Laparoscopic-aided diagnosis of recurrent peritonitis in a patient on CAPD

Appendicitis Misdiagnosed as Peritoneal Dialysis-Related Peritonitis: A Case Report

Abdominal pain in patients on continuous ambulatory peritoneal dialysis (PD) is considered a serious, alarming symptom since they are at increased risk for exogenous infection introduced through the peritoneal catheter. Differential diagnosis includes perforated peptic ulcer, cholecystitis, ischemic colitis, appendicitis, diverticulitis, ingestion of foreign body, or malignancy. Typical features of perforation include signs of acute abdomen in addition to free air under the diaphragm detected on imaging. Perforation is an indication of emergency laparotomy, which is the gold standard for diagnosis. We reported a case of a 23-year-old Palestinian male patient who had recently started continuous ambulatory PD. He presented with generalized, colicky abdominal pain associated with nausea and vomiting. He noticed turbid peritoneal fluid while performing daily dialysis sessions. The patient was diagnosed with PD-related peritonitis but had no improvement on intraperitoneal antibiotics. Further evaluation revealed an intraabdominal cause, a perforated appendix. He underwent an urgent laparotomy and switched to hemodialysis. The patient expired due to the complications of his disease. Although PD-related peritonitis is readily diagnosed in patients on continuous ambulatory PD, an underlying intraabdominal pathology should be suspected when the condition is resistant to conventional treatment. Accepting or refuting such a diagnosis can be challenging.

Malfunctioning Peritoneal Dialysis Catheter and Accompanying Surgical Pathology Repaired by Laparoscopic Surgery

♦ Objectives

To review the laparoscopic salvaging of malfunctioning peritoneal dialysis (PD) catheters, and to present our experience with laparoscopic repair of dysfunctional Tenckhoff catheters and the treatment of accompanying surgical pathologies.

♦ Design

Malfunctioning peritoneal catheters were repaired using laparoscopic rescue techniques. Accompanying surgical problems were treated in the same operation. The effectiveness of these approaches was validated by comparison with other remedial techniques described previously.

♦ Patients

Malfunctioning PD catheters were salvaged by laparoscopic surgery in 8 patients, and accompanying surgical problems were treated in the same operation in 3 of the 8 patients.

♦ Main Outcome Measures

Outcome was measured by the successful return to adequate PD and effective treatment of surgical problems.

♦ Results

Eight patient studies show laparoscopic correction of malfunctioning catheters and the treatment of accompanying surgical pathologies with the return to successful PD.

♦ Conclusion

The salvaging of malfunctioning PD catheters by laparoscopic surgery is an ideal method. This procedure permits simultaneous identification and correction of other surgical problems that could otherwise complicate dialysis therapy.

Video-assisted laparoscopic procedures in peritoneal dialysis

BACKGROUND

Although laparoscopy is commonly adopted for the diagnosis and management of various medical or surgical problems, its use for patients with peritoneal dialysis has seldom been addressed. This retrospective study analyzes the indications and clinical effects of this procedure.

METHODS

A retrospective chart was drawn up and a videotape review performed for 18 laparoscopic procedures involving 198 patients receiving peritoneal dialysis on a long-term basis at our dialysis unit from May 1992 to June 2002. The clinical and demographic parameters in this study included gender, age, underlying renal diseases, duration of peritoneal dialysis before laparoscopy, indications of laparoscopic intervention, laparoscopic findings, time of operation, laparoscopic procedures, postoperative complications, mortality, and catheter results.

RESULTS

A total of 18 laparoscopic procedures were performed in 17 uremia patients, with indications including catheter malfunction in five cases, preimplantation evaluation of peritoneal space in three cases, evaluation of the etiology underlying intractable peritonitis in nine cases, and verification of the cause for dialysate leakage in one case. Four (80%) of the five catheter malfunctions were successfully corrected, including one case of catheter migration and three cases of omental wrapping, whereas correction failed in the remaining case because of severe bowel adhesion. New catheter placement after adhesiolysis was successful in all three cases of preimplantation peritoneal evaluation (100%). Of the nine patients whose peritonitis episodes were evaluated, two were found to have secondary peritonitis, two had fungal peritonitis; one had tuberculous peritonitis and four had bacterial peritonitis. In the case of persistent exit-site dialysate leakage, laparoscopy showed a penetrating injury of the abdominal wall, raising a strong suspicion of iatrogenic injury during the tunneling maneuvers in initial catheter placement. Two conversions to laparotomy were performed: one to repair the penetrating injury and the other to save the life of a patient threatened by severe fungal peritonitis with abdominal cocoon formation. The laparoscopic procedures lasted 20 to 150 min (average, 50 min). Despite one instance of postoperative hydrocele, there was no operative mortality.

CONCLUSIONS

The analytical results of this study demonstrate that the current video-assisted laparoscopic technique is an effective means for managing several problems related to peritoneal dialysis such as catheter malfunction, preimplantation evaluation, location of the source of the dialysate leak, and assessment of the causes for peritonitis. Thus, this technique should always be considered when the these problems arise.

Emergency Laparotomy in Patients on Continuous Ambulatory Peritoneal Dialysis

Peritonitis is the most common complication of chronic ambulatory peritoneal dialysis (CAPD). It is often a diagnostic challenge to differentiate those patients with CAPD-associated infections from those who have unrelated gastrointestinal pathology as the cause of peritonitis and would benefit from surgical exploration. A retrospective chart review was performed on all patients at a single institution who were on CAPD between the years 1990 and 1998 and who underwent laparotomy for peritonitis. Six patients underwent laparotomy. Four were male and two were female; ages ranged from 34 to 80 years. Perforated appendicitis was the cause of peritonitis in three patients, perforated diverticulitis was present in two, and one was without any suppurative intra-abdominal process. In each case CT scan of the abdomen was nondiagnostic. There was a delay in diagnosis of 10 days (range 3–21 days) and an operative mortality of 16 per cent.