Massive Panniculectomy in the Super Obese and Super-Super Obese

Safety and utility of panniculectomy in renal transplant candidates and end stage renal disease patients

BACKGROUND

As the obesity crisis in the United States continues, some renal transplantation centers have liberalized their BMI criteria necessary for transplant eligibility. More individuals with larger body-habitus related comorbidities with End-Stage Renal Disease (ESRD) now qualify for renal transplantation (RT). Surgical modalities from other fields also interact with this patient population.

METHODS

In order to assess surgical outcomes of panniculectomy in the context of renal transplantation and ESRD, the authors performed a systematic review following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) 2020 guidelines. Due to a paucity of existing primary studies, we retrospectively collected data on patients with ESRD undergoing panniculectomy from the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) to evaluate outcomes of body contouring in this patient population.

RESULTS

From the systematic review, a total of 783 ESRD patients underwent panniculectomy among the studies identified. Of these, 91 patients underwent panniculectomy simultaneously to RT while 692 had their pannus resected prior to kidney transplant. The most common complication was hematoma followed by wound dehiscence. From the NSQIP database, 24 868 patients met the inclusion criteria for analysis. In the setting of renal transplant status, patients with diabetes, hypertension requiring medication, and requiring dialysis were more likely to suffer postoperative complications (OR 1.31, 1.15, and 2.2, respectively). However, upon sub-analysis of specific types of complications, the only retained association was between diabetes and wound complication.

CONCLUSION

Preliminary data show that panniculectomy in ESRD patients appears to be safe, though with a nominal increased risk for complications. Pannus resection does not appear to impact post-transplantation outcomes, including long-term allograft survival. Larger, higher powered, randomized studies are needed to confirm the safety, utility, and medical benefit of panniculectomy in the context of renal transplantation.

Perioperative Risk Stratification Model for Readmission after Panniculectomy

BACKGROUND

Readmission is an important metric for surgical quality of care. This study aimed to develop a validated risk model that reliably predicts readmission after panniculectomy using the American College of Surgeons National Surgical Quality Improvement Program database.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify all patients who had undergone panniculectomy from 2005 to 2018. The outcome of interest was 30-day readmission. The cohort was divided randomly into 70 percent development and 30 percent validation groups. Independent predictors of 30-day readmission were identified using multivariable logistic regression on the development group. The predictors were weighted according to beta coefficients to generate an integer-based clinical risk score predictive of readmission, which was validated against the validation group.

RESULTS

For the model selection, 22 variables were identified based on criteria of p < 0.05 percent and complete data availability. Variables included in the development model included inpatient surgery, hypertension, obesity, functional dependence, chronic obstructive pulmonary disease, wound class greater than or equal to 3, American Society of Anesthesiologists class greater than 3, and liposuction. Receiver operating characteristic curve analysis of the validation group rendered an area under the curve of 0.710, which demonstrates the accuracy of this prediction model. The predicted incidence within each risk stratum was statistically similar to the observed incidence in the validation group ( p < 0.01), further highlighting the accuracy of the model.

CONCLUSIONS

The authors present a validated risk stratification model for readmission following panniculectomy. Prospective studies are needed to determine whether the implementation of the authors' clinical risk score optimizes safety and reduces readmission rates.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Abdominal Panniculectomy: An Analysis of Outcomes in 238 Consecutive Patients over 10 Years

Panniculectomy is a commonly performed body contouring procedure to address skin laxity and its related complications. This study aimed to assess clinical outcomes of abdominal panniculectomy and identify predictors of complications at a tertiary academic healthcare center.

Methods

A retrospective review of patients who underwent panniculectomy between January 2010 and January 2020 at our institution was performed. Exclusion criteria were a history of prior panniculectomy or abdominoplasty. Patient characteristics and clinical outcomes were collected. Univariate and multivariable analyses were performed to assess the risk factors of complications.

Results

The mean age in the included 238 patients was 51.7 ± 12.7 years, and the mean body mass index (BMI) at the time of panniculectomy was 33 ± 7.5 kg/m². Median resection weight was 2.7 kg (range: 0.15-14.6) and median length of hospital stay was 2 days (range: 0-24). Mean follow-up time was 50 ± 37 months. The rate of major complications was 22.3%. Revision surgery was performed in 3.4% of the cases. Multivariable analyses demonstrated that increase in BMI (P = 0.007) and active smoking (P = 0.026) were significantly associated with increased odds of major complication, and increase in BMI (P = 0.0004), history of venous thromboembolism (P = 0.034) and having a concomitant ventral hernia repair (P = 0.0044) were significantly associated with having a length of hospital stay of 3 days or more.

Conclusions

Panniculectomy is generally safe to perform, with major postoperative complication rate of 22.3% in our series. Increase in BMI and active smoking were significantly associated with having a major complication. Higher BMI, concomitant hernia repair, and a history of venous thromboembolism were associated with length of hospital stay of 3 days or more.

Is simultaneous panniculectomy an ideal approach to repair a ventral hernia: a general surgeon's experience

BACKGROUND

The number of Australian patients undergoing ventral hernia repair has seen a significant increase in the last twenty years. With the obesity epidemic, the general surgeon is frequently seeing patients with hernias and significant abdominal aprons and is being asked to address this at the time of the hernia repair. This can be performed utilising a general surgery and plastic surgery team, but there may be some advantages to general surgeon being able incorporate this into their practice. We present our approach to patients undergoing ventral hernia repair and simultaneous panniculectomy (VHR + PAN) by a single general surgeon.

METHODS

Data were analysed from a single surgeon's experience performing VHR + PAN at the same operation. Data were collected prospectively from 2009 to 2020. 146 cases of patients undergoing VHR + PAN were identified and included in this study.

RESULTS

The mean age of patients undergoing VHR + PAN was 58 years. The mean BMI was 35, with 59% of patients losing weight loss prior to surgery. 66% of patients had a hernia repair with biosynthetic mesh and 91% of patients had retro-rectus or pre-peritoneal mesh approach to the repair. 42% of patients had a post-operative complication with 80.6% of these being related to surgical-site occurrences. Other complications included gastrointestinal (14%), respiratory (13%) and venous thromboembolism, such as a deep vein thrombus or pulmonary embolism (6%). There were 2 deaths in the series (1.3%). The hernia recurrence rate was 6%.

CONCLUSION

Simultaneous PAN is possible in patients with an abdominal apron who are undergoing VHR, with an acceptable risk of SSOs and other complications. This technique provides excellent exposure and with appropriate training is well within the remit of the general surgeon. This may save further operative management in the future and can offer patients improved self-esteem, mobility, and independence. Patient optimisation is key, paying careful attention to pre-operative weight loss, diabetic control, smoking cessation and respiratory function. VHR + PAN is an important technique that should be in the repertoire of all abdominal wall reconstruction units.

Reducing the Risk of Postoperative Problems With Panniculectomies Using the Prevena Plus™ 125 Incisional Management Dressing

Abdominal wall reconstruction procedures have become increasingly popular in recent years as technology and surgical techniques have improved. The downside to these procedures has been the high rate of postoperative complications. Surgical site infections have been reported as high as 33.7% of the $9.8 billion spent annually on these complications. I present the case of a 62-year-old morbidly obese woman who underwent a combined procedure of abdominal wall reconstruction and panniculectomy. A total of 45 lbs of pannus was removed through a transverse incision that extended from hip to hip, measuring 90 cm in length. Following panniculectomy, abdominal wall reconstruction was performed by mobilizing the abdominal skin flap from the lower abdominal panniculectomy incision (avoiding a T-shaped incision with a traditionally high risk of dehiscence), and placement of biologic mesh as an underlay followed by fascial closure. Prevena Plus™ 125 (3M + KCI, San Antonio, TX) was applied for postoperative closed incisional negative pressure therapy (ciNPT) and continued for 10 days. No postoperative complications occurred. The incision healed without incident with no hernia recurrence at one year. ciNPT in high-risk patients can help minimize the risk of postoperative wound healing complications and should be considered in high-risk patients. Those patients undergoing combined procedures and especially morbidly obese patients undergoing combined abdominal wall reconstruction and panniculectomy are at particularly high risk for wound healing complications. ciNPT should be considered as a postoperative dressing of choice in this challenging patient population.

Postoperative Outcomes in Obese Patients That Undergo Ventral Hernia Repair versus Ventral Hernia Repair with Concurrent Panniculectomy

BACKGROUND

The safety of concurrent panniculectomy during ventral hernia repair remains a widely debated topic. This study aims to compare outcomes in obese patients who undergo ventral hernia repair with concurrent panniculectomy versus ventral hernia repair alone.

METHODS

An 8-year retrospective cohort study was performed on obese patients who underwent ventral hernia repair. Patients were divided into those who underwent concurrent panniculectomy and those who did not. Postoperative complications were compared between these groups.

RESULTS

A total of 223 patients were analyzed: 122 in the ventral hernia repair with concurrent panniculectomy group and 101 in the ventral hernia repair-only group. Median follow-up duration was 141 days. Patients in the ventral hernia repair with concurrent panniculectomy group had more surgical-site occurrences (57 percent versus 40 percent; p = 0.012). Both groups had similar rates of surgical-site occurrences that required an intervention (39 percent versus 31 percent; p = 0.179) and similar rates of hernia recurrence (23 percent versus 29 percent; p = 0.326). Multivariate analysis showed that concurrent panniculectomy increased the risk of surgical-site occurrences by two-fold; however, it did not increase the risk of surgical-site occurrences that required an intervention.

CONCLUSIONS

The addition of a panniculectomy to ventral hernia repair increases surgical-site occurrences but does not increase complications that require an intervention. As such, ventral hernia repair with concurrent panniculectomy can be considered in obese patients with a symptomatic panniculus who wish to have a single-stage operation and the lifestyle benefits of a panniculectomy.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Abdominal Contouring Outcomes in Class III Obesity: Analysis of the ACS-NSQIP Database

BACKGROUND

Obesity may increase the risk of complications following abdominal contouring. The aim of this study is to evaluate panniculectomy outcomes in patients with class III obesity (BMI > 40 kg/m²).

METHODS

The American College of Surgeon's National Surgical Quality Improvement Program ACS-NSQIP (2010-2014) was used to identify patients who underwent panniculectomy. Class III obesity patients were identified. Demographics, comorbidities and postoperative outcomes were evaluated. Risk-adjusted multivariate logistic regression analyses were performed to assess impact of class III obesity on panniculectomy outcomes.

RESULTS

A total of 4497 panniculectomies were identified. Of these, 545 (12.1%) were performed in patients with class III obesity. This group was older (mean age 50.3 vs. 45.9, p < 0.01) with a higher proportion of men (23.4 vs. 12.4%, p < 0.01). Class III obesity group also had higher rates of comorbidities (p < 0.01). Postoperatively, class III obesity patients experienced much higher rates of wound complications (17.8 vs. 6.8%), sepsis (3.3 vs. 0.8%), venous thromboembolism (1.5 vs. 0.7%) and medical complications (6.4 vs. 1.8%), p < 0.05. Additionally, this group had higher rates of unplanned reoperation (9.2 vs. 3.7%) and 30-day readmissions (3.5 vs. 1.0%), p < 0.01. On risk-adjusted multivariate regression analyses, class III obesity was independently associated with increased risk of wound complications (OR 2.22, p < 0.01), sepsis (OR 3.53, p < 0.01), medical adverse events (OR 1.98, p < 0.05), unplanned reoperation (OR 1.62, p < 0.05) and 30-day readmission (OR 2.30, p < 0.05).

CONCLUSION

Class III obesity patients are at significantly increased risk of adverse outcomes following abdominal contouring. Plastic surgeons should consider these risks for counseling and preoperative risk optimization.

LEVEL OF EVIDENCE IV

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