|Year : 2022 | Volume
| Issue : 6 | Page : 760-763
The role of dermal regeneration template in anterior abdominal wall defect after burst abdomen: A case report in acute graft versus host disease of the gastrointestinal tract in aplastic anemia
Srikanth Vasudevan, Harish Kumar Kabilan, Krithika Jagadish, YN Anantheswar, Ashok Basur Chandrappa, Dinkar Sreekumar, Annika Marwah
Department of Plastic Surgery, Manipal Hospitals, Bengaluru, Karnataka, India
|Date of Submission||25-Jan-2022|
|Date of Decision||08-Jul-2022|
|Date of Acceptance||27-Aug-2022|
|Date of Web Publication||11-Nov-2022|
Harish Kumar Kabilan
Department of Plastic Surgery, Manipal Hospitals, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Acute graft-versus-host disease of the gastrointestinal tract (GI-aGVHD) is a rare condition, often requiring multiple laparotomies, ultimately leading to a burst abdomen. We report the successful use of a dermal regeneration template (DRT), combined with negative pressure wound therapy (NPWT) and skin grafts, to reconstruct the abdominal skin in an 11-year-old boy. The patient was a case of aplastic anemia, who underwent bone marrow transfers, the first of which failed and the second one was successful. He eventually developed gastrointestinal GVHD. Repeated laparotomies were done for recurrent intestinal obstruction. He also underwent resection anastomosis and end ileostomy, after which he developed an anterior abdominal wall defect due to a burst abdomen. After 12 months of management with multiple dressings, NPWT, and DRT, a stable coverage was achieved, without skin retraction. We report our experience in anterior abdominal wall reconstruction in a case of GI-aGVHD using DRT
Keywords: Dermal regeneration template, gastrointestinal graft-versus-host disease, laparotomy wound
|How to cite this article:|
Vasudevan S, Kabilan HK, Jagadish K, Anantheswar Y N, Chandrappa AB, Sreekumar D, Marwah A. The role of dermal regeneration template in anterior abdominal wall defect after burst abdomen: A case report in acute graft versus host disease of the gastrointestinal tract in aplastic anemia. J Indian Assoc Pediatr Surg 2022;27:760-3
|How to cite this URL:|
Vasudevan S, Kabilan HK, Jagadish K, Anantheswar Y N, Chandrappa AB, Sreekumar D, Marwah A. The role of dermal regeneration template in anterior abdominal wall defect after burst abdomen: A case report in acute graft versus host disease of the gastrointestinal tract in aplastic anemia. J Indian Assoc Pediatr Surg [serial online] 2022 [cited 2022 Nov 30];27:760-3. Available from: https://www.jiaps.com/text.asp?2022/27/6/760/360951
| Introduction|| |
Burst abdomen is a continuing problem for the general surgeon, as the incidence may reach 3% in major laparotomy wounds with a mortality rate ranging from 24% to >44%.
Various methods have been used to close the dehiscence, ranging from simply closing the skin over the defect and leaving the fascia and peritoneum wide open, to doing relaxing incisions of both fascia and skin away from the wound, closing the primary wound, and skin grafting the resulting defect. Recently, negative pressure wound therapy (NPWT), with a mesh of some type, has been used, including proline, marlex, polytetrafluoroethylene, and vicryl, or more complex closures using pedicled or rotation flaps are being used. None of these methods proved to be ideal or without a significant hazard, and certain disadvantages inherent in each technique require a departure from the ideal, i.e., primary tension-free parietal closure without the use of prosthetic material.
Since the inception of the dermal regeneration template (DRT), several reports have been published worldwide proving its capacity as a less invasive reconstructive tool.
No standardized recommendations exist for the reconstruction of these defects. We report our experience with DRT for reconstruction in a case of a burst abdomen.
The technical details of debridement, DRT placement, and finally skin grafting in the management of this complex case are described.
| Case Report|| |
Our patient was an 11-year-old male presenting with acquired aplastic anemia. He underwent allogeneic bone marrow transplantation which was rejected after 6 months. After the second allotransplantation, he developed small bowel obstruction with moderate ascites about 2 months later.
He developed perforative peritonitis with necrotic terminal ileum requiring an emergency laparotomy with resection of the perforated necrotic terminal ileum and end ileostomy with a mucous fistula.
A few days later, he developed intestinal obstruction again after which he was diagnosed with Steroid refractory gut graft-versus-host disease (GVHD).
Fourteen days later, he developed an ileal perforation again and underwent a second laparotomy for a redo resection anastomosis of the ileum (to ascending colon) and resection of perforated necrotic terminal ileum (end ileostomy with mucous fistula creation).
On the whole, he underwent laparotomy thrice over 60 days, ultimately leading to a burst abdomen.
The plastic surgery team was called on to manage the burst abdomen [Figure 1]a.
|Figure 1: (a) Burst abdomen with end ileostomy stoma and mucous fistula. (b) Initial management with negative pressure wound systems and laparotomy bags. (c) Wound after the dressingss|
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At this point, the patient's requirements for blood and blood products were as follows: 11 packed red blood cells (PRBC), nine random donor platelets, two fresh frozen plasma, 27 single donor platelets, and six cryoprecipitates making a total of 270. During this time 2 months, we initially applied a Bogota bag [Figure 1]b and then carried out a total of 10 dressings under sedation and short general anesthesia [Figure 1]c.
He underwent DRT placement and negative pressure dressings after 2 months of conservative wound management.
The DRT was left on the wound with the VAC for 5 days. On postoperative day 6, after the application of DRT, he underwent the first dressing change and three other dressings subsequently.
The DRT silicone sheet was removed after 3 weeks and saline dressings were done.
The total requirement of blood and blood products after DRT application reduced significantly from 270 to 55 (81% reduction in the requirement).
Exactly 4 weeks after the initial DRT placement, he underwent skin grafting and underwent regular dressings every 3–4 days [Figure 2].
|Figure 2: (a) Placement of dermal regeneration template. (b) A meshed split-thickness skin graft was placed on the dermal regeneration 4 weeks later. (c) The final result of the wound with a well-settled skin graft 1 month later|
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After the split skin grafting, his total blood product requirement was further reduced to 14 requiring only five PRBCs and nine cryoprecipitates.
He was discharged from the hospital after a week.
After an uneventful 6 months, he was readmitted for episodes of dehydration, dyselectrolytemia, and acute gastroenteritis during which he was diagnosed with acute kidney injury and passed away.
During that period, no further blood or blood products were used. The wound condition remained stable till the very end.
| Discussion|| |
Allogeneic hematopoietic cell transplantation is a well-established treatment for hematological diseases such as aplastic anemia which are incurable by conventional treatments. The most common life-threatening complication is GVHD
GVHD occurs when immune-competent T-cells in the donated tissue (the graft) recognize the recipient (the host) as foreign (nonself).
The incidence of acute GVHD varies with respect to several clinical variables, with cumulative incidence rates ranging from 40% to 80% of Hematopoietic stem cell transplantation (HSCT) recipients. Gastrointestinal GVHD results from damage to the recipient's gastrointestinal epithelium produced by the donor's lymphocytes.
Risks for the development of GVHD include Human leukocyte antigen (HLA) antigen mismatch, myeloablative conditioning, the use of stem cells derived from blood, and the use of an unrelated donor.
Severe bowel obstruction is a rare complication after allo-HSCT.
Bowel obstruction is the most important indication for surgical treatment, with other indications for surgical intervention also being fistulation, perforation, or bleeding.
The terminal ileum was the predilection site for inflammation and strangulation, which was also the case in our patient.
Surgical intervention for intestinal GVHD is rarely necessary, and only a few cases are reported regarding this treatment approach. There has been no report thus far regarding the use of DRT in a patient with (acute GVHD of the gastrointestinal tract) for an abdominal wall defect.
The first report of DRTs was published by Burke et al. in 1981, and its most widely used commercial form is “Integra” (Integra LifeScience Corporation, New Jersey, USA). It is derived from bovine collagen and shark chondroitin sulfate, covered by a silicon surface layer. This bilayer regeneration matrix has been successfully used in a variety of reconstructive methods for burns, trauma, extremities, and chronic wounds among others.
The wound bed is prepared as one prepares for a skin graft and the DRT is applied. By the end of week 4, the neodermis is fully vascularized. Two–three weeks later, after the dermal analog is incorporated, the silicon layer is removed and replaced by an ultrathin split-thickness skin graft.
A DRT for complex abdominal wall reconstruction has been reported to be used in only two other studies, and no other cases have used DRT directly on the peritoneum, let alone in a GVHD patient.
Large multicenter studies designed to assess the safety of DRT have described complications such as seromas, hematomas, and failure of graft take, with infections being the most common. However, in our study, there were no DRT-related complications.
In many studies, the additional application of NPWT over the DRT is considered instrumental in promoting neodermis formation, decreasing fluid accumulation under the graft, and potentially decreasing the rate of infection. However, in our case, due to the exudative nature of the wound along with the ileostomy stoma, NPWT was an indispensable component of the treatment.
| Conclusion|| |
We were able to finally discharge the patient after successfully covering the anterior abdominal wall without any donor defects. The additional effects of timely closure are also reflected in the weaning of the blood and blood products, although this warrants further study regarding the same.
With this case report, we want to highlight our experience with DRT s as an interesting alternative for abdominal wall soft-tissue reconstruction. We have found that DRT and skin graft were good enough for long-term colostomy bag placement too. Despite the risk of infection that could dampen practitioners' enthusiasm to use it with children, it is a better alternative than thin skin grafts for long-term esthetic and functional results, with a more pliable skin, and less retraction. In addition, combining it with NPWT accelerates the tissue and blood vessel growth within the matrix, limits infectious risks, and exhibits rapid improvement in terms of fever, episodes of sepsis, wound healing, as well as antibiotic requirements.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bucknall TE, Cox PJ, Ellis H. Burst abdomen and incisional hernia: A prospective study of 1129 major laparotomies. Br Med J (Clin Res Ed) 1982;284:931-3.
Madsen G, Fischer L, Wara P. Burst abdomen-Clinical features and factors influencing mortality. Dan Med Bull 1992;39:183-5.
Tremblay LN, Feliciano DV, Schmidt J, Cava RA, Tchorz KM, Ingram WL, et al
. Skin only or silo closure in the critically ill patient with an open abdomen. Am J Surg 2001;182:670-5.
Lévy E, Palmer DL, Frileux P, Hannoun L, Nordlinger B, Tiret E, et al
. Septic necrosis of the midline wound in postoperative peritonitis. Successful management by debridement, myocutaneous advancement, and primary skin closure. Ann Surg 1988;207:470-9.
Forman SJ, Negrin RS, Antin JH, Appelbaum FR. Thomas' Hematopoietic Cell Transplantation: Stem Cell Transplantation. Wiley Publishing company:John Wiley & Sons; 2015.
Yannas IV, Burke JF. Design of an artificial skin. I. Basic design principles. J Biomed Mater Res 1980;14:65-81.
[Figure 1], [Figure 2]