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pen Abdomen Management With Human Acellular Dermal Matrix iniver Transplant Recipients

.K. Singh, J.P. Rocca, C. Rochon, M.E. Facciuto, P.A. Sheiner, and M.I. Rodriguez-Davalos

ABSTRACT

Background. Abdominal wall closure after liver transplantation is not always feasibleand may result in increased intra-abdominal pressure along with associated complications.Various temporary closure techniques as well as open wound management have been usedto address this complex problem. The aim of this series was to describe an approach todefinitive wound closure of the open abdomen in liver transplant patients.Methods. We performed a retrospective review of all liver transplant patients at ourinstitution from September 2005 to November 2007. The management of the openabdomen in 10 liver transplant patients was reviewed, and a novel approach described tomanage these defects.Results. Ten patients with open wounds were closed during the study period usinghuman acellular dermal matrix (HADM). There were 7 men and 3 women of median age55 years. Average size of HADM was 235 cm2. The median follow-up is 10 months with noincidence of evisceration or hernia. In 1 patient, the graft failed along the lateral side dueto infection; it dislodged during vacuum-assisted closure dressing change in anotherpatient 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).Conclusions. 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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RIMARY ABDOMINAL wound closure is not alwayspossible after liver transplantation. The inability to

urgically close the wound may be secondary to donorraft/recipient size mismatch, postperfusion hepatic edema,r intestinal edema after portal vein clamping with hemo-ynamic instability.1–5 Abdominal closure under these con-itions may cause increased intrathoracic and intra-abdominalressures. This situation predisposes the recipient to pul-onary barotrauma, vascular thrombosis, impaired renal

erfusion, and hepatic outflow obstruction. Attempts to avoidtight abdominal wall closure have included temporary patch

losure with mesh (PTFE4/Vicryl) or open wound manage-ent with nonadherent wound vacuum-assisted closure

VAC; KCI USA, San Antonio, Tex). Abdominal wall trans-lantation has recently been performed to compensate for thebdominal wall defect in isolated bowel and multivisceralransplant patients, who frequently have lost the domain of thebdominal compartment.6

We have presented herein a series demonstrating the use

f human acellular dermal matrix (HADM), a biological l

2008 by Elsevier Inc. All rights reserved.60 Park Avenue South, New York, NY 10010-1710

ransplantation Proceedings, 40, 3541–3544 (2008)

aterial derived from donor human skin, as a fascialubstitute for difficult wound closures after liver transplant.ADM is cleansed of immune reactive cells and cellular

omponents, leaving a matrix that consists of basementembrane, collagen, elastin, cytokines, and growth factors.he advantage of HADM is its resistance to infection inddition to its mechanical properties.7–11

ETHODS

e performed a retrospective review of all patients undergoingiver transplantation at our institution from September 2005 toovember 2007. The primary sources of data were the transplantatabase and medical records. The gathered data included recipi-nt primary diagnosis, demographics including pretransplanteight, donor weight, operative data, and postoperative course. All

From the Department of Hepato-biliary and Liver Transplant,estchester Medical Center, Valhalla, New York.Address reprint requests to Dr Manoj K. Singh, Hepato-biliary

nd Liver Transplant, Transplant Center, BHC-A Wing, 95 Grass-

ands Road, Valhalla, NY 10595. E-mail: msingh78@gmail.com

0041-1345/08/$–see front matterdoi:10.1016/j.transproceed.2008.06.105

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3542 SINGH, ROCCA, ROCHON ET AL

atients were followed after surgery and at each clinic visit patientso record complications.

urgical Technique

ADM (Life Cell Corp., Branchburg, NJ) was reconstitutedntraoperatively with warm sterile normal saline. HADM sheets ofarious dimensions were used depending on the size of fascialefect, namely 4 � 12, 6 � 16, and 8 � 12 cm with minimalhicknesses of 0.7–2 mm and 2–3 mm. HADM was used like arosthetic patch sewn under minimal tension to the fascial edgesith a running 0/1 polypropylene suture. Large defects were closedith HADM patches in continuity. Skin and soft tissue closure waserformed at the discretion of the operating surgeon. If the skinas not closed (Figure 1A), either wet-to-dry saline-soaked dress-

ngs or VAC therapy was applied; split-thickness skin grafts werelaced after the wound had healed with healthy granulation tissueFigure 1B).

After surgery, patients received similar routine care and moni-oring. All patients received induction therapy with thymoglobulinn postoperative days 1 and 4 (1 mg/kg). The immunosuppressiveegimen consisted of a steroid taper (discontinued after 3 months),alcineurin inhibitors (tacrolimus 0.05 mg/kg per day) starting onostoperative day 4 and mycophenolate mofetil (1000 mg BID)rom postoperative day 1. The immunosuppressive protocol wasot altered; patients were extubated when clinically indicated.

ESULTS

uring the study period, 178, liver transplants were per-ormed including 10 patients with a fascial closure usingADM. There were 7 male and 3 female patients of overalledian age of 58 years (range, 42–67). Their indications for

ransplantation were end-stage liver disease secondary toepatitis C (n � 4), hepatitis B cirrhosis (n � 1), alcoholicirrhosis (n � 2), nonalcoholic steatohepatitis (n � 1), andryptogenic cirrhosis (n � 1). The median donor to recip-ent weight ratio was 0.8 (range, 0.66–1.41). Primary fasciallosure was not possible owing to organ edema (n � 3),arked loss of abdominal compartment or large donor

rgans (n � 4); or wound infection with dehiscence (n � 3).atients with difficult closure owing to organ and abdominalall edema received massive transfusions and had pro-

onged operative times.The average size of the HADM sheets was 235 cm2. In 3

atients (30%) the skin was closed primarily over theADM; 1 of these patient required incision and drainage

or hematoma evacuation at 1 month after closure. The skinas left open in 7 patients (70%). These wounds wereanaged with a VAC dressing device, which was changed

very 72 hours by the surgical team. Plastic closure withplit-thickness skin grafts was achieved in 1 patient after therowth of good granulation tissue over the HADM. Skinlosure was performed with advancement flaps in 2 patientst 3–4 weeks after HADM fascial closure. The HADMraft was detached from the fascia in 1 patient at 3 monthsuring a VAC dressing change. A small fascial defect was

eft, which healed by secondary intention requiring flapobilization for skin closure. The graft failed in 1 patient

long the lateral wound edge owing to infection; the wound a

as managed with a VAC dressing after graft removal. Inhe remaining 3 patients, the wound healed by secondaryntention for eventual closure by split-thickness skin grafts.

None of the patients required reoperation for technicaleasons as a result of HADM closure. The presence ofADM did not limit sonographic evaluation of the liver

nd its blood supply. HADM closure did not pose anyifficulty during reexploration in 2 patients; 1 for a biliary

eak and the other for intra-abdominal bleeding. HADMas easily incised and closed without difficulty or postoper-

ig 1. A. Facial closure with HADM. B. Abdominal wound 4onths after closure shows growth of granulation tissue and

ncorporation of HADM.

tive complications related to the closure.

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OPEN ABDOMEN MANAGEMENT 3543

The median follow-up was 10 months (range, 2 days to 24onths). One patient died 2 days after transplantation from

cute respiratory, distress syndrome; the remaining 9 pa-ients are alive with good graft function. No abdominal wallomplications were seen at follow-up (Table 1).

ISCUSSION

uccessful abdominal wound closure remains a challenge inome liver transplantation patients. Morbidity and seriousomplications are associated with suboptimal wound clo-ure and delayed healing in this immunosuppressed group,hich can lead to lengthy hospitalizations and life-threatening

nfections. Presently, given the difficulty in managing theseatients, the most common approach is to try to prevent theroblem, either by waiting for a smaller donor or byeducing the size of the graft. Abdominal wall closure isost often obtained when the donor’s body weight is

0%–100% of the recipent. However, waiting for a smallerize donor can increase wait list mortality. To circumventhis problem, some workers have advocated the use of

Table 1. Patient Charac

Patient Age/Gender

Do/ReWeightRatio

BMI(kg/m2)

HADMSurface

Area (cm2) Reason fo

1 58 M 1.02 25.7 384 Liver and bodone after

2 51 M .74 25 264 Necrotic wouafter transclose fascdebrideme

3 51 F 1.41 27.3 444 Large liverHADM closu

after failedof open abevisceratio

4 67 M 0.77 26.8 96 Wound infecDehiscencliver/kidne

5 55 M 0.72 25.3 192 Bowel, organOLT#2 w/o

6 52 M 0.66 33 288 Liver edemareexplorati

7 54 M 1.4 26.7 240 Large liver, inabdominaldifficulty vetransplant

8 58 F 0.8 28.5 144 Wound infecdefect pos

9 66 F 1.19 26.7 256 Large liverTight fascia

10 42 M 1.37 29 40 Large liver, t

Abbreviations: VAC, vacuum-assisted closure; Do/Re, donor/recipient; BMI,

educed sized grafts using the split liver technique.1,2 o

The use of extended criteria donor (ECD) as suggestedy Jafri et al12 may increase the number of posttransplantatients who have to be managed as open abdomens so aso not compromise graft function owing to abdominalypertension. The use of a temporary mesh closure andecond look as proposed by this group may be helpful inome patients, but is not mandatory. HADM usage wouldave a trip to the operating room and provide definitelosure at the time of transplantation avoiding the compli-ations of an open abdomen.

An HADM patch permits a low-pressure abdominallosure without compression or compromise of liver perfu-ion. It also avoids the high central venous pressure and theeed for increased ventilatory support that inevitably re-ults from abdominal closure under tension. Pulmonaryarotrauma and ventilator dependence eventually prolong

ntensive unit stay and increase infections complicationsnd overall costs. The HADM patch makes reexplorationasier because of the lack of intra-abdominal adhesionso its undersurface. It maintains its strength for reclo-ure. HADM along with a VAC system has been part of

ics and Follow-Up Data

M Closure Follow-Up Hernia Recurrence

dema, closureek

Split-thickness skin graft None at 18 mos

fection 1 mounable tor

Skin closure by advancementflap 20 days after HADMplacement.

Died 24 mos after transplantfrom intracranialhemorrhage

None at 24 mos

days latermanagementn with

Healed by secondaryintention

None at 16 mos

ithmos aftersplant

HADM detached during vacchange 5 mos after closure

Wound healed by secondaryintention

None at 12 mos

a afterabdomen

Died 2 days after secondtransplant

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g Skin closure by advancementflap 5 mos after fascialclosure

None at 8 mos

sed intra-sure anding during

Healed by secondaryintention

None at 7 mos

arge fascialidement

Failed graft, healing bysecondary intention

None at 5 mos

Primary closure None at 13 mos

scia Primary closure None at 6 days

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ffectively utilized for the management of the complexounds.

CKNOWLEDGMENT

he authors thank Maureen Burke Davis, NP, for her assistanceith data collection and Nancy Ehrlich for editorial assistance.

EFERENCES

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3. de Ville de Goyet J, Struye de Swielande Y, Reding R, et al:elayed primary closure of the abdominal wall after cadaveric and

iving related donor liver graft transplantation in children: A safend useful technique. Transpl Int 11:117, 1998

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ransplantation. Transplantation 62:1034, 1996 d

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erm): A new alternative for abdominal hernia repair. Ann Plasturg 52:188, 20049. Silverman RP, Li EN, Holton LH 3rd, et al: Ventral hernia

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