2023+SAGES指南：腹膜透析通路（更新版）.pdf

Vol.:(0123456789)1 3Surgical Endoscopy https:/doi.org/10.1007/s00464-023-10550-8SAGES/EAES OFFICIAL PUBLICATIONSAGES peritoneal dialysis access guideline update 2023StephenP.Haggerty1 SunjayS.Kumar2 AmeliaT.Collings3 VamsiV.Alli4 EmilyMiraflor5 NaderM.Hanna6 DimitriosI.Athanasiadis7 DavidJ.Morrell8 MohammedT.Ansari9 AhmedAbouSetta10 DanielleWalsh11 DimitriosStefanidis7 BethanyJ.Slater12Received:8 September 2023/Accepted:17 October 2023 The Author(s),under exclusive licence to Springer Science+Business Media,LLC,part of Springer Nature 2023AbstractBackground Minimally invasive surgery has been used for both de novo insertion and salvage of peritoneal dialysis(PD)catheters.Advanced laparoscopic,basic laparoscopic,open,and image-guided techniques have evolved as the most popular techniques.The aim of this guideline was to develop evidence-based guidelines that support surgeons,patients,and other physicians in decisions on minimally invasive peritoneal dialysis access and the salvage of malfunctioning catheters in both adults and children.Methods A guidelines committee panel of the Society of American Gastrointestinal and Endoscopic Surgeons reviewed the literature since the prior guideline was published in 2014 and developed seven key questions in adults and four in children.After a systematic review of the literature,by the panel,evidence-based recommendations were formulated using the Grad-ing of Recommendations Assessment,Development and Evaluation approach.Recommendations for future research were also proposed.Results After systematic review,data extraction,and evidence to decision meetings,the panel agreed on twelve recommen-dations for the peri-operative performance of laparoscopic peritoneal dialysis access surgery and management of catheter dysfunction.Conclusions In the adult population,conditional recommendations were made in favor of:staged hernia repair followed by PD catheter insertion over simultaneous and traditional start over urgent start of PD when medically possible.Furthermore,the panel suggested advanced laparoscopic insertion techniques rather than basic laparoscopic techniques or open insertion.Conditional recommendations were made for either advanced laparoscopic or image-guided percutaneous insertion and for either nonoperative or operative salvage.A recommendation could not be made regarding concomitant clean-contaminated surgery in adults.In the pediatric population,conditional recommendations were made for either traditional or urgent start of PD,concomitant clean or clean-contaminated surgery and PD catheter placement rather than staged,and advanced lapa-roscopic placement rather than basic or open insertion.Keywords Chronic renal failure Guidelines Laparoscopic peritoneal dialysis catheter insertion Pediatrics Peritoneal dialysis accessAbbreviationsAL Advanced laparoscopic techniqueBL Basic laparoscopic techniqueCAPD Continuous ambulatory peritoneal dialysisCI Confidence intervalCKD Chronic kidney diseaseESRD End stage renal diseaseEtD Evidence to decisionGRADE Grading of Recommendations,Assessment,Development,and EvaluationHD HemodialysisHPD Concomitant hernia repair and peritoneal dialy-sis accessIR Interventional radiologyISPD International Society for Peritoneal DialysisKQ Key questionOR Odds ratioPD Peritoneal dialysisPICO Population,intervention,comparator,outcomeRCT Randomized controlled trialRRT Renal replacement therapyand Other Interventional Techniques Extended author information available on the last page of the article Surgical Endoscopy1 3RIGHT Essential Reporting Items for Practice Guide-lines in HealthcareSAGES The Society of American Gastrointestinal and Endoscopic SurgeonsUS United States of AmericaExecutive summaryBackgroundContinuous ambulatory peritoneal dialysis(CAPD)has become a widespread mode of renal replacement therapy(RRT)for patients with chronic renal failure.The surgeons role in caring for these patients is to provide access to the peritoneal cavity via a peritoneal dialysis(PD)catheter and to diagnose and manage catheter complications.Since the early 1990s many surgeons have utilized laparoscopy for insertion of PD catheters as well as salvage of malfunction-ing catheters.In 2014,the Society for American Gastro-intestinal and Endoscopic Surgeons(SAGES)published clinical practice guidelines for laparoscopic peritoneal dial-ysis access surgery 1.Topics included:Indications and contraindications,insertion options,advanced laparoscopic techniques to avoid catheter dysfunction,peri-operative considerations,surgical techniques,postoperative protocols,outcomes in adults,postoperative complications,and PD catheter malfunction.Since that publication,the guidelines committee has adopted a more formal methodology using the Grading of Recommendations Assessment,Development and Evaluation(GRADE)approach 2.MethodsThis document is an evidence-based guideline based on a systematic review of current literature and expert opinion.It provides specific recommendations to assist physicians who care for PD patients.Interpretation ofstrong andconditional recommendationsThe strength of these evidence-based recommendations is either“strong”or“conditional”as per the GRADE approach 2,3.The phrase“the guideline panel recommends,”is used for strong recommendations and“the guideline panel sug-gests,”for conditional recommendations 2,4.Strong rec-ommendations can be adopted as a policy in most situations.Conditional recommendations require shared decision-mak-ing between the surgeon and their patients.When insufficient evidence existed to inform recommendations,expert opinion consensus was sought.How touse these guidelinesThese guidelines are primarily intended to help surgeons make decisions about the peri-operative management of their patients undergoing minimally invasive surgery.Other purposes are to educate,inform policy and advo-cacy,and to define future research needs.Guidelines are applicable to all physicians facing patient management uncertainties addressed herein without regard to spe-cialty,training,or interests.Due to the complexity of the healthcare environment,these guidelines are intended to indicate the preferred,but not necessarily the only,accept-able approach to management.Guidelines are intended to be flexible depending on individual circumstances.Given the wide range of variation in any health care problem,the surgeon must always tailor the approach to the individual patient.These guidelines can also be used by patients as a basis of discussion with their treating surgeon.RecommendationsKQ1:In adult patients needing both renal replacement therapy and hernia repair,should hernia repair be per-formed concurrently with peritoneal dialysis catheter placement or be staged?The panel suggests staged hernia repair and peritoneal dialysis catheter placement rather than simultaneous oper-ations for adults needing both renal replacement therapy and hernia repair(conditional recommendation,very low certainty evidence).KQ2:Should urgent start(less than 2weeks)or tra-ditional start be used for adult and pediatric patients who are initiating peritoneal dialysis?For adult patients initiating peritoneal dialysis,the panel suggests that traditional start is favored over urgent start.(conditional recommendation,very low certainty evidence).However,if urgent initiation of renal replacement ther-apy is deemed medically necessary,the panel suggests that the benefits of urgent start peritoneal dialysis may out-weigh the risks of interval hemodialysis prior to traditional start of peritoneal dialysis(conditional recommendation,expert opinion due to insufficient evidence).For pediatric patients,the panel suggests either tradi-tional or urgent start when initiating peritoneal dialysis(expert opinion due to insufficient evidence).KQ3:Should clean-contaminated surgery be per-formed concomitantly with peritoneal dialysis catheter placement or as separate procedures in adult and pedi-atric patients who are initiating peritoneal dialysis?For adult patients,the panel suggests concomitant lapa-roscopic cholecystectomy and peritoneal dialysis catheter Surgical Endoscopy 1 3placement when patients are initiating peritoneal dialysis and also require cholecystectomy(expert opinion due to insufficient evidence).The panel did not find sufficient evidence to make rec-ommendations for other clean-contaminated operations in adults.For pediatric patients,the panel suggests concomitant clean or clean-contaminated operations when patients are initiating peritoneal dialysis and also require another opera-tion(expert opinion due to insufficient evidence).KQ4:Should advanced laparoscopic insertion tech-niques or basic laparoscopic insertion techniques be used for adult and pediatric patients needing renal replace-ment therapy?For adult patients,the panel suggests advanced laparo-scopic insertion as opposed to basic laparoscopic inser-tion(conditional recommendation,very low certainty of evidence).For pediatric patients,the panel suggests advanced lapa-roscopic insertion as opposed to basic laparoscopic insertion(expert opinion due to insufficient evidence).KQ5:Should advanced laparoscopic insertion tech-niques or open insertion be used for adult and pediatric patients needing renal replacement therapy?For adult patients,the panel suggests advanced laparo-scopic insertion as opposed to open insertion(conditional recommendation,very low certainty evidence).For pediatric patients,the panel suggests advanced lapa-roscopic insertion as opposed to open insertion(conditional recommendation,very low certainty evidence).KQ6:Should advanced laparoscopic insertion tech-niques or ultrasound-guided percutaneous techniques be used for adult patients needing renal replacement therapy?The panel suggests either advanced laparoscopic or image-guided percutaneous insertion for adults needing renal replacement therapy(conditional recommendation,very low certainty evidence).KQ7:In adult patients with peritoneal dialysis cath-eter malfunction,should operative or nonoperative sal-vage be attempted?The panel suggests either operative or nonoperative sal-vage for adult patients with peritoneal dialysis catheter mal-function(conditional recommendation,very low certainty evidence).Aim ofthese guidelines andspecific objectivesThe aim of these evidence-based guidelines by the Soci-ety of American Gastrointestinal and Endoscopic Surgeons(SAGES)is to provide recommendations regarding the peri-operative performance of laparoscopic peritoneal dialysis(PD)access surgery and salvage of malfunctioning catheters.The key target audiences include surgeons,nephrologists,interventional radiologists(IR),and patients.Policy makers and insurance providers involved in delivering health care services related to PD access surgery or evaluating direct and indirect benefits,harms,and costs related to the vari-ous procedures used to insert or salvage malfunctioning PD catheters may also consider these recommendations in their deliberations.Description ofthehealth problemsIn 2022 over 786,000 patients in America suffered from stage V chronic kidney disease and relied on renal replace-ment therapy(RRT)according to the National Institute of Diabetes and Digestive and Kidney Diseases 5.Of these,71%were on dialysis and 29%had a functioning transplant.PD has been a proven mode of renal replacement therapy since 1980 and while its use has risen globally,it has waxed and waned in the United States of America(USA).There has been slow growth since 2008 in the USA with current statistics showing that in 2020 16,528 patients initiated PD,representing 12.7%of individuals with incident end stage renal disease(ESRD).Hemodialysis(HD),the alternative to PD,requires central venous cannulation or creation of a fistula and has been found to be inferior to PD with regards to patient autonomy,quality of life,preservation of residual renal function,survival for the first 2years,and cost 613.Absolute contraindications to PD include documented ultrafiltration failure of the peritoneal membrane,severe protein calorie malnutrition and/or proteinuria 10g/day,active intraabdominal infection,loss of domain/unrepair-able abdominal wall hernia,and loss of peritoneal volume due to dense abdominal adhesions not amenable to laparo-scopic lysis.There are also perceived barriers to PD such as advanced age,obesity,and polycystic kidney disease 14.Once a patient is deemed an appropriate candidate for PD,the preoperative evaluation includes consultation with a surgeon,history and physical examination,medical evalu-ation,risk stratification for anesthesia,and patient education.If an abdominal wall hernia is found,there are three options:hernia repair followed by PD catheter insertion,concomi-tant hernia repair and catheter insertion,or watchful waiting with interval hernia repair if patients develop symptoms.Unfortunately there is no consensus in the literature regard-ing the optimal strategy,leading to the first key question on this topic.Postoperative protocols for initiation of PD as per Inter-national Society for Peritoneal Dialysis(ISPD)guidelines include a 2week healing or“break-in”period between PD catheter insertion and PD initiation 15.The“urgent start”of PD less than 2weeks after PD catheter insertion has also been described with the goal of avoiding HD in patients who Surgical Endoscopy1 3need RRT urgently 16.Therefore the use of urgent start PD was also considered a relevant guideline question.Surgeons who place PD catheters must have knowledge of various insertion options and be able to follow best prac-tices for PD catheter insertion to optimize outcomes.Popular options currently include laparoscopic,open,and percuta-neous fluoroscopic-guided insertion.In addition,advanced laparoscopic(AL)techniques have been described such as rectus sheath tunneling,suture fixation,and omentectomy or omentopexy to help improve catheter survival.However,there is still debate regarding when each technique should be utilized 15.Three key questions were formulated to address the differences in these approaches.Finally,patients who experience PD catheter dysfunc-tion need urgent attention to avoid a lapse in dialysis.The surgeon often plays a role in assessing and managing these patients,though non-surgical interventions are also avail-able.Multimodal evaluation of the cause of dysfunction usually includes plain X-ray,interventional radiology fluor-oscopic catheter evaluation,attempted nonoperative man-agement,and exploratory laparoscopy with surgical manage-ment 1.The aim of the final key question was to assess how nonoperative management of catheter dysfunction compares with operative management.Properly addressing these clinical questions in the pedi-atric population requires consideration of additional factors.For example,vascular access for HD in these patients can be incredibly challenging to manage 17.Omentopexy,frequently employed during AL PD catheter placement in the adult population,may not be