Incisional hernia following liver transplantation: incidence and predisposing factors

Evaluation of Induction Immunosuppression and Risk of Incisional Hernia After Liver Transplantation

INTRODUCTION

Liver transplantation (LT) is a technically complex operation and usually performed on ill patients. A major postoperative morbidity is incisional hernia, occurring in 9.5%-32.4% of cases. There are mixed results in transplant studies regarding potential risk factors. Additionally, the literature is lacking in the relationship between specific immunosuppressive induction agents administered during LT and postoperative incisional hernia.

METHODS

A single center, retrospective cohort study of patients who underwent primary LT between 4/2011-1/2018 was conducted. Clinical variables including demographics and comorbidities were reviewed. The primary end point was the development of an incisional hernia following LT. Sub analysis was performed for secondary end points to determine potential risk factors, including immunosuppressive induction agent.

RESULTS

Overall, 418 patients met inclusion criteria. At 5 y post-LT, there were 66/271 (24.4%) and 53/147 (36.1%) patients diagnosed with an incisional hernia in the methylprednisolone and basiliximab groups, respectively. After propensity score matching, there was no difference in incisional hernia development between induction agents, P = 0.19. For patients with body mass index ≥30 and postoperative seroma of the abdominal wall, the hazard ratios were 2.67 (95% CI = 1.7, 4.3) and 2.03 (95% CI = 1.1, 3.9), respectively.

CONCLUSIONS

Incisional hernia rate after LT was 28.5% at 5 y. Our analysis found that immunosuppressive induction agent at LT was not associated with the development of postoperative incisional hernia. However, preoperative obesity (body mass index ≥30) and postoperative seroma of the abdominal wall were potential risk factors. Further studies are needed to delineate if these risk factors remain across institutions and in alternative settings.

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

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.

Outcomes of a Large Series of Laparoscopic Ventral Hernia Repairs after Liver Transplantation

BACKGROUND

The hernia defects that develop in liver transplant recipients tend to be complex. Unfortunately, there is a paucity of data to guide post-transplant hernia management. Our goal was to evaluate the outcomes following laparoscopic ventral hernia repair (LVHR) in liver transplant recipients.

METHODS

A retrospective review of a prospectively kept database of liver transplant patients at a single tertiary healthcare facility was completed. All patients between 2007 and 2020 who underwent LVHR for a hernia at their transplant incision site were included. The primary outcome studied was hernia recurrence. Secondary outcomes included time-to-hernia repair, complications, and length of stay (LOS).

RESULTS

There were 89 patients who met inclusion criteria. 82% were male, mean age was 60 years, and mean body mass index was 30.2 kg/m2. 94.4% were on tacrolimus and 36% on mycophenolate mofetil. Median time-to-hernia repair was 16 months with a mean mesh size of 743 cm2 and length of stay of 3.7 days. None required conversion to an open operation. Postoperative complications included ileus (20.2%), acute kidney injury (11.2%), pneumonia (6.7%), and bleeding requiring re-operation (1.1%). Hernia-related complications included chronic suture site pain (1.1%), seroma requiring intervention (3.3%), surgical site infection (3.3%), nonoperative mesh infection (1.1%), and mesh infection requiring explantation (1.1%). Median follow-up was 23 months. Hernia recurrence occurred in 4.5% and no predictive variables for recurrence were identified.

CONCLUSIONS

Although the hernia defects that develop in liver transplant recipients are complex and their comorbidities significant, LVHR can safely and effectively repair these defects with low rates of recurrence and complications.

Corticosteroid Dose in Kidney Transplantation and Its Effect on Surgical Complication: A Systematic Review

OBJECTIVES

Although several studies have explored the connection between corticosteroids and renal transplant surgical complications, these studies have overlooked several factors. In addition, no review of the literature, to our knowledge, has been conducted to evaluate corticosteroid dose and incidence of posttransplant surgical complications in these patients. Thus, our objective was to carry out a systematic investigation ofthe correlationbetween corticosteroids and surgical complications in renaltransplant patients.

MATERIALS AND METHODS

A systematic search was conducted on the PubMed and Embase databases from their inception until April 2023. Retrospective and prospective cohort studies were included if they met the association between corticosteroids and surgical complications. The search strategy was performed using MeSH and non-MeSH key words. Terms used in the electronic search included kidney transplant* OR kidney transplant(mesh) AND steroid* OR steroids(mesh) AND complication* OR intraoperative complications(mesh).

RESULTS

From 3274 articles, 8 articles were included in the systematic review. Six studies were conducted as retrospective cohorts and 2 studies as prospective cohorts. The mean age of patients included in the studies was 42.1 years. The studies were conducted between 1981 and 2023. Findings suggested that decreasing the postoperative corticosteroid dosage was associated with a lower incidence of various postoperative surgical complications.

CONCLUSIONS

We investigated the potential benefits of reducing the dose of corticosteroids following kidney transplant. Findings suggested thatreducing the dose of corticosteroids following kidney transplant might be a viable strategy for minimizing the risk of surgical complications. However, it is essential to note that the optimal dosage and duration of corticosteroid therapy after kidney transplant may vary for each patient and should be carefully determined by the health care provider.

Outcomes of Ventral Hernia Repair After Orthotopic Liver Transplant Using Component Separation and Onlay Biologic Mesh

INTRODUCTION

The management of ventral hernias (VHs) after orthotopic liver transplant (OLT) can be uniquely challenging because of immunosuppression coupled with large laparotomy size that can compromise the quality of the abdominal wall. The component separation with multipoint suture onlay acellular dermis fixation technique has proven to be effective in high-risk abdominal wall reconstructions. The goal of this study was to elucidate the factors that affect safety and efficacy of VH repair in post-OLT patients.

METHODS

A retrospective review of 345 patients who underwent repair of VH with compartment separation and onlay acellular dermal matrix reinforcement from a single surgeon from 2012 to 2020 was conducted. Of these, 27 patients were identified with a history of OLT and were stratified based on whether the defect was a initial or recurrent hernia repair. The majority of patients had a standard chevron incision (70%). Data abstraction was performed for preoperative risk factors, hernia characteristics, surgical site complications, and postoperative course including hernia recurrence.

RESULTS

A majority of cases in the study period were initial hernia repairs (59%) with no significant differences in the patient demographics and size of VH defects (190 ± 112.69 cm 2 ). Comorbidities were similar between the groups with the exception of a significantly higher baseline creatinine levels and higher history of smoking in the recurrent hernia repair group ( P < 0.05). Of the 27 cases, there were no demonstrable hernia recurrences noted and an overall 11% complication rate. Univariate analysis noted a statistically significant difference in surgical site complication rate ( P = 0.017), with the initial hernia repair group having the lowest rate of surgical site complications.

CONCLUSIONS

In complex post-OLT patients with large VH, modified component separation with onlay acellular mesh was shown to have acceptable medium-term results. Further studies investigating the factors leading to postoperative complications are necessary to reduce recurrence in this evolving patient population.

EARLY INCISIONAL HERNIA AFTER LIVER TRANSPLANTATION: RISK FACTORS AND HERNIA REPAIR RESULTS

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.

Diaphragmatic Hernia after Pediatric Living Donor Liver Transplantation: An Indian Experience with Review of Literature

Aim:

Although intestinal obstruction following living donor liver transplantation (LDLT) is relatively common, diaphragmatic hernia (DH) as the attributing cause is rarely reported. The study aimed to find out the incidence, clinical presentation, and management of DH after liver transplant in pediatric patients.

Materials and Methods:

A retrospective review of all cases of pediatric liver transplants was performed. Case sheets, operation records, and investigations including radiology were studied.

Results:

Out of 79 cases of pediatric liver transplants, two cases of posttransplant DH were identified. The first case is a 2-year-old male child who was transplanted for progressive familial intrahepatic cholestasis, and the second one is a 4-year-old boy who underwent LDLT for hepatitis A-induced acute liver failure. The first child presented abdominal symptoms and the second one with pulmonary symptoms. The DHs were diagnosed at 132 and 70 days, respectively, posttransplant by chest radiographs and computed tomography scan. The defects were located at the posteromedial aspect of the diaphragm in both the cases and were closed by primary closure with mesh reinforcement. Both the children are doing well with no recurrence.

Conclusion:

High index of clinical suspicion is mandated in pediatric patients after liver transplant and once the diagnosis is confirmed, urgent surgical exploration is mandatory.

Length of stay and surgical site complications are not increased after elective incisional hernia in patients with a history of solid organ transplantation

BACKGROUND

The incidence of ventral hernia development after solid organ transplantation has been reported to be up to 30%. We aim to determine the impact of previous solid organ transplant on post-operative length of stay (LOS) and surgical site complications in elective ventral hernia repairs.

METHODS

A retrospective review of prospectively collected data from the Abdominal Core Health Quality Collaborative (ACHQC) was conducted to include all patients age 18 years or older who underwent elective incisional hernia repair. Those with and without a history of solid organ transplantation were compared. The primary outcome was in-hospital LOS. Secondary outcomes included 30-day surgical site infection (SSI) rate, 30-day surgical site occurrence requiring procedural intervention (SSOPI) rate, 30-day overall post-operative complications and recurrence. The association between transplant and the LOS was tested with a negative binomial regression model adjusted for the demographic characteristics, comorbidities and hernia characteristics in the model.

RESULTS

The population analyzed included 13,452 (98.79%) patients without a history of organ transplantation and 165 (1.21%) patients who had a history of organ transplantation. After adjusting for age, hernia width, BMI, gender, race, insurance type, ASA class, hypertension, dyspnea, OR time > 2 h, abdominal wall SSI history, recurrent hernia, operative approach the median LOS was not significantly different between patients with a history of solid organ transplant [2.8 (2.6, 2.9) days] and those without [2.6 days (2.2, 3.1)] (p = 0.5). The proportion of SSI (2.4% vs 4.04%; p = 0.42), SSOPI (4.2% vs 5.8%; p = 0.38) and recurrence (0.6% vs 0.4%, p = 0.51) was similar between both groups. Other remaining 30-day post-operative were negligible in our sample.

CONCLUSIONS

There were no significant differences in LOS or infection rates between patients with and without a history of solid organ transplantation despite known risks of immunosuppression and chronic steroid use. Therefore, although these patients have many classic risk factors for poor outcomes, the data suggest that their history of solid organ transplantation should not preclude them from surgery.

Risk Factors for Surgical Site Occurrence or Infection and Recurrence After Incisional Hernia Repair in Abdominal Transplant Population

PURPOSE

To investigate risk factors for hernia recurrence, surgical site occurrence/infection (SSO/I) and those requiring procedural intervention (SSOPI) after incisional hernia repair (IHR) following abdominal transplantation.

METHODS

Patients undergoing IHR following abdominal transplant were retrospectively identified in the Americas Hernia Society Quality Collaborative database. Primary outcome measures were SSO/I, SSOPI and hernia recurrence.

RESULTS

There was a total of 166 patients. Seventeen patients (10%) had an SSO/I at 30 days. Overall complication rate was 26%, and there was 1 mortality (1%). Composite recurrence rate was 28% (21/75) over 2 years. In univariate analysis, history of diabetes (DM), body mass index (BMI) >35 kg/m², and history of open abdomen were associated with SSO/I (P < .05). Immunosuppression had a negative correlation with SSO/Is and SSOPIs. BMI >35 kg/m² was associated with 180-day recurrence, whereas history of hypertension remained significant for recurrence at 2 years (P < .05).

CONCLUSION

History of an open abdomen, DM, and obesity are risk factors for SSO/I, and obesity and hypertension are associated with short-term and long-term recurrence after IHR following abdominal organ transplantation. Immunosuppression had negative correlation with SSO/I. However, long-term outcomes and those related to immunosuppression should be interpreted cautiously in view of the small sample size and low follow-up rates. Baseline comorbidities seem to be the main drive for hernia outcomes for transplant population, similar to the general population. Larger cohorts and longer follow-up are necessary to delineate preventable risk factors for SSO/Is and hernia recurrences after organ transplantation.

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.

Incisional hernia after liver transplantation: mesh-based repair and what else?

Purpose

Incisional hernia (IH) is not uncommon after liver transplantation (LT). We investigated the long-term outcome of mesh-based hernia repair using an inlay-onlay technique.

Methods

Our analysis was based on a prospective collected database of all LT recipients from our hospital over a period of 15 years. We analyzed clinical data including the period between LT and hernia development, the size and localization of the hernia, the length of in-hospital stay, immunosuppression, and postoperative morbidity, as well as follow-up data. The median follow-up period was 120 (range 12–200) months.

Results

Among a total of 220 patients who underwent a collective 239 LTs, 29 (13%) were found to have an IH after a median period of 27.5 months (range 3–96 months). There were 12 (41%) men and 17 (59%) women, with a median age of 51 years. The median size of the IH was 13 cm (range 2–30 cm) and the median in-hospital stay was 6 days. Mild postoperative complications developed in seven patients, including two onlay mesh infections. One patient (3.4%) suffered recurrence.

Conclusion

Mesh-based hernia repair using the inlay/onlay technique represents an effective and safe method for patients with an IH after LT, without additional risk from continuous immunosuppression.

Incisional Hernia After Orthotopic Liver Transplantation: A Systematic Review and Meta-analysis

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.

Incisional Hernias Post Liver Transplantation: Current Evidence of Epidemiology, Risk Factors and Laparoscopic Versus Open Repair. A Review of the Literature

BACKGROUND/AIM

The occurrence of an incisional hernia after liver transplantation consists of a potential complication that may seriously affect the postoperative course and the quality of patient's life in general. The purpose of this study was to report the current epidemiological data, analyze the risk factors, evaluate the role of laparoscopic repair in this condition, and present the technical difficulties in the management of this special patient group.

MATERIALS AND METHODS

A literature search was performed through PubMed. Our criteria included all studies published from March 1982 to February 2019 in English, regarding incisional post-transplant hernias and open or laparoscopic repair. Finally, we collected 19 relevant studies.

RESULTS

Incisional hernia may occur independently of the type of abdominal incision. Risk factors are both patient- and technique-related.

CONCLUSION

Well-organized randomized controlled studies are needed, in order to estimate the best treatment strategy for these patients.

Utility of a modified components separation for abdominal wall reconstruction in the liver and kidney transplant population

Background

Incisional hernia is a common complication following visceral organ transplantation. Transplant patients are at increased risk of primary and recurrent hernias due to chronic immune suppression and large incisions. We conducted a retrospective review of patients with a history of liver or kidney transplantation who underwent hernia repair to analyze outcomes and hernia recurrence.

Methods

This is a single center, retrospective review of 19 patients who received kidney and/or liver transplantation prior to presenting with an incisional hernia from 2011 to 2017. All hernias were repaired with open component separation technique (CST) with biologic mesh underlay.

Results

The mean age of patients was 61.0±8.3 years old, with a mean body mass index of 28.4±4.8 kg/m², 15 males (78.9%), and four females (21.1%). There were seven kidney, 11 liver, and one combined liver and kidney transplant patients. The most common comorbidities were hypertension (16 patients, 84.2%), diabetes (9 patients, 47.4%), and tobacco use (8 patients, 42.1%). Complications occurred in six patients (31.6%) including hematoma (1/19), abscess (1/19), seroma (2/19), and hernia recurrence (3/19) at mean follow-up of 28.7±22.8 months. With the exception of two patients with incomplete follow-up, all patients healed at a median time of 27 days.

Conclusions

This small, retrospective series of complex open CST in transplant patients shows acceptable rates of long-term hernia recurrence and healing. By using a multidisciplinary approach for abdominal wall reconstruction, we believe that modified open CST with biologic mesh is a safe and effective technique in the transplant population with complex abdominal hernias.

Postoperative renal impairment is associated with increased length of stay for incisional hernia repair after liver transplantation

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

PRevention of INCisional hernia after liver transplantation (PRINC trial): study protocol for a randomized controlled trial

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.

Very Early Introduction of Everolimus in De Novo Liver Transplantation: Results of a Multicenter, Prospective, Randomized Trial

Early everolimus (EVR) introduction and tacrolimus (TAC) minimization after liver transplantation may represent a novel immunosuppressant approach. This phase 2, multicenter, randomized, open-label trial evaluated the safety and efficacy of early EVR initiation. Patients treated with corticosteroids, TAC, and basiliximab were randomized (2:1) to receive EVR (1.5 mg twice daily) on day 8 and to gradually minimize or withdraw TAC when EVR was stable at >5 ng/mL or to continue TAC at 6-12 ng/mL. The primary endpoint was the proportion of treated biopsy-proven acute rejection (tBPAR)-free patients at 3 months after transplant. As secondary endpoints, composite tBPAR plus graft/patient loss rate, renal function, TAC discontinuation rate, and adverse events were assessed. A total of 93 patients were treated with EVR, and 47 were controls. After 3 months from transplantation, 87.1% of patients with EVR and 95.7% of controls were tBPAR-free (P = 0.09); composite endpoint-free patients with EVR were 85% (versus 94%; P = 0.15). Also at 3 months, 37.6% patients were in monotherapy with EVR, and the tBPAR rate was 11.4%. Estimated glomerular filtration rate was significantly higher with EVR, as early as 2 weeks after randomization. In the study group, higher rates of dyslipidemia (15% versus 6.4%), wound complication (18.32% versus 0%), and incisional hernia (25.8% versus 6.4%) were observed, whereas neurological disorders were more frequent in the control group (13.9% versus 31.9%; P < 0.05). In conclusion, an early EVR introduction and TAC minimization may represent a suitable approach when immediate preservation of renal function is crucial.

Predictors of incisional hernia in adult liver transplant recipients

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.

Acquired diaphragmatic hernia in pediatrics after living donor liver transplantation: Three cases report and review of literature

RATIONALE

Diaphragmatic hernia (DH) in pediatrics following living donor liver transplantation (LDLT) has been seldom reported in the past.

PATIENT CONCERNS

We report successful diagnosis and treatment of three pediatric cases with DH secondary to LDLT, discuss the possible etiology, and review the relevant literature.

DIAGNOSES

The primary disease was biliary atresia and DH was diagnosed by computed tomography scan or x-ray of chest.

INTERVENTIONS

Laparotomy was performed successfully to repair the DH.

OUTCOMES

The respiratory and digestive function was gradually recovered in 1 to 2 weeks after repair operation. In 2 to 8 months follow-up, patients were asymptomatic without any respiratory or digestive complications.

LESSONS

DH post-LDLT should be recognized as a possible complication when a left lateral segment graft is used. Careful clinical examination and prompt surgery could minimize complications.

[Treatment of postoperative ventral hernias in recipients of solitary organs]

AIM

To perform retrospective analysis of treatment of postoperative ventral hernias (PVH) in kidney and extrarenal organs recipients, to assess its safety and effectiveness.

MATERIAL AND METHODS

Hernia repair has been performed in 84 PVH patients for the period from May 2006 to November 2017. The main group consisted of 41 patients (24 males, 17 females, mean age 55 (44; 59)) years with PVH due to previous transplantation. The control group included 43 PVH patients (21 males, 22 females, mean age 51 (50, 56)) years without previous transplantation.

RESULTS

Incidence of surgical complications was similar in two groups: 63.4% in group 1 vs. 53.5% in group 2 (p>0.05). There were no significant differences in the incidence of surgical complications depending on immunosuppressive therapy and synthetic endoprosthesis deployment technique.

CONCLUSION

Treatment of postoperative ventral hernias using synthetic endoprostheses in recipients of solid organs is effective and safe and should be considered as a preferable in treatment of this pathology.

Incisional Hernia After Liver Transplant

OBJECTIVES

An incisional hernia seriously burdens the quality of life after liver transplant. The incidence of incisional hernia after liver transplant is reported to be 4% to 20%. Here, we evaluated incisional hernias that occurred after adult liver transplant and incisional hernias intentionally made in infant liver transplant procedures.

MATERIALS AND METHODS

Between December 1988 and May 2016, we performed 536 liver transplant procedures in 515 patients. Demographic features, surgical outcomes, and predisposing factors were evaluated.

RESULTS

Of 452 liver transplant patients included, incisional hernias were diagnosed in 29 patients (6.4%; 7 pediatric, 22 adult). Most were males (77%) with Child-Pugh score C cirrhosis (62%), moderate/severe ascites (81%), and serum albumin levels <3.5 g/L (86%). Incisional hernia developed in 16 of 51 patients (31%) with wound infection. Twelve incisional hernias were seen in 40 recipients (30%) with body mass index ≥30 kg/m2. Eight of 45 patients (18%) with repeated surgery had incisional hernias. Five of 22 adult incisional hernias (23%) had primary fascia repair, and 17 (77%) were repaired with Prolene mesh graft (3 sublay, 14 onlay). No other complications and no hernia recurrence were shown during follow-up (range, 8-138 mo). Of 7 pediatric liver transplant patients with intentionally made incisional hernias during liver transplant, 5 patients had primary fascia repair and 2 patients had onlay mesh repair. No complications or recurrence were shown during follow-up (range, 12-60 mo).

CONCLUSIONS

Repeated surgery, postoperative wound infection, and obesity were found to be predisposing risk factors for incisional hernia development after liver transplant in adults. Abdomen closure in infant liver transplant with large-for-size grafts is a different area of discussion. Here, we suggest that an intentionally made incisional hernia with staged closure of the abdomen is safe and effective for graft and patient survival.

Laparoscopic Repair of Incisional Hernia Following Liver Transplantation-Early Experience of a Single Institution in Taiwan

BACKGROUND

Ventral incisional hernia (VIH) is not uncommon following liver transplantation. Open repair was traditionally adopted for its management. Laparoscopic repair of VIH has been performed successfully in nontransplant patients with evidence of reduced recurrence rates and hospital stay. However, the application of VIH in post-transplantation patients has not been well established. Herein, we provide our initial experience with laparoscopic repair of post-transplantation VIH.

METHODS

From March 2015 to March 2016, 18 cases of post-transplantation VIH were subjected to laparoscopic repair (laparoscopy group). A historical control group of 17 patients who underwent conventional open repair (open group) from January 2013 to January 2015 were identified for comparison. The demographics and clinical outcomes were retrospectively compared.

RESULTS

There were no significant differences among basic demographics between the 2 groups. No conversion was recorded in the laparoscopy group. Recurrence of VIH up to the end of the study period was not noted. In the laparoscopy group, the minor complications were lower (16.7% vs 52.9%; P = .035), the length of hospital stay was shorter (3 d vs 7 d, P = .007), but the median operative time was longer (137.5 min vs 106 min; P = .003).

CONCLUSIONS

Laparoscopic repair of post-transplantation VIH is a safe and feasible procedure with shorter length of hospital stay.

Imaging panorama in postoperative complications after liver transplantation

The liver is the second most-often transplanted solid organ after the kidney, so it is clear that liver disease is a common and serious problem around the globe. With the advancements in surgical, oncological and imaging techniques, orthotopic liver transplantation has become the first-line treatment for many patients with end-stage liver disease. Ultrasound, and Doppler are the most economical and cost-effective imaging modalities for evaluating postoperative fluid collections and vascular complications. Computed tomography (CT) is used to confirm the findings of ultrasound and look for pulmonary complications. Magnetic resonance imaging (MRI) is used for the diagnosis of biliary complications, bile leaks and neurological complications. This article illustrates the imaging options for diagnosing the various complications that can be encountered in the postoperative period after liver transplantation.

Incisional hernia in recipients of adult to adult living donor liver transplantation

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.

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.

Diaphragmatic hernia after liver transplantation in children: case series and review of the literature

A diaphragmatic hernia (DH) is a rare complication of pediatric liver transplantation (LT), with multiple factors implicated in the pathophysiology. It is a potentially life-threatening condition in the absence of early recognition and surgical treatment. A DH after LT has been reported in 16 patients in 7 case series. We report 10 cases from our institution and review the published literature to understand the underlying pathophysiology. The study sample included all children (<18 years of age) who underwent LT from October 1989 to August 2013 at our center and subsequently presented with a DH. Among 4433 LT procedures performed in this time period, 1032 were for children. Ten DH cases were recognized, and risk factors were assessed. The mean age at diagnosis was 4.9 years, all patients with a DH received left lateral segment split grafts, and the mean graft weight was 248 ± 41 g with a mean graft-to-recipient body weight ratio (GBWR) of 3% ± 1.22% (range = 1.7%-5.0%). The mean cold ischemia time was 510.7 ± 307.6 minutes (range = 60-900 minutes). Six patients had a primary abdominal muscle closure, 3 had a temporary Silastic mesh closure, and 1 had a skin closure only. Postoperative ascites and pleural effusion did not appear to be significant risk factors. All 10 children presented with a right posterolateral DH, with 1 also having a left DH. The small bowel was herniated in the majority. All patients underwent prompt surgical intervention without complications. An early age, a split graft, and a high GBWR may be risk factors for a DH. A high index of suspicion and prompt surgical intervention minimize complications.

Effectiveness of porcine dermal collagen in giant hernia closure in patients with deleterious fascia constitution after orthotopic liver transplantation

Incisional hernias (IHs) occur universally after orthotopic liver transplantation (OLT). This study aimed to investigate the effectiveness of porcine dermal collagen (PDC) as a closing aid in giant hernias after OLT in a prospective trial. If direct closure (DC) was not feasible due to the hernia size and abdominal wall constitution, a PDC mesh was implanted. All patients from the PDC and DC groups were followed prospectively for 24 months. IH recurrence rates served as the primary endpoint, and the development of infections and wound healing disorders served as the secondary endpoints. Recurrence rate was 21% (4/19) in DC patients and 12% (2/16) in PDC patients (P = 0.045). Implant site infections occurred in five of PDC and one of DC patients (P < 0.05). All of them were managed with antibiotics; two of the PDC patients required surgical drainage. Histological analysis of PDC mesh biopsies indicated good angiogenesis and integration of the PDC into the abdominal wall. PDC was effective in our study for incisional hernia repair, and our results compared favourably with those of patients in whom direct hernia closure was feasible.

A meta-analysis of complications following deceased donor liver transplant

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.

Intrahepatic cholangiocarcinoma in a transplant liver--selective internal radiation therapy followed by right hemihepatectomy: report of a case

Intra- or extrahepatic cholangiocarcinomas are the second most common primary liver malignancies behind hepatocellular carcinoma. Whereas the incidence for intrahepatic cholangiocarcinoma is rising, the occurrence of extrahepatic cholangiocarcinoma is trending downwards. The treatment of choice for intrahepatic cholangiocarcinoma remains liver resection. However, a case of liver resection after selective internal radiation therapy in order to treat a recurrent intrahepatic cholangiocarcinoma in a transplant liver is unknown in the literature so far. Herein, we present a case of a patient undergoing liver transplantation for Wilson’s disease with an accidental finding of an intrahepatic cholangiocarcinoma within the explanted liver. Due to a recurrent intrahepatic cholangiocarcinoma after liver transplantation, a selective internal radiation therapy with yttrium-90 microspheres was performed followed by right hemihepatectomy. Four years later, the patient is tumor-free and in a healthy condition.

Incisional hernia after liver transplantation: risk factors and health-related quality of life

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.

Laparoscopic repair of incisional hernia in solid organ-transplanted patients: the method of choice?

Due to immunosuppressive (IS) therapy, incisional hernias are overrepresented in the organ-transplanted (Tx) population with larger defects, a high rate of recurrence, and a tendency toward more seromas and infectious problems. Thirty-one Tx/IS patients with a control group of 70 non-IS patients with incisional hernia (6/7 recurrences) were included in a prospective interventional study. Both cohorts were treated with laparoscopic ventral hernia repair (LVHR). Follow-up time and rate was 37 months and 95%. One hundred LVHR's were completed as there was one conversion in the Tx/IS group. No late infections or mesh removals occurred. Recurrence rates were 9.7% vs. 4.2% (P = 0.37) and the overall complication rates were 19% vs. 27% (P = 0.80). The Tx/IS group had a higher mesh-protrusion rate (29% vs. 13%, P = 0.09), but also larger hernias. Polycystic kidney disease was overrepresented in the Tx cohort (44% of kidney-Tx). Incisional hernias in Tx/IS patients may be treated by LVHR with the same low complication rate and recurrence rate as non-IS patients. By LVHR, the highly problematic seroma/infection problems encountered in Tx/IS patients treated by conventional open technique seem almost eliminated. The minimally invasive procedure seems particularly rational in the Tx/Is population and should be the method of choice. (ClinicalTrials.gov number: NCT00455299, date: 5 May 2006).

Late post liver transplant protein losing enteropathy: Rare complication of incisional hernia

Development of oedema and hypoproteinaemia in a liver transplant recipient may be the first signs of graft dysfunction and should prompt a full assessment. We report the novel case of a patient who, years after liver transplantation developed a functional blind loop in an incisional hernia, which manifested as oedema and hypoproteinaemia secondary to protein losing enteropathy. After numerous investigations, the diagnosis was made by flurodeoxyglucose positron emmision tomography (FDG-PET) imaging. Surgical repair of the incisional hernia was followed several months later by resolution of the protein loss, and confirmed at a post operative FDG-PET scan at one year.

Uncommon gastrointestinal complications after liver transplantation: radiologic findings and clinical features

There are various uncommon gastrointestinal complications, as liver transplantation becomes increasingly popular as the only curative method for patients with end-stage liver diseases. It is important for radiologists evaluating postoperative liver transplantation recipients to have a perspective on the possible gastrointestinal complications after liver transplantation and their radiologic features for early detection and early treatment. This article illustrates radiologic findings and clinical features of various uncommon gastrointestinal complications after liver transplantation.

Early use of mammalian target of rapamycin inhibitors is an independent risk factor for incisional hernia development after liver transplantation

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.

Feasibility and effectiveness of laparoscopic incisional hernia repair after liver transplantation

BACKGROUND

Incisional hernia is a frequent problem after liver transplantation. It is related to immunosuppression, use of steroids, obesity, as well as the type of incision. Laparoscopic repair shows a lower rate of complications in terms of infection and recurrence, as well as reduced postoperative pain and faster recovery.

METHODS

We reviewed our experience with laparoscopic incisional hernia repair (LIHR) in patients after liver transplantation, using the BARD Composix mesh which is composed of two layers of polypropylene and polytetrafluoroethylene (PTFE) and fixed with metal ProTack.

RESULTS

Between March 2002 and April 2010, we performed 20 LIHR in 17 male and three female subjects of overall mean age of 58.3 years, and body mass Index of 31.05 kg/m(2). The mean size of the defects was 215.25 cm(2). All patients had undergone bilateral subcostal incisions with a midline extension, and seven had additional operations after the transplantation for various reasons. There were no differences in immunosuppression. Three patients had needed steroid boluses for acute graft rejection episodes. There was no conversion of therapy. The size of mesh was 18 × 23 cm in seven cases and 20 × 25 in 12 cases. The mean postoperative hospital stay was 2.1 days. Oral feeding was initiated a few hours after surgery, and routine immunosuppression was not discontinued. There were no major early complications. During follow-up, we identified one patient with a mesh infection (5%) and one with a recurrence (5%).

CONCLUSION

LIHR is safe and feasible even for major hernias after liver transplantation with few complications.

Switching to sirolimus-based immune suppression after liver transplantation is safe and effective: a single-center experience

BACKGROUND

Sirolimus is unlicensed for use in liver transplantation because of concerns over safety, particularly in regard to hepatic artery thrombosis and excess mortality. However, sirolimus offers potential advantages over calcineurin inhibitor-based immunosuppression, relating to its renal sparing and antiproliferative properties.

METHODS

A review was undertaken of 148 liver transplant patients converted to sirolimus over 10 years at a single center.

RESULTS

The main indications for sirolimus were renal impairment and hepatitis C virus fibrosis. One hundred eleven (75%) patients remained on sirolimus after median follow-up of 1006 days. Mean (+/-standard deviation) glomerular filtration rate improved significantly from 59+/-29 mL/min preconversion to 72+/-39 mL/min at censor point (P<0.05). Improvement in glomerular filtration rate was most marked in patients converted for renal impairment. Liver function tests remained stable or improved, particularly in patients transplanted for hepatitis C virus. Side effects attributed to sirolimus occurred in 101 (68%) patients requiring withdrawal in 20 patients (14%). Moderate increases in serum lipids were observed and controlled effectively with statins. The incidence of proteinuria increased postconversion but had no deleterious impact on renal function. No episodes of hepatic artery thrombosis were observed.

CONCLUSIONS

Sirolimus was safe and may improve outcome in selected patients after liver transplantation.

Diaphragm rupture in a liver transplant patient under chronic immunosuppressive therapy with sirolimus: rare complication after liver transplantation

A diaphragm rupture is a very rare event. A variety of conditions such as coughing, delivery, and vigorous exercise causing a sudden increase of the intra-abdominal pressure can result in diaphragm rupture [1]. The diagnosis can be difficult because of non-specific symptoms and no history of blunt or penetrating trauma. Due to anatomical reasons, diaphragmatic lesions in the left side are more common than those in the right side. Chronic immunosuppressive therapy in transplanted patients, especially with antiproliferative drugs such as mTOR inhibitor, has been considered as a risk factor for the development of incisional hernia [2, 3]. We present the case of diaphragm rupture in a liver transplant patient under chronic immunosuppressive therapy with sirolimus.

Liver and vascularized posterior rectus sheath fascia composite tissue allotransplantation

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.

Human acellular dermal matrix for ventral hernia repair reduces morbidity in transplant patients

PURPOSE

Organ transplantation is widely accepted as the treatment of choice for native organ failure. Due to required immunosuppression, however, organ recipients are prone to wound infections, incisional hernias, and fascial dehiscence. These complications are especially dangerous in this patient population, as they can compromise the survival of the transplanted organ. Various methods have been employed to repair ventral and incisional hernias in these patients. These include primary repair, synthetic mesh, biologic mesh, tensor fascia lata grafts (TFL), component separation, flaps from the thighs, or a combination of these. The goal of this study was to review the experience at our institution with ventral hernia repair in transplant patients and to compare outcomes of the various repair techniques.

METHODS

Patients with liver, renal, or pancreas transplants requiring immunosuppression who underwent a ventral or incisional hernia repair at the University of Maryland from 2000-2005 were reviewed retrospectively. Factors examined include type and location of hernia, type of repair, post operative infection, hernia recurrence, reoperation, mesh removal, and length of follow up. Complication rates were compared using odds ratio and chi-square.

RESULTS

A total of 104 patients met the criteria with a mean length of follow up of 26 months. Of these, 34 patients had repair with human acellular dermal matrix (HADM), 26 had synthetic mesh, 25 had primary repair, and 9 had TFL. Rates of wound infection in these groups were 15, 65, 8, and 11% respectively (χ (2) = 28, P < 0.001). Rates of recurrence were 24, 77, 36, and 11% respectively (χ (2) = 22, P < 0.001). The rate of mesh removal with HADM and synthetic mesh were 12 and 69%, respectively (χ (2) = 14, P < 0.001). When comparing HADM and synthetic mesh, the odds ratio for wound infection is 11 (95% CI 3.2-38) and for mesh removal is 8.7 (95% CI 2.6-28).

CONCLUSION

When repairing ventral or incisional hernias in immunosuppressed transplant patients, HADM provides significantly reduced morbidity from reduced rates of infection, recurrence, and need for operative removal of mesh.

Incisional hernia repair after liver transplantation: role of the mesh

BACKGROUND

Patients undergoing orthotopic liver transplantation (OLT) show a high risk of developing an incisional hernia. The aim of this retrospective study was to establish the incidence and the factors influencing the outcomes of this complication.

METHODS

We reviewed 450 consecutive OLT performed in 422 adult recipient between January 2000 and December 2005. Herniae were analysed with aspect to localization, classification, repair technique, and recurrence. All treated herniae were followed for a median of 50.5 months.

RESULTS

Incisional herniae occurred in 36 patients (8.5%, Group 1). Their mean age OLT was 51.4 years with 94.4% male subjects. No significant difference was observed between affects and unaffected individuals for age, OLT indication, Child-Pugh score, albumin, comorbidities, operative time, transfusions, immunosuppressant regimen, and graft rejection episodes as well as for the incisional approach and hospital stay. Gender, body mass index (BMI), preoperative ascites, and pulmonary complications after OLT were significantly different (P < .01). Herniae were small (<5 cm; n = 12), medium (5-10 cm; n = 28), or large (> 10 cm; n = 2). Herniorrhaphy techniques included primary suture repair in 5 (13.9%) and mesh repair in 31 (86.1%) cases. In 3 patients with a primary repair and 1 patient with a mesh repair there were recurrences.

CONCLUSIONS

Preoperative ascites, gender, BMI, and pulmonary complications after OLT seemed to have significant influences on the formation of incisional herniae. Polypropylene mesh may be a first choice for the surgical treatment of there transplant recipients.

Sirolimus-based immunosuppression is associated with increased survival after liver transplantation for hepatocellular carcinoma

Liver transplantation is an important treatment option for selected patients with nonresectable hepatocellular carcinoma (HCC). Several reports have suggested a lower risk of posttransplant tumor recurrence with the use of sirolimus and a higher one with calcineurin inhibitors, but the selection of an ideal immunosuppression protocol is still a matter of debate. The aim of this study was to define the immunosuppression associated with the best survival after liver transplantation for HCC. It was based on the Scientific Registry of Transplant Recipients and included 2,491 adult recipients of isolated liver transplantation for HCC and 12,167 for non-HCC diagnoses between March 2002 and March 2009. All patients remained on stable maintenance immunosuppression protocols for at least 6 months posttransplant. In a multivariate analysis, only anti-CD25 antibody induction and sirolimus-based maintenance therapy were associated with improved survivals after transplantation for HCC (hazard ratio [HR] 0.64, 95% confidence interval [CI]: 0.45-0.9, P < or = 0.01; HR 0.53, 95% CI: 0.31-0.92, P < or = 0.05, respectively). The other studied drugs, including calcineurin inhibitors, did not demonstrate a significant impact. In an effort to understand whether the observed effects were due to a direct impact of the drug on tumor or more on liver transplant in general, we conducted a similar analysis on non-HCC patients. Although anti-CD25 induction was again associated with a trend toward improved survival, sirolimus showed a trend toward lower rates of survival in non-HCC recipients, confirming the specificity of its beneficial impact to cancer patients.

CONCLUSION

According to these data, sirolimus-based immunosuppression has unique posttransplant effects on HCC patients that lead to improved survival.

Laparoscopic incisional hernia repair is feasible and safe after liver transplantation

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.

Late surgical complications following liver transplantation

1. Biliary strictures and incisional hernias are the most common surgical complications encountered late after liver transplantation. 2. Anastomotic biliary strictures are amenable to endoscopic intervention and rarely need surgical intervention. 3. The presence of a biliary stricture mandates an evaluation of the patency of the hepatic artery. 4. Ischemic-type intrahepatic strictures are common indications for retransplantation.5. Recipients of living related liver transplantation and donation after cardiac death allografts are at the highest risk for biliary and vascular complications late after transplantation.

Incidence of abdominal wall numbness post-liver transplantation and its complications

Liver transplantation (LTx) is a life-saving procedure for end-stage liver disease. However, LTx remains a major surgical procedure with a significant amount of morbidity and mortality. Several different types of post-LTx complications have been studied and reported; however, the numbness of the abdominal skin between the subcostal incision and the umbilicus and its associated complications have not been studied in a large patient population. The aim of this study was to report the incidence of numbness in the abdominal skin post-LTx and its implications in routine life. One hundred and one post-LTx patients were questioned in the clinic about numbness. There were 52 male patients and 49 female patients with a mean age of 51.9 +/- 11.3 years at the time of LTx, and the mean time from transplant was 35.0 +/- 29.5 months (range, 3-113 months). The implications were recorded. All 101 patients (100%) had an area of numbness between the subcostal incision and the umbilicus. Four of these patients had an area of superficial-to-deep burns from hot food (accidentally dropped on the abdomen), heating pads, or a hot cup of tea. One patient had ecchymosis from blunt trauma during gardening. Out of 36 diabetic patients, more than 24 patients were insulin-dependent and used the area for subcutaneous insulin injections. In addition, some of the 43 hepatitis C virus-positive patients used the area for subcutaneous interferon therapy. In conclusion, 100% of the patients had persistent numbness up to 9 years following LTx. Five percent of the patients developed thermal injuries or blunt trauma complications that could have been prevented with better education and awareness. More then 24% of the patients used the area for subcutaneous injections of insulin and/or interferon.