Peritoneal Dialysis Catheter Implantation Research Articles

Single-port laparoscopic placement of peritoneal dialysis catheter: A safe and effective technique

Background/Aim: Laparoscopic techniques for placement of peritoneal dialysis catheters are becomingincreasingly popular. Currently, there are several techniques for such laparoscopic approach. The aim ofthis study is to describe our technique and outcomes of using single port laparoscopic placement of peritoneal dialysis catheters. Patients and methods: Laparoscopic implantation of peritoneal dialysis catheters was performed in 64 consecutive patients.The technique was performed via a single port inserted in the supra-umbilical region. The tip of the catheter was placed in the true pelvis while its deep cuff was placed into the rectus sheath. A subcutaneous tunnel was created to the selected exit site of the catheter. Mean duration of surgery, hospital stay, morbidity, mortality, and catheter survival were assessed. Results: The mean operating time was 22 ± 7 minutes. The mean post-operative hospital stay was 2 ± 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 100% and 96.8% at 6 months and one year respectively Conclusion: The laparoscopic method described in this study is compliant with consensus guidelines for the best-demonstrated practices in peritoneal dialysis access placement. The results reported in this paper support the opinion that laparoscopic placement of peritoneal dialysis catheter should become the standard care for clinical practice. The use of single-port technique is safe, effective and reproducible method.

Can peritoneal dialysis be applied for unplanned initiation of chronic dialysis?

Late referral of patients with chronic kidney disease (CKD) and unforeseeable deterioration of residual renal function in known CKD patients remain a major problem leading to the need of unplanned start on chronic dialysis without a mature access for dialysis. In most centres worldwide, these patients are started on haemodialysis (HD) using a temporary tunnelled central venous catheter (CVC) for access. However, during the last decade, increasing clinical experience with unplanned start on peritoneal dialysis (PD) right after PD catheter implantation has been published. Key studies are reviewed in the present paper, and the results seem to indicate that compared with patients starting PD in a planned setting with peritoneal resting after PD catheter implantation, patients starting unplanned PD have an increased risk of mechanical complications but apparently no increased risk of infectious complications. In contrast, patients starting unplanned HD using a temporary CVC have an increased risk of both mechanical and infectious complications when compared with patients starting planned HD using an arterio-venous fistula or a permanent CVC. Regarding clinical outcome in terms of survival, unplanned PD seems to be at least as safe as unplanned HD. Combining the unplanned PD programme with a nurse-assisted PD programme is crucial in order to offer the patient a real opportunity to choose a home-based dialysis option. In conclusion, unplanned start on PD seems to be a feasible, safe and efficient alternative to unplanned start on HD for the late referred patient with end-stage renal disease and urgent need for dialysis.

Laparoscopic Peritoneal Dialysis Catheter Implantation With an Intra-abdominal Fixation Technique

The purpose of this study was to evaluate the feasibility, the safety, and outcomes of renal replacement therapy with the laparoscopic technique for peritoneal dialysis (PD) catheter implantation with an intra-abdominal fixation. Medical records of 53 patients with end-stage renal disease who underwent laparoscopic PD catheter implantation with an intra-abdominal fixation in our department from December 2008 to October 2009 were reviewed retrospectively. Their surgical procedure, operative outcomes, postoperative complications, and follow-up outcomes were analyzed. All patients underwent laparoscopic PD catheter implantation with an intra-abdominal fixation successfully. Neither conversion to open surgery nor major intraoperative complications were observed. The median operative time was 24.2±10.5 minutes. The operative cost was 837.3±107.0 US$. Two patients (3.8%) had catheter obstruction peritonitis 12 and 15 months after surgery, respectively, and both of them had the catheter removed. Laparoscopic PD catheter implantation with an intra-abdominal fixation of the catheter tip is feasible and safe. It had a low incidence of PD catheter migration and other PD-related postoperative complications with the benefit of minimal invasiveness, a shorter operation time, and quicker postoperative recovery.

Causes of death in peritoneal dialysis patients with different kidney diseases and comorbidities: a retrospective clinical analysis in a Chinese center

The objective of the study is to identify and compare the different causes of death among peritoneal dialysis (PD) patients varying in baseline characteristics, including gender, age, primary diseases, and comorbidities and to assess risk factors for first-year death. The clinical data of 179 PD patients who were regularly followed up in our hospital and died between January 2006 and February 2011 were retrospectively reviewed. Median age at PD catheter implantation was 73 years. The most common primary diseases leading to ESRD were diabetic nephropathy (DN; 26.3 %), chronic glomerulonephritis (CGN; 24.6 %), and hypertensive nephropathy (HN; 21.8 %). The main causes of death in the DN and CGN groups were infections (42.6 %) and cardiocerebrovascular accidents (34.1 %), respectively. Patients with systemic vasculitis (SV) had the highest mortality rate from infection (71.4 %). Cox regression model showed that, compared with patients with CGN, those who had primary disease of DN, renal amyloidosis, multiple myeloma, or vasculitis were at higher risk of first-year death. Cerebrovascular disease, chronic heart failure, and/or lower serum albumin at baseline were also risk factors for first-year death. The main causes of death in PD patients with DN and CGN were infections and cardiocerebrovascular accidents, respectively. Risk factors for first-year death included the primary diseases, cerebrovascular diseases, chronic heart failure, and lower serum albumin at baseline.

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

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. 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. 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. 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.

Dual-Incision Laparoscopic Surgery for Peritoneal Dialysis Catheter Implantation and Fixation: A Novel, Simple, and Safe Procedure

Peritoneal dialysis (PD) is an alternative modality to hemodialysis and is usually used to treat patients with end-stage renal disease. Dual-incision laparoscopic surgery (DILS) had been reported in several surgical fields; however, no report was proposed about DILS in PD catheter implantation (DILS-PD). In this study, we present DILS with a novel, simple, and safe procedure for PD catheter implantation with fixation and describe the long-term outcome. We conducted a prospective data collection and retrospective review of all PD patients from April 2010 until June 2012. During this study period, we performed open surgery for PD catheter implantation (OS-PD) and DILS-PD concurrently. Demographic data, medical, operative, and postoperative findings, and information regarding complications were compared between these two groups. Forty-eight patients had DILS-PD, and 70 patients had OS-PD. There was no difference between the two groups in age, gender, American Society of Anesthesiologists grade, creatinine level, body mass index, and previous abdominal surgery. There was no surgical mortality in either group. The follow-up period ranged from 6 to 24 months, with a mean of 22.4±16.5 months. There was no tube migration in the DILS-PD group, but 25.7% of the patients in the OS-PD group had tube migration (P<.001). A significantly decreased exit-site/tunnel infection rate was found in the DILS-PD group (4.2%) compared with the OS-PD group (17.1%) (P=.032). However, there was no obvious difference in peritonitis occurrence between groups. A significantly decreased catheter failure rate was found in the DILS-PD group (4.2%) compared with the OS-PD group (22.9%) (P=.006). DILS-PD group patients had a favorable survival rate for catheter implantation compared with OS-PD group patients. Our DILS-PD with fixation technique is a simple and safe procedure. This procedure minimized or even eliminated the possibility of migration without additional cost. Our DILS-PD fixatation technique should be recommended for use routinely.

Peritoneal Dialysis—Moving from Current Status to the Future

Peritoneal dialysis (PD) has been widely used as one of the major renal replacement therapies (RRT) for end-stage renal disease (ESRD) patients. Although PD therapy has witnessed remarkable technical advances, and the patient's survival early after starting PD is comparable, or superior, to that of hemodialysis, it is currently faced with many challenges. Long-term PD is associated with progressive loss of UF capacity, resulting in increased cardiovascular morbidity or ultimate discontinuation of PD. This is related to inflammation, new vessel formation (angiogenesis), and fibrotic thickening of the peritoneal membrane (PM). Bioincompatible PD fluid, along with peritonitis, is the major contributor to the PM change. In order to establish PD as a more general and longstanding renal replacement therapy, clinicians and scientists need to investigate the pivotal issues such as adequate volume control and long-term preservation of the peritoneal membrane and the prevention from devastating conditions such as encapsulating peritoneal sclerosis. In this special issue, we have compiled elegant reviews and clinical studies with a special interest in the above-mentioned “Contemporary issues of PD therapy.” This special issue deals with many of the current issues such as PD catheter implantation by nephrologists, clinical benefits of the newer biocompatible PD fluid, peritonitis, and how to cope with low ultrafiltration volume with bimodal and twice-daily icodextrin use and several others. It is the hope of our editorial committee that this special issue will contribute to an improved patient care and serve as a stimulus to seek a new knowledge in renal replacement therapy. Kook-Hwan Oh Yong-Lim Kim Wai-Kei Lo Peter J. Margetts

The Choice of Peritoneal Dialysis Catheter Implantation Technique by Nephrologists

Peritoneal dialysis catheter (PDC) is the lifeline of peritoneal dialysis (PD) patients. One of the critical issues for successful PD is a well-functioning PDC which is timely inserted. It is the implantation technique rather than the catheter design that determines the outcome of the catheter. Dedication in acquiring the appropriate technique is vital to the success of a PD program. In this paper, we discuss the pros and cons of various techniques used for PDC implantation. A detailed description of PDC implantation by using the minilaparotomy method is presented. We strongly recommend mini-laparotomy as the method of choice for PDC implantation by nephrologists.

Early Initiation of Peritoneal Dialysis after Arterial Switch Operations in Newborn Patients

Background and aim: We investigated the clinical outcome of early initiated peritoneal dialysis (PD) use in our newborn patients who underwent arterial switch operation (ASO) for transposition of the great arteries (TGA) and had routine intraoperative PD catheter implantation. We determined the risk factors for PD, factors associated with prolonged PD, morbidity, and mortality. The aim of the present study was to describe our experience of using PD in this patient cohort. Materials and Methods: Eighty two patients who were diagnosed with TGA and TGA-ventricular septal defect (VSD) and who had undergone TGA correction operation in Başkent University, Istanbul Medical Research and Training Hospital between 2007 and 2012 were retrospectively investigated. All the patients were under 30 days old. PD catheters were routinely implanted intraoperatively at the end of the operation. PD was initiated in transient renal insufficiency. In the absence of oliguria and increased creatinine level, PD was established in the presence of one of the following: clinical signs of fluid overload, hyperkalemia (>5 mEq/L), persistent metabolic acidosis, lactate level above 8 mmol/L or low cardiac output syndrome. The patients were divided into two groups according to the need for postoperative PD (PD group and non-PD group). PD was initiated in 32 (39%) patients after the operation, whereas 50 (61%) patients did not need dialysis. The clinical outcomes and perioperative data of the two groups were compared. Results: The demographics in the two groups were similar. Cardiopulmonary bypass time was longer in the PD group [non-PD group, 175.24 ± 32.39 min; PD group, 196.22 ± 44.04 min (p < 0.05)]. Coronary anomaly was found to be higher in the PD group [non-PD group, n = 2 patients (4.0%); PD group, n = 7 patients (21.9%); p < 0.05]. There was more need for PD in TGA + VSD patients [simple TGA patients, n = 14; TGA + VSD patients, n = 18 (p < 0.05)]. PD rate was higher in patients whose sterna were left open at the end of the operation (p < 0.05). The ventilator time [non-PD group, 4.04 ± 1.51 days; PD group, 8.12 ± 5.21 days (p < 0.01)], intensive care unit stay time [non-PD group, 7.98 ± 5.80 days; PD group, 15.93 ± 18.31 days (p < 0.01)], and hospital stay time were significantly longer in the PD group [non-PD group, 14.98 ± 10.14 days; PD group, 22.84 ± 20.87 days (p < 0.01)]. Conclusion: We advocate routine implantation of PD catheters to patients with TGA-VSD, coronary artery anomaly, and open sternum in which we have determined high rate of postoperative PD need.

Characterizing peritoneal dialysis catheter use in pediatric patients after cardiac surgery

Children who undergo cardiac surgery are at high risk for renal insufficiency and abdominal compartment syndrome. Peritoneal dialysis catheter (PDC) implantation is used in this population for abdominal decompression and access for dialysis. However, there is no consensus regarding PDC use, and the practice varies widely. This study was undertaken to assess associated factors, outcomes, and variability in the use of PDC in patients who have undergone cardiac surgery. The cohort was obtained from the Kids' Inpatient Database, years 2006 and 2009. Patients who underwent cardiac surgery were included and the subset that underwent PDC implantation during the same hospitalization was identified. Univariable and multivariable analyses assessed factors associated with PDC and survival. A cohort of 28,259 patients underwent cardiac surgery, of whom 558 (2%) had PDCs placed. In the PDC group, 39.1% (n = 218) had acute renal failure whereas 3.5% or patients (n = 974) in the non-PDC group had acute renal failure. Among patients receiving PDC, mortality was 20.3% (n = 113; vs 3.4% overall mortality, n = 955). Excluding patients with acute renal failure, mortality remained 12% (n = 41) for the PDC group. Factors associated significantly with PDC placement in the overall cohort were younger age, greater surgical complexity, nonelective admission, hospital region, use of cardiopulmonary bypass, and acute renal failure. Patients receiving PDC after cardiac surgery had 20% mortality, which remained 12% after excluding patients with acute renal failure. Given the variability in PDC use and poor outcomes, further research is needed to assess the possible benefit of earlier intervention for peritoneal access in this high-risk cohort.

Ascites Complicating Unilateral Nephrectomy and Peritoneal Dialysis Catheter Implantation in a Patient with Massive Polycystic Kidney and Liver Disease

Peritoneal dialysis (PD) is a well-established therapeutic option for patients with polycystic kidney disease. However, in patients with massive polycystic kidney and liver disease, subclinical hepatic venous outflow obstruction may elicit the appearance of ascites after implantation of a peritoneal catheter. The case of a patient who developed ascites after implantation of a PD catheter and further lowering of abdominal pressure after unilateral nephrectomy is discussed.

Similar Outcomes of Catheters Implanted by Nephrologists and Surgeons: Analysis of the Brazilian Peritoneal Dialysis Multicentric Study

A good catheter implantation technique is important to allow for effective peritoneal access function and long-term technique survival. Studies regarding results obtained by nephrologists in comparison with surgeons have been limited to small single-center experiences. Thus, the objective of this study was to explore the impact of the peritoneal dialysis (PD) catheter insertion operator on early catheter complications and on technique survival in a large national multicentric cohort study (Brazilian Peritoneal Dialysis Multicentric Study, BRAZPD). Adult incident patients recruited in the BRAZPD from December 2004 to October 2007 having undergone first PD catheter implantation were included in the analysis. Mechanical and infectious early complication rates were defined as time to the first event occurring up to 3 months after catheter insertion and adjusted for comorbidities. Valid data of 736 patients (mean age of 59 ± 16 years old, 52% women, 61% white) were analyzed. Mechanical (HR 0.99 [CI 0.56-1.76]; p = 0.98) and infectious (HR 0.63 [CI 0.32-1.23]; p = 0.17) early complication rates were similar between groups. Long-term catheter survival was also similar between groups. Early complications rates and catheter survival were similar between groups defined by operator profile (nephrologist or surgeon), supporting the role of interventional nephrology in the placement of PD catheters.

Single-site multi-channel transumbilical laparoscopic implantation of long-term peritoneal dialysis catheters: initial clinical experience with 2 cases

Objective To present our initial experience of single-port multi-channel laparoscopic urologic surgery for the transumbilical laparoscopic implantation of long-term peritoneal dialysis catheters.Methods On May 17th and August 18th,2009,2patients underwent single-port multi-channel laparoscopic surgery for chronic renal failure(CRF)due to benign arteriolonephrosclerosis and type 2diabetes mellitus(DM).The flexible laparoscopic instrumentation with a homemade single port and multichannels was used for the transperitoneal approach.Results The 2cases were completed without conversion to standard laparoscopic or laparotomy.The operation time for implantation was 15-25min,and the estimated blood loss was about 20ml.The patients were discharged 1day after operation and were followed up for 6-8months.Conclusion Singleport multi-channel laparoscopy is feasible,safe,and effective for transumbilical laparoscopic implantation of long-term peritoneal dialysis catheters,with the advantages of minimal incision and better cosmetic benefit.

Single site with multichannel transumbilical laparoscopic implantation of long‐term peritoneal dialysis catheters: Initial clinical experience of two cases

International Journal of UrologyVolume 18, Issue 8 p. 609-610 Single site with multichannel transumbilical laparoscopic implantation of long-term peritoneal dialysis catheters: Initial clinical experience of two cases Yinhui Yang M.D., Ph.D., Yinhui Yang M.D., Ph.D. Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China, [email protected]Search for more papers by this authorBing Liu M.D., Ph.D., Bing Liu M.D., Ph.D. Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China, [email protected]Search for more papers by this authorYinghao Sun M.D., Ph.D., Yinghao Sun M.D., Ph.D. Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China, [email protected]Search for more papers by this author Yinhui Yang M.D., Ph.D., Yinhui Yang M.D., Ph.D. Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China, [email protected]Search for more papers by this authorBing Liu M.D., Ph.D., Bing Liu M.D., Ph.D. Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China, [email protected]Search for more papers by this authorYinghao Sun M.D., Ph.D., Yinghao Sun M.D., Ph.D. Department of Urology, Changhai Hospital, Second Military Medical University, Shanghai, China, [email protected]Search for more papers by this author First published: 20 June 2011 https://doi.org/10.1111/j.1442-2042.2011.02792.xCitations: 1 The three authors contributed equally to this work. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume18, Issue8August 2011Pages 609-610 RelatedInformation

Dissociative Conscious Sedation, An Alternative to General Anesthesia for Laparoscopic Peritoneal Dialysis Catheter Implantation: A Randomized Trial Comparing Intravenous and Subcutaneous Ketamine

Laparoscopy is an effective method of implantation for peritoneal dialysis (PD) catheters. Use of the laparoscopic technique is increasing because of its potential advantages over other techniques. In most patients, selection for PD is based on negative criteria, and because of the need for general anesthesia, the laparoscopic technique can be life-threatening in these patients. On the other hand, local anesthesia is insufficient for laparoscopic catheter implantation. To avoid the need for general anesthesia and to achieve patient safety and satisfaction, we designed a type of conscious sedation (dissociative conscious sedation) and compared the efficacy of subcutaneous (SC) and intravenous (IV) ketamine added to narcotics in patients scheduled for laparoscopic implantation of a PD catheter. Our prospective randomized double-blind study enrolled 60 adult patients with chronic renal failure who were scheduled for laparoscopic implantation of a PD catheter. Patients were randomly assigned to one of two groups: one receiving IV ketamine, and the other receiving SC ketamine. In both groups, patients were premedicated with IV midazolam 0.015 mg/kg, fentanyl 1-2 μg/kg, and lidocaine 1.5 mg/kg. Patients then received 0.6 mg/kg ketamine either intravenously (IV group) or by subcutaneous injection at the anterior aspect of the forearm (SC group). If systolic blood pressure (BP) increased more than 20% from baseline or exceeded 170 mmHg, IV nitroglycerine (TNG) 50 μg was administered incrementally (repeated 50-μg doses). After a desirable level of conscious sedation was achieved, local anesthesia and nitrous oxide pneumoperitoneum were applied, and the PD catheter was implanted under laparoscopic guidance. Heart rate and BP were measured throughout the procedure. Adverse effects and recovery events were recorded. All patients tolerated the procedure well. Administration of TNG was significantly more frequent in the IV ketamine group. Pain intensity during the surgery was similar in both groups. Both groups were comparable with regard to heart rate, but patients in the SC ketamine group had a significantly lower systolic BP at the 2nd measurement and a lower rate-pressure product at the 2nd, 4th, and 5th measurements. All patients in the SC ketamine group were cooperative during surgery and experienced uneventful recoveries; mild hallucinations were observed in 5 patients in the IV ketamine group. In the IV ketamine group, 3 patients lost the ability to cooperate during surgery. All catheters were successfully placed. Dissociative conscious sedation is an acceptable alternative to general anesthesia in laparoscopic implantation of the PD catheter. Ketamine by the SC route is as effective as, but safer than, IV ketamine.

Katheterassoziierte Komplikationen bei der Peritonealdialyse – Infektiöse und nicht infektiöse Komplikationen sowie Prophylaxe

Katheterassoziierte Infektionen sind eine wichtige Ursache für einen Wechsel von Peritonealdialysepatienten zur Hämodialyse. Eine Frühdiagnose dieser Infektionen und einer eventuellen Tunnelbeteiligung (mittels Sonografie des Kathetertunnels) sind ebenso wichtig wie eine rechtzeitige adäquate Therapie. Schmerzen beim Dialysatein- oder -auslauf können durch vorzeitigen Abbruch des Dialysatauslaufes, Umstellung auf Tidal-Peritonealdialyse oder Wechsel zu biokompatibleren Dialyselösungen behandelt werden. Bei Dialysatauslaufproblemen kann man zunächst Laxanzien und Antiflatulenzien verabreichen und die Patienten können im Falle einer Katheterdislokation gymnastische Übungen durchführen. Bei einer persistierenden Fehllage des Katheters ist eine Relokalisation mittels Führungsdraht oder Laparoskopie oder ein Wechsel des Katheters notwendig. Beim Auftreten eines Dialysatlecks an der Katheteraustrittsstelle sollte man die Peritonealdialyse unterbrechen. Sie kann meist nach ein paar Tagen mit reduziertem Füllvolumen oder nach der Umstellung auf eine automatisierte Peritonealdialyse fortgeführt werden. In seltenen Fällen ist eine kontinuierliche Drainage der Peritonealhöhle oder eine chirurgische Revision (besser Katheterwechsel) notwendig. Die Erfahrung des Peritonealdialyseteams und des Chirurgen sind aus prophylaktischer Sicht für das Katheterüberleben bedeutender als das verwendete Kathetermodell oder die Implantationsmethode. Eine korrekte Anlage der Austrittsstelle und die Patientennachschulung bezüglich des Verbandswechsels haben eine große Bedeutung. Aktuelle Guidelines empfehlen die tägliche Anwendung einer antibiotischen Salbe an der Peritonealdialysekatheter-Austrittsstelle.

Mini-Laparotomy Implantation of Peritoneal Dialysis Catheters: Outcome and Rescue

Continuous ambulatory peritoneal dialysis is one of the main treatments for end-stage renal disease. To correct mechanical outflow obstruction after open surgical methods of catheter insertion, laparoscopic techniques are widely employed. ♢ Between January 2001 and December 2006, 228 open Tenckhoff catheter implantations were carried out by mini-laparotomy in 218 patients at our medical center. The procedures were all performed by an experienced surgeon, and the postoperative care, patient education, and long-term follow-up were all conducted by the same peritoneal dialysis team. ♢ Infection of the exit site or tunnel was the most common complication (27/228, 11.8%), followed by peritonitis (18/228, 7.9%) and refractory mechanical catheter obstruction (9/228, 3.9%). The main causes of catheter removal were successful renal transplantation (21/228, 9.2%), peritonitis (18/228, 7.9%), and infection of the exit site or tunnel (7/228, 3.1%). In the 9 cases of refractory mechanical catheter obstruction, laparoscopic surgery was performed to identify the pathology and to rescue the catheter at the same time. Omental wrapping was the major cause (8/9) of catheter obstruction, with blood clot in the lumen and tube migration occurring in the remaining case (1/9). Partial omentectomy was performed in 5 patients to prevent recurrent obstruction. Neither technique failure nor operation-related complications were noted in our laparoscopic rescue group. For 20 of the 25 patients with refractory infection of the exit site or tunnel, the salvage technique of partial re-plantation was performed, with an 85% (17/20) technique survival rate. ♢ With an experienced surgeon and a good postoperative care team, open paramedian placement is a simple, safe, and effective method for Tenckhoff catheter insertion, with a low complication rate. Laparoscopic surgery is effective as rescue for mechanical obstruction, and partial re-plantation is effective as salvage for exit-site or tunnel infection.

Is Retroperitoneoscopy the Gold Standard for Endoscopic Nephrectomy in Children on Peritoneal Dialysis?

The literature on minimally invasive nephrectomy in adults and children on peritoneal dialysis is sparse. Case reports suggest that the transperitoneal approach is effective. We present our experience with retroperitoneoscopic nephrectomy in children on peritoneal dialysis. At 11 consecutive retroperitoneoscopic nephrectomies a total of 14 kidneys were removed from 10 children with a mean age of 12 years. We used a 3-port lateral retroperitoneoscopic nephrectomy technique with active trainee participation. Preoperative and postoperative biochemistry results within 3 months of surgery were compared with the Wilcoxon signed rank test. Three bilateral synchronous, 1 bilateral staged and 6 unilateral retroperitoneoscopic nephrectomies were done. Mean operative time was 174 minutes for unilateral and 458 minutes for bilateral nephrectomy, including 1 simultaneous peritoneal dialysis insertion and 1 umbilical hernia repair. No open conversion, blood transfusion or postoperative surgical complication was noted. Peritoneal dialysis was initiated at a median of 9 hours postoperatively and dialysate volume was titrated to target within a median of 60 hours. One patient with a small peritoneotomy needed temporary hemodialysis despite intraoperative airtight repair. After surgery median serum albumin increased from 30.0 to 34.3 gm/l. Retroperitoneoscopic nephrectomy for end stage renal disease is a safe, effective technique that preserves peritoneal integrity in children who require immediate postoperative peritoneal dialysis. Avoiding post-nephrectomy hemodialysis decreases patient morbidity, preserving vessels for future vascular access. Compared to the literature on laparoscopy in this setting, retroperitoneoscopic nephrectomy can be considered the ideal approach for minimally invasive nephrectomy in patients on peritoneal dialysis.

Moncrief-Popovich technique is an advantageous method of peritoneal dialysis catheter implantation

A safe and well-functioning peritoneal catheter is fundamental for adequate peritoneal dialysis (PD) treatment. Peritoneal catheter implantation by Moncrief-Popovich (MP) technique might add several clinical advantages besides allowing timely access implantation. The aim of this study was to investigate the rate of catheter-related complications and survival in a single-centre university hospital PD unit, according to the method of catheter implantation. Four hundred and sixty-seven consecutive Tenckhoff catheters were implanted after antibiotic prophylaxis in an operating room: surgical mini-laparotomy (ML) was used in 211 (45%), Seldinger technique (S) in 76 (16%) and mini-laparotomy with MP method in 180 (38.5%). The MP technique was significantly associated with a lower rate of early exit-site infection (ESI) (P = 0.02), lower rate of leak (P < 0.0001) and also lower rate of obstruction (P = 0.034) in spite of prolonged break-in (median 55 days, range 0-991 days). Catheter survival by MP technique was 92%, 83% and 64% at 12, 24 and 60 months, respectively, and significantly superior in comparison with the previous methods (log-rank, P = 0.032). By Cox multivariate analysis, adjusted for age, sex and diabetes, the MP technique remained independently associated with better catheter survival [hazard ratio (HR) 0.587 (0.397-0.870), P = 0.008]. Our experience documented improved PD clinical outcomes with the MP method of catheter implantation while assuring timely access management and logistic advantages.

ASDIN: Establishing Learning Curve for Tenckhoff Catheter Insertion by Interventional Nephrologist Using CUSUM Analysis: How Many Procedures and in Which Situation?

Peritoneal dialysis (PD) catheter insertion success rate is known to vary among different operators, and peritoneoscope PD catheter insertion demands mastery of a steep learning curve. Defining a learning curve using a continuous monitoring tool such as a Cumulative Summation (CUSUM) chart is useful for planning training programs. We aimed to analyze the learning curve of a trainee nephrologist in performing peritoneoscope PD catheter implantation with CUSUM chart. This was a descriptive single-center study using collected data from all PD patients who underwent peritoneoscope PD catheter insertion in our hospital. CUSUM model was used to evaluate the learning curve for peritoneoscope PD catheter insertion. Unacceptable primary failure rate (i.e., catheter malfunction within 1 month of insertion) was defined at >40% and acceptable performance was defined at <25%. CUSUM chart showed the learning curve of a trainee in acquiring new skill. As the trainee became more skillful with training, the CUSUM curve flattened. Technical proficiency of the trainee nephrologist in performing peritoneoscope Tenckhoff catheter insertion (<25% primary catheter malfunction) was attained after 23 procedures. We also noted earlier in our program that Tenckhoff catheters directed to the right iliac fossae had poorer survival as compared to catheters directed to the left iliac fossae. Survival of catheters directed to the left iliac fossae was 94.6% while the survival for catheters directed to the right iliac fossae was 48.6% (p < 0.01). We advocate that quality control of Tenckhoff catheter insertion is performed using CUSUM charting as described to monitor primary catheter dysfunction (i.e., failure of catheter function within 1 month of insertion), primary leak (i.e., within 1 month of catheter insertion), and primary peritonitis (i.e., within 2 weeks of catheter insertion).