RESUMO
BACKGROUND: The optimal methodology of establishing access for peritoneal dialysis (PD) remains controversial. Previously published randomized controlled trials and cohort studies do not demonstrate an advantage for 1 technique over another. Four published meta-analyses comparing outcomes of laparoscopic versus open PD catheter (PDC) insertion have given inconsistent conclusions and are flawed since they group basic and advanced laparoscopy together. The aim of this systematic review and meta-analysis is to examine whether advanced laparoscopic interventions consisting of rectus sheath tunneling and adjunctive procedures produce a better outcome than open insertion or basic laparoscopy used only to verify the catheter position. METHODS: A literature search using Medline, Embase, and Cochrane Database was performed, and meta-analysis was performed using RevMan 5.3.5 software (Nordic Cochrane Centre, The Cochrane Collaboration, London, UK). Outcomes evaluated incidence of catheter obstruction, migration, pericannular leak, hernia, infectious complications (peritonitis and exit-site infection) and catheter survival. RESULTS: Of the 467 records identified, 7 cohort studies, including 1,045 patients, were included in the meta-analysis. When advanced laparoscopy was compared with open insertion, a significant reduction was observed in the incidence of catheter obstruction (odds ratio [OR] 0.14, 95% confidence interval [CI] 0.03 - 0.63; p = 0.01), catheter migration (OR 0.12, 95% CI 0.06 - 0.26; p = 0.00001), pericannular leak (OR 0.27, 95% CI 0.11 - 0.64; p = 0.003), and pericannular and incisional hernias (OR 0.29, 95% CI 0.09 - 0.94; p = 0.04), as well as better 1- and 2-year catheter survival (OR 0.52, 95% CI 0.28 - 0.97; p = 0.04 and OR 0.50, 95% CI 0.28 - 0.92; p = 0.03, respectively). Compared with basic laparoscopy, catheter obstruction and migration were significantly lower in the advanced laparoscopic group, whereas catheter survival was similar in both groups. All outcomes, except catheter obstruction, were similar between the basic laparoscopy and open insertion. The infectious complications such as peritonitis and exit-site infections were similar between the 3 groups. CONCLUSIONS: Advanced laparoscopy was associated with a significant superior outcome in comparison with open insertion and basic laparoscopy.