Synchronous laparoscopic-assisted percutaneous endoscopic gastrostomy and peritoneal dialysis catheter placement is a valid alternative to open surgery

Journal of Pediatric Urology (2012) 8, 527e530

Synchronous laparoscopic-assisted percutaneous endoscopic gastrostomy and peritoneal dialysis catheter placement is a valid alternative to open surgery R.M. Lindley a,*, A.R. Williams b, N. Fraser b, M.U. Shenoy b a b

Department of Paediatric Surgery, Sheffield Children’s NHS Trust, Western Bank, Sheffield S10 2TH, UK Nottingham University Hospitals NHS Trust, Nottingham, UK

Received 3 August 2011; accepted 28 September 2011 Available online 22 October 2011

KEYWORDS PEG; Peritoneal dialysis; Laparoscopic; Child; Peritonitis

Abstract Objective: Gastrostomy feeding is frequently necessary in children receiving chronic peritoneal dialysis (PD). Synchronous laparoscopic-assisted placement of percutaneous endoscopic gastrostomy (PEG) and PD catheter has many potential advantages. This study investigates whether this technique is comparable to open placement. Methods: The notes of all patients over a 16-year time period were reviewed retrospectively. Peritonitis was defined as the presence of a white blood cell count > 100/mm3 with at least 50% being polymorphonuclear leukocytes, and infection was defined as the presence of positive peritoneal cultures with peritonitis. Results: Ten patients received primary laparoscopic-assisted PEG and PD catheter insertion (LAP) and 23 patients open gastrostomy and PD catheter (OPEN). PD catheter survival was median 12 months in the LAP group and 17 months in the OPEN group. Peritonitis and infection rates per catheter-year were 0.89 and 0.7 LAP and 0.59 and 0.5 OPEN. The risk of peritonitis and infection was not related to method of placement. Conclusions: There were no statistically significant differences in outcomes between the two groups. We conclude that laparoscopic-assisted synchronous PD and PEG catheter insertion is safe and effective. ª 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: þ44 1142267918; fax: þ44 1142747469. E-mail address: [email protected] (R.M. Lindley). 1477-5131/$36 ª 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2011.09.011

528

Introduction The use of gastrostomy feeding to supplement enteral nutrition in children with renal failure on peritoneal dialysis (PD) is well established [1]. Laparoscopic placement of peritoneal dialysis catheters has been advocated on the basis that the catheter can be placed accurately, omentectomy is facilitated and cosmesis is improved [2e4]. Laparoscopic-assisted percutaneous endoscopic gastrostomy (LAP-PEG) placement has also been advocated as it avoids the potentially serious complications of blind PEG placement [5]. However, due to concerns over infection it has previously been stated that placement of a PEG while on PD is contraindicated and that an open gastrostomy (OG) is preferable [6]. Interpretation of more recent data has suggested that these risks may have been overstated [7], and we have therefore moved to simultaneous placement of PEG and PD catheter when indicated. The aim of this current study was therefore to assess the efficacy and safety of this technique when compared to our previous practice of OG insertion with PD catheter placement.

Methods The records of all children undergoing PD at our institution over a 16-year period were reviewed retrospectively and those having simultaneous placement of PEG and PD catheter were selected and analysed. Collected data included demographic details, cause of renal failure, date and method of initial PEG and PD insertion, patient age and weight at initial insertion, time to initial PEG and PD catheter use, presence of haemodialysis catheter cover, time and cause of removal of PEG/PD catheter, subsequent PEG and PD placements, details of any peritoneal/exit site infections and other complications. OG and PD catheter placement was performed as previously described [1]. Our technique of LAP-PD placement has also been described recently [8]. LAP-PEG placement was performed using the same single 5-mm umbilical port and direct visualization of a Seldinger needle and guidewire into the body of the stomach, using a 12Fr Corflo PEG kit (Merck Serono Ltd, Feltham, UK). Indications for removal of PD catheters were Candida peritonitis or recurrent severe peritonitis (not settling with appropriate antibiotic treatment), non-function (retention of significant volumes of dialysate) and persistent tunnel infection. Failure of PD was frequently followed by introduction of a period of haemodialysis. PD was reintroduced whenever possible and subsequent catheter infections and complications were analysed on the basis of the initial method of placement. Peritoneal infection was defined as the presence of positive peritoneal cultures taken at the time of clinically suspected peritonitis. Peritonitis was defined as the presence of a white blood cell (WBC) count >100/mm3 with at least 50% being polymorphonuclear leukocytes. Treatment for clinical PD peritonitis was commenced promptly, usually with intraperitoneal tobramycin and cefuroxime commensurate with local microbiology policy and previous culture results.

R.M. Lindley et al. Data were analysed using Microsoft Excel and GraphPad InStat (version 3.06, GraphPad Software). The peritonitis and peritoneal infection rates were analysed using the AndersoneGill model of ordered multiple events with Stata 9.1, using method of insertion (OPEN or LAP), age at insertion and time to initial PD catheter usage as variables (StataCorp. 2005. Stata Statistical Software: Release 9. College Station, TX: StataCorp LP).

Results There were 23 patients having open PD and gastrostomy (OPEN group) and 10 patients having simultaneous LAP-PD and LAP-PEG (LAP group). Basic demographic details and results of the two groups are shown in Table 1. Because we moved to laparoscopicassisted placement in 2005, there is necessarily a shorter duration of follow-up between the two groups. There were no significant differences in basic demographic details between the two groups although patients in the LAP group tended to be younger. The diagnosis at the time of insertion of gastrostomy and PD catheter is shown in Table 2.

PD catheter use, function and survival Our ideal practice after insertion of a PD catheter would be to wait for at least 7 days prior to commencing PD, but as Table 1 Details of patients with either open placement of gastrostomy and PD catheter (OPEN Group) or laparoscopicassisted placement of gastrostomy and PD catheter (LAP Group). OPEN Group LAP Group Number of patients M:F ratio Age at initial insertion (years) Follow-up (years) PD catheter survival (months) Time to first use of PD (days) Time to first use of gastrostomy Episodes of peritonitis Peritonitis rate/catheter-year Exit-site infections Peritoneal infections Candida infections (%) Time to first infection (months) Peritoneal infection rate/catheter-year

p-Value

23 11:12 4.9 (0.1e16.1) 7.7 (0.4e15) 17 (0.1e82)

10 8:2 0.13a 3.72 0.4b (0.01e8.6) 2.8 <0.001b (0.9e4.4) 12 (1e46) 0.23c

10 (1e25)

2 (1e7)

0.02b

2 (1e5)

2 (1e13)

0.9c

41 0.59

19 0.89

0.12d

4 35 5 (14%) 9 (1e23)

2 15 4 (27%) 4 (1e15)

0.5

0.7

Data are expressed as median (range). a Fisher’s exact test. b Two-tailed t-test. c ManneWhitney U-test. d Regression.

0.42a

0.1d

Laparoscopic-assisted PEG and PD catheter placement

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Table 2 Diagnosis at time of insertion of gastrostomy and PD catheter.

Bilateral renal dysplasia Congenital nephritic syndrome Cystinosis DenyseDrash syndrome Finnish nephrotic syndrome Focal segmental glomerulosclerosis Glomerulonephritis MCDK with contralateral dysplasia Nephronophthisis Neuropathic bladder Posterior urethral valves Reflux nephropathy Renal vein thrombosis Twinetwin transfusion syndrome Unknown

OPEN Group

LAP Group

7 0 1 1 0 0

2 1 0 0 1 1

2 1

0 2

0 1 1 4 1 2

1 0 1 0 0 0

2

1

MCDK Z multicystic dysplastic kidney.

can be seen from Table 1 the time before the PD catheter was initially used was often much shorter, with a median wait of 10 days in the OPEN group and 2 days in the LAP group. This difference was statistically significant. Although a PD catheter was placed at the original surgery, many patients went on to require subsequent catheters due to infection or catheter failure. The number of PD catheters placed in patients according to the initial mode of placement is shown in Fig. 1, and catheter survival rates in Table 1. There was no significant difference in catheter survival rate between the two groups (ManneWhitney U-test). 10 (45%) of OPEN patients required a subsequent PD catheter revision and 4 (40%) of LAP patients required a PD catheter revision. In total, 43 PD catheters were placed in the OPEN group and 21 PD catheters were placed in the LAP group. The reasons for catheter revision are shown in Table 3.

PD catheter infection Peritonitis rates and confirmed peritoneal infections in the two groups are shown in Table 1. There was no significant difference between the number of episodes of peritonitis and peritoneal infection in each group, and the infection rates per catheter-year were similar (0.5 vs 0.7). There were apparently more Candida spp. infections in the LAP group but this was also not statistically significant. There were no episodes of peritonitis or peritoneal infections in either group within the first 2 weeks of insertion, and just one infection in the LAP group within 4 weeks of insertion (Pseudomonas aeruginosa grown at 28 days).

Gastrostomy function and survival Formal gastrostomy revision was not necessary in either group, although it is our routine practice to change the

Figure 1

Number of PD catheters per patient.

initial PEG tube to a gastrostomy button after 9e12 months should the parents/carers of the child wish this to be done. There were two minor gastrostomy site infections within the first month of placement in the OPEN group that required treatment with oral antibiotics.

Discussion The current guidelines produced by the European Society for Paediatric Nephrology recommend that a gastrostomy can be placed at the same time as a PD catheter with minimal additional morbidity [9]. This study demonstrates that laparoscopic-assisted simultaneous placement of PEG and PD catheter is a safe option with no increase in the risk of peritoneal infection or peritonitis when compared to an open technique. This is a significant finding given the

Table 3

Reason for revision of PD catheter.

Infected (recurrent bacterial) Infected (Candida) Displaced Retaining/not working Leaking End of use/transplanted

OPEN Group

LAP Group

4 5 2 8 2 12

1 4 3 5 0 3

(9) (12) (5) (19) (5) (28)

(5) (19) (14) (24) (0) (14)

Results are given as actual number (% of total number of PD catheters per group).

530 previously available advice in the literature that the open technique is to be preferred. In particular, there were no instances of immediate peritonitis in the LAP group. Although the nominal rates of peritonitis and infection are higher in the LAP group, these differences do not reach statistical significance. It should also be noted that the longer duration of follow-up in the OPEN group may bias the results, as well established PD catheters with no episodes of infection will produce a lower infection rate per catheter year. It is also apparent from our results that the more recent patients in the LAP group were having PD catheters placed at a younger age, and these catheters were being used sooner than planned, with a significantly shorter time to first use (median 2 days). It should however be noted that neither time to first use nor age of the patient were significant variables for infection in the multiple regression analysis, although the numbers in the LAP group are small. In terms of peritonitis and infection rates these results compare favourably to those previously reported in the literature. Our overall peritonitis rates per catheter-year of 0.59/year and 0.89/year in the OPEN and LAP groups are similar to those cited by Ramage et al. [10] (0.5/year) and Ledermann et al. [6] (0.6/year) when looking at those groups where a gastrostomy was placed prior to the commencement of PD, and are lower than those where a gastrostomy was placed after the initiation of PD (1.4 per catheter-year [6]). Particular concerns when PEG placement occurs after the initiation of PD are Candida infection and immediate peritonitis [6,7]. Our rates of Candida infection are significantly higher than those reported recently [11e13] and this is obviously of concern. However, these rates of infection are reported in a different population in that they are not restricted to children with a PD catheter and gastrostomy, and factors such as poor nutrition (and hence the need for gastrostomy) may increase the risk of infection in our groups. In addition, in the LAP group, all Candida infections occurred at least 12 months after the initial insertion of the PEG and PD catheter, and in the OPEN group 3/5 Candida infections occurred in the same patient within a 6-month time period, suggesting that other factors (such as failure to clear existing infection, immune dysfunction and care of the PD catheter) may be a factor. It is also important to note that in contrast to previous reports on simultaneous gastrostomy and PD catheter placement, we had no episodes of immediate peritonitis and only one episode within the first month of insertion (at 28 days). We therefore believe that although there appears to be a late increase in the risk of fungal infection following simultaneous placement of gastrostomy and PD catheter in this series, there is no increase in this risk when using a minimally invasive technique. However, the number of patients in this study is necessarily small given the paediatric population studied, and therefore further monitoring of national registers would be required to ensure that there are no excess complications. In the interim, our data support the conclusion that simultaneous laparoscopic-

R.M. Lindley et al. assisted placement of a PD catheter and PEG is as safe and effective as the open technique.

Conflict of interest statement No conflicts of interest exist.

Ethical approval The study was approved by the audit department at Nottingham University Hospitals NHS Trust. No further ethical approval was required.

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