Immediate initiation of CAPD following percutaneous catheter placement without break-in procedure.

OBJECTIVE: To evaluate the effect of a modified method of percutaneous catheter placement without a break-in procedure on the development of catheter-related complications in patients on continuous ambulatory peritoneal dialysis (CAPD). DESIGN: A prospective, observational clinical study. SETTING: Peritoneal dialysis (PD) units of two university-based hospitals. PATIENTS AND METHODS: This study included 51 consecutive patients on CAPD. A straight double-cuffed Tenckhoff catheter with a straight intraperitoneal segment was used, and all catheters were inserted using a modified percutaneous placement method under local anesthesia. The catheter was introduced directly into the deep pelvis through an intramuscular tract, which had been created by tapered dilators. Peritoneal dialysis was initiated immediately after catheter insertion without a break-in procedure. Catheter-related complications were surveyed during the 12 months after initiation of CAPD. RESULTS: Within the first month, only 1 pericatheter leakage (1.9%) was detected. There were no cases of visceral perforation or severe hemorrhage during catheter insertions. Catheter malfunction due to catheter tip migration, exit-site infection, and peritonitis developed in only 1.9%, 3.9%, and 3.9% of patients, respectively. After 1 month following catheter insertion, no further incidences of pericatheter leakage occurred during the follow-up period. All catheters, except one that was reinserted due to tip migration, survived throughout the study period. CONCLUSION: The rates of pericatheter leakage and other catheter-related complications are relatively low in CAPD patients using our percutaneous catheter placement method without a break-in procedure. This procedure is comparatively simple and less invasive than other catheter placement methods, and allows for immediate start of PD after catheter insertion, without a break-in procedure.     

A simple method to prevent peritoneal dialysis catheter tip migration.

BACKGROUND: We report here a one-stitch fixation method that prevents catheter tip migration during implantation of the double-cuffed straight Tenckhoff catheter. METHODS: From July 2003 to September 2005, 38 patients with end-stage renal disease underwent implantation of the double-cuff straight Tenckhoff catheter for peritoneal dialysis by this method. RESULTS: No patient had catheter tip migration out of the true pelvis. No patient had pericatheter dialysate leakage or developed incisional hernia. Two patients (5.3%) experienced exit-site infection during the 2- and 5-month follow-up and they recovered well after wound care. Three patients (7.9%) developed peritonitis during the 3-day and 2- and 6-month follow-up; the conditions were controlled after antibiotic care. One patient (2.6%) experienced mechanical catheter obstruction during the 10-day follow-up due to omental wrapping; surgical revision was necessitated. CONCLUSIONS: We believe that the method is an easy, safe, and effective technique for preventing catheter tip migration.     

Early start of CAPD with the Seldinger technique.

The ideal method for inserting continuous ambulatory peritoneal dialysis (PD) catheters remains debatable. Minimally invasive techniques are becoming more popular. The routine recommendation for starting PD is 4 - 6 weeks after catheter insertion. We planned a prospective study to evaluate whether this waiting period is necessary. From January 2003 to July 2004, 42 double-cuff Tenckhoff CAPD catheters were inserted into 41 patients. Percutaneous technique was used and PD was started on the sixth day. Only 2 pericatheter leakages (4.8%) were detected. This procedure is comparatively safe, simple, and less costly than surgical and peritoneoscopic placement. The rate of early pericatheter leakage may be lowered with this technique and PD may be started earlier.     

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.Key words: Catheter tip migration, omental wrappingCatheter malfunction, defined as mechanical failure in dialysate inflow or drainage, is not uncommon in peritoneal dialysis (PD) patients. The most common causes of catheter malfunction are catheter tip migration and omental wrapping. Catheter malfunction develops in 3.9% - 13.3% of patients with a Tenckhoff catheter (1,2). Catheter malfunction leads to interruption of PD, and a rescue operation such as fluoroscopy-guided manipulation using correction instruments, or laparoscopy or minilaparotomy is usually required (1-10). The success and malfunction recurrence rates vary between methods because of differences in the procedures.We previously introduced a catheter implantation technique using two-point catheter fixation to straighten the intraperitoneal catheter segment (11). In the present study, we extended that idea to the rescue of malfunctioning catheters and the prevention of recurrent catheter migration and omental wrapping.     

腹腔镜腹膜透析管置入术在慢性肾衰竭合并腹部手术后患者中的应用

目的研究既往有腹腔手术、腹膜炎等特殊情况的慢性肾功能不全患者安全有效的腹膜透析管置入方法。对象与方法对第二军医大学长海医院肾内科符合CKD5期诊断标准8例患者,均有下腹部手术史或腹膜炎病史。手术方法为经脐下切1cm的弧形切口,插入5mm圆锥套管针(Trocar),以此孔做为观察镜通道,初步了解腹腔内情况。如患者有脏器粘连等情况,则在右侧腹直肌旁、脐下2cm处插入另一5mmTrocar为辅助操作孔,用以插入切割器,分离粘连组织,使用无损伤抓钳在屏幕直视下置入腹膜透析管。如无粘连等情况,则直接经操作孔置入腹膜透析管。结果2例患者应用切割器分离粘连的组织,4例患者借助无损伤抓钳使腹膜透析管放入膀胱直肠窝或子宫直肠窝,4例患者直接经操作孔道丝引导置入腹膜透析管。腹膜透析液进出通畅,无明显并发症发生。结论腹腔镜下置管术能在直视下将导管放入膀胱直肠窝或子宫直肠窝,是为有过腹腔手术或腹膜炎的患者置入腹膜透析管的有效方法。     

Laparoscopic placement of Oreopoulos-Zellerman catheters in CAPD patients.

BACKGROUND: Continuous ambulatory peritoneal dialysis (CAPD) is widely accepted for the management of end-stage renal disease. Various techniques have been described for the insertion of peritoneal dialysis catheters. Lately, with the evolution of laparoscopic surgery, different laparoscopic techniques have also been presented, suggesting the technique is preferable to the open and percutaneous methods. OBJECTIVE: To introduce and evaluate a new laparoscopic technique for insertion of Oreopoulos-Zellerman catheters in CAPD patients. SETTING: The study was carried out in the First Department of Propaedeutic Surgery, Athens University Medical School, Hippokration Hospital. PATIENTS AND METHODS: Between November 2000 and March 2002, the technique was applied in 20 consecutive patients (mean age 62 years, range 54 - 70 years) with end-stage renal disease. During this technique, a 10-mm trocar is placed just below the umbilicus for the optics and a 5-mm trocar is placed in the right lower quadrant. With the help of a 10-mm trocar, a tunnel is formed in the standard paramedian position on the left side, 2 - 3 cm below the plane of the umbilicus, for the insertion of the peritoneal catheter. A laparoscopic needle (GraNee needle; R-Med, Oregon, Ohio, USA) is used for the closure of the 10-mm trocar-induced peritoneal and fascia defect using a purse-string suture. The catheter is advanced into the abdomen under direct vision and guided toward the Douglas pouch. The subcutaneous tunnel and the patency test of the catheter are performed as the last main steps in our procedure. One surgeon undertook all procedures. RESULTS: All procedures were completed laparoscopically. The mean operative time was 30 minutes (range 25 - 40 minutes). There was no intraoperative complication or surgical mortality. One patient developed leakage at the catheter exit site 3 days after surgery; it was corrected under local anesthesia. During a mean follow-up time of 17 months (range 12 - 28 months), 1 patient required catheter removal due to fungal peritonitis. CONCLUSION: Laparoscopic insertion of the Oreopoulos-Zellerman catheter is a simple, quick, and safe method. We believe future experience will encourage the laparoscopic technique as the method of choice.     

Six-year experience with swan neck catheters.

From the beginning of our continuous ambulatory peritoneal dialysis (CAPD) program in January 1977 until June 1985, we used Tenckhoff and Toronto Western Hospital catheters. Throughout these years catheter survival probabilities of about 30% at three years persisted unchanged and were similar to survival probabilities reported by the National CAPD Registry special survey for these catheters. The first improvement in catheter results regarding leaks was noted after the adoption of lateral catheter insertion. Malfunction was less using swan neck prototypes from August 1985 to April 1986. The latter catheters were made of 80 degrees arc angle tubing between 8.5 cm spaced cuffs and were inserted in a reversed U-shape tunnel with the incision at the top of the tunnel. The use of these catheters was abandoned because of high cuff extrusion and exit infection rates. The next generation of swan neck catheters, the swan neck Missouri 2 and 3 catheters with straight intraperitoneal segments, improved the results dramatically. These catheters were made of 180 degrees arc angle tubing between 5 or 3 cm spaced cuffs. The estimated survival probability of 61% at three years more than doubled compared to previously used catheters. Recently we modified the intraperitoneal segment of the catheters, replacing the straight segment with a coiled one. These modified catheters, the swan neck Missouri coiled catheters, have been used exclusively since February 1990. In addition to an acceptable survival probability of 88% at one year, there are two major advantages of these catheters, the same as for other coiled catheters: elimination of infusion pain due to a jet effect and pain related to straight catheter tip pressure on the peritoneum experienced by some patients.     

腹腔镜下腹膜透析置管术的疗效及安全性

目的 比较腹腔镜下与常规腹膜透析置管术的疗效和安全性.方法 回顾苏州大学附属第一医院肾内科2007年12月～2010年12月接受腹膜透析置管并且规律腹膜透析(PD)的终末期肾病(ESRD)患者共86例,根据手术方式分为全麻下腹腔镜组(A组)和局麻常规手术组(B组),A组41例,B组45例,记录手术前后两组的基本状况、并...     

Combined abdominal hernia repair and continuous ambulatory peritoneal dialysis (CAPD) catheter insertion

Out of a series of 290 surgically inserted continuous ambulatory peritoneal dialysis (CAPD) catheters, 19 patients had 24 abdominal hernias repaired at the same time as CAPD catheter insertion. All catheters were used immediately after our normal postoperative break in protocol. There were no fluid leaks from the hernia repair site but 3 catheters failed due to complications unrelated to the hernia repair. CAPD technique survival was not adversely affected in the hernia repair group.     

慢性肾功能衰竭患者腹腔镜引导下腹膜透析置管术11例临床分析

目的:总结腹腔镜外科技术应用在放置Tenckhoff卷曲腹透管的经验。方法:选择11例慢性肾功能衰竭患者,在腹腔镜引导下将Tenckhoff卷曲腹透管置入腹腔并经皮下隧道引出。结果:11例患者腹透管均放置成功,手术时间约45min,均成功进行了腹膜透析,患者术后一周内出院。结论:腹腔镜引导下放置Tenckhoff卷曲腹透管具有腹透管放置定位准确,无手术切口,优于常规开腹手术,值得推广应用。     

Preperitoneal Tunneling—A Novel Technique in Peritoneal Dialysis Catheter Insertion

♦ Introduction: This study describes a new preperitoneal tunneling (PPT) method for inserting a peritoneal dialysis catheter (PDC), thereby lessening surgical complications and increasing the catheter’s survival.♦ Methods: This new technique was used in 23 cases from December 2005 to January 2007 and followed up until March 2011 (63 months). The procedure was performed laparoscopically under local (16 cases) or general (7 cases) anesthesia by one surgeon. Catheter survival is reported by Kaplan-Meyer analysis.♦ Results: The catheters were mechanically obstructed in 2/23 cases (8.7%); and were withdrawn due to a peritonitis in 2 cases and inadequacy of peritoneal dialysis in 1 case. Ten patients received kidney transplantation and six died before completing this follow-up period. The patients still reaped the benefits of the PDC until receiving a kidney transplant or death. The 5-year survival rate of the catheter was 89%. No incidence of catheter migration, omental wrapping, herniation or leakage was noticed.♦ Conclusion: Preperitoneal tunneling is a simple and safe method for insertion of PDC, and can effectively prevent catheter migration, dislocation and omental wrapping.     

Fluoroscopically guided peritoneal dialysis catheter placement: long-term results from a single center.

OBJECTIVE: Despite percutaneous fluoroscopy ensuring appropriate placement of peritoneal dialysis (PD) catheters, the efficacy of this method is not well known. Therefore, we evaluated our long-term experience with fluoroscopy-assisted placement of PD catheters. Patients and METHODS: We retrospectively reviewed 134 PD catheters in 114 PD patients that were treated in the PD center of a university-based hospital. We evaluated complications related to PD catheters, causes for catheter removal, and catheter survival. We used the multivariate Cox proportional hazard model to identify independent factors related to PD catheter survival. RESULTS: Early complications related to insertion included 1 case of pericatheter bleeding; there were no placement failures. Early complications occurred in 8.5% of patients. Most late complications were migration and leakage, which occurred in 10.4% and 9.7% of patients respectively. The most common cause for catheter removal was intractable and recurrent peritonitis. The 12- and 24-month survival rates of the catheters were 80.0% and 74.9%. The most significant prognostic factor of percutaneous fluoroscopy-assisted PD catheter survival was late leakage (p < 0.01). CONCLUSIONS: In addition to the advantages of simplicity, minimal invasiveness, and relative safety, the survival rate of PD catheters placed using the percutaneous fluoroscopy-assisted method was comparable to that of more invasive methods. Percutaneous fluoroscopy-assisted placement of PD catheters should be considered when available, and may be preferred to other placement methods.     

Does previous abdominal surgery increase postoperative complication rates in continuous ambulatory peritoneal dialysis?

BACKGROUND: This study was to compare the postoperative complication rates of continuous ambulatory peritoneal dialysis (CAPD) catheter insertion via open technique between two groups of patients, those with and those without a history of previous abdominal surgery. METHODS: A review was carried out in 122 patients over a 2-year period. The patients were divided into two groups: those with and those without previous lower abdominal surgery. All patient records were retrospectively analyzed until the time of catheter failure or to current time if alive and receiving CAPD. Patient characteristics, operative factors, and postoperative complications were recorded. RESULTS: Postoperative complications were reported as catheter malfunction in 16 patients and CAPD-related peritonitis in 36 patients. The complication rates in the group of patients with previous abdominal surgery were 16.7% catheter malfunction and 33.3% CAPD-related peritonitis. In patients without previous lower abdominal surgery, a catheter malfunction rate of 12.5% and a peritonitis rate of 28.8% were seen. The operation time in patients with previous abdominal surgery was longer than that in patients without previous abdominal surgery. However, no statistically significant difference in postoperative complication rates was detected between patients with and patients without previous lower abdominal surgery. CONCLUSION: CAPD remains a reliable modality in the treatment of end-stage renal disease and does not increase postoperative complications in patients with previous abdominal surgery.     

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.     

A New Simplified One-Port Laparoscopic Technique for Peritoneal Dialysis Catheter Placement

♦ Background: Various techniques for laparoscopic insertion of a peritoneal dialysis catheter have been described. Usually 2 - 3 ports are required, and complications related to the port sites (such as abdominal wall hernia, leakage, and hemorrhage) cannot be avoided. To minimize the potential complications, we designed a simplified 1-port laparoscopic technique for peritoneal dialysis catheter placement.♦ Methods: We conducted a retrospective data review of 44 patients who underwent 1-port laparoscopic insertion of a Tenckhoff catheter from June 2009 to February 2011. All patient data, including postoperative complications, were analyzed.♦ Results: The mean follow-up period was 11.52 months. All catheters were working properly, except in 1 patient who developed peritonitis 3 months after catheter placement. (The catheter was removed.) No postoperative abdominal wall hemorrhage, early leaks, hernias, or catheter migration occurred. No exit-site or tunnel infections were observed.♦ Conclusions: Our 1-port laparoscopic technique provides excellent catheter fixation, avoids excessive port sites, and yields good cosmesis. The low complication rate and the simplicity of the method justify its standard use for Tenckhoff catheter placement.     

Tenckhoff catheter salvage by closed stiff-wire manipulation without fluoroscopic control.

OBJECTIVE: To describe the results of Tenckhoff catheter salvage by a modified, closed, stiff-wire manipulation technique without the use of general anesthesia or fluoroscopy, and compare this with previously described techniques. DESIGN: Retrospective study in patients treated with continuous ambulatory peritoneal dialysis (CAPD) over a 41-month period. SETTING: Renal unit in an inner city hospital. PATIENTS: Eighteen patients using CAPD who had 22 episodes of outflow failure due to radiologically confirmed malposition of straight two-cuff Tenckhoff catheters. INTERVENTIONS: Closed stiff-wire manipulation of malpositioned Tenckhoff catheter without the use of general anesthesia or fluoroscopy. MAIN OUTCOME MEASURES: Initial success rate of manipulation, catheter and technique (CAPD) survival, and procedure-related complications. RESULTS: Catheter manipulation was technically successful in 21 of 22 cases. An additional six episodes of malposition occurred ranging from 2 to 630 days after the primary manipulation (median 7 days). A second manipulation was carried out in four cases that resulted in long-term success in two. Three patients were forced to discontinue CAPD for reasons other than catheter malposition, and the overall success rate at 1 month (patient successfully performing CAPD) was 59.1% (+/-0.1%). No major complications were experienced during the procedure and no episodes of peritonitis occurred. CONCLUSION: The technique described is relatively straightforward, does not require fluoroscopy or general anesthetic, and its success is comparable to previously reported methods of Tenckhoff catheter salvage. We would recommend this technique of catheter salvage in patients with Tenckhoff catheter malposition in whom conservative treatment has failed.     

Experience using presternal catheter for peritoneal dialysis in Poland: a multicenter pediatric survey.

OBJECTIVES: Permanent and adequate access to the peritoneal cavity is the key to successful chronic peritoneal dialysis (PD). A variety of catheter designs and implantation techniques have been developed to achieve optimal peritoneal access. One such new and modified PD catheter is the presternal catheter [swan neck presternal catheter (SNPC)], with the exit site located on the chest wall. DESIGN: A multicenter survey was undertaken to summarize 10 years of experience with the presternal catheter in children in Poland. SETTING: Four pediatric institutions using the SNPC in children: (1) Medical University of Warsaw, Warsaw; (2) Children's Memorial Health Institute, Warsaw; (3) District Children's Hospital, Szczecin; (4) University of Medical Sciences, Poznan. PATIENTS: During the past 10 years, 20 presternal catheters were implanted in 19 children, aged 0.2-17.7 years (mean 8 +/- 5.8 years), with end-stage renal failure.The main indications for the SNPC include urinary diversion (ureterocutaneostomy or vesicostomy), use of diapers, young age, obesity, abdominal wall weakness, and recurrent exit-site infections (ESI) with previous abdominal PD catheters. INTERVENTION: In all children the presternal catheter was implanted surgically under general anesthesia by one surgeon. Uniform operative technique and uniform perioperative management were used. RESULTS:The mean observation time for the 20 presternal catheters was 24.8 +/- 25 months (range 1-83 months). The ESI rate was 1/70.9 patient-months (0.17 episodes per year), tunnel infection rate was 1/248 patient-months (0.05 episodes per year), and the overall peritonitis rate was 1/26.6 patient-months (0.51 episodes per year). Non-infectious complications associated with the SNPC included disconnection of both sections (2 children) and trauma to the exit site located on the chest wall (4 children). Mean survival time of the presternal catheter, as calculated by the Kaplan-Meier method, was 57.5 +/- 8.5 months; 50% catheter survival reached 72 months. CONCLUSIONS: The good outcome in patients with a SNPC validates the rationale for the presternal catheter design and should encourage its more widespread use. The SNPC seems to be suitable for any patient on PD; however, this catheter is particularly useful in patients with specific indications (ie., higher tendency to ESI). The SNPC allows safe and long-term chronic PD in very young children using diapers and in patients with urinary diversion.     

Peritoneal catheters and exit-site practices toward optimum peritoneal access: a review of current developments.

OBJECTIVE: This review updates the 1998 International Society for Peritoneal Dialysis (ISPD) recommendations for peritoneal dialysis catheters and exit-site practices (Gokal R, et al. Peritoneal catheters and exit-site practices toward optimum peritonealaccess: 1998 update. Perit Dial Int 1998; 18:11-33.) DESIGN: DATA SOURCES: The Ovid and PubMed search engines were used to review the Medline databases of January 1980 through June 2003. Searches were restricted to human data; primary key word searches included dialysis, peritoneal dialysis, and continuous ambulatory peritoneal dialysis cross referenced with access, catheter, dialysis catheter, peritoneal dialysis catheter, and Tenckhoff catheter. Related searches were provided via the PubMed related articles link. Study Selection: Reports were selected if they provided identifiable information on catheter design, catheter placement technique, and survival or placement complications. Reports without such data were excluded from review. Each study was then categorized by its characteristics: single-center or multicenter; retrospective or prospective; controlled trial, with or without random patient assignment; or review article. MAIN RESULTS: There are few randomized controlled evaluations testing how catheter design and/or placement influence long-term survival and function, and these are typically conducted at a single center. The majority of reports represent retrospective single-center experiences, and these are supplemented by occasional multicenter data registries. CONCLUSIONS: There is substantial variability in catheter outcomes between centers, and this variability is more closely correlated with operator and center characteristics than with catheter design. Some catheter designs appear to impact long-term catheter success, and, in some cases, specific patient characteristics and dialysis formats combine with specific catheter designs to influence catheter survival. Most reporters prefer two-cuff designs and placement of the deep cuff at an intramuscular location. Intramuscular cuff placement results in fewer pericatheter leaks and hernias, but makes catheter removal more difficult. High-risk patients (those with previous pelvic surgery) benefit from visual inspection of the peritoneum during catheter placement, and in randomized controlled trials, catheters with pre-shaped arcuate subcutaneous segments ("swan neck" designs) reduce the risk of early drainage failure via "migration."     

直型与卷曲型腹膜透析导管相关并发症和导管生存率的meta分析

目的 腹膜透析是治疗终末期肾脏病的有效方法,良好的腹膜透析导管功能是其技术成功的关键.本项meta分析的目的是对比直型与卷曲型腹膜透析导管的临床预后.方法 综合检索PubMed（1990 to Sept2013）,Embase（1990 to August 2012）,CNKI（1990 to Sept 2013）和CENTRAL（theCochrane Library 2013）数据库,文章的参考文献进行手工检索.按照种族进行亚组分析.比较直管和卷曲管在导管移位、渗漏、感染、1年及2年技术生存率等10项临床指标发生情况.结果 共纳入11项RCT研究,共843例患者,在10项临床观察指标中,直管和卷曲管仅在导管移位发生率有统计学差异（9项RCT研究和685例患者,OR,2.33;95％ CI 1.46～3.71;P=0.0004）,亚组分析结果显示亚洲人群卷曲管导管移位发生率明显高于直管（5项RCT研究和422例患者,OR 2.96,95％ CI 1.59 to 5.51;P=0.0006）,而欧洲人群两者之间差异无显著性意义（OR 1.65,95％ CI 0.80～3.40;P=0.18）.在机械相关其他并发症、感染相关并发症以及1年和2年的导管技术生存率方面,卷曲管与直管均无统计学差异,且不存在种族差异.结论 亚洲人群中卷曲管的导管移位发生率明显高于直管,但欧洲人群则无显著性差异,提示直管可能更适合于亚洲人应用.