Laparoscopic Peritoneal Dialysis Surgery is Safe and Effective in Patients with Prior Abdominal Surgery

Recent advances in peritoneal dialysis catheter placement: the association between method of insertion, operator, and prior abdominal surgery and outcomes

PURPOSE OF REVIEW

Peritoneal dialysis (PD) is associated with comparable outcomes to hemodialysis and is much less expensive to provide in most parts of the world. A well functioning PD catheter is required, but complications are frequent, and while there are guidelines for the placement and care of a PD access, they are based on low-quality evidence.

RECENT FINDINGS

Data reporting the outcomes of percutaneous, as compared to surgical pathways for placement of catheters and the role of operator type in determining outcomes are examined. The impact of prior abdominal procedures on patient selection and the prognostic importance of the presence of adhesions at the time of catheter insertion are reviewed.

SUMMARY

There are conflicting data about the relative merits of percutaneous as compared to surgical placement of catheters that may relate to differences in patient selection, operator experience, or operator volume. Prior abdominal procedures are not associated with worse PD catheter outcomes and likely should not influence patient selection, except in exceptional circumstances. Finally, the presence of adhesions is associated with a higher risk of complications. However, even in the presence of adhesions, the termination of PD therapy and need for re-intervention occurs in <20% of patients.

Peritoneal dialysis catheter insertion and maintenance

The treatment of end-stage kidney disease (ESKD with peritoneal dialysis (PD) continues to increase. Timely initiation of PD is dependent on successful PD catheter placement, which can be performed using open or laparoscopic surgical or percutaneous techniques. Dialysis access surgeons who incorporate PD catheter insertion in their practice can uniquely offer comprehensive access services to their patients. This review discusses the various methods of PD catheter insertion, patient conditions that impact surgical decision-making, and the management of catheter-related complications.

The Association of Intra-Abdominal Adhesions with Peritoneal Dialysis Catheter-Related Complications

BACKGROUND

This study investigated the association of intra-abdominal adhesions with the risk of peritoneal dialysis (PD) catheter complications.

METHODS

Individuals undergoing laparoscopic PD catheter insertion were prospectively enrolled from eight centers in Canada and the United States. Patients were grouped based on the presence of adhesions observed during catheter insertion. The primary outcome was the composite of PD never starting, termination of PD, or the need for an invasive procedure caused by flow restriction or abdominal pain.

RESULTS

Seven hundred and fifty-eight individuals were enrolled, of whom 201 (27%) had adhesions during laparoscopic PD catheter insertion. The risk of the primary outcome occurred in 35 (17%) in the adhesion group compared with 58 (10%) in the no adhesion group (adjusted HR, 1.64; 95% confidence interval [CI], 1.05 to 2.55) within 6 months of insertion. Lower abdominal or pelvic adhesions had an adjusted HR of 1.80 (95% CI, 1.09 to 2.98) compared with the no adhesion group. Invasive procedures were required in 26 (13%) and 47 (8%) of the adhesion and no adhesion groups, respectively (unadjusted HR, 1.60: 95% CI, 1.04 to 2.47) within 6 months of insertion. The adjusted odds ratio for adhesions for women was 1.65 (95% CI, 1.12 to 2.41), for body mass index per 5 kg/m 2 was 1.16 (95% CI, 1.003 to 1.34), and for prior abdominal surgery was 8.34 (95% CI, 5.5 to 12.34). Common abnormalities found during invasive procedures included PD catheter tip migration, occlusion of the lumen with fibrin, omental wrapping, adherence to the bowel, and the development of new adhesions.

CONCLUSIONS

People with intra-abdominal adhesions undergoing PD catheter insertion were at higher risk for abdominal pain or flow restriction preventing PD from starting, PD termination, or requiring an invasive procedure. However, most patients, with or without adhesions, did not experience complications, and most complications did not lead to the termination of PD therapy.

Exploring Preconceptions as Barriers to Peritoneal Dialysis Eligibility: A Global Scenario-Based Survey of Kidney Care Physicians

Introduction

Despite the growing number of patients requiring kidney replacement therapy (KRT), peritoneal dialysis (PD) is underutilized globally. A contributory factor may be clinician myths about its use. The aim of this study was to explore perceptions about PD initiation by clinicians according to various physical, social, and clinical characteristics of patients.

Methods

An online global survey (in English and Thai) was administered to ascertain nephrologists' and nephrology trainees' decisions on recommending PD as a treatment modality.

Results

A total of 645 participants (522 nephrologists and 123 trainees; 56% male) from 54 countries (66% from high-income countries [HICs], 22% from upper middle-income countries [UMICs], 12% from lower middle-income countries, and 1% from low-income countries [LICs]) completed the survey. Of the respondents, 81% identified as attending physicians or consultants, and 19% identified as trainees or other. PD was recommended for most scenarios, including repeated exposures to heavy lifting, swimming (especially in a private pool and ocean), among patients with cirrhosis or cognitive impairment with available support, and those living with a pet if a physical separation can be achieved during PD. Certain abdominal surgeries were more acceptable to proceed with PD (hysterectomy, 90%) compared to others (hemicolectomy, 45%). Similar variation was noted for different types of stomas (nephrostomies, 74%; suprapubic catheters, 53%; and ileostomies, 27%).

Conclusion

The probability of recommending PD in various scenarios was greater among clinicians from HICs, larger units, and consultants with more clinical experience. There is a disparity in recommending PD across various clinical scenarios driven by experience, unit-level characteristics, and region of practice. Globally, evidence-informed education is warranted to rectify misconceptions to enable greater PD uptake.

Urinary Bladder Traversed by Peritoneal Dialysis Catheter and Discovered Accidently During Living Donor Kidney Transplant: A Case Report and Review of the Literature

Peritoneal dialysis is a well-established renal replacement therapy for end-stage renal disease. Insertion of a peritoneal dialysis catheter has inherent complication risks. We present a case of a triple-cuff peritoneal dialysis catheter that traversed the urinary bladder on its way to its final destination and was discovered 3 months later during living donor kidney transplant. We observed a 22-year-old male patient on peritoneal dialysis who was admitted for living related kidney transplant. Intraoperatively, we discovered that the well-functioning peritoneal dialysis catheter was inserted through the urinary bladder. Diagnostic intraoperative cystogram and cystoscopy were conducted. Open removal of the peritoneal dialysis catheter and repair of entry and exit sites were performed. The postoperative course was uneventful, and the patient was discharged 11 days postoperatively with a functioning graft. Bladder catheterization before peritoneal dialysis catheter insertion, even in low-risk patients, is mandatory, to avoid bladder perforation. In addition to the case report, we reviewed the pertinent literature.

A Service Reconfiguration Bundle for Expanding Access to Peritoneal Dialysis Including for Older Frailer Patients

INTRODUCTION

Rates of peritoneal dialysis (PD) have been traditionally low in Northern Ireland. With rising numbers of patients reaching end-stage kidney disease, PD is a more cost-effective treatment than haemodialysis and aligns with international goals to increase home-based dialysis options. The aim of our study was to highlight how a service reconfiguration bundle expanded access to PD in Northern Ireland.

METHODS

The service reconfiguration bundle consisted of the appointment of a surgical lead, a dedicated interventional radiologist for fluoroscopically guided PD catheter insertion, and a nephrology-led ultrasound-guided PD catheter insertion service in an area of particular need. All patients in Northern Ireland who had a PD catheter inserted in the year following service reconfigurations were included and prospectively followed up for one-year. Patient demographics, PD catheter insertion technique, setting of procedure, and outcome data were summarised.

RESULTS

The number of patients receiving PD catheter insertion doubled to 66 in the year following service reconfigurations. The range of approaches to PD catheter insertion (laparoscopic n = 41, percutaneous n = 24 and open n = 1) allowed a wide range of patients to benefit from PD. Six patients had emergency PD catheter insertion, with four receiving urgent or early start PD. Nearly half (48%, 29/60) of the PD catheters inserted electively were in smaller elective hubs rather than the regional unit. A total of 97% of patients successfully started PD. Patients who experienced percutaneous PD catheter insertion were older [median age 76 (range 37-88) vs. 56 (range 18-84), p < 0.0001] and had less previous abdominal surgery than patients who experienced laparoscopic PD catheter insertion (25%, 6/24 vs. 54%, 22/41, p = 0.05).

DISCUSSION

Through a service reconfiguration bundle, we were able to double our annual incident PD population. This study highlights how flexible models of service delivery introduced as a bundle can quickly deliver expanded access to PD and home therapy.

Clinical Benefits of Laparoscopic Adhesiolysis during Peritoneal Dialysis Catheter Insertion: A Single-Center Experience

Background and Objectives: In peritoneal dialysis (PD) therapy, intra-abdominal adhesions (IAAs) can cause catheter insertion failure, poor dialysis function, and decreased PD adequacy. Unfortunately, IAAs are not readily visible to currently available imaging methods. The laparoscopic approach for inserting PD catheters enables direct visualization of IAAs and simultaneously performs adhesiolysis. However, a limited number of studies have investigated the benefit/risk profile of laparoscopic adhesiolysis in patients receiving PD catheter placement. This retrospective study aimed to address this issue. Materials and Methods: This study enrolled 440 patients who received laparoscopic PD catheter insertion at our hospital between January 2013 and May 2020. Adhesiolysis was performed in all cases with IAA identified via laparoscopy. We retrospectively reviewed data, including clinical characteristics, operative details, and PD-related clinical outcomes. Results: These patients were classified into the adhesiolysis group (n = 47) and the non-IAA group (n = 393). The clinical characteristics and operative details had no remarkable between-group differences, except the percentage of prior abdominal operation history was higher and the median operative time was longer in the adhesiolysis group. PD-related clinical outcomes, including incidence rate of mechanical obstruction, PD adequacy (Kt/V urea and weekly creatinine clearance), and overall catheter survival, were all comparable between the adhesiolysis and non-IAA groups. None of the patients in the adhesiolysis group suffered adhesiolysis-related complications. Conclusions: Laparoscopic adhesiolysis in patients with IAA confers clinical benefits in achieving PD-related outcomes comparable to those without IAA. It is a safe and reasonable approach. Our findings provide new evidence to support the benefits of this laparoscopic approach, especially in patients with a risk of IAAs.

Successful use of peritoneal dialysis after abdominal surgery in a patient with factor XI deficiency: A case report

Factor XI (FXI) deficiency is a rare bleeding disorder of unpredictable severity that correlates poorly with FXI coagulation activity and that poses great challenges for perioperative hemostatic management and the dialysis methods potentially available to new end-stage renal disease (ESRD) patients. We describe an individual with both ESRD and severe FXI deficiency, who successfully underwent peritoneal dialysis (PD) after emergency abdominal surgery. In the traditional concept, recent abdominal surgery is a contraindication to PD, especially for patients with bleeding risk. However, this case report highlights that PD can still be an possible option for patients with FXI deficiency who have just undergone abdominal surgery; laparoscopic PD catheter placement offers a chance to establish PD access in patients traditionally viewed as noncandidates for this method. Careful perioperative management and fresh frozen plasma transfusion ensure successful surgery. This case should be of help to clinicians and patients considering PD in similar situations.

When end-stage kidney disease complicates abdominal surgery

Patients receiving peritoneal dialysis (PD) encounter an increased risk for infection, bleeding, and PD fluid leakage after abdominal surgery. These complications may affect the future use of PD. Appropriate patient preparation may mitigate complications. Certain complications or procedures allow patients to remain on PD while others require transition to hemodialysis. We review the etiology and management of infection, bleeding, and PD fluid leakage associated with abdominal surgery as well as the relationship of specific abdominal procedures to continuing PD.