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

Abstract

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.

Optimizing Perioperative Fluid Management in Complex Abdominal Wall Reconstruction to Prevent Postoperative Acute Kidney Injury

“…20 Additionally, in elective operations, there is generally no routine use of invasive hemodynamic monitoring adjuncts to assist with assessment of volume status. 16,21…”

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

“…1 The orthotopic liver transplant (OLT) patient population, in particular, is at up to a 43% risk for ventral hernia. [1][2][3][4][5][6] The orientation of the larger chevron incisions used with liver transplants can lead to greater myofascial weakening and further compromise the ventral abdominal wall compared with other post laparotomy patients. 7 In the last 20 years, the number of OLTs performed and the posttransplant survival of patients have increased steadily, 8,9 leading to an older population with an increased risk over their life span of abdominal wall defects.…”

“…7 In the last 20 years, the number of OLTs performed and the posttransplant survival of patients have increased steadily, 8,9 leading to an older population with an increased risk over their life span of abdominal wall defects. [1][2][3]10,11 Orthostatic liver transplant ventral hernias are further complicated by patient susceptibility to obesity, pulmonary disease, local and remote infections, and malnutrition that leads to a notable challenge for plastic, transplant, and general surgeons. 4,12 When managing abdominal wall defects, the objectives are to (1) recreate myofascial and overlying soft tissue integrity, (2) prevent infection and eventration of viscera, and (3) reestablish dynamic muscle support.…”

“…Patients with large and complex hernias represent a major surgical problem that will require surgical repair 1 . The orthotopic liver transplant (OLT) patient population, in particular, is at up to a 43% risk for ventral hernia 1–6 . The orientation of the larger chevron incisions used with liver transplants can lead to greater myofascial weakening and further compromise the ventral abdominal wall compared with other post laparotomy patients 7 .…”

“…The orientation of the larger chevron incisions used with liver transplants can lead to greater myofascial weakening and further compromise the ventral abdominal wall compared with other post laparotomy patients 7 . In the last 20 years, the number of OLTs performed and the posttransplant survival of patients have increased steadily, 8,9 leading to an older population with an increased risk over their life span of abdominal wall defects 1–3,10,11 . Orthostatic liver transplant ventral hernias are further complicated by patient susceptibility to obesity, pulmonary disease, local and remote infections, and malnutrition that leads to a notable challenge for plastic, transplant, and general surgeons 4,12 …”