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Incisional Hernia After Peritoneal Dialysis Catheter Placement in a Patient Simratdeep Sandhu,1 Richard Dickerman,2 Bruce Smith,3 Anupkumar Shetty1,2 on Sirolimus

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Incisional Hernia After Peritoneal Dialysis Catheter Placement in a Patient Simratdeep Sandhu,1 Richard Dickerman,2 Bruce Smith,3 Anupkumar Shetty1,2 on Sirolimus Advances in Peritoneal Dialysis, Vol. 33, 2017 Incisional Hernia After Peritoneal Dialysis Catheter Placement in a Patient Simratdeep Sandhu,1 Richard Dickerman,2 Bruce Smith,3 Anupkumar Shetty1,2 on Sirolimus Hernias and peritoneal dialysis (PD) catheter leaks stopped the mycophenolate sodium on his own, and we are frequent complications in patients on PD. Trans- did not resume it. He is still on low-dose prednisone. plant recipients have multiple risk factors for delayed In end-stage renal disease resulting from failing wound healing, such as use of corticosteroids and renal transplantation or from calcineurin inhibitor sirolimus, and the presence of uremia and diabetes nephropathy in solid-organ transplantation, sirolimus mellitus. We report a rare occurrence of incisional is a risk factor for wound dehiscence, development of hernia attributable to internal wound dehiscence incisional hernia, and peritoneal dialysate leak. after PD catheter placement in a patient on sirolimus. Practical tips: Sirolimus should be stopped several A 34-year-old Latino American man was started on days before PD catheter placement. Sirolimus should PD training 4 weeks after placement of a PD catheter. also be stopped if a PD catheter leak is detected or Soon after completing training, he developed a large if incisional hernia develops soon after initiation of soft bulge close to the PD catheter, with expansile PD. Sirolimus should be held till surgical repair of the cough impulse suggestive of an incisional hernia filled hernia and removal and replacement of the catheter. with peritoneal dialysate. The size of the bulge would decrease after the dialysate was drained. No external Key words leak of dialysate was evident along the exit site. Hernia, herniorrhaphy, end-stage renal disease, sirolimus Because of the size of the hernia and the history of it filling soon after dialysis exchange, the feeling Introduction was that wound dehiscence had occurred from the Techniques for lowering the rate of peritonitis have peritoneal side, resulting in a large incisional her- been extremely successful in patients on peritoneal nia. Because of the large size of the hernia within dialysis (PD), making noninfectious complications rel- few weeks of starting PD, sirolimus was suspected atively more frequent. Prevention, early recognition, to have induced poor wound healing, contributing to and appropriate management of such complications formation of the hernia. is important because of the morbidity and technique Sirolimus was stopped, and the patient underwent failure that can follow (1–3). Use of sirolimus in pa- PD catheter removal and repair of the hernia. A new tients after renal transplantation increases the risk of PD catheter was placed on the opposite side of the wound dehiscence and incisional hernia because of abdomen 10 days later. After another 6 weeks, the inhibition of fibroblast activity through the inhibition patient was started on PD. He has been doing well of mTOR (the mammalian target of rapamycin) (4–8). for the 15 months since then, with no recurrence of the Even though incisional hernia is common after hernia. Because he still had residual renal function, renal transplantation, no reports have been published he continued to receive low-dose prednisone and my- of incisional hernia attributable to sirolimus in pa- cophenolate sodium. At 10 months after PD start, he tients on PD. Here, we report the first such patient in the literature. In our patient, we believe that con- tinuous use of sirolimus and initiation of PD after From: 1Dallas Nephrology Associates, 2Methodist Dallas peritoneal catheter placement resulted in the forma- Medical Center, and 3Baylor University Medical Center, tion of a large incisional hernia. Early recognition Dallas, Texas, U.S.A. of causative factors and discontinuation of specific 36 Incisional Hernia After PD Catheter Placement in a Patient on Sirolimus immunosuppressant drugs known to delay wound helped us to suspect sirolimus as the cause of such a healing can diminish the risk of dialysate leaks and large early postoperative incisional hernia. incisional hernias in PD patients. Subsequently. the patient was referred to a surgeon Incisional hernias and PD catheter leaks are fre- with expertise in repairing large hernias. He under- quent complications in patients on PD. The risk is went open herniorrhaphy 2 weeks after sirolimus was further increased in patients who undergo renal trans- stopped. The PD catheter was wrapped with omentum plantation or experience allograft failure. Renal trans- and was removed. A fascial defect measuring 8×6 cm plantation patients often have multiple risk factors for was found. delayed wound healing, such as use of corticosteroids A 10×16 cm piece of semi-absorbable mesh was and mTOR inhibitors such as sirolimus, and the pres- placed into the preperitoneal space after 1.25 cm had ence of uremia, obesity, and diabetes mellitus. The been trimmed at the lateral side in the short dimen- rare occurrence of incisional hernia because of fascial sion. Corner sutures were placed in the inferior medial wound dehiscence after PD catheter implantation that corner, through all fascial layers, with the fascial layers we report here occurred in a patient on sirolimus. retracted in appropriate tension, through the mesh, and Dialysate leak because of poor wound healing is a then back up to the fascial layers about 2 cm off the largely preventable complication of PD. Withholding initial suture placement. This suturing was used in 2 sirolimus for several weeks and minimizing cortico- corners and then snugged down so that a little bit of steroids before PD catheter implantation can help to tension would be exerted on the closure (enough to avoid the delayed healing that results in incisional reapproximate the muscle fascial layers). Inferior and hernia and dialysate leak. superior midpoints were identified, with similar place- ment of sutures and then intervening stitches, 2 in each Case presentation of the four quadrants. Once all sutures were in place A 34-year-old Mexican American man, born in in the fascia, the layers were closed with a running Mexico, had end-stage renal disease secondary to suture, being sure to incorporate the transversalis and lupus nephritis and uremic pericarditis requiring internal oblique portions of the fascia to bring them pericardial window and initiation of hemodialysis. He back to the midpoint of the wound. had undergone related living-donor transplantation in A 15×15 cm piece of a non-absorbable mesh was Mexico in 2008. then placed between the fascia and the subcutaneous This patient’s history included embolic stroke in fat. The mesh was turned on the diagonal to create 2008, with good recovery and ongoing use of antico- a longer elliptical piece. The 2 corner sutures were agulation; pulmonary hypertension of unknown source again passed through the mesh and tied down. They diagnosed in 2009; and non-ischemic dilated cardio- were then snugged down to hold them in place. All myopathy diagnosed in January 2015, followed by the sutures were then threaded through the mesh and placement of an automated implantable cardioverter tied down. Once the mesh was nicely snugged down to and defibrillator in February 2015. His immunosup- the fascia, excess mesh was trimmed such that at least pression included prednisone, mycophenolate sodium, 4 cm overlay from the fascial incision was achieved and tacrolimus. As his renal function deteriorated, in all directions. tacrolimus was replaced with sirolimus. The patient underwent laparoscopic PD catheter In August 2015, the patient underwent laparoscop- placement on the other side of the abdomen 10 days ic PD catheter placement, with successful PD training later, and he resumed low-volume PD 6 weeks later, 6 weeks later. Soon after completing PD training, he gradually increasing to his optimum volume. He has reported a large bulge around the PD catheter after the been doing well since then. Because the patient had abdomen had been filled with fluid; the bulge would residual kidney function, mycophenolate sodium was disappear after the dialysate was drained. continued for 10 more months. For the same reason, On examination, an expansile cough impulse the patient is still taking low-dose prednisone. He around the surgical scar was observed, suggestive of developed 1 episode of culture-negative peritonitis a large hernia. No external leak of the fluid around the that was treated with antibiotics, achieving prompt PD catheter was evident. Referral to a transplantation resolution. We suspect that this episode was a non- surgeon who also performs PD catheter placements infective peritonitis from an unclear cause. Sandhu et al. 37 Discussion and possibly better quality of life because of a lesser The unique features of this case are the patient’s very need for fluid restriction, among other considerations. early development of incisional hernia (a possible The disadvantages of continuing immunosuppression fascial wound dehiscence without PD fluid leak), the are the standard risks of infections and malignancies medical challenges of immunosuppression when a that are associated with an increase in lifetime immu- patient is on dialysis, and the surgical challenges in a nosuppression. The risks specific to the PD population patient on immunosuppression. Moreover, this case are the potential risks of peritonitis and calcineurin- is the first to be published of a PD-related incisional induced peritoneal toxicity. In addition, measures have hernia
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