A novel technique of sutureless omentopexy during dual-incision laparoscopic peritoneal dialysis catheter insertion to prevent catheter dysfunction due to omental wrapping

BACKGROUND

Omental wrapping (OW) is the leading cause of obstruction of the peritoneal dialysis (PD) catheter, which interferes with dialysis treatment. Routinely or selectively performing omentopexy during laparoscopic PD catheter placement has been suggested to prevent OW. However, most of the published techniques for performing this adjunctive procedure require additional incisions and suturing. Herein, we aimed to report our experience in performing omentopexy with a sutureless technique during dual-incision PD catheter insertion. We also performed a comparative analysis to assess the benefit/risk profile of routine omentopexy in these patients.

METHODS

This retrospective study enrolled 469 patients who underwent laparoscopic PD catheter insertion. Their demographic characteristics and operative details were collected from the database of our institution. Omentopexy was performed by fixing the inferior edge of the omentum to the round ligament of the liver using titanium clips. For analysis, the patients were divided into the omentopexy group and the non-omentopexy group. We also reviewed the salvage management and outcomes of patients who experienced OW.

RESULTS

The patients were categorized into the omentopexy (n = 81) and non-omentopexy (n = 388) groups. The patients in the non-omentopexy group had a higher incidence of OW, whereas no patient in the omentopexy group experienced this complication (5.2% vs. 0.0%, p = 0.033). The median operative time was 27 min longer in patients who underwent omentopexy than in those who did not [100 (82-118) min vs. 73 (63-84) min, p < 0.001]. One patient had an intra-abdominal hematoma after omentopexy and required salvage surgery to restore catheter function. The complication rate of omentopexy was 1.2% (1/81).

CONCLUSION

Sutureless omentopexy during laparoscopic PD catheter insertion is a safe and reliable technique that does not require additional incisions and suturing. Routinely performing omentopexy provides clinical benefits by reducing the risk of catheter dysfunction due to OW.

Care of the pediatric patient on chronic peritoneal dialysis

Peritoneal dialysis is the most commonly prescribed dialysis modality for infants and young children with kidney failure worldwide. Provision of high-quality care for the pediatric patient on chronic peritoneal dialysis requires a multidisciplinary approach and a strong collaboration with the patient and their caregiver. This article not only reviews current recommendations and advances in the care of pediatric patients on peritoneal dialysis with a focus on the provision of high-quality care and improvement in outcomes, but it also draws attention to health care disparities that exist locally and globally.

Experience using Presternal Catheter for Peritoneal Dialysis in Poland: A Multicenter Pediatric Survey

← Objectives

Permanent and adequate access to the peritoneal cavity is the key to successful chronic peritoneal dialysis (PD). A variety of catheter designs and implantation techniques have been developed to achieve optimal peritoneal access. One such new and modified PD catheter is the presternal catheter [swan neck presternal catheter (SNPC)], with the exit site located on the chest wall.

← Design

A multicenter survey was undertaken to summarize 10 years of experience with the presternal catheter in children in Poland.

← Setting

Four pediatric institutions using the SNPC in children: ( 1 ) Medical University of Warsaw, Warsaw; ( 2 ) Childrens’ Memorial Health Institute, Warsaw; ( 3 ) District Children's Hospital, Szczecin; ( 4 ) University of Medical Sciences, Poznan.

← Patients

During the past 10 years, 20 presternal catheters were implanted in 19 children, aged 0.2 – 17.7 years (mean 8 ± 5.8 years), with end-stage renal failure. The main indications for the SNPC include urinary diversion (ureterocutaneostomy or vesicostomy), use of diapers, young age, obesity, abdominal wall weakness, and recurrent exit-site infections (ESI) with previous abdominal PD catheters.

← Intervention

In all children the presternal catheter was implanted surgically under general anesthesia by one surgeon. Uniform operative technique and uniform perioperative management were used.

← Results

The mean observation time for the 20 presternal catheters was 24.8 ± 25 months (range 1 – 83 months). The ESI rate was 1/70.9 patient-months (0.17 episodes per year), tunnel infection rate was 1/248 patient-months (0.05 episodes per year), and the overall peritonitis rate was 1/26.6 patient-months (0.51 episodes per year). Noninfectious complications associated with the SNPC included disconnection of both sections (2 children) and trauma to the exit site located on the chest wall (4 children). Mean survival time of the presternal catheter, as calculated by the Kaplan–Meier method, was 57.5 ± 8.5 months; 50% catheter survival reached 72 months.

← Conclusions

The good outcome in patients with a SNPC validates the rationale for the presternal catheter design and should encourage its more widespread use. The SNPC seems to be suitable for any patient on PD; however, this catheter is particularly useful in patients with specific indications ( i.e., higher tendency to ESI). The SNPC allows safe and long-term chronic PD in very young children using diapers and in patients with urinary diversion.

Factors associated with early peritoneal dialysis catheter malfunction

BACKGROUND

Peritoneal dialysis (PD) catheter obstruction often leads to surgical revision and may require transition to hemodialysis. The purpose of this study was to evaluate risk factors (including omentectomy) associated with early PD catheter obstruction (<6 months from insertion).

METHODS

A retrospective review of all PD catheters inserted at a single high-volume referral center (2005-2018) was performed. 185 PD catheters were placed in 123 patients (45 female). Potential risk factors for early catheter obstruction were analyzed using Chi-square analysis (p < 0.05 considered statistically significant).

RESULTS

Median age at catheter insertion was 3.42 years (3 days-39 years). Early catheter obstruction occurred in 42 cases (22.7%). Median time to early obstruction was 24 days (3-118 days). Previous PD catheter placement (p = 0.9) or prior abdominal surgery (p = 0.89) was not associated with obstruction. Weight ≥ 10 kg (p = 0.011) and age ≥ 1 year (p = 0.048) were associated with a significantly higher incidence of obstruction. Overall, omentectomy was associated with a trend in reduction of early obstruction in patients with weight ≥ 10 kg (p = 0.08) and significantly in patients ≥1 year (p = 0.028).

CONCLUSION

Early PD catheter obstruction appears to occur more often in older patients with a higher weight. Concomitant omentectomy seems beneficial at reducing early catheter obstruction events in those patients.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

III.

History of Peritoneal Access Development

The first peritoneal accesses were devices that had been used in other fields (general surgery, urology, or gynecology): trocars, rubber catheters, and sump drains. In the period after World War II, numerous papers were published with various modifications of peritoneal dialysis. The majority of cases were treated with the continuous flow technique; rubber catheters for inflow and sump drains for outflow were commonly used. At the end of the 1940s, intermittent peritoneal dialysis started to be more frequently used. Severe complications of peritoneal accesses created incentive to design accesses specifically for peritoneal dialysis. The initial three, in the late 1940s, were modified sump drains; however, Ferris and Odel for the first time designed a soft, polyvinyl intraperitoneal tube with metal weights to keep the catheter tip in the pelvic gutter where the conditions for drain are the best. In the 1950s, intermittent peritoneal dialysis was established as the preferred technique; polyethylene and nylon catheters became commercially available and peritoneal dialysis was established as a valuable method for treatment of acute renal failure. The major breakthrough came in the 1960s. First of all, it was discovered that the silicone rubber was less irritating to the peritoneal membrane than other plastics. Then, it was found that polyester velour allowed an excellent tissue ingrowth creating a firm bond with the tissue. When a polyester cuff was glued to the catheter, it restricted catheter movement and created a closed tunnel between the integument and the peritoneal cavity. In 1968, Tenckhoff and Schechter combined these two features and designed a silicone rubber catheter with a polyester cuff for treatment of acute renal failure and two cuffs for treatment of chronic renal failure. This was the most important development in peritoneal access.

Technological evolution never ends. Multiple attempts have been made to eliminate remaining complications of the Tenckhoff catheter such as exit/tunnel infection, external cuff extrusion, migration leading to obstruction, dialysate leaks, recurrent peritonitis, and infusion or pressure pain. New designs combined the best features of the previous ones or incorporated new elements. Not all attempts have been successful, but many have. To prevent catheter migration, Di Paolo and his colleagues applied the old idea of providing weights at the catheter tips to Tenckhoff catheters. In another modification, Twardowski and his collaborators created a permanent bend to the intra-tunnel portion of the silicone catheter to eliminate cuff extrusions.

The Tenckhoff catheter continues to be widely used for chronic peritoneal dialysis, although its use is decreasing in favor of swan-neck catheters. Soft, silicone rubber instead of rigid tubing virtually eliminated such early complications as bowel perforation or massive bleeding. Other complications, such as obstruction, pericatheter leaks, and superficial cuff extrusions have been markedly reduced in recent years, particularly with the use of swan-neck catheters and insertion through the rectus muscle instead of the midline. However, these complications still occur, so new designs are being tried.

Care of the Pediatric Patient on Chronic Dialysis

Optimal care of the pediatric end-stage renal disease (ESRD) patient on chronic dialysis is complex and requires multidisciplinary care as well as patient/caregiver involvement. The dialysis team, along with the family and patient, should all play a role in choosing the dialysis modality which best meets the patient's needs, taking into account special considerations and management issues that may be particularly pertinent to children who receive peritoneal dialysis or hemodialysis. Meticulous attention to dialysis adequacy in terms of solute and fluid removal, as well as to a variety of clinical manifestations of ESRD, including anemia, growth and nutrition, chronic kidney disease-mineral bone disorder, cardiovascular health, and neurocognitive development, is essential. This review highlights current recommendations and advances in the care of children on dialysis with a particular focus on preventive measures to minimize ESRD-associated morbidity and mortality. Advances in dialysis care and prevention of complications related to ESRD and dialysis have led to better survival for pediatric patients on dialysis.

A clinical review of peritoneal dialysis

OBJECTIVE

To review the principles and practice of peritoneal dialysis in veterinary medicine.

DATA SOURCES

Clinical and experimental studies and current guideline recommendations from the human literature; and original case studies, case reports, and previous reviews in the veterinary literature.

SUMMARY

Peritoneal dialysis involves the exchange of solutes and fluid between the peritoneal capillary blood and the dialysis solution across the peritoneal membrane. It requires placement of a peritoneal dialysis catheter for repeated dialysate exchange. The ideal catheter provides reliable, rapid dialysate flow rates without leaks or infections. Catheter selection and placement are reviewed along with dialysate selection, exchange prescriptions, and overall patient management. PD does not require specific or complex equipment, and it can achieve effective control of uremia and electrolyte imbalances.

CONCLUSIONS

Peritoneal dialysis is a potential life-saving measure for patients with acute renal failure. Peritoneal dialysis results in gradual decline in uremic toxins. Previously low success rates have been reported. Improved success rates have been noted in dogs with acute kidney injury (AKI) secondary to leptospirosis. Cats also have a good success rate when PD is elected in patients with a potentially reversible underlying disease. Overall, PD remains a viable intervention for patients with AKI unresponsive to medical management. In select patients a favorable outcome is attained whereby PD provides temporary support until return of effective renal function is attained.

Mupirocin application at the exit site in peritoneal dialysis patients: five years of experience

INTRODUCTION

In this study, we aimed to analyze the effects of once- or thrice-weekly mupirocin application on peritonitis, exit-site infection (ESI), and antibiotic resistance with mupirocin.

PATIENTS AND METHODS

By 2000 mupirocin began to be applied once a week to 33 patients who previously did not use mupirocin at the exit site. By the beginning of 2002, the patients were assigned to two groups. In group I patients continued to apply mupirocin once a week. In group II patients began to apply mupirocin to the exit site three times weekly and we began to obtain cultures from the nares, inguinal area, axillae, and the exit site.

RESULTS

A total of 28 episodes of ESI and 41 episodes of peritonitis were seen in 33 patients prior to mupirocin treatment, while a total of 14 episodes of ESI and 34 episodes of peritonitis were observed in all groups of patients who used mupirocin. In a subgroup analysis, 13 episodes of peritonitis and 7 episodes of ESI were determined in group I, while 6 episodes of peritonitis and 1 episode of ESI were determined in group II. Staphylococcus aureus reproduction rate and mupirocin resistance were 2.11 and 0.2%, respectively. Coagulase-negative staphylococcus reproduction rate was 70.56% (MuR: 59.87% and MeR: 33.7%) and 72.6% (MuR: 64.7% and MeR: 33.3%) in groups I and II, respectively.

CONCLUSION

Mupirocin application at the exit sites reduces peritonitis and ESI to a considerable amount, and thrice-weekly application of mupirocin seems to be more efficient compared to once-weekly application.

A change to radiological peritoneal dialysis catheter insertion: three-month outcomes

BACKGROUND

Best practices for peritoneal dialysis (PD) catheter insertion call for timely placement of catheters to reduce complications and increase the likelihood of a successful initiation of PD. The purpose of our study was to assess if a change in approach to PD catheter insertion, including a switch to radiological insertion of PD catheters and introduction of a dialysis access nurse to coordinate all patient care, was associated with more outpatient procedures and achievement of guideline-based outcomes, including timelier PD starts. ♢

METHODS

We conducted a single-center retrospective chart review of all patients that had their first PD catheter inserted at our center over a 7-year period ending in 2007. ♢

RESULTS

PD catheters were placed in 88 patients by interventional radiology and in 125 patients by surgical insertion during an earlier period. Insertion of PD catheters by interventional radiology was significantly associated with a higher rate of outpatient procedures (70% vs 32%, p < 0.0001) than surgical placement. At PD start, 82% of patients that underwent radiological insertions had an estimated glomerular filtration rate of over 8 mL/minute/1.73 m(2) and their mean serum albumin level was 38.2 g/L. ♢

CONCLUSIONS

The new procedure of radiological insertion of PD catheters, coordinated by a dedicated dialysis access nurse, was associated with more outpatient procedures than the earlier surgical method and allowed patients to receive a PD catheter with timing consistent with clinical practice recommendations.

Use of the multipurpose drainage catheter for the provision of acute peritoneal dialysis in infants and children

BACKGROUND

Prior experience with the Cook (Cook Inc, Bloomington, IN) Teflon rigid catheter (CTC) showed it to be a suboptimal access for acute peritoneal dialysis (PD) treatment in infants and children because of the frequency of catheter-related complications associated with its use. The objective of this study is to report our experience with the bedside-placed flexible Cook Mac-Loc Multipurpose Drainage catheter (CMMDC) for acute PD in critically ill infants, comparing it with the historic Tenckhoff catheter (TC) and CTC use.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

All patients with acute renal failure (ARF) seen in our institution between December 2003 and April 2005 who underwent CMMDC placement for acute PD are included.

PREDICTOR

CTCs versus CMMDCs versus TCs.

OUTCOMES & MEASUREMENTS

Catheter-related complications and catheter-free survival.

RESULTS

21 infants and children with ARF were treated with acute PD using a CMMDC; 16 patients were post-cardiac surgery and 5 had other diagnoses. Mean patient age was 6.9 +/- 14.4 (SD) months (range, 4 days to 5.2 years; median, 1.6 months). Of 21 catheters, 3 had complications, and in 2 patients, this precluded continuation of PD therapy. In the remaining 18 patients, catheter use continued until recovery from ARF or nonrenal death. All patients achieved target fluid and solute removal with no catheter-related infectious complications. Mean complication-free survival of CMMDCs was 10.5 +/- 7.9 days (range, 2 to 29 days), with the 90% probability of survival at 14 days. Although there was no significant difference between lengths of complication-free survival of CMMDCs and TCs (58 days; P = 0.57), the difference between CMMDCs and CTCs (6 days) was significant (P < 0.001). Likewise, incidences of catheter-related complications with TCs and CMMDCs were similar, and in both cases, significantly less than the incidence associated with CTCs (49%; P < 0.01).

LIMITATIONS

Small number of patients and comparison with historic experience.

CONCLUSIONS

Use of CMMDCs is associated with the provision of effective dialysis with a satisfactory complication-free survival and should be considered when bedside placement of an acute PD access in infants and children is desired.