Advanced Strategies for Managing Pleuroperitoneal Communication in Peritoneal Dialysis Patients: Report of Two Cases

Introduction

Pleuroperitoneal communication (PPC) is a rare but serious complication that can occur in patients undergoing peritoneal dialysis (PD). It involves an abnormal passage between the peritoneal and pleural cavities, which can lead to leakage of peritoneal dialysis fluid into the pleural space, resulting in pleural effusion and other respiratory complications [1]. This condition typically results in dyspnea without concomitant signs of peripheral edema or heart failure. Moreover, it is associated with impaired peritoneal technique, leading to a reduction in ultrafiltration volume. This complication is relatively uncommon and requires a differential diagnosis from other, more prevalent diseases. In particular, it is crucial to exclude the presence of pulmonary infection, congestive heart failure, and primary lung carcinoma. A meticulous clinical assessment, including a detailed physical examination, biochemical tests, and first- or second-level instrumental investigations, can help determine an accurate diagnostic and therapeutic pathway.

Although this condition is unusual, its impact on patient outcomes can be significant, as it may necessitate the discontinuation of peritoneal dialysis and the transition to hemodialysis. PPC poses a major challenge because it not only disrupts the dialysis process but also threatens residual renal function, which is crucial for the patient’s long-term health and quality of life.

The incidence of PPC has been reported to range from 1% to 6% among patients undergoing peritoneal dialysis in adult [2] and 3% in pediatric patients. The prevalence in Italy comparable to that reported in the scientific literature. Although most of the literature consists of individual case reports [3], larger series indicate that the condition tends to occur most frequently in the first few years of peritoneal dialysis. Anatomical defects are more commonly found on the right side of the diaphragm. The left side is covered by the pericardium, while the right side has a greater presence of the lymphatic network [1].

The etiology of PPC remains largely speculative, but increased intra-abdominal pressure from dialysate infusion is believed to play a key role in the development of diaphragmatic defects that facilitate pleuroperitoneal communication. Additionally, episodes of peritonitis or other infections can exacerbate the risk of developing this complication [2].

The diagnosis and management of this complication remain non-standardized. Various imaging techniques, including computed tomography, ultrasound, and scintigraphy, are used for diagnosis. Treatment options range from conservative measures to surgical interventions of varying degrees of invasiveness and effectiveness [4]. Given the potential severity of PPC, prompt diagnosis and intervention are essential to prevent complications such as respiratory failure, further damage to the diaphragm, and the need for urgent conversion to hemodialysis. Successful management of this condition typically requires a multidisciplinary approach, involving nephrologists, thoracic surgeons, dietitians, and nuclear medicine specialists, to ensure optimal timing and treatment strategies that preserve peritoneal dialysis and renal function.

In this report, we present 2 cases of PPC diagnosed at our center, describing the diagnostic and therapeutic challenges encountered, as well as the multidisciplinary approach that enabled successful management. By sharing our experience, we aim to provide insights into the effective use of advanced imaging techniques such as peritoneal scintigraphy, and minimally invasive surgical interventions such as video-assisted thoracic surgery (VATS), in the treatment of PPC.

Case Reports

CASE 1:

A 60-year-old woman with chronic glomerulonephritis had been on automated peritoneal dialysis (APD) for 3 months (fill volume 1800 mL, body weight 62 kg, BMI 23.62 kg/m²). Following the diagnosis of leakage, she opted for transition to extracorporeal dialysis. In addition to imaging, she underwent a thorough evaluation of nutritional status and residual renal function to optimize nutritional management and the dialysis protocol.

CASE 2:

A 52-year-old man with congenital obstructive uropathy had been on APD for 6 months (fill volume 2200 mL, body weight 95 kg, BMI 29.65 kg/m2). The onset of pleuroperitoneal communication followed an episode of peritonitis. Desiring to continue peritoneal dialysis, he underwent conservative management. With a residual renal function of 5 mL/min, he was placed on a very low-protein diet (VLPD) with ketoanalogs (1 tablet per 5 kg body weight) for 45 days. This dietary intervention allowed him to avoid transition to extracorporeal dialysis, achieving favorable clinical and biochemical outcomes. Notably, serum urea remained stable, and serum phosphorus decreased. During this period, he was told to reduce water intake and to avoid taking any nephrotoxic drugs [6]. He was closely monitored, and follow-up scintigraphy performed at 45 days demonstrated complete resolution of the leakage.

However, approximately 1 month after resuming peritoneal dialysis with a reduced fill volume (1600 mL), he had a recurrence. After renewed nutritional therapy, a consultation with a thoracic surgeon, and informed consent, the decision was made to proceed with video-assisted thoracic surgery (VATS). A multidisciplinary team meeting identified the likely site of the defect, developed the surgical protocol, and outlined the postoperative management plan.

SURGICAL TECHNIQUE: BIPORTAL VATS AND CLOSURE OF PPC:

Surgical intervention began with general anesthesia. Single-lung ventilation was achieved with a double-lumen tube placed under bronchoscopic guidance. After ensuring complete lung collapse, the patient was positioned in full lateral decubitus. The table was slightly flexed at the scapular tip to facilitate rib splaying without the need for a rib spreader. Prior to surgery, 2000 mL of dialysate containing 50 mg of methylene blue was infused to enhance lesion visibility.

Biportal VATS for diaphragmatic repair required 2 incisions: one at the 8th–9th intercostal space along the mid-axillary line for thoracoscope insertion, and another at the 6th intercostal space along the mid-clavicular line for suturing the diaphragm. Long, curved surgical instruments were used, and a 12-mm trocar for the 10 mm, 30° camera was inserted. The initial inspection focused on locating the defect, usually found in the central tendinous diaphragm (Figure 4A, 4B). Any adhesions present were lysed to improve exposure.

The diaphragm was gently retracted using an Endo Peanut™ to expose the defect. Peritoneal fluid leakage helped further localize the communication. The defect was closed with polypropylene (Prolene®) sutures and secured with metal clips (Figure 5A, 5B). The sutures were applied using either endoscopic or traditional needle holders, with an endoscopic knot pusher required for knotting. Alternatively, an EndoStich™ device was used to simplify suturing. After closure, fibrin glue (Tisseel®) was applied to promote tissue healing (Figure 6). A 28-Fr chest drain was inserted, connected to a drainage system.

POSTOPERATIVE COURSE:

The patient had an uneventful recovery with no complications. In the following days, biweekly peritoneal catheter flushes were performed. After 20 days, peritoneal dialysis was resumed with reduced volumes, with no recurrence noted.

Discussion

The first cases of PPC were reported as early as 1967 by Edward and Ungar, while the first use of VATS in the treatment of this complication dates back to 1996 [7]. In the existing literature, there is a consensus on the critical role of accurate preoperative diagnosis of the lesion. Confirmation of the communication is associated with a therapeutic success rate of 89%, whereas the success rate drops to 38% in cases without a confirmed diagnosis [8]. The method of identifying the leak site using 99mTc has been previously reported by other authors [9,10]. In our opinion, scintigraphy integrated with CT is the most sensitive, detailed, and minimally invasive technique for the diagnosis of PPC.

While VATS is well-documented for treating PPC, most studies remain limited to case reports, and no standardized technique exists [11,12]. Surgical approaches vary, including polyglycolic acid (PGA) sheets with or without fibrin glue [13], and simultaneous thoracoscopic and laparoscopic procedures [14]. Other methods have been reported for repairing fistulas, including pericardial fat tissues, excision with a stapler, a pedicled latissimus dorsi muscle flap, or a falciform ligament [15]. In our experience, direct suturing or ligation with fibrin glue is an effective, minimally invasive solution with a lower recurrence rate [16]. The conservative approach without surgical intervention appears to result in lower success rates (around 50%), with high recurrence rates, as observed in our experience and in several previous case series. Due to the limited sample size and the lack of controlled comparative studies, a definitive statistical evaluation cannot be provided.

Nutritional therapy helped avoid the need for hemodialysis, minimizing risks associated with vascular access and preserving residual renal function. The prevention of recurrence in patients with pleuroperitoneal communication relies on targeted surgical treatment and careful postoperative monitoring, including regular assessment of peritoneal function and signs of pleural effusion. Additionally, reducing intra-abdominal pressure through appropriate control of dialysis volume could be an additional protective factor.

Our therapeutic approach ensures good long-term outcomes with low recurrence rates. However, the patient must demonstrate a strong commitment to preserving the technique and be informed that no universally accepted guidelines exist regarding the use of VATS. Additionally, the patient must be able to tolerate general anesthesia, as this is a prerequisite for undergoing laparoscopic surgery. A multidisciplinary approach involving dietitians, nephrologists, thoracic surgeons, and nuclear medicine specialists is critical for optimal timing and intervention. Preoperative planning accurately identifies the lesion site, while nutritional therapy can prevent the need for hemodialysis, avoiding vascular access placement and preserving residual renal function.

Conclusions

A solid knowledge of the peritoneal dialysis technique is essential for recognizing complications, even if rare. Clinical examination and the assessment of the technique’s efficiency, particularly peritoneal ultrafiltration, can guide clinicians toward an early and targeted diagnosis. In this context, tools such as remote monitoring can enhance clinical management. Moreover, thorough knowledge of all available diagnostic imaging and instrumental tests is crucial for establishing an accurate differential diagnosis. The combination of peritoneal scintigraphy and advanced VATS allows for accurate diagnosis, preoperative mapping, and minimally invasive treatment of PPC. Nutritional therapy serves as an effective bridging therapy. Involvement of a multidisciplinary team ensures optimal outcomes, preserving peritoneal dialysis and renal function. Future prospective studies and clinical trials are necessary to standardize surgical techniques and improve diagnostic protocols. Moreover, new studies should lead to the development of shared guidelines for the treatment of PCC.

Therefore, comparative studies on use of VATS in the treatment of this complication should be conducted using standardized diagnostic and surgical techniques. Integrating less invasive techniques, such as VATS combined with advanced imaging, could revolutionize PPC management, reducing surgical risks and improving patient quality of life.