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

Establishing an animal model for peritoneal catheter malfunction caused by omental wrapping using negative pressure suction: in vitro and in vivo exploration

BACKGROUND

This study aims to establish a simplified and effective animal model of catheter malfunction caused by omental wrapped using negative pressure suction.

METHOD

The peritoneal dialysis catheter outlet was linked to a negative-pressure (0-75mmHg) suction pump to intensify the negative pressure. Different negative pressures were tested for model construction in vitro. In vivo, a model of peritoneal catheter malfunction caused by omental wrapped was constructed in five beagles after catheter placement. Catheter drainage conditions and related complications were monitored before and after the model establishment.

RESULTS

In the vitro experiment, the overall success rate of constructed models was 90% (36/40). The total malfunction rate was higher in 62.5 mmHg (10/10) and 75 mmHg (10/10) than in 12.5 mmHg (8/10) and 37.5 mmHg (8/10). The outflow velocity of dialysate at 62.5 mmHg was significantly lower than that at 12.5 mmHg and 37.5 mmHg, without a statistically significant difference compared to 75 mmHg. In the in vivo experiment, catheter outflow velocity increased, and residual fluid volume decreased after omental wrapped (99.6 ± 6.7 ml/min vs. 32.6 ± 4.6 ml/min at initial five minutes, p < 0.0001; 69.2 ± 16.3 ml vs. 581.0 ± 109.4 ml, p < 0.001). And the outflow velocity was finally below 2 ml/min. No severe related complications (such as infection, organ damage, or bleeding) were observed through laparoscopic examination and dialysate tests seven days post-operation.

CONCLUSION

Utilizing negative pressure suction to increase negative pressure around catheter tip is a simple, safe, and effective method for establishing an animal model of omental wrapped leading to catheter malfunction.

Minimizing early catheter failure using a risk stratification model for peritoneal dialysis

BACKGROUND

Early catheter failure is the main reason for peritoneal dialysis (PD) failure, which often causes patients to withdraw from PD. Reducing the early catheter failure is critical to increase the acceptance of PD. The purpose of our study was to establish a risk stratification model to minimize early catheter failure.

METHODS

A retrospective study with patients underwent PD catheter placement from January 2013 to March 2022 was conducted. The primary outcome event was early catheter failure. Univariate and multivariable logistic regression were performed to select potential risk predictors. A risk stratification model and a clinical procedure were established. The effectiveness of the model was evaluated by external validation.

RESULTS

A total of 432 patients were finally enrolled in the study. The risk for early catheter failure was associated with younger age (odds ratio [OR], 0.930; 95% confidence interval [95% CI], 0.884 to 0.972; p = 0.002), lower body mass index (BMI) (OR, 0.797; 95% CI, 0.629 to 0.964; p = 0.036), and lower albumin (ALB) levels (OR, 0.881; 95% CI, 0.782 to 0.985; p = 0.036). The risk stratification model was established and performed great discrimination capability with AUC of 0.832 (cut-off value: 0.061, sensitivity: 0.853, specificity: 0.812). The model proved to be effective in external validation; the rate of early catheter failure was dropped off from 4.1% to 0%.

CONCLUSIONS

We established an effective risk stratification model, by which patients with high risk of early catheter failure could be precisely identified. The clinical procedure based on the model was proved to be helpful to minimize early catheter failure.

SAGES peritoneal dialysis access guideline update 2023

BACKGROUND

Minimally invasive surgery has been used for both de novo insertion and salvage of peritoneal dialysis (PD) catheters. Advanced laparoscopic, basic laparoscopic, open, and image-guided techniques have evolved as the most popular techniques. The aim of this guideline was to develop evidence-based guidelines that support surgeons, patients, and other physicians in decisions on minimally invasive peritoneal dialysis access and the salvage of malfunctioning catheters in both adults and children.

METHODS

A guidelines committee panel of the Society of American Gastrointestinal and Endoscopic Surgeons reviewed the literature since the prior guideline was published in 2014 and developed seven key questions in adults and four in children. After a systematic review of the literature, by the panel, evidence-based recommendations were formulated using the Grading of Recommendations Assessment, Development and Evaluation approach. Recommendations for future research were also proposed.

RESULTS

After systematic review, data extraction, and evidence to decision meetings, the panel agreed on twelve recommendations for the peri-operative performance of laparoscopic peritoneal dialysis access surgery and management of catheter dysfunction.

CONCLUSIONS

In the adult population, conditional recommendations were made in favor of: staged hernia repair followed by PD catheter insertion over simultaneous and traditional start over urgent start of PD when medically possible. Furthermore, the panel suggested advanced laparoscopic insertion techniques rather than basic laparoscopic techniques or open insertion. Conditional recommendations were made for either advanced laparoscopic or image-guided percutaneous insertion and for either nonoperative or operative salvage. A recommendation could not be made regarding concomitant clean-contaminated surgery in adults. In the pediatric population, conditional recommendations were made for either traditional or urgent start of PD, concomitant clean or clean-contaminated surgery and PD catheter placement rather than staged, and advanced laparoscopic placement rather than basic or open insertion.

ISPD Catheter-related Infection Recommendations: 2023 Update

Peritoneal dialysis (PD) catheter-related infections are important risk factors for catheter loss and peritonitis. The 2023 updated recommendations have revised and clarified definitions and classifications of exit site infection and tunnel infection. A new target for the overall exit site infection rate should be no more than 0.40 episodes per year at risk. The recommendation about topical antibiotic cream or ointment to catheter exit site has been downgraded. New recommendations include clarified suggestion of exit site dressing cover and updated antibiotic treatment duration with emphasis on early clinical monitoring to ascertain duration of therapy. In addition to catheter removal and reinsertion, other catheter interventions including external cuff removal or shaving, and exit site relocation are suggested.

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.

Are salvage techniques safe and effective in the treatment of peritoneal dialysis catheter-related exit-site and tunnel infections? A systematic review and description of the authors' preferred technique

BACKGROUND

Peritoneal dialysis catheter (PDC)-related infections account for significant morbidity, PD disruptions and costs. Patients with refractory exit-site or tunnel track infections without peritonitis may need catheter removal and reinsertion which can be complicated by bleeding, organ injury, catheter failure or malposition. Some patients may need to switch to haemodialysis in such a setting. An alternative is a salvage procedure. The purpose of this systematic review is to evaluate the safety and efficacy of salvage techniques.

METHODS

A comprehensive search of PubMed, Medline and Scopus databases was performed from inception to December 2021 in accordance with PRISMA guidelines. After a broad search, articles were stratified into two main categories for assessment: (1) cuff-shaving (CS) techniques and its variations of en-bloc resection (BR) and/or catheter diversion (CD) and (2) partial reimplantation with CD.

RESULTS

A total of 409 patients (445 salvage procedures) from 20 studies were included in analysis. Of 409 patients, 234 patients (57.2%) underwent 251 (56.4%) CS procedures and its variations, 163 patients (39.9%) underwent 182 (40.9%) partial PDC reimplantations with CD and 12 patients (2.7%) underwent local curettage. Overall PDC salvage rate after intervention was 73.2%. Overall PDC removal rate attributable to infection was 26.8%. Overall complication rate attributable to the procedures was 2.7%, with the most common complication being dialysate leakage (n = 10) followed by PDC laceration (n = 1) and subcutaneous haematoma (n = 1). We also included a description of our technique of BR of infected tissue, CS and CD. In a series of six patients, the PDC salvage rate was 83.3% and median PDC survival after intervention was 10 months.

CONCLUSION

PDC salvage techniques are relatively safe and provide reasonable catheter salvage rates in selected patients. Results of this review should lend weight to consideration of a salvage-first approach as an option in selected patients.

Success rates and safety of a modified percutaneous PD catheter placement technique: Ultrasound-guided percutaneous placement of peritoneal dialysis catheters using a multifunctional bladder paracentesis trocar

BACKGROUND

We modified the blind Seldinger technique by incorporating ultrasound guidance and the use of a multifunctional bladder paracentesis trocar for PD catheter (PDC) placement, which can be easily performed by a nephrologist and is a feasible technique. To compare success rates and safety of our modified percutaneous PD catheter placement technique to open surgery.

METHODS

Two hundred and twelve stage-5 chronic kidney disease(CKD) patients receiving PD therapy from June 2016 to June 2019 were included, 105 patients treated by ultrasound-guided percutaneous placement of peritoneal dialysis catheters using a multifunctional bladder paracentesis trocar (Group A) and 107 patients receiving open surgical placement (Group B). Outcomes of patients via either catheter placement technique were retrospectively compared. The clinical success rate as defined by proper catheter drainage within 4 weeks after placement, complication rates (both technical complications and infections), and 1-year catheter survival were compared.

RESULTS

There was no significant difference in sex ratio, age, or previous abdominal surgery history between groups (P > .05). Both surgical time and incision length were significantly shorter in Group A than in Group B (P < .05). Clinical success rate was also higher inGroup A (P < .05). Moreover, Group A demonstrated lower overall complication rates (P < .05) and lower incidence rates of early peritonitis, initial drainage disorder, and peritubular leakage (all P < .05). One-year catheter survival was also higher in Group A (P < .05).

CONCLUSION

Percutaneous placement of PD catheters using our modified technique demonstrates superior success rates and safety compared to open surgery. In addition, our modified technique can be a better alternative to traditional Seldinger percutaneous catheterization for its higher success rate and safety, more accurate positioning.

Risk Factors and Management of Catheter Malfunction During Urgent-Start Peritoneal Dialysis

Background: Catheter malfunction is a common complication of peritoneal dialysis (PD). This study aimed to retrospectively analyze the risk factors and management of catheter malfunction in urgent-start PD.

Methods: Patients who underwent urgent-start PD were divided into catheter-malfunction and control groups. Baseline demographic and laboratory data of the two groups were compared, and the risk factors for catheter malfunction were analyzed. Primary outcome measure was catheter survival, and the secondary outcomes were surgical complications and malfunction treatment.

Results: Total of 700 patients was analyzed, among whom 143 (20.4%) experienced catheter malfunctions, specifically catheter migration (96, 67.1%), omental wrapping (36, 25.2%), and migration plus omental wrapping (11, 7.7%). Catheter survival time in the malfunction group (202.5 ± 479.4 days) was significantly shorter than that in the control group (1295.3 ± 637.0 days) (P < 0.001). Multivariate analysis revealed higher body mass index [hazard ratio (HR), 1.061; 95% confidence intervals (CI), 1.010–1.115; P = 0.018], lower surgeon count (HR, 1.083; 95% CI, 1.032–1.136; P = 0.001), and higher serum potassium (HR, 1.231; 95% CI, 1.041–1.494; P = 0.036) as independent risk factors for catheter malfunction, while older age (HR, 0.976, 95% CI, 0.962–0.991; P = 0.002) and colonic dialysis (HR, 0.384; 95% CI, 0.254–0.581; P < 0.001) as protective factors. Further subgroup analysis revealed a shorter catheter survival time in patients with younger age ( ≤ 40 years), higher serum potassium levels (≥5 mmol/L), while a longer catheter survival time in patients with colonic dialysis. PD tube and subcutaneous tunnel preservation was successful in 41 out of 44 patients with omental wrapping. All patients had good post-incision prognoses.

Conclusions: Urgent-start PD is safe and effective for unplanned PD patients. Adequate pre-operative colonic dialysis and serum potassium level control are conducive in preventing catheter malfunction. Conservative treatment is effective in managing catheter migration alone, while preservation of the PD tube and the subcutaneous tunnel is effective for omental wrapping.

Implantation of a peritoneal dialysis catheter in patients with ESRD using local anesthesia and Remifentanil

Study objective

The main objective of this study is to test the feasibility of the local anesthetic (LA) Mepivacaine 1% and sedation with Remifentanil as the primary anesthetic technique for the insertion of a peritoneal dialysis (PD) catheter, without the need to convert to general anesthesia.

Methods

We analyzed 27 consecutive end-stage renal disease (ESRD) patients who underwent the placement of a peritoneal catheter at our center between March 2015 and January 2019. The procedures were all performed by a general or vascular surgeon, and the postoperative care and follow-up were all conducted by the same peritoneal dialysis team.

Results

All of the 27 subjects successfully underwent the procedure without the need of conversion to general anesthesia. The catheter was deemed prone to usage in all patients and was found to be leak-proof in 100% of the patients.

Conclusion

This study describes a safe and successful approach for insertion of a PD catheter by combined infiltration of the local anesthetic Mepivacaine 1% and sedation with Remifentanil. Hereby, ESRD patients can be treated without general anesthesia, while ensuring functionality of the PD catheter.

Comparison of single-injection ultrasound-guided thoracic paravertebral block with transversus abdominis plane block in peritoneal dialysis catheter implantation: a randomized controlled trial

Background

Previous study indicated that transversus abdominis plane (TAP) block could be the principal anesthetic technique for peritoneal dialysis catheter (PDC) implantations. However, a TAP block could not provide an optimal anesthetic effect on catheter exit site during PDC implantation. We hypothesized that single-injection ultrasound-guided thoracic paravertebral block (US-TPVB) could be the principal anesthetic technique with better pain relief at catheter exit site during PDC implantation, compared to a TAP block. And anesthesia quality of a single-injection US-TPVB was compared with that of a TAP block and local anesthetic infiltration (LAI).

Methods

Patients undergoing PDC implantations were randomized into groups TPVB or TAP or LAI. In group TPVB, single-injection US-TPVB at T10-T11 level was performed with 20 ml of 0.25% ropivacaine. In group TAP, oblique subcostal TAP block was performed with 20 ml of 0.25% ropivacaine. In group LAI, 40 ml of 0.25% ropivacaine was used. Anesthesia quality was compared among the three groups, including general anesthesia conversion rate, cumulative rescuing sufentanil consumption, and satisfaction rate by nephrologists and patients.

Results

Eighty-eight eligible patients were enrolled. Visual analogue scale (VAS) at most time points (except for the catheter exit site) were lower in group TAP, compared with group TPVB. VAS at parietal peritoneum manipulation was 6 (5, 7), 3 (0, 6), and 7 (4.75, 9) in groups TPVB, TAP, and LAI, respectively (P < 0.001). VAS at catheter exit site was 4 (3, 4), 5.5 (4, 8), and 5 (3, 7.25) in groups TPVB, TAP, and LAI, respectively (P = 0.005). Lower general anesthesia conversion rate, less cumulative rescuing sufentanil consumption, and higher satisfaction rates by nephrologists and patients were recorded in group TAP, compared with groups TPVB and LAI.

Conclusions

Single-injection US-TPVB provided a better pain relief at catheter exit site. The quality and reliability of anesthesia after a single-injection US-TPVB was comparable to that of LAI, but not better than that of an oblique subcostal TAP block for PDC implantation.

Trial registration

TCTR20160911002. Registered on 8 September 2016.

Impact of peritoneal catheter intramural design on dialysis discontinuation rate

AIM

Catheter dislocation is an important cause of technique failure for peritoneal dialysis (PD). Aim of this study is to evaluate the effect of intramural trait configuration on this outcome.

METHODS

We considered 240 swan neck, double-cuffed catheters positioned in adult patients in our Centre with mini-laparotomy technique partitioned, according with the intramural segment design, in a standard technique group (ST) (n. 199): oblique passage of the catheter through the rectus sheath in the craniocaudal direction, and in a modified technique group (MT) (n. 41): anterior fascia lanced 3 cm cranially to the deep cuff to let catheter out. The primary end-point was dialysis failure due to tip migration. Secondary end-points were any other causes of catheter removal.

RESULTS

Incidence of catheter removal for non-responsive tip migration was 14.3% in MT and 6.1% in ST. Neither this difference nor the catheter survival rate for this outcome was statistically significant. PD interruption for refractory exit site/tunnel infection (ESI) was in favour of ST (4% ST, 35.7% MT; P < .01) whereas ESI catheter survival rate was only marginally significant (292.8 days in MT vs 743.6 in ST, P = .045). No other recorded cause of PD discontinuation was significantly different.

CONCLUSION

Modified technique group is associated with a major ESI risk but, given the average survival, it seems to be due more to exit site management than to the specific surgical procedure. MT is not superior to ST to prevent catheter dislocation nevertheless, considering its simplicity and rapidity it can be deemed as first-choice option.

Ultrasound-Guided Oblique Sub-Costal Transversus Abdominis Plane Block as the Principal Anesthesia Technique in Peritoneal Dialysis Catheter Implantation and Plasma Ropivacaine Concentration Evaluation in Esrd Patients: A Prospective, Randomized, Double-Blinded, Controlled Trial

Background

The ultrasound-guided transversus abdominis plane (TAP) block is generally used for analgesia but not for anesthesia. A TAP block has a partial analgesic effect on the parietal peritoneum in abdominal surgeries. We hypothesized that an ultrasound-guided oblique subcostal TAP block, used as the principal anesthesia technique, could provide a better anesthetic effect on peritoneum stimulation in peritoneal dialysis catheter (PDC) implantation in end-stage renal diseases (ESRD) patients than local anesthetic infiltration (LAI).

Methods

End-stage renal disease patients undergoing PDC implantation were randomized into 3 groups: LAI Group, unilateral TAP group (Uni-TAP Group) and bilateral TAP group (Bi-TAP Group). A 40-mL dose of 0.25% ropivacaine was used for the regional block (LAI or TAP). The quality of anesthesia, visual analogue scale (VAS) of pain, cumulative rescuing sufentanil consumption, and venous plasma ropivacaine concentrations were compared among the 3 groups.

Results

Sixty-nine patients were enrolled, and higher ‘Satisfied’ anesthesia rates from nephrologists and patients were recorded in the 2 TAP groups, compared with the LAI Group. Significantly lower VAS scores were observed in the Uni-TAP Group at a majority of time points compared with the LAI Group. Less cumulative rescuing sufentanil was used in the 2 TAP groups (2.5 ± 2.7 and 3.0 ± 2.8 μg, respectively) compared with the LAI Group (5.8 ± 2.6 μg, p < 0.05). The median peak venous plasma ropivacaine concentrations were below the reported toxic threshold in all 3 groups.

Conclusions

As the principal anesthesia technique, an ultrasound-guided unilateral oblique subcostal TAP block with 40 mL of 0.25% ropivacaine provided better anesthetic effect in PDC implantations in ESRD patients than LAI.

Protocol for a randomised, open-label, parallel group, multicentre controlled study to evaluate the clinical performance and safety of Stay Safe Link compared with Stay Safe in patients with end-stage kidney disease on continuous ambulatory peritoneal dialysis

INTRODUCTION

Peritonitis is a major complication of continuous ambulatory peritoneal dialysis (CAPD), the risk of which is significantly influenced by the type of PD transfer system. Although the Y-disconnect and double-bag system is more efficient in preventing peritonitis compared with the spike system, little information is available to differentiate risks between different brands of the Y-disconnect double-bag system. A randomised controlled trial to evaluate the safety and efficacy of a newly introduced system is needed to provide the necessary clinical evidence to guide policy decision-making.

METHODS AND ANALYSIS

The study is an open-label randomised controlled trial. A total of 434 patients with end-stage renal disease undergoing CAPD will be enrolled and randomised to either the intervention group, Stay Safe Link, or the control group, Stay Safe. All study subjects will be followed up and monitored for 1 year. The primary safety outcome is the rate of peritonitis while the primary efficacy outcomes are the delivered dialysis dose and ultrafiltration volume.

ETHICS AND DISSEMINATION

The study was approved by the Medical Research Ethics Committee, National Institute of Health Malaysia. A written informed consent will be obtained from all participating subjects prior to any trial-related procedure and the study conduct will adhere strictly to Good Clinical Practice. The findings will be disseminated in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT03177031; Pre-results.

Reducing the occurrence rate of catheter dysfunction in peritoneal dialysis: a single-center experience about CQI

To reduce the occurrence rate of peritoneal dialysis (PD) catheter dysfunction caused by catheter displacement or plugging, this study screened all patients with peritoneal dialysis catheterization from 2002 to 2015 from the Third Xiangya Hospital of Central South University. There were 256 patients before continuous quality improvement (CQI) (from 2002 to 2007) and 813 patients after CQI (from 2008 to 2015). The occurrence rate of catheter dysfunction was 5.9% in the preCQI group: seven cases were associated with peritonitis, six cases were involved in omentum wrapping, one case was blocked by oviduct, and one case was blocked by blood clot. Through PDCA (plan-do-check-act) four-step of CQI, the following measures were adopted: (1) Preoperative: treat complications, enema and urine catheterization (2) Intraoperative: strengthen analgesia, Lower the insert position of catheter to 7.5 ∼ 8.5 cm above the pubic symphysis, extending the straight distance of catheter in rectus abdominis and decrease the times of peritoneal dialysis catheter implantation. (3) Postoperative: strengthen the training of nurses, patients and their families. (4) strengthen anticoagulation therapy during peritonitis treatment. (5) use laparoscopic technology for refractory patients, and so on. The occurrence of catheter dysfunction was 1.5% in the postCQI group (p < 0.05): two cases were associated with peritonitis, ten cases were involved in omentum wrapping. The measures we adopted in CQI reduce the occurrence rate of catheter displacement or plugging in peritoneal dialysis.

Continuous Ambulatory Peritoneal Dialysis Catheter Insertion Technique: A Comparative Study of Percutaneous versus Surgical Insertion

Continuous ambulatory peritoneal dialysis (CAPD) is a standard renal replacement therapy, but there is a lack of consensus for catheter insertion method and type of catheter used. We retrospectively analyzed 140 peritoneal dialysis catheters (PDC) inserted in 139 CAPD patients by two methods; percutaneous (Group “P,” n = 47) and surgical mini laparotomy (Group “S,” n = 93) technique over a 39-month period, with cumulative experience of 2415 catheter-months: 745 catheter-months for Group “P” and 1670 catheter-months for Group “S.” Break-in period was shorter in Group “P” (P = 0.002) whereas primary nonfunction rate was comparable (P = 0.9). The mean catheter survival was better in Group “S” (17.95 ± 10.96 months vs. 15.85 ± 9.41 months in “P” group, P = 0.05) whereas the death-censored and overall catheter survival was comparable in both groups. PDC removal due to refractory peritonitis was also comparable. Mechanical complications were more in “P” group (P = 0.049), leading to higher catheter removal (P = 0.033). The peritonitis rates were higher in “P” group (1 episode per 24.8 catheter-months vs. 1 episode per 34.8 catheter-months in “S” group, P = 0.026) and related to a higher number of rural patients in the group (P = 0.04). Patient survival was comparable. There was no effect on episodes of peritonitis in those CAPD patients who had diabetic etiology or prior hemodialysis catheter-related sepsis, age, and PDC insertion method.

Peritoneal Dialysis Catheter Revision and Replacement by Nephrologist for Peritoneal Dialysis Catheter Malfunction

BACKGROUND

Catheter malfunction is an important cause of technique failure for peritoneal dialysis (PD) patients, and is commonly managed by surgeons or intervention radiologists. We reviewed our experience in catheter revision or replacement by nephrologists.

METHOD

We reviewed the clinical outcome and complication rate of 95 consecutive patients who had PD catheter malfunction, with catheter revision or replacement by nephrologist.

RESULT

Amongst the 95 patients, 32 had catheter revision, 24 catheter replacement via the original wound, and 39 catheter replacement via a new mini-laparotomy wound. Catheter survival was 71.6% at 1 month and 48.4% at 6 months; technique survival was 88.4% at 1 month and 77.4% at 6 months. When the 3 types of procedure were analyzed separately, technique survival at 1 month was 96.8, 75.0, and 89.7%, respectively, for patients who received catheter revision, catheter replacement via the original wound, and catheter replacement via a new mini-laparotomy wound (p = 0.0002), although their catheter survival rates were not significantly different. Also, 2 patients had bleeding that required urgent surgical exploration, 2 had wound infection, and 8 had peritonitis within 4 weeks after the surgery.

CONCLUSION

PD catheter revision and replacement by nephrologist has an acceptable catheter survival and a reasonable complication rate. Given that prompt intervention is an important consideration, catheter revision and replacement by nephrologist is a suitable method for the management of catheter malfunction.

Chronic peritoneal dialysis in children: the role of ultrasound in the diagnosis of peritoneal catheter obstruction

PURPOSE

Over the past two decades, continuous ambulatory peritoneal dialysis has emerged as the first-choice dialysis modality in children awaiting for transplantation. Despite the improvements observed in catheter survival over the past several years, the obstruction is one of the reasons for immediate catheter non-function. This study assessed usefulness of ultrasound (US) in visualizing the obstruction of chronic peritoneal dialysis (CPD) catheter and identifying the etiology.

MATERIALS AND METHODS

Between January 2000 and November 2012, 38 patients (20 M, 18 F) were treated with CPD and examined with US. The type of catheter in all subjects was the straight two-cuff Tenckhoff catheter. We evaluated the typical sonographic signs of the most common CPD catheter complications.

RESULTS

We had 12/38 cases with catheter malfunction due to its obstruction. In eight patients, US showed the presence of echogenic material fragmented into the lumen and around the distal tip of the catheter. In the other four patients, US demonstrated the displacement of catheter in bowel loops and an amorphous material as homogeneous echoic area around the distal tip.

CONCLUSIONS

Our results confirm the effectiveness of US in the assessment of the complications related to intraperitoneal catheters. US is able to identify the catheter obstruction and recognize the etiology (endoluminal strands of fibrin, other materials or the omental wrapping), facilitating a correct therapeutic approach.

Transversus abdominis plane block as the primary anesthetic for peritoneal dialysis catheter surgery

STUDY OBJECTIVE

The primary goal of this study was to determine whether transversus abdominis plane (TAP) blocks were effective as the primary anesthetic technique for insertion and/or removal of peritoneal dialysis catheters.

DESIGN

This study is a descriptive case series investigation.

SETTING

Operating rooms at a tertiary care academic medical center.

PATIENTS

Twenty-four patients, American Society of Anesthesiologists (ASA) physical status 3 and 4, were included in this study.

INTERVENTIONS

Patients who had received a TAP block preoperatively for open surgical insertion or removal of a peritoneal dialysis catheter over a 26-month period with the intent of the block to serve as the primary anesthetic were included in this study.

MEASUREMENTS

Preoperative and intraoperative sedative medications and local anesthetic medications were analyzed. The primary outcome of the study was the ability of the TAP block to provide surgical anesthesia as determined by a lack of need to convert to general anesthesia (defined by placement of an airway device, use of volatile anesthetics, intraoperative propofol infusion dose equal to or greater than 100 μg kg(-1) min(-1)). Secondary outcomes included analysis of any complications from the higher concentrations of local anesthetics required for surgical block.

MANI RESULTS

Of 24 patients, 21 underwent the procedure without conversion to general anesthesia as defined above. No complications related to local anesthetics were found.

CONCLUSION

Transversus abdominis plane blockade can be successful at serving as the primary anesthetic modality for the insertion and/or removal of a peritoneal dialysis catheter by open-surgical approach. There were no systemic toxic effects or other complications recorded.

Chronic peritoneal dialysis in children

The incidence of end-stage renal disease in children is increasing. Peritoneal dialysis (PD) is the modality of choice in many European countries and is increasingly applied worldwide. PD enables children of all ages to be successfully treated while awaiting the ultimate goal of renal transplantation. The advantages of PD over other forms of renal replacement therapy are numerous, in particular the potential for the child to lead a relatively normal life. Indications for commencing PD, the rationale, preparation of family, technical aspects, and management of complications are discussed.

Flexible endoscopic single-incision extraperitoneal implant and fixation of peritoneal dialysis catheter: proof of concept in the porcine model

BACKGROUND

Peritoneal dialysis (PD) catheters placed in the pelvic space without anchoring present a high rate of migration. We aimed to assess the feasibility of a single-incision approach, using a flexible endoscopic preperitoneal tunneling for catheter implantation and fixation.

MATERIALS AND METHODS

Eight pigs were involved in this experimental study. A 2/0 Vicryl loop was sutured at the tip of a PD catheter. In 4 pigs, a 1.5 cm incision was made on the left paramedian line and the parietal peritoneal layer was identified by splitting rectal muscles. A gastroscope was inserted in the incision and advanced in the extraperitoneal space. An exit hole was made in the peritoneum over the low pelvic cavity. A guidewire was left in the abdominal cavity, and the PD catheter was inserted over the guidewire. The endoscope was inserted in the tunnel again, and endoscopic clips were deployed over the Vicryl loop to fix the catheter. In 4 pigs, the PD catheter was inserted laparoscopically using a two-port approach. The catheter's tip was fixed with laparoscopic clips on the Vicryl loop. A strain test to assess the force required to detach clips was performed using a digital dynamometer.

RESULTS

Operative time for flexible endoscopic tunneling was longer when compared to the laparoscopic implant (29.5 ± 4.43 vs. 22.7 ± 2.51 min). Mean force to displace the catheter was similar after flexible endoscopic fixation when compared to laparoscopic clip fixation (5.57 N ± 2.76 vs. 4.15 N ± 1.76).

CONCLUSIONS

Flexible endoscopic extraperitoneal tunneling allows for minimally invasive single-incision PD catheter placement and fixation.

A novel method for salvage of malfunctioning peritoneal dialysis catheter

CONTEXT

Continuous ambulatory peritoneal dialysis (CAPD) has been widely used as an effective therapy in the management of patients with end-stage renal disease. Long-term use of CAPD needs methods with low incidence of catheter-related complications. Moreover, some complications may cause failure of fluid drainage and treatment interruption.

AIMS

We have innovated and studied a new minimal-invasive method of malfunctioning peritoneal catheter repair.

MATERIALS AND METHODS

Thirty-five patients agreed to undergo catheter rescue operation by this new method during 2004 and 2012. Under local anesthesia and light sedation, access to the abdominal cavity was made, the catheter and wrapped omentum grasped and the tip of catheter was released, debris were removed and the catheter was directed toward the pelvic floor with a finger guide. The patients were followed after catheter salvage up to the end of study (April 2012). PD catheter function restored to the normal level in 28 (80%) of patients, and PD was started 1-2 days after the procedure.

RESULTS

All patients had an uneventful recovery. PD catheter function was restored to the normal level in 28 (80%) patients, and PD was started 1-2 days after the procedure. Of these patients, 10 (35%) died of reasons unrelated to catheter or catheter complications; 7 (25%) were ultimately referred for kidney transplant; 8 (29%) continued PD up to the end of this study with no problem, and only 3 (11%) due to catheter complications. Catheter function did not restore to the normal level in seven patients (20%); however, six patients continued PD for 1-18 months with the catheter.

CONCLUSIONS

Comparing the advantages and disadvantages of this method to the previous laparoscopically repaired catheter, we concluded that this new method is efficient, and is a suitable way for malfunctioning PD catheter salvage.

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.

A novel adaptation of laparoscopic Tenckhoff catheter insertion technique to enhance catheter stability and function in automated peritoneal dialysis

INTRODUCTION

Automated peritoneal dialysis (APD) normally takes place overnight. Maintaining a stable PD catheter position, independent of body position, omental wrapping or catheter displacement secondary to bowel movements is essential in maintaining effective catheter function.

METHODS

We developed a new procedure of catheter placement through combining and adapting several previously described operative techniques including laparoscopic placement of a curled double cuff Tenckhoff catheter with subcutaneous tunneling superior to the rectus sheet, an oblique course through the abdominal wall, deep entry into the pelvic peritoneum and directed placement of the curled tip within the pouch of Douglas. Retrospective analysis of catheter function was conducted, evaluating catheter position, function, complication rate and catheter survival against findings for current insertion techniques described within literature.

RESULTS

Between March 2009 and November 2011, 54 patients underwent PD catheter insertion. The observation period was an average of 343 ± 273 days. All patients received abdominal plain film showing optimal catheter position in 89 %. Reported catheter function was very good in 85.2 %, with no or few alarms per week during APD, moderate in 9.3 % with occasional minor dysfunctions (≤ 2 alarms per night), and poor in 5.6 %, with regular alarm disturbance. In one case, primary dysfunction led to catheter replacement. At completion, stable catheter function with occasional minor dysfunction was achieved in 52 of 54 cases. Catheter-related complications (leakage, hydrocele formation, infection and need for replacement) were observed in 14.8 %. At the end of the observation period, 55.6 % of catheters remained in use. Patient dropout occurred through death (18.5 %), renal transplantation (7.4 %), renal recovery (1.9 %), removal secondary to infection or dysfunction (9.3 %) and conversion to HD due to poor dialysis quality (7.4 %).

CONCLUSION

The above technique combines and optimises previously described laparoscopic catheter implantation techniques, allowing increased catheter stability resulting in an undisturbed catheter function suitable for APD.

Dual-incision laparoscopic surgery for peritoneal dialysis catheter implantation and fixation: a novel, simple, and safe procedure

BACKGROUND

Peritoneal dialysis (PD) is an alternative modality to hemodialysis and is usually used to treat patients with end-stage renal disease. Dual-incision laparoscopic surgery (DILS) had been reported in several surgical fields; however, no report was proposed about DILS in PD catheter implantation (DILS-PD). In this study, we present DILS with a novel, simple, and safe procedure for PD catheter implantation with fixation and describe the long-term outcome.

SUBJECTS AND METHODS

We conducted a prospective data collection and retrospective review of all PD patients from April 2010 until June 2012. During this study period, we performed open surgery for PD catheter implantation (OS-PD) and DILS-PD concurrently. Demographic data, medical, operative, and postoperative findings, and information regarding complications were compared between these two groups.

RESULTS

Forty-eight patients had DILS-PD, and 70 patients had OS-PD. There was no difference between the two groups in age, gender, American Society of Anesthesiologists grade, creatinine level, body mass index, and previous abdominal surgery. There was no surgical mortality in either group. The follow-up period ranged from 6 to 24 months, with a mean of 22.4±16.5 months. There was no tube migration in the DILS-PD group, but 25.7% of the patients in the OS-PD group had tube migration (P<.001). A significantly decreased exit-site/tunnel infection rate was found in the DILS-PD group (4.2%) compared with the OS-PD group (17.1%) (P=.032). However, there was no obvious difference in peritonitis occurrence between groups. A significantly decreased catheter failure rate was found in the DILS-PD group (4.2%) compared with the OS-PD group (22.9%) (P=.006). DILS-PD group patients had a favorable survival rate for catheter implantation compared with OS-PD group patients.

CONCLUSIONS

Our DILS-PD with fixation technique is a simple and safe procedure. This procedure minimized or even eliminated the possibility of migration without additional cost. Our DILS-PD fixatation technique should be recommended for use routinely.

A modified method in laparoscopic peritoneal catheter implantation: the combination of preperitoneal tunneling and pelvic fixation

Introduction. Continuous ambulatory peritoneal dialysis (CAPD) is widely accepted for the management of end-stage renal disease (ESRD). Although not as widely used as hemodialysis, CAPD has clear advantages, especially those related to patient satisfaction and simplicity. Peritoneal dialysis (PD) catheter insertion can be accomplished by several different techniques. In this study, we aimed to evaluate our results obtained with peritoneal dialysis catheter placement by combination of pelvic fixation plus preperitoneal tunneling. Material and Methods. Laparoscopic peritoneal catheter implantation by combining preperitoneal tunneling and pelvic fixation methods was performed in 82 consecutive patients with end-stage renal disease. Sex, age, primary disease etiology, complications, mean duration of surgery, mean duration of hospital stay, morbidity, mortality, and catheter survival rates and surgical technique used were assessed. Analysis of catheter survival was performed using the Kaplan-Meier method. Results. Mean follow-up period was 28.35 ± 14.5 months (range of 13–44 months). Mean operative time was 28 ± 6 minutes, and mean duration of hospital stay was 3 ± 1 days. There were no conversions from laparoscopy to other insertion methods. None of the patients developed serious complications during surgery or the postoperative period. No infections of the exit site or subcutaneous tunnel, hemorrhagic complications, abdominal wall hernias, or extrusion of the superficial catheter cuff was detected. No mortality occurred in this series of patients. Catheter survival was found to be 92% at 3 years followup. Conclusions. During one-year followup, we had seven patients of migrated catheters due to separation of pelvic fixation suture from peritoneal surface, but they were reimplanted and fixated again laparoscopically with success. Over a three-year followup period, catheter survival was found to be 92%. In the literature, similar catheter survival rates without combination of the two techniques are reported. As a conclusion, although laparoscopic placement of PD catheters avoids many perioperative and early complications, as well as increasing catheter free survival period and quality of life, our results comparing to other studies in the literature indicate that different laparoscopic placement methods are still in debate, and further studies are necessary to make a more accurate decision.

Laparoscopic versus open peritoneal dialysis catheter insertion: a meta-analysis

BACKGROUND

Peritoneal dialysis is an effective treatment for end-stage renal disease. Key to successful peritoneal dialysis is a well-functioning catheter. The different insertion techniques may be of great importance. Mostly, the standard operative approach is the open technique; however, laparoscopic insertion is increasingly popular. Catheter malfunction is reported up to 35% for the open technique and up to 13% for the laparoscopic technique. However, evidence is lacking to definitely conclude that the laparoscopic approach is to be preferred. This review and meta-analysis was carried out to investigate if one of the techniques is superior to the other.

METHODS

Comprehensive searches were conducted in MEDLINE, Embase and CENTRAL (the Cochrane Library 2012, issue 10). Reference lists were searched manually. The methodology was in accordance with the Cochrane Handbook for interventional systematic reviews, and written based on the PRISMA-statement.

RESULTS

Three randomized controlled trials and eight cohort studies were identified. Nine postoperative outcome measures were meta-analyzed; of these, seven were not different between operation techniques. Based on the meta-analysis, the proportion of migrating catheters was lower (odds ratio (OR) 0.21, confidence interval (CI) 0.07 to 0.63; P = 0.006), and the one-year catheter survival was higher in the laparoscopic group (OR 3.93, CI 1.80 to 8.57; P = 0.0006).

CONCLUSIONS

Based on these results there is some evidence in favour of the laparoscopic insertion technique for having a higher one-year catheter survival and less migration, which would be clinically relevant.

Minilaparotomy salvage of malfunctioning catheters in peritoneal dialysis

BACKGROUND

Catheter malfunction is a common and significant complication during peritoneal dialysis (PD). We developed a minilaparotomy procedure to rescue malfunctioning catheters and to prevent recurrence of malfunction.

METHODS

From 2006 to 2011, 11 patients receiving PD had a malfunctioning catheter. In all patients, a 2-cm incision, 5 cm caudally to the previous peritoneal entry site was used to correct the malfunctioning catheter, with concomitant fixation of the catheter to the peritoneum.

RESULTS

Catheter tip migration occurred in 7 patients, omental wrapping in 3, and blood clot obstruction in 1. The mean onset time to catheter malfunction was 197.5 days (range: 4 - 1270 days), and the mean operating time was 41 minutes (range: 35 - 56 minutes). There was no recurrence of catheter malfunction and no surgery-related peritonitis.

CONCLUSIONS

Our minilaparotomy procedure is safe and feasible for the salvage of malfunctioning PD catheters.

A comparative analysis of percutaneous and open surgical techniques for peritoneal catheter placement

BACKGROUND

Peritoneal dialysis (PD) is the preferred available option of renal replacement therapy for a significant number of end-stage kidney disease patients. A major limiting factor to the successful continuation of PD is the long-term viability of the PD catheter (PDC). Bedside percutaneous placement of the PDC is not commonly practiced despite published data encouraging use of this technique. Its advantages include faster recovery and avoidance of general anesthesia.

METHODS

We carried out a retrospective analysis of the outcomes of 313 PDC insertions at our center, comparing all percutaneous PDC insertions between July 1998 and April 2010 (group P, n = 151) with all surgical PDC insertions between January 2003 and April 2010 (group S, n = 162).

RESULTS

Compared with group P patients, significantly more group S patients had undergone previous abdominal surgery or PDC insertion (41.8% vs 9.3% and 33.3% vs 3.3% respectively, p = 0.00). More exit-site leaks occurred in group P than in group S (20.5% vs 6.8%, p = 0.002). The overall incidence of peritonitis was higher in group S than in group P (1 episode in 19 catheter-months vs 1 episode in 26 catheter-months, p = 0.017), but the groups showed no significant difference in the peritonitis rate within 1 month of catheter insertion (5% in group P vs 7.4% in group S, p = 0.4) or in poor initial drainage or secondary drainage failure (9.9% vs 11.7%, p = 0.1, and 7.9% vs 12.3%, p = 0.38, for groups P and S respectively).Technical survival at 3 months was significantly better for group P than for group S (86.6% vs 77%, p = 0.037); at 12 months, it was 77.7% and 68.7% respectively (p = 0.126). No life-threatening complications attributable to the insertion of the PDC occurred in either group.

CONCLUSIONS

Our analysis demonstrates further encouraging outcomes of percutaneous PDC placement compared with open surgical placement. However, the members of the percutaneous insertion group were primarily a selected subset of patients without prior abdominal surgery or PDC insertion, therefore limiting the comparability of the groups. Studies addressing such confounding factors are required. Local expertise in catheter placement techniques may affect the generalizability of results.

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