Abdominal Panniculectomy Can Simplify Kidney Transplantation in Obese Patients

Abstract

<b><i>Background:</i></b> 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. <b><i>Methods:</i></b> A retrospective database review of 10 cases of abdominal panniculectomies performed in patients with ESRD prior to kidney transplantation was conducted. <b><i>Results:</i></b> The median body mass index was 35.2 kg/m<sup>2</sup> (range 28.5–53.0 kg/m<sup>2</sup>) at first transplant-assessment versus 31.0 kg/m<sup>2</sup> (range 28.0–34.4 kg/m<sup>2</sup>) at panniculectomy, and 31.6 kg/m<sup>2</sup> (range 30.3–32.4 kg/m<sup>2</sup>) 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. <b><i>Conclusion:</i></b> 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.

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

“…21 In this review, the majority of patients became candidates after panniculectomy, though it is not clear in these studies whether this was due to weight loss, panniculectomy further reducing BMI, or factors not discussed in the manuscripts. However, as pointed out by Promny et al (2021), panniculectomy in the context of ESRD should focus on function rather than aesthetics. Additional body contouring procedures, while possible, do increase rates of complications and worsen outcomes.…”

“…Additional body contouring procedures, while possible, do increase rates of complications and worsen outcomes. 9 Ultimately, the risks of plastic surgery could potentially exceed the functional benefits to ESRD patients. Therefore, it is important to evaluate candidates for panniculectomy not as a pathway to weight loss prior to transplantation, but rather as an elective procedure which will, ideally, help assure a lower risk of complication for renal transplantation.…”

“…27 The cohort in this review demonstrated an exceptional graft survival greater than 98%, suggesting that panniculectomy performed in the obese ESRD population confers a negligible risk to graft survival. 9,16,17 Secondly, obesity, especially in BMI above 35 kg/m 2 , is largely associated with comorbid conditions that impact graft survival, including diabetes and hypertension. 20 While panniculectomy may not directly impact the course of such conditions, reduction of overall adipose tissue has been associated with improvements in glycemic and lipid levels.…”

“…In eight articles, authors described performing the transverse technique, a single surgical incision is performed allowing for horizontal pannus dissection. 9,13,[15][16][17][18][19] One study also employed the Fleur-de-Lis technique in which both horizontal and vertical incisions are carried, increasing the possible amount of skin ressected. 14 Surgical drains were routinely placed in all but one study.…”

“…In surgeries performed at the lower abdomen, including RT, excess skin can make appropriate surgical access a challenge and increase perioperative morbidity. 8,9 Excess skin folds may be prone to post-operative complications including infection and wound dehiscence in part due to the increased moisture associated with skin on skin contact. BMI is often correlated with higher rates of thrombo-embolic events, dysfunction of the transplanted organ, impaired blood pressure control, increased convalescence time, increased hospital length of stay, and decreased and more challenging recovery of functional status.…”