a 43-year - old woman with end - stage renal disease due to glomerulonephritis had been on peritoneal dialysis ( pd ) for 2 years . the patient had no history of diabetes mellitus , cardiovascular disease , chronic pulmonary disease or chronic hepatic disease and no previous pd - related infections . the latest comprehensive evaluation revealed that she was anuric and with adequate solute clearance ( kt / vurea 1.79 , creatinine clearance 58.3 l / week ) , mild anemia ( hemoglobin 96 g / l ) and acceptable nutrition status ( serum albumin 38.1 g / l ) ; daily ultrafiltration was 800 ml . she came to our center complaining of mild abdominal pain , cloudy effluent and low fever . her effluent white blood cell ( wbc ) count was 130 cells / mm with 88% neutrophils . empirical treatment was started immediately with intraperitoneal cefradine ( loading dose 500 mg / l ; maintenance dose 125 mg / l ) and amikacin ( 2 mg / kg per exchange , once daily ) after effluent culture sampling . however , her clinical manifestation aggravated gradually during the empirical treatment : the patient had high fever and severe abdominal pain ; effluent wbc count rose up to 2,180 cells / mm ; peripheral wbc count and c - reactive protein ( crp ) increased significantly . consequently , the pd catheter was removed on the 6th day , and the patient was put on continuous renal replacement therapy ; antibiotics were changed to intravenous imipenem / cilastatin ( 500 mg / day ) , vancomycin ( 800 mg , once every 5 days ) and fluconazole ( 200 mg / day ) . however , after catheter removal , her abdominal pain , distension and high fever persisted and deteriorated , and the infection indicators such as crp increased further . both blood and catheter tip cultures revealed absence of any growth . ultrasound showed that there was abdominal and pelvic encapsulated effusion . to eliminate the infection source and control ongoing peritoneal contamination , more than 400 ml of purulent effusion was sucked out , and adhesiolysis was performed . after that , peritoneal lavage with povidone - iodine and normal saline was implemented , and 3 indwelling tubes were placed for continuous postoperational peritoneal lavage and drainage . an infusion tube to the middle abdomen was used for continuous peritoneal irrigation with normal saline ( 2,000 ml / day ) ; for drainage , a low negative pressure draining tube to the right abdomen and a double cannula connected with an electric suction device to the pelvis where encapsulating abscess was located were used . the patient 's condition improved dramatically after the operation ; her body temperature fell to normal , and abdominal pain subsided . effusion culture identified multiple organisms ( acinetobacter baumannii 50% , acinetobacter lowffi 20% and staphylococcus caprae 30% ) . three days after the operation ( the 21st day ) , peritoneal irrigation was stopped , and the infusion tube was removed since the effluent became clear , and another 6 days later the drain tubes were also removed . the patient has now been on hemodialysis for more than 3 years without any peritoneal complications . despite advances to reduce the incidence of pd - related infectious complications , peritonitis still remains the leading cause of technique failure in the pd population and an important cause of morbidity and mortality . poor outcome of patients who suffer from refractory pd - related peritonitis is a big issue in clinical practice . the international society for peritoneal dialysis ( ispd ) guideline recommends appropriate management process and medical treatment of pd - related peritonitis . however , in some cases , intractable intra - abdominal infection continues after catheter removal and probably leads to severe abdominal complications , and even more seriously , critical systemic complications as sepsis and death can result from these local complications . conservative treatment can hardly resolve these severe abdominal complications , and the condition necessitates surgical intervention to improve the patients outcome . so far , surgical intervention in refractory pd - related peritonitis besides catheter removal has lacked evidence , and only a few studies have investigated this issue . in a prospective observational study , peacock et al .   observed that 5 in 37 ( 13.5% ) patients with staphylococcus aureus - related peritonitis developed serious abdominal complications ; most of them needed laparotomy , but the outcomes were poor , including 2 cases of death and 2 cases of unsolved intermittent small bowel obstruction . a surgical team from the uk reported that 7 in 62 ( 11.3% ) patients with pd - related peritonitis needed a second laparotomy after catheter removal , but the reasons and outcomes were not described . chang et al .   reported surgical intervention due to unrelieved abdominal symptoms and a great amount of turbid ascites after pd catheter removal in 2 cases of pseudomonas - related peritonitis , and both patients survived . presented a rare case of peritonitis secondary to colon perforation caused by ingestion of a piece of bamboo in a pd patient ; the pd catheter was removed , followed by peritoneal lavage and continuous abdominal drainage , and the patient finally recovered . it is important to identify which patients developing pd - related peritonitis need surgical intervention . unfortunately , there has been no consensus on this issue . generally , if an episode of peritonitis is secondary to acute abdomen such as gastric or intestinal perforation , appropriate procedures should follow surgical principles , and the aim should be effective source control , which refers to drainage of infected foci , controlling ongoing peritoneal contamination and restoration of anatomic and physiological function . the pd catheter needs to be removed concomitantly , as in the case shown by suzuki et al . . while an episode of refractory pd - related peritonitis is a primary one , the situation can be more complicated . pd catheter removal is recommended by the ispd guideline since the catheter may be the source of infection , and as a foreign body it can be a barrier to infection control . however , the guideline does not mention any additional procedure to minimize bacterial burden in the abdominal cavity at the time of catheter removal , and it does not provide any recommendations or opinions about management of ongoing and severe intra - abdominal infection after catheter removal . in practice , whether to perform further surgical intervention is determined according to the comprehensive judgment of the patient 's individual condition , as well as very cautious balancing between potential benefits and risks , and the decisions are very likely to be various among different doctors . what we learn from the present case may help us manage these kinds of patients . when the local symptoms show no improvement or even aggravate after catheter removal , doctors should remember to exclude emerging intra - abdominal complications . the manifestations of severe abdominal complications can be heterogeneous [ 2 , 4 ] , including significant purulent exudation , abscess , adhesion , enteric fistula , ischemic or necrotic bowel , toxic colonic dilatation , intestinal obstruction or perforation , and so forth . ct scan and ultrasound examination usually can define the site and nature of the infection responsible for the clinical syndrome and guide subsequent intervention . further surgical procedures may consist of peritoneal lavage , abscess drainage , debridement , adhesiolysis , etc . , determined by the nature of abdominal complication . though it is difficult to verify the clinical efficacy of peritoneal lavage for the treatment of peritonitis due to lack of studies , we support to perform it if there is a significant amount of purulent ascites or extensive intra - abdomen contamination since a flush to the peritoneal cavity may reduce the bacterial load , inhibit bacterial proliferation and possibly minimize peritoneal adhesions . a meta - analysis on experimental non - pd - related peritonitis reported that the mortality in studied animals with antibiotic lavage , saline lavage , antiseptic lavage and no lavage was 16.4 , 48.9 , 75.0 and 73.9% , respectively , suggesting a preference for treatment options . drainage converts a closed intra - abdominal infection into a controlled sinus which is to the exterior , and facilitates cleaning of the remaining ascites or postoperative peritoneal exudation . in the present case , we performed continuous peritoneal irrigation and drainage because of the large amount and thick density of the effusion observed during laparotomy . debridement is necessary when there is ischemic or necrotic tissue , and adhesiolysis is indicated when there is compartment or intestinal adhesion to avoid residuals of capsulated abscess or bowel obstruction . the risks of surgical intervention for refractory pd - related peritonitis are mainly procedure related , such as bleeding and bowel perforation . in addition , these patients are usually very sick , which might be a significant barrier to anesthesia and invasive procedures . however , if an invasive procedure is indicated , prolonged waiting time before it may be associated with increased likelihood of adverse events . on the other hand , intervention measures as inserting and keeping intra - abdominal drain tubes may increase the potential pathway to unmanageable infection since biofilm may be formed in the tube and become an additional infection source . therefore , successful surgical intervention calls for definite diagnosis , appropriate timing , experienced surgeon and intensive postoperative care , and before the intervention , supposed benefits should overweigh potential risks . furthermore , it would be much more promising if we could find patients who are at high risk of further adverse events . theoretically , this is associated with the pathogen 's properties and patient 's individual condition . gram - negative organisms , s. aureus and fungus are related to poor outcomes of peritonitis . as demonstrated by the teams of peacock   and chang , s. aureus and pseudomonas can lead to complicated intra - abdominal complications , while other relatively mild pathogens as coagulase - negative staphylococcus are unlikely to cause such kinds of adverse events . recent basic research also supports the role of s. aureus in forming peritoneal abscess in pd patients . therefore , more intensive monitoring is needed in patients suffering from peritonitis caused by these organisms . generally , the majority of the patients developing refractory pd - related peritonitis can be cured by catheter removal in combination with systemically administrated antibiotics . however , it was found that a high serum crp level at 72 h of peritonitis and long pd duration before peritonitis were significant predictors of the development of encapsulating peritoneal sclerosis within 90 days after catheter removal , while effluent wbc at 72 h was associated with the development of recurrent ascites . additionally , the optimal timing of intervention remains unclear and needs further study . in conclusion , we presented a case suggesting that appropriate surgical intervention for refractory peritonitis is necessary for saving lives in certain subgroups of patients . pd - related infections accompanied by unresolved intra - abdominal complications , or those secondary to intra - abdominal pathology may require further surgical procedures . clearly , the indication , timing and measures of surgical intervention need further studies .
peritonitis is the most common infection in peritoneal dialysis ( pd ) and has been noted to be not only a cause of mortality but also the leading cause of technique failure in patients maintained on pd . 
 appropriate management of peritonitis to improve patient outcome has been the focus of clinical practice . 
 we report a case of refractory pd - related peritonitis with surgical intervention intending to control ongoing peritoneal infection despite aggressive antibiotics and timely catheter removal . 
 exploratory laparotomy was performed in this case , and an encapsulated abscess in the peritoneal and pelvic cavity was obliterated . 
 adhesiolysis was done simultaneously . 
 continuous postoperative peritoneal lavage and drainage were implemented . 
 symptoms dramatically improved after operation , and indwelling tubes were removed several days later . finally , the patient recovered and switched to permanent hemodialysis without intra - abdominal complications . 
 our case suggested that appropriate and timely surgical intervention in refractory peritonitis is necessary for saving lives in certain subgroups of patients . 
 clearly , well - designed studies with large samples are warranted to explore this issue in more detail .