Bowel Perforation During Peritoneal Dialysis Catheter Placement

Confirmation of intestinal and bladder perforations in a peritoneal dialysis patient using SPECT/CT: a case report and review of literature

Background

Peritoneal dialysis (PD) is a common treatment method for patients with renal failure. While peritonitis and tube floating migration are commonly observed complications, visceral perforation caused by PD is relatively rare. We present a case report of a patient undergoing PD due to renal failure, who encountered two instances of visceral perforation. In both occurrences, Single-Photon Emission Computed Tomography/Computed Tomography (SPECT/CT) played a pivotal role in providing accurate diagnoses and precise localization of the perforation sites. This report underscores the paramount significance of SPECT/CT in diagnosing visceral perforations in the context of PD.

Case presentation

A 73-year-old elderly male has been undergoing PD for 1 year due to renal failure. Recently, there has been impaired drainage of the PD catheter. The clinical team suspected the occurrence of peritonitis. The patient underwent a 99mTc Sodium Pertechnetate (99mTc-NaTcO4) SPECT/CT examination, which identified intestinal perforation. After 20 days of conservative treatment, a SPECT/CT follow-up examination revealed the resolution of the intestinal perforation, but a new bladder perforation emerged. The dialysis catheter was methodically and gradually withdrawn in stages while simultaneously performing bladder decompression. Following these interventions, the patient remained free from peritonitis and cystitis.

Conclusion

The utilization of SPECT/CT proved to be highly valuable in the accurate diagnosis of visceral perforation, a relatively rare complication observed in PD patients.

Jejunal perforation secondary to blind insertion of peritoneal dialysis catheter: a case report and review of literature

BACKGROUND

Peritoneal dialysis (PD) depends upon a functioning and durable access to the peritoneal cavity. Many techniques exist to insert a peritoneal catheter, showing similar outcomes and benefits. Blind percutaneous insertion represents a bedside intervention predominantly performed by nephrologists requiring only local anesthesia, sedation and minimal transcutaneous access. Although current guidelines recommend insertion techniques allowing visualization of the peritoneal cavity, the blind percutaneous approach is still widely used and has been proven safe and effective to bring durable peritoneal dialysis access. Herein, we described a rare case of jejunal perforation secondary to blind PD catheter placement, and conduct a review of the current medical literature describing early bowel perforations secondary to PD catheter placement, gathering descriptions of symptomatology and outcomes and their relations to the insertion technique.

CLINICAL PRESENTATION

We herein describe the case of a 48 year-old patient with a history of appendectomy who suffered from triple jejunal perforation after blind percutaneous insertion and subsequent embedment of his peritoneal catheter. Accurate diagnosis was made 1 month after insertion due to atypical clinical presentation and because physicians had no access to the peritoneal cavity after catheter embedment. After surgical repair and broad-spectrum antibiotics, the patient was switched to HD.

CONCLUSION

Early catheter-related visceral injury is a rare, yet threatening condition that is almost always causing a switch to hemodialysis or death. Our review highlights that laparoscopic catheter placement might bring better outcomes if perforation occurs, as it allows immediate diagnosis and treatment. On the contrary, catheter embedment may delay clinical diagnosis and therefore bring worse outcomes.

Bladder perforation injury after percutaneous peritoneal dialysis catheterization: A case report

BACKGROUND

Insertion of a catheter into the bladder is a rare complication of peritoneal dialysis (PD), and is mainly related to surgical injury. This paper reports a case of bladder perforation that was caused by percutaneous PD catheterization.

CASE SUMMARY

A 64-year-old man underwent percutaneous PD catheterization for end-stage renal disease. On the second day after the operation, urgent urination and gross hematuria occurred. Urinalysis showed the presence of red and white blood cells. Empirical anti-infective treatment was given. On the third day after the operation, urgent urination occurred during PD perfusion. Ultrasound showed that the PD catheter was located in the bladder, and subsequent computed tomography (CT) showed that the PD catheter moved through the anterior wall into the bladder. The PD catheter was withdrawn from the bladder and catheterization was retained. Repeat CT on the fourth day after the operation showed that the PD catheter was removed from the bladder, but there was poor catheter function. The PD catheter was removed and the patient was changed to hemodialysis. CT cystography showed that the bladder healed well and the patient was discharged 14 d after the operation.

CONCLUSION

Bladder perforation injury should be considered and treated timeously in case of bladder irritation during and after percutaneous PD catheterization. The use of Doppler ultrasound and other related technologies may reduce the incidence of such complications.

Delayed Erosion of Peritoneal Dialysis Catheter Tip into the Small Bowel

Catheter erosion into the small bowel is an uncommonly reported complication of continuous ambulatory peritoneal dialysis (CAPD). This can result in peritonitis, sepsis, fistula formation, and mortality. We report a 29-year-old female with end-stage renal disease presenting with nausea, profuse diarrhea immediately after dialysate instillation, change in color and odor of the dialysis output, and pain at the site of her peritoneal dialysis (PD) catheter. After a thorough evaluation, catheter tip erosion into the patient's small bowel lumen was diagnosed. This was confirmed when a blue bowel movement followed instillation of a saline solution with methylene blue into the dialysis catheter. A laparoscopic-assisted procedure was performed with removal of the dialysis catheter, resection of the diseased small bowel, and insertion of a right internal jugular tunneled dialysis catheter. Small bowel biopsy was benign. Post-operatively, the patient had no complications, was started on hemodialysis, and was discharged home.

Going Home: Access for Home Modalities

The cost and health burden of ESRD continues to increase globally. Total Medicare expenditure on dialysis has increased from 229 million USD in 1973 to 35.4 billion USD in 2016. Dialysis access can represent almost a tenth of these costs. Central venous catheters have been recognized as a significant factor driving costs and mortality in this population. Home dialysis, which includes peritoneal dialysis and home hemodialysis, is an effective way of reducing costs related to renal replacement therapy, reducing central venous catheter usage and in many cases improving the clinical and psychosocial aspects of patients' health. Addressing access-related issues for peritoneal dialysis, urgent-start peritoneal dialysis and home hemodialysis can have impact on the success of home dialysis. This article reviews issues related to dialysis access for home therapies.

Successful Initiation of Dialysis with a 20-Year-Old Buried Peritoneal Dialysis Catheter: Case Report and Literature Review

Buried peritoneal dialysis (PD) catheters are typically inserted several weeks or months before the anticipated need for dialysis. Occasionally, renal function unexpectedly stabilizes after the surgery, and a patient may go years before the catheter is needed. We report a case of successful initiation of PD with a twenty-year-old buried catheter. We outline the steps needed to optimize the catheter function and review the benefits of the buried PD catheter.

Peritoneal Dialysis in Austere Environments: An Emergent Approach to Renal Failure Management

Peritoneal dialysis (PD) is a means of renal replacement therapy (RRT) that can be performed in remote settings with limited resources, including regions that lack electrical power. PD is a mainstay of end-stage renal disease (ESRD) therapy worldwide, and the ease of initiation and maintenance has enabled it to flourish in both resource-limited and resource-abundant settings. In natural disaster scenarios, military conflicts, and other austere areas, PD may be the only available life-saving measure for acute kidney injury (AKI) or ESRD. PD in austere environments is not without challenges, including catheter placement, availability of dialysate, and medical complications related to the procedure itself. However, when hemodialysis is unavailable, PD can be performed using generally available medical supplies including sterile tubing and intravenous fluids. Amidst the ever-increasing global burden of ESRD and AKI, the ability to perform PD is essential for many medical facilities.

Wang's Forceps-Assisted Percutaneous Insertion and Fixation of Peritoneal Dialysis Catheter

Percutaneous insertion of peritoneal dialysis catheters is theoretically most preferred by nephrologists because of the advantages of bedside performing, surgery independence, and minimal injury over other procedures of catheter placement such as open surgical dissection or laparoscopic operation. However, blindly placing catheters in the percutaneous procedure brings the risk of catheter malposition or bowel perforation; this largely retarded it's implementation. We had previously developed a novel technique termed "Wang's forceps-assisted catheter insertion and fixation," which had been successfully applied in the open surgical catheter insertion and displaced catheter reposition in our center. In this study, we further explored the possibility of applying the Wang's forceps in the procedure of percutaneous catheter insertion both in porcine model and patients with end stage renal disease (ESRD). A total of three miniature pigs successfully received percutaneous catheter insertion using Seldinger's technique with Wang's forceps assistance. The catheters were all placed in the right position and functioning well in dialysate drainage. This novel method of percutaneous catheter insertion was then performed on 20 ESRD patients. The procedure showed effective time-saving with the average operating time of 29.2 ± 3.53 min and was well tolerated by patients with minimal pain and injury. During a follow-up time of 6 months, no complications of catheter displacement, leakage, or blockade occurred. Our preliminary observation demonstrates that utilization of Wang's forceps in a percutaneous procedure conferred benefits of accurately placing and fixing catheters while preserving the merits of minimal invasion and simple performance.

Peritoneal Dialysis Catheter Insertion

The success of peritoneal dialysis as renal-replacement therapy depends on a well-functioning peritoneal catheter. Knowledge of best practices in catheter insertion can minimize the risk of catheter complications that lead to peritoneal dialysis failure. The catheter placement procedure begins with preoperative assessment of the patient to determine the most appropriate catheter type, insertion site, and exit site location. Preoperative preparation of the patient is an instrumental step in facilitating the performance of the procedure, avoiding untoward events, and promoting the desired outcome. Catheter insertion methods include percutaneous needle-guidewire with or without image guidance, open surgical dissection, peritoneoscopic procedure, and surgical laparoscopy. The insertion technique used often depends on the geographic availability of material resources and local provider expertise in placing catheters. Independent of the catheter implantation approach, adherence to a number of universal details is required to ensure the best opportunity for creating a successful long-term peritoneal access. Finally, appropriate postoperative care and catheter break-in enables a smooth transition to dialysis therapy.

Intra-abdominal hypertension and abdominal compartment syndrome in pediatrics. A review

PURPOSE

To consolidate pediatric intensivists' understanding of the pathophysiology, definition, incidence, monitoring, and management of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS); and to highlight the characteristics related to the pediatric population.

METHODS

This is a narrative review article that utilized a systematic search of the medical literature published in the English language between January 1990 and august 2016. Studies were identified by conducting a comprehensive search of Pub Med databases. Search terms included "intra-abdominal hypertension and child", "intra-abdominal hypertension and pediatrics", "abdominal compartment syndrome and child", and "abdominal compartment syndrome and pediatrics".

RESULTS

Intra-abdominal hypertension and ACS are associated with a number of pathophysiological disturbances and increased morbidity and mortality. These conditions have been well described in critically ill adults. In children, the IAH and the ACS have a reported incidence of 13% and 0.6 to 10% respectively; they carry similar prognostic impact but are still under-diagnosed and under-recognized by pediatric health care providers.

CONCLUSIONS

Intra-abdominal hypertension and ACS are conditions that are regularly encountered in critically ill children. They are associated with an increased morbidity and mortality. Early recognition, prevention and timely management of this critical condition are necessary to improve its outcome.

Imaging and Peritoneal Dialysis Catheters

The placement of a peritoneal dialysis (PD) catheter by interventionalists demands not only procedural skill but also an ability to decipher real-time ultrasonographic and fluoroscopic images. In this article, we discuss how imaging assists in PD placement and recognition of complications. To aid this endeavor, we have provided images and video clips that should assist interventionalists. Compared with the fluoroscopic technique, peritoneoscopic PD catheter placement provides direct visual imaging to also aid placement of the initial trocar and the peritoneal catheter.