Nephroscope-assisted single trocar peritoneal dialysis catheter insertion improves catheter survival compared with laparoscopic technique: Ten-year experience of a single-center

BACKGROUND

An ideal technique for peritoneal dialysis (PD) catheter insertion should provide a long-term functioning catheter until permanent renal replacement therapy becomes available. We developed a technique using the nephroscope-assisted single-trocar approach in 2011. In this study, we report the outcomes, learning curve analysis and cost-effectiveness analysisof the nephroscopic approach compared with the traditional laparoscopic approach.

METHOD

Between January 2005 and December 2020, we retrospectively reviewed 511 patients who received PD catheter insertions using the laparoscopic or nephroscopic approach. We compared the baseline characteristics of the patients, surgical outcomes, and complications of the two groups. We further analyzed the nephroscopic group to determine the cost-effectiveness analysis, learning curve and the complication frequency between the learning and mastery periods of the nephroscopic approach.

RESULTS

A total of 208 patients underwent laparoscopic PD catheter insertion, whereas 303 patients received nephroscopic surgery. The median catheter survival in the nephroscopic group is significantly longer (43.1 vs. 60.5 months, p = 0.019). The incidence of peritonitis (29.3% vs.20.8%, p = 0.035) and exit site infection (12.5% vs. 6.6%, p = 0.019) were significantly lower in the nephroscopic group. The cost-effectiveness analysis showed a medical expense reduction of 16000 USD annually by using the nephroscopic technique. There was no difference in the frequency of surgical complications between the learning and mastery phases when examining the learning curve analysis for the nephroscopic technique.

CONCLUSIONS

Compared with the traditional laparoscopic approach, the nephroscopic technique effectively prolonged catheter survival and reduces health care cost by reducing infectious complications. The low complication rate during the learning phase of surgery makes the procedure safe for patients and surgeons.

The "Half-Perc" technique using a simple modified metal trocar for peritoneal dialysis catheter placement: results of a 3-year follow-up of 280 patients and a literature review

PURPOSE

There is an ongoing debate about the ideal technique for peritoneal dialysis (PD) catheter insertion in patients with end-stage renal disease (ESRD). A half-percutaneous ("Half-Perc") technique shares some of the advantages of both percutaneous technique and traditional open surgery. This retrospective study aimed to evaluate the clinical feasibility, safety, and effects of the "Half-Perc" technique for PD catheter placement, and to compare the clinical outcomes of the "Half-Perc" technique with various imaging-assisted percutaneous techniques from the current literature.

METHODS

We included 280 consecutive patients with ESRD who underwent the "Half-Perc" insertion of the first PD catheter between September 2016 and September 2019. We recorded baseline characteristics, operative parameters, catheter-related complications, catheter survival, and the reason behind PD cessation.

RESULTS

We included 174 men and 106 women, with a mean age of 50.4 years (range, 11-85 years). The mean operative time was 28.8 min (range, 15-38 min) and technical success rate was observed in 278 patients (99.3%). There were 28 episodes (10%) of mechanical complications with initial catheters occurring during the follow-up. Catheter malfunctions were the most common mechanical complication and were observed in 15 patients. Peritonitis was the most frequent catheter-related complication, with 32 episodes of peritonitis observed in 29 (10.4%) patients. After a mean follow-up period of 15.4 months (range, 2-36 months), 235 patients (83.9%) survived with their initial PD catheter by the end of the study. Of the 280 patients analyzed, 35 patients (12.5%) ceased PD at some stage during follow-up. The most common reason for PD cessation was kidney transplantation (18 patients (6.4%)), followed by death (9 patients (3.2%)) and switch to hemodialysis (HD) (7 patients (2.5%)), and recovery of renal failure (1 patient (0.4%)).

CONCLUSION

The "Half-Perc" technique, including a modified metal trocar, is a simple, safe, and effective method for PD catheter placement that can be used for patients with ESRD.

Peritoneal Dialysis Catheter Insertion by Nephrologist Using Minilaparotomy: Do Survival and Complications Vary in Obese?

Introduction:

Peritoneal dialysis catheter (PDC) placement for chronic kidney disease (CKD) amongst overweight and obese patients is difficult owing to deeper operating field. Literature being discordant on survival and complications in this patient subset, we attempted to analyse this research question in Indian population.

Materials and Methods:

We retrospectively analysed PDC inserted by nephrologist using surgical minilaparotomy for survivals and complications amongst 'overweight and obese' cohort ('O') at two tertiary care government hospitals in India, and compared results with normo-weight cohort ('N'), with 12−36 months follow-up.

Results:

245 PDCs were inserted by surgical minilaparotomy and 'N' to 'O' ratio was 169:76. 'O' group were more rural residing (P = 0.003) and post-abdominal surgery (P = 0.008) patients. The 1, 2, and 3-year death censored catheter survival rate was 98.6%, 95.8%, and 88.2% respectively in 'O' group, and 97.6%, 94.5% and 91.8% in 'N' group respectively (P = 0.52). Patient survival (P = 0.63), mechanical complications (P = 0.09) and infective complications (P = 0.93) were comparable despite technically challenging surgery in 'O' group. Refractory peritonitis related PDC removal was comparable (P = 0.54). Prior haemodialysis or catheter related blood stream infections or diabetes were non-contributory to results.

Conclusions:

Catheter survival and patient survival amongst obese and overweight CAPD patients was non-inferior to normal weight patients. Mechanical, and infective complications were comparable despite technically challenging abdominal terrain in 'O' group. The overall CAPD performance was good amongst obese and overweight.

Midline or long peripheral catheters in difficult venous access conditions? A comparative study in patients with acute cardiovascular diseases

BACKGROUND

Midline catheters (MCs) are commonly inserted in patients with difficult venous access (DVA) needing peripheral access. Recently, the alternative placement of ultrasound-guided long peripheral catheters (LPCs) has spread. However, no study has compared the reliability of the 2 devices. This study aims to compare the safety and reliability of MCs and LPCs in DVA patients.

METHODS

A retrospective cohort study was conducted, enrolling 184 DVA patients. Polyurethane MCs and 2 lengths of polyethylene LPCs (8/10 cm and 18 cm) were compared. The independent effect of catheter type on uncomplicated catheter survival was determined through a Cox regression analysis.

RESULTS

The relative incidences of overall catheter-related complications (CRCs) were 15.84 of 1,000, 10.64 of 1,000, and 6.27 of 1,000 catheter-days for 8/10 cm-LPCs, 18 cm-LPCs, and MCs, respectively. The relative incidences of catheter-related bloodstream infections were 0.72 of 1,000 for both length LPCs and 0.48 of 1,000 catheter-days for MCs. Compared to MCs, a significant increase in CRC risk for 8/10 cm LPCs (hazard ratio [HR] 5.328; 95% confidence interval [CI] 2.118-13.404; P < 0.001) was found, along with a nonsignificant trend toward an increased risk for 18 cm-LCPs (HR 2.489; 95% CI 0.961-6.448; P = 0.060).

CONCLUSION

MCs allow for longer uncomplicated indwelling times than LPCs. The decision regarding which catheter to use should consider the planned duration of intravenous therapy, the patient's clinical condition, and the cost of the device.

Chronic Hemodialysis in Small Children

When peritoneal dialysis is inapplicable, chronic hemodialysis (HD) becomes the only available treatment option in small children. Due to small patient size, central venous catheters (CVC) are mainly used for vascular access. Over the past 4 years, four children weighing less than 15 kg received chronic HD in our unit. A total of 848 dialysis sessions were performed. Altogether, 21 catheters were inserted. In all but one occasion, uncuffed catheters were used. Catheter revision was performed 15 times during the study period, either due to infection or catheter malfunction. The median number of catheter revisions and the median line survival was 3.0/patient-year and 53 days (range; 6-373 days), respectively. There were 14 episodes of catheter related infections requiring 11 CVC revisions (78.6%). The median rate of line infections was 2.8/patient-year. Chronic HD in small children is demanding and labor intensive. Issues pertain mainly to CVCs and limit its long-term use.

Non-infectious complications of continuous ambulatory peritoneal dialysis and their impact on technique survival

Data on non-infectious complications of continuous ambulatory peritoneal dialysis (CAPD) are sparingly reported from different centres of the country. We studied the non-infectious complications in patients of end stage-renal disease (ESRD) undergoing CAPD. Double-cuffed straight catheter was inserted in all patients using the surgical method and CAPD was started on the 15^th day of catheter insertion. The nature of non-infectious complications was noted during follow-up in these patients. Forty-five (male 31, female 14) patients with the mean age of 54.5±11.6 years were studied. Diabetic nephropathy was the most common (59.5%) cause of ESRD. Overall, non-infectious complications were noted in 18/45 (40%) cases. Ultrafiltration failure was the most common (15.5%) followed by incisional hernia (6.6%), exit site leak (4.4%), hydrothorax (4.4%), catheter malposition (4.4%), scrotal swelling (2.2%) and hemoperitoneum (2.2%). Patients with ultrafiltration failure were either shifted to hemodialysis or underwent renal transplantation. The remaining (62%) non-infectious complications did not affect the catheter survival and CAPD could be continued. Non-infectious complications occurred in 40% of our CAPD patients and ultrafiltration failure was the most common (15.5%). A majority (62%) of the complications did not affect catheter survival.