Malfunctioning Peritoneal Dialysis Catheter and Accompanying Surgical Pathology Repaired by Laparoscopic Surgery

♦ Objectives

To review the laparoscopic salvaging of malfunctioning peritoneal dialysis (PD) catheters, and to present our experience with laparoscopic repair of dysfunctional Tenckhoff catheters and the treatment of accompanying surgical pathologies.

♦ Design

Malfunctioning peritoneal catheters were repaired using laparoscopic rescue techniques. Accompanying surgical problems were treated in the same operation. The effectiveness of these approaches was validated by comparison with other remedial techniques described previously.

♦ Patients

Malfunctioning PD catheters were salvaged by laparoscopic surgery in 8 patients, and accompanying surgical problems were treated in the same operation in 3 of the 8 patients.

♦ Main Outcome Measures

Outcome was measured by the successful return to adequate PD and effective treatment of surgical problems.

♦ Results

Eight patient studies show laparoscopic correction of malfunctioning catheters and the treatment of accompanying surgical pathologies with the return to successful PD.

♦ Conclusion

The salvaging of malfunctioning PD catheters by laparoscopic surgery is an ideal method. This procedure permits simultaneous identification and correction of other surgical problems that could otherwise complicate dialysis therapy.

The Self-Locating Catheter: Clinical Evaluation and Comparison with the Tenckhoff Catheter

Background

Peritoneal catheter displacement appears to be related to various causes including omental attachment, bowel contractions, peritoneal adhesions, and the catheter floating in the dialysis fluid. In order to prevent this complication, which can impair peritoneal dialysis efficacy, Di Paolo et al. designed a “self-locating catheter” (SLC) that is similar to the Tenckhoff catheter (TC) and includes a small tungsten cylinder (weight 12 g) at the distal end (Di Paolo N, et al. The self positioning catheter. Proceedings of the VII Italian Congress on Peritoneal Dialysis. Milan: Wichtig Editore, 1993:539–42). The weight of the tip prevents the catheter from floating and migrating by gravitation toward the Douglas cavity.

Objective

Starting in 1996, we implanted SLC in 15 continuous ambulatory peritoneal dialysis patients. The aim of our study was to compare the ratio of migration and other catheter-related complications between patients with SLC (196 patient-months) and 13 patients with conventional straight TC (295 patient-months).

Results

Peritonitis ratio, catheter complication rate, dialysate inflow and outflow, and weekly creatinine clearance were similar in the two groups of patients. The incidence of catheter displacement was significantly higher ( p = 0.0349) in the TC group than in the SLC group (4 vs 0).

Conclusion

In our experience, the SLC seems to be useful in preventing catheter migration by continuous gravitation of its extremity toward the pelvic cavity.

Operative Technique for Laparoscopic Placement of Continuous Ambulatory Peritoneal Dialysis Catheter

Background: Peritoneal dialysis (PD) is an increasingly utilized treatment modality for renal replacement therapy that affords medical and lifestyle benefits to the patient and financial savings to the health care system. Successful long-term use of PD is reliant upon an optimally functioning catheter. Many potential catheter-related complications can be avoided through utilizing optimal placement technique. As widespread use of PD as a renal replacement modality continues to increase, the need for a safe, standardized, catheter placement technique has become more evident. Objectives: To present a succinct synopsis of the rationale and elements of our current surgical management strategy for patients undergoing evaluation for PD and to provide a detailed stepwise description of our operative technique for PD catheter placement. This review describes potential pitfalls that may prevent optimal catheter function and describes each step taken to prevent potential complications. This description is combined with intraoperative photographs to highlight key steps. Conclusion: Following a defined reproducible stepwise approach, laparoscopic placement of continuous ambulatory peritoneal dialysis catheters can be performed safely and known potential complications hindering optimal catheter function can be addressed prophylactically.

The placement of peritoneal dialysis catheters: a prospective randomized comparison of open surgery versus "Mini-Perc" technique

PURPOSE

Currently, most ESRD patients are treated with open surgical technique or with laparoscopic technique. In this study, we examined the role of the ureteroscope-assisted "Mini-Perc" technique versus the modified open surgery in the treatment of ESRD in a prospective randomized manner.

METHODS

A total of 72 patients with chronic renal failure were prospectively randomized for the ureteroscope-assisted "Mini-Perc" technique or modified open surgery. Intraoperative and postoperative morbidity, incision size, dose of local anesthesia, operative time, hospital stay, and initial catheter survival and follow-up were compared for both methods.

RESULTS

"Mini-Perc" group was associated with shorter incision size, operative time, and hospital stay, with lower dose of local anesthesia and incidence of bloody ascites. Two of five patients with the history of abdominal surgery in "Mini-Perc" group required adhesiolysis under direct vision of telescope. All adhesions were easily dissected. All complications of leakage (8.1 %) and incisional hernia (2.7 %) occurred in the open surgery group, but a difference of no significant value with "Mini-Perc" group (p = 0.2400, p = 1.0000). There was no any other significant difference in common complications between two groups. After 2 years of follow-up, 54 patients (75 %) survived with their initial PD catheter. The overall death was 5 (6.9 %).

CONCLUSIONS

Compared to modified open surgical technique, the ureteroscope-assisted "Mini-Perc" technique can be used to achieve the same clinical efficacy for placement of peritoneal dialysis catheters in ESRD patients, and it carries minimal morbidity.

Laparoscopic-assisted placement of a peritoneal dialysis catheter with partial omentectomy and omentopexy in dogs: an experimental study

OBJECTIVE

To describe a technique of laparoscopic-assisted placement of a peritoneal dialysis (PD) catheter with simultaneously performed partial omentectomy and omentopexy.

STUDY DESIGN

Pilot experimental study.

ANIMALS

Beagle dogs (n = 6).

METHODS

After placement of 1 sub-umbilical laparoscope portal and 1 instrument portal in the left cranial abdominal quadrant, laparoscopic-assisted partial omentectomy, and omentopexy were performed, and a modified Tenckhoff PD catheter was placed under laparoscopic guidance. A modified dialysis protocol was used twice daily for 4 days. The feasibility of the procedure, surgical duration, operative complications, and dialysis efficacy were evaluated. Postoperative pain and inflammation were graded (0-3).

RESULTS

The procedure was successfully performed in all dogs with a median operating time of 25 minutes. No operative complications occurred. Procedure-related postoperative pain and inflammation were minimal. Eight consecutive PD procedures were successfully performed, and no leakage or obstruction was observed.

CONCLUSIONS

Laparoscopic-assisted partial omentectomy and omentopexy can be performed at the same time as PD catheter placement with minimal morbidity.

The ureteroscope-assisted "Mini-Perc" technique of placement of peritoneal dialysis catheters with a 16-Fr Peel-Away sheath: 3-year results in 47 patients

OBJECTIVES

This study was undertaken to evaluate the clinical feasibility, safety and effect of the ureteroscope-assisted "Mini-Perc" technique with a 16-Fr Peel-Away sheath for insertion of peritoneal dialysis catheters in end-stage renal disease (ESRD) patients.

PATIENTS AND METHODS

47 consecutive ESRD patients underwent ureteroscope-assisted placement of peritoneal dialysis catheters via a 16-Fr Peel-Away sheath. Informed consent form was signed by patients under principle of voluntary.

RESULTS

The mean duration of the operation was 40 min (range, 21-75 min). Seven patients (14.9 %) experienced mechanical complications: catheter tip migration in 1 patient (2.1 %), slightly bloody ascites in 4 patients (8.5 %) and catheter-related peritonitis in 2 patients (4.3 %). Two catheters (4.3 %) were removed after renal transplantation. One patient (2.1 %) died from heart failure. One catheter (2.1 %) was explanted because of malfunction. After a mean follow-up time of 15 months (range, 2-36 months), 42 catheters are still functioning properly.

CONCLUSIONS

The ureteroscope-assisted "Mini-Perc" technique with a 16-Fr Peel-Away sheath is a simple, safe and effective method for placement of peritoneal dialysis catheters in ESRD patients.

Laparoscopic versus open peritoneal dialysis catheter insertion, the LOCI-trial: a study protocol

Background

Peritoneal dialysis (PD) is an effective treatment for end-stage renal disease. It allows patients more freedom to perform daily activities compared to haemodialysis. Key to successful PD is the presence of a well-functioning dialysis catheter. Several complications, such as in- and outflow obstruction, peritonitis, exit-site infections, leakage and migration, can lead to catheter removal and loss of peritoneal access. Currently, different surgical techniques are in practice for PD-catheter placement. The type of insertion technique used may greatly influence the occurrence of complications. In the literature, up to 35% catheter failure has been described when using the open technique and only 13% for the laparoscopic technique. However, a well-designed randomized controlled trial is lacking.

Methods/Design

The LOCI-trial is a multi-center randomized controlled, single-blind trial (pilot). The study compares the laparoscopic with the open technique for PD catheter insertion. The primary objective is to determine the optimum placement technique in order to minimize the incidence of catheter malfunction at 6 weeks postoperatively. Secondary objectives are to determine the best approach to optimize catheter function and to study the quality of life at 6 months postoperatively comparing the two operative techniques.

Discussion

This study will generate evidence on any benefits of laparoscopic versus open PD catheter insertion.

Trial registration

Dutch Trial Register NTR2878

Mini-laparotomy implantation of peritoneal dialysis catheters: outcome and rescue

BACKGROUND

Continuous ambulatory peritoneal dialysis is one of the main treatments for end-stage renal disease. To correct mechanical outflow obstruction after open surgical methods of catheter insertion, laparoscopic techniques are widely employed. ♢

METHODS

Between January 2001 and December 2006, 228 open Tenckhoff catheter implantations were carried out by mini-laparotomy in 218 patients at our medical center. The procedures were all performed by an experienced surgeon, and the postoperative care, patient education, and long-term follow-up were all conducted by the same peritoneal dialysis team. ♢

RESULTS

Infection of the exit site or tunnel was the most common complication (27/228, 11.8%), followed by peritonitis (18/228, 7.9%) and refractory mechanical catheter obstruction (9/228, 3.9%). The main causes of catheter removal were successful renal transplantation (21/228, 9.2%), peritonitis (18/228, 7.9%), and infection of the exit site or tunnel (7/228, 3.1%). In the 9 cases of refractory mechanical catheter obstruction, laparoscopic surgery was performed to identify the pathology and to rescue the catheter at the same time. Omental wrapping was the major cause (8/9) of catheter obstruction, with blood clot in the lumen and tube migration occurring in the remaining case (1/9). Partial omentectomy was performed in 5 patients to prevent recurrent obstruction. Neither technique failure nor operation-related complications were noted in our laparoscopic rescue group. For 20 of the 25 patients with refractory infection of the exit site or tunnel, the salvage technique of partial re-plantation was performed, with an 85% (17/20) technique survival rate. ♢

CONCLUSIONS

With an experienced surgeon and a good postoperative care team, open paramedian placement is a simple, safe, and effective method for Tenckhoff catheter insertion, with a low complication rate. Laparoscopic surgery is effective as rescue for mechanical obstruction, and partial re-plantation is effective as salvage for exit-site or tunnel infection.

Comparison of open and laparoscopic secure placement of peritoneal dialysis catheters

BACKGROUND

A major and frustrating complication of peritoneal dialysis catheter placement is mechanical outflow obstruction, which may be caused by catheter tip migration. Therefore, a secure and correct positioning of the catheter is important to minimize this risk. This technique is easily accomplished by a laparoscopic approach.

METHODS

The outcomes of 50 patients in whom peritoneal dialysis catheters were inserted laparoscopically with a secure catheter placement technique were compared with those of 52 patients who underwent an open surgical technique using a stiff wire as guidance for the catheter. The data were prospectively collected but not randomized. All the patients had virgin abdomens, and all the procedures were undertaken or supervised by one surgeon.

RESULTS

Catheter migration occurred in six patients (12%) in the open group, as compared with none in the laparoscopic group (p = 0.027). There were no significant differences in catheter survival between the two groups.

CONCLUSIONS

The laparoscopic technique with secure placement of the catheter lowered the incidence of catheter migration, but did not increase the catheter survival.