Advanced Laparoscopic Peritoneal Dialysis Catheter

Peritoneal Dialysis International, Vol. 38, pp. 163–171 www.PDIConnect.com

0896-8608/18 $3.00 + .00 Copyright © 2018 International Society for Peritoneal Dialysis

REVIEW

ADVANCED LAPAROSCOPIC PERITONEAL DIALYSIS CATHETER INSERTION: SYSTEMATIC REVIEW AND META-ANALYSIS

Badri M. Shrestha,1 Donna Shrestha,2 Avneesh Kumar,1 Alice Shrestha,3 Simon A. Boyes,1 and Martin E. Wilkie1

♦♦ Background: The optimal methodology of establishing access for peritoneal dialysis (PD) remains controversial. Previously published randomized controlled trials and cohort studies do not demonstrate an advantage for 1 technique over another. Four published meta-analyses comparing outcomes of laparoscopic versus open PD catheter (PDC) insertion have given inconsistent conclusions and are flawed since they group basic and advanced laparoscopy together. The aim of this systematic review and meta-analysis is to examine whether advanced laparoscopic interventions consisting of rectus sheath tunneling and adjunctive procedures produce a better outcome than open insertion or basic laparoscopy used only to verify the catheter position. ♦♦ Methods: A literature search using Medline, Embase, and Cochrane Database was performed, and meta-analysis was performed using RevMan 5.3.5 software (Nordic Cochrane Centre, The Cochrane Collaboration, London, UK). Outcomes evaluated incidence of catheter obstruction, migration, pericannular leak, hernia, infectious complications (peritonitis and exit-site infection) and catheter survival. ♦♦ Results: Of the 467 records identified, 7 cohort studies, including 1,045 patients, were included in the meta-analysis. When advanced laparoscopy was compared with open insertion, a significant reduction was observed in the incidence of catheter obstruction (odds ratio [OR] 0.14, 95% confidence interval [CI] 0.03 – 0.63; p = 0.01), catheter migration (OR 0.12, 95% CI 0.06 – 0.26; p = 0.00001), pericannular leak (OR 0.27, 95% CI 0.11 – 0.64; p = 0.003), and pericannular and incisional hernias (OR 0.29, 95% CI 0.09 – 0.94; p = 0.04), as well as better 1- and 2-year catheter survival (OR 0.52, 95% CI 0.28 – 0.97; p = 0.04 and OR 0.50, 95% CI 0.28 – 0.92; p = 0.03, respectively). Compared with basic laparoscopy, catheter obstruction and migration were significantly lower in the advanced laparoscopic group, whereas catheter survival was similar in both groups. All outcomes, except catheter obstruction, were similar between the basic laparoscopy Correspondence to: Badri Shrestha, Division of Renal Transplantation, Sheffield Kidney Institute, Herries Road, Sheffield, S5 7AU, United Kingdom. [email protected] Received 24 October 2017; accepted 20 December 2017.

and open insertion. The infectious complications such as peritonitis and exit-site infections were similar between the 3 groups. ♦♦ Conclusions: Advanced laparoscopy was associated with a significant superior outcome in comparison with open insertion and basic laparoscopy. Perit Dial Int 2018; 38(3):163–171 https://doi.org/10.3747/pdi.2017.00230

KEY WORDS: Access; rectus sheath; tunneling; omentopexy; adhesiolysis; outcomes.

T

he key to successful peritoneal dialysis (PD) is a wellfunctioning PD catheter (PDC) that permits in- and outflow of dialysis solution without any impediment. Complications such as catheter obstruction, migration, pericannular leak, peritonitis, and exit-site infection can lead to catheter loss and a switch to hemodialysis, which can be distreqssing to the patients and expensive (1). A PDC can be inserted into the peritoneal cavity employing open surgical, blind percutaneous, fluoroscopically-guided percutaneous, peritoneoscopic, and laparoscopic techniques. Over the past 6 decades, the open surgical technique of PDC insertion has been adopted worldwide because of its ease of application and perceived low cost to healthcare providers. The introduction of laparoscopic insertion by Amerling et al. in 1993 offers potential advantages over other techniques, including the ability to insert the catheter under direct vision, which ensures correct position of the catheter, reduced length of hospital stay, morbidity, postoperative pain, and recovery period, and improved catheter survival (2). The major strengths of laparoscopy include the prevention and resolution of common mechanical problems that adversely affect catheter outcomes. The laparoscopic insertion technique may be either basic, where the laparoscope is used to verify the position of the catheter, or advanced. The advanced technique, introduced by Crabtree et al., includes rectus sheath tunneling (RST)

This single copy is for your personal, non-commercial use only.

163 For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]

Downloaded from http://www.pdiconnect.com/ by guest on May 30, 2018

Sheffield Kidney Institute,1 Northern General Hospital, Sheffield, United Kingdom; North Manchester General Hospital,2 Manchester, United Kingdom; and Parkview Surgery,3 Stockport, United Kingdom

SHRESTHA et al.

MAY 2018 – VOL. 38, NO. 3 PDI

METHODS LITERATURE SEARCH STRATEGY

A systematic electronic literature search was performed in PubMed, EMBASE, and Cochrane Library databases from inception to 20 September 2017. The search terms “peritoneal dialysis,” “laparoscopy,” “laparotomy,” “open,” “rectus sheath,” tunnelling,” “preperitoneal,” and “catheter” were used. There was no language restriction. All articles relevant to the laparoscopic or open insertion of PDC were identified, reference lists of relevant studies were further scrutinized for additional citations, and all pertinent references were compiled in the EndNote software (Version X 7.4; Thomson Reuters, Philadelphia, PA, USA). LITERATURE SCREENING

The authors independently screened the titles and abstract of the records identified in the electronic searches, excluding all obviously not relevant studies, and examined the full texts of potential studies. Any discrepancies in eligibility judgments were resolved by discussion between the authors. The studies had to describe 1 or more of the following outcome measures: the incidence of catheter obstruction, migration, pericannular leak, hernia, peritonitis, exit-site/tunnel infection, and catheter survival. Clinical question structured in PICOM format: Is advanced laparoscopic insertion of PDC associated with improved outcomes compared with open or basic laparoscopic insertion techniques? 164

Population: Adult patients who had PDC insertion Intervention: Laparoscopic insertion of PDC employing advanced laparoscopic technique Comparator: Insertion of PDC using open and basic laparoscopic techniques Outcomes: Catheter dysfunction (obstruction, migration, and leak), hernia, infections (peritonitis, exit-site infection, and tunnel infection), and catheter survival Methods: Randomized controlled trials (RCTs), cohort studies, and case-control studies (intervention and comparator group) Exclusion criteria: Duplicate publications and those which did not conform to the PICOM format were excluded. DATA EXTRACTION AND CRITICAL APPRAISAL

The methodological quality of the observational cohort studies was assessed using the Newcastle-Ottawa scale (NOS); the quality score was calculated based on 3 major components: selection of the group of study (0 – 4 points), comparability of the group (0 – 2 points) and assessment of the outcome (0 – 3 points). The maximum of 9 points represents the highest methodological quality; a NOS score of 7 or more was considered a “good” study (10). The level of evidence of individual studies was assessed using the Oxford Centre of EvidenceBased Medicine – Level of Evidence document (11). Quality and potential for bias of the randomized controlled trials was evaluated using the Cochrane Collaboration’s tool for assessing risk of bias by Higgins (12). STATISTICAL METHODS

The meta-analysis was performed using RevMan 5.3.5 software (Nordic Cochrane Centre, The Cochrane Collaboration, London, UK). Heterogeneity of treatment effects between studies was assessed using the Q (heterogeneity chi square (χ2) and the I2 statistics. For I2, > 50% indicated significant heterogeneity in the studies, and in this situation a randomeffects model was used. For homogeneous studies, a fixedeffects model and the Mantel–Haenszel (M-H) method for calculation was adopted. For smaller event rates (0 – 1), the Peto method was applied. For dichotomous outcomes, we reported results as an odds ratio (OR), while in reporting continuous outcomes, weighted mean difference (WMD) was used. Summary estimates and 95% confidence intervals (CIs) were calculated. Overall effects were determined by the using Z-test. A p value < 0.005 was considered significant. Forest plots were drawn based on these results. The minimum number of studies considered appropriate for display of a forest plot was 2 (13). Finally, the quality of each conclusion was assessed by the GRADE tool (GRADEpro GDT, Cochrane Community, London, UK) (14). Univariate analysis was performed on the studies of advanced laparoscopy that did not have control groups by comparing their outcomes with control groups from the open insertion studies used in the meta-analysis. Epi Info (V7.2.1.0,

This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]

Downloaded from http://www.pdiconnect.com/ by guest on May 30, 2018

and adjunctive procedures such as omentopexy, adhesiolysis, excision of appendix epiploica (epiploectomy), salpingectomy, and colopexy (3,4). It facilitates laparoscopic visualization of the peritoneal cavity for adhesions and hernias. Through a paramedian approach, with or without the help of a trocar, the PDC is inserted so that a length of 4 to 6 cm of the catheter passes through a tunnel in the rectus sheath on the surface of the posterior rectus sheath prior to its entry into the peritoneal cavity inferior to the arcuate line. A long course of the catheter in the rectus sheath and a short course in the peritoneal cavity prevents migration and omental wrapping. In addition, omentopexy is carried out either as routine or selectively, where the redundant omentum is anchored to the anterior abdominal wall of the upper abdomen (5). Currently, there are 4 published meta-analyses comparing the outcomes of laparoscopic versus open PDC insertion (6–9). However, all of these meta-analyses are flawed, as they group together studies that have used both basic and advanced laparoscopic techniques. They therefore are unable to explore the potential advantages of the advanced laparoscopic technique. The aim of this systematic review and meta-analysis is to examine the outcomes of advanced laparoscopic PDC insertion technique in adults and compare them with those of the open insertion and basic laparoscopic insertion techniques.

PDI

MAY 2018 – VOL. 38, NO. 3

ADVANCED LAPAROSCOPY AND PD

supplied by Centre for Disease Control and Prevention, Atlanta, GA, USA) was used for the univariate analysis. RESULTS SEARCH RESULTS

The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) flow diagram is presented in Figure 1. The search yielded 467 records, of which 7 cohort studies, including 1,045 patients, were included in the meta-analysis group that compared advanced laparoscopy with open insertion and basic laparoscopy (Table 1). There were 14 studies of advanced laparoscopic PDC insertion that did not include a comparator group (Table 2). Seven studies compared basic laparoscopy with the open insertion technique (Table 3).

There was no RCT comparing advanced laparoscopy with open insertion or basic laparoscopy. With NOS criteria, the cohort studies scored an average of 6.3 points, indicating medium quality (3,15–20). ADVANCED LAPAROSCOPY VS OPEN INSERTION

Figure 1 — PRISMA flow diagram of the systematic literature search. * 2 studies (3 and 16) compared advanced and basic laparoscopic with open-insertion technique.

Catheter-related outcomes: In the 5 studies (3,15,16,18,19) involving 668 patients that compared the outcomes of advanced laparoscopy with open insertion and were included in the meta-analysis, catheter obstruction occurred significantly less frequently in the advanced group (Figure 2A). Catheter

TABLE 1 Characteristics of the Studies Comparing Advanced Laparoscopic, Basic Laparoscopic, and Open PDC Insertion Year

Country

Study type

Groups

N

Evidencea

Bircan (15)

2016

Turkey

Retrospective cohort

2016

USA


Lund (17)

2007

Denmark


Soontrapornchai (18)

2005

Thailand

Prospective cohort

Ogunc (19)

2005

Turkey


Crabtree (3)

2005

USA

Prospective cohort

Attaluri (20)

2010

USA


35 34 80 92 63 9 13 50 52 44 35 78 200 63 68 129

2b

Krezalek (16)

Advanced laparoscopic Open Basic laparoscopic Advanced laparoscopic Open Advanced laparoscopic Open Advanced laparoscopic Open Advanced laparoscopic Open Basic laparoscopic Advanced laparoscopic Open Basic laparoscopic Advanced laparoscopic

Author

2b 2b 2b 2b 2b 2b 2b 2b 2b

PDC = peritoneal dialysis catheter; RCT = randomized controlled trial. a Evidence 2b = Cohort study and low-quality RCT with