TY - JOUR
AU - Nicholson, M L
AB - Abstract Background Peritonitis is the major complication of peritoneal dialysis (PD). Some 25–40 per cent of patients require surgical intervention, traditionally laparotomy, washout and removal of the PD catheter. The aim was to compare this open procedure with laparoscopic washout and catheter removal. Methods In a case–control comparison, 20 patients who had laparoscopic washout for PD-associated peritonitis were matched by age and causative organism with 20 patients who had open washout. Results The groups were well matched for age, sex, causative organism, preoperative C-reactive protein level, white cell count and presence of bowel wall sclerosis. Laparoscopic surgery was quicker than open operation (mean(s.d.) 49(13) versus 73(30) min; P = 0·006) and postoperative morphine requirements were significantly lower (median 0 versus 27 mg; P < 0·001). Bowel function recovered more quickly in the laparoscopic group, as measured by time to first passage of flatus (mean(s.d.) 2(1) versus 5(4) days; P = 0·004) and resumption of free fluids (median 2 versus 4 days; P = 0·044). Reoperation rates and 30-day mortality were identical in the two groups. Conclusion This study suggests that laparoscopic washout for PD peritonitis is as effective as open washout, but is quicker and less painful with earlier return of bowel function. Introduction Peritonitis remains the major complication in patients treated with peritoneal dialysis (PD), with 0·5–1·5 episodes per patient per year1,2 and a mortality rate of 2·5–5 per cent3,4. It is also the commonest cause of technique failure, with 25–40 per cent of affected patients requiring catheter removal2,4. Although most patients respond to conservative management with intraperitoneal antibiotics, a significant minority require surgical intervention. This has traditionally involved a laparotomy, washout of the abdominal cavity and removal of the PD catheter. The authors have recently developed a laparoscopic technique for washout and removal of the catheter in patients with PD-associated peritonitis. The laparoscopic approach, which has been reported briefly in the literature with varying results5–7, has a number of potential advantages over open surgery. It may allow a more thorough examination of the peritoneal cavity and easier identification of secondary causes. The washout may be more comprehensive, with better access particularly to the upper quadrants of the abdomen. In addition, it is now well recognized that laparoscopic surgery is less painful than open surgery and allows quicker postoperative recovery. The aim of this case–control study was to compare the efficacy and safety of laparoscopic and open washout for PD peritonitis. Methods The laparoscopic washout technique was introduced in January 2006, and the study ended in October 2007. During this time, 20 patients with PD-associated peritonitis underwent laparoscopic washout, all of whom were included in this study. These patients were matched for age and causative organism with 20 non-consecutive patients who had open washout for PD-associated peritonitis between January 2004 and October 2007. Demographic details of the patients were collected prospectively, and perioperative and survival data were retrieved retrospectively from case notes and computerized hospital records. Indications for surgical intervention in both groups were: failure to improve after 5 days of medical treatment (intraperitoneal antibiotics in all patients initially and intravenous antibiotics in some), generalized peritonitis (indicated by generalized abdominal pain with guarding, rebound tenderness or evidence of sepsis), fungal peritonitis or Pseudomonas peritonitis. Selection for laparoscopic or open surgery generally depended on which consultant surgeon was on duty. Laparoscopic surgery was not restricted to younger patients or those deemed to have less severe peritonitis. No exclusions were made on the basis of body mass index. All procedures were performed or supervised by a consultant surgeon. For laparoscopic washout, pneumoperitoneum was established with carbon dioxide via the PD catheter, at a relief pressure of 15 mmHg. The first port (12 mm) was inserted using the Hassan technique and another two ports (one 12 mm, one 5 mm) under direct vision. The ports were usually placed in the upper quadrant on the contralateral side to the exit site (Fig. 1). A thorough examination of the peritoneal cavity was performed to identify any secondary causes of peritonitis. Washout was performed with at least 3 litres of warmed saline using a motorized lavage system until the effluent became clear. The cuff of the catheter was then dissected free intraperitoneally using hook or scissor diathermy. The catheter was divided above the cuff and removed via the second 12-mm port. Tube drains were placed as necessary via the existing or new ports. Fig. 1 Open in new tabDownload slide Position of laparoscopic ports (arrows) Open washout involved a periumbilical incision large enough to allow adequate visualization of the abdominal cavity and exclusion of secondary causes of peritonitis. Washout was again performed with at least 3 litres of warmed saline and drains placed as necessary. The catheter was removed before mass closure of the abdomen. Primary outcome measures included duration of surgery, postoperative analgesia requirements, reoperation rates and survival. Secondary outcome measures included change in white cell count and C-reactive protein level, time to return of bowel function and length of hospital stay. Return of bowel function was assessed by establishment on free fluids and passage of flatus. Statistical analysis Normally distributed data were expressed as mean(s.d.) and analysed using the t test. Data for other continuous variables were presented as median (interquartile range (i.q.r.)) and analysed using the Mann–Whitney U test. Fisher's exact test was used for categorical variables. P⩽0·050 was considered significant. Results Table 1 shows the demographic details of the two groups. The sex distribution was similar (11 men and nine women in the laparoscopic group, and 12 men and eight women in the open group; P = 1·000). There was no significant difference in the incidence of bowel wall sclerosis (seven and 11 patients respectively; P = 0·341). Table 1 Demographic and preoperative data . Laparo scopic (n = 20) . Open (n = 20) . t or U . d.f. . P . Age at surgery (years)* 56(17) 56(19) − 0·069 38 0·945‡ Duration of PD (months)† 30 (16–49) 57 (21–120) − 1·988 — 0·047§ White cell count (×109/l)† 12 (9–16) 12 (7–13) 0·960 — 0·337§ C-reactive protein (mg/l)* 165(95) 211(115) 1·363 37 0·181‡ . Laparo scopic (n = 20) . Open (n = 20) . t or U . d.f. . P . Age at surgery (years)* 56(17) 56(19) − 0·069 38 0·945‡ Duration of PD (months)† 30 (16–49) 57 (21–120) − 1·988 — 0·047§ White cell count (×109/l)† 12 (9–16) 12 (7–13) 0·960 — 0·337§ C-reactive protein (mg/l)* 165(95) 211(115) 1·363 37 0·181‡ Values are * mean(s.d.) and † median (interquartile range). PD, peritoneal dialysis. ‡ t test; § Mann–Whitney U test. Open in new tab Table 1 Demographic and preoperative data . Laparo scopic (n = 20) . Open (n = 20) . t or U . d.f. . P . Age at surgery (years)* 56(17) 56(19) − 0·069 38 0·945‡ Duration of PD (months)† 30 (16–49) 57 (21–120) − 1·988 — 0·047§ White cell count (×109/l)† 12 (9–16) 12 (7–13) 0·960 — 0·337§ C-reactive protein (mg/l)* 165(95) 211(115) 1·363 37 0·181‡ . Laparo scopic (n = 20) . Open (n = 20) . t or U . d.f. . P . Age at surgery (years)* 56(17) 56(19) − 0·069 38 0·945‡ Duration of PD (months)† 30 (16–49) 57 (21–120) − 1·988 — 0·047§ White cell count (×109/l)† 12 (9–16) 12 (7–13) 0·960 — 0·337§ C-reactive protein (mg/l)* 165(95) 211(115) 1·363 37 0·181‡ Values are * mean(s.d.) and † median (interquartile range). PD, peritoneal dialysis. ‡ t test; § Mann–Whitney U test. Open in new tab Causative organisms are listed in Table 2. Of note, culture of the PD fluid from some patients revealed multiple organisms (one patient in the laparoscopic group and five in the open group; P = 0·182). None of the patients had peritonitis from secondary causes. Table 2 Causative organisms . Laparoscopic (n = 20) . Open (n = 20) . P* . Gram positive 10 14 0·767 Gram negative 6 7 1·000 Candida species 2 2 1·000 No growth 3 2 0·648 . Laparoscopic (n = 20) . Open (n = 20) . P* . Gram positive 10 14 0·767 Gram negative 6 7 1·000 Candida species 2 2 1·000 No growth 3 2 0·648 * Fisher's exact test. Open in new tab Table 2 Causative organisms . Laparoscopic (n = 20) . Open (n = 20) . P* . Gram positive 10 14 0·767 Gram negative 6 7 1·000 Candida species 2 2 1·000 No growth 3 2 0·648 . Laparoscopic (n = 20) . Open (n = 20) . P* . Gram positive 10 14 0·767 Gram negative 6 7 1·000 Candida species 2 2 1·000 No growth 3 2 0·648 * Fisher's exact test. Open in new tab The operating time was shorter for laparoscopic than open washout (mean(s.d.) 49(13) versus 73(30) min respectively; P = 0·006). None of the laparoscopic procedures was converted to open surgery. The efficacy of washout was measured by the difference in white cell counts and C-reactive protein levels before and 2 days after surgery, as well as reoperation rates. The increase in white cell count in the laparoscopic group was similar to that in the open group (median (i.q.r.) 0·6 (−2 to 3) versus 1·3(0–5) × 109/l respectively; P = 0·129), as was the increase in C-reactive protein level (mean(s.d.) 89(123) versus 77(97) mg/l respectively; P = 0·748). Three patients from each group required further surgery, all because of ongoing sepsis with worsening signs of peritonitis. Reoperations in the laparoscopic group all involved a laparotomy and laparoscopic treatment was therefore deemed to have failed. In two of these three patients the PD catheter was left in situ after the initial laparoscopic washout. Postoperative parameters were significantly in favour of laparoscopic surgery. Patients in the laparoscopic group required less morphine in the first 48 h than those who had open washout (median (i.q.r.) 0 (0–5) versus 27 (5–44) mg respectively; P < 0·001). Patients in the laparoscopic group passed flatus sooner than those in the open group (mean(s.d.) 2(1) versus 5(4) days; P = 0·004), and were also quicker to become established on free fluids (median (i.q.r.) 2 (1–3) versus 4 (2–7) days; P = 0·044). There was no difference in duration of hospital stay (median (i.q.r.) 15 (8–30) versus 21 (15–37) days respectively; P = 0·133). Three patients in each group died within 30 days of operation. Causes of death in the laparoscopic group were ischaemic heart disease (one patient), leg ischaemia, gastrointestinal bleed and withdrawal of renal replacement therapy (one), and ischaemic bowel (one). In the open group, causes of death were line sepsis and endocarditis (one), pneumonia and a cerebrovascular event (one), and ongoing sepsis (one). No patient was lost to follow-up. Discussion This study suggests that laparoscopic washout for PD-associated peritonitis is quicker than open surgery, and is associated with more rapid postoperative recovery, less analgesia requirement and faster return of bowel function. There is no evidence that laparoscopic washout is less effective, as reoperation rates and 30-day mortality were the same as those after open surgery. It is important to note that, of four patients in the laparoscopic group who had the PD catheter left in situ, two required reoperation. Therefore, to ensure successful laparoscopic washout, the catheter should be removed. This case–control comparison provides a robust evaluation of laparoscopic surgery for PD-associated peritonitis. The two groups were well matched for all preoperative factors other than duration of PD. The latter does have an influence on outcome following PD-associated peritonitis, but only because the incidence of encapsulating sclerosing peritonitis increases with duration of PD. However, there was no difference in the incidence of sclerosis in the open and laparoscopic groups, so this should not have been a confounding factor. Overall, the two groups were comparable in terms of prognostic factors and severity of peritonitis. Other advantages of the present study are that all demographic details were collected prospectively and that data collection was complete for all patients, with none lost to follow-up. The main disadvantages are that outcome data were not collected prospectively, and patient numbers were relatively small. In addition, the use of passage of flatus as a marker of bowel function may be inaccurate, as it is difficult to assess silent flatus passed at night. However, this should have affected both groups similarly and not biased the results. Previous reports of laparoscopic washout for PD-associated peritonitis have mainly suggested that it is not as effective as open washout, although Chiu and colleagues5 reported one patient in whom laparoscopic washout and continuous peritoneal lavage was successful. Woltmann and co-workers6 described staged laparoscopic lavage in three patients, all of whom eventually required open treatment. Mutter and colleagues7 noted that laparoscopic washout did not allow salvage of infected catheters in three patients. However, these papers were published over 10 years ago, and there has since been a significant improvement in laparoscopic techniques and equipment. In particular, modern motorized lavage systems allow extremely effective peritoneal washout. The ‘gold standard’ for comparing these two techniques would be a randomized controlled trial; however, in view of the mixed results in the literature, it was considered unwise to embark on such a trial immediately without some proof of principle. In the light of the potential advantages of laparoscopic washout for PD-associated peritonitis demonstrated in the present study, a randomized controlled trial is now being planned. References 1 Vargemezis V , Thodis E. Prevention and management of peritonitis and exit-site infection in patients on continuous ambulatory peritoneal dialysis . Nephrol Dial Transplant 2001 ; 16 ( Suppl 6 ): 106 – 108 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Brook NR , White SA, Waller JR, Nicholson ML. The surgical management of peritoneal dialysis catheters . Ann R Coll Surg Engl 2004 ; 86 : 190 – 195 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Zalunardo NY , Rose CL, Ma IW, Altmann P. Higher serum C-reactive protein predicts short and long-term outcomes in peritoneal dialysis-associated peritonitis . Kidney Int 2007 ; 71 : 687 – 692 . Google Scholar Crossref Search ADS PubMed WorldCat 4 Kavanagh D , Prescott GJ, Mactier RA. Peritoneal dialysis-associated peritonitis in Scotland (1999–2002) . Nephrol Dial Transplant 2004 ; 19 : 2584 – 2591 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Chiu CK , Karmakar MG, Yang HK, Da Silva MC, Karanfilian RG. Laparoscopic management of peritonitis in the setting of an infected Tenckhoff catheter: a case report and description of technique . J Am Coll Surg 1996 ; 183 : 640 – 642 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 6 Woltmann A , Eckmann C, Hoyer J, Bruch HP. Laparoscopic staged lavage in CAPD catheter peritonitis—an alternative to open treatment? Langenbecks Arch Chir Suppl Kongressbd 1997 ; 114 : 1188 – 1190 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 7 Mutter D , Marichal JF, Heibel F, Marescaux J, Hannedouche T. Laparoscopy: an alternative to surgery in patients treated with continuous ambulatory peritoneal dialysis . Nephron 1994 ; 68 : 334 – 337 . Google Scholar Crossref Search ADS PubMed WorldCat Copyright © 2008 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Copyright © 2008 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
TI - Case–control comparison of laparoscopic and open washout for peritoneal dialysis-associated peritonitis
JO - British Journal of Surgery
DO - 10.1002/bjs.6298
DA - 2008-10-09
UR - https://www.deepdyve.com/lp/oxford-university-press/case-control-comparison-of-laparoscopic-and-open-washout-for-WKmpZyVMWm
SP - 1416
EP - 1419
VL - 95
IS - 11
DP - DeepDyve
ER -