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. 2024 May 15;10(6):e1624.
doi: 10.1097/TXD.0000000000001624. eCollection 2024 Jun.

Multilevel Analysis of the Neovascularization and Integration Process of a Nonvascularized Rectus Fascia Transplantation

Ewout Muylle  1   2   3 , Arne Maes  4   5   6 , Gert De Hertogh  1   7   8 , Nele Van De Winkel  1   9   10 , Greet Kerckhofs  4   5   6   11 , Antoine Dubois  1   2   12 , Vincent Vandecaveye  13   14 , Lieven Thorrez  15 , Ina Hennion  15 , Marie-Paule Emonds  16 , Steven Pans  17 , Nathalie P Deferm  17 , Diethard Monbaliu  1   2   12 , Emilio Canovai  18 , Tim Vanuytsel  1   19   20 , Jacques Pirenne  1   2   12 , Laurens J Ceulemans  1   3   21
Affiliations

Multilevel Analysis of the Neovascularization and Integration Process of a Nonvascularized Rectus Fascia Transplantation

Ewout Muylle et al. Transplant Direct. .

Abstract

Background: Failure to close the abdominal wall after intestinal transplantation (ITx) or multivisceral Tx remains a surgical challenge. An attractive method is the use of nonvascularized rectus fascia (NVRF) in which both layers of the donor abdominal rectus fascia are used as an inlay patch without vascular anastomosis. How this graft integrates over time remains unknown. The study aims to provide a multilevel analysis of the neovascularization and integration process of the NVRF.

Methods: Three NVRF-Tx were performed after ITx. Clinical, radiological, histological, and immunological data were analyzed to get insights into the neovascularization and integration process of the NVRF. Moreover, cryogenic contrast-enhanced microfocus computed tomography (microCT) analysis was used for detailed reconstruction of the vasculature in and around the NVRF (3-dimensional histology).

Results: Two men (31- and 51-y-old) and 1 woman (49-y-old) underwent 2 multivisceral Tx and 1 combined liver-ITx, respectively. A CT scan showed contrast enhancement around the fascia graft at 5 days post-Tx. At 6 weeks, newly formed blood vessels were visualized around the graft with Doppler ultrasound. Biopsies at 2 weeks post-Tx revealed inflammation around the NVRF and early fibrosis. At 6 months, classical 2-dimensional histological analysis of a biopsy confirmed integration of the fascia graft with strong fibrotic reaction without signs of rejection. A cryogenic contrast-enhanced microCT scan of the same biopsy revealed the presence of microvasculature, enveloping and penetrating the donor fascia.

Conclusions: We showed clinical, histological, and microCT evidence of the neovascularization and integration process of the NVRF after Tx.

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Conflict of interest statement

The authors declare no conflicts of interest.

Figures

FIGURE 1.
FIGURE 1.
Surgical procedure of NVRF procurement and transplantation. A, Illustration of the 4 layers of the rectus bloc consisting of (from anterior to posterior) anterior fascia, rectus muscles, posterior fascia, and peritoneum (Data from Muylle E, Van De Winkel N, Hennion I, et al., Abdominal Wall Closure in Intestinal and Multivisceral Transplantation. Gastroenterol Clin N Am. 2024. Available online. https://doi.org/10.1016/j.gtc.2023.12.001; with permission. B, Appearance of prepared rectus fascia with anterior and posterior sheet pretransplantation. C, Illustration of the position of the NVRF in the recipient posttransplantation. D, Intraoperative image of NVRF that is sutured to the native rectus fascia of the recipient with a running suture. E, Appearance of the NVRF posttransplantation into the recipient. NVRF, nonvascularized rectus fascia.
FIGURE 2.
FIGURE 2.
Radiological and classical 2-dimenional histology findings of NVRF in case 1. A. CT scan showing the NVRF 5 days posttransplantation. An increase in contrast is seen around the fascia graft, mainly on the right side (white arrows). B, CT scan showing the NVRF, 1 month posttransplantation. The CT image is shown reconstructed in the coronal plane over the anterior abdominal wall in maximum intensity projection of the arterial phase scan. The contrast enhancement around the NVRF is raised compared with the previous CT scan and is present on both sides of the fascia graft. C, Abdominal Doppler US at 6 weeks posttransplantation showing the presence of newly formed blood vessels around the NVRF graft. D, General overview of the NVRF graft at the interphase with the native fascia. The edges of the donor NVRF are indicated with arrows. The arrowheads show another part of the donor NVRF that is sutured against the recipient’s fascia and muscle tissue (H&E staining). E, Detail of a surgical stitch (arrow) close to the interphase of donor and recipient fascia. Around the stitch, highly cellular fibrotic tissue with blood vessels is present (H&E staining). F, Detail of the NVRF graft and fibrotic reaction. The NVRF (indicated by the double arrow) appears as an eosinophilic mass consisting of precipitated collagen bundles of fascia tissue. The graft is surrounded by the fibrotic reaction, indicated with asterisks, consisting of newly formed connective tissue with inflammatory cells (H&E staining). G, Immunohistochemistry analysis for CD31 of the NVRF. The arrows indicate several vessels at the interphase of the fibrotic reaction of the recipient and the NVRF. The arrow heads are showing blood vessels running through the NVRF. H, Detail of a foreign-body reaction in the direct neighborhood of the NVRF. The arrow indicates a foreign-body giant cell (H&E staining). I, Detail of muscle tissue bundles, colored in red, of the recipient’s abdominal wall becoming atrophic at the interphase with the NVRF (Masson’s trichrome staining). CD, cluster of differentiation; CT, computed tomography; H&E, hematoxylin and eosin; NVRF, nonvascularized rectus fascia.
FIGURE 3.
FIGURE 3.
Three-dimensional histology findings using CECT and cryo-CECT analysis of NVRF in case 1. A, Transverse CECT slice through the biopsy, containing the NVRF (blue arrows), penetrating blood vessel (red arrow), suturing wire (green arrow), adipose tissue (yellow arrows), and muscle tissue (pink arrow). B, A magnification (orange rectangle in A) showing the NVRF (blue arrows) and the penetrating blood vessel (red arrows) C, Cryo-CECT slice corresponding to (B), showing in more detail the blood vessels (red arrows) and the collagen fiber bundles within the NVRF (orange arrow). D and E, Histological sections (H&E staining in D, and CD31 immunohistochemistry in E) corresponding to (B and C), validating the (cryo-)CECT visualization of the blood vessels (red arrows), the NVRF (blue arrows), and the collagen fiber bundles (orange arrow). F, Three-dimensional volume rendering, based on the cryo-CECT data, of the same penetrating blood vessel (red arrows) showing that it originates from the outside of the NVRF and runs through the whole width of the NVRF graft (indicated by the encapsulating sheets in blue). CD, cluster of differentiation; cryo-CECT, cryogenic contrast-enhanced microfocus computed tomography; H&E, hematoxylin and eosin; NVRF, nonvascularized rectus fascia.
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