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Kim JY, Hong SK, Kim J, Choi HH, Lee J, Hong SY, Lee JM, Choi Y, Yi NJ, Lee KW, Suh KS. Risk factors for incisional hernia after liver transplantation in the era of mammalian target of rapamycin inhibitors use: a retrospective study of living donor liver transplantation dominant center in Korea. Ann Surg Treat Res 2024; 106:115-123. [PMID: 38318092 PMCID: PMC10838656 DOI: 10.4174/astr.2024.106.2.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/31/2023] [Accepted: 11/26/2023] [Indexed: 02/07/2024] Open
Abstract
Purpose Incisional hernia (IH) is a common complication after liver transplantation (LT) with an incidence rate of 5% to 46%. This retrospective study aimed to evaluate the risk factors for IH development after LT in the era of mammalian target of rapamycin (mTOR) inhibitors use. Methods Data on patients who underwent LT between 2015 and 2021 were retrospectively reviewed. The patients were divided into 2 groups (IH group and non-IH group) according to the postoperative occurrence of IH. Results We analyzed data from 878 patients during the study period, with 28 patients (3.2%) developing IH. According to multivariate analysis, body mass index exceeding 25 kg/m2 and the use of mTOR inhibitors within the first month after LT were the sole significant factors for both IH occurrence and the subsequent need for repair operations. Notably, a history of wound complications, a Model for End-stage Liver Disease score, and the timing of LT-whether conducted during regular hours or at night-did not emerge as significant risk factors for IH after LT. Conclusion Our study reveals a higher incidence of IH among obese patients following LT, often requiring surgical repair, particularly in cases involving mTOR inhibitor usage within the initial month after LT. Consequently, it is crucial to exercise increased vigilance, especially in obese patients, and exercise caution when considering early mTOR inhibitor administration after LT.
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Affiliation(s)
- Jae-Yoon Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Suk Kyun Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jiyoung Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Hwa Choi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jaewon Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Su young Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong-Moo Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - YoungRok Choi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Ferri JVV, Dick SM, Grezzana-Filho TDJM, Feier FH, Prediger L, Lazzaretti GS, Kruel CRP, Corso CO, Cavazzola LT, Chedid MF. EARLY INCISIONAL HERNIA AFTER LIVER TRANSPLANTATION: RISK FACTORS AND HERNIA REPAIR RESULTS. ABCD. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA (SÃO PAULO) 2022; 35:e1698. [DOI: 10.1590/0102-672020220002e1698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 08/18/2022] [Indexed: 11/06/2022]
Abstract
ABSTRACT BACKGROUND: Liver transplantation is a complex and valuable therapy. However, complications that burden postoperative quality of life, such as incisional hernia, are to be better elucidated, such as risk factors and prophylactic measures. AIM: This study aimed to define the rate of incisional hernia in patients who underwent liver transplantation in a population in southern Brazil and to assess the related risk factors in order to establish measures for prior optimization and specific prophylactic care in the future. METHODS: Patients undergoing adult Liver transplantation from January 2004 to November 2020 were retrospectively analyzed, assessing demographic features, surgical outcomes, and predisposing factors. RESULTS: Among 261 liver transplantation patients included, incisional hernia was diagnosed in 71 (27.2%). Of the 71 incisional hernia patients, 28 (39.4%) developed IH during the first post-transplant. Majority of the patients were male (52/71, 73.2%); of the 71 patients, 52 had hepatitis C virus (HCV) and 33 (46.5%) had hepatocellular carcinoma (HCC). Male gender (p=0.044), diabetes mellitus (p=0.008), and acute cellular rejection (p<0.001) were risk factors for IH. In all, 28 (39.4%) patients were submitted for hernia repair with mesh, with a recurrence rate of 17.8%. CONCLUSION: Incisional hernia after liver transplantation is a relatively common problem associated with male gender, diabetes, and acute cellular rejection. This is a problem that should not be trivialized in view of the complexity of liver transplantation, as it can lead to a reduction in quality of life as well as jeopardize late liver transplantation results and lead to incarceration and strangulation.
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Zarbaliyev E, Sevmiş M, Kilercik H, Çelik S, Aktaş S, Çağlıkülekçi M, Sevmiş Ş. Is the incision type important for the development of hernia in liver transplant patients? Clin Transplant 2021; 36:e14497. [PMID: 34591336 DOI: 10.1111/ctr.14497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/04/2021] [Accepted: 09/25/2021] [Indexed: 12/07/2022]
Abstract
OBJECTIVE In this study, we aimed to investigate the rates and causes of incisional hernia that developed in the postoperative follow-up of patients who underwent liver transplantation. MATERIAL AND METHOD The results of patients who underwent LT by using three different incisions at the İstanbul Yeni Yüzyıl University Gaziosmanpaşa Hospital organ transplant center between January 2015 and December 2019 were retrospectively analyzed. Patients were divided into Chevron (group-1), reverse T (group-2), and J incisions (group-3) and hernia development rates were examined. RESULTS There was no significant difference in terms of incisional hernia in groups 1 and 2 according to the incision type (p = .723). Incisional hernia rate was significantly lower in the J incision group (p < .001). When the factors that increase the development of hernia in all LT patients were examined, it was seen that male gender (p = .021), high BMI rate (p = .003), postoperative bleeding (p = .018), and wound infection (p = .039) caused a significant increase in risk. CONCLUSION The incision, which is made during liver transplant, is important for the development of hernia. The J incision has a low hernia development rate without causing access problems. Regardless of the incision, high BMI index, male gender, postoperative bleeding, and wound infection increase the development of incisional hernia in liver transplant patients.
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Affiliation(s)
- Elbrus Zarbaliyev
- Department of General Surgery, Gaziosmanpaşa Hospital, Yeni Yüzyil University, İstanbul, Turkey
| | - Murat Sevmiş
- Department of General Surgery and Transplantation, Gaziosmanpaşa Hospital, Yeni Yüzyil University, İstanbul, Turkey
| | - Hakan Kilercik
- Department of Anesthesiology, Gaziosmanpaşa Hospital, Yeni Yüzyıl University, İstanbul, Turkey
| | - Sebahattin Çelik
- Department of General Surgery, Van Training and Research Hospital, Health Scıences Unıversıty, Van, Turkey
| | - Sema Aktaş
- Department of General Surgery and Transplantation, Gaziosmanpaşa Hospital, Yeni Yüzyil University, İstanbul, Turkey
| | - Mehmet Çağlıkülekçi
- Department of General Surgery, Gaziosmanpaşa Hospital, Yeni Yüzyil University, İstanbul, Turkey
| | - Şinasi Sevmiş
- Department of General Surgery and Transplantation, Gaziosmanpaşa Hospital, Yeni Yüzyil University, İstanbul, Turkey
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Incisional Hernia After Liver Transplantation: Analysis of Tailored Open Mesh Repair. Int Surg 2020. [DOI: 10.9738/intsurg-d-17-00046.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
ObjectiveIncisional hernia is a frequent complication post liver transplantation (LT). The aim of this study was to compare divergent approaches to open abdominal wall repair post-LT.Summary of background dataAfter liver transplantation (LT) via Mercedes incision (MSI) we observed an incidence of incisional hernia between 5% and 34%. Conventional repair consists of reopening the whole incision and reinforcement of the whole fascia using a mesh plastic in sublay position. This retrospective analysis compares open mesh repair with complete reinforcement of the Mercedes incision and open mesh repair of solely the abdominal wall defect.MethodsBetween 2010 and 2015, 218 orthotopic liver transplantations (LT) were performed at our institution, and 25 (11.5%) of those patients required an incisional hernia repair post-LT. One group received a local hernia repair (n = 15) while the other group obtained a reconstruction of the whole MSI (n = 10). We analyzed the preoperative status, causative factors for incisional hernia, operative details, and long-term outcome of these patients.ResultsAnalyzing preoperative details no significant differences were found between the 2 groups. The mean time post-LT at which the abdominal wall defect appeared was 18 ± 12 months. The mean follow-up time after abdominal wall repair was 15 (11–19) months. Additionally, 1 (4%) patient developed a hernia recurrence without statistic significant difference between the 2 groups (P = 0.400).ConclusionLocal mesh reinforcement seems to be feasible and safe in incisional hernia patients after Mercedes incision due to liver transplantation.
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Butler JR, O'Brien DC, Kays JK, Kubal CA, Ekser B, Fridell JA, Mangus RS, Powelson JA. Incisional Hernia After Orthotopic Liver Transplantation: A Systematic Review and Meta-analysis. Transplant Proc 2020; 53:255-259. [PMID: 32532557 DOI: 10.1016/j.transproceed.2020.03.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Incisional hernia (IH) is a well-known complication of orthotopic liver transplantation. Despite wide recognition of the impact of this problem, the incidence remains imprecisely known. METHODS The MEDLINE, EMBASE, Cochrane Central Register of Clinical Trials and Cochrane Database of Systematic Reviews databases were searched from their inception to November 2017 for abstracts documenting IH after orthotropic liver transplantation (OLT). The primary endpoint of this study was incidence of IH, secondary endpoints were time to hernia and recurrence. Three reviewers independently graded abstracts for inclusion in this review. Heterogeneity in combining data was assumed prior to pooling. Random-effects meta-analyses were performed to estimate percentages and 95% CIs. RESULTS After a review of 77 abstracts, 18 studies were graded as relevant. The methodological quality of studies was assessed with a minimum Oxford Centre for Evidence-Based Medicine level of 2B. These represent a cohort of 981 patients with IH after OLT reported in the literature. A meta-analysis of studies meeting inclusion criteria shows mean incidence of 15.1% (CI 12.1%-18.2%). Aggregate recurrence rate reported in the literature is 12.4% (CI 4.3%-20.5%). Overall reported time to IH after OLT was 42.9 months. CONCLUSIONS Although reported incidences of IH after OLT vary widely across studies, an overall incidence of 15.1% is reported. This is a relatively late complication after transplantation. Recurrence of hernia after initial repair is 12.4% within this patient population.
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Affiliation(s)
- James R Butler
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Daniel C O'Brien
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Joshua K Kays
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Chandrashekhar A Kubal
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Burcin Ekser
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Jonathan A Fridell
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Richard S Mangus
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, United States
| | - John A Powelson
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, United States.
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Butler JR, O'Brien DC, Kays JK, Ridlen K, Kubal CA, Ekser B, Timsina L, Fridell JA, Mangus RS, Powelson JA. Postoperative renal impairment is associated with increased length of stay for incisional hernia repair after liver transplantation. Surg Open Sci 2019; 1:69-73. [PMID: 32754695 PMCID: PMC7391902 DOI: 10.1016/j.sopen.2019.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 06/04/2019] [Accepted: 06/06/2019] [Indexed: 02/05/2023] Open
Abstract
Background Incisional hernia repair is the most common procedure after orthotopic liver transplantation. Although enhanced recovery protocols are increasingly employed, the post–orthotopic liver transplantation patient may not benefit from all aspects of these models. The aim of the present study is to assess which perioperative interventions and patient factors affect hospital length of stay in a cohort of post–orthotopic liver transplantation patients undergoing incisional hernia repair. Methods We conducted a retrospective review of a series of adult patients undergoing incisional hernia repair after orthotopic liver transplantation. The primary endpoint was length of stay. Results were stratified by demographic, intraoperative, and postoperative variables. Results Eleven percent (172/1523) of patients who received orthotopic liver transplantation during the study period underwent subsequent incisional hernia repair. Median length of stay was 5 days (range 2–50). The strongest predictor of length of stay was postoperative renal function. Despite liberal intraoperative administration of volume (median 642 mL/h) and brisk intraoperative urine output (median 72 mL/h), postoperative acute kidney injury occurred in 48% of patients. Those that developed acute kidney injury received less intraoperative volume (6 vs 8.5 mL/kg/h; P = .031) and the severity of postoperative renal injury was inversely related to the amount intraoperative volume given. Conclusions In patients undergoing incisional hernia repair after orthotopic liver transplantation, postoperative renal function is frequently impaired. Although many aspects of current ERAS protocols may be applied to post-transplant patients, restrictive intraoperative fluid administration strategies should be employed with caution given a high propensity for the development of post-operative acute kidney injury in this complex population. Eleven percent (172/1523) of patients who received OLT during the years 2005 to 2016 underwent subsequent IHR. The strongest predictor of length of stay in this population was postoperative renal function. Despite liberal intraoperative administration of volume (median 642 mL/h; 7 mL/kg/h) and brisk intraoperative urine output (median 72 mL/h), postoperative acute kidney injury (AKI) occurred in 48% of patients. Those that developed AKI received less intraoperative volume (6 vs 8.5 mL/kg/h; P = .031) and the severity of postoperative renal injury was inversely related to intraoperative volume
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Affiliation(s)
- James R Butler
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Daniel C O'Brien
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Joshua K Kays
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kyle Ridlen
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Burcin Ekser
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lava Timsina
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jonathan A Fridell
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Richard S Mangus
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - John A Powelson
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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Kniepeiss D, Waha JE, Auer T, Berghold A, Schemmer P. PRevention of INCisional hernia after liver transplantation (PRINC trial): study protocol for a randomized controlled trial. Trials 2019; 20:371. [PMID: 31221206 PMCID: PMC6585129 DOI: 10.1186/s13063-019-3477-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 05/29/2019] [Indexed: 12/29/2022] Open
Abstract
Background Incisional hernia is a common complication after liver transplantation with an incidence of 5 to 46%. Concerning non-transplant patients, a recently published meta-analysis describes a reduction of the incidence of incisional hernia of up to 85% due to prophylactic mesh replacement in elective, midline laparotomy. The aim of our study is to show a reduction of the incidence of incisional hernia after liver transplantation with minimal risk for complication. Methods/design This is an unblinded, randomized controlled trial comparing time to incisional hernia over a period of 12 months between patients undergoing liver transplantation and standardized abdominal closure with or without prophylactic placement of Phasix™ (Bard – Davol Inc., Warwick, RI, USA) mesh in an onlay position. As we believe that the mesh intervention is superior to the standard procedure in reducing the incidence of hernia, this is a superiority trial. Discussion The high risk for developing incisional hernia following liver transplantation might be reduced by prophylactic mesh placement. Immunosuppressed patients are at high risk for developing surgical-site infections. We chose a mesh which has anti-inflammatory properties and is fully resorbed after 18 months. Trial registration ClinicalTrials.gov, ID: 03222102. Registered retrospectively on 17 July 2018. Protocol version 1.4, 7 October 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3477-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daniela Kniepeiss
- General, Visceral and Transplant Surgery, Transplant Center Graz, Medical University of Graz, Graz, Austria.,Transplant Center Graz, Medical University of Graz, Graz, Austria
| | - James Elvis Waha
- General, Visceral and Transplant Surgery, Medical University of Graz, Graz, Austria
| | - Thomas Auer
- General, Visceral and Transplant Surgery, Medical University of Graz, Graz, Austria
| | - Andrea Berghold
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Peter Schemmer
- General, Visceral and Transplant Surgery, Transplant Center Graz, Medical University of Graz, Graz, Austria. .,Transplant Center Graz, Medical University of Graz, Graz, Austria. .,Department of General, Visceral and Transplant Surgery, Transplant Center Graz, Medical University of Graz, Auenbruggerplatz 29, 8036, Graz, Austria.
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Lee JS, Kim JM, Kim KS, Choi GS, Joh JW, Lee SK. Predictors of incisional hernia in adult liver transplant recipients. Hernia 2018; 23:61-65. [PMID: 30406851 DOI: 10.1007/s10029-018-1845-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 10/29/2018] [Indexed: 01/14/2023]
Abstract
PURPOSE Incisional hernia is a complication following abdominal operation. Patients undergoing liver transplantation have a high risk of developing incisional hernia because of immunosuppression. The purpose of this study was to evaluate incisional hernia after liver transplantation and to identify risk factors for hernia formation in those patients. METHODS We retrospectively reviewed 1044 adult patients with more than 2 years of follow-up in patients who underwent liver transplantation from January 2000 to December 2015. RESULTS Incisional hernia was identified in 79 patients with more than 2 years of follow-up. The overall incisional hernia rate was 7.6%. The mean age and body mass index (BMI) of the patients with incisional hernia were 55 ± 9 years and 25.3 ± 3.7 kg/m2, respectively. No significant differences in gender, diagnosis, diabetes, Child-Pugh score, model for end-stage liver disease (MELD) score, donor type, hepatorenal syndrome, varix bleeding, ascites, hepatic encephalopathy, ventilator use, spontaneous bacterial peritonitis (SBP), or bile leakage were found between patients who did and did not develop incisional hernia. Patients with acute rejection before hernia development were more to have herniated patients hernia (p < 0.05). CONCLUSION Age greater than 55 years and high BMI were significant risk factors. We identified risk factors for the development of incisional hernia. Based on these risk factors, attention should be paid to incisional hernia in older and obese patients.
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Affiliation(s)
- J S Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - J M Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea.
| | - K S Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - G-S Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - J-W Joh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - S-K Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
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Abstract
BACKGROUND After receiving a living donor liver transplant (LDLT), an incisional hernia is a potentially serious complication that can affect the patient's quality of life. In the present study we evaluated surgical hernia repair after LDLT. MATERIALS AND METHODS Medical records of patients who underwent surgery to repair an incisional hernia after LDLT in Turgut Ozal Medical Center between October 2006 and January 2010 were evaluated in this retrospective study. A reverse-T incision was made for liver transplantation. The hernias were repaired with onlay polypropylene mesh. Age, gender, post-transplant relaparatomy, the type, the result of surgery for the incisional hernia, and risk factors for developing incisional hernia were evaluated. RESULTS An incisional hernia developed in 44 of 173 (25.4%) patients after LDLT. Incisional hernia repair was performed in 14 of 173 patients (8.1%) who underwent LDLT from October 2006 to January 2010. Relaparatomy was associated with incisional hernia (p = 0.0002). The mean age at the time of the incisional hernia repair was 51 years, and 79% of the patients were men. The median follow-up period was 19.2 (13-36) months after the hernia repair. Three patients with intestinal incarceration underwent emergency surgery to repair the hernia. Partial small bowel resection was required in one patient. Postoperative complications included seroma formation in one patient and wound infection in another. There was no recurrence of hernia during the follow-up period. CONCLUSIONS The incidence of incisional hernia after LDLT was 25.4% in this study. Relaparatomy increases the probability of developing incisional hernia in recipients of LDLT. According to the results of the study, repair of an incisional hernia with onlay mesh is a suitable option.
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Smith CT, Katz MG, Foley D, Welch B, Leverson GE, Funk LM, Greenberg JA. Incidence and risk factors of incisional hernia formation following abdominal organ transplantation. Surg Endosc 2015; 29:398-404. [PMID: 25125093 PMCID: PMC4324562 DOI: 10.1007/s00464-014-3682-8] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 06/09/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND Hernia formation is common following abdominal operations, and transplant patients are at increased risk due to postoperative immunosuppression. The purpose of this study was to estimate the incidence of incisional hernia formation following primary abdominal solid organ transplantation and identify clinical risk factors for hernia formation. METHODS We performed a single-institution retrospective review of a prospectively collected database to evaluate all patients who underwent primary liver, kidney, or pancreas transplantation between 2000 and 2011. The primary outcome was hernia formation at the transplant incision. Univariate and multivariate Cox proportional hazards models were used to identify risk factors for incisional hernia formation. RESULTS A total of 3,460 transplants were performed during the study period: 2,247 kidney only, 718 liver only, and 495 pancreas or simultaneous pancreas and kidney (pancreas group). The overall incisional hernia rate was 7.5 %. The Kaplan-Meier rates of hernia formation at 1, 5, and 10 years were 2.5, 4.9, and 7.0 % for kidney; 4.5, 13.6, and 19.0 % for liver; and 2.5, 12.7, and 21.8 % for the pancreas groups. On univariate analysis, surgical site infection (SSI), body mass index (BMI) >25, delayed graft function, and withholding a calcineurin inhibitor or mycophenolate mofetil (MMF) were associated with hernia formation in the kidney group. SSI and BMI >25 were associated with hernia formation in the liver group. In the pancreas group, SSI, cyclosporine, and withholding MMF were all associated with hernia formation. On multivariate analysis, SSI was strongly associated with hernia formation in all groups. Hazard ratio: kidney = 24.71 (13.00-46.97); liver = 12.0 (6.40-22.52); pancreas = 12.95 (2.78-60.29). CONCLUSION Incisional hernias are common following abdominal organ transplant with nearly one in five patients developing an incisional hernia 5 years after liver or pancreas transplantation. Strategies focusing on prevention and early treatment of SSI may help to decrease the risk of incisional hernia formation following abdominal organ transplantation.
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Affiliation(s)
- Carter T Smith
- University of Wisconsin Hospital and Clinics, 600 Highland Avenue, K4/748 CSC, Madison, WI, 53792, USA
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McElroy LM, Daud A, Davis AE, Lapin B, Baker T, Abecassis MM, Levitsky J, Holl JL, Ladner DP. A meta-analysis of complications following deceased donor liver transplant. Am J Surg 2014; 208:605-18. [PMID: 25118164 DOI: 10.1016/j.amjsurg.2014.06.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 05/14/2014] [Accepted: 06/09/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Liver transplantation is a complex surgery associated with high rates of postoperative complications. While national outcomes data are available, national rates of most complications are unknown. DATA SOURCES A systematic review of the literature reporting rates of postoperative complications between 2002 and 2012 was performed. A cohort of 29,227 deceased donor liver transplant recipients from 74 studies was used to calculate pooled incidences for 17 major postoperative complications. CONCLUSIONS This is the first comprehensive review of postoperative complications after liver transplantation and can serve as a guide for transplant and nontransplant clinicians. Efforts to collect national data on complications, such as through the National Surgical Quality Improvement Program, would improve the ability to provide patients with informed consent, serve as a tool for individual center performance monitoring, and provide a central source against which to measure interventions aimed at improving patient care.
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Affiliation(s)
- Lisa M McElroy
- Center for Healthcare Studies, Institute for Public Health and Medicine, Chicago, IL, USA; Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Chicago, IL, USA.
| | - Amna Daud
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Chicago, IL, USA
| | - Ashley E Davis
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Chicago, IL, USA
| | - Brittany Lapin
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Chicago, IL, USA
| | - Talia Baker
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Chicago, IL, USA
| | - Michael M Abecassis
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Chicago, IL, USA
| | - Josh Levitsky
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Chicago, IL, USA
| | - Jane L Holl
- Center for Healthcare Studies, Institute for Public Health and Medicine, Chicago, IL, USA
| | - Daniela P Ladner
- Center for Healthcare Studies, Institute for Public Health and Medicine, Chicago, IL, USA; Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Chicago, IL, USA
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de Goede B, Eker HH, Klitsie PJ, van Kempen BJH, Polak WG, Hop WCJ, Metselaar HJ, Tilanus HW, Lange JF, Kazemier G. Incisional hernia after liver transplantation: risk factors and health-related quality of life. Clin Transplant 2014; 28:829-36. [PMID: 24806311 DOI: 10.1111/ctr.12386] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2014] [Indexed: 12/13/2022]
Abstract
The aim of this cross-sectional study was to analyze the incidence of incisional hernia after liver transplantation (LT), to determine potential risk factors for their development, and to assess their impact on health-related quality of life (HRQoL). Patients who underwent LT through a J-shaped incision with a minimum follow-up of three months were included. Follow-up was conducted at the outpatient clinic. Short Form 36 (SF-36) and body image questionnaire (BIQ) were used for the assessment of HRQoL. A total of 140 patients was evaluated. The mean follow-up period was 33 (SD 20) months. Sixty patients (43%) were diagnosed with an incisional hernia. Multivariate analysis revealed surgical site infection (OR 5.27, p = 0.001), advanced age (OR 1.05, p = 0.003), and prolonged ICU stay (OR 1.54, p = 0.022) to be independent risk factors for development of incisional hernia after LT. Patients with an incisional hernia experienced significantly diminished HRQoL with respect to physical, social, and mental aspects. In conclusion, patients who undergo LT exhibit a high incidence of incisional hernia, which has a considerable impact on HRQoL. Development of incisional hernia was shown to be related to surgical site infection, advanced age, and prolonged ICU stay.
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Affiliation(s)
- Barry de Goede
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
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Montalti R, Mimmo A, Rompianesi G, Serra V, Cautero N, Ballarin R, De Ruvo N, Cunningham Gerring R, Enrico Gerunda G, Di Benedetto F. Early use of mammalian target of rapamycin inhibitors is an independent risk factor for incisional hernia development after liver transplantation. Liver Transpl 2012; 18:188-94. [PMID: 21987434 DOI: 10.1002/lt.22445] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Incisional hernias (IHs) are common complications after liver transplantation (LT) with a reported incidence of 1.7% to 34.3%. The purpose of this retrospective study was to evaluate the risk factors for IH development after LT with a focus on the role of immunosuppressive therapy during the first month after LT. We analyzed 373 patients who underwent LT and divided them into 2 groups according to their postoperative course: an IH group (121 patients or 32.4%) and a no-IH group (252 patients or 67.6%). A univariate analysis demonstrated that the following were risk factors related to IH development: male sex (P = 0.03), a body mass index ≥ 29 kg/m(2) (P = 0.005), LT after 2004 (P = 0.02), a Model for End-Stage Liver Disease (MELD) score ≥ 22 (P = 0.01), and hepatitis B virus infection (P = 0.01). The highest incidence of IHs was found in patients treated with mammalian target of rapamycin (mTOR) inhibitors (54.5%, P = 0.004). A multivariate analysis revealed male sex (P = 0.03), a pretransplant MELD score ≥ 22 (P = 0.04), and the use of mTOR inhibitors (P = 0.001) to be independent risk factors for IHs after LT. In conclusion, immunosuppressive therapy with mTOR inhibitors is an important independent risk factor for IH development after LT. To reduce the incidence of IHs, mTOR inhibitors should be avoided until the fourth month after LT unless their use is deemed to be strictly necessary.
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Affiliation(s)
- Roberto Montalti
- Liver and Multivisceral Transplant Center, University of Modena and Reggio Emilia, Modena, Italy.
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Agarwal S, Dorafshar AH, Harland RC, Millis JM, Gottlieb LJ. Liver and vascularized posterior rectus sheath fascia composite tissue allotransplantation. Am J Transplant 2010; 10:2712-6. [PMID: 21114648 DOI: 10.1111/j.1600-6143.2010.03331.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Abdominal wall closure in pediatric solid organ recipients may be confounded by donor size discrepancy and structural insults from previous surgery. Here we describe the novel use of vascularized donor abdominal wall posterior rectus sheath fascia, as a composite tissue allotransplant (CTA), to achieve abdominal wall closure in a liver and double kidney pediatric recipient who could not be closed primarily due to donor/recipient size mismatch. The posterior rectus sheath fascia was procured in continuity with the liver and falciform ligament. Blood supply was achieved using the single hepatic artery anastomosis as part of the standard liver transplantation procedure. Specimens of posterior rectus sheath fascia taken on postoperative days 3 and 30 showed no signs of acute rejection. The patient succumbed to an overwhelming fungal infection on day 51, with no signs of intraabdominal involvement. The patient received no additional immunosuppression in conjunction with the posterior rectus sheath fascia allotransplant.
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Affiliation(s)
- S Agarwal
- Section of Plastic and Reconstructive Surgery, University of Chicago, Chicago, IL, USA
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Kurmann A, Beldi G, Vorburger SA, Seiler CA, Candinas D. Laparoscopic incisional hernia repair is feasible and safe after liver transplantation. Surg Endosc 2009; 24:1451-5. [PMID: 20039072 DOI: 10.1007/s00464-009-0799-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2009] [Accepted: 11/11/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Incisional hernia is a common complication after liver transplantation. The current study evaluated incidence and risk factors for incisional hernia and compared laparoscopic and open hernia repair in terms of feasibility and outcome. METHODS A cohort of 225 patients was prospectively investigated. The median follow-up period was 61 months (range, 6-186 months). The study cohort had 31 patients who underwent open repair and 13 who underwent laparoscopic repair. RESULTS Incisional hernia, found in 57 patients (25%), had occurred after a median of 17 months (range, 5-138 months). The significant risk factors were male gender (p = 0.001) and body mass index (BMI) greater than 25 kg/m(2) (p = 0.002). A trend toward a lower recurrence rate (15% vs 35%; p = 0.28) and fewer surgical complications (15% vs 19%; p = 0.99) was found in the laparoscopic group. CONCLUSIONS Incisional hernia is a frequent complication after liver transplantation. Associated risk factors are male gender and a BMI greater than 25 kg/m(2). Laparoscopic hernia repair for such patients is feasible and safe.
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Affiliation(s)
- Anita Kurmann
- Department of Visceral Surgery and Medicine, Inselspital University Hospital Bern and University Bern, CH-3010 Bern, Switzerland
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Gastaca M, Valdivieso A, Ruiz P, de Urbina JO. Reducing the incidence of incisional hernia after liver transplantation. Transpl Int 2009; 23:559-60. [PMID: 19906033 DOI: 10.1111/j.1432-2277.2009.00992.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Heisterkamp J, Marsman HA, Eker H, Metselaar HJ, Tilanus HW, Kazemier G. A J-shaped subcostal incision reduces the incidence of abdominal wall complications in liver transplantation. Liver Transpl 2008; 14:1655-8. [PMID: 18975274 DOI: 10.1002/lt.21594] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A novel J-shaped incision for liver transplantation was introduced in attempt to reduce the wound-related complication rate while maintaining comparable access. Some 58 consecutive patients with the classic Mercedes incision were compared with the following 60 consecutive patients with a J-shaped incision. Nine of 60 patients (15%) with a J-shaped incision were converted to an extensive incision. The duration of surgery did not differ between both groups, and relaparotomy rates were comparable in both groups (45% versus 31%, P = 0.487) whereas the early wound-related morbidity was significantly reduced in the J-shaped incision group (3% versus 19%, P = 0.009), as well as incisional hernia rate (7% versus 24%, P = 0.002, corrected for different length of follow-up). Other factors such as previous surgery, ascites, abdominal drainage, retransplantation, and indications for transplantation did not differ between both groups and were not predictive of wound-related morbidity or incisional hernia. We therefore conclude that a J-shaped incision should be the incision of choice in liver transplantation. This new, seemingly minor modification reduces wound infections, fascial dehiscence, and incisional hernia.
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Mekeel K, Mulligan D, Reddy KS, Moss A, Harold K. Laparoscopic incisional hernia repair after liver transplantation. Liver Transpl 2007; 13:1576-81. [PMID: 17969189 DOI: 10.1002/lt.21290] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Incisional hernias occur in up to 17% of patients after liver transplantation. Laparoscopic ventral hernia repair is associated with fewer wound complications and a decreased incidence of recurrence when compared to open hernia repair in nontransplant patients. This is a retrospective review of 13 patients who underwent laparoscopic incisional hernia repair (LAP group) after liver transplantation compared to 14 patients who had open repairs (OP group; all but one with mesh). Primary immunosuppression in both groups at the time of transplantation was tacrolimus, but more patients in the LAP group were on sirolimus at the time of hernia, while more patients in the OP group were on prednisone at the time of hernia repair. All operations were completed with a laparoscopic approach; there were no conversions to open. Length of stay differed significantly between the 2 groups, with a mean of 5.4 days for the LAP group compared to 2.7 days in the OP group (0.0059). Complications occurred in 2 (15%) of the patients in the LAP group and 5 (36%) in the OP group. One patient in the LAP group required mesh removal to exclude causes of recurrent ascites, and 1 in the OP group for mesh infection. One (7.6%) of the patients in the LAP group developed a recurrence, compared to 29% (4) of the OP group (P =0.3259). In conclusion, laparoscopic incisional hernia repair is safe in patients after liver transplantation, with a low risk of infection or recurrence.
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Affiliation(s)
- Kristin Mekeel
- Division of Transplant Surgery and General Surgery, Mayo Clinic Hospital, Phoenix, AZ 85254, USA.
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Kahn J, Müller H, Iberer F, Kniepeiss D, Duller D, Rehak P, Tscheliessnigg K. Incisional hernia following liver transplantation: incidence and predisposing factors. Clin Transplant 2007; 21:423-6. [PMID: 17488396 DOI: 10.1111/j.1399-0012.2007.00666.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Patients after orthotopic liver transplantation (OLT) have a high risk of developing incisional hernia (IH). In the literature incidences between 5% and 17% are reported. PATIENTS AND METHODS In 90 patients, who underwent OLT between October 1998 and December 2005, a retrospective analysis on the occurrence of IH was performed. Surgical access for OLT was a transversal upper laparotomy. Age, gender, primary disease, ICU stay, immunosuppressive regimen and two different closure techniques (running suture or single sutures in layers) were evaluated. RESULTS In 73 patients (76.7%, group 2) healing of the incision was without problems, in 17 patients (23.3%, group 1), IH occurred. Total survival was similar between the groups (86.3% vs. 94.1%, n.s.). No significant differences between the groups concerning age, gender, body mass index, platelet count and duration of ICU stay were found. Also, the technique of abdominal closure had no impact on the development of IH. No IH was found in patients with hepatocellular carcinoma (n = 15), whereas end-stage liver cirrhosis (n = 75) was associated with development of IH (p = 0.064). Multivariate analysis revealed end-stage liver cirrhosis, Sirolimus, and MMF to be independent significant risk factors for IH after OLT. CONCLUSION IH following OLT has to be regarded a frequent complication. While technique of abdominal closure seems to have no impact, primary diagnosis and kind of immunosuppressive regimen exerted a significant influence on the formation of IH.
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Affiliation(s)
- Judith Kahn
- Department of Transplant Surgery, Medical University Graz, University Clinic of Surgery, Graz, Austria.
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Vardanian AJ, Farmer DG, Ghobrial RM, Busuttil RW, Hiatt JR. Incisional hernia after liver transplantation. J Am Coll Surg 2006; 203:421-5. [PMID: 17000384 DOI: 10.1016/j.jamcollsurg.2006.06.017] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2006] [Revised: 06/20/2006] [Accepted: 06/20/2006] [Indexed: 11/21/2022]
Abstract
BACKGROUND Incisional hernia is a potential complication of orthotopic liver transplantation (OLT), with various options for repair. STUDY DESIGN We conducted a retrospective review of a series of adult patients with incisional hernias after OLT to identify risk factors and to compare methods of repair. RESULTS Incisional hernia repair was performed in 44 of 959 patients (4.6%) who underwent OLT from 1999 to 2005. Mean age at time of OLT was 53 years, and 73% were men. One or more complications of OLT occurred in 33 patients (75%) and included reoperation for bile leak or hemoperitoneum (34%), pulmonary problems (27%), early acute rejection (7%), and severe ascites and retransplantation (5% each). Incisional hernia was diagnosed at 419 days (range 62 to 1,524 days) and repaired at 471 days (range 109 to 1,581 days) after OLT. Presentation included pain or discomfort (78%) and incarceration or strangulation (5%); 17% were asymptomatic. Herniorrhaphy techniques included fascial repair with onlay polypropylene mesh reinforcement (n=25, 57%); fascial repair only (n=15, 34%); or inlay mesh sewn to fascial edges (n=4, 9%). Complications of repair included recurrence in seven patients (16%) and wound infection and seroma in one patient each. Recurrence occurred in five patients with primary repair and two with mesh techniques (33% versus 6%, p=0.04). CONCLUSIONS Incisional hernia is a late complication of OLT for which male gender and early post-OLT complications are risk factors. Repair is safe when undertaken after acute problems have resolved and is best accomplished using mesh reinforcement of autologous tissue.
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Affiliation(s)
- Andrew J Vardanian
- Division of Liver and Pancreas Transplantation, Department of Surgery, Dumont-UCLA Transplant Center, David Geffen School of Medicine at UCLA, 650 C.E. Young Drive South, Los Angeles, CA 90095, USA
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Piazzese E, Montalti R, Beltempo P, Bertelli R, Puviani L, Pacilè V, Nardo B, Cavallari A. Incidence, predisposing factors, and results of surgical treatment of incisional hernia after orthotopic liver transplantation. Transplant Proc 2005; 36:3097-8. [PMID: 15686704 DOI: 10.1016/j.transproceed.2004.10.047] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The literature provides little data about incisional herniae (IH) developing after orthotopic liver transplantation (OLTx). We evaluated the incidence, predisposing factors, and results of surgical treatment of this pathological condition. We reviewed the records of 718 consecutive OLTx performed in 623 patients between April 1986 and May 2002. Patients whose IH developed after transplantation were included in the study. We identified 31 patients (incidence, 4.9%) whose IH developed from 2 to 140 months after the transplantation. This complication was significantly more frequent in men. Important predisposing factors included: virus-correlated cirrhosis, body mass index >25, severe ascites, incision type for OLTx (bilateral subcostal extended upper midline to xiphoid), and post-OLTx complications. In 17 patients, repair of hernia was performed using direct fascial approximation, in 20 patients, it required a prosthesis. After hernia treatment, we observed no deaths but a morbidity rate of 6.4%, a mean postoperative hospital stay of 8 days and a recurrence rate of 6.4%. IH post-OLTx need surgical treatment.
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Affiliation(s)
- E Piazzese
- Surgery, ICU, and Transplantation, University of Bologna, S. Orsola Hospital, Bologna, Italy
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