Role of tissue expanders in patients with loss of abdominal domain awaiting intestinal transplantation

Abstract

SummaryAbdominal 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.

Current status of intestinal and multivisceral transplantation

“…Due to multiple surgeries, scar formation, infectious complications and visceral allograft tissue edema, loss of the abdominal domain has become a surgical challenge in transplant patients [56]. Recent innovations such as implantation of tissue expanders prior to transplant, acellular dermal allograft, simultaneous vascularized abdominal wall and non-vascularized rectus fascia transplant have reduced complications associated with an open abdomen [57]. In situ pre-placement of free vascular grafts, duct-duct biliary reconstruction and piggyback duodeno-duodenal anastomosis in patients with preserved native duodenum are other novel implantation techniques that have been introduced [58].…”

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

“…Finally, this bi‐planar placement directed the force of the expansion outward on the abdominal wall musculature, vs. inwards to exert more pressure on the peritoneal contents. This latter point is also an advantage over the subcutaneous placement of tissue expanders in recent reports .…”

“…Two recent case reports have detailed the successful use of tissue expanders placed in the subcutaneous layer to increase abdominal domain prior to intestinal transplantation . Surprisingly, our review of the literature revealed only a single case report of the use of intra‐abdominal tissue expanders in the setting of isolated intestinal transplantation.…”

Advances in small bowel transplantation

“…Although sometimes reduced-size grafts can be used to facilitate primary closure, various strategies have been introduced to reconstruct and enhance the abdominal domain. Some strategies that have been employed are usage of tissue expanders, staged abdominal closure with mesh, bioengineered skin equivalents, acellular dermal matrix, vascularized or nonvascularized rectus muscle fascia grafts, skin grafts, and vascularized abdominal wall transplantation from the same donor (12,13). Abdominal wall transplantation permits primary skin and abdominal wall closure without causing abdominal compartment syndrome.…”