Surgical management of pleuro-peritoneal fistula in chronic renal failure patient—safety and effectiveness

Abstract

Background: Pleuro-peritoneal fistula (PPF) is a known complication arising in patients receiving continuous ambulatory peritoneal dialysis (CAPD) as a form of renal replacement therapy with an incidence of approximately 2% (1). Previous literature has shown that the recurrence rate of non-operative management of PPF to be ~45%. Video-assisted thoracoscopic surgery (VATS) has been shown to be an effective and safe means of treating patients with PPF. However, to the author's knowledge, there is currently no sizeable case series that discuss the various intra-operative findings, operative techniques employed, postoperative complications, duration of peritoneal dialysis suspension and fistula recurrence in this particular patient group.

Vagino-peritoneal fistula in pediatric patient with continuous ambulatory peritoneal dialysis and lupus nephropathy: An unusual case report

“…The pathophysiology of fistulas in CAPD patients has not been described in detail, but in patients with a history of chronic systemic infection or prior episodes of peritonitis, fistulas may occur due to friable tissue. A vagino-peritoneal fistula is indeed a rare case, but based on the anatomical position that is sandwiched between the bladder and the rectum, a fistula through the vagina may form [2] , [3] , [5] . The case of vagino-peritoneal fistula in young female has been reported as early as 1983 as an unusual complication of peritoneal dialysis [6] .…”

Pleuroperitoneal communication in a patient on automated peritoneal dialysis: A rare but important complication

“…2,3 Several factors may explain this phenomenon in APD patients: (1) the presence of a trans-diaphragmatic defect, (2) a higher-pressure gradient caused by the gravitational effect of the supine position, (3) the more frequent pressure from pumping the dialysate from the cycler to the peritoneal cavity. 4 In general, suspicion of pleuroperitoneal communication arises when a pleural fluid to serum glucose gradient of greater than 50 mg/ dL is observed. A lower pleural fluid-to-serum glucose gradient does not preclude the leakage diagnosis and can be explained by the size of the communication and the difference in dialysate infusion time and sample collection (as glucose undergoes metabolism within the mesothelial cells).…”

“…Despite its rare frequency, it is a well‐documented complication in the literature, occurring in ~2% of continuous ambulatory peritoneal dialysis (CAPD) patients, with uncertain incidence on APD patients 2,3 . Several factors may explain this phenomenon in APD patients: (1) the presence of a trans‐diaphragmatic defect, (2) a higher‐pressure gradient caused by the gravitational effect of the supine position, (3) the more frequent pressure from pumping the dialysate from the cycler to the peritoneal cavity 4 …”

“…The diagnosis can also be corroborated with dynamic imaging methods, such as CT and technetium scans. A therapeutical conservative approach may be an option, as well as conventional pleurodesis, open thoracotomy or video‐assisted‐thoracoscopic approach, with further studies needed to access the standard of care treatment in this complication 1,4 …”