Management of chronic peritoneal catheter malfunction

The Curled Catheter: Dependable Device for Percutaneous Peritoneal Access

The curled peritoneal dialysis catheter is theoretically less prone to catheter migration and drainage failure. It also allows percutaneous placement, rather than surgical placement exclusively, whenever desired or necessary. Review of 213 curled-catheter placements, 134 (63%) percutaneous and 79 (37%) surgical, over the last 4 years, shows that the probability of continuing catheter function by life-table analysis was 88% at one year, 71% at 2 years, and 61% at three years, with no difference comparing percutaneous to surgical placement. Among the 213 total cases, nearly 50% of all catheters were still functioning at last follow up, and 38 catheters (17.8%) have been lost in total, attributed to infectious complications in 24 cases (tunnel-exit infection alone in 5, peritonitis alone in 11, combined infection in 8), refractory drain failure in 9 cases (early drain failure in 4, late drain failure in 5), recurrent late subcutaneous dialysate leaking in 3 cases, and peri-catheter hernia in 2 cases.

Among other complications, the incidence of early drain failure (7.0%), and late drain failure (4.2%), compare favorably to reports describing other devices or other placement methods having comparable size of reported experience. Analyzing our own percutaneous and surgical placements separately, there were no differences in the respective frequencies of early drain failure, late drain failure, late subcutaneous dialysate leaking, outer cuff extrusion, required hernia repair, peritonitis or tunnel-exit infection. Only early external dialysate leaking was more frequent using percutaneous placement methods (21.6% vs. 10.1%; p < 0.05), although no catheters were lost due to early external leaking.

In conclusion, the present experience suggests that the curled catheter is both amenable to safe and convenient percutaneous placement methods in the majority of cases, as well as dependable for long-term peritoneal dialysis in a large university program.

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

♦ Objectives

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

♦ Design

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

♦ Patients

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

♦ Main Outcome Measures

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

♦ Results

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

♦ Conclusion

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

Fluoroscopically-Guided Manipulation of Malfunctioning Peritoneal Dialysis Catheters

Objective

To review our experience with fluoroscopic evaluation and manipulation of malpositioned, malfunctioning, peritoneal dialysis (PD) catheters.

Materials and Methods

Thirty-one patients, over a 5-year period (1 May 1992 to 30 April 1997) with malfunctioning PD catheters, who had fluoroscopically-guided manipulation were reviewed. Catheters were manipulated using a malleable aluminum bar and, if necessary, guide wires or other stiffeners. Technical success was assessed on the basis of adequate, fluoroscopically verified, catheter placement at the time of the procedure and improved flows. A functional PD catheter at 30 days post manipulation was considered to be a clinically successful manipulation.

Results

There were 41 manipulations [33 initial (IM) and 8 remanipulations (RM)] for malpositioned or kinked catheters. In 31 (19 male, 12 female) patients ranging in age from 31 to 76 years (mean age 60 years), the initial technical success rate was 85% for IM ( n = 28/33) and 63% ( n = 5/8) for RM. The overall clinical success rate, or 30-day primary patency, was 55% for IM ( n = 18/33) and 63% for RM. Catheter function (combined IM and RM) continued for a median 869 days (95% CI: 118, 1620). No early complications were noted.

Conclusions

Fluoroscopic manipulation, including attempts at remanipulation, of PD catheters is a safe procedure. The technique is a simple, inexpensive, and effective way of prolonging PD catheter life, thereby reducing the number of surgical interventions.

Double Guidewire Method: A Novel Technique for Correction of Migrated Tenckhoff Peritoneal Dialysis Catheter

Twenty-two consecutive patients with a continuous ambulatory peritoneal dialysis (CAPD) catheter malfunctioning due to catheter migration were treated with a novel radiological manipulation technique, the “double guidewire method.” The first guidewire is used to correct the direction of the catheter tip and the second wire is used to anchor the CAPD catheter so that an ideal course of the catheter can be maintained during removal of the first guidewire. Immediate catheter repositioning was achieved in 19 of 22 patients, and durable repositioning success was achieved in 13 patients.

In conclusion, the “double guidewire method” is a simple but effective technique for prolonging CAPD catheter life in patients with malfunction due to catheter migration.

Malfunctioning Peritoneal Dialysis Catheter Repaired by Laparoscopic Surgery

Objectives

To review peritoneal dialysis catheter failures and to describe a technique of repairing malpositioned catheters.

Design

Two prospective case reports utilizing this technique are reported.

Setting

A tertiary care hospital.

Patients

Two patients on chronic peritoneal dialysis with malfunctioning catheters.

Intervention

Both patients underwent reposition of their malpositioned continuous ambulatory peritoneal dialysis catheters by laparoscopic suture technique.

Main Outcome Measures

Outcome was measured by the successful return of adequate peritoneal dialysis.

Results

Both case studies show correction of malpositioned catheters with the return of successful peritoneal dialysis.

Conclusion

The repositioning and suture application of malpositioned Tenckhoff catheters by laparoscopic surgery is a viabletechnique that can salvage the majority of mal positioned catheters and save the patients additional hospital time and recovery.

A New Self-Locating Peritoneal Catheter

Objective

Peritoneal catheters often become dislocated, and this may lead to malfunction. Since it is not usually possible to bring them back into their correct position, they must be replaced. With the aim of preventing this complication, we designed a new catheter.

Design

The new catheter has the same form as the Tenckhoff catheter except for a small increase in external diameter of the last 2 cm, made possible by the high specific weight of a small12-g tungsten cylinder incorporated in the Silasticat the abdominal end. The new catheter may be inserted by a percutaneous technique.

Setting

University hospitals of Sienaand Perugia, Italy.

Patients

In the last three years, 32 of these catheters have been implanted for a total experience of 468 patientmonths. Their position was checked on insertion and every two months thereafter by radiography; 26 Tenckhoff catheters (415 patient-months) were studied at the same time. Insertion was performed surgically and by a percutaneous method. The frequency of cuff extrusion, exit-site infections, leakage, and peritoneal infection were noted, together with peritoneal function, which was evaluated by KTN and weekly creatinine clearance one month after catheter insertion; the tests were repeated when dislocation occurred and at the end of the trial.

Results

No dislocations occurred with the self-locating catheters, whereas nine dislocations occurred in control patients (p = 0.0003). There were no significant differences with respect to controls for cuff extrusion, exit-site infections, leakage, peritoneal infection, and peritoneal function.

Conclusions

The presence of a small weight at the catheter tip prevents displacement completely, keeping the intraperitoneal part of the catheter in place.

Outcomes following peritoneal dialysis catheter removal with reinsertion or permanent transfer to haemodialysis

INTRODUCTION

Long-term use of peritoneal dialysis catheter is associated with complications such as infection and malfunction, necessitating removal of catheter with subsequent reinsertion or permanent transfer to haemodialysis. This study aims to investigate the outcome in patients who underwent reinsertion.

METHODS AND MATERIALS

A single-centre retrospective study was performed in Singapore General Hospital for all adult incident peritoneal dialysis patients between January 2011 and January 2016. Study data were retrieved from patient electronic medical records up till 1 January 2017.

RESULTS

A total of 470 patients had peritoneal dialysis catheter insertion with median follow-up period of 29.2 (interquartile range = 16.7-49.7) months. A total of 92 patients required catheter removal. Thirty-six (39%) patients underwent catheter reinsertion. The overall technique survival at 3 and 12 months were 83% and 67%. Median time to technique failure of the second catheter was 6.74 (interquartile range = 0-50.2) months. The mean survival for patients who converted to haemodialysis and re-attempted peritoneal dialysis was comparable (54.9 ± 5.5 vs 57.3 ± 3.6 months; p = 0.75). Twelve (13%) patients had contraindication for peritoneal dialysis and were excluded from analysis. Of 11 patients who required catheter removal due to malfunction, 7 (64%) underwent catheter reinsertion and 6 (86%) patients ultimately converted to haemodialysis during study period. Of the 69 patients who had catheter removal due to infection, 29 (42%) underwent catheter reinsertion and 8 (28%) patients eventually converted to haemodialysis during the study period.

CONCLUSION

Patient survival was comparable between patients who re-attempted peritoneal dialysis and patients who transferred to haemodialysis. Patients who had previous catheter removal due to infections had favourable technique survival than those due to catheter malfunction.

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.

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.

A Prospective Randomized Study Comparing Tenckhoff Catheters Inserted using the Triple Incision Method with Standard Swan Neck Catheters

Background and Objective

The downward directed exit of the swan neck catheter may decrease the risk of exit-site infection (ESI). The percentage of migrations of the swan neck catheter seems to be less than the conventional Tenckhoff catheter and the swan neck catheter is more expensive and cannot be manipulated by guidewire technique if tip migration occurs. In this study, the conventional Tenckhoff catheter was used. The straight tunnel was converted to an arcuate one using the triple incision method, resulting in a downward directed exit. The arcuate tunnel was created by passing the catheter through an additional incision located between the paramedian incision and the exit site. We compared the infective and mechanical complications of the Tenckhoff catheter with a downward exit, implanted using the triple incision method, with the swan neck catheter.

Patients and Methods

101 new peritoneal dialysis patients were prospectively randomized to receive either the Tenckhoff catheter with a downward exit, implanted using the triple incision method, or the swan neck catheter. Each patient was followed up for 24 months. 50 patients were in the triple incision method group (TIMG) and 51 were in the swan neck catheter group (SNCG).

Results

Over a mean period of 18.9 ± 8.0 months of follow-up, ESI occurred in 35 patients (70%) in TIMG and 37 patients (72.5%) in SNCG ( p = 0.83). The ESI rates were 0.71 and 1.0 episodes/catheter-year in TIMG and SNCG respectively ( p = 0.21). The peritonitis rates were similar in the 2 groups (0.64 episodes/year in TIMG and 0.68 episodes/year in SNCG, p = 0.47). More patients in TIMG had tip migration [15 patients (30%) in TIMG vs 10 patients (19.6%) in SNCG] but the difference was not statistically significant. Repositioning of the catheter by guidewire manipulation was successful in patients in TIMG but not in SNCG. Overall catheter survival at 12 and 24 months was 95% and 83% in TIMG and 93% and 79% in SNCG respectively ( p = 0.72).

Conclusion

By using the conventional Tenckhoff catheter with a downward exit created using the triple incision method, high catheter survival rates with infective and mechanical complication rates similar to those of the swan neck catheter can be achieved. The triple incision method has the additional advantages of lower cost and the catheter can be manipulated by guidewire technique if tip migration occurs.

Laparoscopic correction of peritoneal catheter dysfunction

PURPOSE

To present our experiences with laparoscopic repair of peritoneal catheter dysfunction

METHODS

Total of 24 patients with peritoneal catheter malfunction were considered for two-port laparoscopic manipulation. Two patients with unsuccessful result in the first trial and 3 patients with successful peritoneal dialysis results were reoperated because of catheter dysfunction.

RESULTS

The success rates at the first and second manipulation was 79% and 80%. The most frequent cause of catheters dysfunction was migration of catheters out of the true pelvis. During the follow up, 8 patients were referred for renal transplantation, 8 underwent hemodialysis and 5 continued with normal catheter function. The mean longevity of the catheters after laparoscopic correction was 42 months. One year longevity rate as measured as 79%.

CONCLUSION

Laparoscopy is the procedure of choice even in recurrent cases, for correction of malfunctioning continuous ambulatory peritoneal catheters, because this procedure is the only technique that can detects pathologic causes of catheters malfunction and can resolve those problems at the same time.

Comparison of outcomes of peritoneal dialysis catheters placed by the fluoroscopically guided percutaneous method versus directly visualized surgical method

PURPOSE

To compare complications in catheters placed by the fluoroscopically guided percutaneous method versus directly visualized surgery.

MATERIALS AND METHODS

A retrospective cohort analysis was performed. Mechanical complication rate data, including catheter leakage, malfunction, malposition, and bleeding, were compared between the two groups over a 1-year follow-up period. Additionally, exit site infection rates, tunnel infection rates, and peritonitis episodes were evaluated based on the incidence within 30 days of insertion and 30 days to 1 year after insertion.

RESULTS

A total of 101 patients were analyzed (52 in the fluoroscopic guidance group, 49 in the direct visualization group). Prevalence of diabetes was similar: 56% in the directly visualized surgery group and 47% in the fluoroscopically guided treatment group (P = .37). Although the difference was not significant, complication rates tended to be higher in the directly visualized surgery group compared with the percutaneous placement group. These included catheter leakage (13% vs 4%; P = .093), malfunction (11% vs 9%; P = .73), malposition (13% vs 6%; P = .20), and bleeding (8% vs 2%; P = .21). There were no differences in early and late exit site infections and tunnel infections. Late peritonitis rates were lower in the percutaneous placement group (20%) than in the direct visualization group (42%) (P = .018). Diabetic patients had approximately six times greater risk of catheter malfunction than nondiabetic patients regardless of method of catheter insertion.

CONCLUSIONS

Placement of peritoneal dialysis catheters percutaneously with fluoroscopic guidance is as safe as placement with direct visualization techniques.

The adequacy of laparoscopy for continuous ambulatory peritoneal dialysis procedures

The aim of this study was to determine the safety and efficacy of diagnostic/therapeutic laparoscopy in the management of peritoneal Tenchoff catheter placement in end-stage renal disease patients who had previous abdominal surgery and malfunctioning peritoneal dialysis catheters. From 1999 to 2004, 16 videolaparoscopic procedures were performed in 16 patients who had previous laparotomies. Laparoscopy was performed before peritoneal catheter placement in seven (group 1) and in 9 patients with peritoneal dialysis catheters in place, laparoscopy was performed for the management of catheter dysfunction (group 2). All laparoscopic procedures were performed under general anesthesia. The mean follow-up was 31.5 (range, 11 to 60) months. In group 1, six patients (85.7%), and in group 2, seven patients (77.7%) are still on peritoneal dialysis. Laparoscopy resulted in the placement/salvage of peritoneal dialysis catheter dysfunction. Placement of catheter was accomplished in patients who would have been previously designated as unsuitable candidates. Laparoscopy is a useful tool in every step of a peritoneal dialysis program.

Mini-laparoscopy-assisted placement of Tenckhoff catheters: an improved technique to facilitate peritoneal dialysis

BACKGROUND AND PURPOSE

Despite its overall efficacy and patient satisfaction with it, peritoneal dialysis has a history of significant complications, which has contributed to the evolution in the technique from open laparotomy to minimally invasive placement of the catheters. Our goal was twofold: (1) to review our early experience with a technique of mini-laparoscopy-assisted (MLA) placement of dialysis catheters compared with open placement and (2) to demonstrate that urologists are able to provide a satisfactory procedure while concurrently developing and maintaining laparoscopic skills within a residency training program.

PATIENTS AND METHODS

The charts of the first 14 consecutive patients who underwent MLA placement of Tenckhoff dialysis catheters by a single surgeon (LCM) from January 1, 2000, through March 31, 2001, were reviewed. Postoperative narcotic analgesia, length of hospital stay, operative times, days until cycling, and rates of leakage, infection, and malfunction necessitating removal of catheters were compared with the corresponding data from 12 consecutive patients who underwent traditional open placement during the same time period. A telephone survey was performed to corroborate and supplement the findings from the chart review.

RESULTS

Differences in complications necessitating catheter removal were not significant. The difference in the mean operative times of 41.7 minutes in the MLA group and 55.7 minutes for open placement was statistically significant. Postoperatively, the MLA group used less narcotic analgesia, had shorter hospital stays, and returned earlier to usual activities. The incidence of leakage after catheter placement was greater in the open group, although this difference was not statistically significant.

CONCLUSIONS

The MLA technique of dialysis catheter placement appears to have similar or greater efficacy than the open technique. It is a viable teaching procedure, and with reusable 3-mm ports and shorter operative times, it is cost efficient as well.

Laparoscopic omentectomy for salvage of peritoneal dialysis catheters

BACKGROUND AND PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Role of Fogarty catheter manipulation in management of migrated, nonfunctional peritoneal dialysis catheters

Peritoneal dialysis (PD) catheter migration to the upper abdomen is not an uncommon cause of catheter failure. We prospectively examined the role of the Fogarty catheter manipulation technique to reposition the PD catheter in the pelvis and regain patency. All patients with PD catheter malfunction caused by migration, confirmed by abdominal radiograph, underwent the same protocol. The patient was placed flat on the back, and the Fogarty was advanced into the PD catheter to a premarked point at which the end of the Fogarty was near the end of the PD catheter. The Fogarty balloon was inflated with 0.5 mL of sterile saline, and manipulation was performed by tugging movements until proper placement of the PD catheter into the pelvis was suspected. Infusion and drainage of dialysate was performed to determine patency. The return of the PD catheter into the pelvis was then confirmed by repeated radiograph. Success rates of Fogarty catheter manipulation, early and late recurrence (remigration < or =90 days or >90 days), and complications were prospectively examined in 232 patients over a 6-year period. Catheter migration occurred in 34 of 232 patients (15% incidence). All patients had curled-end, double-cuffed, non-swan-neck PD catheters. Successful repositioning occurred in 24 of 34 patients (71%). None of the 24 repositioned catheters had early recurrence, and 1 of 24 catheters (4%) had late recurrence. None of the patients had procedure-related peritonitis, bowel perforation, or exit-site trauma. These results show that PD catheter migration is relatively common (15%). The Fogarty manipulation technique is a simple, cost-effective way to prolong PD catheter life and preserve its long-term patency. This eliminates the need for surgical intervention in approximately 70% of patients with PD catheter migration.

The repositioning of migrated Tenckhoff continuous ambulatory peritoneal dialysis catheters under fluoroscopic control

We describe a non-invasive, simple technique which, under fluoroscopic control, repositions migrated Tenckhoff CAPD catheters back into the pelvis. 18 patients, who had a total of 23 manipulations, were studied retrospectively over 2 1/2 years. Technical success (successful repositioning of the catheter at screening) and clinical success (continued effective CAPD for at least 6 months thereafter) were obtained in 84% and 45% of patients respectively. The results showed this technique to be effective in restoring the correct catheter position in CAPD patients whose catheters have migrated. Clinical success was more likely to be achieved in patients who had fewer risk factors for the development of peritoneal adhesions. The use of custom-made stainless steel wires eased manipulations and significantly reduced the radiation dose to patient and operator from the procedure.

Secure Placement of Continuous Ambulatory Peritoneal Dialysis Catheters under Laparoscopic Assistance

Laparoscopic surgical procedures were performed in 18 patients with end-stage renal disease for the placement of a Tenckhoff peritoneal dialysis catheter. Among them, 6 patients had received previous lower abdominal surgical treatment and 3 patients underwent laparoscopic rescue of dysfunctional Tenckhoff catheters. The operating time was between 40 and 80 minutes (median, 50 minutes). After a median follow-up period of 11 months, the short-term results revealed that no significant morbidity was associated with this procedure, and all catheters except two functioned well postoperatively. One of the catheters was not functional because of the patient's death, and the other one was removed because of persistent peritonitis. Laparoscopic secure placement of continuous ambulatory peritoneal dialysis catheters appears to be a simple, safe, and viable procedure, even in patients with previous lower-abdominal operations. The same technique can be used to rescue dysfunctional catheters that are displaced or obstructed by adhesion and omental wrapping, thus increasing catheter longevity.

Simultaneous catheter replacement and removal in refractory peritoneal dialysis infections

The present report describes more than nine years of experience with simultaneous removal and replacement of the chronic peritoneal dialysis (PD) catheter in treating refractory mechanical and infectious complications. Simultaneous catheter replacement and removal not only succeeded in 22 of 23 cases with non-infectious mechanical complications, allowing uninterrupted PD in all but three, but also succeeded in 30 (83%) of 36 additional cases with persisting or recurring infection. Simultaneous procedures failed in six (17%) of 36 infectious cases, due to persistent infection in two cases and to procedure complications in four cases. The clinical characteristics of the 30 successful infectious cases were compared to the characteristics of both the six failures, as well as 29 additional infectious cases in which the peritoneal catheter was removed but was not replaced because of a variety of serious complications (such as pancreatitis, abscess, sepsis, or fluid overload). At the time of simultaneous catheter replacement in successful cases, temporary control of active peritoneal inflammation was achieved more frequently (80% vs. 31%, P less than 0.001) with a shorter interval of antibiotic coverage (6.4 +/- 0.9 vs. 14.7 +/- 1.3 days, P less than 0.001). In addition, the successful cases were characterized by significantly more Staphylococcal infections (70% vs. 26%, P less than 0.001) and significantly fewer Pseudomonal or fungal infections (6% vs. 59%, P less than 0.001), although successful cases included some non-Pseudomonal, non-enteric gram negative infections (23%).(ABSTRACT TRUNCATED AT 250 WORDS)

Malpositioned peritoneal dialysis catheters: a critical reappraisal of correction by stiff-wire manipulation

Tenckhoff peritoneal dialysis (PD) catheter malposition is one of the leading causes of catheter malfunction. Fluoroscopically directed stiff-wire manipulation of malpositioned PD catheters has been advocated as a method of catheter salvage. Two hundred eighty-nine single-cuff PD catheters were placed surgically into 203 patients during this 4-year study. Thirty-three patients developed catheter malfunction attributed to malposition. Forty-eight stiff-wire manipulations were performed on these patients. Thirty-eight (78%) of the manipulations were described as successful at the time of transfer from radiology. However, only 25 (51%) and 12 (25%) resulted in functioning catheters at 1 week and 1 month, respectively. Only 11 of 33 patients who underwent manipulation had functional prolongation of catheter life beyond 1 month. The PD catheter was replaced by a column-disk PD catheter without additional catheter dysfunction in six patients. A second single-cuff Tenckhoff PD catheter was inserted in another six patients. Three of these six catheters again malpositioned. We conclude that stiff-wire manipulation is a useful and safe technique worth using on a limited basis for the initial episode of catheter malposition. Catheters that repetitively malposition should be replaced with a catheter that is resistant to malpositioning.

Value of peritoneoscopy for nonfunctioning continuous ambulatory peritoneal dialysis catheters

We examined our results in restoring continuous ambulatory peritoneal dialysis (CAPD) catheter function via peritoneoscopy in 10 procedures performed on nine patients. Malfunction was caused by the catheter being encased in adhesions, being buried in small bowel, or being wrapped and occluded in omentum. In five of these cases we were successful in restoring catheter patency, thereby allowing immediate reinstitution of dialysis. Neither previous abdominal surgeries nor the length of time the catheter had been in place prior to malfunction appeared to be predictive for the cause of malfunction or the success of peritoneoscopic manipulation. We found outpatient peritoneoscopy to be safe and cost effective. We recommend it as the initial procedure to restore patency to malfunctioning CAPD catheters after conservative therapy has failed.

Peritoneoscopy in the management of catheter malfunction during continuous ambulatory peritoneal dialysis

Continuous ambulatory peritoneal dialysis is widely used in the maintenance of patients with chronic renal failure. Obstruction or displacement of the chronic dialysis catheter, which prevents dialysate drainage, can compromise ongoing dialysis. Conservative approaches (body position change, saline infusion, and enema) are often unsuccessful and more aggressive therapy may be required. We report the use of peritoneoscopy to reposition malfunctioning peritoneal dialysis catheters. The procedure proved to be safe and gave excellent long-term results.

Analysis of a new technique to stabilize the chronic peritoneal dialysis catheter

A significant cause of morbidity for peritoneal dialysis patients is catheter dysfunction. In our experience, the most common cause of catheter dysfunction was cephalad migration of the catheter tip out of the true pelvis. A new technique for catheter placement that reduces catheter migration from 35% to 6% (P less than .01 chi 2) is described. Our results demonstrate that peritoneal catheters which dysfunction because of catheter flip generally do so in the first 3 months.