Download Surgical Management of Complications with Peritoneal Dialysis

Surgical Management of Complications
with Peritoneal Dialysis
Andrzej Ratajczak, Małgorzata Lange-Ratajczak, Adam Bobkiewicz, and
Adam Studniarek
Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of
Medical Sciences, Poznan, Poland
ABSTRACT
This report reviews the most common surgical interventions and complications of chronic peritoneal dialysis
(PD) patients. Based on the current knowledge as well as
our experience we detail the role of these surgical procedures. We supplement the reported knowledge in the field
with our own experience in this area. The areas discussed
include early complications such as surgical wound hemorrhage, bleeding from the catheter, intestinal perforation
and urinary bladder perforation, dialysate leakage
through the wound, as well as late complications including catheter kinking or occlusion, retention of fluid in the
peritoneal recess, hernias and hydrothorax, and encapsulating peritoneal sclerosis. We also briefly cover the surgical aspects of exit-site infection and peritonitis. An
understanding by nephrologists of the role for surgical
intervention in PD patients will improve their care and
outcomes.
The complications of peritoneal dialysis (PD)
that require surgical intervention are not well documented in the literature (1). There are not many
studies, most of which are outdated and do not
evaluate this issue in detail (2,3). The vast majority of them focuses on describing an individual
complication and its treatment. Below we present
a review of literature regarding surgical complications as well as our own experiences and
comments.
Complications of PD are commonly classified as
(i) infectious and noninfectious or (ii) early and
late. The latter subgroup is more logical from a
surgeon’s point of view; thus, we take this
approach in our review. This subdivision is inexact because the described complications may happen at different times following placement of a
PD catheter. The most common early and late
complications associated with PD are summarized
below (Table 1).
Early Complications
Surgical Wound Hemorrhage or Catheter ExitSite Hemorrhage
Hemorrhage from the wound site after a Tenckhoff catheter placement is rare and is most commonly the result of improper hemostasis.
Hemorrhage usually occurs in the skin and subcutaneous tissue, and is treated by placing a compression dressing or by suture ligation. Sometimes,
despite the most precise surgical technique, hematomas still form in the subcutaneous tissue most commonly in patients with a bleeding diathesis or on
anticoagulants or antiplatelet aggregating agents.
Only rarely is the bleeding intense.
More often, surgeons have to deal with exit-site
catheter hemorrhage where placing sutures can
potentially damage the catheter. The creation of a
subcutaneous tunnel to insert the catheter is performed blindly and can cause damage to the surrounding small vessels and therefore lead to exit-site
hemorrhage. At our institution, we have abandoned
use of a sharp tunneler and instead we use a long,
narrow, curved, and blunt dissecting forceps. We
have not observed exit-site catheter hemorrhage
since this change. The literature does not indicate
which surgical technique for catheter placement
(open surgery, laparoscopic, percutaneous) has the
lowest rate of the described complication (4). Studies from different institutions often show the advantage of the technique performed by that specific
team, but it is always possible to find a study to
Address correspondence to: Adam Studniarek, MD,
Department of General, Endocrinological Surgery and
Gastroenterological Oncology, Poznan University of
Medical Sciences, Przybyszewskiego 49, 60-355 Poznan,
Poland, Tel.: +48 618 691 122, Fax: +48 618 691 684, or
e-mail: [email protected].
Seminars in Dialysis—Vol 30, No 1 (January–February) 2017
pp. 63–68
DOI: 10.1111/sdi.12538
© 2016 Wiley Periodicals, Inc.
63
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Ratajczak et al.
TABLE 1. The most common early and late surgical complications
associated with peritoneal dialysis
Early
Surgical wound hemorrhage or
catheter exit-site hemorrhage
Bleeding/bloody fluid from the
catheter
Intestinal perforation, urinary
bladder perforation
Dialysate leakage through the wound
or close to the exit site of the
catheter
Late
Problems with the
outflow of the dialysate
Hernias
Leakage of dialysate to
scrotum
Hydrothorax
Exit-site infection (ESI)
Peritonitis
Encapsulating peritoneal
sclerosis (EPS)
contradict such findings. It is also important to note
that surgical wound hemorrhage can be expected in
cases of certain diseases, such as coagulopathies or
hemolytic uremic syndrome (5,6).
In conclusion, the technique of catheter placement
should be individually developed by the team involved
in a patient care. The frequency of complications
decreases as the experience gained by the operator
increases regardless of the specific technique.
Bleeding/Bloody Fluid from the Catheter
Bloody fluid exiting the catheter during patency
control or with the first dialysis is quite common
and does not necessarily indicate a hemorrhage, but
may be caused by a small amount of blood that
entered the peritoneal cavity or by adhesiolysis during catheter placement. This type of hemorrhage
does not lead to a hemodynamic instability. It is
important to prevent an associated thrombotic
event inside the catheter that can lead to its obstruction. Mechanical flushing is enough to prevent this
complication in most cases. Gadallach et al. found
that this approach is usually successful (7). Severe
or persistent hemorrhage through the catheter is a
sign of bleeding from the peritoneal cavity and
requires an emergent surgical intervention through
a laparotomy or a laparoscopy. The details of its
surgical management depend on the site of damage
and is not the topic of this review.
insertion of the catheter (Seldinger procedure) which
is often performed blindly.
Another mechanism whereby the intestinal wall is
damaged and later perforated occurs relatively late
after catheter placement. It usually happens, when
the lower cuff migrates into the peritoneal cavity.
The cuff has adhesive properties which causes adhesion to the intestinal wall followed by perforation
and, often, fistula creation with fecal peritonitis.
Dialysate Leakage Through the Wound or
Close to the Exit Site of the Catheter
This complication usually occurs relatively early
after the catheter placement, during the first dialyses. The reason is usually a loose purse-string suture
on the peritoneum, improperly sutured fascia, or, as
indicated by Perl and colleagues, wound healing
complications (8). Patients with a history of numerous surgical operations and weakened abdominal
wall are especially predisposed to this type of complication. Other reasons may be starting dialysis
“too early” after the catheter placement or use of
excessive volume of dialysate particularly when not
limited to the supine position (see below).
The appropriate extent of the delay between
catheter placement and the beginning of dialysis is a
constant topic of discussion and randomized
prospective clinical trials (9). Certainly, a longer
delay can only be beneficial with respect to minimizing the risk of leakage. However, more to the point
is the risk incurred by prompt catheter use, often a
consequence of the clinical need to initiate dialysis.
This risk is not well documented.
The accepted course of action with such leakage
is a temporary withdraw of dialysis which allows
for healing of the small damage in the abdominal
wall. In cases of sustained leakage, it is necessary to
perform a surgical revision. To precisely define the
site of the leakage, a peritoneography or CT peritoneography can be performed. It is important to
remember that mechanical damage to the catheter
will produce identical symptoms. A catheter puncture during suturing will be followed by leakage of
dialysis fluid at the exit site.
Late Complications
Intestinal Perforation and Urinary Bladder
Perforation
These intraoperative complications are fortunately very rare. They result from poor operative
technique, a lack of operator experience or inattention. It is not a problem if the operator recognizes
the complication intraoperatively and immediately
corrects the defect. However, it becomes more serious when the first symptom is a leakage of the
intestinal fluid or urine through the catheter after
the surgery. It is an indication for an emergent
reoperation. There have been slightly more complications after guide wire-based percutaneous
Problems with the Outflow of the Dialysate
A problem with the outflow of dialysate is
undoubtedly the most common surgical complication of dialysis. It results from catheter kinking or
its occlusion from the overgrown omentum or retention of fluid in the peritoneal recesses.
Catheter Kinking
Even a properly placed PD catheter can be
moved by the intestinal peristalsis and curved
upward, more cranially. It will result in more difficult outflow and retention of dialysate in the
SURGICAL MANAGEMENT OF PD
bottom of the peritoneal cavity, in the pouch of
Douglas. Sometimes, the kinking forms such an
acute angle that it bends the catheter causing an
obstruction. When such obstruction occurs, some
physicians recommend prokinetics or intense physical activity; there is no scientific proof that these
treatments work.
There are a few nonsurgical methods to fix the
problem. One of them is to place a hydrophilic guide
wire or a balloon into the lumen with the control of
a fiberscope; the modified method created by Ozyer
shows a high success rate (10). These methods are by
definition noninvasive, but are not free of complications because there is a risk that sliding of the guide
wire outside of the catheter will cause intestinal or
vesical perforation. The most successful method is
surgical repositioning with most authors preferring
the noninvasive method of laparoscopy; it has also
been supported in the literature (11,12). In authors’
opinion, it only requires an insertion of two trocars,
one for the camera and one for the dissecting forceps
which we use to place the catheter in the correct
position. In addition, to create a pneumoperitoneum
we can use the Tenckoff catheter to avoid a blind
insertion of a Veress needle.
As prophylaxis for migration, catheters that are
weighted or utilize a swan neck design can be used;
studies suggest better long-term results with these
methods of treatment (13,14). Some authors recommend catheter placement with an additional suture
from the inside of the peritoneum when catheter is
inserted. There are a few laparoscopic techniques to
do this which some authors recommend to reduce
the possibility of catheter kinking and migration
(15). Stucky et al. described a successful catheter
repositioning by attaching the tip of the catheter to
a testicular prosthesis as an additional weight (16).
Catheter Occlusion by the Omentum
Catheter occlusion by the omentum is a relatively
common complication. It results from a close contact of the catheter with the omentum sometimes
with omental ingrowth through the pores in the
catheter. The symptoms of occlusion usually
develop gradually and often lead to complete
obstruction. Sometimes it only requires flushing the
catheter under pressure, but forceful flushing can
result in mechanical damage to the omentum leading to hemorrhage. Ohira et al. presented a very
interesting method of removing the overgrown
omentum from the catheter’s lumen by the use of
biopsy forceps that are used in gastroscopy (17).
Another author used the endoscopic cytology brush
for the same purpose (18). If these actions are not
successful, then a laparoscopic mobilization of the
catheter from the surrounding omentum should be
performed or the catheter should be removed if necessary. Due to the high frequency of this problem,
some surgeons recommend a prophylactic omentectomy at the time of the first catheter insertion (19).
Laparoscopic and open techniques of folding the
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omentum have been described and, according to
some authors, they significantly reduce the risk of
the described complication (20).
Retention of Fluid in the Peritoneal Recesses
The most common reason for retention of fluid in
the peritoneal recesses is the presence of adhesions
from previous surgeries. Sometimes, the omentum
and other adhesions divide the peritoneal cavity into
sections where dialysate is retained. The treatment
of this complication is adhesiolysis, either laparoscopic or, in more severe cases, open laparotomy
(21). In patients with a large number of adhesions
PD may be ineffective and the only alternative is
hemodialysis.
Hernias
Hernia is one of the most common complications of PD (22). Peritoneal dialysis is mentioned
as one of the risk factors predisposing to the formation of hernias according to the European Hernia Society standards. In a surgical practice,
dialysis patients develop inguinal (especially men),
umbilical (both gender), and postoperative incisional hernia. Hernia formation definitely complicates and often makes dialysis impossible because
of the fluid retention in the hernial sac, bulging
outside the peritoneal cavity. The constant, daily
inflow and outflow of dialysate and the following
changes in volume of the peritoneal cavity may
lead to a rapid enlargement of hernias. It is also
important to remember that hernia incarceration
may occur requiring emergent surgical intervention.
Therefore, an existing hernia is an indication for a
surgical procedure.
The surgical technique goes beyond the content
of this review, but it is important to emphasize the
value of mesh placement. Around the biomaterial
there is a formation of inflammatory state which
additionally seals the peritoneal cavity and avoids a
difficult to manage complication—leakage of dialysate through the wound.
For a hernia in a patient in whom we are just
planning to start dialysis, we perform a multiprocedural surgery combining hernia management
and catheter implantation at the same time (23).
The postoperative time after which we can start
PD is still debatable. Some authors recommend
postoperative initiation of dialysis after as few as
1–3 days (24,25). Other authors recommend early
PD after the procedure without the use of
hemodialysis, but with a reduction in the volume
of dialysis fluid (26). Data on the relationships of
volume and body position to intraabdominal pressure suggest that limiting PD to the supine position only (even using full volumes) keeps
pressures quit low and may safely allow even
immediate postoperative use of PD. Fluid must be
drained before any shift to an upright position
with this approach.
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Finally, it is important to mention hiatal hernia.
PD tends to cause an enlargement of this hernia;
the treatment, when required, is laparoscopic Nissen
fundoplication or one of its modifications.
Kumagain and colleagues described a stapled closure of the diaphragmatic defect without any interruptions to PD schedule (34). Pleurodesis, a widely
used method of treatment in the past, is still recommended and performed by many authors.
Leakage of Dialysate to Scrotum
During fetal life, when the testes are descending
down to the scrotum, they pull behind a small part
of parietal peritoneum known as the processus vaginalis. It descends down through a deep inguinal ring
to the inguinal canal and it then obliterates. If it
does not obliterate and it has a lumen, it becomes a
potential hernial sac of a congenital indirect inguinal hernia. In rare circumstances, processus vaginalis remains patent throughout its entire length
and allows dialysate to flow to the scrotum which is
the essence of the described complication (27). The
leakage usually happens unilaterally. Because it is a
rare complication, not extensively documented in
the literature, there is no standard of treatment for
this type of problem. In terms of diagnosis CT peritoneography has been successfully used to point out
the exact location of leakage (28,29).
The authors have operated on two patients with
this problem; in one of them, the leakage was present bilaterally. We intuitively performed a resection
and ligation of the processus vaginalis. In addition,
we used polypropylene mesh in a fashion similar to
that used in Lichtenstein hernioplasty. By creating a
new, artificial deep inguinal ring, we created an
inflammatory reaction next to the mesh which seals
and separates the peritoneal cavity from the inguinal canal. In both cases, PD was discontinued for
14 days awaiting wound healing. The final effect
was good, without a leakage to scrotum after the
initiation of dialysis.
Hydrothorax
A leakage of dialysate from the peritoneal space
to the pleural cavity is rare and most often due to
pathological, often congenital, diaphragmatic openings connecting the two cavities. The positive pressure in the peritoneal cavity exacerbated by the
presence of dialysate together with the negative
pressure in the pleural cavity promotes fluid movement (30). The main symptom is dyspnea which
usually occurs immediately after the initiation of
dialysis and gradually increases. Hydrothorax usually involves only one pleural cavity, more commonly on the right side (31). To confirm the
association with dialysis, scintigraphy can be used
as a diagnostic modality. Some authors recommend
a CT scan using dialysate with diluted contrast
(peritoneography) to help localize the outflow of
fluid from the peritoneal cavity to the pleural
cavity.
Treatment usually involves a videothoracoscopic
closure of the defect (32), sometimes with a biomaterial patch (33). While the patient is usually
switched to hemodialysis for a period of time,
Infectious Complications
Exit-Site Infection and Peritonitis
The medical management of these infectious complications is outside the scope of this review. However, surgical issues do arise.
By definition, exit-site infection (ESI) can be diagnosed with the presence of at least two of three
symptoms: (i) outflow of purulent fluid from the
exit, (ii) erythema, and (iii) pain. International Society for Peritoneal Dialysis accepted a simpler definition—the presence of purulent exudate with or
without the presence of erythema (35–37). Tunnel
infection (TI) is defined as a presence of erythema,
tenderness, or edema over the skin covering the
catheter. TI is more common in association with
ESI rather than as an isolated event.
In cases of ESI in which there is no improvement
or deterioration with 1 week of therapy, a cuffshaving procedure may be applied, especially for
Gram-positive infections (43). In cases of Pseudomonas aeruginosa infection (as well as with TI)
removal and reinsertion of the catheter at the same
surgical procedure under the coverage of appropriate antibiotic regimen, it is recommended that intervention be considered earlier because of the higher
failure rate with medical management and to prevent progression to peritonitis (42).
In general, ESI and superficial TI should be treated conservatively with antibiotics (or, for ESI, with
hypertonic saline or vinegar soaks). In cases of deep
TI (without evidence of peritonitis), antibiotics
should be the first line treatment and US examination should be performed weekly. If the hypoechogenic area alongside the cuff decreases,
conservative management should be continued. In
cases with no improvement based on US examination after 2 weeks of antibiotic therapy, catheter
removal is generally recommended. However,
Andreoli et al. proposed a novel technique to eradicate TI without catheter removal (44). Excision of
both primary exit site and floor of abscess cavity in
combination with application of topical antiseptic
agents and systemic antibiotic regimen resulted in
eradication of TI.
Peritonitis
Peritoneal dialysis peritonitis is treated at first
empirically pending the results of dialysate culture.
Preferably, the antibiotics should be administered
for at least 2 weeks ideally via the peritoneal catheter to maximize their concentration. However, the
exact duration of antibiotic regimen depends on
clinical response as well as the type of pathogen
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SURGICAL MANAGEMENT OF PD
caused PD peritonitis. In cases with no clinical
improvement, confirmed by persisting peritoneal
leukocytosis and clinical findings of peritonitis, the
PD catheter should be removed (45,46). In general,
catheter loss, rate of mortality, switching rate to
HD is higher in Gram-negative bacterial PD peritonitis than in Gram-positive PD peritonitis (47).
Regarding PD peritonitis, catheter should be
removed in the following clinical scenarios: (i) fungal peritonitis; (ii) no improvement within 5-day
antibiotic therapy; (iii) relapsing peritonitis; and (iv)
refractory infection (42).
There are no firm recommendations for extending
the dwell time on the cycler or switching to CAPD
to optimize antibiotic therapy. With regard to
managing fungal peritonitis, the current gold standard comprises obligatory removal of PD catheter
and administration of systemic antifungal treatment
at least for 3 weeks (48).
Encapsulating Peritoneal Sclerosis
Encapsulating peritoneal sclerosis (EPS) is a syndrome of gradually increasing obstruction of the
small intestine due to formation of massive adhesions between intestinal loops often covered with
fibrin capsule. Initially, symptoms suggest intermittent incomplete obstruction, but with time they progress to a complete obstruction requiring a surgical
intervention (49). As indicated by Kawanishi et al.
(49,50) EPS occurs in 2.5% of patients on PD and
the incidence increases with the duration of PD.
Paradoxically, it often occurs after the termination
of PD, for example, following a successful renal
transplant or when switching to hemodialysis.
When the diagnosis of EPS is confirmed, PD
should be discontinued. The practice of leaving the
peritoneal catheter for the purpose of peritoneal
lavage (to reduce fibrin formation and inflammatory
cytokines levels) has not shown significantly longterm benefits and has been abandoned (51).
Nutritional support in EPS patients is crucial
using both parenteral and/or enteral nutrition to
prevent the malnutrition that contributes to the
high mortality and morbidity rates in these patients
(52). In the encapsulating stage of EPS, bowel rest
is firmly recommended using TPN.
Adhesiolysis and eterolysis are the methods of
choice for surgical management of EPS. However,
these procedures are challenging, time consuming,
and associated with a high risk of intestinal fistulas
as well as a high rate of EPS recurrence. In general,
it is stated that this management may relieve intestinal obstruction but does improve the progressive
deterioration within the peritoneum. Kawanishi
et al. proposed Noble’s procedure to reduce the
incidence of intestinal obstruction with good longterm outcomes resulting in an impressively low 22%
rate of recurrence over a 5-year follow-up period
(50). Enterectomy with primary anastomosis is associated with a high mortality rate, and thus is contraindicated in EPS. After adhesiolysis, new
adhesions may form leading to a recurrent obstruction (49,50).
Conclusions
The numerous surgical requirements and complications of PD patients require that nephrologists
and surgeons work closely with each other and have
a basic understanding of each other’s potential contribution in providing optimal care for the patient.
In this model of cooperation, many complications
can be avoided and treatment results improved.
References
1. Twardowski ZJ: History of peritoneal access development. Int J Artif
Organs 29(1):2–40, 2006
2. Fleisher AG, Kimmelstiel FM, Lattes CG, Miller RE: Surgical
complications of peritoneal dialysis catheters. Am J Surg 149:
726–729, 1985
3. Valenti G, Cresseri D, Bianchi ML, Corghi E, Lorenz M, Buccianti
G: Surgical complications during continuous ambulatory peritoneal
dialysis. Perit Dial Int 5:39–42, 1985
4. Sun TY, Voss D, Beechey D, Lam-Po-Tang M: Comparison of peritoneal dialysis catheter insertion techniques: peritoneoscopic, radiological and laparoscopic – a single centre study. Nephrology 21:416–422,
2016
5. Weil BR, Andreoli SP, Billmire DF: Bleeding risk for surgical dialysis
procedures in children with hemolytic uremic syndrome. Pediatr
Nephrol 25(9):1693–1698, 2010
6. Mital S, Fried LF, Piraino B: Bleeding complications associated with
peritoneal dialysis catheter insertion. Perit Dial Int 24(5):
478–480, 2004
7. Gadallah MF, Torres-Rivera C, Ramdeen G, Myrick S, Habashi S,
Andrews G: Relationship between intraperitoneal bleeding, adhesions,
and peritoneal dialysis catheter failure: a method of prevention. Adv
Perit Dial 17:127–129, 2001
8. Perl J, Jassal SV, Bargman JM. Persistent peritoneal dialysis catheter
exit-site leak in a patient receiving maintenance immunosuppression
with sirolimus. Clin Transplant 22(5):672–673, 2008
9. Ranganathan D, Baer R, Fassett RG, Williams N, Han T, Watson
M, et al.: Randomised controlled trial to determine the appropriate
time to initiate peritoneal dialysis after insertion of catheter to minimise complications (Timely PD study). BMC Nephrol 11:11, 2010
10. Ozyer U, Harman A, Aytekin C, Boyvat F, Ozdemir N: Correction of
displaced peritoneal dialysis catheters with an angular stiff rod. Acta
Radiol 50(2):139–143, 2009
11. Ovnat A, Dukhno O, Pinsk I, Peiser J, Levy I: The laparoscopic
option in the management of peritoneal dialysis catheter revision. Surg
Endosc 16(4):698–699, 2002
12. Yilmazlar T, Yavuz M, Ceylan H: Laparoscopic management of malfunctioning peritoneal dialysis catheters. Surg Endosc 15(8):820–822,
2001
13. Lanuza M, Minguela JI, Rodado R, Muriel J, Ruiz-de-Gauna R: Our
nine-year experience with the self-locating catheter: comparison of
malfunction rate with other Tenckhoff catheter variants. Int J Artif
Organs 29(1):138–141, 2006
14. Bergamin B, Senn O, Corsenca A, Dutkowski P, Weber M, W€uthrich
RP, et al.: Finding the right position: a three-year, single-center experience with the “self-locating” catheter. Perit Dial Int 30(5):519–523,
2010
15. Wang H, Jia H, Lv X, Ding G: Peritoneal catheter fixation to the
abdominal wall in surgical catheter implantation to prevent malfunction. Blood Purif 38(2):109–114, 2014
16. Stucky CC, Mason MC, Madura JA 2nd, Harold KL: A technique to
address peritoneal dialysis catheter malfunction. JSLS 14(4):
608–610, 2010
17. Ohira N, Yorioka N, Ito T, Takasugi K, Takasugi N: Correction of
CAPD catheter displacement using gastric biopsy forceps: the pushpull method. Int J Artif Organs 22(4):202–204, 1999
18. Intarawongchot P: Tenckhoff catheter malfunction corrected by gastric channel-cleaning brush without fluoroscopy. J Med Assoc Thai 95
(4):505–507, 2012
19. Crabtree JH, Fishman A: Selective performance of prophylactic omentopexy during laparoscopic implantation of peritoneal dialysis catheters. Surg Laparosc Endosc Percutan Tech 13(3):180–184, 2013
68
Ratajczak et al.
20. Chen G, Wang P, Liu H, Zhou L, Cheng M, Liu Y, et al.: Greater
omentum folding in the open surgical placement of peritoneal dialysis
catheters: a randomized controlled study and systemic review. Nephrol
Dial Transplant 29(3):687–697, 2014
21. Keshvari A, Fazeli M.S., Meysamie A, Seifi S, Taromloo MK: The
effects of previous abdominal operations and intraperitoneal adhesions
on the outcome of peritoneal dialysis catheters. Perit Dial Int 30
(1):41–45, 2010
22. Gracia Toledo M, Borras Sans M, Gabarrell A, Duran J, Fernandez
Gir
aldez E: Risk factors for abdominal hernias in patients undergoing
peritoneal dialysis. Nefrologia 31(2):218–219, 2011
23. Sodo M, Bracale U, Argentino G, Merola G, Russo R, Sannino G,
et al.: Simultaneous abdominal wall defect repair and Tenckhoff
catheter placement in candidates for peritoneal dialysis. J Nephrol
2015 [Epub ahead of print]
24. Mettang T, Stoeltzing H, Alscher DM, Magadum S, Dunst R, Kuhlmann U: Sustaining continuous ambulatory peritoneal dialysis after
herniotomy. Adv Perit Dial 17:84–87, 2001
25. Tast C, Kuhlmann U, St€
olzing H, Alscher D, Mettang T: Continuing
CAPD after herniotomy. EDTNA ERCA J 28(4):173–175, 2002
26. Wakasugi M, Hirata T, Okamura Y, Minamimura K, Umemura A,
Kikuichi M, et al.: Perioperative management of continuous ambulatory peritoneal dialysis patients undergoing inguinal hernia surgery.
Surg Today 41(2):297–299, 2011
27. Mill
an I, Sirvent AE, Francisco Ram
on J, Dıez M: Patent processus
vaginalis in peritoneal dialysis. Kidney Int 84(3):628, 2013
28. Xie JY, Chen N, Shi T, Xu ZP, Lu Y, Ren H: Computed tomographic peritoneography in the investigation of patent processus vaginalis in CAPD patients. Clin Nephrol 73(2):153–156, 2010
29. Capelouto CC, DeWolf WC: Genital swelling secondary to leakage
from continuous ambulatory peritoneal dialysis: computerized tomography diagnosis. J Urol 150(1):196–198, 1993
30. Kennedy C, McCarthy C, Alken S, McWilliams J, Morgan RK, Denton M, et al.: Pleuroperitoneal leak complicating peritoneal dialysis: a
case series. Int J Nephrol 2011:526753, 2011
31. Guest S: The curious right-sided predominance of peritoneal dialysisrelated hydrothorax. Clin Kidney J 8(2):212–214, 2015
32. Di Bisceglie M, Paladini P, Voltolini L, Garosi G, Ghiribelli C, Di
Paolo N, et al.: Videothoracoscopic obliteration of pleuroperitoneal
fistula in continuous peritoneal dialysis. Ann Thorac Surg 62(5):
1509–1510, 1996
33. Nishina M, Iwazaki M, Koizumi M, Masuda R, Kakuta T, Endoh
M, et al.: Case of peritoneal dialysis-related acute hydrothorax, which
was successfully treated by thoracoscopic surgery, using collagen
fleece. Tokai J Exp Clin Med 36(4):91–94, 2011
34. Kumagai H, Watari M, Kuratsune M: Simple surgical treatment for
pleuroperitoneal communication without interruption of continuous
ambulatory peritoneal dialysis. Gen Thorac Cardiovasc Surg 55
(12):508–511, 2007
35. Dell’aquila R, Berling
o G, Pellanda V, Contestabile A, Lentini P:
Diagnosis and therapy of exit-site infection in peritoneal dialysis: an
update. G Ital Nefrol 28(1):39–47, 2011
36. De Vecchi AF: Exit-site infection in peritoneal dialysis. G Ital Nefrol
21(6):519–530, 2004
37. Clou^atre Y, Cartier P, Charbonneau R, Deziel C, Allard M, Madore
F: Outpatient CAPD catheter salvage for persistent exit-site/tunnel
infection. Nephrol Dial Transplant 15(2):231–234, 2000
38. Akoh JA: Peritoneal dialysis associated infections: an update on diagnosis and management. World J Nephrol 1(4):106–122, 2012
39. Yoshino A, Honda M, Ikeda M, Tsuchida S, Hataya H, Sakazume S,
et al.: Merit of the cuffshaving procedure in children with chronic
infection. Pediatr Nephrol 19:1267–1272, 2004
40. Andreoli SP, West KW, Grosfeld L, Bergstein JM: A technique to
eradicate tunnel infection without peritoneal dialysis catheter removal.
Perit Dial Int 4:156–157, 1984
41. Morton AR, Waldek S, Holmes AM: Removal and replacement of
Tenckhoff catheters. Lancet 1(8526):229, 1987
42. Rodrigues AS, Matos CB, Silva F, Fonseca I, Nogueira C, Santos J,
et al.: Long-term peritoneal dialysis experience in Portugal. Int J Artif
Organs 29:1109–1116, 2006
43. Prasad N, Gupta A, Sharma RK, Prasad KN, Gulati S, Sharma AP:
Outcome of gram-positive and gram-negative peritonitis in patients on
continuous ambulatory peritoneal dialysis: a single-center experience.
Perit Dial Int 23(Suppl 2):S144–S147, 2003
44. Garcıa-Agudo R, Garcıa-Martos P: Clinical and microbiological
aspects of fungal peritonitis in peritoneal dialysis. Nefrologia 29:
506–517, 2009
45. Kawanishi H, Moriishi M, Ide K, Dohi K: Recommendation of the
surgical option for treatment of encapsulation peritoneal sclerosis.
Perit Dial Int 28:S205–S210, 2008
46. Kawanishi H, Shintaku S, Moriishi M, Dohi K, Tsuchiya S: Seventeen years’ experience of surgical options for encapsulating peritoneal
sclerosis. Adv Perit Dial 27:53–58, 2011
47. Yamamoto T, Nagasue K, Okuno S, Yamakawa T: The role of peritoneal lavage and the prognostic significance of mesothelial cell area
in preventing encapsulating peritoneal sclerosis. Perit Dial Int 30
(3):343–352, 2010
48. Jordaan A, de Freitas D, Hurst H, Alderdice J, Curwell J, Brenchley
PE, et al.: Malnutrition and refeeding syndrome associated with EPS.
Perit Dial Int 27(1):100–101, 2007
49. Shroff R, Stefanidis CJ, Askiti V, Edefonti A, Testa S, Ekim M, et al.:
Encapsulating peritoneal sclerosis in children on chronic PD: a survey
from the European Paediatric Dialysis Working Group. Nephrol Dial
Transplant 28(7):1908–1914, 2013
50. Latus J, Ulmer C, Fritz P, Rettenmaier B, Biegger D, Lang T, et al.:
Encapsulating peritoneal sclerosis: a rare, serious but potentially curable complication of peritoneal dialysis–experience of a referral centre
in Germany. Nephrol Dial Transplant 28(4):1021–1030, 2013