Panniculectomy at the time of living donor renal transplantation: An 8-year experience

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.

Robot-assisted kidney transplantation in a morbidly obese patient with incisional hernia reconstruction and abdominoplasty: a case report

Performing kidney transplantations in patients with morbid obesity presents unique challenges using the conventional retroperitoneal approach. Robot-assisted kidney transplantation (RAKT) offers several advantages, such as better access to hard-to-reach areas. A 56-year-old morbidly obese woman presented with end-stage renal disease due to diabetic nephropathy. The patient had a history of obesity for over 20 years, with a peak body mass index (BMI) of 46.9 kg/m2. Before transplantation, she successfully reduced her BMI to 28.9 kg/m2, but was left with excessive skin folds. The surgery began with the removal of the sac from the incisional hernia and umbilical hernia, which was then used as the site for the GelPOINT port. The da Vinci X robot system was utilized to perform RAKT. After completing RAKT, the plastic surgery team initiated abdominal reconstruction involving panniculectomy, followed by hernial reconstruction and abdominoplasty. The patient's postoperative course was uneventful, and she was discharged on postoperative day 7. Her creatinine level was 0.69 mg/dL, and she did not experience any episodes of rejection during the 16 months following RAKT. This case report describes the successful combination of RAKT with incisional hernia reconstruction and abdominoplasty in a patient with morbid obesity.

Obesity Metabolic Phenotypes and Unplanned Readmission Risk in Diabetic Kidney Disease: An Observational Study from the Nationwide Readmission Database

BACKGROUND AND AIM

Obesity is a potentially modifiable factor for reducing readmissions, with heterogeneity that varies according to the metabolic status. Our objective was to examine the independent or mutual relationship between obesity and metabolic abnormalities and diabetic kidney disease (DKD)-related hospitalizations.

METHODS

493,570 subjects with DKD were enrolled in the 2018 Nationwide Readmission Database (NRD, United States). The at-risk population was reclassified into refined obesity subtypes based on the body mass index (BMI) classification of metabolic abnormalities (hypertension and/or dyslipidemia) to investigate the 180 d readmission risk and hospitalization costs related to DKD.

RESULTS

The overall readmission rate was 34.1%. Patients with metabolic abnormalities, regardless of obesity, had a significantly higher risk of readmission compared to non-obese counterparts (adjusted HR, 1.11 [95% CI, 1.07-1.14]; 1.12 [95% CI, 1.08-1.15]). Hypertension appeared to be the only metabolic factor associated with readmission among individuals with DKD. Obesity without metabolic abnormalities was independently associated with readmission (adjusted HR,1.08 [1.01,1.14]), especially among males and those >65 years (adjusted HR,1.10 [1.01-1.21]; 1.20 [1.10-1.31]). Women or those ≤65 years with metabolic abnormalities (all p <0.050) had elevated readmission rates, regardless of obesity; however, no such trend was observed in obese subjects without metabolic abnormalities (adjusted HR, 1.06 [0.98,1.16]). Additionally, obesity and metabolic abnormalities were associated with elevated hospitalization costs (all p <0.0001).

CONCLUSIONS

Increased BMI and hypertension are positively associated with readmissions and related costs among patients with DKD, which should be considered in future studies.

Abdominal Panniculectomy Can Simplify Kidney Transplantation in Obese Patients

BACKGROUND

Obesity is frequently present in patients suffering from end-stage renal disease (ESRD). However, overweight kidney transplant candidates are a challenge for the transplant surgeon. Obese patients tend to develop a large abdominal panniculus after weight loss creating an area predisposed to wound-healing disorders. Due to concerns about graft survival and postoperative complications after kidney transplantation, obese patients are often refused in this selective patient cohort. The study aimed to analyze the effect of panniculectomies on postoperative complications and transplant candidacy in an interdisciplinary setting.

METHODS

A retrospective database review of 10 cases of abdominal panniculectomies performed in patients with ESRD prior to kidney transplantation was conducted.

RESULTS

The median body mass index was 35.2 kg/m2 (range 28.5-53.0 kg/m2) at first transplant-assessment versus 31.0 kg/m2 (range 28.0-34.4 kg/m2) at panniculectomy, and 31.6 kg/m2 (range 30.3-32.4 kg/m2) at kidney transplantation. We observed no major postoperative complications following panniculectomy and minor wound-healing complications in 2 patients. All aside from 1 patient became active transplant candidates 6 weeks after panniculectomy. No posttransplant wound complications occurred in the transplanted patients.

CONCLUSION

Abdominal panniculectomy is feasible in patients suffering ESRD with no major postoperative complications, thus converting previously ineligible patients into kidney transplant candidates. An interdisciplinary approach is advisable in this selective patient cohort.

Implications for body weight extremes in solid organ transplantation

The pharmacokinetic profiles of medications are altered in overweight and underweight patients, but few studies have described these differences in patients with body mass index extremes. As solid organ transplant programs expand their candidate selection criteria to accommodate a growing population of patients with weight extremes, it has become imperative to understand and evaluate the impact weight extremes have on the pharmacokinetics of life-sustaining immunosuppression in this population. This review will describe pharmacokinetic and dosing considerations for weight extremes in solid organ transplant recipients, including changes following bariatric surgeries, non-pharmacologic and pharmacologic management strategies for weight loss and gain, and potential drug-drug interactions with popular weight management products.

Panniculectomy at the time of bariatric surgery: a propensity score-matched analysis of outcomes in the MBSAQIP database

BACKGROUND

Body contouring in the postbariatric surgery patient improves quality of life and daily function.

OBJECTIVES

To determine the risk profile of panniculectomy when performed in select patients at the time of bariatric surgery.

SETTING

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) participating centers.

METHODS

We examined the MBSAQIP database (2016-2017), in which data on 379,544 bariatric surgeries are reported. Concurrent panniculectomy procedures were identified by Current Procedural Technology (CPT) codes. Patient characteristics and in-hospital as well as 30-day complications were compared between the body contouring group and propensity score-matched bariatric surgery controls.

RESULTS

One hundred twenty-four patients met inclusion criteria and were matched to 248 controls. An infra-umbilical panniculectomy was performed in the majority of patients (n = 94, 75.8%). Most patients received an open rather than laparoscopic bariatric surgery (n = 87, 70.2%). There were no statistically significant differences between 30-day mortality (1.9%), wound complications (11.5%), readmission (12.5%) and reoperation (5.8%) between the 2 groups (P > .05). Wound complications occurred in 11.5% of patients and were associated with prolonged hospital stay (odds ratio 4.65, 95% confidence interval 1.99-10.86, P < .001) and a body mass index (BMI) > 50 (odds ratio 3.19, 95% confidence interval 1.02-9.96, P = .046).

CONCLUSION

In select patients, panniculectomy at the time of bariatric surgery was not associated with increased in-hospital or 30-day adverse outcomes compared with matched bariatric surgery controls. This procedure may be performed in select patients, with awareness that revision surgery may be needed once weight loss stabilizes.