Stesura Seveso Archivio Italiano di Urologia e Andrologia 2023; 95(4):12049 1 SYSTEMATIC REVIEW hemodialysis, PD has the advantage to be performed in a continuous ambulatory setting, called Continuous Ambulatory Peritoneal Dialysis (CAPD). Other advantages are less risk to induce hemodynamic instability due to less pro-inflammatory effect involved with the procedure, pro- viding nutritional support via dextrose in the dialysate, lower cost in long-term treatment due to minimal hospital visits or home-care hemodialysis, especially in a remote or rural setting where long-term dialysis is hardly obtained (2- 4). The mortality risk for patients treated with PD is better than with hemodialysis in the short-term and long-term survival is better (1). Even though CAPD treatment was less common than hemodialysis, CAPD has recently become the preferred mode of treatment for pediatric patients with ESRD (1, 5). Despite these facts, CAPD is related to several mechanical complications related to catheter placement, including catheter obstruction by omentum, clot, or fibrin, and catheter migration out of the pelvis. Other complications are hypoalbuminemia, hyperglycemia, and infection, which can lead to peritonitis. All complications can lead to catheter failure, needing catheter removal or reinsertion (2, 6). According to ISPD Guidelines, the insertion of catheters in pediatric patients had an 18% of complication rate, including peritonitis, block of catheter, and catheter leakage (7). The omentectomy procedure, partial or total, was hypothesized for lowering the complication incidence. However, the role of the omentectomy procedure on CAPD catheter placement in pediatric patients has been different- ly evaluated in the literature, with some studies showing improvement while others showing no difference (6, 8-11). Our study aims to define the advantages of omentectomy as a prophylactic procedure in pediatric patients. METHODS The systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta- Analysis (PRISMA) (12). Our protocol was registered in the PROSPERO database (CRD42023412846). Introduction: The role of the omentectomy procedure on Continuous Ambulatory Peritoneal Dialysis (CAPD) catheter placement in pediatric patients has been differently evaluated in the literature, with some studies showing improvement while others showing no dif- ference. Our study aims to define the advantages of omentectomy compared to a procedure without omentectomy. Methods: The literature searching in online databases (PubMed/MEDLINE, Cochrane Library, EMBASE, Scopus, and ClinicalTrial.gov) following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, has been registered on PROSPERO (CRD42023412846). The proto- col was performed through April 2023 and focused on pediatric patients treated with an omentectomy procedure and related complications. The risk of bias in each study was assessed using the risk of bias for the non-randomized control trials (ROBINS-I). The effect estimates were extracted as risk ratios with 95% confi- dence intervals (CI). The heterogeneity of the studies was consid- ered as high heterogeneity if I2 values above 50% or p < 0.05. Results: In the total of 676 articles identified in the database searching for screening, nine studies with 775 patients met the criteria for inclusion. The omentectomy procedure significantly showed a lower incidence of catheter obstruction compared to the control group, (OR 0.24 [95% CI, 0.12-0.49], p < 0.0001, I2 = 0%). Moreover, omentectomy demonstrated a similar trend in the rate of removal or reinsertion of the catheter with high hetero- geneity, OR 0.25 [95% CI, 0.12-0.51), p = 0.0002, I2 = 70%). Conclusions: The omentectomy procedure showed a lower inci- dence of catheter obstruction and complications leading to removal or reinsertion of the catheter. KEY WORDS: Continuous ambulatory peritoneal dialysis; Omentectomy; Omental procedure; Pediatric; Renal failure; Complication. Submitted 5 November 2023; Accepted 11 November 2023 INTRODUCTION Renal replacement therapy for pediatric patients with end- stage renal disease (ESRD) can be through both peritoneal dialysis (PD) and hemodialysis modalities (1). Compared to The prophylactic omentectomy procedure in reducing the complication rate of continuous ambulatory peritoneal dialysis in pediatric: A systematic review and meta-analysis GedeWirya Kusuma Duarsa 1, Ronald Sugianto 2, Pande Made Wisnu Tirtayasa 3, Ni Made Apriliani Saniti 4, Komang Harsa Abhinaya Duarsa 5 1 Department of Urology, Faculty of Medicine, Universitas Udayana, Prof. Dr. I.G.N.G Ngoerah General Hospital, Bali, Indonesia; 2 Medical Doctor Study Program, Faculty of Medicine, Universitas Udayana, Bali, Indonesia; 3 Department of Urology, Faculty of Medicine, Universitas Udayana, Universitas Udayana Teaching Hospital, Bali, Indonesia; 4 Department of Surgery, Faculty of Medicine, Universitas Udayana, Prof. Dr. I.G.N.G Ngoerah General Hospital, Bali, Indonesia; 5 Undergraduate Medical Doctor Study Program, Faculty of Medicine, Universitas Udayana, Bali, Indonesia. DOI: 10.4081/aiua.2023.12049 Summary Archivio Italiano di Urologia e Andrologia 2023; 95(4):12049 G.W. Kusuma Duarsa, R. Sugianto, P.M.W. Tirtayasa, et al. 2 Search strategy According to the PRISMA statement, the systematic search was conducted in electronic databases, including PubMed/MEDLINE, Cochrane Library, EMBASE, Scopus, and ClinicalTrial.gov for studies published until April 2023. The literature search included the following terms: (peritoneal dialysis[MeSH Terms]) OR continuous ambu- latory peritoneal dialysis[MeSH Terms] OR (peritoneal dialysis[Title/Abstract] OR continuous ambulatory peri- toneal dialysis[Title/Abstract] OR catheter dialysis [Title/Abstract] OR CAPD[Title/Abstract]) AND (omen- tum[MeSH Terms] OR bursa, omental[MeSH Terms] OR omentectomy[Title/Abstract] OR omental procedure [Title/Abstract] OR omentum procedure[Title/Abstract]). Eligibility criteria For the systematic review, we included studies reporting about pediatric patients, below 18 years old, diagnosed with the end-stage renal disease treated by CAPD. The exclusion criteria were studies that did not compare the outcome or report a comparative outcome without any data on omentectomy. Review articles, case reports, case series, animal studies, and editorial articles were not eli- gible for this study. The literature screening was done for the article in English only. Study selection Two author reviewers, at least one specialized in pediatric urology, independently evaluated the citations and abstracts. Each reviewer iden- tified article titles relevant to the topic. The selection processes of the study initiate with assessing the clarity of the eligibility criteria and the consistency of each author's decisions. The literature was screened by two reviewers inde- pendently (G.W.K.D. and R.S.) for the study's eligibility. First, the studies were screened by the title and the abstract, then they proceeded to full-text screening. In case of disagreement with the study selection, a third author (P.M.W.T) helped to solve controversies. Data extraction One reviewer conducted data extraction, while another double-checked it to tabulate the necessary data for each study. Data were extracted by two reviewers (G.W.K.D. and R.S.) from all the included studies, including the first author's name, publication date, place were studies were performed, sample mean age, sex, surgical procedure, complica- tion rate (including catheter malposition, migrating catheter, catheter failure, catheter leakage, bleeding, and peritonitis). Catheter failure was defined as the complication of CAPD that needed the removal or re-insertion of the catheter, while catheter obstruction was defined as the occlusion of the catheter due to omental wrapping or fibrin deposition. Risk of bias assessment The risk of bias assessment of included stud- ies was evaluated with the risk of bias in non-randomized studies of interventions (ROBINS-I) tool by two reviewers (13). Based on the eligibility of the information, the study was classified as low, moderate, serious, or critical for each domain. In case of discrepancies in the scores, the reviewers discussed to define a mutually accepted score. Statistical analysis All dichotomous outcomes of retrospective studies were estimated as odd ratios (OR) with 95% confidence intervals (CI). When the heterogeneity of the studies showed a p value < 0.05, the random-effects model will be used for the calculation. The meta-analysis data were presented as a Forest plot using the RevMan version 5.4 application. RESULTS A total of 676 articles were identified in the database searching for screening. After duplicate removal and 573 studies were screened by title and abstract. Out of them 27 studies were identified as potentially eligible studies and assessed by full-text for eligibility. Nine studies (14-22) including 775 patients met the criteria for inclusion, as shown in Figure 1. Figure 1. Literature Search and Selection Flow Chart. Archivio Italiano di Urologia e Andrologia 2023; 95(4):12049 3 Peritoneal dialysis with omentectomy in pediatric patients Four studies were conducted in America, three in Europe, one in Africa, and another in Asia. The characteristics of included studies are summarized in Table 1. The risk of bias assessment showed that all included stud- ies have a serious bias, as shown in Table 2. The funnel plot used to assess the publication bias and heterogeneity Table 1. Characteristics study and profile patient of the included studies. Author Location Study Total Age Sex Operation Complication Catheter surgery patients (year) (Gender, %) technique survival time Ahmed, 2012 (14) Saudi Arabia Retrospective 31 3.8 ± 6.5 Male, 55 Open Laparotomy Peritonitis N/A Review Female, 45 Catheter Occlusion by omentum Catheter Malposition Catheter leakage Cribs, 2012 (15) USA Retrospective 81 12 Male, 56 Laparoscopy and Catheter Occlusion omentum and fibrin plug 177 ± 204 days Review Female, 44 Open Approach Dialysate Leakage Perforation Ladd, 2011 (16) USA Retrospective 163 6.3 ± 5.6 Male, 49.1 Laparoscopy and Catheter Occlusion by omental wrapping, 759 days Review Female, 50.9 Open Surgery fibrin plug for omentectomy Peritonitis 198 days Catheter Malposition for non-omentectomy Dialysate Leakage Intestinal Perforation Catheter Disruption LaPlant, 2018 (17) USA Retrospective 153 4 ± 5.3 N/A Open and Catheter Leakage 585 days, Review Laparoscopy Surgery Infection range 36–2872 days Adhesion Catheter Migration Ventral Hernia Macchini, 2006 (18) Italy Retrospective 78 6.3 ± 6.1 Male, 61.5 Open Technique Infection 80% > 12 months Review Female, 38.5 Inguinal Hernia 62% > 24 months Catheter Dislocation 58% > 48 months Catheter Obstruction by intestinal organs Catheter Leakage Numanoglu, 2008 (19) South Africa Prospective 26 8.6 Male, 53.8 Laparoscopy Technique Catheter Obstruction by fibrinous adhesion, 6.4 ± 6.3 months Cohort Female, 46.2 fimbria, sigmoid colod, omentum Catheter Leakage Bleeding Displacement Infection Schuh, 2021 (20) USA Retrospective 184 7.4 (0.27-14.7) Male, 62.5 Open and Laparoscopy Mechanical Failure 39 days (17-112) Review Female, 37.5 technique Infection Catheter Migration Catheter Leakage Pumford, 1994 (21) United Kingdom Retrospective 21 1-10 (range) Male, 47.6 Mini-Laparotomy Catheter obstruction N/A Review Female, 52.4 Lewis, 1995 (22) United Kingdom Retrospective 38 7.8 N/A Mini Laparotomy Catheter obstruction by omentum N/A Review Peritonitis Appendicitis N/A: not available. Data are expressed as mean ± standard deviation or median (min-max interquartile range) or count %, as appropriate. Table 2. Risk of Bias Assessment. Study Design Bias Bias in selection Bias in Bias due to Bias due Bias in Bias in Overall due to of participants measurement departures from to missing measurement selection of the bias confounding into the study of interventions intended interventions data of outcomes reported result Ahmed 2012 Retrospective Review Serious No Information Serious Moderated Low Moderated Moderated Serious LaPlant 2018 Retrospective Review Serious Serious Serious No Information Low Moderate Moderate Serious Ladd 2011 Retrospective Review Serious Serious Serious Moderated Moderated Serious Serious Serious LaPlant 2018 Retrospective Review Serious Serious Serious No Information Low Moderate Moderate Serious Manchini 2006 Retrospective Review Serious No Information Moderate Low Low Moderate Moderate Serious Numanoglu 2008 Prospective Cohort Serious No Information Serious Moderate Low Moderate Serious Serious Schuh 2021 Retrospective Review Serious Moderate Moderate Moderated Moderate Moderated Moderated Serious Pumford 1994 Retrospective Review Serious Serious Serious No Information No Information Serious Moderate Serious Lewis 1995 Retrospective Review Serious Serious Serious No Information No Information Serious Serious Serious Archivio Italiano di Urologia e Andrologia 2023; 95(4):12049 G.W. Kusuma Duarsa, R. Sugianto, P.M.W. Tirtayasa, et al. 4 is presented in Figure 2. The meta-analysis was assessed for four comparative outcomes: complications leading to removal or reinsertion, catheter obstruction, infections, and catheter leakage. Among 339 patients in four studies, the omentectomy pro- cedure significantly showed a lower incidence of catheter obstruction compared to the control group (OR 0.24 [95% CI, 0.12-0.49], p < 0.0001, I2 = 0%) as in the Forest plot shown in Figure 3A (16, 18, 21, 22). Moreover, omentec- tomy demonstrated a similar trend for removal or reinser- tion of the catheter in five studies, including 685 patients, with high heterogeneity (OR 0.25 [95% CI, 0.12-0.51), p = 0.0002, I2 = 70%). Forest plot is shown in Figure 3B (14-17, 19, 20). The complication of peritonitis and catheter leakage were reported only in two studies for each complication (16, 17, 22). In contrast, the analysis of both complications demonstrated insignificant results with no heterogeneity Figure 3. Forest plot pooled effect estimated showed statistical significance. A) Omentectomy showed a lower incidence of complications lead to catheter removal in pediatric patients; B) Omentectomy showed a lower incidence of complication specific to catheter obstruction compare than without performing omentectomy. Figure 2. Funnel Plot showing that the analysis of removal or reinsertion and leakage of the catheter has high heterogeneity. Archivio Italiano di Urologia e Andrologia 2023; 95(4):12049 5 Peritoneal dialysis with omentectomy in pediatric patients found (p-value heterogeneity > 0.05). The omentectomy procedure has a insignificantly lower incidence of infec- tions leading to peritonitis (OR 0.61 [95% CI, 0.28-1.34], p = 0.22, I2 = 73%), as shown in Forest plot in Figure 4A. The omentectomy procedure showed a insignificantly higher incidence of catheter leakage compared to CAPD without omentectomy (OR 1.55 [0.70-3.45], p = 0.28, I2 = 0%), as shown in Forest plot in Figure 4B. DISCUSSION In pediatric renal replacement therapy, CAPD is the pre- ferred treatment option which can be performed at home by low-trained caregivers without routinely visiting the hospital. To reduce the complication of CAPD, catheter insertion and the improvement in out-hospital care are essential (23). The catheters used for PD are varied, includ- ing rigid catheters, Tenckhoff catheters, which consist of straight, swan neck, or coiled, and adapted catheters, either from nasogastric tube, surgical drain, or dialysis catheter. However, the most preferred catheter in CAPD is a flexible cuffed, single or double cuffed, catheter, which can be placed through laparoscopic surgery, open surgery, or the Seldinger technique (a guidewire technique under local anesthesia). The omentectomy procedure can be per- formed only in surgical insertion, either laparoscopic or open technique (2, 23). Despite the catheter variability and differences in insertion methods, the comparison of differ- ent types and different techniques did not affect the com- plication rate of CAPD (24, 25). The complication of CAPD catheter may lead to PD fail- ure, which prompts catheter removal/reinsertion or return to hemodialysis. The most common causes of CAPD fail- ure are catheter-related infection and malfunction (26). However, most infectious complications, catheter-related or peritonitis, resolve with conservative treatment, while the catheter obstruction, due to omental blockage, fibrin blockage, clot blockage, or catheter migration with obstruction, may necessitate removal or replacement (10). Even if catheter-related infections and peritonitis can be resolved by medication, peritonitis is the more common cause of catheter revision in the first year of treatment (27). The study by Phan et al. demonstrated that non- omentectomy catheter insertion was associated with a high re-operative rate for infection and malfunction (25). Therefore, the malfunction of the catheter, related to obstruction and catheter migration, often leads to catheter failure (7). Moreover, pediatric patients have thinner abdominal mus- cle layers compared to adults making it difficult to affix the catheter in place, but it helps prevent catheter tip movement and catheter liquid leakage to the skin. These differences might contribute to the different complication rates in pediatrics (15).The comparative studies demon- strated that omentectomy is a statistically significant pro- tective factor in ages below one year old to lower the inci- dence of early obstruction. The catheter placement with an omentectomy procedure was postulated as a preventive measure against catheter failure due to fluid entrapment or obstruction (24, 27). In this study, the analysis of odds of catheter failure and catheter obstruction in pediatrics sig- nificantly assessed the advantage of omentectomy proce- dures, which means that omentectomy reduces the risk of catheter failure and catheter obstruction due to omental wrap. The same result was shown in a meta-analysis study by Kim et al. in the general population (28). The current guidelines for PD in pediatrics did not dis- cuss in deepl regarding the effect of omentectomy proce- dures (7, 29, 30). On the contrary, there were several rec- ommendations for successful peritoneal dialysis in infants Figure 4. Forest plot pooled effect estimated showed an insignificant result. A) Omentectomy procedure was compared to non-omentectomy for peritonitis, showing an insignificant different result; B) Odds of catheter leakage was insignificantly higher in patients with omentectomy. Archivio Italiano di Urologia e Andrologia 2023; 95(4):12049 G.W. Kusuma Duarsa, R. Sugianto, P.M.W. Tirtayasa, et al. 6 and children. The most common complication is peri- tonitis, minimalized by prophylactic antibiotics and a downward or lateral exit site placement, appropriate dis- tance from the ostomy site and double-cuffed peritoneal dialysis catheter. For catheter leakage, prevention depend by subcutaneous tissue. Therefore, in infants weighing below 3 kg it is recommended to use a single cuff due to the lack of substantial subcutaneous tissue. The other rec- ommendations are delaying initiation of peritoneal dialy- sis post-catheter insertion for more than 48 hours, using low fill volumes when initiation is started, and using a Tenckhoff catheter (7, 30, 31). Our study meta-analysis is an update on omentectomy outcome, with more specific analysis in pediatric patients. The previous study by Kim et al. has a similar design, but it analyses omental procedures in the general population (27). The limitation of our study is that all included studies were retrospective studies, which are at high risk of bias. Therefore, this study cannot differenti- ate confounding factors that may affect the outcome, including children’s age, weight, type of catheter, surgical techniques (laparoscopic or open surgical), and out-hos- pital care. However, the current literature demonstrated that those confounding factors, except the patient’s age, did not statistically affect the results. Our meta-analysis study brings conclusive finding for controversial advan- tages of the prophylactic omentectomy procedure. Besides, inclusion studies demonstrated a low hetero- geneity, which ascertains the findings of the analysis. The rating of the evidence base of this study according to the GRADE criteria, classified it as moderate (32). Finally, we encourage all academicians to perform further research on the omentectomy procedure, as a mono-factor, to decrease the incidence of CAPD complications. CONCLUSIONS Our meta-analyses demonstrated that the CAPD with omentectomy as prophylactic procedure in pediatrics is advantageous. In fact, although the omentectomy proce- dures might increase the risk of catheter exit leakage (p = 0.28), it significantly showed a lower incidence of catheter obstruction (p < 0.0001, OR 0.24) and compli- cations leading to removal or reinsertion of the catheter (p < 0.0001, OR 0.25). FUNDING STATEMENT Our study received funding from Universitas Udayana in contract no: B/1.683/UN14.4.A/PT.01.03/2023 for the cost of research and publication. REFERENCES 1. Himmelfarb J, Vanholder R, Mehrotra R, Tonelli M. The current and future landscape of dialysis. Nat Rev Nephrol. 2020; 16:573-85. 2. de Galasso L, Picca S, Guzzo I. Dialysis modalities for the man- agement of pediatric acute kidney injury. Pediatr Nephrol. 2020; 35:753-65. 3. Spector BL, Misurac JM. Renal Replacement Therapy in Neonates. NeoReview. 2019; 20:e697-710. 4. Niang A, Iyengar A, Luyckx VA. 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Renal replacement therapies for infants and children in the ICU: Curr Opin Pediatr. 2020; 32:360-6. 32. Guyatt G, Oxman AD, Akl EA, et al. GRADE guidelines: 1. Introduction—GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011; 64:383-94. Correspondence Gede Wirya Kusuma Duarsa (Corresponding Author) gwkurology@gmail.com Department of Urology, Faculty of Medicine, Universitas Udayana, Prof. Dr. I.G.N.G Ngoerah General Hospital, Denpasar, Bali, Indonesia Jl. Sudirman, Denpasar, Bali, Indonesia, 80113 Ronald Sugianto rsugianto@student.unud.ac.id Medical Doctor Study Program, Faculty of Medicine, Universitas Udayana, Bali, Indonesia Pande Made Wisnu Tirtayasa wisnu_tirtayasa@unud.ac.id Department of Urology, Faculty of Medicine, Universitas Udayana, Universitas Udayana Teaching Hospital, Bali, Indonesia Ni Made Apriliani Saniti apriliani.saniti@gmail.com Department of Surgery, Faculty of Medicine, Universitas Udayana, Prof. Dr. I.G.N.G Ngoerah General Hospital, Bali, Indonesia Komang Harsa Abhinaya Duarsa abhinaya.duarsa@gmail.com Undergraduate Medical Doctor Study Program, Faculty of Medicine, Universitas Udayana, Bali, Indonesia Conflict of interest: The authors declare no potential conflict of interest.