Laparoscopic versus Open-surgery Catheter Placement in Peritoneal Dialysis Patients: A Meta-analysis of Outcomes.

The peritoneal dialysis catheter (PDC) can be placed either through the laparoscopic technique, percutaneous technique or surgical procedures. The utilization of these PDC placement procedures is based on successful placement and reduced risk of development of complications. The main objective of this study was to compare the complications associated with laparoscopic vs. open-surgery PDC placement procedure. Literature for this review was obtained from PubMed and Google Scholar databases. The literature search was limited to studies published in the period between 1998 and 2019. The meta-analysis was done using Stata Version 12. The results showed significant difference in catheter malfunction between the laparoscopic and open-surgery group (relative risk [RR] =0.58; 95% CI: 0.42-0.8; P = 0.031). Furthermore, there was no significant statistical difference in dialysate leakage (RR = 0.77; 95% CI: 0.51-1.17, P = 0.116) peritonitis (RR = 0.8; 95% CI: 0.6-1.06, P = 0.349) and exit-site infection (RR = 0.84; 95% CI: 0.65-1.09, P = 0.834) between the laparoscopic and open-surgery PDC placement groups. In conclusion, the laparoscopic PDC placement procedure was superior to open surgery in regards to catheter malfunction. Additionally, the choice of treatment procedure should put in consideration factors such as cost and comfortability of the patient. Copyright:

Introduction

Peritoneal dialysis (PD) is one of the documented alternative treatments for end-stage renal disease (ESRD). However, some of the challenges associated with this treatment method include catheter-related infections, leakage of dialysate and outflow obstruction among others.[1] Since the introduction of the PD in 1976, increased use of the treatment method has been reported by patients. In the period between 2009 and 2013 for instance, there was a 68% increase in use of PD among ESRD patients.[2] The increased acceptance of the treatment procedure was attributed to improved quality of life among patients, improved catheter survival rates after the first year of dialysis initiation and good protection of residual renal functioning.[3]

The placement of the peritoneal dialysis catheter (PDC) can be done through open surgical method, laparoscopic procedure, percutaneous fluoroscopic procedure and peritoneoscopic implantation.[4] Among the PDC procedures, the open surgical method is commonly used though constrained by high risks of complications among the ESRD patients.[5] In recent years, the laparoscopic procedure has been recommended since it is less invasive and has good visibility during catheter placement.[1] Some studies have, therefore, documented high efficacy of the laparoscopic catheter insertion technique as compared to open surgery.[6] On the other hand, some researchers report that the laparoscopic technique cannot avert the complications of PD.[17]

In the midst of the contradicting information, no studies have extensively and exhaustively compared the open-surgery and laparoscopic PDC placement procedures. Furthermore, most recent meta-analysis studies have not incorporated the current clinical studies.[8] Additionally, ESRD is significantly contributing to the global burden of disease with annual increasing rate of 20,000 cases.[910] Thus, this study aimed at comparing the laparoscopic and open-surgery catheter placement procedures in regards to catheter-related complications.

Methodology

Search strategy

A comprehensive and systematic literature search was conducted in PubMed and Google Scholar for studies focusing on the comparison between laparoscopic and open-surgery catheter placement procedures in PD. The following keywords were used in the search: PD, open surgery, laparoscopic, catheter placement and ESRD.

Study selection

The inclusion criteria included studies that were randomized controlled trials, cohort studies or retrospective studies. It also included studies that measured PDC placement outcomes, that is catheter malfunctioning, dialysate leakages, peritonitis and exit-site infection. Additionally, only the most recent clinical studies were considered. Studies that were excluded were case reports, letters and studies with unavailable data. Also, practical guides/manuals, non-English studies and paediatric studies were also excluded from the analysis. Two independent authors reviewed all articles obtained in the initial search against the inclusion criteria. Disagreements among the reviewers were resolved through consensus.

Data abstraction

Out of the 50 potential studies, 35 of them were eliminated due to duplication, unavailability of data, focusing on paediatric studies, being non-comparative studies and being written in a non-English language [Figure 1]. Data were abstracted using a standard form that captured the number of patients, demographic characteristics, study design and PDC placement-related outcomes.

Figure 1

Selection strategy for studies to be included in meta-analysis

Statistical analysis

Statistical analysis was conducted using Stata version 12 (Stata Corporation, College Station, TX 77845, USA). The random effects model was employed to assess the key outcomes of interest (dialysate leakage, catheter malfunction, peritonitis and exit-site infection). Forest plots were employed to show the between study variation in effect sizes. Publication bias was assessed using funnel plots. The heterogeneity across the studies was evaluated using the Q statistic and I2 index. Statistical analysis was done at 95% confidence interval.

Results

The studies included in the meta-analysis followed 4819 patients. The patients included in the study were adults aged 51.5 ± 33.5 years. The study period for the incorporated studies was from 1992 to 2019 as shown in Table 1. Based on the meta-analysis, there was no statistical significant difference in dialysate leakages between the laparoscopic and open-surgery groups (relative risk [RR] = 0.77; 95% CI: 0.51–1.17, P = 0.116) as shown in Figure 2. There was a significant difference in catheter malfunction between the laparoscopic and open-surgery group (RR = 0.58; 95% CI: 0.42–0.80, P = 0.031). Comparison of peritonitis between laparoscopic and open-surgery group showed that neither of the procedures had inferior incidences of peritonitis (RR = 0.8; 95% CI: 0.6–1.06, P = 0.349). There was no significant difference in exit-site infection between the laparoscopic and open-surgery group (RR = 0.84; 95% CI: 0.65–1.09, P = 0.834).

Table 1

Characteristics of the studies included in the meta-analysis

Study	Country	Year of publication	Study design	Study period	Number of patients	Age (years)	Comparison	Outcomes
Tuncer, Yardimsever and Ersoy[11]	Turkey	2003	Prospective, non-randomized	March 1998-October 2001	42	46.9±8.8	Laparoscopic omental fixation vs. open surgical placement	Complications
Soontrapornchai and Simapatanapong[12]	Thailand	2005	Prospective, non-randomized	May 1999-May 2001	102	57.5±19.1	Open and laparoscopic secure placement	Complications
Jwo et al.[1]	China	2008	Prospective randomized	December 2002-October 2006	77	54.4±16.5	Open surgery with laparoscopic-assisted placement	Positive findings of complications
Wright et al.[13]	UK	1999	Prospective randomized		45	49.3±20.2	Laparoscopic and open peritoneal dialysis	Complications of catheter insertion
Prabhakar et al.[14]	USA	2019	Retrospective, non-randomized	May 2005-March 2018	173	58.3±1.1	Laparoscopic and open CAPD placement	Complications (infection, malposition and malfunction)
Atapour et al.[15]	Iran	2011	Randomized clinical trial	2009-2010	61	55.1±17.2	Outcome of open surgical procedure and PDC insertion using laparoscopic needle	Complications
Cox et al.[16]	USA	2016	Retrospective, non-randomized	2005-2012	3134	59.4±24.0	Laparoscopic vs. open peritoneal dialysis	Surgical outcomes for PDC placement
van Laanen et al.[17]	Netherlands	2018	Randomized controlled trial	March 2010-March 2016	90	63.6±21.3	Open vs. laparoscopic placement	Reasons for failure and clinical successes
Bircan and Kulah[18]	Turkey	2016	Prospective non-randomized	2007-2014	69	63.1±21.1	Open vs. laparoscopic preperitoneal tunnelling	Catheter-related complications
Gadallah et al.[19]	USA	1999	Prospective cohort	October 1992-October 1995	148	46.4±4.5	Peritoneoscopic vs. surgical placement	Complications and causes of termination of study monitoring
Tsimoyiannis et al.[20]	Greece	2000	Prospective randomized		50	60±17	Laparoscopic placement of the Tenckhoff catheter	Operative variables
Gajjar et al.[21]	USA	2007	Retrospective non-randomized		75	55.7±32.2	Laparoscopic vs. traditional placement techniques	Immediate function and complications
Crabtree and Fishman[22]	USA	2005	Prospective cohort	1992-2002	341	52.3±16.5	Basic and advanced laparoscopic vs. open dissection	Clinical details of PDC placement
Batey et al.[6]	Kentucky	2002	Retrospective cohort	January 2000-March 2001	26	45.5±26.5	Mini laparoscopic assisted vs. open surgical method	Operative and post-operative data
Draganic et al.[23]	Australia	1998	Retrospective cohort		60	50.5±32.5	Laparoscopy vs. laparotomy	Perioperative complications
Eklund et al.[24]	Finland	1998	Retrospective cohort	June 1994-March 1997	102	51.1±1.1	Peritoneoscopic vs. surgical	Catheter-related complications
Sun et al.[25]	New Zealand	2016	Retrospective cohort	August 2009-July 2013	224	55.2±16.4	Peritoneoscopic vs. surgical	Perioperative outcomes

Figure 2

Relative ratio of dialysate leakages between laparoscopic and open-surgery PDC placement technique

Publication bias

Funnel plots of studies included in the meta-analysis reporting on occurrence of dialysate leakage, catheter malfunction, peritonitis and exit-site infection between laparoscopic and open-surgery group are shown in Figures 6–9. All funnel plots were symmetrical and thus there was no publication bias.

Figure 6

Funnel plot from all studies comparing dialysate leakage between laparoscopic and open-surgery PDC placement techniques

Figure 9

Funnel plot from all studies comparing exit-site infection between laparoscopic and open-surgery PDC placement techniques

Relative ratio of catheter malfunction between laparoscopic and open-surgery PDC placement techniques

Relative ratio of peritonitis between laparoscopic and open-surgery PDC placement techniques

Relative ratio of exit-site infection between laparoscopic and open-surgery PDC placement techniques

Funnel plot from all studies comparing catheter malfunction between laparoscopic and open-surgery PDC placement techniques

Funnel plot from all studies comparing peritonitis between laparoscopic and open-surgery PDC placement techniques

Risk of bias assessment

Risk of bias was assessed using Harbord test as shown in Tables 2–5. Based on the analysis, the meta-analysis was not significantly affected by small studies. Therefore, the meta-analysis could be affected by other factors and not small study effect.

Table 2

Harbord test assessing the presence of small study effects in 14 studies comparing dialysate leakage between laparoscopic and open-surgery PDC placement procedure

Z/sqrt (V)	Coef.	Std. err.	t	P>t	95% Conf. interval
sqrt (V)	−1.242677	0.9392929	−1.32	0.210	−3.289221	0.803866
Bias	1.179963	1.094247	1.08	0.302	−1.204196	3.564121

Test of H0: No small-study effects, P=0.302

Table 5

Harbord test assessing the presence of small study effects in 11 studies comparing dialysate leakage between laparoscopic and open-surgery PDC placement procedure

Z/sqrt (V)	Coef.	Std. Err.	t	P>t	95% Conf. interval
sqrt (V)	0.2393408	0.3787949	0.63	0.543	−.6175528	1.096234
Bias	−0.9076283	0.6999336	−1.30	0.227	−2.490988	0.6757315

Test of H0: no small-study effects, P=0.227

Discussion

The success of PD is measured by reduction of catheter-relatedcomplications. Catheter-related complications may result to technical failures which may reduce catheter survival and may consequently warrant for haemodialysis.[26]

The results of this meta-analysis show that there was no statistically significant difference in dialysate leakages between the laparoscopic and open-surgery PDC placement. The results of this study were similar to other meta-analysis which reported no significant difference in dialysate leakages between the laparoscopic and open-surgery groups.[2728] A number of articles have been published which are concurrent with the findings of the meta-analysis. For instance, a prospective randomized study done by Jwo et al. reported no significant difference in dialysate leakage between the laparoscopic and open-surgery group.[1] Similarly a review done by John H. Crabtree revealed no differences in the incidences of dialysate leakage between open surgery and laparoscopic group.[22] However, it is noteworthy to note that dialysate leakage is influenced by other factors such as the time when PD is started. Beginning PD immediately after insertion increases the risk to occurrence of leakage due to inadequate healing of the peritoneum. Additionally, the number of cuffs in a catheter has been documented to influence the occurrence of leaks, especially for the laparoscopic procedure.[28]

The results of the meta-analysis are in agreement with other meta-analysis which concluded that there was significant difference in catheter malfunction between laparoscopic and open-surgery group.[28] Similarly, other studies have reported laparoscopic as a superior catheter placement procedure with lower incidences of catheter malfunction as compared to open surgery. For instance, the study by Crabtree and Fishman which had the highest weight (19.64%) reported higher incidences (17.5%) in the open-surgery group as compared to the laparoscopic group (0.5%).[22] However based on a study conducted in the USA, there was no significance difference in incidences of catheter malfunction between the laparoscopic and open-surgery group.[19] The inconsistency among studies could be attributed to differences in catheters used in different studies.[28] For instance, studies have reported that use of coiled catheters tends to reduce incidences of catheter malfunction.[29] Additionally, the size of the studies may confound the results of the meta-analysis.

Peritonitis remains a big impediment to the application of PD and a contributor to patients going back to haemodialysis.[30] Based on the results of the meta-analysis, there was no significant difference in peritonitis between the laparoscopic and the open-surgery group (P = 0.349). Similarly, based on other meta-analyses, neither the laparoscopic nor the open-surgery PDC placement was superior to the other in terms of peritonitis.[2731] It is worth noting that the results of meta-analysis could be potentially influenced by factors such as application of perioperative antibiotics which has been reported to significantly reduce the risk of early development of peritonitis.[32] Additionally, studies have documented that there is still no consensus on the type of antibiotics to use to prevent occurrence of peritonitis as well as when the antibiotics should be administered.[28]

Our meta-analysis suggests that there is no significant difference in exit-site infection between laparoscopic and open-surgery PDC placement (P = 0.834). Based on a study which had the highest weight (34.95%), the incidences of exit-site infection among the open-surgery and laparoscopic group were not significantly different.[19] Furthermore, the results of this study were in agreement with a previous meta-analyses.[831] Potential confounding factor of occurrence of exit-site infection in the open-surgery and laparoscopic group is the time when PD is started after the insertion of a catheter. Some studies recommend immediate start of PD after catheter insertion,[20] other studies recommend a waiting period of 3–5 days[23] while some authors suggest a waiting period of 2 weeks.[122122]

The limitation of the study is that 6 of the 17 studies included in the meta-analysis were non-randomized. The non-randomized studies could have contributed to bias due to uncaptured differences between the groups. Furthermore, the estimates generated were not adjusted and hence some confounding factors may have impacted negatively on the study. Nevertheless, despite the limitations, the meta-analysis provides meaningful information regarding complications associated with laparoscopic and open-surgery PDC placement procedures.

Conclusion

The present study shows that there was statistically significant difference in catheter malfunction between the laparoscopic and open-surgery group. Furthermore, there were no statistically significant differences in dialysate leakage, peritonitis and exit-site infection between the laparoscopic and open-surgery PDC placement procedures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Table 3

Harbord test assessing the presence of small study effects in 14 studies comparing catheter malfunction between laparoscopic and open-surgery PDC placement procedure

Z/sqrt (V)	Coef.	Std. err.	t	P>t	95% Conf. interval
sqrt (V)	−1.350746	0.9195935	−1.47	0.168	−3.354368	0.652876
Bias	1.083912	1.333848	0.81	0.432	−1.822292	3.990117

Test of H0: No small-study effects, P=0.432

Table 4

Harbord test assessing the presence of small study effects in 12 studies comparing dialysate leakage between laparoscopic and open-surgery PDC placement procedure

Z/sqrt (V)	Coef.	Std. err.	t	P>t	95% Conf. interval
sqrt (V)	0.0531265	0.771228	0.07	0.946	−1.665277	1.77153
Bias	−0.5625115	1.290941	−0.44	0.672	−3.438908	2.313885

Test of H0: No small-study effects, P=0.672