Incisional hernia after simultaneous pancreas kidney tranplantation: a single-center experience from Budapest

Post-Abdominal Transplant Hernia: Can We Predict Size and Onset?

INTRODUCTION

Abdominal organ transplant is a life-saving treatment. However, the resultant weakening of abdominal muscles leaves patients susceptible to incisional hernia. Obesity, smoking, and diabetes mellitus are common risk factors for post-transplant hernia. However, the literature is void on the impact these risk factors have on timing and size of hernia.

METHODS

We performed a retrospective review of all post-abdominal transplant patients who underwent hernia repair in 2010-2017 at a single institution. Primary outcomes were hernia size and time from transplant to hernia repair.

RESULTS

We identified 31 patients. The majority of patients were female (15 male, 16 female), and the average patient was 56 ± 8.7 years old and obese (body mass index 30.6). Smoking (26.7%, n = 8) and diabetes mellitus (51.6%, n = 16) were prevalent. Transplant types represented were renal (n = 24), simultaneous pancreas-kidney (n = 5), liver (n = 1), and liver with subsequent kidney (n = 1). The median size of hernia was 100.0 cm² (interquartile range [IQR]: 78.5-234.0), and median time to hernia repair was 53.0 months (IQR: 12.5-110.0). Risk factors (obesity, smoking, and diabetes) did not influence hernia size, nor alter time to hernia repair.

CONCLUSION

Obesity, smoking, and diabetes mellitus are not prognostic of size or onset of post-transplant incisional hernia. Large cohort studies are needed to determine predictive factors of size and onset of hernia.

[Preventive anterior abdominal wall repair in recipients of renal allograft]

AIM

Retrospective analysis of safety and efficacy of preventive anterior abdominal wall repair in recipients of renal allograft.

MATERIAL AND METHODS

Kidney transplantation was performed in 396 patients with terminal renal failure within January 2015 - May 2017. Preventive endoprosthetics (PE) was applied in 28 (7.1%) patients. There were 7 women (26.9%) and 19 men (73.1%) aged 25-69 years (mean 44.5 (35, 56) years). Median of body mass index (BMI) was 27.5 (23.9, 29.9) kg/m².

RESULTS

Postoperative morbidity was 42.3%. Complications were mild (type I and II) and did not require invasive treatment. Postoperative morbidity was similar regardless protocol of immunosuppressive therapy (IST).

CONCLUSION

Preventive abdominal wall repair after kidney transplantation is effective and safe to prevent postoperative hernia.

Optimal surgical management in kidney and pancreas transplantation to minimise wound complications: A systematic review and meta-analysis

Background

Immunosuppression in transplant patients increases the risk of wound complications. However, an optimal surgical approach to kidney and pancreas transplantation can minimise this risk.

Materials and methods

We performed a systematic review and meta-analysis to examine factors contributing to incisional hernia formation in kidney and pancreas transplant recipients. Bias appraisal of studies was conducted via the Newcastle-Ottawa scale. We considered recipient factors, surgical methods, and complications of repair.

Results

The rate of incisional hernia formation in recipients of kidney and pancreas transplants was 4.4% (CI 95% 2.6-7.3, p < 0.001). Age above or below 50 years did not predict hernia formation (Q (1) = 0.09, p = 0.77). Body mass index (BMI) above 25 (10.8%, CI 95% 3.2-30.9, p < 0.001) increased the risk of an incisional hernia. Mycophenolate mofetil (MMF) use significantly reduced the risk of incisional hernia from 11.9% (CI 95% 4.3-28.7, p < 0.001) to 3.8% (CI 95% 2.5-5.7, p < 0.001), Q (1) = 4.25, p = 0.04. Sirolimus significantly increased the rate of incisional hernia formation from 3.7% (CI 95% 1.7-7.1, p < 0.001) to 18.1% (CI 95% 11.7-27, p < 0.001), Q (1) = 13.97, p < 0.001. While paramedian (4.1% CI 95% 1.7-9.4, p < 0.001) and Rutherford-Morrison incisions (5.6% CI 95% 2.5-11.7, p < 0.001) were associated with a lower rate of hernia compared to hockey-stick incisions (8.5% CI 95% 3.1-21.2, p < 0.001) these differences were not statistically significant (Q (1) = 1.38, p = 0.71). Single layered closure (8.1% CI 95% 4.9-12.8, p < 0.001) compared to fascial closure (6.1% CI 95% 3.4-10.6, p < 0.001) did not determine the rate of hernia formation [Q (1) = 0.55, p = 0.46].

Conclusions

Weight reduction and careful immunosuppression selection can reduce the risk of a hernia. Rutherford-Morrison incisions along with single-layered closure represent a safe and effective technique reducing operating time and costs.

Effectiveness and versatility of biological prosthesis in transplanted patients

AIM

To emphasize the effectiveness and versatility of prosthesis, and good tolerance by patients with incisional hernia (IH).

METHODS

From December 2001 to February 2016, 270 liver transplantations were performed at San Camillo Hospital. IH occurred in 78 patients (28.8%). IH usually appeared early within the first year post-orthotopic liver transplantation. In the first era, fascial defect was repaired by primary closure for defects smaller than 2.5 cm or with synthetic mesh for greater defects. Recently, we started using biological mesh (Permacol™, Covidien). We present a series of five transplanted patients submitted to surgery for abdominal wall defect correction repaired with biological mesh (Permacol™, Covidien).

RESULTS

In our cases, the use of biological prosthesis (Permacol™, Covidien) have proven to be effective and versatile in repairing hernia defects of different kinds; patients did not suffer infections of the prosthesis and no recurrence was observed. Furthermore, the prosthesis remains intact even in the years after surgery.

CONCLUSION

The cases that we presented show that the use of biological mesh (Permacol™, Covidien) in transplanted patients may be safe and effective, being careful in the management of perioperative immunosuppression and renal and graft function, although the cost of the product itself has been the main limiting factor and there is need for prospective studies for further evaluations.

Incidence and risk factors of incisional hernia formation following abdominal organ transplantation

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.

Surgical procedures not connected with transplantation in patients after kidney or kidney and pancreas transplant with stable function of graft

The aim of the study was to evaluate complication during and after surgical procedure without connection with transplantation among patients after kidney, kidney and pancreas transplantation with stable function of graft.

MATERIAL AND METHODS

54 patients underwent 62 surgical procedures without connection with transplantation procedure. Main characteristic: standard immunosuppressive treatment, main age 51.1±13.95 years, men 77.4%, hospitalization time 5.27±3.31 day, group 1 - 55 procedures among patients after kidney transplantation, group 2 - 7 procedure among patients after kidney and pancreas transplantation.

RESULTS

Procedures from general surgery comprised 60% [cholecystectomy 19 (51%), left hemicolectomy 1 (3%), esophagus removal 1 (3%), hernia repair 8 (22%), nefrectomy 3 (8%), pancreas transplantation in patients with functional renal graft 1 (3%), laparotomy 4 (11%), vascular surgery 27% (correction of arteriovenosus fistula 13 (76%), by-pass surgery 1 (6%), embolectomy 1 (6%), implantation of aortal - iliac stentgraft 1 (6%), surgery of iliac artery 1 (6%)]. There has been no difference between parameters measured before and after procedure: creatinine (p=0.93), GFR (p=0.07), urea (p=0.25), glycaemia (p=0.322), glycated hemoglobin (p=0.3), C-peptide (p=0.3). In both groups were no differences in levels of creatinine (p=0.78) and urea (p=0.23), measured in the next years after surgical procedure. Mortality 0%, lost of graft 0%, in - hospital morbidity 10 (16.2%) (hematoma 1.6%, endocavitary electrode 1.6%, wound healing defect 16.2%). Morbidity in group 1 - 12.7%, group 2 - 48.8%, p=0.04.

CONCLUSIONS

Surgical procedures performed in a specialist center do not impaire prognosis of patients with stable function of graft, after kidney, kidney and pancreas transplantation.