Laparoscopic internal fixation is a viable alternative option for continuous ambulatory peritoneal dialysis catheter insertion

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.

Modified minimally invasive laparoscopic peritoneal dialysis catheter insertion with internal fixation

BACKGROUND

Laparoscopic technique is widely used in peritoneal dialysis (PD) catheter placement. We developed a modified minimally invasive laparoscopic PD catheter (PDC) insertion with internal fixation and evaluated the early results by observing the intraoperative and postoperative conditions of the novel technique with those of conventional open surgery.

METHODS

Retrospective research was performed on 59 patients who underwent PDC insertion from June 2019 to January 2022, including 23 patients who received open surgery and 36 patients who received modified minimally invasive laparoscopic surgery. Information such as preoperative conditions, operation time, incision length, incidence of intraoperative complications, time from operation to starting PD, time from operation to discharge, and incidence of catheter-related complications were collected and analyzed.

RESULTS

The incision length, intraoperative blood loss, catheter migration rates and the total incidence of complications 6 months after operation in the laparoscopic group were lower than those in the conventional group. There were no statistically significant differences between the two groups in operation time, time from operation to starting PD, time from operation to discharge and the incidence of catheter blockage, leakage, exit-site infection, peritoneal dialysis associated peritonitis and hernia.

CONCLUSIONS

Modified minimally invasive laparoscopic PDC insertion and internal fixation method achieved direct vision and reliable fixation of the catheter, significantly reduced incision length and blood loss. The incidence of catheter migration was significantly lower than that of open surgery. Our primary findings reveal that modified minimally invasive laparoscopic PDC insertion with internal fixation is safe, effective and beneficial for PD patients.

New method of internal fixation in laparoscopic Tenckhoff catheter placement

BACKGROUND

Despite obvious advantages of peritoneal dialysis (PD), mechanical complications are responsible for the failure of PD at early stage. Suture fixation in laparoscopic PD catheter method could reduce mechanical complications. In our study, a simple method to fix PD catheter was developed.

METHODS

Tenckhoff catheter placement was performed in 49 consecutive patients. In the technique, only two trocars were used. With the help of syringe needle and forceps, a loop of silk was prepared at the abdominal wall. The PD catheter was thread through the loop. The silk ligature was tied subcutaneously keeping the catheter suspended from the abdominal wall. Primary outcomes were catheter-related complications. Secondary outcomes were 6-month catheter survival rates and death within 30 days. Data were analyzed retrospectively.

RESULTS

The average operation time was 49.7 ± 15.8 min. Minimum follow-up time was 6 months. No catheter displacement or hernia was detected. One patient had omental wrapping after silk suture rupture, 2 patients had outflow obstruction, and 3 patients had leakage. No one died within 30 days postoperatively. Catheter survival was 95.8% at 6 months.

CONCLUSIONS

The method we described greatly reduced the risk of catheter displacement and omental wrap. Also, the required instrument and laparoscopic skill were simple.

Laparoscopic versus open-surgery catheter placement in peritoneal dialysis patients: A meta-analysis of outcomes

The peritoneal dialysis catheter (PDC) can be placed either through the laparoscopic technique, percutaneous technique or surgical procedures. The utilization of these PDC placement procedures is based on successful placement and reduced risk of development of complications. The main objective of this study was to compare the complications associated with laparoscopic vs. open-surgery PDC placement procedure. Literature for this review was obtained from PubMed and Google Scholar databases. The literature search was limited to studies published in the period between 1998 and 2019. The meta-analysis was done using Stata Version 12. The results showed significant difference in catheter malfunction between the laparoscopic and open-surgery group (relative risk [RR] =0.58; 95% CI: 0.42–0.8; P = 0.031). Furthermore, there was no significant statistical difference in dialysate leakage (RR = 0.77; 95% CI: 0.51–1.17, P = 0.116) peritonitis (RR = 0.8; 95% CI: 0.6–1.06, P = 0.349) and exit-site infection (RR = 0.84; 95% CI: 0.65–1.09, P = 0.834) between the laparoscopic and open-surgery PDC placement groups. In conclusion, the laparoscopic PDC placement procedure was superior to open surgery in regards to catheter malfunction. Additionally, the choice of treatment procedure should put in consideration factors such as cost and comfortability of the patient.

Different techniques for peritoneal dialysis catheter implantation: A systematic review and network meta-analysis

The current consensus recommended the peritoneal dialysis catheter (PDC) techniques based on the patients' anesthesia situation and previous abdominal surgery. However, the research comparing of all the existing PDC techniques is lacking. The objective was to compare the efficacy and safety of PDC techniques by network meta-analysis (NMA). A systematic review of databases was conducted to identify eligible studies. NMA was used to estimate the ranking for endpoints. Our NMA included 41 studies (9 randomized controlled trials (RCTs) and 32 observational trials) and enrolled 3902 patients, comparing three techniques: the laparoscopic catheterization (LC), open surgery catheterization (OSC), and percutaneous catheterization (PC). NMA in RCTs showed OSC had the highest incidence of catheter mechanical dysfunction, PC and LC were very similar, but this result had no statistical difference. NMA in observational studies showed that LC had the highest 1-year catheter survival but without statistical difference (LC vs. OSC: odds ratio (OR) 1.75, 95% credible intervals (CrIs) 0.90-3.40; PC vs. OSC: OR 1.55, 95% CrIs 0.80-2.97; PC vs. LC: OR 0.88, 95% CrIs 0.54-1.44). OSC had the lowest incidence for bleeding. The complications of leakage, peritonitis, and exit/tunnel infection were inconclusive due to the inconsistent results between RCTs and observational studies. Our NMA revealed LC may have the best 1-year catheter survival. PC and LC might be efficacious in lowering the mechanical dysfunction. OSC had the lowest incidence for bleeding. More RCTs with larger scale and higher quality are needed in order to obtain more credible evidence.

Minilaparotomy for malfunctioning peritoneal dialysis catheter by nephrologists: experiences at two centers

Catheter malfunction is one of the most important complications of peritoneal dialysis (PD). We have performed minilaparotomy for catheter repair by nephrologists. This study aimed to evaluate the effectiveness and safety of the surgery. The surgery was performed 11 times on 10 PD patients with catheter malfunction (3 man, 7 women; mean age 54.3 ± 14.6 years; 4 diabetes, 3 glomerulonephritis, 3 other) at two hospitals. All patients had inflow and/or outflow obstruction. One patient had inserted the PD catheter using conventional surgical technique, and the remaining nine patients had used Moncrief-Popovich technique. Seven patients with catheters embedded using the Moncrief-Popovich technique showed catheter occlusion at the time of externalization. The remaining three patients experienced catheter obstruction 6.0 ± 2.9 months after commencing PD. The cause of obstruction was fibrin in six patients, wrapping by fimbriae of the fallopian tube in two patients, omentum wrapping in two patients. One patient had no blockage in the catheter. Operative time was 97 ± 46 min, and no intraoperative complications were observed. PD was interrupted for 5.9 ± 3.0 days and was resumed without leakage in all patients. However, catheter malfunction recurred in one patient 3 months after the surgery. The mean hospital stay was 22.4 ± 14.7 days. Minilaparotomy by nephrologists is a safety and suitable for the management of catheter malfunction. In addition, it is necessary to always consider the possibility that the catheter has been occluded at the time of externalization in the Moncrief-Popovich technique.

Minimally invasive surgery for salvage of malfunctioning peritoneal dialysis catheters

Background:

Malfunction of continuous ambulatory peritoneal dialysis (CAPD) catheters is a frequent complication and has traditionally been treated with a laparotomy. We present our experience with minimally invasive surgical (laparoscopic and thoracoscopic) salvage of CAPD catheters.

Materials and Methods:

Between October 2003 and June 2013, 19 patients (13 males and 6 females with a mean age of 37 years [range 28–64]) underwent minimally invasive laparoscopic salvage of malfunctioning CAPD catheters. These catheters had been placed with either a percutaneous or open technique and had been in place for a mean of 4.5 months (range 2–18 months). All the salvage procedures were performed under general anaesthesia using one 10 mm and two or three 5 mm ports. The various manoeuvres undertaken to re-establish catheter function included correct positioning the catheter and anchoring it to the pelvic peritoneum, clearing the fibrin clot/sheath, freeing up the omentum/bowel/taenia coli. In addition, all patients underwent an omentopexy.

Results:

Laparoscopic salvage could be completed in 18 patients with good catheter inflow and outflow established at the end of the surgery and one patient underwent thoracoscopic salvage. The median operative time was 63 min (range 45–96 min) and median post-operative hospital stay was 2 days (range 2–5 days). Low volume dialysis was commenced the day after surgery and full volume dialysis by the 10^th day. There were no intra- or post-operative complications. All the catheters were functioning at the end of 6-month follow-up.

Conclusions:

Minimally invasive surgery is a valid, safe and efficacious way of salvaging malfunctioning CAPD catheters. This modality reduces the chances of re-formation of adhesions, ensures rapid recovery, reduced wound-related complications and allows for early institution of peritoneal dialysis.

Early technical complications and long-term survival of urgent peritoneal dialysis according to break-in periods

BACKGROUND

Guidelines recommend a break-in period of 2 weeks before starting peritoneal dialysis (PD), but PD within 14 days is also an acceptable and safe alternative to hemodialysis (HD) in patients with an urgent need. However, the effect of the break-in period within 48 hours or later had not been evaluated for early technical complications, long-term maintenance, and survival in patients starting urgent PD.

METHODS

Of 360 patients with a surgically inserted PD catheter, we evaluated 190 patients who needed urgent PD and 29 patients who received conventional PD at a single center between January 2007 and December 2014 in this retrospective observational study. Enrolled patients were divided according to break-in period of <48 hours (P1) or 2-13 days (P2) before starting urgent PD. The primary endpoint was incidence of early technical complications and secondary endpoints included long-term PD maintenance, and patient survival.

RESULTS

PD was started in 103 patients (54.2%) within 48 hours and in 87 patients (45.8%) within 2 to 13 days. The incidence of early technical complication was significantly higher in P1 group (28.2%) than in P2 group (10.3%) (P = 0.002). The need for a repositioning procedure was significantly greater in P1 group (14.6%) than in P2 group (3.4%) (P = 0.009). However, we observed no significant differences between the two groups with respect to the prevalence of catheter dysfunction requiring change to HD within 6 months or incidence of peritonitis or exit-site infection. There was no significant difference in PD maintenance and patient survival according to the break-in period between P1 and P2 as well as against the control group.

CONCLUSION

Urgent PD was associated with a low incidence of early technical complications if start was avoided within 48 hours after catheter insertion, and long-term PD maintenance was independent of the break-in period.

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.

Laparoscopic-assisted catheter insertion for continuous ambulatory peritoneal dialysis: A case report of simple technique for optimal placement

A 40-year-old male underwent tube placement surgery for continuous ambulatory peritoneal dialysis (CAPD). A 2-cm skin incision was made, and the peritoneum was reflected enough to perform secure fixation. A swan-necked, double-felted silicone CAPD catheter was inserted, and the felt cuff was sutured to the peritoneum to avoid postoperative leakage. An adequate gradient for tube fixation to the abdominal wall was confirmed. The CAPD tube was passed through a subcutaneous tunnel. Aeroperitoneum was induced to confirm that there was no air leakage from the sites of CAPD insertion. Two trocars were placed, and we confirmed that the CAPD tube led to the rectovesical pouch. Tip position was reliably observed laparoscopically. Optimal patency of the CAPD tube was confirmed during surgery. Placement of CAPD catheters by laparoscopic-assisted surgery has clear advantages in simplicity, safety, flexibility, and certainty. Laparoscopic technique should be considered the first choice for CAPD tube insertion.