Laparoscopic omental fixation technique versus open surgical placement of peritoneal dialysis catheters.

BACKGROUND: Continuous ambulatory peritoneal dialysis (CAPD) is an effective form of treatment for patients with end-stage renal disease. Open insertion of peritoneal dialysis (PD) catheters is the standard surgical technique, but it is associated with a relatively high incidence of catheter outflow obstruction and dialysis leak. Omental wrapping is the most common cause of mechanical problems. The purpose of this study was to determine the efficacy of the laparoscopic omental fixation technique to prevent the obstruction caused by omental wrapping and also to compare this laparoscopic technique with open peritoneal dialysis catheter insertion with respect to postoperative discomfort, complication rates, and catheter survival. METHODS: Between March 1998 and October 2001, 42 double-cuff, curled-end CAPD catheters were placed in 42 patients. The outcomes of the 21 patients in whom the PD catheters were placed laparoscopically with omental fixation technique were compared with those of the 21 patients in whom the catheters were placed with open surgical technique. Recorded data included patient demographics, catheter implantation method, early and late complications, catheter survival, and catheter outcome. RESULTS: Early peritonitis episodes occurred in 8 of 21 patients (38.0%) in the open surgical group (OSG) versus 2 of 21 patients (9.5%) in the laparoscopic omental fixation group (LOFG) ( p < 0.05); late peritonitis episodes occurred in 3 of 21 patients (14.2%) in the OSG versus 1 of 21 patients (4.7%) in the LOFG ( p < 0.05). Early exit site infection occurred in 8 of 21 patients (38.0%) in the OSG versus 4 of 21 patients (19.0%) in the LOFG ( p < 0.05), with many catheter-related problems in the conventional surgical group. There was no outflow obstruction in the LOFG. The conventional procedure was faster than the laparoscopic omental fixation technique. Analgesic requirements and hospital stay were less in the laparoscopic group. Laparoscopic surgery also enabled diagnosis of intraabdominal pathologies and treatment of the accompanying surgical problems during the same operation. Occult inguinal hernia was diagnosed in 2 patients, inguinal hernioplasty was performed in 4 patients, adhesiolysis was performed in 8 patients who had previous abdominal surgery, and liver biopsy was taken in 2 patients. Ovarian cystectomy was performed in another patient during laparoscopic CAPD catheter placement. CONCLUSION: The laparoscopic omental fixation technique (described by Ogünç and published in 1999) is a highly effective and successful method for preventing obstruction due to omental wrapping with a better catheter survival. Laparoscopic surgery also allows the diagnosis and treatment of the accompanying surgical pathologies during the same operation.

[The factors affecting morbidity and mortality in surgical treatment of severe necrotizing pancreatitis]. / Nekrotizan pankreatit'in cerrahi tedavisinde morbidite ve mortaliteyi etkileyen faktörler.

Necrotizing pancreatitis is the most severe form of acute pancreatitis with high morbidity and mortality rates. In this retrospective study we report our experience with 22 patients (17 men, 5 women with a mean age of 52.714) who were operated on at Akdeniz University School of Medicine Department of General Surgery, from February 1993 to July 2000 and define the factors affecting the morbidity and mortality in surgical treatment of NP. Diagnosis of NP and decision of laparotomy was performed by clinical findings and contrast-enhanced abdominal computed tomography (CT). The patients with pancreatic and peripancreatic necrosis confirmed intraoperatively included to the study. All patients had required intensive care therapy. The relationship between mortality/morbidity and with demographic and clinical data of patients, APACHE II score, presence of multiple organ dysfunction (MOD), and local-regional complications (LRC) was examined. The Fischer Chi-Square test was used to evaluate statistical significance and p < 0.05 was accepted as meaningful. The mean number of reoperations were 4.44.9 (1 to 23). Local-regional complications were observed in 17 (77%) patients and mostly consisted of intra-abdominal abscess (15 patients). The overall hospital mortality rate was 36% (8 of 22 patients died). In the 7 patients with low APACHE-II score on admission (< or = 10) no mortality was encountered. Eight of 15 patients with high APACHE-II score (> 10) on admission were died. Multiple-organ dysfunction developed in 7 (32%) patients and 6 (86%) of them died. Two of the 15 patients (13%) died without MOD. In conclusion, poor outcome was associated with high APACHE-II score (> 10) on admission (p = 0.02), and progression of MOD (p = 0.002) during the treatment. Local-regional complications increase the hospital stay and frequency of surgical interventions but these complications do not effect the mortality in negative manner in the surgical treatment of NP.

Videolaparoscopy with omentopexy: a new technique to allow placement of a catheter for continuous ambulatory peritoneal dialysis.

Malfunction of a peritoneal dialysis (PD) catheter is common and usually occurs shortly after its insertion, due to omental wrapping. In fact, we have encountered this complication in 183 of 578 (31.6%) patients treated at our hospital since 1987. To overcome this problem, I have devised a new laparoscopic technique for catheter insertion. First, the omentum is fixed onto the peritoneum of the lateral abdominal wall at two points using a laparoscopic instrument (Pro Tack 5-mm Auto Suture, Norwalk, CT, USA) placed at the level of the umbilicus. The catheter is then introduced through the umblical trocar deep into the true pelvis. The cuff is positioned between the posterior rectus sheath and the rectus fibers, and the fascia is sewn. The catheter is then pulled through the 5-mm trocar site. This technique was successfully performed on ten patients with a median age of 46.1 years. There was no morbidity or any malfunction in continuous ambulatory peritoneal dialysis (CAPD) during follow-up periods ranging from 20 days to 9 months. Therefore, this new laparoscopic technique may prevent the obstruction caused by omental wrapping in CAPD.

[Legionnaires' disease following kidney transplantation]. / Böbrek transplantasyonu sonrasi gelisen Lejyoner hastaligi.

Legionella pneumonia was diagnosed in two patients receiving triple immunosuppressive drug therapy after renal transplantation. High fever was the predominant symptom of these patients. Hyponatremia, leucopenia and anemia were also observed. The disease was diagnosed by immunofluorescence antigen technique and easily controlled with erythromycin therapy.