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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. [ABSTRACT FROM AUTHOR]

Abdominal wall closure after pediatric liver transplantation (pLT) in infants may be hampered by graft‐to‐recipient size discrepancy. Herein, we describe the use of a porcine dermal collagen acellular graft (PDCG) as a biological mesh (BM) for abdominal wall closure in pLT recipients. Patients <2 years of age, who underwent pLT from 2011 to 2014, were analyzed, divided into definite abdominal wall closure with and without implantation of a BM. Primary end‐point was the occurrence of postoperative abdominal wall infection. Secondary end‐points included 1‐ and 5‐year patient and graft survival and the development of abdominal wall hernia. In five out of 21 pLT recipients (23.8%), direct abdominal wall closure was achieved, whereas 16 recipients (76.2%) received a BM. BM removal was necessary in one patient (6.3%) due to abdominal wall infection, whereas no abdominal wall infection occurred in the no‐BM group. No significant differences between the two groups were observed for 1‐ and 5‐year patient and graft survival. Two late abdominal wall hernias were observed in the BM group vs none in the no‐BM group. Definite abdominal wall closure with a BM after pLT is feasible and safe when direct closure cannot be achieved with comparable postoperative patient and graft survival rates. [ABSTRACT FROM AUTHOR]

Abdominal closure in children less than 10 kg following liver or kidney transplantation can be challenging. Excessive pressure attained from a tight closure can result in abdominal compartment syndrome, graft compromise and loss. Concerns over using prosthetic patches are that of infection and dehiscence. We report a series of definitive abdominal wall closure using a biodegradable membrane from porcine intestinal submucosa (Surgisis®; Cook Biotech Incorporated, West Lafayette, IN, USA). A prospective collection and follow up of liver and kidney transplant patients weighing less than 10 kg who required abdominal wall augmentation with Surgisis® in order to achieve satisfactory closure. There were 10 liver and two renal transplant patients. The average weight of the liver transplant patients was 6.6 kg (5.4–8.5 kg) and the renal 9.8 kg. The average area of Surgisis® used was 71.2 cm2 (25–160 cm2) and length of follow up was 15.3 months (1–27 months). Concomitant measures to aid abdominal closure included bilateral recipient nephrectomy for the renal patients and reduction by 33% of the lateral segmental grafts in two liver transplant patients. Delayed closure occurred in all patients except one and the average days to closure from the first surgery was 3.75 days (0–6 days). Following liver transplantation one patient died from multiple organ failure at one month secondary to hemophagocytosis from underlying combined immune deficiency syndrome and one patient with hepatic artery thrombosis was salvaged at re-exploration. There were two wound complications, one patient developed two small sinuses and some skin dehiscence which healed over four months and the second developed a skin sinus following trans-patch liver biopsy which healed in three wk. Both had positive microbial cultures but neither necessitated removal of the graft. There were no incisional hernias. Surgisis® is a safe method for facilitating abdominal closure in pediatric transplant patients. It appears to have long-term durability with no incisional hernias on short- and medium-term follow up, and is fairly resistant to infection. [ABSTRACT FROM AUTHOR]

Children may have kidneys transplanted from donors larger than themselves. Abdominal wall closure may be difficult, with risks of abdominal compartment syndrome and graft compromise. Meshes used to facilitate closure may cause dense intra-abdominal adhesions, making further surgery or peritoneal dialysis difficult. We present five cases in which abdominal wall closure was facilitated by porcine dermal collagen implant. Five children (2–15 yr) received transplanted kidneys from adult donors of significantly greater weight. In four recipients, the kidney was transplanted onto the aorta and vena cava intra-abdominally using a midline incision. In the fifth, the kidney was anastomosed onto the iliac vessels. The skin overlying the implant was closed normally. Maximum follow-up was three yr. In all cases, primary closure was achieved. One child received a second intra-abdominal transplant as an emergency, which later failed. The other kidneys are functioning well. One recipient developed a small incisional hernia three yr post-transplant. Another developed a skin dehiscence over the implant 23 days post-operatively. The implant was removed and skin closed. The other two recipients recovered well. Porcine dermal collagen implant is a helpful adjunct to abdominal wall closure following organ transplantation in children with donor size discrepancy. [ABSTRACT FROM AUTHOR]

Lafosse A, de Magnee C, Brunati A, Bayet B, Vanwijck R, Manzanares J, Reding R. Combination of tissue expansion and porcine mesh for secondary abdominal wall closure after pediatric liver transplantation. Abstract: We report the case of a two and a half yr boy hospitalized in our Pediatric Transplantation Unit for portal vein thrombosis following liver transplantation. After performing a meso-Rex shunt, abdominal wall closure was impossible without compressing the portal flow. A combination of two techniques was used to perform the reconstruction of the muscular fasciae and skin layers. The association of tissue expanders and porcine mesh (Surgisis®) allowed complete abdominal wall closure with good functional and esthetic results. Use of both techniques is a useful alternative for difficult abdominal closure after liver pediatric transplantation. [ABSTRACT FROM AUTHOR]