Role of “reduced-size” liver/bowel grafts in the “abdominal wall transplantation” era

Abstract

The evolution of multi-visceral and isolated intestinal transplant techniques over the last 3 decades has highlighted the technical challenges related to the closure of the abdomen at the end of the procedure. Two key factors that contribute to this challenge include: (1) Volume/edema of donor graft; and (2) loss of abdominal domain in the recipient. Not being able to close the abdominal wall leads to a variety of complications and morbidity that range from complex ventral hernias to bowel perforation. At the end of the 90’s this challenge was overcome by graft reduction during the donor operation or bench table procedure (especially reducing liver and small intestine), as well as techniques to increase the volume of abdominal cavity by pre-operative expansion devices. Recent reports from a few groups have demonstrated the ability of transplanting a full-thickness, vascularized abdominal wall from the same donor. Thus, a spectrum of techniques have co-evolved with multi-visceral and intestinal transplantation, ranging from graft reduction to enlarging the volume of the abdominal cavity. None of these techniques are free from complications, however in large-volume centers the combinations of both (graft reduction and abdominal widening, sometimes used in the same patient) could decrease the adverse events related to recipient’s closure, allowing a faster recovery. The quest for a solution to this unique challenge has led to the proposal and implementation of innovative solutions to enlarge the abdominal cavity.

Keywords: Abdominal wall transplant; Reduced-size graft; Combined liver-bowel transplantation

Core tip: Matching donors with recipients to perform liver-bowel transplantation is a challenging task, especially in front of pediatric candidates due to the shortage of suitable donors. Historically, the issue was overcome reducing the size of liver and bowel during donation in order to implant the combined graft in the small abdominal cavity of the recipient. Due to the presence of complications, the procedure has been improved by enlarging the abdominal cavity of the recipients, initially through conventional techniques used in hernia repair or trauma surgery and later by transplanting the donor abdominal wall into the recipient. Results are encouraging but limited to high experienced centers.