Pneumoperitoneum needle vs. introducer needle: Comparison of complications and short-term outcomes in percutaneously inserted peritoneal dialysis catheters in naïve abdomens

Percutaneous peritoneal dialysis catheter (PDC) insertion for continuous ambulatory peritoneal dialysis (CAPD) entails a higher risk of complications such as bowel injury, vascular injury, and catheter migration compared to the surgical insertions. We conducted a comparative analysis of two techniques of peritoneal entry for PDC insertion by Seldinger technique. We performed a retrospective review of 426 percutaneously inserted PDCs in nonobese naïve abdomens for CAPD at two tertiary care teaching hospitals in India over 6 years. Comparison of various mechanical complications, and short-term catheter survival was done between use of introducer needle (Group "I") and spring-loaded pneumoperitoneum (Veress) needle (Group "V"). Group "I" to "V" patient ratio was 277:149. Group "I" had heavier patients (p = 0.03) whereas "V" group had a dominance of diabetes (p = 0.009) and prior hemodialysis patients (p = 0.03). At 3 months, the odds of mechanical complications (OR = 0.27, p = 0.004), PDC migration (OR = 0.18, p = 0.02), and omental wrapping (OR = 0.13, p = 0.04) were less in "V" group. No bowel injury occurred with Veress needle use. At 6 months, "V" group had higher odds of event-free sustained PDC tip position (OR = 0.39, p = 0.003), and catheter survival (p = 0.03), and the cumulative events were lesser too (p = 0.002). Refractory peritonitis and deaths with functioning catheter were comparable between both the groups. In this first-of-its-kind study, spring-loaded Veress pneumoperitoneum needle use was safer, entrusted sustained PDC tip position in pelvis, and had a better catheter survival compared to use of introducer needle for peritoneal entry in percutaneously inserted PDCs. These findings should be confirmed by a randomized controlled study.

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.

Rescue and Salvage Procedures for Mechanical and Infectious Complications of Peritoneal Dialysis

Mechanical and infectious complications are the two most common reasons for removal of peritoneal dialysis catheters and permanent transfer of patients to in-center hemodialysis. Early and appropriate intervention can save many catheters, often without interrupting peritoneal dialysis. If peritoneal dialysis must be interrupted, other strategies may be employed to minimize the time on temporary hemodialysis and preserve peritoneal dialysis as renal replacement therapy. Procedures for managing dialysate leaks, abdominal wall hernias, infusion pain, and catheter flow dysfunction are described. Salvage techniques for catheter-related infections and peritonitis are presented. Clinical conditions are discussed where urgent removal of the dialysis catheter is indicated to protect the future integrity of the peritoneal membrane.

The role of laparoscopic surgery in the management of a malfunctioning peritoneal catheter

INTRODUCTION

Peritoneal catheter malfunction is a common complication of peritoneal dialysis (PD). It has a high failure rate with conservative management. Catheter replacement was historically the standard surgical treatment of choice. Nowadays, laparoscopy has been introduced as an alternative surgical modality to rescue the malfunctioning peritoneal catheter and also offers the possibility of replacement if indicated. The aim of this study was to compare the outcomes of these two surgical modalities.

METHODS

The medical records of consecutive patients who underwent surgical treatment for malfunctioning PD catheters (between January 2010 and April 2013) were analysed. The primary outcome included successful return to adequate PD. The secondary endpoint was length of catheter patency and the cause of catheter failure.

RESULTS

A total of 32 cases were identified, of which 8 had open catheter replacement and 24 had a laparoscopic intervention. The overall median follow-up duration was 12.5 months. The success rate for laparoscopic surgery in terms of functioning catheter at 12 months was 62.5% but only 37.5% for open surgery. The mean length of catheter patency after laparoscopic intervention was 31.6 months compared with only 13.6 months for the open surgery group. The most common cause of catheter failure diagnosed during laparoscopic intervention was catheter migration (33.0%), followed by omental wrap and catheter blockage by fibrin/blood plug (25.0% each). Open surgery did not have any diagnostic potential.

CONCLUSIONS

Laparoscopy is the treatment of choice for malfunctioning PD. Its proven benefit includes simultaneous identification of the aetiological cause of malfunction together with direct correction of this problem, thereby maximising outcome. It also allows for rapid recommencement of PD and avoidance of haemodialysis, saving cost and resources.

A single-center experience on percutaneously performed partial omentectomy in pediatric peritoneal dialysis patients

OBJECTIVE

This study describes a single-center experience on percutaneously performed partial omentectomy procedure in pediatric peritoneal dialysis (PD) patients who showed early catheter dysfunction and required catheter replacement due to catheter flow obstruction.

MATERIALS AND METHODS

We performed a retrospective review of clinical outcomes from pediatric PD patients who underwent percutaneous catheter replacement by pediatric nephrologists between November 1995 and December 2012. Partial omentectomy was performed in those patients in whom omental or adhesion trapping to the catheter tip was seen.

RESULTS

During the study period, catheter dysfunction that eventually required percutaneous catheter replacement occurred in 32 (23.7%) children. Of these, 9 patients were performed partial omentectomy. Mean age at initiation of PD and time of omentectomy was 97.48 ± 46.06 and 98.53 ± 45.55 months, respectively. Catheter dysfunction appeared after a mean 1.20 ± 1.0 months. The causes of catheter dysfunction were omental wrapping and malposition. No peritonitis occurred before omentectomy. Mean total operation time was 60 ± 8.83 min. No complications were encountered during the procedure. After omentectomy, mean catheter survival period was 5.92 ± 6.88 months. A total of five peritonitis episodes occurred. Three patients were transferred to hemodialysis. Six patients were on PD treatment without any problem at the end of the first year of their follow-up. Two patients underwent kidney transplantation. Four patients were still on chronic PD treatment at the end of the study period.

CONCLUSION

When performed by an experienced nephrologist, the performance of partial omentectomy by percutaneous route, when required, is an easy, safe and efficient therapeutic procedure in children on chronic PD treatment.

Laparoscopic omentectomy for salvage of peritoneal dialysis catheters

BACKGROUND AND PURPOSE

Maintaining long-term peritoneal catheter function for peritoneal dialysis is commonly threatened by problems with catheter obstruction. Multiple methods have been used to salvage nonfunctioning catheters, including omentopexy, catheter repositioning, and omentectomy. We report on our experience with a laparoscopic method of omentectomy and catheter fixation for salvage of nonfunctioning peritoneal dialysis catheters.

PATIENTS AND METHODS

Thirteen patients with nonfunctioning peritoneal dialysis catheters underwent 16 laparoscopic procedures with the intent to restore function. Clinically, all patients presented with outflow obstruction. At initial presentation, all patients underwent diagnostic laparoscopy and a definitive procedure. In 12 patients, catheters were enveloped by omentum, and we performed laparoscopic omentectomy and catheter fixation to the anterior pelvic wall. In one patient, we identified a broken catheter and performed a laparoscopic omentectomy at the time of catheter replacement. One 10-mm and two 5-mm trocars were utilized. Omentectomy was performed using either endo-GIA stapled resection (2 patients) or the Harmonic Scalpel (11 patients). All trocar incisions (including the 5-mm site) were closed with a suture-passing (Carter-Thomason) device to provide water-tight closure in anticipation of immediate return to peritoneal dialysis. Patients were followed postoperatively for an average of 17 months (range 4-35 months).

RESULTS

All patients' catheter function was restored intraoperatively with laparoscopic omentectomy and catheter fixation. Eight catheters remained functioning following omentectomy without further intervention. Five patients (38%) experienced repeat catheter malfunction and underwent laparoscopic exploration. Of these, three catheters (60%) were restored to function with laparoscopic manipulation alone. Three catheters were found encased in extensive adhesions. Laparoscopic adhesiolysis was successful in one patient and unsuccessful in one patient, who converted to hemodialysis. One patient failed laparoscopic salvage and required open laparotomy and fibrin clot removal to restore catheter function. One catheter was found to be obstructed within a pericolic hematoma. One catheter was found within residual omentum at the hepatic flexure. Both of these catheters were freed laparoscopically and continued to function at 12 and 16 months' follow-up. Complications included one episode of peritonitis, one case of postoperative ileus, and one trocar site hernia necessitating repair. The nephrologists were instructed that they could begin peritoneal dialysis on postoperative day 1. Seven patients resumed peritoneal dialysis without leak from trocar sites. The remaining patients received temporary hemodialysis through a central venous catheter and returned to peritoneal dialysis at the discretion of their nephrologists.

CONCLUSIONS

Laparoscopic omentectomy with catheter fixation is a minimally invasive means of salvaging peritoneal dialysis catheters with outflow obstruction. Complications are few, and closure of laparoscopic incisions in water-tight fashion allows rapid return to peritoneal dialysis.

Laparoscopic management of malfunctioning peritoneal dialysis catheters

BACKGROUND

Continuous ambulatory peritoneal dialysis (CAPD) is an established alternative method to hemodialysis for treating end-stage renal disease patients. However, this method is associated with a significant number of complications, such as catheter malposition, omental wrapping, and infection. The purpose of this study was to determine the efficacy of laparoscopy in the treatment of malfunctioning CAPD catheters.

METHODS

Between November 1994 and June 1999, a total of 16 patients with CAPD underwent laparoscopy for the evaluation and management of CAPD catheter dysfunction. Two trocars (10-mm and 5-mm) were used. Recorded data included patient demographics, catheter implantation method, date of malfunction, cause of dysfunction, procedure performed, complications, and catheter outcome.

RESULTS

The primary etiology of dysfunction was omentum and/or small bowel wrapping with adhesions in eight cases, malpositioning in five cases, and infection in the remaining three cases. Adhesiolysis was performed in the eight cases with adhesions. In the five cases with malpositioning but no adhesions, the catheters were repositioned in the pelvic cavity. Two catheters had to be withdrawn because of infection. In one case with tunnel infection, the catheters were exchanged simultaneously. There was only one perioperative complication, consisting of temporary dialysate leakage. There were no mechanical or infection problems. The overall success rate of catheter function (>30 days after laparoscopy) was 100%, except for two cases in which the catheters had to be removed.

CONCLUSION

Laparoscopy is a highly effective and successful method for the evaluation and management of peritoneal dialysis catheter dysfunction.