- Email: [email protected]
Management of complicated gastroschisis with porcine small intestinal submucosa and negative pressure wound therapy
Journal of Pediatric Surgery (2006) 41, 1836 – 1840
www.elsevier.com/locate/jpedsurg
Management of complicated gastroschisis with porcine small intestinal submucosa and negative pressure wound therapy Allen Gabriela, Gerald Gollinb,* a
Division of Plastic and Reconstructive Surgery, Loma Linda University School of Medicine Loma Linda, CA 92354, USA Division of Pediatric Surgery, Loma Linda University School of Medicine Loma Linda, CA 92354, USA
b
Index words: Gastroschisis; Abdominal wall defects; SIS; VAC therapy; Subatmospheric pressure therapy
Abstract Introduction: In almost all cases of gastroschisis, fascial closure may be achieved primarily or after silo reduction. Rarely, fascial and skin closure are impossible. We report our experience with visceral coverage in complicated cases of gastroschisis with porcine small intestinal submucosa (SIS) augmented by negative pressure wound therapy (NPWT). Methods: Over a 3-year period, 55 infants with gastroschisis were managed. In 3 of these cases, fascia and skin could not be approximated safely after complete reduction of abdominal viscera with a spring-loaded silo. Visceral coverage in each case was achieved with 0.42-mm-thickness Surgisis ES (Cook Surgical, Bloomington, Ind) that was sewn to the fascial edges. Negative pressure wound therapy was then initiated at 75 mm Hg over the exposed SIS using vacuum-assisted closure. Results: In each case, granulation tissue developed quickly and was followed by complete epithelialization. Two patients subsequently developed umbilical hernias. Conclusion: We have successfully used SIS augmented by NPWT in the management of 3 infants with complicated gastroschisis. In the rare situation in which fascial closure cannot be achieved, the combination of SIS and NPWT can provide a safe and effective means of abdominal wall closure. D 2006 Elsevier Inc. All rights reserved.
In infants with gastroschisis, fascial closure is usually achieved either primarily or after silo reduction [1,2]. In rare cases, fascial and skin closure are impossible. If fascial closure of a gastroschisis defect cannot be achieved after a silo has been in place for 7 to 10 days, and
Presented in part at the 38th Annual Meeting of the Pacific Association of Pediatric Surgeons, Vancouver, British Columbia, Canada, May, 2005. * Corresponding author. Tel.: +1 909 558 4619; fax: +1 909 558 7978. E-mail address: [email protected] (G. Gollin). 0022-3468/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2006.06.050
visceral contents are reduced to the level of the abdominal wall, several strategies are available [1-5]. A prosthetic graft may be used to cover exposed bowel but is unlikely to result in definitive closure unless skin coverage can be obtained. Alternatively, a biologic dressing can be used to cover the abdominal wall defect to achieve a temporary or permanent closure. We present a novel approach to the management of complicated abdominal wall defects using porcine small intestinal submucosa (SIS) augmented by negative pressure wound therapy (NPWT) using vacuumassisted closure (VAC).
Management of complicated gastroschisis
1837
1. Patients and methods Between January 2002 and January 2005, 55 infants with gastroschisis were managed at the Loma Linda University Children’s Hospital. In 24 of these cases, the abdominal wall defect was closed primarily. Staged reduction with a springloaded silo and planned subsequent fascial and skin closure were undertaken in the remaining 31 patients in whom primary closure could not be achieved without adverse physiologic effects. In 3 cases, fascia and skin could not be approximated after complete reduction of abdominal viscera. The fascial defects in these cases were between 5 and 10 cm in maximal diameter. Visceral coverage was achieved in each case with 0.42-mm-thickness (4-ply) Surgisis ES (Cook Surgical, Bloomington, Ind). The SIS was cut to extend 10 mm beyond the fascial edge and secured to the peritoneal surface of the abdominal wall with interrupted, 3-0 Vicryl, horizonal mattress sutures placed 10 mm apart. Negative pressure wound therapy was initiated over the exposed SIS at 75 mm Hg using the VAC system (Kinetic Concepts, San Antonio, Tex). Parents were informed that the use of SIS and NPWT in complicated gastroschisis was a novel application of welldescribed techniques. The institutional review board at the Loma Linda University Children’s Hospital and Medical Center did not mandate prospective review of the use of this procedure.
2. Results 2.1. Case 1 A 36-week-gestation male infant had strangulated bowel at birth owing to a very narrow gastroschisis defect. After the fascia was incised to permit reduction of the bowel, a 7.5-cm spring-loaded silo (Benetec Medical, Woodland, Calif) was placed. Fifteen days later, after reduction of viscera, skin and
Fig. 1 Abdominal wall defect measuring 8.0 10.5 cm in case 1, covered with SIS intraoperatively.
Fig. 2 Wound in case 1 covered with a sheet of nonadherent dressing (Xeroform).
fascia could not be approximated because of a noncompliant abdominal wall. The defect measuring 8.0 10.5 cm (Fig. 1) was covered with SIS, and a sheet of Xeroform (Johnson and Johnson Medical, New Brunswick, NJ) (Fig. 2). A VAC GranuFoam (Kinetic Concepts, San Antonio, TX) dressing was placed over the defect. Negative pressure wound therapy was initiated at 75 mm Hg (Fig. 3). The dressing was changed every 2 to 3 days for 54 days. At that point, the wound was completely epithelialized (Fig. 4). Because of a stricture owing to the perinatal compression of intestine at the fascial defect, the patient underwent cecal resection. The bneofasciaQ (Fig. 5) was resected and found to have increased activity of fibroblasts and continuous inflammation, consistent with a wound in the remodeling phase (Fig. 6). The fascia and skin were closed. The total hospital stay was 270 days.
2.2. Case 2 A 35-week-gestation infant with gastroschisis had a 5-cm spring-loaded silo placed at birth. Nine days after
Fig. 3 Wound in case 1 covered with VAC GranuFoam after initiation of NPWT at 75 mm Hg.
1838
A. Gabriel, G. Gollin
Fig. 4 Wound in case 1 at postoperative day 54 with nearcomplete epithelialization.
visceral reduction, skin and fascia could not be approximated because of a noncompliant abdominal wall. The defect measuring 5.0 6.5 cm was covered with SIS, and NPWT was initiated at 75 mm Hg. The dressing was changed every 2 to 3 days for 28 days until there was nearly complete epithelialization. The total hospital stay was 66 days. Six months later, the patient was noted to have a small umbilical hernia that has subsequently closed (Fig. 7).
2.3. Case 3 An infant born at 38 weeks of gestation with gastroschisis had a 5-cm spring-loaded silo placed. Thirteen days after silo reduction, there was a defect measuring 4.0 5.5 cm, and the skin and fascia could not be approximated, despite a relatively small defect, because of abdominal distension and a noncompliant abdominal wall. Small intestinal submucosa was placed, and NPWT was initiated at 75 mm Hg and continued for 58 days. The total hospital
Fig. 5
The excised neofascia in case 1.
Fig. 6 Photomicrograph of the neofascia in case 1 that demonstrates increased activity of fibroblasts and continuous inflammation.
stay was 90 days. At subsequent outpatient follow-up, the patient was found to have a small, reducible umbilical hernia that was being managed conservatively.
3. Discussion It is unusual when the fascial defect in gastroschisis cannot be closed either primarily or after silo reduction of viscera. Over a 3-year period, fascial closure was not possible in only 5.4% of our patients in whom there was a prolonged period of silo reduction and resultant loss of abdominal wall compliance. This clinical series represents the first report of the management of such complicated cases of gastroschisis with SIS and NPWT. The ideal material for the repair of abdominal fascial defects should be strong, be biocompatible, and support
Fig. 7 The fully epithelialized wound in case 2, 6 months after SIS placement.
Management of complicated gastroschisis growth of new tissue. Nonabsorbable patches such as knitted polypropylene (Marlex [BardCorp, Murray Hill, NJ] or Prolene [Ethicon, Piscataway, NJ]), polytetrafluoroethylene (PTFE; Gore-Tex [WL Gore and Associates, Flagstaff, AZ]), polyester (Dacron [Textile Development Associates, Frankin Square, NY]), and polyglycolic acid (Dexon [US Surgical Corp, Norwalk, CT]) can increase the risk of infection and offer little support for granulation tissue if skin coverage cannot be achieved [6]. Polyglactin 910 (Vicryl) mesh may be more biocompatible than nonabsorbable materials but is relatively porous and does not support permanent tissue ingrowth. Small intestinal submucosa is a naturally occurring, acellular, resorbable biomaterial derived from the extracellular matrix of porcine SIS [7,8]. It provides a scaffold for host cells to reconstruct related tissues.[6] Animal studies have confirmed the high tensile strength of SIS in abdominal wall defects and also the safety and efficacy of SIS in repair of esophageal defects [8,9]. In addition, SIS grafts in animals have been shown to have a lower incidence of infection than PTFE [10]. Small intestinal submucosa can be used as either an inlay or an onlay graft to repair abdominal wall fascial defects in contaminated or infected fields [6,11-13]. All reports of fascial reconstruction with SIS have included only cases in which there was adequate skin for coverage [6,11]. Our patients lacked adequate skin for closure after fascial reconstruction with SIS; therefore, NPWT was used, which has been accepted since 1995 as an adjunct to the management of complex wounds in adults. Negative pressure promotes the reduction of edema and the development of granulation tissue, thereby facilitating wound healing [14-16]. Negative pressure wound therapy has been used as an adjunct to the repair of full-thickness abdominal wall defects in animals without graft rejection, fistula formation, erosion into abdominal viscera, infection, or hernia recurrence [14-22]. Numerous case reports in the plastic, general surgical, thoracic, and orthopedic literature have described the applications of NPWT in adults [14-22]. A large series reported successful management of various tissue defects with NPWT in children [23]. Arca et al [24] showed that it was also safe in premature infants weighing less than 1500 g. Mooney et al [25] reported that NPWT in children lessened the need for complex microvascular operations in extremity wounds. Although NPWT in adults is usually initiated at 125 mm Hg and sometimes increased during the course of therapy, we maintained the VAC pressure at 75 mm Hg. Because there is no precedent for the appropriate negative pressure to be applied to the neonatal abdomen, we chose to use the lowest pressure possible, although higher pressures might be equally safe and potentially more effective. In our cases, SIS and NPWT were simple to use, elicited a favorable biologic response, and provided good mechanical strength. Histologic studies of the tissue excised during reoperation from 1 patient showed rapid host tissue ingrowth
1839 and an absence of an acute or delayed hypersensitivity response. Because of tissue ingrowth, SIS is theoretically resistant to the infectious complications seen with other prostheses [6,12,26]. However, SIS did not provide a complete and permanent fascial closure in all of our cases because 2 of our 3 patients developed ventral hernias. These hernias were, however, much smaller than the original defects; one has closed and the other has continued to decrease in size and will be easily repaired, if necessary. Surgisis Gold, an 8-ply version of the 4-ply SIS used in our cases might reduce the risk of hernia formation. The dermal collagen matrices Permacol (Tissue Science Laboratories, Covington, GA) [27] and Alloderm (LifeCell, Branchburg, NJ) [28] have been successfully used in the repair of ventral hernias and might also be effective in the setting of nonclosable gastroschisis in conjunction with NPWT. We have successfully used SIS augmented by NPWT in the management of 3 infants with complicated gastroschisis. In the rare situation in which fascial closure of gastroschisis or even ruptured omphalocele cannot be achieved, the combination of SIS and NPWT can provide a safe and effective means of visceral coverage and, in some cases, definitive abdominal wall closure.
References [1] Wu Y, Vogel AM, Sailhamer EA, et al. Primary insertion of a silastic spring-loaded silo for gastroschisis. Am Surg 2003;69:1083 - 6. [2] Schlatter M. Preformed silos in the management of gastroschisis: new progress with an old idea. Curr Opin Pediatr 2003;15:239 - 42. [3] Kidd Jr JN, Jackson RJ, Smith SD, et al. Evolution of staged versus primary closure of gastroschisis. Ann Surg 2003;237:759 - 64. [4] Schlatter M, Norris K, Uitvlugt N, et al. Improved outcomes in the treatment of gastroschisis using a preformed silo and delayed repair approach. J Pediatr Surg 2003;38:459 - 64. [5] Sydorak RM, Nijagal A, Sbragia L, et al. Gastroschisis: small hole, big cost. J Pediatr Surg 2002;37:1669 - 72. [6] Pu LL. Small intestinal submucosa (Surgisis) as a bioactive prosthetic material for repair of abdominal wall fascial defect. Plast Reconstr Surg 2005;115:2127 - 31. [7] Luo JC, Yang ZM. Preparation and characteristics of small intestinal submucosa. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2003; 17:425 - 8. [8] Zhang F, Zhang J, Lin S, et al. Small intestinal submucosa in abdominal wall repair after TRAM flap harvesting in a rat model. Plast Reconstr Surg 2003;112:565 - 70. [9] Badylak S, Meurling S, Chen M, et al. Resorbable bioscaffold for esophageal repair in a dog model. J Pediatr Surg 2000;35: 1097 - 103. [10] Badylak SF, Coffey AC, Lantz GC, et al. Comparison of the resistance to infection of intestinal submucosa arterial autografts versus polytetrafluoroethylene arterial prostheses in a dog model. J Vasc Surg 1994;19:465 - 72. [11] Admire AA, Greenfeld JI, Cosentino CM, et al. Repair of cloacal exstrophy, omphalocele, and gastroschisis using porcine smallintestinal submucosa or cadaveric skin homograft. Plast Reconstr Surg 2003;112:1059 - 62. [12] Badylak SF, Record R, Lindberg K, et al. Small intestinal submucosa: a substrate for in vitro cell growth. J Biomater Sci Polym Ed 1998; 9:863 - 78.
1840 [13] Badylak S, Liang A, Record R, et al. Endothelial cell adherence to small intestinal submucosa: an acellular bioscaffold. Biomaterials 1999;20:2257 - 63. [14] Morykwas MJ, Argenta LC. Nonsurgical modalities to enhance healing and care of soft tissue wounds. J South Orthop Assoc 1997; 6:279 - 88. [15] Morykwas MJ, Argenta LC, Shelton-Brown EI, et al. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation. Ann Plast Surg 1997;38:553 - 62. [16] Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg 1997;38:563 - 77. [17] DeFranzo AJ, Argenta LC, Marks MW, et al. The use of vacuumassisted closure therapy for the treatment of lower-extremity wounds with exposed bone. Plast Reconstr Surg 2001;108:1184 - 91. [18] DeFranzo AJ, Marks MW, Argenta LC, et al. Vacuum-assisted closure for the treatment of degloving injuries. Plast Reconstr Surg 1999; 104:2145 - 8. [19] Argenta PA, Rahaman J, Gretz III HF, et al. Vacuum-assisted closure in the treatment of complex gynecologic wound failures. Obstet Gynecol 2002;99:497 - 501. [20] Morykwas MJ, Faler BJ, Pearce DJ, et al. Effects of varying levels of subatmospheric pressure on the rate of granulation tissue formation in experimental wounds in swine. Ann Plast Surg 2001;47:547 - 51.
A. Gabriel, G. Gollin [21] Morykwas MJ, David LR, Schneider AM, et al. Use of subatmospheric pressure to prevent progression of partial-thickness burns in a swine model. J Burn Care Rehabil 1999;20:15 - 21. [22] Morykwas MJ, Kennedy A, Argenta JP, et al. Use of subatmospheric pressure to prevent doxorubicin extravasation ulcers in a swine model. J Surg Oncol 1999;72:14 - 7. [23] Caniano DA, Ruth B, Teich S. Wound management with vacuumassisted closure: experience in 51 pediatric patients. J Pediatr Surg 2005;40:128 - 32. [24] Arca MJ, Somers KK, Derks TE, et al. Use of vacuum-assisted closure system in the management of complex wounds in the neonate. Pediatr Surg Int 2005;21:532 - 5. [25] Mooney III JF, Argenta LC, Marks MW, et al. Treatment of soft tissue defects in pediatric patients using the V.A.C. system. Clin Orthop Relat Res 2000;26 - 31. [26] Badylak SF, Kropp B, McPherson T, et al. Small intestinal submucosa: a rapidly resorbed bioscaffold for augmentation cystoplasty in a dog model. Tissue Eng 2000;4:379 - 87. [27] Liyanage SH, Purohit GS, Frye JN, et al. Anterior abdominal wall reconstruction with a Permacol implant. Br J Plast Surg 2005 [Electronic publication ahead of print]. [28] Butler CE, Langstein HN, Dronowitz SJ. Pelvic, abdominal, and chest wall reconstruction with AlloDerm in patients at increased risk for mesh-related complications. Plast Reconstr Surg 2005;116:1263 - 75.
www.elsevier.com/locate/jpedsurg
Management of complicated gastroschisis with porcine small intestinal submucosa and negative pressure wound therapy Allen Gabriela, Gerald Gollinb,* a
Division of Plastic and Reconstructive Surgery, Loma Linda University School of Medicine Loma Linda, CA 92354, USA Division of Pediatric Surgery, Loma Linda University School of Medicine Loma Linda, CA 92354, USA
b
Index words: Gastroschisis; Abdominal wall defects; SIS; VAC therapy; Subatmospheric pressure therapy
Abstract Introduction: In almost all cases of gastroschisis, fascial closure may be achieved primarily or after silo reduction. Rarely, fascial and skin closure are impossible. We report our experience with visceral coverage in complicated cases of gastroschisis with porcine small intestinal submucosa (SIS) augmented by negative pressure wound therapy (NPWT). Methods: Over a 3-year period, 55 infants with gastroschisis were managed. In 3 of these cases, fascia and skin could not be approximated safely after complete reduction of abdominal viscera with a spring-loaded silo. Visceral coverage in each case was achieved with 0.42-mm-thickness Surgisis ES (Cook Surgical, Bloomington, Ind) that was sewn to the fascial edges. Negative pressure wound therapy was then initiated at 75 mm Hg over the exposed SIS using vacuum-assisted closure. Results: In each case, granulation tissue developed quickly and was followed by complete epithelialization. Two patients subsequently developed umbilical hernias. Conclusion: We have successfully used SIS augmented by NPWT in the management of 3 infants with complicated gastroschisis. In the rare situation in which fascial closure cannot be achieved, the combination of SIS and NPWT can provide a safe and effective means of abdominal wall closure. D 2006 Elsevier Inc. All rights reserved.
In infants with gastroschisis, fascial closure is usually achieved either primarily or after silo reduction [1,2]. In rare cases, fascial and skin closure are impossible. If fascial closure of a gastroschisis defect cannot be achieved after a silo has been in place for 7 to 10 days, and
Presented in part at the 38th Annual Meeting of the Pacific Association of Pediatric Surgeons, Vancouver, British Columbia, Canada, May, 2005. * Corresponding author. Tel.: +1 909 558 4619; fax: +1 909 558 7978. E-mail address: [email protected] (G. Gollin). 0022-3468/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2006.06.050
visceral contents are reduced to the level of the abdominal wall, several strategies are available [1-5]. A prosthetic graft may be used to cover exposed bowel but is unlikely to result in definitive closure unless skin coverage can be obtained. Alternatively, a biologic dressing can be used to cover the abdominal wall defect to achieve a temporary or permanent closure. We present a novel approach to the management of complicated abdominal wall defects using porcine small intestinal submucosa (SIS) augmented by negative pressure wound therapy (NPWT) using vacuumassisted closure (VAC).
Management of complicated gastroschisis
1837
1. Patients and methods Between January 2002 and January 2005, 55 infants with gastroschisis were managed at the Loma Linda University Children’s Hospital. In 24 of these cases, the abdominal wall defect was closed primarily. Staged reduction with a springloaded silo and planned subsequent fascial and skin closure were undertaken in the remaining 31 patients in whom primary closure could not be achieved without adverse physiologic effects. In 3 cases, fascia and skin could not be approximated after complete reduction of abdominal viscera. The fascial defects in these cases were between 5 and 10 cm in maximal diameter. Visceral coverage was achieved in each case with 0.42-mm-thickness (4-ply) Surgisis ES (Cook Surgical, Bloomington, Ind). The SIS was cut to extend 10 mm beyond the fascial edge and secured to the peritoneal surface of the abdominal wall with interrupted, 3-0 Vicryl, horizonal mattress sutures placed 10 mm apart. Negative pressure wound therapy was initiated over the exposed SIS at 75 mm Hg using the VAC system (Kinetic Concepts, San Antonio, Tex). Parents were informed that the use of SIS and NPWT in complicated gastroschisis was a novel application of welldescribed techniques. The institutional review board at the Loma Linda University Children’s Hospital and Medical Center did not mandate prospective review of the use of this procedure.
2. Results 2.1. Case 1 A 36-week-gestation male infant had strangulated bowel at birth owing to a very narrow gastroschisis defect. After the fascia was incised to permit reduction of the bowel, a 7.5-cm spring-loaded silo (Benetec Medical, Woodland, Calif) was placed. Fifteen days later, after reduction of viscera, skin and
Fig. 1 Abdominal wall defect measuring 8.0 10.5 cm in case 1, covered with SIS intraoperatively.
Fig. 2 Wound in case 1 covered with a sheet of nonadherent dressing (Xeroform).
fascia could not be approximated because of a noncompliant abdominal wall. The defect measuring 8.0 10.5 cm (Fig. 1) was covered with SIS, and a sheet of Xeroform (Johnson and Johnson Medical, New Brunswick, NJ) (Fig. 2). A VAC GranuFoam (Kinetic Concepts, San Antonio, TX) dressing was placed over the defect. Negative pressure wound therapy was initiated at 75 mm Hg (Fig. 3). The dressing was changed every 2 to 3 days for 54 days. At that point, the wound was completely epithelialized (Fig. 4). Because of a stricture owing to the perinatal compression of intestine at the fascial defect, the patient underwent cecal resection. The bneofasciaQ (Fig. 5) was resected and found to have increased activity of fibroblasts and continuous inflammation, consistent with a wound in the remodeling phase (Fig. 6). The fascia and skin were closed. The total hospital stay was 270 days.
2.2. Case 2 A 35-week-gestation infant with gastroschisis had a 5-cm spring-loaded silo placed at birth. Nine days after
Fig. 3 Wound in case 1 covered with VAC GranuFoam after initiation of NPWT at 75 mm Hg.
1838
A. Gabriel, G. Gollin
Fig. 4 Wound in case 1 at postoperative day 54 with nearcomplete epithelialization.
visceral reduction, skin and fascia could not be approximated because of a noncompliant abdominal wall. The defect measuring 5.0 6.5 cm was covered with SIS, and NPWT was initiated at 75 mm Hg. The dressing was changed every 2 to 3 days for 28 days until there was nearly complete epithelialization. The total hospital stay was 66 days. Six months later, the patient was noted to have a small umbilical hernia that has subsequently closed (Fig. 7).
2.3. Case 3 An infant born at 38 weeks of gestation with gastroschisis had a 5-cm spring-loaded silo placed. Thirteen days after silo reduction, there was a defect measuring 4.0 5.5 cm, and the skin and fascia could not be approximated, despite a relatively small defect, because of abdominal distension and a noncompliant abdominal wall. Small intestinal submucosa was placed, and NPWT was initiated at 75 mm Hg and continued for 58 days. The total hospital
Fig. 5
The excised neofascia in case 1.
Fig. 6 Photomicrograph of the neofascia in case 1 that demonstrates increased activity of fibroblasts and continuous inflammation.
stay was 90 days. At subsequent outpatient follow-up, the patient was found to have a small, reducible umbilical hernia that was being managed conservatively.
3. Discussion It is unusual when the fascial defect in gastroschisis cannot be closed either primarily or after silo reduction of viscera. Over a 3-year period, fascial closure was not possible in only 5.4% of our patients in whom there was a prolonged period of silo reduction and resultant loss of abdominal wall compliance. This clinical series represents the first report of the management of such complicated cases of gastroschisis with SIS and NPWT. The ideal material for the repair of abdominal fascial defects should be strong, be biocompatible, and support
Fig. 7 The fully epithelialized wound in case 2, 6 months after SIS placement.
Management of complicated gastroschisis growth of new tissue. Nonabsorbable patches such as knitted polypropylene (Marlex [BardCorp, Murray Hill, NJ] or Prolene [Ethicon, Piscataway, NJ]), polytetrafluoroethylene (PTFE; Gore-Tex [WL Gore and Associates, Flagstaff, AZ]), polyester (Dacron [Textile Development Associates, Frankin Square, NY]), and polyglycolic acid (Dexon [US Surgical Corp, Norwalk, CT]) can increase the risk of infection and offer little support for granulation tissue if skin coverage cannot be achieved [6]. Polyglactin 910 (Vicryl) mesh may be more biocompatible than nonabsorbable materials but is relatively porous and does not support permanent tissue ingrowth. Small intestinal submucosa is a naturally occurring, acellular, resorbable biomaterial derived from the extracellular matrix of porcine SIS [7,8]. It provides a scaffold for host cells to reconstruct related tissues.[6] Animal studies have confirmed the high tensile strength of SIS in abdominal wall defects and also the safety and efficacy of SIS in repair of esophageal defects [8,9]. In addition, SIS grafts in animals have been shown to have a lower incidence of infection than PTFE [10]. Small intestinal submucosa can be used as either an inlay or an onlay graft to repair abdominal wall fascial defects in contaminated or infected fields [6,11-13]. All reports of fascial reconstruction with SIS have included only cases in which there was adequate skin for coverage [6,11]. Our patients lacked adequate skin for closure after fascial reconstruction with SIS; therefore, NPWT was used, which has been accepted since 1995 as an adjunct to the management of complex wounds in adults. Negative pressure promotes the reduction of edema and the development of granulation tissue, thereby facilitating wound healing [14-16]. Negative pressure wound therapy has been used as an adjunct to the repair of full-thickness abdominal wall defects in animals without graft rejection, fistula formation, erosion into abdominal viscera, infection, or hernia recurrence [14-22]. Numerous case reports in the plastic, general surgical, thoracic, and orthopedic literature have described the applications of NPWT in adults [14-22]. A large series reported successful management of various tissue defects with NPWT in children [23]. Arca et al [24] showed that it was also safe in premature infants weighing less than 1500 g. Mooney et al [25] reported that NPWT in children lessened the need for complex microvascular operations in extremity wounds. Although NPWT in adults is usually initiated at 125 mm Hg and sometimes increased during the course of therapy, we maintained the VAC pressure at 75 mm Hg. Because there is no precedent for the appropriate negative pressure to be applied to the neonatal abdomen, we chose to use the lowest pressure possible, although higher pressures might be equally safe and potentially more effective. In our cases, SIS and NPWT were simple to use, elicited a favorable biologic response, and provided good mechanical strength. Histologic studies of the tissue excised during reoperation from 1 patient showed rapid host tissue ingrowth
1839 and an absence of an acute or delayed hypersensitivity response. Because of tissue ingrowth, SIS is theoretically resistant to the infectious complications seen with other prostheses [6,12,26]. However, SIS did not provide a complete and permanent fascial closure in all of our cases because 2 of our 3 patients developed ventral hernias. These hernias were, however, much smaller than the original defects; one has closed and the other has continued to decrease in size and will be easily repaired, if necessary. Surgisis Gold, an 8-ply version of the 4-ply SIS used in our cases might reduce the risk of hernia formation. The dermal collagen matrices Permacol (Tissue Science Laboratories, Covington, GA) [27] and Alloderm (LifeCell, Branchburg, NJ) [28] have been successfully used in the repair of ventral hernias and might also be effective in the setting of nonclosable gastroschisis in conjunction with NPWT. We have successfully used SIS augmented by NPWT in the management of 3 infants with complicated gastroschisis. In the rare situation in which fascial closure of gastroschisis or even ruptured omphalocele cannot be achieved, the combination of SIS and NPWT can provide a safe and effective means of visceral coverage and, in some cases, definitive abdominal wall closure.
References [1] Wu Y, Vogel AM, Sailhamer EA, et al. Primary insertion of a silastic spring-loaded silo for gastroschisis. Am Surg 2003;69:1083 - 6. [2] Schlatter M. Preformed silos in the management of gastroschisis: new progress with an old idea. Curr Opin Pediatr 2003;15:239 - 42. [3] Kidd Jr JN, Jackson RJ, Smith SD, et al. Evolution of staged versus primary closure of gastroschisis. Ann Surg 2003;237:759 - 64. [4] Schlatter M, Norris K, Uitvlugt N, et al. Improved outcomes in the treatment of gastroschisis using a preformed silo and delayed repair approach. J Pediatr Surg 2003;38:459 - 64. [5] Sydorak RM, Nijagal A, Sbragia L, et al. Gastroschisis: small hole, big cost. J Pediatr Surg 2002;37:1669 - 72. [6] Pu LL. Small intestinal submucosa (Surgisis) as a bioactive prosthetic material for repair of abdominal wall fascial defect. Plast Reconstr Surg 2005;115:2127 - 31. [7] Luo JC, Yang ZM. Preparation and characteristics of small intestinal submucosa. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2003; 17:425 - 8. [8] Zhang F, Zhang J, Lin S, et al. Small intestinal submucosa in abdominal wall repair after TRAM flap harvesting in a rat model. Plast Reconstr Surg 2003;112:565 - 70. [9] Badylak S, Meurling S, Chen M, et al. Resorbable bioscaffold for esophageal repair in a dog model. J Pediatr Surg 2000;35: 1097 - 103. [10] Badylak SF, Coffey AC, Lantz GC, et al. Comparison of the resistance to infection of intestinal submucosa arterial autografts versus polytetrafluoroethylene arterial prostheses in a dog model. J Vasc Surg 1994;19:465 - 72. [11] Admire AA, Greenfeld JI, Cosentino CM, et al. Repair of cloacal exstrophy, omphalocele, and gastroschisis using porcine smallintestinal submucosa or cadaveric skin homograft. Plast Reconstr Surg 2003;112:1059 - 62. [12] Badylak SF, Record R, Lindberg K, et al. Small intestinal submucosa: a substrate for in vitro cell growth. J Biomater Sci Polym Ed 1998; 9:863 - 78.
1840 [13] Badylak S, Liang A, Record R, et al. Endothelial cell adherence to small intestinal submucosa: an acellular bioscaffold. Biomaterials 1999;20:2257 - 63. [14] Morykwas MJ, Argenta LC. Nonsurgical modalities to enhance healing and care of soft tissue wounds. J South Orthop Assoc 1997; 6:279 - 88. [15] Morykwas MJ, Argenta LC, Shelton-Brown EI, et al. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation. Ann Plast Surg 1997;38:553 - 62. [16] Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg 1997;38:563 - 77. [17] DeFranzo AJ, Argenta LC, Marks MW, et al. The use of vacuumassisted closure therapy for the treatment of lower-extremity wounds with exposed bone. Plast Reconstr Surg 2001;108:1184 - 91. [18] DeFranzo AJ, Marks MW, Argenta LC, et al. Vacuum-assisted closure for the treatment of degloving injuries. Plast Reconstr Surg 1999; 104:2145 - 8. [19] Argenta PA, Rahaman J, Gretz III HF, et al. Vacuum-assisted closure in the treatment of complex gynecologic wound failures. Obstet Gynecol 2002;99:497 - 501. [20] Morykwas MJ, Faler BJ, Pearce DJ, et al. Effects of varying levels of subatmospheric pressure on the rate of granulation tissue formation in experimental wounds in swine. Ann Plast Surg 2001;47:547 - 51.
A. Gabriel, G. Gollin [21] Morykwas MJ, David LR, Schneider AM, et al. Use of subatmospheric pressure to prevent progression of partial-thickness burns in a swine model. J Burn Care Rehabil 1999;20:15 - 21. [22] Morykwas MJ, Kennedy A, Argenta JP, et al. Use of subatmospheric pressure to prevent doxorubicin extravasation ulcers in a swine model. J Surg Oncol 1999;72:14 - 7. [23] Caniano DA, Ruth B, Teich S. Wound management with vacuumassisted closure: experience in 51 pediatric patients. J Pediatr Surg 2005;40:128 - 32. [24] Arca MJ, Somers KK, Derks TE, et al. Use of vacuum-assisted closure system in the management of complex wounds in the neonate. Pediatr Surg Int 2005;21:532 - 5. [25] Mooney III JF, Argenta LC, Marks MW, et al. Treatment of soft tissue defects in pediatric patients using the V.A.C. system. Clin Orthop Relat Res 2000;26 - 31. [26] Badylak SF, Kropp B, McPherson T, et al. Small intestinal submucosa: a rapidly resorbed bioscaffold for augmentation cystoplasty in a dog model. Tissue Eng 2000;4:379 - 87. [27] Liyanage SH, Purohit GS, Frye JN, et al. Anterior abdominal wall reconstruction with a Permacol implant. Br J Plast Surg 2005 [Electronic publication ahead of print]. [28] Butler CE, Langstein HN, Dronowitz SJ. Pelvic, abdominal, and chest wall reconstruction with AlloDerm in patients at increased risk for mesh-related complications. Plast Reconstr Surg 2005;116:1263 - 75.