Synchronous Abdominal Wall and Small-bowel Transplantation: A 1-year Follow-up

Abstract

Abdominal wall-vascularized composite allotransplantation (AW-VCA) has evolved as a technically feasible but challenging option in the rare event of abdominal wall reconstruction in patients whose abdomen cannot be closed by applying conventional methods. The authors conducted the first synchronous child-to-adult recipient AW-VCA using an arteriovenous loop technique. This article presents a 1-year follow-up of the patient's postoperative course. Frequent skin biopsies were performed in accordance with Duke Institutional Review Board protocol, with 3 episodes of rejection treated with high-dose steroids and Thymoglobulin (Genzyme Corp, Cambridge, Mass.). The patient developed an opportunistic fungal brain abscess secondary to immunosuppression, which led to temporary upper extremity weakness. Future considerations for AW-VCA include a modified surgical technique involving utilization of donor vein graft for arteriovenous loop formation. In addition, reduction in postoperative biopsy schedule and changes in immunosuppression regimen may lead to improved outcomes and prevent unnecessary high-dose immunosuppression.

Fig. 1.

Abdominal wall of the patient following multiple laparotomies, with extensive scarring and multiple recurrent enterocutaneous fistulas. It was determined that the use of conventional methods for soft-tissue closure after intestinal transplant would not be sufficient to provide adequate coverage.

Fig. 2.

Creation of an arteriovenous loop using the saphenous vein with end-to-side anastomosis with common femoral artery. Figure originally published in the American Journal of Transplantation. Reprinted with permission.

Fig. 3.

Matured arteriovenous loop is transected and anastomosed end-to-end to the donor inferior epigastric vessels. Figure originally published in the American Journal of Transplantation. Reprinted with permission.

Fig. 4.

The patient underwent intestinal biopsies bimonthly with only a single mild rejection score that resolved without additional immunotherapy treatment.

Fig. 5.

Schedule of skin biopsy regimen bimonthly or at any sign of clinical rejection. The patient had 4 episodes of Banff III rejection treated with Solu-Medrol (Pfizer, New York, N.Y.) and Thymoglobulin.

Fig. 6.

Representative findings of abdominal wall allograft during Banff III rejection episode. The abdominal wall demonstrates multiple scars from frequent skin biopsies.

Fig. 7.

Biopsy of abdominal wall demonstrating severe inflammation and epidermal involvement with epithelial apoptosis, dyskeratosis, and keratinolysis consistent with Banff III rejection.

Fig. 8.

(A) Magnetic resonance imaging of the brain demonstrates an abscess resulting in headaches and right-sided weakness. (B) The patient is currently being treated with voriconazole therapy with remarkable clinical and radiographic improvement.

Fig. 9.

Well healed allograft 10 months postoperatively from abdominal wall transplantation.