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Presenter: Richard S., Mangus, Indianapolis, United States
Authors: Richard S. Mangus1, Chekar Kubal1, A Joseph Tector1, Jonathan Fridell1, Karl Klingler1, Rodrigo Vianna1
Richard S. Mangus, Chekar Kubal, A Joseph Tector, Jonathan Fridell, Karl Klingler, Rodrigo Vianna
Surgery, Indiana University School of Medicine, Indianapolis, IN, United States
Introduction: Loss of abdominal domain is a frequent problem in intestinal transplantation. Inadequate abdominal space can be addressed at the time of transplant with graft reduction, choice of a smaller donor, fascia closure with mesh or tissue, or simultaneous transplantation of the donor abdominal wall. Mesh reconstruction of the abdominal wall may consist of either permanent or non-permanent material, from a variety of biologic and synthetic sources. This study reports the outcomes for a large number of intestinal transplant patients who have undergone abdominal wall closure with Alloderm biologic mesh.
Methods: This single center study reviews the records of 146 intestinal transplant patients between 2004 and 2010. The abdominal wall closure for all patients was reviewed and categorized as primary fascial closure or closure with any foreign material. Mesh closures were with either Alloderm or other mesh material. A thorough chart review was performed to assess complications specifically related to fascia reconstruction including reoperation for perioperative dehiscence, hernia or enterocutaneous fistula.
Results: There were 37 of 146 patients (25%) who required implantation of a foreign material for fascial closure at the time of transplant (109/146 primary repair (75%)). Of these 37, 30 (81%) had implantation of an Alloderm mesh and 7 (19%) received implantation of another mesh. Perioperative dehiscence was rare with 2/109 (2%) in the primary closure group, 0/30 (0%) in the Alloderm group and 1/7 (14%) in the other mesh group. Ventral hernias were only repaired if they were symptomatic. There were 12/146 (8%) of patients that underwent ventral hernia repair. The incidence of hernia by repair type was: primary closure 7/109 (6%), Alloderm mesh 3/30 (10%), and other mesh 2/7 (28%). There were 15/146 (10%) of patients who required surgery for fistula, 4 enterocutaneous and 11 gastrocutaneous (gastrostomy tube site). For the 4 enterocutaneous fistulas, closures included: 2/109 (2%) primary closure, 1/30 (3%) alloderm, and 1/7 (14%) synthetic mesh.
Conclusions: Abdominal wall reconstruction with Alloderm biologic mesh provides an expeditious means of performing a tension-free closure of the fascial layer after intestinal transplantation. Complications associated with use of this material are similar to those seen with primary closure of the fascia, but much lower than those seen with other types of mesh. In our experience, successful use of Alloderm mesh requires aggressive interventions to achieve and maintain skin coverage over the mesh, and to avoid use of suction devices (drains / wound vac) directly over the mesh.
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