Complications after 344 damage-control open celiotomies

BACKGROUND: We reviewed our experience with the open abdomen and hypothesized that the known high wound complication rates were related to the timing and method of wound closure. METHODS: All trauma admissions from 1995 through 2002 requiring an open abdomen and temporary abdominal coverage were included. The study group was then classified by three wound closure methods used in survivors: 1) primary (primary fascial closure); 2) temporizing (skin only, spit thickness skin graft and/or absorbable mesh), and 3) prosthetic (fascial repair using nonabsorbable prosthetic mesh). RESULTS: In all, 344 patients required an open abdomen and temporary abdominal coverage either as part of a planned staged damage-control celiotomy (66%) or the development of the abdominal compartment syndrome (33%). Of these, 276 patients survived to wound closure. Sixty-nine of the 276 (25%) suffered wound complications (wound infection, abscess, and/or fistula). Thirty-four (12%) died after wound closure; seven of the deaths as a direct result of the wound complication. Complications increased significantly after 8 days (p < 0.0001) from the initial operative intervention to fascial closure. Primary fascial closure was achieved in 180 of 276 (65%) patients. Although there was no difference in the mean Injury Severity Score between the three groups, the primary group had significantly fewer mean transfusion requirements, shorter mean time to fascial closure, and a lower complication rate as compared with either the temporizing or prosthetic groups. The primary group thus incurred significantly less mean initial hospitalization charges. CONCLUSION: Morbidity associated with wound complications from the open abdomen remains high (25%). Morbidity is associated with the timing and method of wound closure and transfusion volume, but independent on injury severity. Also, delayed primary fascial closure before 8 days is associated with the best outcomes with the least charges.     

Temporary abdominal closure (TAC) for planned relaparotomy (etappenlavage) in trauma

Planned relaparotomy (temporary abdominal closure) was studied prospectively in 20 trauma patients. Four died in the first 24 hours from hypothermia, coagulopathy, shock (three), and septic shock (one). The 16 survivors had a Velcro-like prosthetic placed to facilitate abdominal closure and re-entry. Prosthetic was necessary in eight because bowel edema precluded fascial closure, and useful for removal of packing (three) and for the management of peritonitis (five). The prosthetic did not open spontaneously, nor was it associated with evisceration or bowel fistula. Temporary abdominal closure (TAC) permitted reappraisal and staged repair of intra-abdominal pathology, including bowel resection and anastomosis. TAC identified 14 problems early: bleeding (five), bile leaks (two), GI complications (six), liver necrosis (one). Five patients developed superficial wound infections, and three went on to develop fascial necrosis.     

Incisional hernia after liver transplantation

BACKGROUND: Incisional hernia is a potential complication of orthotopic liver transplantation (OLT), with various options for repair. STUDY DESIGN: We conducted a retrospective review of a series of adult patients with incisional hernias after OLT to identify risk factors and to compare methods of repair. RESULTS: Incisional hernia repair was performed in 44 of 959 patients (4.6%) who underwent OLT from 1999 to 2005. Mean age at time of OLT was 53 years, and 73% were men. One or more complications of OLT occurred in 33 patients (75%) and included reoperation for bile leak or hemoperitoneum (34%), pulmonary problems (27%), early acute rejection (7%), and severe ascites and retransplantation (5% each). Incisional hernia was diagnosed at 419 days (range 62 to 1,524 days) and repaired at 471 days (range 109 to 1,581 days) after OLT. Presentation included pain or discomfort (78%) and incarceration or strangulation (5%); 17% were asymptomatic. Herniorrhaphy techniques included fascial repair with onlay polypropylene mesh reinforcement (n=25, 57%); fascial repair only (n=15, 34%); or inlay mesh sewn to fascial edges (n=4, 9%). Complications of repair included recurrence in seven patients (16%) and wound infection and seroma in one patient each. Recurrence occurred in five patients with primary repair and two with mesh techniques (33% versus 6%, p=0.04). CONCLUSIONS: Incisional hernia is a late complication of OLT for which male gender and early post-OLT complications are risk factors. Repair is safe when undertaken after acute problems have resolved and is best accomplished using mesh reinforcement of autologous tissue.     

Mesh hood fascial closure in renal allograft compartment syndrome

Renal allograft compartment syndrome (RACS) is an underreported and poorly described surgical complication of renal transplantation. It occurs when a tight fascial closure compresses the graft in its limited retroperitoneal space. Without early recognition and reexploration, graft loss is inevitable. We describe a technique using a polypropylene mesh fascial closure (MHFC) to prevent and treat RACS. MHFC was performed primarily to prevent RACS and secondarily to treat this complication. Between April 2001 and October 2002, 16 patients undergoing 17 renal transplants underwent MHFC. Mean recipient body weight was 17% less than the mean donor weight. Mean follow-up was 9 months. Mean serum creatinine after primary MHFC was 148.4 micromol/L. Three of four patients with RACS regained function following secondary MHFC and had a mean serum creatinine of 155.3 micromol/L. Wound complications were seen in 5 (31%) with no wound or mesh infections and one patient was diagnosed with a lymphocele. We conclude that MHFC can be safely performed after kidney transplantation to prevent or treat RACS.     

Staged management of giant abdominal wall defects: acute and long-term results

INTRODUCTION: Shock resuscitation leads to visceral edema often precluding abdominal wall closure. We have developed a staged approach encompassing acute management through definitive abdominal wall reconstruction. The purpose of this report is to analyze our experience with this technique applied to the treatment of patients with open abdomen and giant abdominal wall defects. METHODS: Our management scheme for giant abdominal wall defects consists of 3 stages: stage I, absorbable mesh insertion for temporary closure (if edema quickly resolves within 3-5 days, the mesh is gradually pleated, allowing delayed fascial closure); stage II, absorbable mesh removal in patients without edema resolution (2-3 weeks after insertion to allow for granulation and fixation of viscera) and formation of the planned ventral hernia with either split thickness skin graft or full thickness skin closure over the viscera; and stage III, definitive reconstruction after 6-12 months (allowing for inflammation and dense adhesion resolution) by using the modified components separation technique. Consecutive patients from 1993 to 2001 at a single institution were evaluated. Outcomes were analyzed by management stage, with emphasis on wound related morbidity and mortality, and fistula and recurrent hernia rates. RESULTS: Two hundred seventy four patients (35 with sepsis, 239 with hemorrhagic shock) were managed. There were 212 males (77%), and mean age was 37 (range, 12-88). The average size of the defects was 20 x 30 cm. In the stage I group, 108 died (92% of all deaths) because of shock. The remaining 166 had temporary closure with polyglactin 910 woven absorbable mesh. As visceral edema resolved, bedside pleating of the absorbable mesh allowed delayed fascial closure in 37 patients (22%). In the stage II group, 9 died (8% of all deaths) from multiple organ failure associated with their underlying disease process, and 96% of the remaining 120 had split-thickness skin graft placed over the viscera. No wound related mortality occurred. There were a total of 14 fistulae (5% of total, 8% of survivors). In the stage III group, to date, 73 of the 120 have had definitive abdominal wall reconstruction using the modified components separation technique. There were no deaths. Mean follow-up was 24 months, (range 2-60). Recurrent hernias developed in 4 of these patients (5%). CONCLUSIONS: The staged management of patients with giant abdominal wall defects without the use of permanent mesh results in a safe and consistent approach for both initial and definitive management with low morbidity and no technique-related mortality. Absorbable mesh provides effective temporary abdominal wall defect coverage with a low fistula rate. Because of the low recurrent hernia rate and avoidance of permanent mesh, the components separation technique is the procedure of choice for definitive abdominal wall reconstruction.     

Polypropylene mesh closure of infected abdominal wounds

The management of extensive abdominal tissue loss in the presence of intraabdominal infection or wound dehiscence challenges the surgeon's ingenuity in wound care. Radical debridement and primary fascial closure may be impossible due to tissue loss or extensive bowel edema. The use of a synthetic mesh to bridge the fascial defect and maintain the integrity of the abdominal cavity may initially appear to be an attractive alternative to simply leaving the viscera exposed. However, this report and review of the literature document the frequent complications and high morbidity associated with this technique. An overall complication rate approaching 80% can be anticipated if polypropylene mesh is used in this emergency situation. Two modifications of wound care appear to markedly diminish the incidence of serious complications. Covering the mesh with full-thickness skin or muscle flaps in the early postoperative period, or removing the mesh at the earliest time conducive to fascial closure (within 2 weeks) reduced the overall complication rate from 55% to 15% in this review. However, it is often impossible to predict which patients will be amenable to early mesh removal, and full-thickness coverage of a persistently infected wound is usually doomed to failure. Despite the occasional usefulness of these modifications, this review suggests that polypropylene mesh in the emergency setting has an unacceptably high complication rate, and alternative methods of wound care in these complex situations should be considered.     

Temporary abdominal closure followed by definitive abdominal wall reconstruction of the open abdomen

BACKGROUND: Inability to close the abdominal wall after laparotomy for trauma may occur as a result of visceral edema, retroperitoneal hematoma, use of packing, and traumatic loss of tissue. Often life-saving, decompressive laparotomy and temporary abdominal closure require later restoration of anatomic continuity of the abdominal wall. METHODS: The trauma registry, open abdomen database, and patient medical records at a level 1 university-based trauma center were reviewed from January 1988 to December 2001. RESULTS: During the study period, more than 15,000 trauma patients were admitted, with 88 patients (0.6%) requiring temporary abdominal closure (TAC). Patients ages ranged from 12 to 75 years with a mean injury severity score (ISS) of 28 (range 5 to 54). Forty-five patients (51%) suffered penetrating injuries, and 43 (49%) were victims of blunt trauma. Indications for TAC included visceral edema in 61 patients (70%), abdominal compartment syndrome in 10 patients (11%), traumatic tissue loss in 9 patients (10%), and wound sepsis and fascial necrosis in 8 patients (9%). Fifty-six patients (64%) underwent TAC at admission laparotomy, whereas 32 patients (36%) required TAC at reexploration. Seventy-one patients (81%) survived and 17 (19%) died. Of the survivors, 24 patients (34%) underwent same-admission direct fascial closure, and 47 patients (66%) required visceral skin grafting and readmission closure. Reconstructive procedures in the patients requiring skin graft excision included direct fascial repair (20 patients, 44%), components separation closure with or without subfascial tissue expansion (18 patients, 40%), pedicled or free-tissue flaps (4 patients, 8%), and mesh repair (4 patients, 8%). One patient refused closure. The mean follow-up was 48 months (range 6 to 144), with an overall recurrence rate of 15% (range 10% to 50%), highest in the mesh repair group. CONCLUSIONS: Silicone sheeting TAC provides a safe and reliable temporary abdominal closure allowing for later definitive reconstruction. Direct fascial repair or components separation closure with or without tissue expansion can be utilized in the majority of patients for definitive reconstruction with low recurrence rate.     

Alternative approaches to abdominal wound closure in severely injured patients with massive visceral edema.

Excessive tension in an abdominal incision line may lead to fascial necrosis and wound sepsis. We utilized two alternative approaches to wound closure in 13 patients with severe abdominal trauma (2 blunt, 11 penetrating) whose midline incision could not be closed primarily without excessive tension at the initial operation because of massive visceral edema. In five patients synthetic mesh was used to bridge the fascial defect. Four patients survived the early postoperative period but had large open midline wounds that required one or more delayed procedures to close the wound or cover the visceral mass with skin graft. Two patients currently have large abdominal wall hernias. In the other eight patients the skin was reapproximated over the visceral mass utilizing towel clips at the initial operation. Six patients survived to be reexplored within 48-96 hours. Acute hemorrhage had stopped, the edema of the bowel and retroperitoneum had largely resolved, and the fascia could be closed primarily without excessive tension. All wounds went on to heal satisfactorily. When massive edema makes fascial closure at the initial operation difficult or impossible, closure of the skin over the visceral mass promotes resolution of the edema and often allows satisfactory primary closure within 48-96 hours. Synthetic mesh should be reserved for cases of abdominal wall tissue loss or dehiscence associated with wound sepsis.     

Reinforced silicone elastomer sheeting,an improved method of temporary abdominal closure in damage control laparotomy

BACKGROUND: The ability to massively transfuse and resuscitate critically ill surgical patients has resulted in unprecedented survival and a new set of complications including abdominal compartment syndrome (ACS) and the "unclosable" abdomen. Traditional methods of temporary abdominal closure have met with several limitations, not the least of which is a marked delay in achieving definitive fascial closure. Since 1991, we have consistently used reinforced silicone elastomer (Silastic) sheeting as a form of temporary abdominal closure in these settings. We report our results using this technique in a large cohort of critically ill surgical patients. METHODS: All patients undergoing silicone elastomer temporary abdominal closure since 1991 were identified and their charts abstracted for principal diagnosis and indication for temporary abdominal closure, fluid requirements, number of operations, and time to fascial closure. Time to definitive closure in the respective groups was analyzed using Kaplan-Meir survival curves and the Wilcoxon rank-sum test. Odds ratios for death were analyzed using logistic regression. RESULTS: One hundred thirty-four patients underwent temporary abdominal closure with silicone elastomer over this period and only 62% (83) survived their hospital admission. Trauma and ruptured abdominal aortic aneurysm were the most frequent diagnoses. The most frequent indication was edema precluding abdominal closure. The mean crystalloid and blood requirements in the 24 hours preceding temporary abdominal closure were 21 +/- 16 L and 15 +/- 11 U, respectively. Of survivors, 75% (63 of 83) achieved fascial closure during their index admission. The median time to fascial closure in patients ultimately closed was 5 days. The median time to closure and the proportion of patients ultimately closed varied with the indication for closure with an earlier and greater chance of success in patients who could not tolerate closure (ACS) or could not be closed primarily (edema). Age-adjusted mortality was 5 times (95% confidence interval: 2 to 13) higher in patients developing ACS. CONCLUSIONS: Nylon reinforced silicone elastomer is a safe, reliable material for temporary abdominal closure in severely ill patients. Primary fascial closure can be obtained in a timely fashion in the majority of patients. The success of obtaining definitive fascial closure depends on the indication for temporary abdominal closure, with visceral edema and ACS having the highest likeliest of early success.     

Wound closure technique and acute wound complications in gastric surgery for morbid obesity: a prospective randomized trial

BACKGROUND: During the past 10 years, numerous clinical studies have supported the use of continuous monofilament fascial closure after laparotomy. Because of the increased incidence of surgical-site infections and other acute wound complications in the morbidly obese, these patients are well suited for a study of technical factors that may affect the frequency of these wound complications. STUDY DESIGN: A prospective, randomized study of the midline fascial closure technique in gastric bariatric operations was conducted between 1991 and 1998 in 331 consecutive morbidly obese patients. At the time of closure of the upper midline laparotomy wound, the patients were randomized into two groups: Group I patients (n = 172) underwent continuous fascial closure and group II patients (n = 159) underwent interrupted fascial closure. All patients received prophylactic antibiotics in a similar fashion. Wounds were monitored for 30 days postoperatively, and acute wound complications were classified as superficial or deep. Superficial complications included superficial surgical-site infections, seromas, and hematomas. In all superficial complications, the fascia remained uninvolved and intact. Deep wound complications included deep surgical-site infections and fascial dehiscence. RESULTS: A total of 49 acute wound complications occurred (15%). There were 22 superficial (7%) and 27 deep (8%) wound complications in the 331 in the patients studied. Group I patients experienced fewer total wound complications than group II patients (18 versus 31; p=0.021). Group I patients also experienced fewer deep wound complications than group II (5 versus 22; p = 0.003). CONCLUSIONS: Continuous fascial closure reduces major acute wound complications in morbidly obese patients undergoing gastric operations for obesity.     

Incisional hernia repair after orthotopic liver transplantation: a technique employing an inlay/onlay polypropylene mesh

Background: The literature provides no data on the incidence and operative management of incisional hernias developing after orthotopic liver transplantation. The use of high-dose immunosuppressive agents results in an appreciable delay in wound healing. There is thus a need for a procedure for the reconstruction of the abdominal wall for patients on immunosuppression. The aim of this retrospective study was to establish the incidence of incisional hernias and an analysis of the results after implantation of a polypropylene mesh in inlay–onlay technique after liver transplantation is given.Methods: The basis for the present retrospective investigations was a total of 207 liver transplantations carried out in 192 patients (15 re-transplantations). After performing tensiometry, a polypropylene mesh (Marlex) was implanted to close the hernias using the inlay/onlay technique or a direct closure of the fascia was done. All treated hernias were followed up for a median of 18 months.Results: Among 184 patients, 17 developed incisional hernias after primary direct closure of the abdominal wall, giving an incidence of 9%. In an additional 8 patients an incisional hernia was seen where an absorbable mesh was used to close the abdominal wall after liver transplantation. In addition, there were 25 incisional hernias after 207 liver transplantations (12%). One of 15 (7%) of the surgically repaired hernias with implantation of a polypropylene mesh (Marlex) developed a recurrence. All the 3 patients after direct apposition of the fascia without using a polypropylene mesh suffered a recurrence (3 of 3; 100%). Significant risk factors for developing an incisional hernia were the amount of ascites and the stay in the ICU after transplantation. Neither severe deep nor superficial wound infection nor bowel fistulas were observed after implantation of a inlay/onlay mesh.Conclusion: In patients after liver transplantation, the implantation of a polypropylene mesh proved to be an efficient and safe method of treating incisional hernias. Implantation of a mesh was not associated with an increased infection rate, despite the use of immunosuppression. In view of the high recurrence rate associated with primary closure, mesh implantation should be given preference.     

Treatment of renal transplant complications with a mesh hood fascial closure technique

Early renal allograft dysfunction may be caused by a number of technical factors including thrombosis, kinking of vessels, and a Page kidney situation in which the allograft is compressed within a shallow false pelvis and limited retroperitoneal space. Without early recognition, compromised graft function, obstruction, or graft loss may ensue. We describe a technique using a polypropylene-assisted mesh hood fascial closure (MHFC) to prevent and treat this potential complication. MHFC was performed both primarily to prevent this phenomenon, and secondarily to treat this complication. Between April 2001 and October 2002, 16 patients undergoing 17 renal transplants underwent MHFC. The mean recipient body weight was 17% less than the mean donor weight. The mean follow-up period was 9 months. The mean serum creatinine level after primary MHFC was 148.4 micromol/L. Three of 4 patients with early allograft dysfunction regained function after secondary MHFC and had a mean serum creatinine level of 155.3 micromol/L. Wound complications were seen in 5 (31%) patients with no wound or mesh infections and 1 patient was diagnosed with a lymphocele. We conclude that the use of mesh in the primary closure of the incision after renal transplantation is safe and has minimal complications.     

The open abdomen and temporary abdominal closure systems – historical evolution and systematic review

Aim Several techniques for temporary abdominal closure have been developed. We systematically review the literature on temporary abdominal closure to ascertain whether the method can be tailored to the indication. Method Medline, Embase, the Cochrane Central Register of Controlled Trials and relevant meeting abstracts until December 2009 were searched using the following headings: open abdomen, laparostomy, VAC (vacuum assisted closure), TNP (topical negative pressure), fascial closure, temporary abdominal closure, fascial dehiscence and deep wound dehiscence. The data were analysed by closure technique and aetiology. The primary end‐points included delayed fascial closure and in‐hospital mortality. The secondary end‐points were intra‐abdominal complications. Results The search identified 106 papers for inclusion. The techniques described were VAC (38 series), mesh/sheet (30 series), packing (15 series), Wittmann patch (eight series), Bogotá bag (six series), dynamic retention sutures (three series), zipper (15 series), skin only and locking device (one series each). The highest facial closure rates were seen with the Wittmann patch (78%), dynamic retention sutures (71%) and VAC (61%). Conclusion Temporary abdominal closure has evolved from simple packing to VAC based systems. In the absence of sepsis Wittmann patch and VAC offered the best outcome. In its presence VAC had the highest delayed primary closure and the lowest mortality rates. However, due to data heterogeneity only limited conclusions can be drawn from this analysis.     

Impact of the recurrence of hepatitis C virus infection after liver transplantation on the long-term viability of the graft.

BACKGROUND: The impact of hepatitis C virus (HCV) infection recurrence after orthotopic liver transplantation (OLT) on graft viability is still not accurately defined. Our study aims to evaluate the magnitude and rate of progression of HCV-induced liver damage after OLT in a single institution cohort of 122 HCV-infected recipients. METHODS: All patients transplanted at our institution between 1988 and 1996 with positive serum HCV antibodies before OLT, minimum postoperative survival of 6 months, and without hepatitis B virus coinfection or severe non-HCV-related graft complications were retrospectively included in the study. RESULTS: HCV infection recurrence was almost universal, and genotype 1b was observed in 87% of the cases. After a median histological follow-up of 43 months (range: 7-96), evidences of HCV-induced histological damage were found in 94% of the cases. The actuarial rates of severe graft damage (including cirrhosis, fibrosing cholestatic hepatitis, and submassive liver necrosis) were 15%, 33%, and 44% at 3, 5, and 7 years, respectively, and among these patients, 52% developed decompensated liver disease during the follow-up and 36% lost their grafts. The biochemical severity at the onset of the recurrent hepatitis and the development of cholestasis or cytomegalovirus disease were independent predictors of severe HCV-related graft damage. No differences were found in graft and patient survival when positive-HCV OLT recipients were compared with a coetaneous cohort of 215 non-HCV OLT recipients. CONCLUSIONS: HCV infection recurrence leads to severe liver damage and subsequently to clinical decompensation in a significant proportion of OLT recipients. Some clinical and biochemical characteristics can predict the severity of HCV-induced graft damage.     

Parenchymal liver injury in orthotopic liver transplantation

BACKGROUND: A 35-year period of clinical development resulted in orthotopic liver transplantation (OLT) becoming a standardized surgical procedure. Despite this progress, the rate of technical complications is still high. Although the main problem in most analyses is vascular or bile duct failure, we observed a remarkable number of parenchymal liver injuries that led to intraoperative problems. Our aim, therefore, is to present an overall report on the incidence, treatment, and clinical course of parenchymal liver injuries in OLT. METHODS: Five hundred seventy-two consecutive OLT procedures performed between 1988 and 1998 were analyzed in a retrospective study. Parenchymal liver injury was diagnosed by means of examination of the surgical reports. Donor- and recipient-related data followed the medical report. The lesions were classified according to the Organ Injury Scale. RESULTS: Parenchymal liver injury was diagnosed in 23 patients (4%). The lesions were classified as grade Ia (13.1%), grade Ib (13.1%), grade IIb (52.1%), grade IIIa (17.1%), and grade IIIb (4.3%). In 19 patients (82.6%), the lesion was detected during OLT, and in four patients (17.4%), during relaparotomy. The latter group showed significantly higher-grade injuries. Treatment was suture or fibringlue alone, 17.4%; fibringlue and hemostyptics, 26.1%, mesh wrapping 30.4%, and mesh packing 26.1%. Seven patients (30.4%) underwent relaparotomy. Further active bleeding was not found in any of them. Statistical analysis found a correlation between injury grade and relaparotomy rate. No patients died as a result of parenchymal liver injury. CONCLUSIONS: Parenchymal liver injuries can be treated well, with no adverse effect on patient or graft survival. An early decision concerning the surgical procedure for controlling hemorrhage is required. A basically aggressive therapeutic approach might avoid further complications relating to reperfusion edema.     

The effect of different temporary abdominal closure techniques on fascial wound healing and postoperative adhesions in experimental secondary peritonitis

Background Secondary peritonitis causes considerable mortality and morbidity. New strategies have been introduced like relaparotomy and temporary abdominal closure in the management of such persistent intra-abdominal infections. Materials and methods Rats were divided into five groups each having ten animals. After induction of peritonitis, relaparotomies were done, and the abdomen was closed by different temporary abdominal closure techniques. After performing two relaparotomies during a 48-h period, all fascias closed primarily and incisional tensile strengths, hydroxyproline contents, and adhesions were measured on the following seventh day. Results The median values of tensile strength and hydroxyproline concentrations were lowest in skin-only closure rats. Intraperitoneal adhesion scores were highest in Bogota bag closure group. Conclusion Primary, Bogota bag, and polyprolene mesh closures seem to be safe in terms of early fascial wound healing. Although it is easy to perform, skin-only closure technique has deleterious effects on fascial wound healing probably due to fascial retraction. Interestingly, Bogota bag has caused increased intraperitoneal adhesion formation.     

Orthotopic liver transplantation for biliary atresia: the U.S. experience.

Biliary atresia is the most common indication for orthotopic liver transplantation (OLT) in the pediatric population. The outcomes of liver transplantation for biliary atresia, however, have not been formally examined on a national scale. The objective of this study was to identify pretransplant variables that predict patient survival after primary liver transplantation for biliary atresia. A cohort of 1,976 pediatric patients undergoing primary liver transplantation for biliary atresia between 1/1988 to 12/2003 was enrolled from the United Network for Organ Sharing database after excluding patients with a history of multiorgan transplant or previous liver transplant. Follow-up data up to 16 years post-OLT was available. The 5- and 10-year actuarial survival rates of patients that underwent liver transplantation for biliary atresia in the United States are 87.2% and 85.8%, respectively, and the 5- and 10-year graft actuarial survival rates are 76.2% and 72.7%, respectively. Early deaths (< or =90 days post-OLT) were more often caused by graft failure (P = 0.01), whereas late deaths (>90 days post-OLT) were more often due to malignancy (P < 0.01). An analysis of outcomes over time demonstrated a decrease in post-OLT survival and an increase in the number of OLTs done for biliary atresia at an increasing number of centers. A multivariate analysis revealed that cadaveric partial/reduced liver grafts, a history of life support at the time of OLT, and decreased age were independent predictors of increased post-OLT mortality. In conclusion, OLT is an effective treatment for biliary atresia. Certain pretransplant variables may help predict patient survival following liver transplantation for biliary atresia.     

Auxiliary Partial Orthotopic Versus Standard Orthotopic Whole Liver Transplantation for Acute Liver Failure: A Reappraisal From a Single Center by a Case-Control Study

OBJECTIVE: To reappraise the results of auxiliary partial orthotopic liver transplantation (APOLT) compared with those of standard whole-liver transplantation (OLT) in terms of postoperative death and complications, including neurologic sequelae. SUMMARY BACKGROUND DATA: Compared with OLT, APOLT preserves the possibility for the native liver to recover, and to stop immunosuppression. METHODS: In a consecutive series of 49 patients transplanted for fulminant or subfulminant hepatitis, 37 received OLT and 12 received APOLT. APOLT was done when logistics allowed simultaneous performance of graft preparation and the native liver partial hepatectomy to revascularize the graft as soon as possible. Each patient undergoing APOLT (12 patients) was matched to two patients undergoing OLT (24 patients) according to age, grade of coma, etiology, and fulminant or subfulminant type of hepatitis. All grafts in the study population were retrieved from optimal donors. RESULTS: Before surgery, both groups were comparable in all aspects. In-hospital death occurred in 4 of 12 patients undergoing APOLT compared with 6 of 24 patients undergoing OLT. Patients receiving APOLT had 1 +/- 1.3 technical complications compared with 0.3 +/- 0.5 for OLT patients. Bacteriemia was significantly more frequent after APOLT than after OLT. The need for retransplantation was significantly higher in the APOLT patients (3/12 vs. 0/24). Brain death from brain edema or neurologic sequelae was significantly more frequent after APOLT (4/12 vs. 2/24). One-year patient survival was comparable in both groups (66% vs. 66%), and there was a trend toward lower 1-year retransplantation-free survival rates in the APOLT group (39% vs. 66%). Only 2 of 12 (17%) patients had full success with APOLT (i.e., patient survival, liver regeneration, withdrawal of immunosuppression, and graft removal). One of these two patients had neurologic sequelae. CONCLUSIONS: Using optimal grafts, APOLT and OLT have similar patient survival rates. However, the complication rate is higher with APOLT. On an intent-to-treat basis, the efficacy of the APOLT procedure is low. This analysis suggests that the indications for an APOLT procedure should be reconsidered in the light of the risks of technical complications and neurologic sequelae.     

真空敷料装置在暂时性关腹中的应用

目的 探讨一种新的暂时性关腹方法一真空敷料装置的临床应用。方法 用聚丙烯薄膜、手术巾、塑料黏贴膜和引流管等构建真空敷料装置。记录使用此装置患者的各种临床资料和并发症。结果 有13例患者共使用真空包扎15次进行暂时性关腹，其中5次（33．3％）是因为腹内压增高无法获得无张力的筋膜对合，4次（26．7％）是为了再次手术探查，2次（13．3％）是因为损伤控制，4次（26．7％）是上述多个因素的联合。7例（53．8％）患者最终完成腹壁全层对合关闭，5例（38．5％）患者无法直接对合腹壁缺损，最后行创面断层皮片植皮；3例（23．1％）患者出现腹腔内脓肿，无1例出现消化道瘘，无内脏脱出。1例（7．7％）在试图关腹之前死亡，与真空包扎无关。结论 真空包扎可使患者获得直接腹壁肌肉筋膜层关闭，并发症发生率低、易于掌握，是一种较好的暂时性关腹方法。     

Liver transplantation with reduced-size donor organs

Orthotopic liver transplantation (OLT) of the pediatric patient is often limited by the availability of a size-matched donor organ. Use of reduced liver transplantation (RLT) can increase the proportion of candidates transplanted and may reduce overall mortality. We report herein the initial clinical application of RLT in the United States. Indications for RLT included fulminant hepatic failure (n = 2), acute hepatic artery thrombosis (n = 3), and chronic liver disease unresponsive to inpatient support and more than 30 days on transplant list (n = 4). Donor hepatectomy was performed using standard techniques. Formal hepatic resection was performed ex-vivo to create a size-matched graft, from the larger donor organ, which was implanted in the orthotopic position. Between 11/84 and 4/87, 70 pediatric patients were evaluated for OLT, and 33 of these were transplanted. During this period only 5 patients (7%) died awaiting OLT. Of 33 patients treated at the University of Chicago, 5 received RLT. Donor: recipient weight ratios ranged from 2:1 to 8.1:1. For RLT median operative blood loss was 1.7 blood volumes (range 0.5-11.7) with an operative time of 9.3 + 3.5 hr. Acceptable early graft function was observed in five patients, all of whom were discharged from the hospital. Four of these five patients are alive between 2 and 48 months after transplantation. Marginal graft function with cholestasis and coagulopathy was associated with acute intracranial hemorrhage and neurologic death in one case. One patient died intraoperatively with non-function caused by the use of a liver from a donor with steatosis and a poor size match. Another patient died on day 5 with primary nonfunction and persistent hemorrhage. Systemic cytomegalovirus infection was the cause of death in the other two cases. RLT can provide life-sustaining liver function in urgent clinical settings. The graft can serve as a temporary or permanent liver replacement. With evolution of the technique RLT could eventually be offered to more elective candidates and increase the utilization of available donors by reducing size limitations in OLT.