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Primary Congenital abdominal Wall Repair Using Human Acellular Dermal Matrix (HADM): a 7 Cases Report
Running title: Abdominal Wall Repair With Acellular Matrix
1. Human acellular dermal matrix (HADM) can repair the primary congenital abdominal wall defect.
2. HADM can effectively increase the abdominal volume, decrease the UBP, decrease the risk of ventral hernia and lower the incidence of reoperation.
3. HADM use is safe in abdominal wall reconstructions.
Objective: The purpose of this study is to report the initial results of primary Congenital abdominal Wall Repair using human acellular dermal matrix in neonate.
Methods: We retrospectively reviewed 7 patients who were underwent an abdominal wall defect repair with human acellular dermal matrix(HADM) patch in our hospital between May 2008 and November 2012. The demographics, complications and the follow-up information of patients were analyzed.
Results: Abdominal wall defect can be repaired with human acellular dermal matrix and all the urinary bladder pressure (UBP) was lower than 30 cmH2O. One patient with heart disease was failed and other 6 patients were survived after surgery. Incision split was observed in 2 patients 14 days after operation. No ventral hernia was seen during the follow up period(6 month-3 years) in all the survival patients.
Conclusions: HADM can repair the primary congenital abdominal wall defect. HADM can effectively increase the abdominal volume, decrease the UBP, decrease the risk of ventral hernia and lower the incidence of reoperation. Human acellular dermis use is safe in abdominal wall reconstructions.
Keywords: human acellular dermal matrix, primary Congenital abdominal Wall defect, complications, neonate.
Gastroschisis is one of the most common congenital abdominal wall defects, which occurs in 1 in 4000 live births. It is caused by underdevelopment of the lateral wall during the early embryonic period. The main clinical feature of gastroschisis is that freely floating loops of bowel within the amniotic fluid with an abdominal wall defect to the right of the insertion of the umbilical cord. Several ways have been described to manage this disease, such as staged silo closure, artificial materials patch repair, sutureless gut reduction and etc[3-4]. Recently, using the human acelllular dermal matrix for gastroschisis has been decribed and the reported outcome is very good.
Here, we retrospectively reviewed 7 patients who were underwent an abdominal wall defect repair with human acellular dermal matrix(HADM) patch in our hospital between May 2008 and November 2012. The outcome of the patients and the efficacy of HADM were evaluated in the following text.
Materials and Methods
The records of all patients who underwent abdominal wall reconstruction using human acellular dermal matrix (Beijing Qingyuanweiye Bio-Tissue Engineering CO.,LTD, China) (Figure 1A) between May 2008 and November 2012 were assessed retrospectively. The protocol was approved by our Hospital Review Board and the written informed consent was provided by patients. For each patient, the following data were collected: age, sex, weight, fascial defect diameter, comorbidities, complications and their treatments, postoperative wound care, and length of hospital stay. All patients were followed up(6 month- 3 years) after surgery and the patients were examined and any complications or findings of hernia recurrence were recorded.
After admission into the hospital, the patients were processed with fasting, gastrointestinal decompression, gastric content extraction, ureteral stent placement, bladder empty and anal dilation for defecation. The exposed organ reduction was fail beside bed. Then the patients were anesthesia by endotracheal intubation and a piezometer tube connected with a pressure transducer was placed transurethral on the patients. The exposed visceral organs and the surrounding skin were cleaned with 0.1% Iodophors and covered with sterilized towel. An incision was made to expose the abdominal wall along the right side of defect wall. The abdominal defect wall and cavity were enlarged to carry out the visceral organs reduction. The belly closure was processed by drawing the up and lower abdominal wall together. The urinary bladder pressure (UBP) was monitored and the biological patch repair was determined if the UBP>30 cm H2O. The skin and the subcutaneous tissue were separated. Then the human acellular dermal matrix patch was sutured with deep fascia and abdominal wall. The incision was covered with the patch and the skin was fully enlarged (a vertical relaxation incision was made on midaxillary line if necessary)to make sure the patch can be covered. The surgical process was showed in Figure 1B.
The data were presented by mean ± SD or median(range).
Preoperative data of the Patients
The patient characteristic before operation was presented in Table 1.There were 5 males and 2 females in these patients. The median Age was 8 h (6-26h) and the weight range was 1.8-2.2 kg. The defect wall diameter was 3.0-4.5 cm. The exposed visceral organ included stomach, small intestine, colon etc. Adhesive ileus can be observed and exposed organs were covered with thick mossy secreta (Figure 2A). One patient had heart disease comorbidity. Other comorbidities such as intestinal atresia or stenosis or Meckel’s diverticulum were not observed.
Postoperative data of the patients
All the 7 patients were process the surgery with human acellular dermal matrix and the UBP<30 cm H2O after the surgery (Figure 2B). One patient was given up the treatment due to the heart disease. The other 6 patients were processed smoothly from anti-infection, mechanical ventilation and parenternal nutrition to oral feeding. The detail data were showed in Table 2. Two patients were presented with exposed patch on the skin incision when removing the sutures 14 days postoperation. The patients were followed up from 6 month to 3 years and no adhesive ileus or ventral hernia was observed.
We presented here is a data review about 7 cases gastroschisis processed with human acellular dermal matrix in our hospital. The results showed that no severe complication was observed in all 6 patients (one patient with congenital heart disease was excluded). Two patients were presented with exposed patch on the skin incision at time of removing the sutures 14 days postoperation. The patients were followed up from 6 month to 3 years and no adhesive ileus or ventral hernia was observed.
As a rare seen disease in neonate, the incidence of gastroschisis has increased over the past few decades. However, the etiology of the disease has been fully determined yet. Mac Bird et al showed that women who used tobacco, alcohol, and ibuprofen during early pregnancy have a moderately increasedriskofgastroschisis. Primary patch repair is idea way to manage the abdominal wall defect and restore the organs. However, 40%-50% of the fetal patients can’t endure the primary patch repair because forceful closure of the abdominal will lead to elevation of diaphragm, airflow limitation and venous return stagnation and severe complication will also come along. Kidd et al compared staged closure method of gastroschisis with primary closure and found that a higher incidence of intestine stenosis, necrotizing enterocolitis and reoperation has madeprimaryclosureof gastroschisis. The incidence of complications in staged and primary closure was 20% and 15%, respectively (p<0.001). Staged silo closure can avoid the over elevation of the abdominal pressure, effectively perfuse the visceral organs with blood supply, decrease the incidence of abdominal compartment syndrome. However, Staged silo closure still has some disadvantages, such as increasing the incidence of sepsis, prolong the duration of parenteral nutrition and mechanical ventilation, and requirement of reoperation.
With the development of tissue engineering, the application of acellular biological tissue patch in clinic has been increased significantly. The key point of abdominal repair surgery is to decrease the abdominal pressure as much as possible. The biological patch has good biocompatibility and it can increase the volume of the abdominal cavity and decrease pressure inside the cavity. Furthermore, the tension strength is suitable for the congenital abdominal wall defect repair. Chin et al suggested the patients who have abdominal pressure<20 cm H2O are suitable for the blood perfusion and have a lower risk of abdominal compartment syndrome. Vegunta et al showed that UBP is an indication of abdominal pressure and UBP≤30 cm H2O is monitoring index of primary closure. The data here indicated that the UBP <30 cm H2O after patch repair. Since the visceral organs are exposed outside, abdominal wall repair is a contaminative operation. The effusion can be found between the patch and skin after the surgery and the placement of the drainage patch for 48 h will avoid the risk of effusion. During the early stage of the operation, the patch was not closely adhered to the skin and the skin incision was unstable. Therefore, the time of suture removing was usually later. Two patients without drainage patch placement showed incision split. Then we used the absorbable suture to do the skin closure and the no incision split was happened again. According to the animal model result, these acellular patch can induce the regeneration of the tissue, degrade with the newly grown tissue, replaced by connective tissue and fulfill the repair of the defect. From our data, no adhesive ileus or ventral hernia was observed during the 6 month – 3 years follow-up. However, this still need to be confirmed by further observation based on longer follow-up data.