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• W2019969371 abstract "We read with great interest the recent article by Jafri et al.1 on temporary silastic mesh closure for adult liver transplantation, but would comment on some of the aspects of the study to help put the authors' large experience in perspective. A total of 51 (25.5%) out of 200 liver transplantations underwent temporary abdominal coverage with silastic sheeting reinforced with vacuum dressing on top. Permanent fascial closure was established in 82% following resolution of the intraabdominal hypertension; component separation and absorbable polyglactin mesh became necessary to reconstruct the abdominal wall in 12% and 6%, respectively, with a 3.9% incidence of ventral hernia in that group.1 Although the work makes a very important contribution to the understanding that temporary abdominal coverage can be performed safely in transplant patients, the following omissions detract somewhat from a full understanding of all aspects of the study. The authors report a median follow-up of 1.3 yr for the silastic group and no statistically significant difference in the hernia incidence compared with the primary closures in the remaining 149 patients. Nearly 50% of recurrences following hernioplasty do not appear until 5 yr after surgery; statistical significance is best determined with a 10-yr follow-up.2 The very short follow-up in the Jafri et al.1 study does not permit sound conclusion as to the superiority of one approach over another. The authors also do not provide details about the closing method (continuous vs. single sutures) or suturing material (absorbable vs. nonabsorbable) used to oppose the fascia. The published randomized clinical trials and meta-analyses suggest that there is very little evidence for superiority of certain types of incisions, suture materials, or closure methods in decreasing the hernia incidence in the general population.3 Recent trials suggest that a fundamental defect in the collagen metabolism plays a most important role in the formation of ventral hernias4, 5; unfortunately, this was not addressed in the work of Jafri et al.1 It will be extremely interesting to know how all these considerations are reflected in the liver transplantation population. We were surprised that the authors used absorbable mesh to augment the closure in some cases. It is known that absorbable materials carry the risk of a significantly higher reherniation rate.6 Using nonabsorbable prosthetic materials in liver transplants has been shown to be safe and very effective7, 8 and should thus become a preferred closing method in that patient group. In addition, Jafri et al.1 could have greatly aided the readers of their article by explaining how component separation was performed after bilateral subcostal incision (“Mercedes incision”). Component separation is typically performed after midline laparotomy by bilateral longitudinal separation of the external oblique layer and/or posterior rectus abdominis sheaths to advance the abdominal wall toward the midline and achieve a sound primary closure.9, 10 Jafri et al.1 must be commended for contributing to the understanding that temporary abdominal coverage improves the survival rate in selected liver transplant patients. However, the above-mentioned issues limit the conclusions that can be drawn from their otherwise valuable experience. Julian E. Losanoff*, J. Michael Millis , * Section of Transplantation, Wayne State University, Detroit, MI, Section of Transplantation University of Chicago Chicago IL." @default.
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• W2019969371 date "2007-01-01" @default.
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• W2019969371 title "Temporary abdominal coverage for adult liver transplantation" @default.
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• W2019969371 doi "https://doi.org/10.1002/lt.21216" @default.
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