Single-port video-assisted thoracoscopic surgery for peritoneal dialysis-related pleuroperitoneal communication using near-infrared fluorescence with indocyanine green

Abstract

Background

Peritoneal dialysis (PD)-related pleuroperitoneal communication is strongly associated with PD discontinuation. Video-assisted thoracoscopic surgery (VATS) has emerged as a promising therapeutic approach. However, there are still challenges in detecting diaphragmatic defects under conventional thoracoscopy, and the repair methods vary significantly.

Methods

We have developed an intervention protocol for pleuroperitoneal communication that includes single-port VATS utilizing near-infrared fluorescence with indocyanine green, as well as the management of perioperative kidney care and PD reinitiation. Patients who underwent VATS for pleuroperitoneal communication repair from September 2022 to March 2024 were identified at a single center. The procedures and outcomes were evaluated, and the success rate of PD resumption was compared with that of a historical cohort treated with non-surgical therapies.

Results

A total of 6 patients underwent VATS. The age was 48.7 ± 11.8 years, 2 were female, and the PD vintage was 8.7 (2.0–28.4) months. Non-dialysis therapy (n = 4) or temporary hemodialysis (n = 2) was prescribed during PD suspension. Fluorescence thoracoscopy identified diaphragmatic defects in all patients, including lesions that were unrecognizable under white light. Mechanical pleurodesis by direct suture of the defects with local mechanical reinforcement was performed. All patients reinitiated PD 15–30 days postoperatively, with no recurrence during a follow-up of 17.0 ± 6.4 months. The success rate significantly exceeded that in the patients who underwent PD suspension or chemical pleurodesis (100% vs. 29%, p = 0.005).

Conclusions

The minimally invasive VATS integrating fluorescence with indocyanine green and pleurodesis with multiple mechanical reinforcements, along with appropriate perioperative care and an incremental approach to resume PD, was a reliable treatment for PD-related pleuroperitoneal communication.