Ann Surg Treat Res.  2024 Feb;106(2):115-123. 10.4174/astr.2024.106.2.115.

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

• Kim JY
• Hong SK
• Kim J
• Choi HH
• Lee J
• Hong Sy
• Lee JM
• Choi Y
• Yi NJ
• Lee KW
• Suh KS

• KMID: 2552392
• DOI: http://doi.org/10.4174/astr.2024.106.2.115

Abstract

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.

Keyword

Incisional hernia; Liver transplantation; mTOR inhibitors

Figure

• 

  Fig. 1 Incisional hernia-free survival months.

Reference

1. Fortelny RH. Abdominal wall closure in elective midline laparotomy: the current recommendations. Front Surg. 2018; 5:34. PMID: 29876355.

2. Licari L, Salamone G, Campanella S, Carfì F, Fontana T, Falco N, et al. Use of the KSVM-based system for the definition, validation and identification of the incisional hernia recurrence risk factors. G Chir. 2019; 40:32–38. PMID: 30771796.

3. Israelsson LA, Jonsson T. Incisional hernia after midline laparotomy: a prospective study. Eur J Surg. 1996; 162:125–129. PMID: 8639725.

4. Mudge M, Hughes LE. Incisional hernia: a 10 year prospective study of incidence and attitudes. Br J Surg. 1985; 72:70–71. PMID: 3155634.

5. Caglià P, Tracia A, Borzì L, Amodeo L, Tracia L, Veroux M, et al. Incisional hernia in the elderly: risk factors and clinical considerations. Int J Surg. 2014; 12 Suppl 2:S164–S169. PMID: 25157994.

6. Gómez R, Hidalgo M, Marques E, Marin L, Loinaz C, Gonzalez I, et al. Incidence and predisposing factors for incisional hernia in patients with liver transplantation. Hernia. 2001; 5:172–176. PMID: 12003043.

7. Kahn J, Müller H, Iberer F, Kniepeiss D, Duller D, Rehak P, et al. Incisional hernia following liver transplantation: incidence and predisposing factors. Clin Transplant. 2007; 21:423–426. PMID: 17488396.

8. Shi LW, Verran D, Rao AR, Stewart GJ, McCaughan GW. Incisional hernia following orthotopic liver transplantation. Transplant Proc. 2003; 35:425–426. PMID: 12591471.

9. Lam HD, Vanlander A, Berrevoet F. A comparative outcome analysis of incisional hernia repair in patients who underwent liver transplantation vs. those that underwent hepatopancreaticobiliary surgery using the EHS guidelines as a means of comparison. Clin Transplant. 2016; 30:226–232. PMID: 26660065.

10. Smith CT, Katz MG, Foley D, Welch B, Leverson GE, Funk LM, et al. Incidence and risk factors of incisional hernia formation following abdominal organ transplantation. Surg Endosc. 2015; 29:398–404. PMID: 25125093.

11. Lee JS, Kim JM, Kim KS, Choi GS, Joh JW, Lee SK. Predictors of incisional hernia in adult liver transplant recipients. Hernia. 2019; 23:61–65. PMID: 30406851.

12. Feldmeyer L, Hofbauer GF, Böni T, French LE, Hafner J. Mammalian target of rapamycin (mTOR) inhibitors slow skin carcinogenesis, but impair wound healing. Br J Dermatol. 2012; 166:422–424. PMID: 21895616.

13. Kaplan B, Qazi Y, Wellen JR. Strategies for the management of adverse events associated with mTOR inhibitors. Transplant Rev (Orlando). 2014; 28:126–133. PMID: 24685370.

14. Rodríguez-Perálvarez M, Tsochatzis E, Naveas MC, Pieri G, García-Caparrós C, O'Beirne J, et al. Reduced exposure to calcineurin inhibitors early after liver transplantation prevents recurrence of hepatocellular carcinoma. J Hepatol. 2013; 59:1193–1199. PMID: 23867318.

15. Saliba F, De Simone P, Nevens F, De Carlis L, Metselaar HJ, Beckebaum S, et al. Renal function at two years in liver transplant patients receiving everolimus: results of a randomized, multicenter study. Am J Transplant. 2013; 13:1734–1745. PMID: 23714399.

16. Cholongitas E, Mamou C, Rodríguez-Castro KI, Burra P. Mammalian target of rapamycin inhibitors are associated with lower rates of hepatocellular carcinoma recurrence after liver transplantation: a systematic review. Transpl Int. 2014; 27:1039–1049. PMID: 24943720.

17. Kelly PA, Gruber SA, Behbod F, Kahan BD. Sirolimus, a new, potent immunosuppressive agent. Pharmacotherapy. 1997; 17:1148–1156. PMID: 9399599.

18. Schäffer M, Schier R, Napirei M, Michalski S, Traska T, Viebahn R. Sirolimus impairs wound healing. Langenbecks Arch Surg. 2007; 392:297–303. PMID: 17384960.

19. Akselband Y, Harding MW, Nelson PA. Rapamycin inhibits spontaneous and fibroblast growth factor beta-stimulated proliferation of endothelial cells and fibroblasts. Transplant Proc. 1991; 23:2833–2836. PMID: 1721292.

20. Montalti R, Mimmo A, Rompianesi G, Serra V, Cautero N, Ballarin R, et al. Early use of mammalian target of rapamycin inhibitors is an independent risk factor for incisional hernia development after liver transplantation. Liver Transpl. 2012; 18:188–194. PMID: 21987434.

21. Hong SK, Lee KW, Kim HS, Yoon KC, Yi NJ, Suh KS. Living donor liver transplantation for hepatocellular carcinoma in Seoul National University. Hepatobiliary Surg Nutr. 2016; 5:453–460. PMID: 28123999.

22. Hong SK, Lee KW, Yoon KC, Kim HS, Ahn SW, Kim H, et al. Different prognostic factors and strategies for early and late recurrence after adult living donor liver transplantation for hepatocellular carcinoma. Clin Transplant. 2019; 33:e13703. PMID: 31464006.

23. Piazzese E, Montalti R, Beltempo P, Bertelli R, Puviani L, Pacilè V, et al. Incidence, predisposing factors, and results of surgical treatment of incisional hernia after orthotopic liver transplantation. Transplant Proc. 2004; 36:3097–3098. PMID: 15686704.

24. Janssen H, Lange R, Erhard J, Malagó M, Eigler FW, Broelsch CE. Causative factors, surgical treatment and outcome of incisional hernia after liver transplantation. Br J Surg. 2002; 89:1049–1054. PMID: 12153634.

25. Giordano SA, Garvey PB, Baumann DP, Liu J, Butler CE. The impact of body mass index on abdominal wall reconstruction outcomes: a comparative study. Plast Reconstr Surg. 2017; 139:1234–1244. PMID: 28445378.

26. Flegal KM, Kruszon-Moran D, Carroll MD, Fryar CD, Ogden CL. Trends in obesity among adults in the United States, 2005 to 2014. JAMA. 2016; 315:2284–2291. PMID: 27272580.

27. Manilich E, Vogel JD, Kiran RP, Church JM, Seyidova-Khoshknabi D, Remzi FH. Key factors associated with postoperative complications in patients undergoing colorectal surgery. Dis Colon Rectum. 2013; 56:64–71. PMID: 23222282.

28. Masetti M, Montalti R, Rompianesi G, Codeluppi M, Gerring R, Romano A, et al. Early withdrawal of calcineurin inhibitors and everolimus monotherapy in de novo liver transplant recipients preserves renal function. Am J Transplant. 2010; 10:2252–2262. PMID: 20486905.

29. Toso C, Meeberg GA, Bigam DL, Oberholzer J, Shapiro AM, Gutfreund K, et al. De novo sirolimus-based immunosuppression after liver transplantation for hepatocellular carcinoma: long-term outcomes and side effects. Transplantation. 2007; 83:1162–1168. PMID: 17496530.

30. Rodríguez-Perálvarez M, Pérez-Medrano I, Guerrero-Misas M, González V, Poyato A, Barrera P, et al. Everolimus is safe within the first month after liver transplantation. Transpl Immunol. 2015; 33:146–151. PMID: 26392195.