Download Successful Laparoscopic Bariatric Surgery in Peritoneal Dialysis

Advances in Peritoneal Dialysis, Vol. 28, 2012
Gabriel A. Valle,1 Barbara E. Kissane,1 Nestor de la Cruz–
Muñoz2
During the past several decades, the conventional
management of peritoneal dialysis (PD) patients
undergoing elective abdominal surgery required a
transition to hemodialysis on a temporary basis. In
recent years, that protocol has been challenged by
various authors who successfully repaired hernias
in such subjects without interruption of their PD
modality. However, that new approach was reserved
for abdominal wall procedures and was not used for
intra-abdominal surgery.
The rapid evolution of laparoscopic surgery
and the development and refinement of minimally
invasive surgical techniques have revolutionized
the field of surgery by providing superior outcomes
for an ever-increasing list of indications including
morbid obesity. The present study, the first of its kind
involving elective intra-abdominal surgery, sought to
determine the safety of uninterrupted PD therapy in
morbidly obese patients with stage 6 chronic kidney
disease undergoing laparoscopic bariatric surgery
as a precursor to transplantation.
Key words
Laparoscopy, bariatric surgery
Introduction
Abdominal surgery in the peritoneal dialysis (PD)
population has invariably led to a transition to hemodialysis (HD) in the perioperative period. Complex,
From: 1The Kidney Group of South Florida, Fort Lauderdale, and 2Department of Surgery, University of Miami,
Miller School of Medicine, Miami, Florida, U.S.A.
Successful Laparoscopic
Bariatric Surgery in
Peritoneal Dialysis Patients
Without Interruption of
Their CKD6 Treatment
Modality
urgent, or complicated interventions may result in
a permanent switch to HD, but after most cases of
elective and uneventful intra-abdominal surgery, reinstitution of PD is the norm.
Even in the stable, uncomplicated preoperative
patient, concerns surround the potential for intra- or
trans-abdominal leaks, peritoneal contamination,
interference with wound healing, aggravation or
perpetuation of ileus, and impairment of respiratory
mechanics, among other issues (1,2). Additionally,
the efficiency and efficacy of dialysis may be in question because of changes in splanchnic macro- and
micro-circulatory hemodynamics, effective peritoneal
surface exchange area, membrane transport properties, delayed bowel function, and patient tolerance of
dialysate dwells (3–6).
The extent and complexity of the operation and
the not-so-subtle effects of the size and location of the
abdominal incision or incisions affecting postoperative recovery in cases of conventional surgery appear
to be the main culprits. However, since the early
1990s, a handful of studies on PD patients undergoing
elective conventional abdominal wall hernia repair
have established that reparative surgery can be successfully performed without temporary conversion
to HD. Indeed, in the largest study of its kind, all
subjects were managed with a protocol of modified
PD prescription without significant complications (7).
Other authors have also shown that, in cases of limited
abdominal wall breakdown and intraperitoneal invasion (such as the straightforward surgical insertion of
a tunneled PD catheter), there is no need to delay the
initiation of PD. Compared with a standard group in
whom initiation of PD exchanges took place 2 weeks
Valle et al.
after catheter placement surgery, a group undergoing
short break-in periods immediately after surgery did
not experience an increase in complications (8).
Nonetheless, no standardized approach has been
developed to date for the PD patient undergoing elective intra-abdominal surgery—a more challenging
problem, because it encompasses a wide variety of
very different surgical interventions. Conventional
management calls for temporary conversion to HD
in the postoperative period. The emergence, since
the early 1990s, of laparoscopic surgery as the preeminent option for a wide variety of indications (9)
may change that approach. Increasingly sophisticated
and minimally invasive, laparoscopic surgery has
rapidly gained acceptance because of its advantages
in shortening length of stay and postoperative pain, allowing for faster recovery, enhanced cosmetic results,
increased patient satisfaction and a lesser incidence
of incisional hernia (10).
The challenging field of morbid obesity is no
exception to this trend and has benefited from the
introduction, development, and subsequent evolution
of the laparoscopic technique as the “gold standard”
approach to the surgical treatment of this serious
condition (10–12). Simultaneously, the convergence
of two modern epidemics (13–16), obesity and chronic
kidney disease (CKD), has given rise to a growing
high-risk population of morbidly obese (MO) patients
with CKD stage 6 who have a critical need for effective
weight management interventions to qualify for kidney
transplantation. Absent a protocol for successful weight
rehabilitation and the option of organ transplantation,
these subjects are left with a very limited outlook with
respect to health and quality of life (17–22).
In an area in which medical management—
combinations of diet, exercise, and psychological
interventions—has met with very limited success
and increasing recidivism, bariatric surgery has been
established as the most successful treatment modality for severely obese individuals who meet specific
criteria from the American Society for Metabolic
and Bariatric Surgery and the National Institutes of
Health (11,23).
Our novel approach to the postoperative care
of the bariatric PD patient is based on two leading
considerations:
•
The very essence of the laparoscopic “minimally invasive” method offers controlled, limited
135
•
disruption of the intra-abdominal organs and
abdominal wall, affording better preservation of
the physiologic integrity of the peritoneum and
of peritoneal cavity compliance.
The strength of a center-of-excellence, certified bariatric surgery program within which all
operations are performed by an experienced
surgeon with an extremely low incidence of
complications.
In addition, patient selection based on dynamic
criteria such as compliance with scheduled clinic
visits, pharmacotherapy, preoperative dietary prescription, achievement of educational goals, and
commitment to the transplant program was of paramount importance.
The present study was designed to determine the
safety of laparoscopic bariatric surgery (LBS) without
interruption of continuous cycling PD (CCPD) in MO
PD patients desirous of kidney transplantation, but
unable to reach their qualifying weight goal.
Methods
Between November 2010 and December 2011, 5 MO
patients [2 men, 3 women; 3 black, 1 white, 1 Hispanic; average age: 41 years (range: 35 – 56 years);
average body mass index: 43.3 kg/m 2] with CKD6
who were enrolled in our home dialysis program
underwent LBS. All subjects were established on
CCPD (duration of therapy: 6 – 36 months) and had
tried a variety of weight loss programs for several
years. All had received conditional approval for
inclusion in regional kidney transplant programs,
contingent on achieving a center-specified target
weight goal. The main causes of CKD in these
patients were diabetes mellitus, hypertension, and
chronic glomerulonephritis (Table I).
Presurgical management included up to 3 weeks of
a hypocaloric liquid diet, which produced significant
weight loss. (For a more detailed description, see the
Discussion section.)
Leading up to the procedure, patients had no oral
intake after midnight, and regular nocturnal exchanges
were continued until the morning of surgery. At the
end of the last CCPD session, the peritoneal cavity was drained completely. Preoperative antibiotic
prophylaxis consisted of a single intravenous dose of
amoxicillin (2 g) or clindamycin (600 mg). Anesthesia
was administered following standard protocols.
136
table i
Laparoscopic Bariatric Surgery in PD Patients
Characteristics of the study patients
Variable
Age (years)
Sex
Race
1
2
Patient ID
3
4
5
Average
38
36
40
56
35
41
Male
Male
Female
Female
Female
—
White
Black
Black
Black
Hispanic
—
Primary diagnosis
CGN/FSGS
HTN
HTN
CGN/SLE
DM1
—
Comorbidities
HTN, OSA
OSA
OSA, DL
DM, HTN
HTN, DL
—
Height (m)
2.00
1.93
1.75
1.67
1.525
Weight (kg)
175
150
132
116
98
43.8
40.5
49
41.1
42.1
43.3
36
6
12
34
7
19
BMI
(kg/m2)
Duration of PD (months)
CGN = chronic glomerulonephritis; FSGS = focal segmental glomerulosclerosis; HTN = hypertension; SLE = systemic lupus erythematosus; DM1 = type 1 diabetes mellitus; OSA = obstructive sleep apnea; DL = dyslipidemia.
Laparoscopic procedures included gastric banding (1 patient) and Roux-en-Y gastric bypass (4
patients). One of the latter patients also underwent
tandem inguinal hernia repair. A standard surgical
laparoscopic approach was used, except that the surgeon explicitly inserted the lowest port as cephalad
as possible to avoid interference with or disruption
of the peritoneal catheter position. Limited upper
abdominal lavage was routinely performed. The
reported estimated blood loss was less than 60 mL.
In all patients undergoing gastric bypass, a Jackson–
Pratt drain was kept in the left subphrenic space until
the following morning.
After completion of their bariatric surgery, 2
patients resumed CCPD without delay; the other 3
remained off dialysis for the first 24 postoperative
hours. Heparin (1000 U/L) was added routinely to
the dialysate for the first week after surgery. Upon
resumption of their CCPD at home, all patients used
the following volume titration protocol: The dwell
volume was initially set at 25% – 50% of the original prescription for the first 3 – 5 days. It was then
increased by 25% every 3 – 5 days until the preoperative prescription was restored (Figure 1). The main
determinants for the selection of starting volume
and the progression of volume titration were patient
height and development of abdominal discomfort.
The dialysate dextrose concentration was maintained
at 1.5% and adjusted to meet ultrafiltration needs as
clinically indicated, paralleling the patient’s ability to
gradually resume a modified bariatric diet.
Results
After 2 – 3 weeks of a strict low-calorie diet and a leadin average weight loss of 6.8 kg (range: 4.5 – 11.3 kg),
all patients underwent successful bariatric surgery
without complications. Overall need for analgesics or
other symptomatic therapy was remarkably minimal.
The patient who received a gastric band was discharged home within 12 hours; the 4 patients undergoing gastric bypass were discharged the day after surgery.
Two patients who started in-hospital CCPD reported
volume-related abdominal discomfort. The adoption
of our volume titration protocol resulted in excellent
patient tolerance. All but 1 patient started home CCPD
on postoperative day 1. The patient who had the additional hernia repair delayed re-institution of CCPD and
reported lower abdominal “soreness and bloating,” but
experienced rapid resolution of those symptoms during
the first dialysis session on postoperative day 3.
None of the patients experienced fluid leakage attributable to early resumption of PD. A hemorrhagic
effluent was universally noted from the first exchange
after surgery and gradually disappeared within 7 – 10
days. An incremental bariatric diet of clear to full
liquids, protein shakes, and soft foods was very well
tolerated. Dumping syndrome a few days after surgery
occurred in 1 patient because of dietary indiscretion;
but otherwise, all patients had loose, but not frequent,
stools for up to 2 weeks.
No significant episodes of volume or metabolic
derangements were noted within the extended postoperative period. All subjects achieved their target
Valle et al.
figure
137
1 Summary of the volume titration protocol in postsurgical peritoneal dialysis patients.
weight within 8 weeks after surgery and were approved for transplantation. One patient received a
living donor organ a year later.
In every instance, weight loss continued beyond
the pre-transplant goal in a gradual, safe, and persistent
manner, leading to substantial improvement in the
control of hyperglycemia, dyslipidemia, hypertension,
and sleep apnea.
Discussion
The increasing prevalence of MO patients with CKD6
has created a cohort of high-risk individuals with a
serious prognosis and the inability to qualify for renal
transplantation. Most are affected by comorbidities
such as diabetes and hypertension, which portend
increased cardiovascular morbidity and mortality
(17,24,25). Furthermore, surgical risks and outcomes
after renal transplantation are both negatively affected
by an elevated body mass index (20,26).
During the past few years, our home dialysis
population has included a growing number of MO
individuals, a well-defined group of mostly younger
CKD6 patients who have unsuccessfully battled
crippling obesity, failed multiple attempts at medical management, and embraced the opportunity of
a proven surgical treatment option (11,20,22,23).
Furthermore, circumventing the temporary switch to
HD was a very strong stimulus in encouraging them
to pursue this course of therapy.
Our CKD program emphasizes ongoing patient
education (CKD4 and beyond), early referral to a
transplant center, and a multidisciplinary approach
to their associated illnesses and psychosocial issues
though specialty care coordination and counseling.
All study subjects were employed and productive,
had developed a keen interest in their health, had
gained substantial and above-average knowledge of
the metabolic aspects of their disease process, and
had become highly motivated about qualifying for
kidney transplantation.
Perioperative management encompassed major
dietary interventions and behavioral changes. A coordinated multispecialty and multidisciplinary approach
and regular follow-up were crucial to the success
of this therapeutic approach. In preparation for the
surgery, patients were asked to follow a low-calorie
liquid diet for 2 – 3 weeks. The main purpose of this
preliminary intervention is to decrease visceral fat
and reduce liver size (steatohepatitis), both of which
help to improve the surgeon’s ability to visualize and
manage the operative field (27–31). The secondary
endpoint was to evaluate patient’s overall compliance
and commitment.
This dietary protocol led to a considerable average preoperative weight loss of 6.8 kg (range: 4.5 –
11.3 kg). Surgery was uneventful and successful in
all the study patients, without significant modification
of the standard bariatric technique. A painless hemorrhagic effluent was present for up to a week. Given
their remarkably benign postoperative course, it is
conceivable that removal of intraperitoneal blood,
cellular debris, and other proinflammatory byproducts
of tissue injury was instrumental in facilitating the
faster restoration of normal peritoneal and splanchnic
homeostasis. In theory, this unintended “peritoneal
lavage” effect could also have helped to mitigate the
development of adhesions (32,33).
Re-initiation of PD in the early postoperative period with a modified volume prescription proved safe
and effective. However, hemodynamically and metabolically stable patients may safely delay the return to
PD for few days. Such was the case in our patient in
whom a hernia repair was also accomplished. A delay
of this kind might also be applicable to individuals
who undergo more extensive, complex, or prolonged
laparoscopic procedures and in whom the compliance
138
of the abdominal cavity and the membrane transport
dynamics of the peritoneum may be significantly
compromised immediately after surgery.
By virtue of tailored perioperative nutrition management, the metabolic demands of the CKD6 bariatric patient may not require the immediate restoration
of PD, particularly in patients whose residual renal
function and urine volume are substantial, making
the transition back to PD less time-sensitive and more
clinically driven.
In PD patients, laparoscopic surgery allows for
maximal preservation of abdominal wall integrity
and of peritoneal cavity compliance—which are the
two most important, sine qua non factors for the
sound delivery of this modality of renal replacement therapy.
Conclusions
Based on our initial experience, we recommend that
CCPD patients undergoing LBS continue their renal
replacement modality using the described volume
titration protocol. This recommendation is likely
also to be applicable to CAPD patients. In this CKD6
population, LBS can be safely and successfully performed without requiring either interruption of the
PD modality or temporary conversion to HD.
Disclosures
The authors have no financial conflicts of interest
to declare.
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Corresponding author:
Gabriel A. Valle, md facp fccp fasn, 2001 NE 48th
Court, Suite 4, Fort Lauderdale, Florida 33308
U.S.A.
E-mail:
[email protected]