Stanford Medicine surgeons perform rare abdominal wall transplant, first on the West Coast

The call came at 10 p.m. on the Friday before Thanksgiving. There was a potential organ match for Isaac Browning-Ortega, 22, who had been waiting for an intestinal transplant since childhood.

But the news was even bigger: He could also receive an abdominal wall transplant from the same donor — a much rarer procedure that had been performed only 38 times. This was the scenario that he, his family and his doctors had hoped for. Reconstructing an abdominal wall — his was underdeveloped since birth — was key to supporting the new intestines and ultimately improving chances for success.

Was he now mentally and physically prepared to go through with it?

He was.

By midnight, the match had been confirmed, and the next afternoon, Browning-Ortega was flown by air ambulance from Phoenix to Stanford Hospital. The next day, he underwent 13 hours of surgery to receive both transplants.

“I can’t wait to see what the future holds for him,” said his mother, Sylvia Ortega.

The challenges of childhood

Browning-Ortega had been living essentially without intestines for 15 years. He was born with bladder exstrophy, meaning his abdominal wall did not fully form, leaving his bladder, intestines and liver to grow outside his body. His first surgery, to close him up, came on his fourth day of life.

He also had necrotizing enterocolitis, which causes the intestines to become inflamed and die. By 7, he had lost all of his large intestines and all but 3 feet of small intestines. A person usually has 20 to 30 feet of small intestines.

Since his body could not absorb nutrients from food, he had to receive all his nutrition and hydration intravenously, known as total parenteral nutrition. For about 18 hours of each day, he was hooked up to one or another IV bag.

Nevertheless, Browning-Ortega worked hard to lead a relatively normal, independent life — making friends, graduating from high school, going to prom. He had made managing his ostomy bag and catheter routine and, since becoming an adult, he’d been making doctor’s appointments and going to them on his own.

But in recent years, the complications from his short bowel and long-term total parenteral nutrition became more frequent — infections that led to sepsis, veins that were difficult to access. His kidneys were failing, and he was tired all the time. He was hospitalized six to eight times a year.

A rare procedure

Browning-Ortega had been turned down multiple times for an intestinal transplant because of his congenital conditions. In 2020, he came to Stanford Medicine for an evaluation and met Gordon Lee, MD, a microsurgeon and professor of surgery, who recommended both an intestinal and abdominal wall transplant. Particularly for someone of his stature — 5 feet, 113 pounds at the time — he would need the extra skin to handle the size of the intestines.

Newly transplanted organs swell, sometimes so much that it’s difficult to close the abdominal wall. “When tissues are devoid of blood supply and then perfused with a blood supply, they immediately swell,” Lee said. “We call it ischemic reperfusion injury. It’s just the body’s natural tissue response.”

Despite little information about the procedure — it’d never been performed at Stanford Medicine, or even on the West Coast — it didn’t take long for the family to say yes, Ortega recalled. They’d been in a situation before in which Isaac had to live with an open wound for months after surgery.

“We’d fought so hard for Isaac to get a transplant throughout his entire life and been denied multiple, multiple times, but we never gave up,” his mother said. “And here at Stanford, they changed his life for sure.”

An abdominal wall transplant is tricky — layers of skin, fat, muscle and fascia (connective tissue) need to be joined and 3-millimeter-wide blood vessels stitched together with sutures finer than human hair. Only a few dozen had been performed.

Lee had never done one. But as a plastic surgeon specializing in complex reconstructive microsurgery — which involves using micro-instruments to connect tissues under a microscope — he knew he had the skills.

“The techniques are very similar to what we would do in a microsurgical reconstruction,” he said. He’d often worked with the abdominal wall in his routine clinical practice — for breast reconstructions, for example — and had connected these same blood vessels many times.  “These were blood vessels that I was very familiar with,” he said.

Surgical teamwork

The Friday evening Browning-Ortega learned about the match, Lee and transplant surgeon Andrew Bonham, MD, associate professor of surgery, set the wheels in motion for the double transplant. Coordination would be key.

They quickly recruited three surgical teams: one led by Bonham to retrieve and transplant the intestines, one led by Lee to retrieve and transplant the abdominal wall, and another to prepare Browning-Ortega to receive the transplants. A fourth team was on backup, in case someone got sick.

Early that Sunday, a chilly November morning, Lee and Bonham’s teams boarded a private jet to Reno, Nevada. There, they removed the intestines and a 32-by-34-centimeter piece of abdominal wall from the donor, a young woman who had died of an overdose. The organs were sealed in a clear bag with sterile ice, placed into a second clear bag, then into a bright red bag, then into a bright red box, and onto the plane.

By 5 p.m., they were back at Stanford Hospital. Browning-Ortega had already been in surgery to prepare for the transplants. First, Bonham’s team connected the intestines. Then Lee’s team connected the abdominal wall, carefully stitching together the transplant’s deep inferior epigastric artery and vein to Browning-Ortega’s. These two blood vessels alone would provide all the blood flow to the transplant.

The team worked until after midnight.

‘A wonderful thing’

Though the recovery has not been easy — it involved emergency surgery to remove a blood clot and a two-month hospital stay — the rare double transplantation has been successful.

Transplant rejection is always a possibility, even years down the road, but “The outlook is quite good,” Lee said. “For Isaac, we are very hopeful that this surgery will last him a lifetime.”

By early January, his new intestines were absorbing enough nutrients that he no longer needed the IVs — the first time since he was 7. Although he could eat before, food would pass through his body within minutes, and he never had the feeling of being full. Now he can even put on weight.

In fact, he has a bit of a pot belly for now to accommodate his new intestines. Once the swelling subsides, Lee will tighten up his abdominal wall, like a tummy tuck.

“It’s changed my life more than I can describe,” Browning-Ortega said. “It’s just been a wonderful thing.”

He is looking forward to traveling, maybe to London or Tokyo, and, like any 23-year-old, figuring out what he wants to do with his life.

“I am just so excited for his life,” his mother said. “He’ll be able to do everything he wants to do, like travel, and get a job, and live his adult life without having to be attached to some type of tube or medical device.”