Acellular Flowable Dermal Matrix for Ostomy Reconstruction: A Safe and Effective Minimally Invasive Technique

BACKGROUND: Acellular dermal matrices have long been used for complex abdominal wall closure and, more recently, for ostomy reconstruction. PURPOSE: To describe ostomy reconstruction with acellular flowable dermal matrix (AFDM) in a pediatric patient with a complex abdominal wall defect. CASE REPORT: A 14-year-old female who was diagnosed with unspecific hemorrhagic colitis at age 6 months and who underwent several abdominal surgeries (including total colectomy and terminal ileostomy) reported frequent, severe periostomy skin ulcerations secondary to improper fitting and ostomy bag leakage due to multiple periostomy skin retraction as a result of multiple abdominal scars. Under sedation, 2 small (5 mm) peristomal skin incisions were made, through which dissection and release of dermal scar tissue was performed. Afterwards, AFDM 40 mL was injected subcutaneously until a uniform, flat surface around the ostomy was achieved. The patient was discharged a few hours postoperatively, after verification of proper fit of the ostomy bag with no leakage. At 18-month follow-up, the patient was very satisfied with the result, with fewer ostomy bag changes and improved quality of life. CONCLUSION: This case report indicates that AFDM is a safe and effective minimally invasive technique for ostomy reconstruction, with minimal complications and satisfactory medium-term results.

In abdominal surgery, acellular dermal matrices have been used mainly in the management of acquired abdominal wall defects resulting from trauma, previous surgery, infection, or tumor resection.¹ In the past decade, such matrices have been used in surgical procedures requiring ostomy as a prosthetic reinforcement to prevent parastomal hernia.² They also have been used in the repair of parastomal hernias.^3,4

Acellular flowable dermal matrix (AFDM) has been used in the management of fascial defects, with similar results in ex vivo and in vivo models.^5,6 To date, no published study has reported its use in the management of abdominal wall defects. In adult patients, AFDM has been successfully used in nasal dorsum reconstruction, as well as in diabetic foot ulcers and chronic wounds.^7-9

In the present study, the authors report preliminary experience with the use of injectable AFDM (Integra Flowable Wound Matrix; Integra LifeSciences) for ostomy repair in a pediatric patient with a complex abdominal wall defect.

The authors treated a 14-year-old female with a history of indeterminate hemorrhagic colitis that was diagnosed at 6 months. When she was 2 years old, the patient underwent partial resection of the affected colon and termino-terminal anastomosis with protective ileostomy in the right iliac fossa (RIF). Owing to persistent disease, total colectomy was performed 6 months later, with a terminal ileostomy in the RIF. When the patient was 5 years old, ileoanal descent with a J-shaped reservoir was performed, with a new protective ileostomy in the RIF that was closed 1 year later. However, persistent inflammatory activity was observed at the reservoir and a rectovaginal fistula occurred; when the patient was 8 years of age, this was managed surgically with subtotal excision of the descended loop, flattening of the fistula, and a new terminal ileostomy in the RIF.

After that surgical intervention, recurrent peri-ileostomy fistulas caused substantial inflammation, scarring, and loss of the surrounding subcutaneous tissue, leading to extensive adherences of the skin to the fascial plane and producing major irregularities in the peristomal abdominal wall (Figure 1). These scars and adherences had a considerable negative effect on a patient’s quality of life because they hindered the proper adhesion of the ostomy bags, resulting in the need for frequent replacements.

 

A minimally invasive ostomy reconstruction with injection of AFDM was proposed. Informed consent was obtained, and the form was signed by the patient and her parents.

With the patient under sedation, 2 small 5-mm incisions were made at the 4-o’clock and 8-o’clock positions in the areas of greatest periostomy depression. Blunt adhesiolysis of the subdermal scars was performed using hemostatic forceps, thus releasing the epidermal and dermal layers from the fascial plane and creating a subdermal pouch. Subsequently AFDM, which has a gel-like consistency once hydrated, was injected through a cannula inserted through each incision. A total of 8 units of the AFDM were injected (40 mL total), resulting in elevation of the hollow areas and creation of a uniform peristomal surface. The key steps of the technique are shown in Figure 2.
 

No postoperative complications occurred, and the patient was discharged home a few hours after the procedure. Before the patient was discharged, adequate adherence of the ostomy bag was verified, with no irregularities or periostomy leaks (Figure 3). At 18-month follow-up, the patient remained satisfied with the outcome of the procedure. She experienced a significant reduction in the number of pouch replacements per day, with an important improvement in her quality of life (Figure 4).
 

The present case report describes a new approach to complex abdominal wall repair that combines percutaneous adhesiolysis with injection of AFDM, which comprises granulated cross-linked bovine tendon collagen and glycosaminoglycan.⁵ The granulated collagen-glycosaminoglycan is hydrated with saline and provides a scaffold for cellular invasion and capillary growth, thus regenerating the deep dermal and subdermal structures.¹⁰

            Numerous surgical interventions in the peristomal area result in loss of dermal and subcutaneous tissue, leading to deep adhesions and extensive scarring, with severe tissue retraction and poor skin elasticity. This irregular peristomal surface makes correct adhesion of the ostomy pouch impossible, with numerous leaks leading to irritation and chronic damage of the periostomy skin. With minimally invasive adhesiolysis, a new layer between the skin and fascial plane is created; this layer is filled with AFDM. Owing to its integrative features and composition, AFDM has the potential to rebuild lost or injured deep dermal structures and enables soft tissue augmentation, allowing for the creation of an optimal, level skin surface for pouch adhesion.

Compared with more traditional approaches such as monolayer acellular matrices—which, similar to AFDM, have the potential to regenerate damaged dermal tissue and have yielded good results in the repair of parastomal wall defects—AFDM allows for minimal incision access, thus minimizing surgical dissection and the risk of infection and rescarring.¹¹ Stoma reinforcement with sublay placement of non-cross-linked porcine-derived acellular dermal matrix at the time of stoma construction to reduce the incidence of para-stomal hernias has been studied in adults;² however, there are no data on this procedure in children. In the present case, AFDM was used to avoid larger incisions in the repair of the tissue around the stoma.

Autologous lipofilling is an alternative minimally invasive approach that has been described for abdominal wall reconstruction in a limited number of cases.¹² Both AFDM and lipofilling stimulate regeneration of deep dermal and subcutaneous tissues. Acellular flowable dermal matrix provides a scaffold for capillary ingrowth and cellular invasion, whereas fat provides stem cells and growth factors. Autologous lipofilling carries no risk of rejection. In contrast, AFDM is a commercially available product and thus, does not require harvesting and carries no risk of donor site morbidity. Although preliminary experiences with these matrices in ex vivo models have been reported,¹³ as of this writing no studies comparing them in human subjects have been published.

The main limitation of this study is that it is a single case report with medium-term follow-up, which makes it difficult to extrapolate the results. To date, no similar studies of pediatric patients undergoing peristomal abdominal wall reconstruction have been published. Prospective randomized controlled clinical trials are needed to further study the use of different materials with the goal of optimizing outcomes in patients who require ostomy reconstruction.

To the best of the authors’ knowledge, this is the first case report that describes the use of AFDM in the management of peristomal abdominal wall reconstruction. The novel use of AFDM combined with percutaneous scar release in the reconstructive management of ostomies is a minimally invasive, safe, and effective option, with minimal morbidity and satisfactory long-term results. However, prospective studies of different materials and procedures are needed to optimize outcomes in patients who require ostomy reconstruction.

Affiliations: ¹Department of Pediatric Surgery, Prisma Health Children’s Hospital, Columbia, South Carolina, USA; ²Department of Pediatric Plastic Surgery, La Paz Children’s Hospital, Madrid, Spain

Address all correspondence to: Carlos Delgado-Miguel, MD; Department of Pediatric Surgery, Prisma Health Children’s Hospital, 9 Richland Medical Park, Columbia, SC 29203, USA; carlosdelgado84@hotmail.com

Potential conflicts of interest: The authors have no financial relationships relevant to this article to disclose.

1. Zhong T, Janis JE, Ahmad J, Hofer SOP. Outcomes after abdominal wall reconstruction using acellular dermal matrix: a systematic review. J Plast Reconstr Aesthet Surg. 2011;64(12):1562-1571. doi:10.1016/j.bjps.2011.04.035
2. Fleshman JW, Beck DE, Hyman N, et al. A prospective, multicenter, randomized, controlled study of non-cross-linked porcine acellular dermal matrix fascial sublay for parastomal reinforcement in patients undergoing surgery for permanent abdominal wall ostomies. Dis Colon Rectum. 2014;57(5):623-631. doi:10.1097/DCR.0000000000000106
3. Asham E, Uknis ME, Rastellini C, Elias G, Cicalese L. Acellular dermal matrix provides a good option for abdominal wall closure following small bowel transplantation: a case report. Transplant Proc. 2006;38(6):1770-1771. doi:10.1016/j.transproceed.2006.05.056
4. Kish KJ, Buinewicz BR, Morris JB. Acellular dermal matrix (AlloDerm): new material in the repair of stoma site hernias. Am Surg. 2005;71(12):1047-1050.
5. Hodgkinson T, Bayat A. Ex vivo evaluation of acellular and cellular collagen-glycosaminoglycan flowable matrices. Biomed Mater. 2015;10(4):041001. doi:10.1088/1748-6041/10/4/041001
6. Später T, Frueh FS, Metzger W, Menger MD, Laschke MW. In vivo biocompatibility, vascularization, and incorporation of Integra® dermal regenerative template and flowable wound matrix. J Biomed Mater Res B Appl Biomater. 2018;106(1):52-60. doi:10.1002/jbm.b.33813
7. Duteille F, Tilliet Le Dentu H, Atlan M, Perrot P. Use of Integra Flowable Wound Matrix for nasal dorsum reconstruction or augmentation: A series of 6 cases. J Plast Reconstr Aesthet Surg. 2019;72(5):848-862. doi:10.1016/j.bjps.2018.12.022
8. Campitiello F, Mancone M, Della Corte A, Guerniero R, Canonico S. To evaluate the efficacy of an acellular flowable matrix in comparison with a wet dressing for the treatment of patients with diabetic foot ulcers: a randomized clinical trial. Updates Surg. 2017;69(4):523-529. doi:10.1007/s13304-017-0461-9
9. Cammarota M, D'Agostino A, Campitiello F, et al. Hard-to-heal wound treated with Integra Flowable Wound Matrix: analysis and clinical observations. J Wound Care. 2021;30(8):644-652. doi:10.12968/jowc.2021.30.8.644
10. Moiemen NS, Vlachou E, Staiano JJ, Thawy Y, Frame JD. Reconstructive surgery with Integra dermal regeneration template: histologic study, clinical evaluation, and current practice. Plast Reconstr Surg. 2006;117(7 Suppl):160S-174S. doi:10.1097/01.prs.0000222609.40461.68
11. Aycock J, Fichera A, Colwell JC, Song DH. Parastomal hernia repair with acellular dermal matrix. J Wound Ostomy Continence Nurs. 2007;34(5):521-523. doi:10.1097/01.WON.0000290731.38817.ed
12. Quiroz YY, Llorens E, Motta G, Bujons A. Autologous fat grafting with stem cell transplantation in an exstrophic patient. A case. J Pediatr Urol. 2021;17(1):119-121. doi:10.1016/j.jpurol.2020.12.017
13. Später T, Frueh FS, Menger MD, Laschke MW. Potentials and limitations of Integra® flowable wound matrix seeded with adipose tissue-derived microvascular fragments. Eur Cell Mater. 2017;33:268-278. doi:10.22203/eCM.v033a20