Laparoscopic omentectomy for salvage of peritoneal dialysis catheters

A modified open surgical revision technique for malfunctioning peritoneal dialysis catheter

Backgrounds: The malfunction of peritoneal dialysis (PD) catheter is still an intractable problem. A modified open surgical revision technique with suturing fixation and without catheter removal for malfunctioning catheter was developed to evaluated the efficacy and safety between simultaneous catheter replacement technique.

Methods: A total of 167 PD patients with malfunctioning catheter were retrospectively reviewed. For the salvage of PD catheters, patients underwent modified open surgical revision (group A) or simultaneous catheter replacement (group B). The baseline characteristics before operation, perioperative condition, complications and outcomes were compared between both groups.

Results: Patients of group A showed significantly shorter operative time (67.4 ± 22.1 versus 82.8 ± 21.1 min, p = 0.009), less postoperative pain score within 24 h (median 0.0 versus 2.0, p < 0.001), quicker start of PD (1.06 ± 0.31 versus 1.89 ± 0.89 days, p < 0.001), shorter length of stay (9.89 ± 5.11 versus 12.55 ± 7.37 days, p = 0.020) than group B. In terms of complications, the incidence of recurred catheter malfunction in group A was significantly lower than those in group B (1/114 versus 12/53, p < 0.001). There were no significant differences in mechanical complications (bloody effluent, dialysate leakage, and hernia) and early peritonitis between the groups. The group A patients had a favorable catheter survival rate compared with group B (log-rank, p = 0.004).

Conclusions: Our modified open surgical revision technique is a safe, simple and fast method, and offers a better outcome with minimal risk of recurrence of catheter malfunction without additional cost and equipment. This technique is worthy of clinical application.

Innovative management of peritoneal catheter malfunction caused by omental wrapping: exploration the modified low-temperature plasma ablation blade in vivo and in vitro

BACKGROUND

Omental wrapping is a common complication of peritoneal dialysis, which manifests as catheter malfunction causing early termination of peritoneal dialysis. This study investigates the efficacy and safety of a Modified Low-Temperature Plasma Ablation (MLTPA) blade in treating omental-wrapped catheter malfunction.

METHOD

In vitro experiments using the MLTPA blade at the 5th power level were conducted to ablate omental tissues and catheters, evaluating ablation effects and potential catheter damage. In vivo, nine beagles were modeled for catheter malfunction due to omental wrapping, randomized into MLTPA blade (n = 5) and the Gastroscopic Biopsy Forceps (GBF) groups (n = 4). Dialysate outflow velocity, dialysate residual volume, and complications were recorded.

RESULTS

In vitro experiments showed that the MLTPA blade effectively ablated omental tissue without damaging the catheter at the 5th power level. In vivo, the MLTPA blade group achieved a 100% (5/5) catheter recanalization success rate, significantly increasing catheter outflow velocity (111.4 ± 5.1 ml vs. 3.0 ± 1.0 ml, p < 0.0001), and reducing dialysate residual volume after ablation (81.0 ± 5.6 ml vs. 976.8 ± 4.6 ml, p < 0.0001). Treatment failures in the GBF group (4/4) were successfully resolved with MLTPA treatment. No significant differences in outflow velocity of dialysate were observed at 3 and 7 days post-canalization in the MLTPA blade group, without severe bleeding, infection, catheter migration, or organ damage.

CONCLUSION

The MLTPA blade rapidly ablates omentum within the lumen, recovering catheter function without severe complications. These findings provide preliminary evidence supporting the safety and feasibility of using the MLTPA blade to treat catheter malfunction caused by omental wrapping.

A nephrologist dream of peritoneal dialysis catheter with zero migration: A multicenter prospective study

INTRODUCTION

PD catheter tip migration is a common complication and a significant cause of catheter malfunction. In this perspective, we present our experience with a new catheter and a new technique that involves the use of a new triple cuff PD catheter and a low entry site in an attempt to prevent PD catheter migration.

METHODS

A total of 503 incident PD patients have been studied in more than one PD center over a period of 5 years.

RESULTS

During the 5-year follow up we recorded zero percent catheter migration. Other technical complications were poor drainage in 3.4%, omental wrap in 2.8%, early leakage in 3.4%, and catheter replacement in 2.4%. By the end of the study, the one-year PD catheter survival was 97.6%.

CONCLUSION

Our new triple cuff PD catheter and our low-entry approach seem to be effective in preventing PD catheter migration and minimizing other mechanical complications.

Peritoneal Dialysis Catheter Placement in Children: Initial Experience with a "2+1"-Port Laparoscopic-Assisted Technique

The placement of a peritoneal dialysis catheter (PDC) is currently a common procedure in pediatric surgeon practice, and the search for the ultimate technique never stops. The purpose of this study is to evaluate our experience with the laparoscopic PDC placement approach, performing a "2+1" ("two plus one") technique, where the "+1" trocar is placed in an oblique manner, pointing toward the Douglas pouch when passing through the abdominal wall. This tunnel is further used to place and maintain the proper position of the PDC.

MATERIALS AND METHODS

We assessed a cohort of five children who underwent laparoscopic-assisted PDC placement between 2018 and 2022.

RESULTS

This procedure is a simple, relatively quick, and safe technique for PDC placement. Furthermore, in our experience, concomitant omentectomy is necessary to reduce the risk of catheter obstruction and migration due to omental wrapping.

CONCLUSIONS

The laparoscopic approach allows for improved visualization and more accurate placement of a catheter inside the abdominal cavity. Concomitant omental excision is necessary to prevent PDC malfunction and migration.

Evaluation of the effectiveness of prophylactic omentopexy during laparoscopic insertion of peritoneal dialysis catheter: a case-control clinical trial

INTRODUCTION

The laparoscopic omentopexy has been described for the prevention of peritoneal dialysis catheter obstruction due to omental wrapping of the catheter. As there are some controversies and limited data regarding the outcomes of prophylactic omentopexy, we designed a study to evaluate the efficacy of prophylactic omentopexy in preventing catheter dysfunction in patients undergoing laparoscopic catheter placement.

MATERIALS AND METHODS

In this randomized clinical trial, patients with end-stage renal disease during 3 months were divided into two groups of peritoneal dialysis catheter implants with and without omentopexy and subsequently evaluated regarding postoperative features.

RESULTS

A total of 43 patients were evaluated, including 22 undergoing prophylactic omentopexies. There was no significant difference among the baseline features of the patients. There was also no significant difference regarding postoperative features, including peritonitis, leakage, reoperation, need for catheter removal, and mortality.

CONCLUSION

Prophylactic omentopexy did not cause any significant differences in complications. In addition, there was no benefit for decreasing postoperative outflow obstruction due to omental wrapping following peritoneal dialysis catheter insertion.

Does laparoscopic omentectomy reduce CAPD catheter malfunction: A three-arm pilot randomized trial

Introduction:

Catheter malfunction secondary to omental wrapping is a frequent complication of continuous ambulatory peritoneal dialysis (CAPD). Of the various methods of peritoneal dialysis catheter insertion (PDCI), open surgical insertion under local anesthesia is most widely practiced. Laparoscopic omentectomy is often undertaken as a salvage procedure in case of malfunctioning catheters. However, there is no randomized controlled trial (RCT) to evaluate the role of prophylactic laparoscopic omentectomy on catheter function. This pilot RCT was undertaken to evaluate the impact of laparoscopic omentectomy on the incidence of catheter malfunction.

Materials and Methods:

Consecutive patients were randomized into three groups: laparoscopic PDCI with omentectomy (Group A), laparoscopic PDCI without omentectomy (Group B) and open surgical PDCI (Group C). The primary outcome was the incidence of catheter malfunction at 6 weeks and 3 months.

Results:

Forty-one patients completed follow-up, with 16, 11, and 14 patients in Groups A, B, and C, respectively. Incidence of catheter malfunction was 6.2%, 27.3%, and 14.3% in Groups A, B, and C, respectively, at 6 weeks and 6.2%, 36.4%, and 21.4% at 3 months, respectively. In patients with previously failed catheter insertion (n = 23), malfunction at 3 months was 8.3% (1/12) in patients who had omentectomy, compared with 45.5% (5/11) in those who did not (P = 0.069). Operating time was significantly higher (P < 0.001) in Group A.

Conclusions:

Laparoscopic omentectomy may be associated with a lower incidence of catheter malfunction, especially in patients with previously failed peritoneal dialysis catheter. Data from this pilot RCT can be used to design a large trial with an adequate number of patients.

Experimental models in peritoneal dialysis (Review)

Peritoneal dialysis (PD) is one of the most commonly used dialysis methods and plays an important role in maintaining the quality of life of patients with end-stage renal disease. However, long-term PD treatment is associated with adverse effects on the structure and function of peritoneal tissue, which may lead to peritoneal ultrafiltration failure, resulting in dialysis failure and eventually PD withdrawal. In order to prevent the occurrence of these effects, the important issues that need to be tackled are improvement of ultrafiltration, protection of peritoneal function and extension of dialysis time. In basic PD research, a reasonable experimental model is key to the smooth progress of experiments. A good PD model should not only simulate the process of human PD as accurately as possible, but also help researchers to understand the evolution process and pathogenesis of various complications related to PD treatment. To better promote the clinical application of PD technology, the present review will summarize and evaluate the in vivo PD experimental models available, thus providing a reference for relevant PD research.

Laparoscopic-Assisted Peritoneal Dialysis Catheter Placement, an Improvement on the Single Trocar Technique

In 2002, Ochsner laparoscopic surgeons and nephrologists began placing peritoneal dialysis (PD) catheters via a laparoscopic-assisted method. We compared laparoscopically placed PD catheters (LAPD) with catheters most recently placed without laparoscopic aid (STPD). The method for this study is a retrospective chart review. Demographics of both groups were similar. Nine of 20 (45%) in the STPD group and 16 of 23 (70%) in the LAPD group had had previous abdominal surgery. Three of 20 (15%) of STPD had complications, including one small bowel injury. Four of 23 (17.4%) of the LAPD had complications. One of 20 (5%) in the STPD group and 3 of 23 (13%) in the LAPD group had dialysate leaks. In the STPD group, 8 of 20 (40%) had catheter problems that led to removal in 7 (35%). In the LAPD group, 6 of 23 (26%) had catheter malfunction: 3 were salvaged with a laparoscopic procedure; 3 (13%) were removed for malfunction. 1) LAPD allows proper PD placement after complex abdominal surgery; 2) Although dialysate leak complications are increased, bowel perforation risk is less; 3) Because of proper placement, PD catheter malfunction rate is less with LAPD; 4) Although no results obtained statistical significance, we found LAPD superior to STPD and have converted to this technique.

When end-stage kidney disease complicates abdominal surgery

Patients receiving peritoneal dialysis (PD) encounter an increased risk for infection, bleeding, and PD fluid leakage after abdominal surgery. These complications may affect the future use of PD. Appropriate patient preparation may mitigate complications. Certain complications or procedures allow patients to remain on PD while others require transition to hemodialysis. We review the etiology and management of infection, bleeding, and PD fluid leakage associated with abdominal surgery as well as the relationship of specific abdominal procedures to continuing PD.

Minilaparoscopic Extraperitoneal Tunneling with Omentopexy: A New Technique for CAPD Catheter Placement

Background

Continuous ambulatory peritoneal dialysis (CAPD) is an effective form of treatment for patients with end-stage renal disease. Open insertion of peritoneal dialysis (PD) catheters is the standard surgical technique, but it is associated with a relatively high incidence of catheter-related problems. To overcome these problems, different laparoscopic techniques have been presented, being preferable to the open and percutaneous methods.

Objective

To introduce and evaluate the efficiency of laparoscopic omental fixation and extraperitoneal placement of the cuff–coil part (the straight portion) of the catheter to prevent catheter tip migration, pericatheter leakage, severe abdominal pain, and the obstruction caused by omental wrapping.

Setting

The study was carried out in the General Surgery Department, Akdeniz University Medical School, in Turkey.

Patients and Methods

Between November 2001 and March 2005, the technique was applied in 44 consecutive patients (mean age 51.6 years, range 18 – 67 years) with end-stage renal disease. During this laparoscopic technique, the omentum was first fixed onto the parietal peritoneum, and then the catheter was introduced through the subumbilical trocar site into the posterior rectus compartment and advanced toward the symphysis pubis. The catheter was then inserted into the abdominal cavity, passing the peritoneal opening, which was prepared before catheter insertion. The straight portion of the catheter was located into the extraperitoneal area of the anterior abdominal wall. The curled end, which contains the side-holes of the catheter, was placed into the true pelvis. Catheter position and patency were verified under direct vision using a 2 mm telescope.

Results

All procedures were completed laparoscopically. Operating time ranged between 40 and 100 minutes (median 52 minutes). There was no intraoperative complication or surgical mortality. Peritoneal dialysis was initiated within 15 – 24 hours after catheter implantation. After a median follow-up period of 17.4 months (range 1 – 38 months), early exit-site infection occurred in 1 of 44 patients. All catheters functioned well postoperatively. There was no pain during CAPD.

Conclusion

This new laparoscopic technique using an extraperitoneal approach with omentopexy for PD catheter placement could prove extremely useful for preventing catheter malfunction caused by catheter tip migration, pericatheter leakage, omental wrapping, and periodic catheter movement that causes abdominal pain in CAPD.

Primary Malfunction of a Peritoneal Dialysis Catheter Due to Encasement in an Encapsulating Sheath

Obstruction of the catheter is one of the potentially serious complications of peritoneal dialysis. Dislocation of the tip of the catheter, intraluminal fibrin formation, and omental wrapping are among the most common etiologies of peritoneal dialysis catheter malfunction that necessitate correction. Here we present a rare case of primary malfunction of a newly placed catheter in which multiple attempts to restore the patency by minimally invasive procedures were unsuccessful. Laparoscopy revealed a thick encapsulating sheath around the entire length of the catheter as the etiology of complete obstruction, without involvement of other intra-abdominal structures. The sheath was opened and the catheter was pulled out in its entirety. There was no intraluminal or orifice obstruction and it subsequently functioned perfectly.

Laparoscopic Findings of Peritoneal Dialysis Catheter Malfunction and Management Outcomes

Objective

Peritoneal dialysis catheter malfunction is a common complication forcing conversion to hemodialysis. The purpose of this study was to evaluate laparoscopic findings of catheter malfunction and to establish a relationship between those findings and the outcomes of procedures performed.

Design

Retrospective study.

Setting

A tertiary referral center.

Patients

40 consecutive patients with stage 5 chronic kidney disease underwent 46 laparoscopic correction procedures for the treatment of peritoneal dialysis catheter malfunction between November 1994 and August 2004.

Main Outcome Measures

Laparoscopic findings of catheter malfunction, procedures performed, catheter survival, and recurrent cases were evaluated.

Results

There were 28 tip migrations in 40 patients; 16 were without adhesions and 10 were associated with omental adhesions. Reposition and adhesiolysis were the most frequent procedures performed. Malfunction recurred in 12 patients and 5 of them underwent 6 secondary laparoscopic procedures. Estimated mean catheter survival was 19.9 ± 3.32 months (%95 confidence interval 13.43 – 26.46).

Conclusions

The most frequent laparoscopic finding was catheter tip migration, with or without adhesions. Laparoscopic repositioning and adhesiolysis without omentectomy are simple and effective procedures that can prolong catheter survival, even in recurrent malfunctions.

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.

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.

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.

Peritoneal response to abdominal surgery: the role of equine abdominal adhesions and current prophylactic strategies

Intra-abdominal adhesions constitute a significant clinical and surgical problem that can lead to complications such as pain and bowel occlusion or subocclusion. These adhesions are frustrating and potentially fatal, representing a major postoperative complication in abdominal surgery. It is estimated that 32% of horses undergoing laparotomy will present clinical symptoms due to adhesions, but the true prevalence is not known because a large proportion of animals with postoperative recurrent colics are medically treated or submitted to euthanasia without necropsy. Adhesions are highly cellular, vascularized, dynamic structures that are influenced by complex signaling mechanisms. Understanding their pathogenesis could assist in applying better therapeutic strategies and in developing more effective antiadhesion products. Currently, there are no definitive strategies that prevent adhesion formation, and it is difficult to interpret the results of existing studies due to nonstandardization of an induction model and evaluation of their severity. The best clinical results have been obtained from using minimally traumatic surgical techniques, anti-inflammatory agents, antimicrobials, anticoagulants, and mechanical separation of serosal surfaces by viscous intraperitoneal solutions or physical barriers. This paper aims to review adhesion formation pathogenesis, guide the understanding of major products and drugs used to inhibit adhesion formation, and address their effectiveness in the equine species.

Bacteria-triggered release of antimicrobial agents

Medical devices employed in healthcare practice are often susceptible to microbial contamination. Pathogenic bacteria may attach themselves to device surfaces of catheters or implants by formation of chemically complex biofilms, which may be the direct cause of device failure. Extracellular bacterial lipases are particularly abundant at sites of infection. Herein it is shown how active or proactive compounds attached to polymeric surfaces using lipase-sensitive linkages, such as fatty acid esters or anhydrides, may be released in response to infection. Proof-of-concept of the responsive material is demonstrated by the bacteria-triggered release of antibiotics to control bacterial populations and signaling molecules to modulate quorum sensing. The self-regulating system provides the basis for the development of device-relevant polymeric materials, which only release antibiotics in dependency of the titer of bacteria surrounding the medical device.

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.

Fluoroscopic manipulation of peritoneal dialysis catheters: outcomes and factors associated with successful manipulation

BACKGROUND AND OBJECTIVES

Mechanical failure of the peritoneal dialysis (PD) catheter is an important cause of technique failure. Fluoroscopic guidewire manipulation may be undertaken in an attempt to correct the failure. The purpose of this study was to determine the efficacy of fluoroscopic manipulation of previously embedded PD catheters, the factors associated with successful manipulation, and the complication rate associated with manipulation.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A single-center, retrospective review of 70 consecutive PD patients undergoing fluoroscopic manipulation for mechanical failure of their PD catheter from June 2006 to February 2011 was undertaken. Logistic regression models were developed to determine the variables associated with successful manipulation.

RESULTS

Of the 70 manipulations, 44 were successful (62.9%). In univariate analysis, catheters located in the pelvis compared with those in the upper abdomen (73.5% versus 42.9%, P=0.01) and catheters that were previously functional compared with those that failed at exteriorization (75.0% versus 46.7%, P=0.04) were more likely to be successfully manipulated. Time embedded, previous hemodialysis, and number of intra-abdominal surgeries were not correlated with likelihood of successful manipulation. In multivariate analysis, catheters located in the pelvis (P=0.01) and those with secondary failure (P=0.01) were more likely to successfully manipulated. Two of the patients developed peritonitis (2.9%), neither requiring cessation of PD.

CONCLUSIONS

Fluoroscopic manipulation is an effective and safe therapy for failed PD catheters that are unresponsive to conservative treatment. Properly positioned catheters and those that were previously functional are more likely to be successfully manipulated.

Continuous ambulatory peritoneal dialysis catheter placement: Is omentectomy necessary?

Context:

There are different methods of continuous ambulatory peritoneal dialysis (CAPD) catheter placement. Open surgical technique is a widely followed method. The complication rate following catheter placement varies and catheter blockage due to omental plugging is one of the main reasons.

Aim:

To analyze the need for routine omentectomy during CAPD catheter placement.

Materials and Methods:

This was a retrospective analysis of 58 CAPD catheter placements performed between July 2002 and June 2007. Tenckhoff double cuffed catheter was used in all. The postoperative complications were analyzed.

Results:

There were 44 males and 14 females. The mean age was 51 years ranging from 15 to 76 years. Of these, 40 (69%) patients underwent omentectomy (group A) and 18 (31%) did not (group B). Laparoscopic and open techniques were performed in 5 and 53 patients, respectively. Omentectomy was not performed in 13 patients with open technique and all the five in the laparoscopic group. One patient in group A developed hemoperitoneum which was treated conservatively. None from group A developed catheter blockage, whereas five (27.8%) from group B developed catheter blockage postoperatively. The median time interval between the primary procedure and development of catheter blockage was 45 days (ranged from 14 to 150 days).

Conclusions:

Omentectomy during CAPD catheter placement prevents catheter blockage and secondary interventions.

[Complications after placement of peritoneal catheter]

INTRODUCTION

Peritoneal dialysis is one of the modalities used for treatment of end-stage chronic kidney failure. Nowadays, this method is complementary to haemodialysis and renal transplantation. Owing to the rich vascularization of the peritoneum, it is used in the processes of osmosis and diffusion, enabling the removal of uremic material from the body. The procedure includes introduction of peritoneal fluid via the peritoneal catheter.

COMPLICATIONS

The catheter is placed through the anterior abdominal wall with its tip positioned in the small pelvis. There are several techniques for catheter placement considered minimally invasive, which, however, may be associated with various complications. These complications can be divided into mechanical (catheter dysfunction, cuff protrusion, hernia, dialysate leaks, visceral perforation) and infectious (early peritonitis, exit site or tunnel infection, surgical wounds). In most cases, such complications are rare and can be successfully managed using conservative therapy; however, in some situations severe complications can endanger the life of the patient. On-time recognition of complications, particularly in patients at risk, is of paramount importance for an effective treatment. The development of complications can increase the morbidity and the chance of treatment failure, and therefore transfer to haemodialysis.

CONCLUSION

The preoperative evaluation and determination of the risk factors as well as the early recognition and adequate management of complications are essential in their prevention.

Laparoscopic management of malfunctioning peritoneal dialysis catheters

OBJECTIVES

Continuous ambulatory peritoneal dialysis (CAPD) is an established alternative method to hemodialysis for treating end-stage renal disease patients. Malfunction of the peritoneal catheter is a frequent complication in peritoneal dialysis (PD). Laparoscopy is a minimal invasive technique that allows rescue therapy of malfunctioning catheters and consecutive immediate resumption of PD. The purpose of this study is to present our experiences with laparoscopic repair of peritoneal catheter dysfunction

METHODS

Between April 2006 and March 2010, 21 cases of laparoscopic interventions were performed for the salvage of malfunctioning CAPD catheter. Two trocars (5 mm) were used. Recorded data included patient demographics, catheter implantation method, date of malfunction, cause of dysfunction, procedure performed and complications.

RESULTS

The primary etiology of dysfunction was omentum and/or small bowel wrapping with adhesions in fifteen cases, malpositioning in four cases, and tunnel infection in the remaining two cases. Adhesiolysis was performed in cases with adhesions. In the cases with malpositioning but no adhesions, the catheters were repositioned in the pelvic cavity. Two catheters had to be withdrawn and exchanged because of infection. 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 safe, highly effective and successful method for the evaluation and management of peritoneal dialysis catheter dysfunction.

Update on recent advances in equine abdominal surgery

In recent years important advancements in colic surgery have led to improved prediction of survival rates, better survival rates, and decreased complication rates. This article describes several modalities to combat and prevent incisional hernia and intestinal adhesion formation in horses undergoing colic surgery. These modalities have had a positive impact on reducing complications in horses after surgery.

Omental Folding: A Novel Laparoscopic Technique for Salvaging Peritoneal Dialysis Catheters

Background

Omental wrap is a common cause of catheter obstruction. Current laparoscopic techniques for correcting obstruction include omentopexy and omentectomy. This study evaluates the efficacy of a new laparoscopic technique for revision of obstructed peritoneal dialysis catheters.

Methods

Between November 2005 and November 2006, the technique was applied in 18 patients (6 female, 12 male; median age 50 years, range 16 – 73 years) on continuous ambulatory peritoneal dialysis with catheter malfunction secondary to omental wrap. Pneumoperitoneum was induced under general anesthesia. Three ports were inserted. The catheter was released from the omentum and repositioned in the pelvis. The omentum was then folded onto itself in a cephalad direction using silk sutures. This shortened the omentum. The risk of catheter migration was minimized with a polypropylene sling passed through the abdominal wall and around the catheter, then knotted subcutaneously. The sling allowed catheter removal without a new laparoscopy. The outcomes were prospectively evaluated.

Results

Median operating time was 90 minutes (range 35 – 160 minutes). Adhesiolysis was performed in 4 patients: 1 patient had port-site leakage of dialysate, which settled with abdominal rest; 1 patient had bleeding during adhesiolysis and laparoscopic hemostasis was successful; 1 patient had recurrent catheter obstruction 2 weeks post-operatively and was converted to hemodialysis; and 1 patient had recurrent malfunction secondary to small bowel wrap after 5.5 months; re-salvage was successful. The success rate of the first salvage procedure was 89%(16/18). The catheters were still functioning after a mean follow-up of 16.5 ± 6.3 months (range 0.5 – 24 months). The 1-year catheter survival rate was 83.3%.

Conclusions

Omental folding is a safe and effective technique for salvaging peritoneal dialysis catheters.

Laparoscopic Salvage of Malfunctioning Tenckhoff Catheters

PURPOSE

Peritoneal dialysis is a practical and appropriate form of dialysis in developing countries, as patients can be trained to do this at home. The aim of this study was to assess the efficacy of laparoscopic techniques in managing malfunctioning Tenckhoff catheters in a supraregional nephrology and transplant center.

MATERIALS AND METHODS

Between 2001 and 2004, 43 patients required Tenckhoff catheter insertion (20 males and 23 females). The average age was 8.9 years (range, 2-17 years). Four patients had their catheter tip sutured to the pelvic peritoneum and 11 underwent omentectomy at initial insertion. Laparoscopic salvage was performed using two or three 5-mm ports. If required, the tip of the catheter could be inspected and cleaned by delivering it through one of the port sites. The catheter was then replaced in the abdomen with the tip lying in the pelvis. Twenty patients (6 males and 14 females) required surgical correction for malfunctioning catheters. Eleven underwent a total of 13 laparoscopic salvage operations, and 9 patients had open replacement of catheters.

RESULTS

The causes of malfunction identified in the laparoscopic group were occlusion by fimbriae (n = 4) or omentum (n = 1), peritonitis (n = 4), and displacement of catheter (n = 4). In the open replacement group 2 patients had peritonitis, 1 had occlusion due to fimbriae, and 1 due to omentum. Five had no cause identified. Re-look laparotomy and diathermy hemostasis of fimbriae was required in one patient due to bleeding from fimbriae following laparoscopic retraction of fimbriae from the peritoneal dialysis catheter.

CONCLUSION

Twenty of forty-three (46%) patients required Tenckhoff catheter salvage surgery. The laparoscopic approach enabled us to visualize the cause of malfunction and correct problems without reinsertion of a new catheter, as had been our previous practice.

Antibiofilm approaches: prevention of catheter colonization

Bacteria frequently attach to medical devices such as intravascular catheters by forming sessile multicellular communities known as biofilms, which can be the source of persistent infections that are recalcitrant to systemic antibiotic therapy. As a result of this persistence, a number of technologies have been developed to prevent catheter-associated biofilm formation. Whereas the most straightforward approaches focus on impregnating catheter material with classical antimicrobial agents, these approaches are not universally effective, thereby underscoring the need for more potent and more sophisticated approaches to the prevention of catheter-related biofilm infections.

Treatment of renal stones by extracorporeal shock wave lithotripsy

Based on an extensive review of the literature and our own clinical experience, this article attempts to present clear guidelines for the management of various kidney stones that will be acceptable to clinical urologists and their patients. Regarding our own patients, we compared different studies and discussed the results concerning the anatomical kidney situation, stone size, stone localization and observation time. Stone-free rates of patients with calyceal diverticula calculi range from 4 to 58%, with an increase after longer follow-up periods. According to the importance of residual fragments following extracorporeal shock wave lithotripsy (ESWL), we have to distinguish between clinical insignificant residual fragments and clinical significant residual fragments. 24 months following ESWL, stone passage occurs as a continuous process, and if there are no clinical symptoms, any endoscopic procedure should be considered as over-treatment. Newer ESWL technology has increased the percentage of clinically insignificant residual fragments. We consider percutaneous nephrolithotripsy in most of the patients with renal calculi smaller than 30 mm in diameter only as second-line therapy.

Effect of lower infundibulopelvic angle, lower infundibulum diameter and inferior calyceal length on stone formation

The effect of anatomical factors such as lower infundibulopelvic angle (LIPA), lower infundibulum diameter (LID) and inferior calyceal length (ICL) on renal stone formation was investigated. These parameters were measured from noncalculous kidneys of 40 healthy kidney donors. The same parameters from 119 patients with single, unilateral, nonobstructive lower calyceal stone were also measured. LID and ICL were significantly higher in calculous kidneys when compared to the control group. On the other hand, the difference between the LIPA of the two groups was not significant. It is concluded that LID and ICL could be good indices in determining lower calyceal stone formation.