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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 There are not many studies, most of which are outdated and do not evaluate this issue in detail (2,3).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 64 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 65 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. 66 Ratajczak et al. 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 67 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. 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