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Clinical Practice: Original Paper

Free Access

Peritoneal Dialysis Catheter Revision and Replacement by Nephrologist for Peritoneal Dialysis Catheter Malfunction

Ma T.K.-W. · Chow K.M. · Kwan B.C.-H. · Ng J.K.-C. · Choy A.S.-M. · Kwong V.W.-K. · Pang W.-F. · Leung C.B. · Li P.K.-T. · Szeto C.C.

Author affiliations

Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China

Corresponding Author

Prof. Cheuk Chun Szeto

Department of Medicine and Therapeutics, Prince of Wales Hospital

The Chinese University of Hong Kong

Shatin, Hong Kong SAR (China)

E-Mail ccszeto@cuhk.edu.hk

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Abstract

Background: Catheter malfunction is an important cause of technique failure for peritoneal dialysis (PD) patients, and is commonly managed by surgeons or intervention radiologists. We reviewed our experience in catheter revision or replacement by nephrologists. Method: We reviewed the clinical outcome and complication rate of 95 consecutive patients who had PD catheter malfunction, with catheter revision or replacement by nephrologist. Result: Amongst the 95 patients, 32 had catheter revision, 24 catheter replacement via the original wound, and 39 catheter replacement via a new mini-laparotomy wound. Catheter survival was 71.6% at 1 month and 48.4% at 6 months; technique survival was 88.4% at 1 month and 77.4% at 6 months. When the 3 types of procedure were analyzed separately, technique survival at 1 month was 96.8, 75.0, and 89.7%, respectively, for patients who received catheter revision, catheter replacement via the original wound, and catheter replacement via a new mini-laparotomy wound (p = 0.0002), although their catheter survival rates were not significantly different. Also, 2 patients had bleeding that required urgent surgical exploration, 2 had wound infection, and 8 had peritonitis within 4 weeks after the surgery. Conclusion: PD catheter revision and replacement by nephrologist has an acceptable catheter survival and a reasonable complication rate. Given that prompt intervention is an important consideration, catheter revision and replacement by nephrologist is a suitable method for the management of catheter malfunction.

© 2017 S. Karger AG, Basel


Background

Catheter malfunction, defined as mechanical failure in dialysate inflow or outflow, develops in 4–20% of peritoneal dialysis (PD) patients [1, 2]. The most common causes of catheter malfunction are catheter tip migration and omental wrapping; other important causes include intraluminal catheter occlusion, extra-luminal catheter occlusion, and catheter kinking [3, 4]. Most episodes, particularly those caused by omental occlusion, occurs within the first month after catheter placement [4, 5]. Although some cases of catheter malfunction improve with laxatives and intra-catheter urokinase, many of them require a rescue operation such as fluoroscopy-guided manipulation, catheter revision, or replacement [6]. The success rate is highly variable between procedures as well as operators [7-13].

In recent years, catheter placement by nephrologist has been widely advocated to enhance the utilization of PD [14-18]. However, catheter malfunctions are still commonly managed by surgeons or intervention radiologists. It remains unknown whether nephrologists with experience in catheter placement are also suitable personnel to perform catheter revision or replacement for patients with catheter malfunction.

Patients and Methods

Study Population

This is a retrospective cohort study of consecutive adult ­Chinese PD patients with catheter malfunction in a university dialysis unit from 2003 to 2012. Demographic and clinical data were obtained by chart review. We excluded patients who had transient catheter malfunction that resolved after laxatives or intra-catheter urokinase. All patients were counted once and only the first episode of catheter malfunction was reviewed. The study was approved by the Clinical Research Ethics Committee of the Chinese University of Hong Kong. All procedures are in adherence to the Declaration of Helsinki.

Surgical Methods

As described previously [14], all surgical procedures related to PD catheters were performed by nephrologists in a minor operation theatre within our unit, using the mini-laparotomy and open dissection technique. There were 8 nephrologists, all with experience over 5 years, who were responsible for the procedures, which were carried out in a dedicated ward-based procedure room. Intravenous cefazolin was used as prophylactic antibiotic unless the patient had penicillin allergy. Anesthesia and surgical analgesia were achieved by pre-operative intramuscular pethidine (0.5–1 mg/kg), oral diazepam (5 mg), and local infiltration of 2% lignocaine.

There were 3 types of surgical procedures that we used for the management of catheter malfunction: simple revision, catheter replacement via the original wound, and catheter replacement via a new mini-laparotomy wound. The choice of procedure was decided by individual nephrologist and the on-table finding of individual patient. In simple catheter revision, incision was made along the original wound, the catheter was identified in the subcutaneous tunnel, and the deep cuff was dissected free from the surrounding rectus muscle. The intra-peritoneal portion of the catheter was taken out for inspection. Any adherent omental wrap and intra-luminal blood clot were removed, and the catheter was then put back into the peritoneal cavity under direct vision. The wound was closed by conventional means as in ordinary catheter placement [14]. If the original catheter was considered not usable (e.g., complete occlusion of the lumen and all side holes by blood clot and tissue debris), it would be removed and a new catheter placed through the original peritoneal opening under direct vision, and a new exit site created. If catheter placement via the original peritoneal opening was considered not feasible (e.g., when the opening was obscured by blood clot), the new catheter would be placed via a separate mini-laparotomy wound by the standard technique [14] after removal of the old one and repeated skin preparation. In all patients, small volume PD was resumed immediately after the procedure unless the catheter malfunction persisted.

Outcome Measures

The primary outcome measure was catheter survival at 1 and 6 months. Catheter survival was defined as continuation of PD without any catheter intervention. Secondary outcome included duration of surgery, hospital stay after the surgery, surgical complications, and technique survival at 1 and 6 months. For the technique survival analysis, death, transfer to hemodialysis, and kidney transplantation were considered as events, while loss to follow-up, transfer to other centers, and recovery of renal function were considered as censoring observations.

Statistical Analysis

Statistical analysis was performed using Statistical Package for Social Science (SPSS) version 18.0 (SPSS Inc., Chicago, IL, USA). Data were presented as mean ± SD if normally distributed, or median (interquartile range [IQR]) otherwise. Data were compared between groups by Student t test, chi-square test, one way analysis of variance, Mann-Whitney U test, or Kruskal-Wallis test as appropriate. Catheter survival and technique survival were calculated by the Kaplan-Meier method, and survival between groups was compared by the log-rank test. A value of p <0.05 was considered statistically significant. All probabilities were 2-tailed.

Results

We studied 95 patients; 32 had catheter revision, 24 had catheter replacement via the original wound, and 39 had catheter replacement via a new mini-laparotomy wound. Their baseline clinical characteristics are summarized in Table 1. The median onset of catheter malfunction was 2.3 months after catheter insertion (IQR 0.7–19.5 months). There was no significant difference in baseline clinical characteristics between groups, except that there were significantly more men in the catheter revision group (chi-square test, p < 0.0001), and the onset of catheter malfunction was marginally different between groups (Kruskal-Wallis test, p = 0.07), although the difference was not statistically significant.

Table 1.

Baseline clinical characteristics of the patients treated by the 3 surgical techniques

/WebMaterial/ShowPic/908813

Short-Term Clinical Outcome

The short-term clinical outcome is summarized in Table 2. The surgical procedure was significantly longer for catheter replacement via a new mini-laparotomy wound than the other procedures (Kruskal-Wallis test, p < 0.0001). However, the duration of hospital stay was similar between all 3 surgical procedures (p = 0.4).

Table 2.

Summary of clinical outcome of the patients treated by the 3 surgical techniques

/WebMaterial/ShowPic/908811

In general, all 3 procedures were well tolerated. Urgent surgical exploration was required in one patient who had catheter revision, and another who had catheter replacement via the original wound. Laceration of omental vessel was found in both cases; 2 patients had wound infection and 8 patients had peritonitis within 4 weeks after the surgery, 1 required catheter removal while the other 7 responded to antibiotic therapy. Because the number of event was small, statistical analysis was not performed to compare the groups. There was no incident of postoperative catheter leak in our cohort.

Catheter and Technique Survival

Within 6 months of the catheter revision, 38 patients required further catheter intervention or catheter removal; 28 of them could resume PD afterwards, and the other 10 were switched to long-term hemodialysis. During this period, another 7 patients died, and 4 had kidney transplantation. The overall catheter survival was 71.6% at 1 month and 48.4% at 6 months. For the group who received catheter revision, catheter replacement via the original wound, and catheter replacement via a new mini-laparotomy wound, catheter survival at 1 month were 90.6, 58.3, and 64.1%, respectively, while catheter survival at 6 months were 50.0, 33.3, and 56.4%, respectively (log-rank test, p = 0.13; Fig. 1).

Fig. 1.

Kaplan-Meier plots comparing the catheter survival of the 3 surgical procedures. Data are compared by the log-rank test.

/WebMaterial/ShowPic/908809

For the entire cohort, the technique survival was 88.4% at 1 month and 77.4% at 6 months. For the group who received catheter revision, catheter replacement via the original wound, and catheter replacement via a new mini-laparotomy wound, technique survival at 1 month were 96.8, 75.0, and 89.7%, respectively, while technique survival at 6 months were 93.4, 48.5, and 82.1%, respectively (log-rank test, p = 0.0002; Fig. 2). Neither short-term outcome nor catheter survival was significantly different between patients with early and late (within versus after 6 months of the original catheter placement) catheter malfunction (details not shown).

Fig. 2.

Kaplan-Meier plots comparing the technique survival of the 3 surgical procedures. Data are compared by the log-rank test.

/WebMaterial/ShowPic/908807

Discussion

In this study, we showed that for the management of PD catheter malfunction, catheter revision or replacement could be safely and efficiently performed by nephrologists who have the appropriate training and experience. The 1-month catheter survival and technique survival rates of our patients were 71.6 and 88.4%, respectively, which compared favorably to previous series of catheter manipulation [7, 8, 10], laparoscopic treatment [9, 11, 12], and open revision by surgeons [13]. Although all these techniques are appropriate for the management of PD catheter malfunction, revision or replacement offer the distinct advantage of more timely operation (i.e., no need to wait for surgeons’ assessment or availability of the main operating theatre) and therefore minimizing the need of temporary hemodialysis support. Although laparoscopic rescue procedures for catheter malfunction are usually successful except in the scenario of extensive peritoneal adhesions or technical error of the previous surgery, operating theatre for laparoscopic rescue procedures are often not readily available. Our results indicate that procedures led by nephrologists have reasonable rate of success and could be considered when laparoscopic procedure is not immediately feasible.

Before attempting to perform catheter revision or replacement, all operating nephrologists require adequate training. All 8 nephrologists who performed the operations in this series had over 5 years of experience in PD catheter placement and removal, and received additional hand-on training by urological surgeons or other nephrologists who were experienced in performing catheter revision or replacement. However, we have not defined the number of supervised operations that a nephrologist needs before being considered as competent.

Amongst the 3 possible operations, our result seems to suggest that catheter revision takes a shorter surgery time and gives rise to better catheter survival and technique survival rates than catheter replacement, either via the original wound or a new mini-laparotomy wound. However, selection bias likely plays an important part in the observed difference. First, catheter malfunction long after insertion was more likely treated by catheter replacement (Table 1), probably because scar of the old surgical wound precluded further exploration via the previous wound. More importantly, many patients had catheter replacement because the on-table intra-operative findings showed that simple catheter revision not feasible. Similarly, a considerable portion of patients had catheter replacement via a new mini-laparotomy wound because catheter re-insertion via the original wound was not possible. Because of the retrospective nature of the study, we have only the record of the actual operation but not the intended procedure planned by the nephrologist originally. Nonetheless, catheter replacement via a new mini-laparotomy wound resulted in better catheter survival and technique survival than replacement via the original wound, even though the former was often chosen as the salvage procedure when the latter was attempted without success. Our result therefore strongly suggests that when catheter replacement is necessary, it should be performed via a new mini-laparotomy wound.

In this series, 2 patients required urgent surgical exploration for bleeding. It is therefore possible to develop a collaborative approach between the nephrologists and surgeons to urgently revise malfunctioning catheters, especially by laparoscopy to enable identification and treatment of the underlying pathology that produced the flow dysfunction. This approach deserves further study.

Although our result is promising, extrapolation to other PD centers need to be cautious. Notably, Hong Kong has the PD-first policy [19, 20] and the case mix of our PD patients is likely to be different from other western countries. Most of our patients are new dialysis patients and the burden of comorbid condition is small (Table 1), which may contribute to the low incidence of surgical complications. Contrary to most published series [7-13], over one-third of our patients had catheter malfunction over 6 months after catheter insertion, suggesting that the distribution of the underlying cause of catheter malfunction is different. Because it is usually difficult to ascertain the exact cause of catheter malfunction and intra-operative findings are often not conclusive, we did not attempt to perform subgroup analysis in this regard. Similarly, we could not ascertain the cause of recurrent catheter malfunction in many cases, but recurrent omental wrap and blood clot obstruction accounted for most of them.

There are several inadequacies of our study. In addition to the limitations for extrapolating the result to other countries, our study has a small sample size, is retrospective and not randomized. We do not have data on the radiological position of the catheters. Moreover, we do not have another control group to compare the outcome of catheter replacement by nephrologist to traditional approaches such as fluoroscopy-guided catheter manipulation or formal surgical exploration by surgeon. Since all of our patients had their initial PD catheter implanted by mini-laparotomy, further studies are needed on the efficacy of nephrologists’ intervention for malfunctioning catheters implanted by peritoneoscopic or laparoscopic means.

Conclusions

We conclude that PD catheter revision and replacement by nephrologist has an acceptable catheter survival and a reasonable complication rate. Although our study is retrospective and has limited sample size, our result supports the notion that catheter revision and replacement by nephrologist is a suitable method for the management of catheter malfunction.

Disclosure Statement

This study was supported in part by Chinese University of Hong Kong research accounts 6901031 and 7101215. The funders of this study do not have any role in study design, data collection, analysis, result interpretation, report writing, or the decision to submit the report for publication. The results presented in this paper have not been published previously in whole or part, except in abstract format. All authors declare no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee at which the studies were conducted and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Clinical Research Ethics Committee of the Chinese University of Hong Kong (IRB approval number CREC-2015.250).

Informed Consent

Written informed consent was obtained from all individual participants included in the study.

Author Contribution

T.K.-W.M., K.M.C., and C.C.S. are responsible for the original idea and data collection. C.C.S. also performs the data analysis, and T.K.-W.M. writes the manuscript. B.C.-H.K., J.K.-C.N., A.S.-M.C., V.W.-K.K., and W.-F.P. are responsible for most of the study procedures and data collection. C.B.L. is responsible for the maintenance of the database. P.K.-T.L. is responsible for overall study coordination.


References

  1. 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: 513–518.
  2. Liu WJ, Hooi LS: Complications after Tenckhoff catheter insertion: a single-centre experience using multiple operators over four years. Perit Dial Int 2010; 30: 509–512.
  3. McCormick BB, Bargman JM: Noninfectious complications of peritoneal dialysis: implications for patient and technique survival. J Am Soc Nephrol 2007; 18: 3023–3025.
  4. Farooq MM, Freischlag JA: Peritoneal dialysis: an increasingly popular option. Semin Vasc Surg 1997; 10: 144–150.
    External Resources
  5. Fleisher AG, Kimmelstiel FM, Lattes CG, Miller RE: Surgical complications of peritoneal dialysis catheters. Am J Surg 1985; 149: 726–729.
  6. Gokal R, Alexander S, Ash S, Chen TW, Danielson A, Holmes C, Joffe P, Moncrief J, Nichols K, Piraino B, Prowant B, Slingeneyer A, Stegmayr B, Twardowski Z, Vas S: Peritoneal catheters and exit-site practices toward optimum peritoneal access: 1998 update. Perit Dial Int 1998; 18: 11–33.
    External Resources
  7. Simons ME, Pron G, Voros M, Vanderburgh LC, Rao PS, Oreopoulos DG: Fluoroscopically-guided manipulation of malfunctioning peritoneal dialysis catheters. Perit Dial Int 1999; 19: 544–549.
    External Resources
  8. Gadallah MF, Arora N, Arumugam R, Moles K: Role of Fogarty catheter manipulation in management of migrated, nonfunctional peritoneal dialysis catheters. Am J Kidney Dis 2000; 35: 301–305.
  9. Ogunc G: Malfunctioning peritoneal dialysis catheter and accompanying surgical pathology repaired by laparoscopic surgery. Perit Dial Int 2002; 22: 454–462.
    External Resources
  10. Ozyer U, Harman A, Aytekin C, Boyvat F, Ozdemir N: Correction of displaced peritoneal dialysis catheters with an angular stiff rod. Acta Radiol 2009; 50: 139–143.
  11. Santarelli S, Zeiler M, Marinelli R, Monteburini T, Federico A, Ceraudo E: Video laparoscopy as rescue therapy and placement of peritoneal dialysis catheters: a thirty-two case single centre experience. Nephrol Dial Transplant 2006; 21: 1348–1354.
  12. Goh YH: Omental folding: a novel laparoscopic technique for salvaging peritoneal dialysis catheters. Perit Dial Int 2008; 28: 626–631.
    External Resources
  13. Kim SH, Lee DH, Choi HJ, Seo HJ, Jang YS, Kim DH, Park JH, Kim CD, Kim YL: Minilaparotomy with manual correction for malfunctioning peritoneal dialysis catheters. Perit Dial Int 2008; 28: 550–554.
    External Resources
  14. Chow KM, Szeto CC, Leung CB, Kwan BC, Pang WF, Li PK: Tenckhoff catheter insertion by nephrologists: open dissection technique. Perit Dial Int 2010; 30: 524–527.
  15. Li PK, Chow KM: Importance of peritoneal dialysis catheter insertion by nephrologists: practice makes perfect. Nephrol Dial Transplant 2009; 24: 3274–3276.
  16. Kelly J, McNamara K, May S: Peritoneoscopic peritoneal dialysis catheter insertion. Nephrology (Carlton) 2003; 8: 315–317.
  17. Li CL, Cui TG, Gan HB, Cheung K, Lio WI, Kuok UI: A randomized trial comparing conventional swan-neck straight-tip catheters to straight-tip catheters with an artificial subcutaneous swan neck. Perit Dial Int 2009; 29: 278–284.
    External Resources
  18. Moon JY, Song S, Jung KH, Park M, Lee SH, Ihm CG, Oh JH, Kwon SH, Lee TW: Fluoroscopically guided peritoneal dialysis catheter placement: long-term results from a single center. Perit Dial Int 2008; 28: 163–169.
    External Resources
  19. Yu AW, Chau KF, Ho YW, Li PK: Development of the “peritoneal dialysis first” model in Hong Kong. Perit Dial Int 2007; 27(suppl 2):S53–S55.
    External Resources
  20. Choy AS, Li PK: Sustainability of the peritoneal dialysis-first policy in hong kong. Blood Purif 2015; 40: 320–325.

Author Contacts

Prof. Cheuk Chun Szeto

Department of Medicine and Therapeutics, Prince of Wales Hospital

The Chinese University of Hong Kong

Shatin, Hong Kong SAR (China)

E-Mail ccszeto@cuhk.edu.hk


Article / Publication Details

First-Page Preview
Abstract of Clinical Practice: Original Paper

Received: July 20, 2017
Accepted: November 10, 2017
Published online: December 14, 2017
Issue release date: Published online first

Number of Print Pages: 6
Number of Figures: 2
Number of Tables: 2

ISSN: 1660-8151 (Print)
eISSN: 2235-3186 (Online)

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References

  1. 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: 513–518.
  2. Liu WJ, Hooi LS: Complications after Tenckhoff catheter insertion: a single-centre experience using multiple operators over four years. Perit Dial Int 2010; 30: 509–512.
  3. McCormick BB, Bargman JM: Noninfectious complications of peritoneal dialysis: implications for patient and technique survival. J Am Soc Nephrol 2007; 18: 3023–3025.
  4. Farooq MM, Freischlag JA: Peritoneal dialysis: an increasingly popular option. Semin Vasc Surg 1997; 10: 144–150.
    External Resources
  5. Fleisher AG, Kimmelstiel FM, Lattes CG, Miller RE: Surgical complications of peritoneal dialysis catheters. Am J Surg 1985; 149: 726–729.
  6. Gokal R, Alexander S, Ash S, Chen TW, Danielson A, Holmes C, Joffe P, Moncrief J, Nichols K, Piraino B, Prowant B, Slingeneyer A, Stegmayr B, Twardowski Z, Vas S: Peritoneal catheters and exit-site practices toward optimum peritoneal access: 1998 update. Perit Dial Int 1998; 18: 11–33.
    External Resources
  7. Simons ME, Pron G, Voros M, Vanderburgh LC, Rao PS, Oreopoulos DG: Fluoroscopically-guided manipulation of malfunctioning peritoneal dialysis catheters. Perit Dial Int 1999; 19: 544–549.
    External Resources
  8. Gadallah MF, Arora N, Arumugam R, Moles K: Role of Fogarty catheter manipulation in management of migrated, nonfunctional peritoneal dialysis catheters. Am J Kidney Dis 2000; 35: 301–305.
  9. Ogunc G: Malfunctioning peritoneal dialysis catheter and accompanying surgical pathology repaired by laparoscopic surgery. Perit Dial Int 2002; 22: 454–462.
    External Resources
  10. Ozyer U, Harman A, Aytekin C, Boyvat F, Ozdemir N: Correction of displaced peritoneal dialysis catheters with an angular stiff rod. Acta Radiol 2009; 50: 139–143.
  11. Santarelli S, Zeiler M, Marinelli R, Monteburini T, Federico A, Ceraudo E: Video laparoscopy as rescue therapy and placement of peritoneal dialysis catheters: a thirty-two case single centre experience. Nephrol Dial Transplant 2006; 21: 1348–1354.
  12. Goh YH: Omental folding: a novel laparoscopic technique for salvaging peritoneal dialysis catheters. Perit Dial Int 2008; 28: 626–631.
    External Resources
  13. Kim SH, Lee DH, Choi HJ, Seo HJ, Jang YS, Kim DH, Park JH, Kim CD, Kim YL: Minilaparotomy with manual correction for malfunctioning peritoneal dialysis catheters. Perit Dial Int 2008; 28: 550–554.
    External Resources
  14. Chow KM, Szeto CC, Leung CB, Kwan BC, Pang WF, Li PK: Tenckhoff catheter insertion by nephrologists: open dissection technique. Perit Dial Int 2010; 30: 524–527.
  15. Li PK, Chow KM: Importance of peritoneal dialysis catheter insertion by nephrologists: practice makes perfect. Nephrol Dial Transplant 2009; 24: 3274–3276.
  16. Kelly J, McNamara K, May S: Peritoneoscopic peritoneal dialysis catheter insertion. Nephrology (Carlton) 2003; 8: 315–317.
  17. Li CL, Cui TG, Gan HB, Cheung K, Lio WI, Kuok UI: A randomized trial comparing conventional swan-neck straight-tip catheters to straight-tip catheters with an artificial subcutaneous swan neck. Perit Dial Int 2009; 29: 278–284.
    External Resources
  18. Moon JY, Song S, Jung KH, Park M, Lee SH, Ihm CG, Oh JH, Kwon SH, Lee TW: Fluoroscopically guided peritoneal dialysis catheter placement: long-term results from a single center. Perit Dial Int 2008; 28: 163–169.
    External Resources
  19. Yu AW, Chau KF, Ho YW, Li PK: Development of the “peritoneal dialysis first” model in Hong Kong. Perit Dial Int 2007; 27(suppl 2):S53–S55.
    External Resources
  20. Choy AS, Li PK: Sustainability of the peritoneal dialysis-first policy in hong kong. Blood Purif 2015; 40: 320–325.
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