Laparoscopic colectomy for transverse colon cancer in an automated peritoneal dialysis patient: A case report

Abstract

INTRODUCTION

To date, intra-abdominal surgery in patients undergoing peritoneal dialysis (PD) has been considered to be associated with increased risk even when it is performed laparoscopically. To our knowledge, this is the first case of laparoscopic colectomy for transverse colon cancer in a patient undergoing automated PD (APD).

PRESENTATION OF CASE

A 67-year-old man undergoing APD for end-stage chronic renal failure secondary to diabetic nephropathy was diagnosed with transverse colon cancer. Laparoscopic tumor resection without removal of the PD catheter was performed uneventfully. After surgery, PD was interrupted for 4 weeks and then safely resumed after confirming no severe complications of anastomotic leakage or intra-abdominal abscess.

DISCUSSION

In patients undergoing PD, the safety of laparoscopic surgery without removal of the catheter and the optimal timing of resuming postoperative PD with or without temporary hemodialysis remain controversial.

CONCLUSION

We believe that laparoscopic colectomy can be safely performed in patients undergoing PD. Further case reports and investigations on this procedure with special reference to safety are warranted in future.

1. Introduction

Peritoneal dialysis (PD) has emerged as one of the most common renal replacement therapies for chronic renal failure (CRF) and has been introduced in 12–15% patients with CRF.¹ It is anticipated that the use of intra-abdominal surgery will increase in patients undergoing PD. There is the high risk of perioperative complications such as leakage of dialysate fluid, wound dehiscence, incisional hernia, peritonitis, and hemoperitoneum in these patients.^2,3 Laparoscopic cholecystectomy in a patient undergoing PD, with a good outcome and early resumption of PD, was recently reported.^4,5 However, there are no reports of laparoscopic colectomy in these patients. Here we present the first case, to our knowledge, of laparoscopic transverse colon cancer resection without PD catheter removal in a patient undergoing automated peritoneal dialysis (APD).

2. Presentation of case

A 67-year-old man was referred to our hospital to undergo APD for end-stage CRF secondary to diabetic nephropathy. The patient's iron deficiency anemia worsened significantly 7 days after initiating APD. Colonoscopy (Fig. 1A) and barium enema (Fig. 1B) revealed an elevated tumor measuring 2 cm in diameter in the right side of the transverse colon. Biopsy specimens revealed well-differentiated tubular adenocarcinoma. Laboratory investigation revealed the following: white blood cell count, 4800/mm³; hemoglobin, 8.8 g/dL; platelets, 26,0000/mm³; blood urea nitrogen, 21 mg/dL; and serum creatinine, 4.77 mg/dL. Radiographs and CT images revealed that the PD shunt catheter was subcutaneously routed from the left lateral region into the abdominal cavity at the right lateral region. On the basis of a provisional diagnosis of TNM stage I (T2, N0, M0) transverse colon cancer, according to the 7th edition of the International Union Against Cancer TNM classification, 7th edition, we performed laparoscopic colectomy without removal of the PD shunt catheter after consulting a nephrologist.

Fig. 1.

Diagnostic methods. Colonoscopic examination (A) and barium enema (B) revealing an elevated tumor measuring 2 cm in diameter in the right side of the transverse colon (arrow).

Laparoscopic colectomy was performed using a standard 5-port technique with induction of an 8-mm Hg pneumoperitoneum. The first port was inserted using the Hasson technique and the others were safely inserted under direct vision away from the PD catheter. Upon insertion of the laparoscope into the abdomen, dialysate fluid retention and the PD catheter with no dense adhesions were observed in the right lateral region (Fig. 2A). We shifted the peritoneal end of the PD catheter to the Douglas pouch, away from the surgical field, to prevent infection or iatrogenic damage to the catheter (Fig. 2B). A partial colectomy with D3 lymphadenectomy was successfully performed. The umbilical port wound was enlarged to a diameter of 3 cm and extracorporeal anastomosis was performed to prevent intra-abdominal contamination. At the end of the surgery, the umbilical wound and the 12-mm trocar incision were sutured in two layers to prevent dialysate leakage from the trocar incision sites; other 5-mm trocar incisions were sutured in a single layer. Second-generation cephalosporin at a dose of 1 g/day was intravenously administrated as a prophylactic measure before incision to postoperative day 3. Postoperative hemodialysis was performed for 4 weeks before safely resuming APD after confirming no signs of anastomotic leakage or intra-abdominal abscess. The patient's postoperative course was uneventful, with no PD-related complications such as dialysate leakage, wound infection, or dehiscence.

Fig. 2.

Surgical findings. Dialysate fluid retention and the PD catheter without adhesions were noted in the right lateral region (A). The peritoneal end of the shunt catheter was shifted away from the surgical field to avoid infection or damage to the catheter (B).

3. Discussion

Patients undergoing PD are in an immunocompromised state and often have a high incidence of comorbidities such as diabetes mellitus, vascular disease, and amyloidosis. Intra-abdominal surgery in these patients may cause complications such as leakage of dialysate fluid, wound infection, dehiscence, and incisional hernia due to delayed wound healing.⁶ It is also well known that uremic platelet dysfunction and coagulopathy can cause perioperative hemoperitoneum.⁷ Bowel resection in patients with CRF has been considered to be associated with remarkable increase in mortality and morbidity, particularly anastomotic leakage.⁸ However, it has recently been reported that the smaller abdominal incisions used in laparoscopic procedures decrease the incidence of these complications along with the risk of postoperative dense adhesions⁹ and should be used preferentially, even for bowel resection in patients with CRF.¹⁰ In fact, laparoscopic cholecystectomy in patients undergoing PD has been reported to be safe and feasible.^4,5,9 However, there are no reports of laparoscopic colectomy for colon cancer in patients undergoing PD. To our knowledge, ours is the first reported case of laparoscopic transverse colon cancer resection in a patient undergoing APD.

Laparoscopic surgery is widely used for treating colorectal cancer because of its minimal invasiveness and cosmetic benefit. Several large-scale randomized controlled trials have reported that the short-term outcomes of laparoscopic surgery are comparable to those of conventional open surgery for colorectal cancer.^11,12 However, because laparoscopy for transverse colon cancer is associated with technical and oncological difficulty, it was excluded from those trials. In Japan, low postoperative complication rates of 1.47% for anastomotic leakage, 0.20% for intra-abdominal abscess, and 0.33% for postoperative bleeding have been reported for laparoscopic surgery for colon cancer; nonetheless, complications occurred more frequently after transverse colectomy than after laparoscopic right or left colectomy.¹³ However, it was recently reported that laparoscopic surgery for transverse colon cancer could be performed with safety and oncological validity comparable to open surgery.¹⁴ We considered that laparoscopic colectomy for transverse colon cancer in patients undergoing PD can be safely performed by close observation during the perioperative period.

With regard to gastrointestinal surgery in patients undergoing PD, it has been assumed that the PD catheter should be removed from the abdominal cavity during the perioperative period to avoid potential infection.¹⁵ In contrast, it has recently been reported that laparoscopic surgery in PD patients without removal of the PD catheter has been performed for cholecystolithiasis^4,5,9 and perforated appendicitis.¹⁶ In the present case, without removal of the PD catheter, the peritoneal end of the PD catheter was kept away from the surgical field and extracorporeal anastomosis was performed to prevent intra-abdominal contamination. However, severe complications may occasionally result in fatality in immunocompromised PD cases; therefore, if anastomotic leakage or intra-abdominal abscess is suspected, the PD catheter should be removed immediately to prevent aggravation of infection.

After open surgery in patients undergoing PD, early resumption of postoperative PD has been associated with leakage of dialysate fluid, wound infection, and dehiscence due to poor wound healing.⁶ On the other hand, laparoscopic procedures may have the advantage of early postoperative resumption of PD and prevention of postoperative dense adhesions. Early PD resumption after laparoscopic cholecystectomy with no period of postoperative hemodialysis has been reported^4,5; however, there are no clear recommendations regarding postoperative PD resumption after gastrointestinal surgery. In gastrointestinal perforation, clinical signs of intraperitoneal contamination may be masked by dilution from dialysate fluid¹⁷; thus, early PD resumption after gastrointestinal surgery may invite the unfortunate oversight of severe complications such as anastomotic leakage or intra-abdominal abscess. In the present case, a brief period for approximately 4 weeks of postoperative hemodialysis was introduced in our patient before safely resuming APD after confirming no signs of anastomotic leakage or intra-abdominal abscess. Further case reports and investigations on this procedure, with special reference to safety, are warranted in future.

4. Conclusion

To our knowledge, this is the first case of laparoscopic transverse colon cancer resection without removal of the PD catheter in a patient undergoing APD. The safety of laparoscopic surgery without removal of the PD catheter and the optimal timing of resumption of postoperative PD remain controversial. However, we believe that laparoscopic colectomy can be safely performed in patients undergoing PD and allow PD resumption after introducing a brief period of hemodialysis during the postoperative period.

Conflict of interest statement

None.

Funding

None.

Ethical approval

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Author contributions

Torigoe T, Akiyama Y and Uehara T performed surgery; Torigoe T, Nakayama Y and Yamaguchi K contribute for the writing to this manuscript.