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Procurement for a Vascularized and Reinnervated Abdominal Wall Allotransplantation
Published on: July 18, 2025
Staged abdominal closure after small bowel or multivisceral transplantation
1Liver Unit (including small bowel transplantation), Birmingham Children's Hospital, Birmingham, UK.
Insights
Sac closure technique (SAC) may prevent abdominal compartment syndrome (ACS) after pediatric small bowel transplantation (SBT). While SAC prolonged recovery, it reduced ACS-related deaths and improved survival in combined liver and small bowel transplants.
Area of Science:
- Pediatric Surgery
- Transplantation Immunology
- Gastroenterology
Background:
- Abdominal compartment syndrome (ACS) is a risk following pediatric small bowel transplantation (SBT) due to size discrepancy.
- The "sandwich" abdominal closure technique (SAC) was developed to manage abdominal wall tension in these cases.
- Comparing SAC with primary abdominal closure (PAC) is crucial for understanding its impact on outcomes.
Purpose of the Study:
- To evaluate the safety and efficacy of the SAC technique in pediatric SBT.
- To compare outcomes between patients undergoing SAC versus PAC.
- To assess the impact of SAC on ACS incidence, graft function, and survival.
Main Methods:
- Retrospective review of 57 children undergoing 62 SBTs between 1993 and 2009.
- Patients were divided into SAC and PAC groups based on intraoperative abdominal wall tension.
- Outcomes including ACS, graft dysfunction, intubation time, ICU/hospital stay, and survival were compared.
Main Results:
- No significant differences in indications, preoperative status, age, weight ratio, or wound complications between SAC and PAC groups.
- SAC was associated with prolonged post-operative intubation, ICU, and hospital stays.
- No ACS-related deaths occurred in the SAC group, compared to two in the PAC group.
- One-year survival rates (since 2000) showed a trend favoring SAC in combined liver and small bowel transplants (75% vs. 57%).
Conclusions:
- SAC is a safe method to reduce severe ACS after pediatric SBT.
- The technique can be safely combined with graft reduction in small recipients.
- While SAC may prolong recovery, it appears to improve survival by preventing ACS.
Abstract:
Following paediatric SBMT, size discrepancy between the recipient's abdomen and the graft may lead to ACS, graft dysfunction, and death. We report our experience with SAC in these patients. Between 04/1993 and 03/2009, 57 children underwent 62 SBMTs. When abdominal wall tension seemed excessive for safe PAC, SAC was performed, using a Silastic® sheet and a vacuum occlusive dressing. Transplantations with SAC (23 combined liver and small bowel [CLB]) were compared with those with PAC [14 ISB and 25 CLB]. Indications for transplantation, preoperative status (after stratification for ISB/CLB transplants), age at transplantation, donor-to-recipient weight ratio, reduction in bowel and/or liver, and incidence of wound complications were not different in both groups. Post-operative intubation, stay in intensive care unit, and hospital stay were prolonged after SAC. Two deaths were related to ACS after PAC, none after SAC. Since 2000, one-yr patient survival is 73% after ISB transplantation and 57% vs. 75% after CLB transplantation with PAC vs. SAC, respectively (NS). SAC safely reduces severe ACS after paediatric SBMT and can be combined with graft reduction for transplantation of small recipients.
