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Introduction: End stage renal disease ESRD ; under peritoneal dialysis PD ; predisposes patients to a number of distinctive surgical situations witch may be related to complications of the dialysis procedure itself or may result from another abdominal pathology, unrelated to PD. Peritonitis are a major life-threatening problem and those failing to respond to treatment represents a real challenge for the medical teams. The objective of our study was to point out the peculiar aspects of surgical peritonitis under PD and the remarkable importance of a correct operative behaviour regarding ESRD patients. Methods We have analysed prospectively the peritonitis episodes under PD assessed by our surgical team between January 1995 and January 2007 regarding the etiology, clinical features, microscopy and culture of drained dialysate, ultrasound and CT scan exams, laparoscopic diagnosis and medical treatment. Results The incidence of peritonitis due to abdominal pathology unrelated to PD was low in 11 years there were 7 versus 423 "catheter-related" episodes ; but every case was a diagnosis challenge and predisposed to gross therapeutical errors due to the modified simptoms under the initial medical treatment. The effect of the peritoneal antibiotic lavage on primary inflammatory focus represented a partial treatment in the absence of a gross fecal contamination. Sometimes the aspect of the dialysate and lab findings suggested a digestive lesion. Ultrasound and CT scan were less sensitive; negative studies never exclude an abdominal severe disease and should not lead to delay in emergency laparotomy. Conclusion Any delay in diagnosis and definitive treatment of surgical peritonitis under PD gives an extremely high mortality rate; earlyest surgery offers the best chance of success. The close collaboration between the nephrology and surgical teams and a common protocol for etiological diagnosis and adequate treatment of peritonitis under PD are mandatory.

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