Objectives: In conditions such as large-for-size syndrome, postreperfusion hepatic edema, and intestinal edema, primary closure of the abdominal wall can cause respiratory complications and thrombosis of vascular structures. Here, we compared results of primary abdominal closure versus a temporary patch closure technique (the Bogota bag technique) in pediatric liver transplant recipients.
Materials and Methods: We performed primary abdominal closure in 295 recipients. In 39 pediatric liver transplant recipients, the Bogota bag technique was used as the abdominal closure technique because of suspected intraoperative tense abdominal closure. In patients who had the Bogota bag technique, we sutured the sterilized saline bag to the skin at the edge of the defect by shaping the defect so as not to cause abdominal hypertension. Primary abdominal closure was achieved in patients after control laparotomies at 48-hour intervals.
Results: The mean age of the primary abdominal closure group was 8.38 years, whereas the mean age of the Bogota bag group was 2 years. The average weight of patients in the primary abdominal closure group was 26.38 kg, and the average weight of patients in the Bogota bag group was 7.93 kg. Biliary atresia was the most common indication in both groups. Mean length of hospital stay was 21 days in the primary abdominal closure group and 24 days in Bogota bag group. Six patients in the Bogota bag group died from sepsis or bleeding in the early postoperative period. In the Bogota bag group, wound closure was achieved within 2 weeks in 25 patients and within 3 weeks in 8 patients.
Conclusions: Temporary patch closure techniques can be used safely in low-weight and young children, children with large-for-size grafts, and those who display increased intra-abdominal pressure.
Key words : Abdominal pressure, Graft-to-body weight ratio, Temporary patch closure
Liver transplant is the only curative treatment option for pediatric patients with end-stage liver failure who develop fulminant liver failure. Liver transplant surgery is more complicated in pediatric patients than in adults. The complication rate of pediatric transplants has been reported to be approximately 40%.1 One of the most important issues to be considered, especially in pediatric liver transplant recipients, is the graft mass-to-body weight ratio. Previous studies have shown that a graft mass-to-body weight ratio of 0.8% to 2% is ideal. When graft mass-to-body weight ratio is >4%, which is often shown in pediatric transplant recipients of adult graft donors, this is called large-for-size syndrome.2
After liver transplant surgery, the abdominal wall is generally closed. However, there may be complications with primary abdominal closure (PAC), causing hepatic and intestinal edema due to intra-abdominal hypertension, and complications are especially seen in donor graft-to-recipient size mismatches in liver transplants from adult donors to pediatric recipients. Complications related to size mismatches generally include limitation of pulmonary ventilation and respiration, delayed graft function, oliguria, impaired abdominal wall circulation, impaired vascular supply to intraabdominal organs, and abdominal compartment syndrome.3,4
When complications secondary to PAC are suspected before or during the surgical procedure, a temporary abdominal wall closure technique should be applied if graft size cannot be downsized.5 The most common among the temporary closure techniques is the Bogota bag (BB) technique, in which the abdominal wall is closed by suturing sterilized intravenous bags to it.6 Herein, we compared the BB technique with PAC in pediatric liver transplant recipients to evaluate the safety of the BB technique and its postoperative and long-term outcomes.
Materials and Methods
Our team performed its first liver transplant in 1988. Between December 1988 and December 2021, our team has performed 701 liver transplants. Of these, 334 were pediatric and 367 were adult patients. We performed PAC in 295 pediatric liver transplant recipients. In 39 pediatric liver transplant recipients, the BB technique was used as the abdominal closure technique, as patients had suspected intraoperative tense abdominal closure or intra-abdominal hypertension.
When a decision was made to use the BB technique, sterilized intravenous saline bags were shaped according to the size of the abdominal wall defect. The skin region adjacent to the abdominal wall defect was then sutured continuously with 3-0 polypropylene suture in a way not to cause any increase in the intra-abdominal pressure. During the postoperative period, wound dressings were changed once per day and whenever wound discharge occurred. The sterilized saline bag was changed every 48 hours in the operating room. Perfusion of the graft liver and other intra-abdominal organs was checked during each change. Hepatic vascular structures and perfusion were checked with Doppler ultrasonography during each BB change until after complete abdominal closure was achieved. When a relaxed, nonrigid abdominal wall on palpation was achieved by downsizing the defect during each change, complete closure was performed (Figure 1).
We noted the demographic characteristics of patients who underwent PAC and BB procedures, including body weight, graft mass, graft type, liver transplant indications, length of hospital stay, and mortality rate; findings were compared between the groups. We also noted the number of dressing changes, the time to complete closure, and any postoperative complications in patients who underwent the BB technique.
For our analyses, we included 295 patients in the PAC group and 39 patients in the BB group. The youngest liver transplant patient was 4 months old, and the oldest was 17 years old.
The mean age of the PAC group was 8.38 years, whereas the mean age of the BB group was 2 years. The average weight of the PAC group was 26.38 kg, and the average weight of the BB group was 7.93 kg. Biliary atresia was the most common indication in both groups. The most commonly used graft type was the left lateral lobe, which was used in 178 patients in the PAC group and 35 patients in the BB group. A whole graft was used in 16 patients in the PAC group and 3 patients in the BB group. The mean length of hospital stay was 21 days in PAC group and 24 days in BB group. Six patients in the BB group died from sepsis or bleeding in the early postoperative period (Table 1).
In the 39 patients in the BB group, 27 patients had a temporary abdominal closure (BB technique) as the first surgery and 12 patients had PAC as the first surgery and then the BB technique because of vascular complications and bleeding (n = 4 patients) and wound dehiscence and ileus (n = 8 patients) in the early postoperative period. Primary closure was achieved after the sterilized saline bag was changed 9 times in 7 patients, 7 times in 4 patients, 4 times in 4 patients, 2 times in 5 patients, and 1 time in 19 patients in the BB group.
It may not always be possible to find an appropriately sized liver graft in pediatric patients with chronic liver failure. Whole grafts may especially cause intra-abdominal hypertension in the abdominal cavity of the pediatric recipient and associated complications. Because of the limited supply of size-matched organs, the use of these grafts remains necessary through various techniques.7 The BB technique is one of the techniques that can be performed when graft-to-recipient size mismatches occur or repeated laparotomies are needed during liver transplant surgery, especially in pediatric patients.6,8
Although temporary abdominal closure techniques have absolute advantages in situations causing intra-abdominal hypertension, they also have some disadvantages.8 The major advantage of the BB technique is to make liver transplant possible in size-mismatched grafts by preventing abdominal hypertension.9 In addition, the use of sterile saline bags minimizes development of intra-abdominal adhesion. Thanks to its transparency, a saline bag enables the surgeon to check the perfusion of a graft liver and intestinal segments. Its disadvantages include fluid discharge from the incision region, the need for extra dressing and wound care, and the need for general anesthesia at each saline bag change. In our study, there was no significant difference between the study groups in terms of graft and patient survival. Furthermore, the groups did not differ with respect to postoperative complications. However, when the length of hospital stay was compared, the mean hospital stay was longer in the BB group. However, a longer hospital stay did not cause any additional complications in the patients. According to s experiences, the use of the BB technique for patients with a body weight under 7 kg, a large-for size graft, and an anhepatic phase over 100 minutes can minimize postoperative complications.
In conclusion, temporary abdominal closure techniques should be used in pediatric patients in cases in when repeated laparotomies are needed or when intra-abdominal hypertension occurs. Because the use of the BB technique did not affect graft and patient survival, we suggest that it can be safely applied in patients because it enables the use of large-for-size grafts.
Volume : 20
Issue : 5
Pages : 53 - 55
DOI : 10.6002/ect.PediatricSymp2022.O18
From the Baskent University, Department of General Surgery, Division of Transplantation, Ankara, Turkey
Acknowledgements: The authors have not received any funding or grants in support of the presented research or for the preparation of this work and have no declarations of potential conflicts of interest.
Corresponding author: Emre Karakaya, Baskent University, Department of General Surgery, Yukarı Bahçelievler, Mareşal Fevzi Çakmak St. No:45, 06490 Çankaya/Ankara, Turkey
Figure 1. Bogota Bag Technique
Table 1. Demographic and Clinical Information of Patients