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.

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.

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.

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

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

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

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

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

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.

Peritoneal Dialysis Catheter Insertion

The success of peritoneal dialysis as renal-replacement therapy depends on a well-functioning peritoneal catheter. Knowledge of best practices in catheter insertion can minimize the risk of catheter complications that lead to peritoneal dialysis failure. The catheter placement procedure begins with preoperative assessment of the patient to determine the most appropriate catheter type, insertion site, and exit site location. Preoperative preparation of the patient is an instrumental step in facilitating the performance of the procedure, avoiding untoward events, and promoting the desired outcome. Catheter insertion methods include percutaneous needle-guidewire with or without image guidance, open surgical dissection, peritoneoscopic procedure, and surgical laparoscopy. The insertion technique used often depends on the geographic availability of material resources and local provider expertise in placing catheters. Independent of the catheter implantation approach, adherence to a number of universal details is required to ensure the best opportunity for creating a successful long-term peritoneal access. Finally, appropriate postoperative care and catheter break-in enables a smooth transition to dialysis therapy.

Surface modification strategies for combating catheter-related complications: recent advances and challenges

This review summarizes the progress made in addressing bacterial colonization and other surface-related complications arising from catheter use.

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.

Greater omentum folding in the open surgical placement of peritoneal dialysis catheters: a randomized controlled study and systemic review

BACKGROUND

Mechanical catheter dysfunction caused by omentum entrapment remains a major complication of peritoneal dialysis (PD) therapy. The purpose of this study was to determine the outcomes of omentum folding at the time of primary open catheter insertion.

METHODS

From March 2008 to December 2012, a total of 67 PD subjects were enrolled in the study and randomly assigned to receive either regular open insertion (ROI group, n = 33) or open insertion with omentum folding (OIOF group, n = 34). The primary outcome was defined as PD catheter tip migration with dysfunction. A systematic review was performed to analyze the outcomes of omentum management in PD catheter implantation, based on published data from 1990 to 2013.

RESULTS

There was no statistical difference in baseline patient characteristics between the ROI and OIOF groups. Nine (27.3%) patients in the ROI group presented with catheter malposition in the late stage (>60 days) of the study, significantly more than in the OIOF group (two; 5.9%) (P = 0.049). Significant differences in catheter survival rate between the two groups were observed in the late stage (P = 0.030) and over the entire study period (P = 0.028). A higher incidence of irreversible catheter dysfunction was shown in the ROI group (15.2%), whereas none occurred in the OIOF group (P = 0.031). No statistical difference was determined in other catheter-related complications or patient survival rate. There were no statistical differences in peritoneal transport characteristics or dialysis adequacy between the two groups upon evaluation at 3, 6 and 12 months. Systemic review of current publications suggested that PD catheter placement with omentum management could lead to less irreversible catheter dysfunction and improved outcome of catheter survival.

CONCLUSIONS

Our data suggest that omentum folding at the initial time of open catheter placement can significantly reduce the risk of catheter tip migration with dysfunction and improve the outcome of the PD technique.

The risk factors and the impact of hernia development on technique survival in peritoneal dialysis patients: a population-based cohort study

OBJECTIVES

There is a lack of consensus on the risk factors for hernia formation, and the impact on peritoneal dialysis (PD) survival has seldom been studied.

METHODS

This was a population-based study and all collected data were retrieved from the National Health Insurance Research Database of Taiwan. Patients who commenced PD between January 1998 and December 2006 were screened for inclusion. Multiple logistic regression and Cox proportional hazards models were applied to estimate the predictors for hernia formation and determine the predictors of PD withdrawal.

RESULTS

A total of 6,928 PD patients were enrolled and followed until December 2009, with 631 hernia events and 391 hernioplasties being registered in 530 patients (7.7%). The incidence rate was 0.04 hernias/patient/year. Longer PD duration (per 1 month increase, hazard ratio (HR) 1.019) and history of mitral valve prolapse (MVP) (HR 1.584) were independent risk factors for hernia formation during PD, and female gender (HR 0.617) was a protective factor. On the other hand, there were 4,468 PD withdrawals, with cumulative incidence rates of 41% at 1 year, 66% at 3 years, and 82% at 5 years. Independent determinants for cumulative PD withdrawal included hernia formation during PD (HR 1.154), age (per 1 year increase, HR 1.014), larger dialysate volume (per 1 liter increase, HR 0.496), female gender (HR 0.763), heart failure (HR 1.092), hypertension (HR 1.207), myocardial infarction (HR 1.292), chronic obstructive pulmonary disease (COPD) (HR 1.227), cerebrovascular accident (CVA) (HR 1.364), and history of MVP (HR 0.712) CONCLUSIONS: Prolonged PD duration was a risk factor for hernia formation, and female gender was protective. Hernia formation during PD therapy may increase the risk of PD withdrawal.

Minilaparotomy salvage of malfunctioning catheters in peritoneal dialysis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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