腹腔镜在腹膜透析管置入术中的临床应用

目的 总结腹腔镜外科技术在腹膜透析管置入方面的临床应用经验.方法 选择16例慢性肾功能衰竭患者,其中7例行腹膜透析管放置固定术,5例行腹膜透析管复位固定术,4例行腹膜透析管疏通固定术.结果 16例患者腹透管均放置成功,手术时间30～45 min,均成功进行了腹膜透析,术后随访未发现严重并发症.结论 腹腔镜引导下放置和复位移位的Tenckhoff卷曲腹透管具有创伤小、腹透管放置定位准确、恢复快等优点,值得推广应用.     

Laparoscopic placement of Tenckhoff catheters for peritoneal dialysis: a safe, effective, and reproducible procedure.

BACKGROUND/AIMS: Currently there are several techniques for laparoscopic placement of peritoneal dialysis catheters. The aim of this paper is to describe our technique and outcomes. PATIENTS AND METHODS: Laparoscopic implantation of peritoneal catheters was performed in 100 consecutive patients. The technique employed laparoscopically guided musculofascial tunneling to maintain catheter orientation toward the deep pelvis, and adhesiolysis to eliminate compartmentalization that could affect completeness of dialysate drainage. Mean duration of surgery, hospital stay, morbidity, mortality, and catheter survival were assessed. Analysis of catheter survival was performed using the Kaplan-Meier method, with censoring of catheter loss due to death or successful transplantation. RESULTS: Mean operative time was 20 +/- 7 minutes and average duration of hospital stay was 3 +/- 1 days. There were no conversions from laparoscopy to conventional catheter insertion methods. No exit-site or tunnel infections, hemorrhagic complications, abdominal wall hernias, or catheter cuff extrusions were detected. No mortality occurred in this series of patients. Catheter survival was 97%, 95%, and 91% at 1, 2, and 3 years, respectively. CONCLUSIONS: The laparoscopic method described in this report is compliant with consensus guidelines for best-demonstrated practices in peritoneal access placement. Laparoscopy permits direct visualization of all procedure steps in a safe efficient reproducible manner. The laparoscopic approach afforded patients the advantage of short procedure times, a minimally invasive approach, and excellent outcomes. The results reported in this paper support our opinion that laparoscopic Tenckhoff catheter implantation should become the standard of care for clinical practice.     

腹膜透析植管手术改进及临床效果观察

目的 探讨腹膜透析导管植入手术的理想方法,减少透析导管相关并发症的发生率以及提高腹膜透析治疗质量.方法 山东省青岛市立医院对传统腹膜透析导管植入方法在手术切口选择、透析导管植入点选择以及内cuff处理等方面进行改进,比较改进前后两种手术方法透析导管机械故障率和相关并发症发生率.结果 改进后的手术患者透析导管机械故障率和相关并发症的发生率明显降低.结论 改进的腹膜透析导管植入手术能减少透析导管机械故障率和相关并发症的发生率,从而提高腹膜透析治疗质量.     

Peritoneoscopic placement of a Tenckhoff catheter for chronic peritoneal dialysis

The use of peritoneoscopic control in the placement of a Tenckhoff catheter for chronic peritoneal dialysis permits accurate positioning of the catheter. As a result, the risk of malfunction during change of dialysis fluid is considerably reduced, and prior abdominal surgery and adhesions no longer automatically represent contraindications. A special trocar permits the introduction of the catheter to be done more gently, causes less scarring, and does away with the lower Dacron cuff. This prevents the kinking of the catheter in the abdominal wall, and makes the change of dialysis fluid more convenient. In addition, the procedure takes less time to carry out, as does the removal of the catheter on termination of dialysis.     

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.     

A randomized clinical trial with a 0.6% amino acid/ 1.4% glycerol peritoneal dialysis solution.

BACKGROUND: Glucose is an accepted osmotic agent for peritoneal dialysis (PD) although it has several drawbacks. Some of these drawbacks have been addressed by the introduction of solutions with low glucose degradation products and physiological pH in dual-chambered bags. Despite this achievement, there is a need for alternative osmotic agents.This randomized clinical trial analyzes 3-month's clinical experience with a mixture of 0.6% amino acids and 1.4% glycerol. METHODS: The study was performed at the renal units of the University Hospitals Ghent, Belgium, and Utrecht, The Netherlands. Stable PD patients were randomized for either protocol A (test solution, n = 5) or protocol B (control regimen, n = 5). In both protocols, there was a run-in phase of 1 month with a dialysis regimen of 2 x 2 L 2.27% glucose solution (Dianeal; Baxter, Nivelles, Belgium), 1 x 2 L Extraneal (Baxter), and 1 x 2 L glucose solution (Dianeal). After this month-long run-in period, patients in group A received during 3 months 2 x 2 L amino acid/glycerol solution, 1 x 2 L Extraneal, and at least 1 x 2 L of a classic glucose solution. RESULTS: Glucose absorption decreased in the test group during the test phase (from 84.2 +/- 8.7 to 11.7 +/- 11.6 g/24 hours, p = 0.001). Dialysate levels of cancer antigen 125 (CA125) increased in the test group, from 17.5 +/- 11.0 to 32.4 +/- 4.6 units/L (p = 0.04), whereas, in the control group, the levels remained stable (15.5 +/- 8.7 and 14.9 +/- 9.8 units/L respectively, p = 0.4).There were no differences in serum urea, serum bicarbonate, serum osmolarity, serum albumin, or parameters related to skin-fold thickness or serum glycerol levels between control and test solutions. No differences were observed in obtained ultrafiltration after a 4-hour dwell with 2.27% glucose or the test solution, both measured at week 4 of the run-in period and week 12 of the test period. CONCLUSION: This study demonstrated that the use of a new 0.6% amino acid/1.4% glycerol-containing dialysis solution is safe and well tolerated. Glucose load was reduced significantly and dialysate CA125 levels improved significantly. Ultrafiltration was comparable with that of a 2.27% glucose solution. All these factors, in combination with the potential nutritional benefits, can contribute to a beneficial impact on the success of the PD technique. Further long-term studies in larger patient groups are warranted to explore the potential of this promising new solution.     

自制弹簧套管钩针在腹腔镜腹膜透析管置入内固定术中的应用

目的 评价应用自制弹簧套管钩针在腹腔镜腹膜透析管置入术中辅助行内固定术的疗效及并发症.方法 2003年9月至2010年8月该院应用自制弹簧套管钩针为263例慢性肾功能不全患者行腹腔镜下腹膜透析管置入术时辅助行内固定术.结果 手术过程顺利,手术时间12～28 min,手术创伤小,术后漂管率低(1/263),患者均恢复满意,可早期行腹膜透析.主要并发症有继发性腹膜炎、穿刺点局部皮下血肿及术后腹膜透析管漂移堵管等.治疗效果良好.结论 自制弹簧套管钩针在腹腔镜下透析管置入及内固定术中的应用安全有效.可以极大的简化手术操作,节约手术时间,减轻手术应激,值得临床推广应用.     

A randomized controlled trial comparing mupirocin versus Polysporin Triple for the prevention of catheter-related infections in peritoneal dialysis patients (the MP3 study).

BACKGROUND: Peritonitis remains the most serious complication of peritoneal dialysis (PD). Gram-positive organisms are among the most common causes of PD peritonitis; however, recent trends show increasing rates of gram-negative and fungal infections. Strategies to prevent peritonitis include the use of prophylactic topical mupirocin at the site where the PD catheter exits from the abdominal wall; however, mupirocin does not afford protection against gram-negative or fungal infections. The aim of this study is to determine if the incidence of catheter-related infections (exit-site infection, tunnel infection, or peritonitis) is significantly reduced by the routine application of Polysporin Triple antibiotic ointment (Pfizer Canada, Markham, Ontario, Canada) in comparison to mupirocin ointment. METHODS AND DESIGN: The Mupirocin Versus Polysporin Triple Study (MP3) is a multicenter, randomized, double-blinded controlled study comparing Polysporin Triple (P3) against the current standard of care. The aim of the study is to recruit 200 patients being treated with or starting on PD and randomize them to receive either mupirocin or P3 at the catheter exit site. Patients will be followed for 18 months or until death or transfer from PD to an alternate treatment modality. The primary outcome will be the time to first catheter-related infection. Catheter-related infections will be strictly defined using current guidelines and categorized into exit-site infections, infective peritonitis, or tunnel infections. The primary analysis will be an intention-to-treat analysis. DISCUSSION: The results of this study will help determine if the use of P3 is superior to mupirocin ointment in the prevention of catheter-related infections and will help guide evidence-based best practices.     

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.     

A randomized clinical trial comparing ranitidine and antacids in critically ill patients

In a randomized trial of gastric pH control for stress ulcer prophylaxis, 200 mg/day ranitidine iv was compared to antacids in 86 patients admitted to an ICU. Six (15%) patients receiving ranitidine and six (13%) given antacids failed to maintain greater than 50% of the hourly gastric pH measurements at or above 4. Increasing the ranitidine dosage to 300 mg/day did not provide additional control. One patient in the antacid group developed an overt upper GI bleed secondary to endoscopically proven erosive disease. We conclude that iv ranitidine in a dosage of 200 mg/day is as effective as antacids in reducing gastric acidity and preventing stress ulcer disease in critically ill patients.     

Insertion of peritoneal dialysis catheters: the lateral approach

Potential complications of peritoneal dialysis catheters include ventral herniation, dialysate leakage, and catheter dysfunction. Using local anesthesia and a paramedian, muscle-splitting approach, we have significantly reduced the morbidity of the procedure. Security of fascial closure and identification of the peritoneum, even in obese patients, has been facilitated through this technique.     

应用扇形拨开器与常规置管术在腹膜透析置管中的效果比较

目的 比较应用扇形拨开器的腹膜透析(peritoneal dialysis,PD)置管术与常规PD置管术术后引起的并发症,探讨应用扇形拨开器的PD置管术的临床效果. 方法 随机入选三峡大学人民医院肾内科2009年2月至2012年4月首次PD置管并接受PD治疗且观察满6个月的终末期肾病(end stage renal disease,ESRD)患者共69例,随机分为用扇形拨开器引导组(A组),常规手术组(B组),A组35例,B组34例,纪录2组术前的基本情况、术后感染并发症;同时观察比较2组术后6个月内的PD管移位率、导管阻塞率、渗漏、疼痛等机械并发症发生情况. 结果 2组患者的年龄、原发病情况无差别(P＞0.05);A组患者导管移位3例(8.57％),B组患者导管移位10例(29.41％),两组相比有显著性差异(x2=4.899,P=0.027);A组患者重新置管2例(5.71％),B组患者重新置管8例(23.53％),2组相比有显著性差异(x2=4.417,P0.036);2组患者发生导管阻塞、渗漏、疼痛等并发症差异均无统计学意义(P＞0.05).2组患者发生感染并发症无统计学差异(P＞0.05). 结论 应用扇形拨开器的PD置管术可降低置管术后PD导管移位率,需重新置管率低.不增加PD置管术后感染率及机械并发症.