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ORIGINAL ARTICLE
Year : 2014  |  Volume : 6  |  Issue : 2  |  Page : 147-151  

A novel method for salvage of malfunctioning peritoneal dialysis catheter


1 Department of Pediatric Surgery, Bahrami Children Hospital, Tehran University of Medical Sciences, Tehran, Iran
2 Legal Medicine Research Center, Legal Medicine Organization, Tehran, Iran
3 Faculty of Educational Sciences and Psychology, Shahid Beheshti University, Tehran, Iran

Date of Submission10-Jan-2013
Date of Acceptance29-May-2013
Date of Web Publication15-Apr-2014

Correspondence Address:
Hojatollah Raji Asadabadi
Resident of General Surgery, Alzahra Hospital, Isfahan University of Medical Sciences, Isfahan
Iran
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DOI: 10.4103/0974-7796.130646

PMID: 24833828

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   Abstract 

Context: Continuous ambulatory peritoneal dialysis (CAPD) has been widely used as an effective therapy in the management of patients with end-stage renal disease. Long-term use of CAPD needs methods with low incidence of catheter-related complications. Moreover, some complications may cause failure of fluid drainage and treatment interruption.
Aims: We have innovated and studied a new minimal-invasive method of malfunctioning peritoneal catheter repair.
Materials and Methods: Thirty-five patients agreed to undergo catheter rescue operation by this new method during 2004 and 2012. Under local anesthesia and light sedation, access to the abdominal cavity was made, the catheter and wrapped omentum grasped and the tip of catheter was released, debris were removed and the catheter was directed toward the pelvic floor with a finger guide. The patients were followed after catheter salvage up to the end of study (April 2012). PD catheter function restored to the normal level in 28 (80%) of patients, and PD was started 1-2 days after the procedure.
Results: All patients had an uneventful recovery. PD catheter function was restored to the normal level in 28 (80%) patients, and PD was started 1-2 days after the procedure. Of these patients, 10 (35%) died of reasons unrelated to catheter or catheter complications; 7 (25%) were ultimately referred for kidney transplant; 8 (29%) continued PD up to the end of this study with no problem, and only 3 (11%) due to catheter complications. Catheter function did not restore to the normal level in seven patients (20%); however, six patients continued PD for 1-18 months with the catheter.
Conclusions: Comparing the advantages and disadvantages of this method to the previous laparoscopically repaired catheter, we concluded that this new method is efficient, and is a suitable way for malfunctioning PD catheter salvage.

Keywords: Catheter malfunction, catheter rescue, continuous ambulatory peritoneal dialysis, minimally invasive surgery, peritoneal dialysis


How to cite this article:
Beig AA, Marashi SM, Asadabadi HR, Sharifi A, Zarch ZN. A novel method for salvage of malfunctioning peritoneal dialysis catheter. Urol Ann 2014;6:147-51

How to cite this URL:
Beig AA, Marashi SM, Asadabadi HR, Sharifi A, Zarch ZN. A novel method for salvage of malfunctioning peritoneal dialysis catheter. Urol Ann [serial online] 2014 [cited 2017 Oct 19];6:147-51. Available from: http://www.urologyannals.com/text.asp?2014/6/2/147/130646


   Introduction Top


Continuous ambulatory peritoneal dialysis (CAPD) has been widely used as an effective therapy in the management of end-stage renal disease. [1],[2] This method provides better mobility

and less dietary restrictions compared to hemodialysis. [3] Successful and long-term use of CAPD needs methods with low incidence of catheter-related complications. [4],[5] Some peritoneal-catheter-related complications such as accumulation of debris within the catheter lumen, migration of catheter tip, and omental wrapping may cause failure of fluid drainage. [2],[6],[7],[8] When conservative treatments fail to restore catheter drainage, catheter repositioning is necessary. [8],[9] Conventional surgery requires general anesthesia and is related to further pain, mechanical and infectious complications, and increased hospitalization. [10],[11] Laparoscopic revision has been widely used for salvage of malfunctioning catheter. [12],[13],[14],[15] Despite several advantages, this method has some disadvantages such as postoperative pain and immobility besides straining the financial resources. [16],[17],[18] Given the medical problems of patients with renal failure, simple and quick methods are preferred. Therefore, we have innovated and studied a new minimally invasive method of malfunctioning peritoneal catheter repair. This method can be performed to provide a quick, safe, and reliable peritoneal access.


   Materials and Methods Top


The present study was conducted in the Department of Vascular Surgery at an Educational University Hospital, Isfahan, Iran, during 2004 and 2012. Forty-six of 286 patients, who were implanted peritoneal dialysis (PD) catheter by conventional open surgery had PD catheter malfunction and were enrolled in the study. Catheter malfunction was considered when normal or reduced inflow was accompanied with slow drainage or no drainage of infused dialysate. Inclusion criteria were patient's consent, self-care ability and having a supportive family for choosing this method and being over 18-year-old age. Exclusion criteria were morbid obesity (BMI>35 kg/m 2 ), ventral or inguinal hernia, or any history of abdominal surgery, except implanting the PD catheter. Conservative treatment (washing of the catheter for fibrin deposition, antibiotic therapy for infectious complications of the catheter) of malfunctioning catheter was given as the first step of treatment if possible. Only those patients whose conservative treatment failed or had omentum wrapping, adhesions, or disposition of the tip of the catheter were enrolled the study. Before the operation, an abdominal X-ray interestingly, confirmed the migration of PD catheter to upper abdomen in all 39 cases.

Four patients did not agree to re-operation to repair the PD catheter and decided to start hemodialysis. The remaining 35 patients with malfunctioning PD catheter were admitted to our hospital to restore catheter function by the introduced new minimally invasive method. This study was approved by the ethics committee of Isfahan University of Medical Sciences and informed consent was obtained from all patients.

Procedure

Patients were placed in the supine position, given 1 g of Keflin; intravenously. After prep and drep, under the local anesthesia with Lidocaine and a light sedation with Midazolam and Ketamine, a 1-cm-long midline sub-umbilical incision was made through the skin, subcutaneous tissue, and fascia. To provide a better access to the abdominal cavity, fascia was more dissected up to 1.5-2 cm. Then, the catheter and wrapped omentum were seen and grasped by a Babcock. Tip of catheter was released from the omentum and other soft tissues; clots and debris were removed by milking the catheter; in addition, 200 ml normal saline was injected into the catheter. Partial omentectomy was performed, the omentum was removed through the incision, and each bite was ligated by absorbable Vicryl 3-0. After that, the catheter was directed toward the pelvic floor with a finger guide, the fascia and skin were closed with sutures (with Nylon 0 and 3-0, respectively). The place of the catheters after surgery was checked by plain X-ray.

Adequacy of dialysis was measured by Kt/V 1 week after catheter repair to evaluate the efficiency of PD. Here, 'Kt' represents the volume of fluid purge of urea during a single period of treatment and 'V' represents the total body water of the patient. Kt/V values equal to or more than 1.7 were considered as normal. [19],[20]


   Results Top


PD catheter was implanted for 286 patients by conventional open surgery over an 8 year period. During a 50.45 ΁ 23.34 months follow up, 46 (16.08%) patients had PD catheter malfunction. In three cases, after washing of the catheter for fibrin deposition or antibiotic therapy for infectious complications, catheter function restored to normal. Four cases have BMI greater than 35 kg/m [2] and were not proper for doing this method. So, 39 cases were candidate for this novel technique; however, 4 patients decided to have no more surgery and start hemodialysis. Non-infectious catheter complications including external leak, internal leak, and hemoperitoneum were recorded in seven, one, and two patients, respectively. Regarding infectious complications of the catheter, four patients had peritonitis and catheter exit site infection while two patients had only peritonitis and one had only catheter exit site infection. All these cases were treated with appropriate topical and systemic antibiotics.

Minimally invasive PD catheter repair was performed on the patients including 24 men and 11 women. Patients were aged from 19 to 82 (mean ΁ SD: 51.51 ΁ 20.60 years). Mean BMI was 22.54 ΁ 4.41 (range: 14.48-38.02). Regarding the cause of renal failure, two major causes were include hypertension in 17 (49%) and diabetes mellitus in 12 (34%) patients.

The operating time was 10-15 minutes. The proper placement of the catheters was confirmed by plain X-ray in all cases after surgery. All patients had an uneventful recovery. The patients asked to report their pain experience using a numbers from 0 to 10. Post-operative pain was easily managed by oral analgesics without needing to intravenous analgesics, and patients were discharged one day after the operation. In patients whose catheter function was restored to normal, PD restarted 1-2 days later. Neither surgical mortality, nor visceral organ damage occurred. Patients were followed for 35.65 ΁ 23.12 months.

Re-operation outcomes

A general view of the study is summarized in [Figure 1].
Figure 1: Summary of patients' outcome

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Patients with normal catheter function after repair

PD catheter function restored to the normal level in 28 (80%) of patients, and PD started 1-2 days after the procedure. These patients were followed after the surgery up to the end of this study for 19.77 ΁ 21.48 months (range: 2-90 months). Mean Kt/v was 2.02 ΁ 0.54 in these patients. [Table 1] represents outcomes of the patients with normal catheter function after repair.
Table 1: Outcomes of the patients with normal catheter function after repair

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Patients with persistent catheter malfunction after repair

Catheter function did not restore to the normal level in seven patients (20%). One patient had hemorrhage; although it was controlled by conservative measures, catheter was removed and hemodialysis commenced. Despite having some problems with catheter, other six patients continued PD for 1-18 months, but finally they were shifted to hemodialysis.


   Discussion Top


Continuous ambulatory PD is known as an effective method of therapy for patients suffering from end-stage renal disease. Both medical and social benefits, such as better patient outcome, easier blood pressure control, more flexible life style, and lower cost than hemodialysis have made this method widely acceptable. [21],[22]

However, malfunction of the PD catheter is still a common problem. [22] Mechanical outflow obstruction is a major cause of treatment interruption in these patients. Catheter misplacement at operation, omental wrapping, catheter migration, and adhesion may result in early or long-term catheter malfunction. [8],[23],[24],[25] Catheter-related problems are blamed for up to 20% of patient transfers to hemodialysis. [5] If conservative measures fail to solve the problem, other treatment option should be considered. Different open or laparoscopic procedures have been developed for catheter rescue. [8]

Dialysis is vital for patients with renal failure; in addition, they have special condition because of uremia itself and other probable contemporaneous diseases (diabetes mellitus, hypertension and other cardiovascular problems). These patients are usually classified as ASA classification status three or four. [26] Therefore, less invasive procedures with less need for general anesthesia is preferred. The presented method is a suitable way to repair catheter malfunction in this regard. Unlike open surgery and laparoscopy that need general anesthesia, this method is performed under light sedation and local anesthesia. [8] Hence, this new method which has none of the risks associated with general anesthesia can be used safely for almost all patients with PD catheter malfunction.

Compared to laparoscopic revision, operating time is significantly shorter in this method. This is an important advantage if we factor in the special condition of uremic patients.

In this method we made only one 1.5-2 cm cut in the fascia which is smaller than the cut length in the open and laparoscopic operations; therefore, healing process is quicker. So, patients could resume the routine PD sooner. Eighty percent of our patients were able to restart routine PD 1-2 days after the operation with a satisfactory Kt/v level. In laparoscopic manipulation of the catheter, PD is restarted with lower volume in 24 hours after the surgery but the normal PD resumption may be postponed for 2-10 days of the procedure. [8] Disadvantages of laparoscopy is need for general anesthesia in most patients, the requirement of an operating theater, the cost of equipment and instrumentation, the long duration of the operative procedure, and the adverse physiologic effects of CO 2 pneumoperitoneum. [27]

In laparoscopic omentectomy, the duration of the operative procedure is too long. The gaps among procedure and dialysis are even longer in open surgery. Three or more large-size ports and additional instruments are needed for laparoscopic surgery. Omental resection by laparoscopy is also more expensive. Renal failure patients frequently are poor risks for lengthy general anesthesia and they commonly have severe coexisting medical problems. Therefore, operative procedures to solve catheter obstruction due to omental wraps should, ideally, be short and simple, effective in resolving the problem, and permit early return to PD. [9],[28],[29]

Given the simplicity of the procedure, no need to general anesthesia or special equipment and early patient discharge, this procedure has significantly lower cost.

Although previous studies suggest laparoscopic methods for PD catheter repair, [4],[8],[26],[30],[31],[32] some disadvantages such as high cost, long operating time, and risks associated with general anesthesia remain.


   Conclusions Top


We believe that this new method can solve aforementioned problems as described for laparoscopic or conventional surgery, and is a suitable way for malfunctioning PD catheter salvage.

 
   References Top

1.Wright MJ, Bel′eed K, Johnson BF, Eadington DW, Sellars L, Farr MJ. Randomized prospective comparison of laparoscopic and open peritoneal dialysis catheter insertion. Perit Dial Int 1999;19:372-5.  Back to cited text no. 1
    
2.Oðünç G, Tuncer M, Oðünç D, Yardimsever M, Ersoy F. Laparoscopic omental fixation technique versus open surgical placement of peritoneal dialysis catheters. Surg Endosc 2003;17:1749-55.  Back to cited text no. 2
    
3.Schmidt SC, Pohle C, Langrehr JM, Schumacher G, Jacob D, Neuhaus P. Laparoscopic-assisted placement of peritoneal dialysis catheters: Implantation technique and results. J Laparoendosc Adv Surg Tech A 2007;17:596-9.  Back to cited text no. 3
    
4.Julian TB, Ribeiro U, Bruns F, Fraley D. Malfunctioning peritoneal dialysis catheter repaired by laparoscopic surgery. Perit Dial Int 1995;15:363-6.  Back to cited text no. 4
    
5.Ogunc G. Minilaparoscopic extraperitoneal tunneling with omentopexy: A new technique for CAPD catheter placement. Perit Dial Int 2005;25:551-5.  Back to cited text no. 5
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11.Atapour A, Asadabadi HR, Karimi S, Eslami A, Beigi AA. Comparing the outcomes of open surgical procedure and percutaneously peritoneal dialysis catheter (PDC) insertion using laparoscopic needle: A two month follow-up study. J Res Med Sci 2011;16:463-8.  Back to cited text no. 11
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12.Caliskan K, Nursal TZ, Tarim AM, Noyan T, Moray G, Haberal M. The adequacy of laparoscopy for continuous ambulatory peritoneal dialysis procedures. Transplant Proc 2007;39:1359-61.  Back to cited text no. 12
    
13.Neufeld D, Korzets Z, Bernheim J, Shpitz B. Laparoscopic management of peritoneal dialysis catheters. Harefuah 2011;150:84-6, 209, 208.  Back to cited text no. 13
    
14.Numanoglu A, McCulloch MI, Van Der Pool A, Millar AJ, Rode H. Laparoscopic salvage of malfunctioning Tenckhoff catheters. J Laparoendosc Adv Surg Tech A 2007;17:128-30.  Back to cited text no. 14
    
15.Uchiyama K, Fujikawa K, Suga A, Naito K. Laparoscopic salvage of malfunctioning peritoneal dialysis catheters caused by ovarian fimbria: A case report. Hinyokika Kiyo 2001;47:669-71.  Back to cited text no. 15
    
16.Mularski RA, Sippel JM, Osborne ML. Pneumoperitoneum: A review of nonsurgical causes. Crit Care Med 2000;28:2638-44.  Back to cited text no. 16
    
17.Schauer PR. Physiologic consequences of laparoscopic surgery. In: Eubanks WS, Soper NJ, Swanstrom LL, editors. Mastery of Endoscopic Surgery and Laparoscopic Surgery. Philadelphia, PA: Lippincott Williams and Wilkins; 2000. p. 22-38.   Back to cited text no. 17
    
18.Riella MC. Challenges in interventional nephrology. Contrib Nephrol 2005;149:131-7.  Back to cited text no. 18
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21.Lo WK. Peritoneal dialysis utilization and outcome: What are we facing? Perit Dial Int 2007;27(Suppl 2):S42-7.  Back to cited text no. 21
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22.Yang PJ, Lee CY, Yeh CC, Nien HC, Tsai TJ, Tsai MK. Mini-laparotomy implantation of peritoneal dialysis catheters: Outcome and rescue. Perit Dial Int 2010;30:513-8.  Back to cited text no. 22
    
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25.Wang JY, Hsieh JS, Chen FM, Chuan CH, Chan HM, Huang TJ. Secure placement of continuous ambulatory peritoneal dialysis catheters under laparoscopic assistance. Am Surg 1999;65:247-9.  Back to cited text no. 25
    
26.Anesthesiologists TASo. ASA Physical Status Classification System. Washington DC, 2012. Available from: http://www.asahq.org/For- Members/Clinical-Information/ASA-Physical-Status-Classification-System.aspx. [Last cited on 2012 Feb 17].  Back to cited text no. 26
    
27.Zadrozny D, Niemierko ML, Draczkowski T, Renke M, Liberek T. Laparoscopic approach for dysfunctiona Tenckhoff catheters. Perit Dial Int 1999;19:170-1.  Back to cited text no. 27
    
28.Crabtree JH, Fishman A. Laparoscopic epiplopexy of the greater omentum and epiploic appendices in the salvaging of dysfunctional peritoneal dialysis catheters. Surg Laparosc Endosc 1996;6:176-80.  Back to cited text no. 28
    
29.Brownlee J, Elkhaira S. Laparoscopic assisted placement of peritoneal dialysis catheter: A preliminary experience. Clin Nephrol 1997;47:122-4.  Back to cited text no. 29
    
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