Repeat Exploratory Laparotomy for Encapsulating Peritoneal Sclerosis

Encapsulating peritoneal sclerosis (EPS), also known as encapsulating sclerosing peritonitis, represents a severe and potentially life-threatening complication primarily associated with long-term peritoneal dialysis (PD).¹ This rare but serious condition is characterized by the formation of a thick, fibrotic layer encasing the small bowel, that can ultimately cause mechanical bowel obstruction with associated high mortality rates.²

The pathophysiology involves an inflammatory process that triggers excessive fibrin deposition and collagen production, resulting in the development of a thick, cocoon-like membrane around the intestines. The incidence of EPS demonstrates a positive correlation with the duration of peritoneal dialysis exposure, with reported rates ranging from 0.7–3.3% among long-term PD patients.³

Glucocorticoids, azathioprine, mTOR inhibitors (sirolimus, everolimus), and tamoxifen can be used to treat EPS in the long term.

However, if a patient experiences an acute obstruction that does not respond to nasogastric decompression and IV hydration, surgical intervention becomes necessary.^4–6 Surgery presents significant challenges due to the extensive thick adhesions that characterize EPS.

The complexity of surgical management is further compounded by several factors:

• High risk of bowel injury during adhesiolysis with the potential for missed enterotomies.
• Comorbid end-stage renal disease and malnutrition.
• Risk of postoperative complications including bleeding, intra-abdominal infection, enteric fistulae, and prolonged paralytic ileus.

This video introduces a complex case of EPS. The patient, suffering from multiple comorbidities, including end-stage renal disease (now managed with hemodialysis) and myasthenia gravis, presents additional challenges. Initially treated at another hospital, the patient was transferred to Mass General for a more specialized surgical approach. Surgery was performed early, within three days of the patient's last surgery, to minimize the chance of additionaladhesions developing in the interim.

Surgical planning for this condition involves a detailed review of CT scans to locate the bowel obstruction, often in collaboration with a radiologist. A thorough informed consent process is critical, as the surgery carries high risk. While laparoscopic approaches may be considered in select cases, the extensive nature of the disease often requires conversion to open laparotomy for adequate treatment.

The surgical procedure began with a preoperative timeout, followed by a laparotomy. Throughout the procedure, the tissue planes were meticulously located and freed. The key challenge was distinguishing tissue layers and carefully separating the sclerotic rind from the bowel. Bleeding sites were controlled, and saline irrigation was used to clarify the tissue structures.

Adhesions to the anterior abdominal wall were progressively lysed, which was particularly challenging where the bowel itself was densely adherent to the posterior rectus sheath.

The primary focus in the next phase was on removing the thick capsule characteristic of sclerosing peritonitis, which had densely encapsulated the bowel. As much of the capsule as possible was attempted to be peeled off by the surgeon, particularly in the right lower quadrant where the bowel obstruction was most pronounced. Special attention was given to avoid damaging surrounding structures, which might be adherent to the fibrotic tissues. Progress was made slowly but steadily, with repeated checks to ensure that the bowel was safely separated from the overlying tissue.

Continued separation of adhesions revealed dilated bowel loops which were adherent to the capsule and to one another. Using meticulous technique, the adhesions were dissected, nearing the obstruction site. The site of bowel obstruction was finally exposed by the surgical team, and it was noted that a twisted, thickened band appeared to be contributing to the blockage.

Following lysis of this band, it was then decided that the appendix, appearing injured and ischemic, would be removed. A purse-string suture was created around the appendix base, which was then ligated and removed.

A thorough inspection of the bowel was conducted to identify any missed injuries.

An interrupted, imbricating suture repair was performed to repair a suspected colonic serosal tear. This closure provided structural reinforcement without undue narrowing, ultimately producing a satisfactory result.

The abdomen was irrigated, and absorbable hemostatic powder was applied for hemostasis, especially around raw surfaces showing minor oozing. An overall check confirmed no other injuries and good hemostasis.

The procedure duration was 210 minutes and estimated blood loss was 400 cc. Two specimens were sent to pathology: the appendix and a sample of the fibrotic capsule. The fibrotic capsule was characterized as dense fibrous tissue with chronic and active inflammation. The appendix was described as having fibrous obliteration of its lumen and serosal adhesions.

The patient was advanced to a clear liquid diet on postoperative day 5 and to a soft diet on postoperative day 6. On postoperative day 8, the patient developed a worsening leukocytosis and had increased tenderness to palpation, and so a CT scan was performed which was concerning for free fluid and small locules of free air in the peritoneal cavity. He was taken back to the operating room for re-exploration. A small volume of hemoperitoneum was found. No missed enterotomies were discovered and the cecal repair was robust and so the abdomen was closed again without intervention. He was started on total parenteral nutrition while awaiting return of bowel function. By postoperative day 9 counting from his second surgery at our institution, he was again tolerating a soft diet. He was discharged home three days later. He had a brief readmission for a recurrent small bowel obstruction one month later, but was discharged after two days, following a reassuring gastrograffin challenge and return of bowel function.

This video is an in-depth demonstration of a complex surgical case involving a repeat exploratory laparotomy for bowel obstruction, with a focus on careful dissection of adhesions, managing serosal tears, and ensuring hemostasis. It is particularly valuable for surgeons, surgical trainees, and medical professionals specializing in emergency abdominal surgery.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.