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Delayed sequential abdominal wall closure in pediatric liver transplantation to overcome "large for size" scenarios
José Andrés Molino1, Ernest Hidalgo2, Jesús Quintero3
1Paediatric Surgery Department, Vall d´Hebron Hospital Campus, Barcelona, Spain.
Insights
Delayed sequential closure (DSC) is a safe technique for pediatric liver transplantation (PLT) when primary closure is not feasible due to graft size. This method ensures good clinical outcomes without permanent materials.
Area of Science:
- Pediatric surgery
- Hepatology
- Transplantation medicine
Background:
- Primary abdominal wall closure after pediatric liver transplantation (PLT) can be challenging due to graft-recipient size discrepancies.
- Large-for-size graft scenarios may preclude immediate abdominal closure.
Purpose of the Study:
- To evaluate the experience and outcomes of delayed sequential closure (DSC) guided by Doppler ultrasound in PLT.
- To assess the safety and efficacy of DSC in managing abdominal wall closure challenges in PLT.
Main Methods:
- Retrospective analysis of 102 PLT cases from 2013 to March 2020.
- Identification and review of 27 cases (26.5%) that underwent DSC.
- Doppler ultrasound guidance was utilized for DSC procedures.
Main Results:
- Patients undergoing DSC had significantly lower mean weight and higher graft-recipient weight ratio (GRWR) compared to primary closure.
- The median time to definitive closure was 6 days, with a median of 4 procedures.
- While DSC patients had longer PICU and hospital stays, overall and 3-year graft/patient survival rates were comparable (96%) to the primary closure group.
- Vascular complications occurred in 7.4% of DSC patients.
Conclusions:
- Delayed sequential closure (DSC) is a simple, safe, and effective technique for managing "large for size" graft scenarios in PLT.
- DSC allows for satisfactory clinical outcomes and avoids the need for permanent biological materials for abdominal closure.
Background:
Primary abdominal wall closure after pediatric liver transplantation (PLT) is neither always possible nor advisable, given the graft-recipient size discrepancy and its potential large-for-size scenario. Our objective was to report the experience accumulated with delayed sequential closure (DSC) guided by Doppler ultrasound control.
Methods:
Retrospective analysis of DSC performed from 2013 to March 2020.
Results:
Twenty-seven DSC (26.5%) were identified out of 102 PLT. Transplant indications and type of grafts were similar among both groups. In patients with DSC, mean weight and GRWR were 9.4 ± 5.5 kg (3.1-26 kg) and 4.7 ± 2.4 (1.9-9.7), significantly lower and higher than the primary closure cohort, respectively. The median time to achieve definitive closure was 6 days (range 3-23 days), and the median number of procedures was 4 (range 2-9). Patients with DSC had longer overall PICU (22.5 ± 16.9 vs. 9.1 ± 9.7 days, p < .05) and hospital stay (33.4 ± 19.1 vs 23, 9 ± 19.8 days (p < .05). These differences are less remarkable if the analysis is performed in a subgroup of patients weighing less than 10 kg. Two patients presented vascular complications (7.4%) within DSC group. No differences were seen when comparing overall, 3-year graft and patient survival (96% and 96% in the DSC group).
Conclusions:
DSC is a simple and safe technique to ensure satisfactory clinical outcomes to overcome "large for size" scenarios in PLT. In addition, we were able to avoid using a permanent biological material for closing the abdomen.
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