importance after multivisceral transplantation, future directions should focus on improvement of functional outcomes and potential expansion of this therapy to include patients with large defects who lack available soft tissue for reconstruction. However, this can only be justified if future therapies provide an improvement over traditional reconstructive methods such as nonfunctional fasciocutaneous flap coverage.…”

“…[9][10][11][12][13][14][15] However, in contrast to other forms of vascularized composite allotransplantation (VCA), such as hand and face allografts, AW-VCA has never been performed in patients who are not already receiving immunosuppression for a solid organ or multivisceral transplants. 12 The reason that AW-VCA has never been offered to patients not already receiving another transplant is multifactorial.…”

The use of bi‐planar tissue expanders to augment abdominal domain in a pediatric intestinal transplant recipient

“…A second approach that we have previously described is the cotransplantation of the rectus fascia as a non‐vascularized allograft or cotransplantation of the abdominal wall as a vascularized composite tissue graft to aid in abdominal wall closure without tension. However, these modalities can be technically complex and add morbidity , and a recent case report describes the possibility of rejection of the abdominal wall graft .…”