Abdominal Domain Research Articles

Successful Treatment of Intestinal and Abdominal Wall Rejection with Vedolizumab by Preventing s T-cell Entry

Introduction: Intestinal transplantation is an accepted treatment option for patients with end-stage intestinal failure. Despite several improvements in immunosuppressive regimes that are largely adapted from other solid organ programs, rejection of the intestinal graft still far exceeds rejection rates of other solid organs.[1] Vedolizumab is an antibody against the gut homing α4β7 receptor, which prevents entry of various immunological cell types into the intestinal graft.[2] It is approved for use in inflammatory bowel diseases and marketed because of its gut selectivity.[3] Here, we present a case report showing that vedolizumab can prevent both intestinal graft and abdominal wall rejection by inhibiting T-cell entry in the grafts. Case and therapy results: A 24-year old woman with Crohn’s disease developed ultra-short bowel syndrome after several resections with loss of abdominal domain. She was treated for 5 years with total parenteral nutrition (TPN) and developed several episodes of catheter related bloodstream infections, TPN-related liver fibrosis and a low BMI. After thorough review by several experts she underwent a combined intestinal (SB) and abdominal wall (AW) transplantation in March, 2015. Immunosuppression therapy consisted of mycophenolic acid (MMF), prednisolone and tacrolimus. The patient suffered from severe neutropenia on day 15 post-transplant, so MMF was stopped. On day 47, the SB graft showed grade 2 rejection, which was temporarily resolved by a 3-day course of methylprednisolone. On day 68, SB and AW biopsies showed a grade 1 rejection, and because of the antecedent of neutropenia, treatment with vedolizumab (300 mg I.V.) was performed on weeks 0 (day 83), 2, 6 and every 8 weeks thereafter. Rejection resolved in conjunction with a decrease in CD-3 and CD-8 positive cells in both the SB and AW graft. During maintenance phase with vedolizumab, combined with low dose tacrolimus and prednisolone, the patient suffered from gastroenteritis by astrovirus and a primary CMV infection that did not affect the efficacy of the treatment nor the clearance of infections. However, after 6 months, vedolizumab treatment was suspended because of a long-lasting infection with NORO virus. Conclusion: This case report shows that selective blockade of α4β7 with vedolizumab can successfully and relatively safely treat intestinal and abdominal wall rejection.

Translation and validation of chronic liver disease questionnaire (CLDQ) in Tamil language.

Chronic liver disease questionnaire (CLDQ), a self-administered quality-of-life (QOL) instrument for chronic liver disease (CLD) patients, was originally developed in English language. We aimed to translate and validate CLDQ in Tamil language (CLDQ-T). CLDQ-T, prepared by two forward and two backward independent translations by four bilingual (Tamil and English) persons, and repeated iterative modifications, was validated in adult, native-Tamil patients with CLD. CLDQ-T was re-tested in some patients 2weeks later. Convergent validity was assessed using Spearman's correlation, and discriminant validity by comparison with World Health Organization's brief QOL tool (WHOQOL-BREF). Reliability was assessed through internal consistency (Cronbach's alpha) and test-retest reliability (intra-class correlation). Cutoff used for statistical significance was p<0.05. The study included 126 patients (age: mean [SD] 46years [12.5]; male 104; cause: alcohol 42%, HBV 25%, HCV 4%, cryptogenic 29%; CTP class A 47%, B 37%, and C 16%). In convergent validity, all domains except the "abdominal domain" showed significant correlation between CLDQ-T and WHOQOL-BREF. Patients with severe disease had lower scores for all domains of CLDQ-T except the "abdominal" domain, but not for any of the domains for WHOQOL-BREF. Overall Cronbach's alpha was 0.942, and more than 0.7 for all the individual domains except the "activity" domain. On retesting in 44 (35%) patients, intraclass correlation coefficient was 0.879 for the overall CLDQ-T score and >0.700 for individual domains. CLDQ-T was easily understood and showed good performance characteristics in assessing QOL in Tamil-speaking patients with CLD.

Ventral hernia repair in patients with abdominal loss of domain: an observational study of one institution's experience.

Abdominal wall hernias are a common problem. The success of abdominal wall reconstruction decreases with increasing hernia size. This study summarizes the outcomes of one surgeon's experience using a "sandwich" technique for hernia repair in patients with loss of abdominal domain. We reviewed our ventral hernia repair (VHR) experience from 2008 to 2015 among patients with loss of domain, as defined by a hernia defect greater than 300cm2. The percent of herniation through the defect, defined by a hernia sac-to-abdominal cavity volume ratio, was measured on preoperative CT scans by four independent reviewers and averaged. Outcomes were compared among those with giant ventral hernias (hernia sac-to-abdominal cavity volume >30%) and those with smaller defect ratios. Over the study period, 21 patients underwent VHR. In 17 patients (81%), a "sandwich" technique was utilized. Ten patients had hernia sac-to-abdominal cavity defects less than 30%, and 11 had defects greater than 30%. Preoperative characteristics were similar in both groups with the exception of a higher ASA score in those with giant ventral hernias and more Ventral Hernia Working Group Grade 3 hernias in those without giant ventral hernias. Postoperative outcomes were similar in both groups. There were no mortalities. There were two recurrences (18%) in the giant VHR group and none in the smaller defect group (p=0.16). Surgical site occurrences were noted in 48% of patients and did not differ between giant and non-giant VHR groups (50 vs 45%, p=0.84). Average postoperative length of stay was significantly longer in the giant VHR group (31 vs. 17days, p=0.03). Our results suggest that the "sandwich" technique for VHR is a safe and durable method to restore abdominal wall integrity in those with LOD, even in patients with giant ventral hernias.

Management of Patients with Gastroschisis Requiring Extracorporeal Membrane Oxygenation for Concurrent Respiratory Failure

Treatment of gastroschisis often requires multiple surgical procedures to re-establish abdominal domain, reduce abdominal contents, and eventually close the abdominal wall. In patients who have concomitant respiratory failure requiring extracorporeal membrane oxygenation (ECMO), this process becomes further complicated. This situation is rare and only five such cases have been reported in the ECMO registry database. Management of three of the five patients along with results and implications for future care of similar patients is discussed here. Two patients had respiratory failure due to meconium aspiration syndrome and one patient had persistent acidosis as well as worsening pulmonary hypertension leading to the decision of ECMO. The abdominal contents were placed in a spring-loaded silastic silo while on ECMO and primary closure was performed three to six days after the decannulation. All three patients survived and are developmentally appropriate. We recommend avoiding aggressively reducing the abdominal contents and using a silo to conservatively reducing the gastroschisis while the patient is on ECMO therapy. Keeping the intra-abdominal pressure below 20 mm Hg can possibly reduce ECMO days and ventilator time and has been shown to decrease morbidity and mortality. Patients with gastroschisis and respiratory failure requiring ECMO can have good outcomes despite the complexity of required care.

The role of osmotic self-inflatable tissue expanders in intestinal transplant candidates

Intestinal transplantation (ITx) is often associated with decreased abdominal domain, rendering abdominal closure difficult. Pre-transplant placement of tissue expanders (TE) can overcome this challenge; however it can be associated with life-threatening complications. This review aimed to comprehensively summarize all available literature on TE in ITx candidates and include the technical details of osmotic, self-inflatable TE -a technique undescribed before. PubMed, EMBASE and CCTR were searched until April 30, 2016. Based on structured data abstraction and detailed analysis, eighteen cases of TE (inflatable) in ITx candidates were found. Localisation of placement was: subcutaneously in 11; intraperitoneally in 4; 1 patient had 1 TE placed retromuscularly and 1 intraperitoneally; 1 patient had biplanar TE (intraperitoneally placed and extending retromuscularly) and in 1 localisation was unreported. Complication rate was high (61%), injection- or intraperitoneal-related, resulting in life-threatening infections/hematoma. With successful expansion, physiological graft protection -by skin+/-fascia- was always achieved. In completion of this review, we describe our own experience with two patients (7.5-, 34-year-old females), in whom osmotic TE were placed subcutaneously pre-ITx. No TE-related complications occurred and both patients underwent uncomplicated ITx with respectively primary skin and skin + fascia closure. The pros and cons of each TE type and placement are discussed, resulting in the overall conclusions that TE offer an important benefit in graft-protection following ITx. Osmotic TE are safer than conventional prostheses by avoiding percutaneous injections. Subcutaneous placement seems to be safer and more reliable.

Staged repair of giant exomphalos major using tissue expanders

Abstract Giant exomphalos, also called hepato-omphalocele, is a major exodus of abdominal viscera. Due to the large discrepancy between abdominal domain and the volume of extra abdominal organs, these defects present a significant challenge to pediatric surgeons. A 10 month old boy with antenatally diagnosed exomphalos major had a giant exomphalos 15 × 15 × 10 cm in size. Investigations revealed significant visceroabdominal disproportion, in view of which staged repair of the exomphalos was planned. An intraperitoneal silicon tissue expander was inserted for this child in the infra-umbilical abdominal cavity with the flat surface in the recto-vesical pouch through pfannenstiel incision & gradually inflated. Subsequently, subcutaneous expanders were placed in both flanks using minimal access technique to get adequate healthy skin cover prior to final ventral hernia repair. At eight years of age, the patient underwent exploratory laparotomy with ventral hernia repair with meshplasty using dual surface mesh & had an excellent and prompt recovery. There are numerous surgical techniques for giant omphalocele closure, which fall into the categories of staged, and delayed closure. Uniqueness of this case is combined use of both intraperitoneal and subcutaneous tissue expansion with the aid of minimal access technique in placement of subcutaneous expanders. The combined use of both intra-abdominal & subcutaneous expanders has not yet been reported in children.

Posterior Component Separation with Transversus Abdominis Release: Technique, Utility, and Outcomes in Complex Abdominal Wall Reconstruction.

Ventral hernia formation is a frequent and increasingly difficult problem. Nonmidline hernias, parastomal hernias, hernias near bony landmarks, and recurrent ventral hernias (especially after anterior component separation) present particular challenges. Typical reconstructive techniques may struggle to reestablish abdominal domain and to create a lasting repair. Posterior component separation with transversus abdominis release is a novel technique that offers a durable solution to a variety of complex ventral hernias. The posterior rectus sheath is incised and the retrorectus plane is developed. In a modification of the Rives-Stoppa technique, the transversus abdominis is released medial to the linea semilunaris to expose a broad plane that extends from the central tendon of the diaphragm superiorly, to the space of Retzius inferiorly, and laterally to the retroperitoneum. This preserves the neurovascular bundles innervating the medial abdominal wall. Mesh is placed in a sublay fashion above the posterior layer. In an overwhelming majority of patients, the linea alba is reconstructed, creating a functional abdominal wall with wide mesh reinforcement. The technique is reliable and durable, with a 5 percent recurrence rate at 2 years. Although wound complications occur with a frequency similar to that of other techniques, they tend to be less severe, rarely requiring operative débridement. The technique is applicable to a broad range of hernias, including midline, parastomal, flank, subcostal, and recurrent hernias after prior component separations. Posterior component separation with transversus abdominis release is a versatile, easy-to-learn technique of hernia repair that offers a reliable, durable solution to complex abdominal wall reconstruction.

Live Donor Renal Transplant With Simultaneous Bilateral Nephrectomy for Autosomal Dominant Polycystic Kidney Disease Is Feasible and Satisfactory at Long-term Follow-up.

Timing of bilateral nephrectomy (BN) is controversial in patients with refractory symptoms of autosomal dominant polycystic kidney disease (APKD) in need of a renal transplant. Adults who underwent live donor renal transplant (LRT) + simultaneous BN (SBN) from August 2003 to 2013 at a single transplant center (n = 66) were retrospectively compared to a matched group of APKD patients who underwent LRT alone (n = 52). All patients received general health and polycystic kidney symptom surveys. Simultaneous BN increased operative duration, estimated blood loss, transfusions, intravenous fluid, and hospital length of stay. Most common indications for BN were pain, loss of abdominal domain, and early satiety. There were more intraoperative complications for LRT + SBN (6 vs 0, P = 0.03; 2 vascular, 2 splenic, and 1 liver injury; 1 reexploration to adjust graft positioning). There were no differences in Clavien-Dindo grade I or II (39% vs 25%, P = 0.12) or grade III or IV (7.5% vs 5.7%, P = 1.0) complications during the hospital course. There were no surgery-related mortalities. There were no differences in readmission rates (68% vs 48%, P = 0.19) or readmissions requiring procedures (25% vs. 20%, P = 0.51) over 12 months. One hundred percent of LRT + SBN allografts functioned at longer than 1 year for those available for follow-up. Survey response rate was 40% for LRT-alone and 56% for LRT + SBN. One hundred percent of LRT + SBN survey responders were satisfied with their choice of having BN done simultaneously. Excellent outcomes for graft survival, satisfaction, and morbidity suggest that the combined operative approach be preferred for patients with symptomatic APKD to avoid multiple procedures, dialysis, and costs of staged operations.

Practical Approaches to Definitive Reconstruction of Complex Abdominal Wall Defects.

With advances in abdominal surgery and the management of major trauma, complex abdominal wall defects have become the new surgical disease, and the need for abdominal wall reconstruction has increased dramatically. Subsequently, how to reconstruct these large defects has become a new surgical question. While most surgeons use native abdominal wall whenever possible, evidence suggests that synthetic or biologic mesh needs to be added to large ventral hernia repairs. One particular group of patients who exemplify "complex" are those with contaminated wounds, enterocutaneous fistulas, enteroatmospheric fistulas, and/or stoma(s), where synthetic mesh is to be avoided if at all possible. Most recently, biologic mesh has become the new standard in high-risk patients with contaminated and dirty-infected wounds. While biologic mesh is the most common tissue engineered used in this field of surgery, level I evidence is needed on its indication and long-term outcomes. Various techniques for reconstructing the abdominal wall have been described, however the long-term outcomes for most of these studies, are rarely reported. In this article, I outline current practical approaches to perioperative management and definitive abdominal reconstruction in patients with complex abdominal wall defects, with or without fistulas, as well as those who have lost abdominal domain.

A novel approach for the closure of challenging giant omphalocele

Abstract Omphalocele is a congenital condition characterized by midline defect of the anterolateral abdominal wall whereby intra-abdominal contents covered by peritoneal sac are found herniated. It can be defined by size of defect or visceral contents. There are various ways of surgical management of omphalocele. Giant omphalocele presents particular challenge in reconstructing the abdominal wall. In this regard the use of tissues expansion as an adjunct in an attempt to recreate functional abdominal wall domain has been emerging. We are presenting a case of giant omphalocele that was closed with the help of extra peritoneal inter muscular tissue expanders.The patient was born at 37 weeks to a 33 year old healthy gravida 3, para 0 G3P0 mother via planned cesarean section. There were no prenatal, natal or postnatal complications. The giant omphalocele was diagnosed prenatally on screening Ultrasound. The patient remained in the neonatal intensive care unit for 6 weeks. The sac was large with abdominal contents including the entire liver. The sac was allowed to epithelialize completely over the course of two years. Due to the small size of the abdominal wall defect contents of the sac, loss of abdominal domain and inability of the abdominal cavity to accommodate the liver, we chose for rectangular tissue expander placement at age 30 months. 3 months later the patient was planned for tissue expander removal and abdominal wall closure. The tissue expanders were removed and omphalocele closure was performed. The patient has been followed up at 6 months and without recurrence of hernia.The management of giant omphalocele is technically challenging. Use of tissue expansion helps in recreating functional abdominal wall domain. There is growing evidence in the literature supporting the use of intra-abdominal tissue expansion in the management of giant omphalocele however because of hemodynamic consequences we think that the use of rectangular shaped, extra peritoneal, inter muscular tissue expanders is more desirable and has additional advantage of facilitating component separation.

Trans–Abdominal Wall Traction as a Universal Solution to the Management of Giant Ventral Hernias

Domain loss following damage-control laparotomy is a challenging problem many surgeons face. The authors recently developed trans-abdominal wall traction, which closed 100 percent of domain loss abdomens in the acute setting. They hypothesized that it can be used successfully in patients with chronic giant ventral defects. From 2008 to 2013, 44 patients with acute loss of domain and 10 with chronically giant ventral defects were enrolled in the open abdomen protocol with subsequent placement of the trans-abdominal wall traction device. Patients' average age in the acute and chronic groups was 28.2 and 35.3 years and average body mass index was 26.4 and 32.4 kg/m2, respectively. Ventral hernia size was reduced with the first trans-abdominal wall traction insertion from 610.5 cm2 to 274.6 cm2 in the acute setting and from 598 cm2 to 236.9 cm2 in the chronic setting. Average time from damage-control laparotomy to device insertion was 12.9 days in the acute group and more than 3 years in the chronic group. Lost domain was achieved with an average of less than 2.5 trans-abdominal wall traction tightenings, correlating to 9.2 and 8.2 days in the acute and chronic groups, respectively. Enterocutaneous fistula occurrence was 9 percent in the acute group and 0 percent in the chronic group. All patients were successfully closed after reestablishment of the lost domain. Trans-abdominal wall traction is an effective means of reestablishing abdominal domain and achieving primary abdominal wall closure in all patients with giant ventral defects, both acute and chronic.

Evaluation of three sources of validity evidence for a laparoscopic duodenal atresia repair simulator.

Laparoscopic duodenal atresia (DA) repair is a relatively uncommon pediatric operation requiring advanced minimally invasive skills. Currently, there are no commercial simulators available that address surgeons' needs for refining skills associated with this procedure. The purposes of this study were (1) to create an anatomically correct, size-relevant model and (2) to evaluate the content validity of the simulator. Radiologic images were used to create an abdominal domain consistent with a full-term infant. Fetal bovine tissue was used to complete the simulator. Following Institutional Review Board exempt determination, 18 participants performed the simulated laparoscopic DA repair. Participants completed a self-report, six-domain, 24-item instrument consisting of 4-point rating scales (from 1=not realistic to 4=highly realistic). Validity evidence relevant to test content and response processes was evaluated using the many-facet Rasch model, and evidence of internal structure (inter-item consistency) was estimated using Cronbach's alpha. The highest observed averages were for "Value as a training and testing tool" (both observed averages=3.9), whereas the lowest ratings were "Palpation of liver" (observed average=3.3) and "Realism of skin" (observed average=3.2). The Global opinion rating was 3.2, indicating the simulator can be considered for use as is, but could be improved slightly. Inter-item consistency was high (α=0.89). We have successfully created a size-appropriate laparoscopic DA simulator. Participants agreed that the simulator was relevant and valuable as a learning/testing tool. Prior to implementing this simulator as a training tool, minor improvements should be made, with subsequent evaluation of additional validation evidence.

Posterior Component Separation with Transversus Abdominis Release

BACKGROUND: Ventral hernia is a frequent and challenging problem. More patients today are presenting with significant comorbidities, loss of domain, and difficult anatomic considerations. The ideal method of hernia repair has not yet been found. Non-midline hernias, parastomal hernias, and recurrent ventral hernias after traditional anterior component separation present a particular challenge to repair. In these cases, typical reconstructive techniques would struggle to reestablish abdominal domain to create a lasting repair. Posterior component separation with transversus abdominis release is a new reconstructive technique that offers a durable solution to challenging ventral hernias. METHODS: Posterior component separation begins with a midline laparotomy incision. All adhesions to the posterior abdominal wall are taken down. A Rives-Stoppa-Wantz retro-rectus dissection is carried out, mobilizing large lateral musculocutaneous flaps. Just medial to the linea semilunaris, the transversus abdominis is released by dividing the fascia and muscle insertion to the posterior layer. This allows a wide plane of pre-peritoneal dissection. The plane extends to the psoas muscle laterally, under the costal margin to the central tendon of the diaphragm superolaterally, below the inguinal ligament inferolaterally, and to the neck of the bladder inferiorly. The perforating neurovascular bundles between the internal oblique and transversus abdominis are spared, creating well-vascularized flaps that retain contractile strength. Large sheets of mesh are placed beneath the transversus abdominis in a sublay fashion to reinforce the repair. The rectus abdominis can reliably be advanced to allow for a midline abdominal closure. This technique can be used in non-midline hernias, subxiphoid or suprapubic hernias, and in patients who previously had an anterior component separation – patients who previously had few or very difficult reconstructive options. RESULTS: Results with posterior component separation are reliable and durable, suggesting a 5% recurrence rate at 2 years. At our institution, prospective data collection is being conducted and is thus far encouraging, as no patients have developed recurrent hernias one year after posterior component separation. CONCLUSION: Posterior component separation is a versatile, easy-to-learn technique of hernia repair that offers a reliable, durable solution to complex abdominal wall reconstruction.

Trans Abdominal Wall Traction as a universal solution to the management of giant ventral hernias

Dennis, Andrew J. DO; Salabat, Reza MD; Kingsley, Samuel MD; Starr, Frederic; Joseph, Kimberly MD; Wiley, Dorion; Messer, Thomas; Poulakidas, Stathis; Nagy, Kimberly K. MD, FACS; Bokhari, Faran MD, FACS Author Information

Volume calculation of rats' organs and its application in the validation of the volume relation between the abdominal cavity and the hernial sac in incisional hernias with "loss of abdominal domain".

BackgroundThe calculation of the volume ratio between the hernia sac and the abdominal cavity of incisional hernias is based on tomographic sections as well as the mathematical formula of the volume of the ellipsoid, which allows determining whether this is a giant hernia or there is a "loss of domain". As the images used are not exact geometric figures, the study of the volume of two solid organs of Wistar rats was performed to validate these calculations.AimTo correlate two methods for determining the volume of the kidney and spleen of rats, comparing a direct method of observation of the volume with the mathematical calculation of this value.MethodsThe volume of left kidney, geometrically more regular, and spleen, with its peculiar shape, of ten animals was established in cubic centimeters after complete immersion in water with the aid of a beaker graduated in millimeters. These values ​​were compared with those obtained by calculating the same volume with a specific mathematical formula: V = 4/3 × π × (r1 x r2 x r3). Data were compared and statistically analyzed by Student's t test. RESULTS: Although the average volume obtained was higher through the direct method (1.13 cm3 for the left kidney and 0.71 cm3 for the spleen) than the values ​​calculated with the mathematical formula (0.81 cm3 and 0.54 cm3), there were no statistically significant differences between the values ​​found for the two organs (p>0.05).ConclusionThere was adequate correlation between the direct calculation of the volume of the kidney and spleen with the result of mathematical calculation of these values ​​in the animals' studies.

Live Donor Renal Transplant With Simultaneous Bilateral Nephrectomy for APKD: 10-Year Experience.

Bilateral native nephrectomy (BNx) is indicated in patients with autosomal dominant polycystic kidney disease (APKD) with medically refractory symptoms and ESRD. However, timing of BNx is controversial. We report the largest study to date examining outcomes for patients with ESRD secondary to APKD who have undergone simultaneous BNx and live donor renal transplant (LRT). Methods: A retrospective review for all adults who underwent simultaneous BNx and LRT from August 2003 to August 2013 at a single, high volume transplant center yielded 66 patients, who were compared to 52 APKD patients who underwent LRT without BNx. Results: Mean age was 50 yrs. There were no differences for age, race, sex, BMI, ASA class, and dialysis status. As expected, simultaneous BNx increased operative duration, EBL, transfusion requirements, fluid administration, and hospital LOS (6.6 vs. 4.8 d). Six patients had staged BNx, of which 4 had BNx prior to LRT (mean 13 mo interval) and required a mean 37 sessions of HD vs 0 for simultaneous BNx. All 6 staged operations required additional hospital stays (mean 9.3 d). Most common indications for BNx were pain, loss of abdominal domain, and early satiety. Simultaneous BNx group had 6 vs 0 (p=.03) intraoperative complications, specifically 2 vascular, 2 splenic, and 1 liver injury, plus 1 immediate re-exploration to adjust graft positioning, Using the Clavien-Dindo classification for postoperative events, there were no significant differences in Grade I or II (pharmacologic intervention or transfusion; 39% vs 25%, p=.12) or Grade III or IV (life or graft-threatening, requiring surgery; 7.5% vs 5.7%, p=1.0) complications. There were no surgery related mortalities. There were no significant differences in general readmission rates (68% vs. 48%, p=.19) or those requiring additional procedure (25% vs. 20%, p=.51) over 12 months. In the BNx group, 100% of allografts functioned at >1 month follow-up and > 1 year for all patients available for 1 year follow-up. Conclusions: The excellent outcomes for patient and graft survival and incidence of morbidities suggest that the simultaneous approach be preferred for patients with symptomatic APKD to avoid multiple operative procedures, dialysis, and costs related to staged operations.

Remote Revascularization of Abdominal Wall Transplants Using the Forearm

Primary abdominal wall closure following small bowel transplantation is frequently impossible due to contraction of the abdominal domain. Although abdominal wall transplantation was reported 10 years ago this, technique has not been widely adopted, partly due to its complexity, but largely because of concerns that storing the abdominal allograft until the end of a prolonged intestinal transplant procedure would cause severe ischemia-reperfusion injury. We report six cases of combined small bowel and abdominal wall transplantation where the ischemic time was minimized by remotely revascularizing the abdominal wall on the forearm vessels, synchronous to the intestinal procedure. When the visceral transplant was complete, the abdominal wall was removed from the forearm and revascularized on the abdomen (n = 4), or used to close the abdomen while still vascularized on the forearm (n = 2). Primary abdominal wall closure was achieved in all. Mean cold ischemia was 305 min (300-330 min), and revascularization on the arm was 50 min (30-60 min). Three patients had proven abdominal wall rejection, all treated successfully. Immediate revascularization of the abdominal wall allograft substantially reduces cold ischemia without imposing constraints on the intestinal transplant. Reducing storage time may also have benefits with respect to ischemia-reperfusion-related graft immunogenicity.

Patients With Massive Ventral Hernia Repairs (VHR) Have Substantial Complications

Intuitively, patients with larger ventral hernias and loss of abdominal domain are likely to have decreased preoperative abdominal wall function and QOL, but little is known on postoperative outcomes in this population. We defined a new set of ventral hernias as massive and hypothesized that they would have worse patient outcomes and QOL after repair.

Component separation for complex congenital abdominal wall defects: not just for adults anymore

PurposeOperative repair of large abdominal wall defects in infants and children can be challenging. Component separation technique (CST) is utilized in adults to repair large abdominal wall defects but rarely used in children. The purpose of this report is to describe our experience with the CST in pediatric patients including the first description of CST use in newborns. MethodsAfter IRB approval, we reviewed all patients who underwent CST between June 1, 2010 and December 31, 2012 at a large children's hospital. CST included dissection of abdominal wall subcutaneous tissue from the muscle and fascia and an incision of the external oblique aponeurosis one centimeter lateral to the rectus sheath. Biologic mesh onlay or underlay was used to reinforce this closure. Patients were followed for complications. ResultsNine children, two patients with gastroschisis and seven with omphalocele, were repaired with CST at median (range) 1.1 years (5 days–10.1 years) of age. CST was the first surgical intervention for five children. There were minor wound complications and no recurrences after a median (range) follow up of 16 months (3–34 months). ConclusionCST can be a very useful technique to repair large abdominal wall defects in children with a loss of abdominal domain.

Free-Flap Failure in Thrombophilia

Free-tissue transfer has become routine surgery because of standardization of instrumentation, techniques, and training. The incidence of microvascular thrombosis leading to free-flap failure is relatively low; however, anastomotic thrombosis can still occur despite the best of circumstances. Although majority of the time it is due to technical mishap or misjudgment, free-flap failure can occur due to intrinsic factors, such as the patient's increased propensity to develop clots. We describe a case report of a patient with malignancy and multiple thrombophilias, which led to 2 successive failures in microvascular flap transfer to restore abdominal domain. The aim o f this article is to increase awareness of the potential for thrombophilias to cause a dismal outcome in free-tissue transfer. A review of the literature will be presented, and published cases of free-flap failure in patients with thrombophilia(s) will be summarized.