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Conflict of Interest of Hideki Kawanishi
I have/had an affiliation (financial or otherwise) with a pharmaceutical, medical device or communications organization. Honoraria of presentations by Terumo Corporation KISSEI PHARMACEUTICAL CO.,LTD Bayer Yakuhin Japan CO.,LTD
Tsuchiya General Hospital, Hiroshima, Japan
Hideki Kawanishi
International PD story
24 years experience of EPS surgery
ISPD, 2018 Vancouver
Prevalence and Mortality of EPS in survey
Study N EPS% /1000p
.y Death PDF
Multi-center
Retro
spective
EDTA, Oules 1988 0.03-0.31% 69% Acid
Japan, Nomoto 1996 6923 1.7% 44% Acid
Australia, Rigby 1998 7374 0.7% 1.8 56% Acid
Koria, Kim 2005 4249 0.8% 24% Acid
ANZDATA, 2010 7618 0.4% 1.8 54% Acid
Netherlands, Korte 2011 2022 2.7% 54% Acid+ico
Italy, Marinangeli 2012 4094 1.26% 7.0 42.9% Acid+Neut+ico
Scotland, Petrie 2016
Dutch EPS registry 2017
1238 2.8%
0.14
13.6 57.1%
48%
Acid
Pediatric Japan, Hoshii 2000 687 1.6% 27% Acid
EU, Shroff 2013 1472 1.5% 8.7 13.6% Acid+Neut+ico
Italy, Vidal 2013 712 1.9% 43% Acid+Neut+ico
Prospective Japan, Kawanishi 2004 1958 2.5% 3.18 38% Acid
Japan, Nakayama 2014 1338 1.0% 2.3 21.4% Neut+ico
Multicenter prospective observation study in Japan EPS study in, JAPAN Kawanishi H et al., AJKD 2004; 44:729-37
1999 – 2003, 1958 in 57center
PD duration:114.3±44.1, Acidic conventional PDF
EPS:48 (2.5%), 3.18/1,000py, after withdrawal PD 33 (68.8%)
Time on PD
< 3 years
3 to < 5 years
5 to < 8 years
8 to < 10 years
10 to 15 years
>= 15 years
Total
EPS cases (%)
0
4 (0.7%)
12 (2.1%)
14 (5.9%)
13 (5.8%)
5 (17.2%)
48 (2.5%)
Mortality (%)
-
0 (0%)
1 (8.3%)
4 (28.6%)
8 (61.5%)
5 (100%)
18 (37.5%)
≥10 years: incidence rate 7.1%,
mortality rate 72%
Acidic PDF
Multicenter prospective observation study in Japan EPS study in, JAPAN Kawanishi H et al., AJKD 2004; 44:729-37
The risk of EPS was high in patients on PD for 8 years or longer.
Acidic PDF
Acidic PDF
Acidic vs Neutral PDF in prospective observation study Acidic, Kawanishi
AJKD 2004
Neutral (NEXT-PD)
PDI 2014
Facility/patients 57/ 1958 55/ 1338
Follow 4ys 4ys
PD durations 114.3±44.1 67.3±18.8
EPS, /1,000 p.y 48 (2.5%), 3.18/1,000py 14 (1.0%), 2.3/1,000py
after withdrawal 33 (68.8%) 3 (21.4%)
EPS grade III I: 9, II: 4, III: 1
Recovery of
symptoms
non 11 (78.6%)
Mortality EPS related 37.5% all-cause 35.7%, EPS
related 21.4%
Neutral, Low GDP solution may be prevented EPS
EPS
Surgical Treatment for Encapsulating
Peritoneal Sclerosis: 24 Years’ Experience
”Submitted to PDI"
2008/7/1 Before After surgery
EPS Surgical case from 1993 to 2017 Cases 243, Total surgeries 318 times
0
5
10
15
20
25
30
35
40
93 94 95 96 97 98 99 2000 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 year
Case
First surgery
Re-surgery
0
5
10
15
20
25
30
35
40
93 94 95 96 97 98 99 2000 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
EPS Surgical case from 1993 to 2017 Cases 243, Total surgeries 318 times
year 1980
First EPS by PD
Gandhi VC
Arch Intern Med 1980
0
5
10
15
20
25
30
35
40
93 94 95 96 97 98 99 2000 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
year
EPS Surgical case from 1993 to 2017 Cases 243, Total surgeries 318 times
1980
First EPS by PD
Gandhi VC
EPS survey in Japan
AJKD 1996
0
5
10
15
20
25
30
35
40
93 94 95 96 97 98 99 2000 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
year
EPS Surgical case from 1993 to 2017 Cases 243, Total surgeries 318 times
1980
First EPS by PD
Gandhi VC
Consensus
meeting in Japan EPS survey in Japan
0
5
10
15
20
25
30
35
40
93 94 95 96 97 98 99 2000 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
year
EPS: Surgery
from 1993 to 2016, Twenty four years
Cases 236, Total surgeries 310 times
1980
First EPS by PD
Gandhi VC
Consensus
meeting in Japan EPS survey in Japan
ISPD Ad Hoc
Committee, Chicago,
December 10-11,
1998
ISPD Ad Hoc Committee, Chicago, December 10-11, 1998
PDI 2000; 20 suppl 4, S43-S55
Sclerosing encapsulating peritonitis (SEP)
Encapsulating peritoneal sclerosis (EPS)
0
5
10
15
20
25
30
35
40
93 94 95 96 97 98 99 2000 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
year
EPS: Surgery
from 1993 to 2016, Twenty four years
Cases 236, Total surgeries 310 times
1980
First EPS by PD
Gandhi VC
Consensus
meeting in Japan EPS survey in Japan
ISPD Ad Hoc
Committee, Chicago,
December 10-11,
1998
Prospective survey
AJKD 2004
AJKD2004
0
5
10
15
20
25
30
35
40
93 94 95 96 97 98 99 2000 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
year
EPS: Surgery
from 1993 to 2016, Twenty four years
Cases 236, Total surgeries 310 times
1980
First EPS by PD
Gandhi VC
Consensus
meeting in Japan EPS survey in Japan
ISPD Ad Hoc
Committee, Chicago,
December 10-11,
1998
Prospective survey
AJKD 2004
Encapsulating
Peritoneal
Sclerosis in Japan,
PDI2005
0
5
10
15
20
25
30
35
40
93 94 95 96 97 98 99 2000 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
year
EPS: Surgery
from 1993 to 2016, Twenty four years
Cases 236, Total surgeries 310 times
1980
First EPS by PD
Gandhi VC
Consensus
meeting in Japan EPS survey in Japan
ISPD Ad Hoc
Committee, Chicago,
December 10-11,
1998
Prospective survey
AJKD 2004
Encapsulating
Peritoneal
Sclerosis in Japan,
PDI2005
Definition of EPS
0
5
10
15
20
25
30
35
40
93 94 95 96 97 98 99 2000 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
year
EPS: Surgery
from 1993 to 2016, Twenty four years
Cases 236, Total surgeries 310 times
Prevention of EPS
~2000, Low GDF PDF
Lactate-Low GDP
0
5
10
15
20
25
30
35
40
93 94 95 96 97 98 99 2000 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
year
EPS: Surgery
from 1993 to 2016, Twenty four years
Cases 236, Total surgeries 310 times
Prevention of EPS
~2000, Low GDF PDF
Prospective survey of Low GDP
NEXT-PD, PDI 2014
0
5
10
15
20
25
30
35
40
93 94 95 96 97 98 99 2000 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
year
EPS: Surgery
from 1993 to 2016, Twenty four years
Cases 236, Total surgeries 310 times
My personal experience:
Small solute ⇒Large solute ⇒Low albumin
JSDT1993
Small solute
Large solute
sAlb
Three pore theory, Rippe B, Blood purif 1992
Small pore
Large pore
Increase of permeability of
Small solute
Large solute permeable
Protein permeable
Lower albuminemia
Bengt Rippe, pass away October 19 2016 1950-2016
3rd ACM-ISPD 2007
After 3 months, 1st EPS surgery, Oct/93
Three pore theory, Rippe B, Blood purif 1992
Small pore
Large pore
Increase of permeability of
Small solute
Large solute permeable
Protein permeable
Lower albuminemia
Increase Fibrin permeable
EPS
Inflammation
Surgery for EPS was contraindication in 1990’s
Most patients treated surgically died due to technical
complications. These deaths occurred by anastomosis failure
because the pathogenesis of EPS was not well understood by
surgeons, and, in many cases, simple resection of adherent
intestinal loops with enteroanastomosis was performed.
However, the final option for patients in whom bowel
obstruction symptoms fail to improve is surgical enterolysis,
0
5
10
15
20
25
30
35
40
93 94 95 96 97 98 99 2000 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
year
EPS: Surgery
from 1993 to 2016, Twenty four years
Cases 236, Total surgeries 310 times
Presentation of EPS surgery
EPS surgery MAP
EPS surgery in Germany Latus J et al., NDT 2013; 28:1021-30
Severe (bowel obstruction) EPS 31 case to Surgical enterolysis.
Mortality 10 cases (32.2%) of 45.6 months
Post-op EPS: 4 case, Other 4 cases, Unknown 2 cases
Surgical cases
(Non-surgical)
EPS surgery in UK Campbell R, Augustine T et al., PDI 2014; doi:10.3747/pdi.2013.00098
Central Manchester University
2007-2010: EPS surgery 51 cases
Mortality 35%
Dutch EPS registry Betjes MH et al., PSI 2017; 37:230-242
2009-2015, EPS 53pts (post Tx 28.3%), 0.85%⇒0.14%
Treatment
Tamoxifen
Surgery
Prednisone
EPS surgery in Japan Japanese renal data registry (JRDR), end of 2015
Anamnestic history of EPS
Anamnesis of EPS
5.2%
Steroid therapy
86.5%
Surgery therapy
79.5%
yes yes
Clinical Practice GL PD in Adults and Children, The National Institute for Health and Care Excellence (NICE), June 2017
Guideline 7.2.1 – PD : Encapsulating Peritoneal Sclerosis: Management
• We recommend that patients with EPS should be referred or discussed
early with units who have expertise in EPS surgery. Surgery should be
performed by teams experienced in EPS surgery (GRADE 1B).
ISPD-GL
• It must be stated, though, that for surgical results to be successful, the
surgical team must have a thorough understanding of the pathology of
EPS. Such surgery should therefore only be done in specialist regional
centers that can provide appropriate surgical training and patient support.
Indication of surgery for EPS
Severe bowel obstruction: risk of bowel perforation
Malnutrition
Repeated obstruction symptoms
Jejunostomy Death
Time on PD 234 months
Scheme of EPS surgery
• Total enterolysis +
• Confirmation by Miller-Abbott’s Ileus tube
• Noble’s plications
Conventional
• +Jejuno-colostomy Sever obstruction
• Decompression by Percutaneous endoscopic gastrostomy (PEG)/PEG-J + home-TPN
Conservative
EPS surgery, Intestine cocooned
EPS surgery Peritoneal adhesions by repeated lysis of fibrin membranes
with a sharp instrument
EPS surgery Cut the fibrin membrane
EPS surgery Adhesiolysis of the mesenteric side is performed first, and
finally, encapsulated intestinal loops are lysed.
EPS surgery To identify the site of stenosis and/or injury part of intestine,
we have been inserting an Miller-Abbott’s ileus tube
balloon
EPS recurrent after surgery Probability of remaining EPS recurrence free
0
.2
.4
.6
.8
1 E
PS
rec
urr
ence
fre
e
0 20 40 60 80 100 120 140 160 180
Follow up (months)
1yr 22%
Enterolysis only:106
Recurrence:30 (28.3%)
Prevention of re-obstructive symptoms (recurrent)
Fixation of small bowel after adhesiotmy
Noble’s plication methods: Suture of small bowel
Noble TB, Am J Surgery 1937: 35, 41
KH, PD duration 115 m; Noble’s plication method
Treitz’s ligament
Ileum end
The prevents of passage disturbance and
escape into and adhesion in the pelvic
cavity
In the cases of risk of re-adhesion and/or Incomplete
enterolysis ; Side to side Jejuno-colostomy
Side to side Jejuno-colostomy
Incomplete enterolysis
Calcification
HK, PD duration 132 m
Side to side Jejuno-colostomy
EPS surgical video, HI, 2016/1/19
PD duration : 116 months, EPS caused by peritoneal sclerosis
EPS : 113 months after catheter, Operation : 12.8 months after EPS
Acidic ⇒ Neutral PDF
EPS surgical video, HI, 2016/1/19
PD duration : 116 months, EPS caused by peritoneal sclerosis
EPS : 113 months after catheter, Operation : 12.8 months after EPS
Acidic ⇒ Neutral PDF
石原
Survival of the EPS surgery, Cases 243, Total surgeries 318 times
1 2 3 5 8 years
Actuarial survival 91 83 77 66 53 %
Mortality EPS related death 5 10 13 20 28 %
Survival rates after diagnosis
0.0
0.2
0.4
0.6
0.8
1.0
0 24 48 72 96 120 144 168 192 216 240 264 288
Cu
mu
lati
ve
surv
ival
Time after diagnosis (months)
All cause death
EPS related death
Assessment of severity of intestinal damage The peritoneal calcification grade on CT
Grade 1<50% Grade 2 50-80% Grade 3 ≥80%
Grade 1 Grade 2 Grade 3
Assessment of severity of intestinal damage Degeneration/deterioration grade of small intestinal wall Grade 1: mild abnormal and soft; Grade 2: whole circumference/partial degeneration in several part, especially in the ileum; Grade 3: highly degenerated in almost all aria, Upper figure; before enterolysis, lower figure; after enterolysis
Kaplan-Maier survival analysis for assessment of severity of intestinal damage
Mortality curve for EPS-related death,
a) evaluation of peritoneal calcification grade (log rank test, grade 1 and 2, p<0.0015, grade 1 and
3, p<0.0065), G1:169, G2:27, G3:47
b) evaluation of degeneration grade of small intestinal wall, (log rank test, grade 1 and 2,
p<0.0452, grade 1 and 3, p<0.0008, grade 2 and 3 p<0.0058). G1:34, G2:163, G3:46
0
0.2
0.4
0.6
0.8
1.0
0 48 96 144 192 240 288 Time after diagnosis (months)
Peritoneal calcification, grade
Cu
mu
lati
ve
surv
ival
Grade 1
2 3
0 48 96 144 192 240 288 0
0.2
0.4
0.6
0.8
1.0
Time after diagnosis (months)
Degeneration of intestinal wall, grade
Cu
mu
lati
ve
surv
ival
Grade 1
2
3
Conclusion
EPS surgical experience and outcomes during 24 years in a
single center were reported; patients who undergo the
surgery showed better outcomes.
The increase in surgical treatment rate in the world promoted
improvements in countermeasures against and better
understanding of EPS.
Currently, EPS is no longer recognized as a fatal
complication.
Acknowledgment
Prof, Yoshindo Kawaguchi Prof Dimitrios Oreopoulos, Pass away April 2012
Prof Anders Tranæus, Pass away August 2015
EPS is no longer
recognized as a fatal complication.
Thank you for your attention