Early Resumption of Peritoneal Dialysis Post Laparoscopic Appendectomy: A Case Report and Literature Review

Abstract

Abdominal pain and fever in patients on peritoneal dialysis (PD) raise suspicion of PD-associated peritonitis. However, other causes of peritonitis such as appendicitis should be considered. The laparoscopic approach is the standard of care in many of these situations. This technique allows PD catheter preservation and early resumption of PD. Here, we report a case where PD was resumed successfully 48 hours after laparoscopic appendectomy. A 45-year-old man with end-stage renal disease on chronic PD presented with acute abdominal pain. On examination, the patient was febrile and had lower abdomen tenderness without a rebound. The exit site of the PD catheter was clean. An initial diagnosis of PD-associated peritonitis was made, and an intraperitoneal antibiotic was given. Abdominal computed tomography revealed appendicitis. It was confirmed that the patient had severe nonperforated appendicitis following a laparoscopic appendectomy. The PD catheter was preserved, although the patient reported good residual kidney function; his electrolyte abnormalities with rising creatinine and potassium indicated the need to resume dialysis. Low-volume PD in a strict supine position was resumed 48 hours after surgery. The patient tolerated low-fill PD without any complications. He was discharged home on post-op day 4, and further follow-up revealed no complications. Resuming PD early in patients who go under laparoscopic surgery with low-volume PD is a reasonable option in select cases. Close follow-up from the dialysis team to detect and manage complications is necessary.

Background

Acute abdominal pain and fever in patients on peritoneal dialysis (PD) are usually considered to be due to PD-associated peritonitis until proven otherwise. However, other causes of abdominal pain such as appendicitis or perforated bowel should be considered. Early diagnosis of underlying intra-abdominal pathologies can lead to a decrease in morbidity and mortality. ¹ For a long time, laparotomy was the standard of care for PD patients in need of abdominal surgery and still may be the best option in some cases. Peritoneal catheter removal was also recommended to avoid complications such as peritonitis, hernia, and PD fluid leakage. ² In recent years, laparoscopic procedures have become more popular due to their less invasive nature, lower peritoneal membrane stress, and greater preservation of peritoneal integrity. It has been a common practice to delay resuming PD for up to 6 weeks to avoid complications like PD fluid leakage and hernia development. ³ This practice will require switching dialysis modality to hemodialysis (HD) while patients are recovering, which may impose other risks associated with HD catheter placement and stress that comes with modality change in some patients.

Here, we present a patient undergoing PD with unperforated appendicitis who had a laparoscopic appendectomy, his peritoneal catheter was preserved in place, and PD was resumed 48 hours after the surgery without switching to HD. Other similar articles were also found and included here as a literature review.

Case Report

A 45-year-old man with a past medical history of essential hypertension and end-stage kidney disease (ESKD) due to diabetes type II on chronic PD presented to the emergency department with abdominal pain. The pain was located in bilateral lower quadrants and associated with fever, chills, nausea, and vomiting. The patient was admitted with a primary diagnosis of PD-associated peritonitis. On admission, he was febrile (T = 38.8°). His blood pressure was 160/88 mmHg. He had sinus tachycardia with a heart rate of 139 beats per minute. The remaining physical examination showed a soft abdomen with tenderness on the lower quadrants without guarding or rebound. The PD catheter exit site was clean. Results of blood test on admission were as follows: white blood cell (WBC) of 28.7 cells/mm³, hemoglobin = 10.7 g/dL, Na = 135 mEq/L, K = 5.1 mEq/L, blood urea nitrogen = 74 mg/dL, creatinine (Cr) = 12.5 mg/dL, calcium = 2 mmol/L, and albumin = 3.4 g/dL. Peritoneal dialysis fluid sample analysis showed 13,745 WBCs/mm³ with 83% polymorphonuclear neutrophils. Peritoneal dialysis fluid and blood cultures were obtained, which turned out to be negative. Suspecting PD-associated peritonitis, the patient was treated empirically with intraperitoneal vancomycin and ceftazidime per International Society for Peritoneal Dialysis recommendations. The patient had an abdominal computed tomography scan demonstrating dilated appendix with mild wall thickening and regional inflammatory changes. The patient was consulted with general surgery. Laparoscopy confirmed appendicitis, and an appendectomy was performed. The pathology reported severe appendicitis without perforation. We discussed preserving PD catheter with the surgery team and decided to maintain the catheter in place as there were no signs of a perforated appendix or severe peritonitis. After surgery, the patient reported a good urine output of up to 2 L/day, which made us assume he has a good residual kidney function and may not need dialysis for a few days. However, a rapid rise in his creatinine (Cr) and serum potassium indicated a need for dialysis after 48 hours. After considering all pros and cons, we decided to resume PD with 1000 mL fill volume (half of his usual fill volume) strictly in a supine position. The patient was monitored for abdominal pain, fever, and other signs of peritonitis as well as PD fluid leakage for 2 more days. He tolerated the treatment well without any signs of PD fluid leak or peritonitis. We continued the maintenance dose of intraperitoneal antibiotics, including vancomycin and ceftazidime for 12 more days for a total of 2 weeks. The patient was discharged from the hospital on postoperative day 4. He was instructed to increase his fill volume to 1500 mL by week 2 and resume his usual 2000 mL by week 4 without a last fill. This plan was communicated with his dialysis clinic and nephrologist. We contacted him over the phone weekly, he did not show any complications after 4 weeks.

Discussion

Acute peritonitis is more common in patients on PD compared with the general population. Although most cases are due to PD-associated peritonitis, other intra-abdominal pathologies such as appendicitis and diverticulitis account for about 10% of the peritonitis in those patients. ³ In the 1980s, abdominal surgery procedures in such patients required a temporary cessation of PD and a switch to HD. Due to the higher rates of complications like infection, peritonitis, and herniation, the studies recommend a 2-week PD-free period post-op. Therefore, patients undergoing abdominal surgery need to be switched to HD. ⁴ Auricchio et al ⁵ reported 3 laparoscopic left hemicolectomy in patients diagnosed with early-stage colon adenocarcinoma undergoing regular PD; however, before surgery, the patients were shifted to HD with a peritoneal catheter left in place. Four weeks post-op, 2 of them resumed dialysis through a peritoneal catheter, and in one case, renal function improved after surgery, so PD was unnecessary. In the past decades, with the widespread laparoscopic surgeries, the need for interruption of PD and shift to HD has decreased. ⁶ Deciding the dialysis modality in patients with end-stage renal disease undergoing abdominal surgery depends on many factors, including the patient’s situation (hemodynamic stability, electrolytes abnormalities, residual kidney function, and intra-abdominal pressure), type of surgery, and hospital facilities such as equipment and supplies for PD. ⁴ It is known that initiation of dialysis right after PD catheter placement, a type of abdominal surgery, is associated with an increased risk of PD fluid leak and hematoma. ⁷ Due to increased intra-abdominal pressure and muscle atrophy, patients with PD are at an increased risk of abdominal wall hernias. In a retrospective study, 50 patients with abdominal hernioplasty were included to identify possible risk factors that could lead to complications. After surgery, dialysis was reinstituted in 96% of cases within 3 days. After hospital discharge, patients were followed up by a clinic appointment. There was no leakage of dialysis fluid during any hernia repair; however, 5 patients required reoperation (4 of them due to PD catheter dysfunction and 1 for wound infection debridement).

A case series about emergency laparotomy in patients on continuous ambulatory peritoneal dialysis (CAPD) showed that all patients diagnosed with unrelated gastrointestinal pathology as the cause of peritonitis had to change their dialysis mode to HD and remained on it for the rest of their lives and only one of the patients was able to continue on CAPD for 6 months. ⁸

In 2013, the first laparoscopic transverse colon resection with preserved PD catheter was introduced. However, the patient could return to PD after a short shift to HD in the postoperative period. ⁹ Imam et al could successfully resume PD without switching to a temporary HD in an obese patient undergoing bariatric surgery. Sleeve gastrectomy was performed without complications, and the patient was initiated on hourly low-volume exchanges, with dry days for the first 2 weeks. ¹⁰ In 2014, a patient with PD and endometrial cancer underwent a robotic-assisted laparoscopic hysterectomy and bilateral salpingo-oophorectomy. During the procedure, the PD catheter was left in place; starting on postoperative day 3, a cycler was used to perform frequent low-volume PD exchanges in a supine position to reduce intra-abdominal pressure. Ultrafiltration and clearance were successfully achieved, and the patient did not experience any metabolic or wound complications. ¹¹ They could avoid hemodialysis in that patient.

Another patient on CAPD presented with perforated appendicitis was switched to HD temporarily for 3 weeks with the peritoneal catheter left in place and resuming CAPD afterward. Authors demonstrated that leaving the catheter in place after laparoscopy could be a safe treatment, provided that extensive abdominal lavage is carried out and antibiotic therapy is administered right away after surgery. ¹² In the present case, peritonitis in a patient on PD resulted from nonperforating acute appendicitis. Laparoscopic appendectomy was performed without complications and the patient was started on low-volume exchange PD 48 hours after the surgery to avoid switching the patient to HD. The patients were followed up for 4 days in the hospital and 4 weeks after he was discharged. The patient was stable, without any abdominal pain, signs or symptoms of infection, peritonitis, or PD fluid leak. We believe resuming PD early post-abdominal surgery in a selected patient may eliminate the need for modality change, and all the complications associated with such a change. We believe those patients with unperforated appendicitis, without signs and symptoms of generalized peritonitis in whom the surgeon is able to do laparoscopic appendectomy with tight sealing and closure at entry points, can resume their PD as early as 48 hours.

Conclusion

To avoid an unnecessary modality change to HD in patients with chronic PD undergoing laparoscopic surgery, resuming low-volume PD in a supine position in selected cases should be considered. The decision to resume PD after laparoscopy depends on the patient’s hemodynamics and type of surgery.