Minimally invasive surgery for salvage of malfunctioning peritoneal dialysis catheters

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.

Salvage of Malfunctioning Peritoneal Dialysis Catheters: An Algorithm for Recanalization and Repositioning

A peritoneal dialysis catheter salvage algorithm was developed and performed for 40 patients with documented catheter malfunction (obstruction and/or malposition) referred to the interventional radiology suite. This procedure utilized a metallic stiffener for repositioning and rotating dual guide wires for recanalization. A retrospective analysis of 35 cases of fluoroscopic manipulation showed that in 83% of the cases, the catheters were successfully repositioned and/or recanalized, and in 59%, they remained patent at 30 days. No major adverse events occurred. The results suggest that this algorithm is a safe and effective approach to salvage malfunctioning peritoneal dialysis catheters and that a trial of fluoroscopic salvage can be considered prior to surgical intervention.

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

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