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Home , Peritoneal dialysis

Advances in Peritoneal , Vol. 28, 2012

Successful Laparoscopic in Peritoneal Dialysis Patients Without Interruption of Their CKD6 Treatment Gabriel A. Valle,1 Barbara E. Kissane,1 Nestor de la Cruz– Muñoz2 Modality

During the past several decades, the conventional urgent, or complicated interventions may result in management of peritoneal dialysis (PD) patients a permanent switch to HD, but after most cases of undergoing elective required a elective and uneventful intra-abdominal surgery, re- transition to on a temporary basis. In institution of PD is the norm. recent years, that protocol has been challenged by Even in the stable, uncomplicated preoperative various authors who successfully repaired patient, concerns surround the potential for intra- or in such subjects without interruption of their PD trans-abdominal leaks, peritoneal contamination, modality. However, that new approach was reserved interference with wound healing, aggravation or for abdominal wall procedures and was not used for perpetuation of ileus, and impairment of respiratory intra-abdominal surgery. mechanics, among other issues (1,2). Additionally, The rapid evolution of laparoscopic surgery the efficiency and efficacy of dialysis may be in ques- and the development and refinement of minimally tion because of changes in splanchnic macro- and invasive surgical techniques have revolutionized micro-circulatory hemodynamics, effective peritoneal the field of surgery by providing superior outcomes surface exchange area, membrane transport proper- for an ever-increasing list of indications including ties, delayed bowel function, and patient tolerance of morbid . The present study, the first of its kind dialysate dwells (3–6). involving elective intra-abdominal surgery, sought to The extent and complexity of the operation and determine the safety of uninterrupted PD therapy in the not-so-subtle effects of the size and location of the morbidly obese patients with stage 6 chronic abdominal incision or incisions affecting postopera- undergoing laparoscopic bariatric surgery tive recovery in cases of conventional surgery appear as a precursor to transplantation. to be the main culprits. However, since the early 1990s, a handful of studies on PD patients undergoing Key words elective conventional abdominal wall repair , bariatric surgery have established that reparative surgery can be suc- cessfully performed without temporary conversion Introduction to HD. Indeed, in the largest study of its kind, all Abdominal surgery in the peritoneal dialysis (PD) subjects were managed with a protocol of modified population has invariably led to a transition to hemo- PD prescription without significant complications (7). dialysis (HD) in the perioperative period. Complex, Other authors have also shown that, in cases of limited abdominal wall breakdown and intraperitoneal inva- sion (such as the straightforward surgical insertion of From: 1The Kidney Group of South Florida, Fort Lauder- a tunneled PD ), there is no need to delay the dale, and 2Department of Surgery, University of Miami, initiation of PD. Compared with a standard group in Miller School of Medicine, Miami, Florida, U.S.A. whom initiation of PD exchanges took place 2 weeks Valle et al. 135 after catheter placement surgery, a group undergoing disruption of the intra-abdominal organs and short break-in periods immediately after surgery did abdominal wall, affording better preservation of not experience an increase in complications (8). the physiologic integrity of the and Nonetheless, no standardized approach has been of compliance. developed to date for the PD patient undergoing elec- • The strength of a center-of-excellence, certi- tive intra-abdominal surgery—a more challenging fied bariatric surgery program within which all problem, because it encompasses a wide variety of operations are performed by an experienced very different surgical interventions. Conventional surgeon with an extremely low incidence of management calls for temporary conversion to HD complications. in the postoperative period. The emergence, since the early 1990s, of laparoscopic surgery as the pre- In addition, patient selection based on dynamic eminent option for a wide variety of indications (9) criteria such as compliance with scheduled clinic may change that approach. Increasingly sophisticated visits, pharmacotherapy, preoperative dietary pre- and minimally invasive, laparoscopic surgery has scription, achievement of educational goals, and rapidly gained acceptance because of its advantages commitment to the transplant program was of para- in shortening length of stay and postoperative pain, al- mount importance. lowing for faster recovery, enhanced cosmetic results, The present study was designed to determine the increased patient satisfaction and a lesser incidence safety of laparoscopic bariatric surgery (LBS) without of incisional hernia (10). interruption of continuous cycling PD (CCPD) in MO The challenging field of morbid obesity is no PD patients desirous of , but exception to this trend and has benefited from the unable to reach their qualifying weight goal. introduction, development, and subsequent evolution of the laparoscopic technique as the “gold standard” Methods approach to the surgical treatment of this serious Between November 2010 and December 2011, 5 MO condition (10–12). Simultaneously, the convergence patients [2 men, 3 women; 3 black, 1 white, 1 His- of two modern epidemics (13–16), obesity and chronic panic; average age: 41 years (range: 35 – 56 years); kidney disease (CKD), has given rise to a growing average body mass index: 43.3 kg/m2] with CKD6 high-risk population of morbidly obese (MO) patients who were enrolled in our home dialysis program with CKD stage 6 who have a critical need for effective underwent LBS. All subjects were established on weight management interventions to qualify for kidney CCPD (duration of therapy: 6 – 36 months) and had transplantation. Absent a protocol for successful weight tried a variety of weight loss programs for several rehabilitation and the option of organ transplantation, years. All had received conditional approval for these subjects are left with a very limited outlook with inclusion in regional kidney transplant programs, respect to health and quality of life (17–22). contingent on achieving a center-specified target In an area in which medical management— weight goal. The main causes of CKD in these combinations of diet, exercise, and psychological patients were mellitus, , and interventions—has met with very limited success chronic glomerulonephritis (Table I). and increasing recidivism, bariatric surgery has been Presurgical management included up to 3 weeks of established as the most successful treatment modal- a hypocaloric liquid diet, which produced significant ity for severely obese individuals who meet specific weight loss. (For a more detailed description, see the criteria from the American Society for Metabolic Discussion section.) and Bariatric Surgery and the National Institutes of Leading up to the procedure, patients had no oral Health (11,23). intake after midnight, and regular nocturnal exchanges Our novel approach to the postoperative care were continued until the morning of surgery. At the of the bariatric PD patient is based on two leading end of the last CCPD session, the peritoneal cav- considerations: ity was drained completely. Preoperative prophylaxis consisted of a single intravenous dose of • The very essence of the laparoscopic “mini- amoxicillin (2 g) or clindamycin (600 mg). Anesthesia mally invasive” method offers controlled, limited was administered following standard protocols. 136 Laparoscopic Bariatric Surgery in PD Patients table i Characteristics of the study patients

Patient ID Variable 1 2 3 4 5 Average

Age (years) 38 36 40 56 35 41 Sex Male Male Female Female Female — Race 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 BMI (kg/m2) 43.8 40.5 49 41.1 42.1 43.3 Duration of PD (months) 36 6 12 34 7 19

CGN = chronic glomerulonephritis; FSGS = focal segmental glomerulosclerosis; HTN = hypertension; SLE = systemic lupus erythema- tosus; DM1 = type 1 diabetes mellitus; OSA = obstructive sleep apnea; DL = dyslipidemia.

Laparoscopic procedures included gastric band- Results ing (1 patient) and Roux-en-Y gastric bypass (4 After 2 – 3 weeks of a strict low-calorie diet and a lead- patients). One of the latter patients also underwent in average weight loss of 6.8 kg (range: 4.5 – 11.3 kg), tandem inguinal . A standard surgical all patients underwent successful bariatric surgery laparoscopic approach was used, except that the sur- without complications. Overall need for analgesics or geon explicitly inserted the lowest port as cephalad other symptomatic therapy was remarkably minimal. as possible to avoid interference with or disruption The patient who received a gastric band was dis- of the peritoneal catheter position. Limited upper charged home within 12 hours; the 4 patients undergo- abdominal lavage was routinely performed. The ing gastric bypass were discharged the day after surgery. reported estimated loss was less than 60 mL. Two patients who started in-hospital CCPD reported In all patients undergoing gastric bypass, a Jackson– volume-related abdominal discomfort. The adoption Pratt drain was kept in the left subphrenic space until of our volume titration protocol resulted in excellent the following morning. patient tolerance. All but 1 patient started home CCPD After completion of their bariatric surgery, 2 on postoperative day 1. The patient who had the addi- patients resumed CCPD without delay; the other 3 tional hernia repair delayed re-institution of CCPD and remained off dialysis for the first 24 postoperative reported lower abdominal “soreness and bloating,” but hours. Heparin (1000 U/L) was added routinely to experienced rapid resolution of those symptoms during the dialysate for the first week after surgery. Upon the first dialysis session on postoperative day 3. resumption of their CCPD at home, all patients used None of the patients experienced fluid leakage at- the following volume titration protocol: The dwell tributable to early resumption of PD. A hemorrhagic volume was initially set at 25% – 50% of the origi- effluent was universally noted from the first exchange nal prescription for the first 3 – 5 days. It was then after surgery and gradually disappeared within 7 – 10 increased by 25% every 3 – 5 days until the preopera- days. An incremental bariatric diet of clear to full tive prescription was restored (Figure 1). The main liquids, shakes, and soft foods was very well determinants for the selection of starting volume tolerated. Dumping syndrome a few days after surgery and the progression of volume titration were patient occurred in 1 patient because of dietary indiscretion; height and development of abdominal discomfort. but otherwise, all patients had loose, but not frequent, The dialysate dextrose concentration was maintained stools for up to 2 weeks. at 1.5% and adjusted to meet ultrafiltration needs as No significant episodes of volume or metabolic clinically indicated, paralleling the patient’s ability to derangements were noted within the extended post- gradually resume a modified bariatric diet. operative period. All subjects achieved their target Valle et al. 137

figure 1 Summary of the volume titration protocol in postsurgical peritoneal dialysis patients. weight within 8 weeks after surgery and were ap- had become highly motivated about qualifying for proved for transplantation. One patient received a kidney transplantation. living donor organ a year later. Perioperative management encompassed major In every instance, weight loss continued beyond dietary interventions and behavioral changes. A coor- the pre-transplant goal in a gradual, safe, and persistent dinated multispecialty and multidisciplinary approach manner, leading to substantial improvement in the and regular follow-up were crucial to the success control of , dyslipidemia, hypertension, of this therapeutic approach. In preparation for the and sleep apnea. surgery, patients were asked to follow a low-calorie liquid diet for 2 – 3 weeks. The main purpose of this Discussion preliminary intervention is to decrease visceral fat The increasing prevalence of MO patients with CKD6 and reduce size (steatohepatitis), both of which has created a cohort of high-risk individuals with a help to improve the surgeon’s ability to visualize and serious prognosis and the inability to qualify for renal manage the operative field (27–31). The secondary transplantation. Most are affected by comorbidities endpoint was to evaluate patient’s overall compliance such as diabetes and hypertension, which portend and commitment. increased cardiovascular morbidity and mortality This dietary protocol led to a considerable aver- (17,24,25). Furthermore, surgical risks and outcomes age preoperative weight loss of 6.8 kg (range: 4.5 – after renal transplantation are both negatively affected 11.3 kg). Surgery was uneventful and successful in by an elevated body mass index (20,26). all the study patients, without significant modification During the past few years, our home dialysis of the standard bariatric technique. A painless hemor- population has included a growing number of MO rhagic effluent was present for up to a week. Given individuals, a well-defined group of mostly younger their remarkably benign postoperative course, it is CKD6 patients who have unsuccessfully battled conceivable that removal of intraperitoneal blood, crippling obesity, failed multiple attempts at medi- cellular debris, and other proinflammatory byproducts cal management, and embraced the opportunity of of tissue injury was instrumental in facilitating the a proven surgical treatment option (11,20,22,23). faster restoration of normal peritoneal and splanchnic Furthermore, circumventing the temporary switch to homeostasis. In theory, this unintended “peritoneal HD was a very strong stimulus in encouraging them lavage” effect could also have helped to mitigate the to pursue this course of therapy. development of adhesions (32,33). Our CKD program emphasizes ongoing patient Re-initiation of PD in the early postoperative pe- education (CKD4 and beyond), early referral to a riod with a modified volume prescription proved safe transplant center, and a multidisciplinary approach and effective. However, hemodynamically and meta- to their associated illnesses and psychosocial issues bolically stable patients may safely delay the return to though specialty care coordination and counseling. PD for few days. Such was the case in our patient in All study subjects were employed and productive, whom a hernia repair was also accomplished. A delay had developed a keen interest in their health, had of this kind might also be applicable to individuals gained substantial and above-average knowledge of who undergo more extensive, complex, or prolonged the metabolic aspects of their disease process, and laparoscopic procedures and in whom the compliance 138 Laparoscopic Bariatric Surgery in PD Patients of the abdominal cavity and the membrane transport nondiabetic peritoneal dialysis patients. Perit Dial Int dynamics of the peritoneum may be significantly 2004;24:554–61. compromised immediately after surgery. 6 Kim YL. Update on mechanisms of ultrafiltration By virtue of tailored perioperative nutrition man- failure. Perit Dial Int 2009;29(suppl 2):S123–7. agement, the metabolic demands of the CKD6 bariat- 7 Shah H, Chu M, Bargman JM. Perioperative manage- ment of peritoneal dialysis patients undergoing hernia ric patient may not require the immediate restoration surgery without the use of interim hemodialysis. Perit of PD, particularly in patients whose residual renal Dial Int 2006;26:684–7. function and urine volume are substantial, making 8 Yang YF, Wang HJ, Yeh CC, Lin HH, Huang CC. the transition back to PD less time-sensitive and more Early initiation of continuous ambulatory peritoneal clinically driven. dialysis in patients undergoing surgical implantation In PD patients, laparoscopic surgery allows for of Tenckhoff . Perit Dial Int 2011;31:551–7. maximal preservation of abdominal wall integrity 9 Kelley WE Jr. The evolution of laparoscopy and the and of peritoneal cavity compliance—which are the revolution in surgery in the decade of the 1990s. two most important, sine qua non factors for the JSLS 2008;12:351–7. sound delivery of this modality of renal replace- 10 Luján JA, Frutos MD, Hernández Q, et al. Laparo- ment therapy. scopic versus open gastric bypass in the treatment of morbid obesity: a randomized prospective study. Ann Surg 2004;239:433–7. 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