Aim:

To report our experience of abdominal wall graft rejection after abdominal wall transplant.

Methods:

Retrospective case notes analysis of all patients undergoing combined intestinal and abdominal wall transplantation was undertaken.

Cause of intestinal failure, pre-transplant abdominal wall quality, operative method and immunosuppressive regime were documented.

Characteristics of rejection, visual and histological, were documented. Method for treatment of rejection was highlighted.

Results:

From January 2012 to December 2012, 3 patients underwent an isolated intestine with abdominal wall transplant from the same donor. The aetiology of intestinal failure was radiation enteritis, ischemic bowel and necrotising enterocolitis respectively. All had scarred contracted abdominal walls with poor skin quality. Two doses of Campath 30mg were given intravenously (IV) at induction and 24 hours later. Monotherapy maintenance immunosupression was with Prograf.

The abdominal wall was remotely perfused via the non-dominant forearm vessels. Two had the abdominal wall disconnected from the forearm vessels and revascularised via the inferior epigastric and internal mammary arteries, at the time of transplantation and 30 days later, respectively.

At post-transplant day 60 and 68 respectively, these two patients presented with a peri-follicular, micro-papular pink rash limited to the abdominal wall graft preceded by neutropenia (neutrophil count<2). Histology revealed grade II-III rejection in each case. The transplant bowel had no evidence of rejection. Treatment was with a single dose of 20mg Basiliximab IV, 500mg methylprednisolone IV for 3 days and low dose azathioprine added to the maintenance regimen. At a median follow up of 6 months, both patients with rejection are alive and well. One patient died from sepsis 62 days after transplantation with a functioning abdominal wall graft.

Conclusion

Rejection of the abdominal wall is an expected entity given the antigenicity of the skin. Post-operative day 60 seems to be a high-risk period for this episode. Both episodes were preceded by neutropenia. CD25 down-regulation with Basiliximab, combined with methylprednisolone was effective in treating the acute rejection. Abdominal wall grafts appear to reject whilst underlying bowel remains healthy. Further studies and more numbers will determine if the skin is a precursor to rejection in the underlying intestinal graft.

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