Successful surgical management of encapsulating peritoneal sclerosis

Abstract

Background: Encapsulating peritoneal sclerosis (EPS) is a serious complication of long-term peritoneal dialysis (PD). The mortality rate for EPS has been high, primarily because of complications related to bowel obstruction. Also, therapeutic guidelines for EPS have not yet been established. In our hospital, favorable postoperative results were obtained in 50 patients whose EPS was treated surgically.

Patients: All patients had chronic glomerulonephritis as the underlying kidney disease. All had undergone PD for between 29 months and 220 months (average: 113.9 months). During the course of PD, 3 patients developed EPS and were subsequently transferred to hemodialysis (HD). The other 47 patients (94.0%) developed EPS after discontinuation of PD. The reasons for transfer to HD were inadequate ultrafiltration (26 patients), bacterial peritonitis (16 patients), hypoalbuminemia (2 patients), renal transplantation (3 patients), and occurrence of EPS (3 patients).

Intervention: At laparotomy, a definitive diagnosis of EPS was established in all patients by the presence of clumped intestine cocooned with a dense sclerotic membrane. In all cases, the small intestine was completely released by ablation of the capsules, resulting in resolution of the bowel obstruction symptoms. In 5 patients, the large intestine was ablated solely at the region of the sigmoid colon. The operating time varied from 3 hours to 18 hours (average: 6.9 hours). Oral food intake was initiated 5 - 60 days (average: 10.2 days) after surgery.

Results: Perforation of the small intestine was detected postoperatively in 2 patients, who died 26 days and 37 days after surgery. The remaining 48 patients were followed for between 9 months and 107 months (average: 34.6 months). During follow-up, 6 - 12 months after the initial surgery, 4 patients experienced a recurrence of bowel obstruction symptoms that required a second laparotomy with enterolysis. Excluding the 2 patients with fatal outcomes, 46 patients (96%) experienced complete relief from bowel obstruction symptoms. The remaining 2 patients continued to experience mild, sub-acute bowel obstruction symptoms that could be successfully controlled solely by diet.

Conclusions: Surgical treatment of 50 patients with EPS produced successful outcomes in all but 2 patients (96% success). Encapsulating peritoneal sclerosis should be actively treated by surgeons who genuinely understand this pathologic condition.