peritoneal dialysis catheter Laparoscopic peritoneal dialysis catheter placement

Laparoscopic peritoneal dialysis catheter placement: description and results of a two-port technique





Laparoscopic placement of peritoneal dialysis catheter: description and results of a two-port technique
Eduard García-Cruza, M .. Vera-Riverab, J.M .. Corral Moroa, J.M .. Mallafré-Salaa, A. .. Alcaraza

    Fig. 1. Oreopoulos-Zellerman catheter with Guyon guide atraumatic tip.
    Fig. 2. Position of the ports. Periumbilical port of 12 mm for the catheter and left pararectal port of 12 mm for the optics.
    Fig. 3. KM curve showing the survival of patients on peritoneal dialysis.
    Fig. 4. Catheters removed or replaced due to technical problems (obstruction, peritonitis or migration).
    Patients excluded from the CAPD program. Cause of exclusion, time from onset, current treatment and catheter status at the time of exclusion

Abstract

Aim: To test the feasibility, efficacy and safety of a new port laparoscopic technique for dialysis catheter placement. Material and methods: From January 2006 to July 2009 51 patients underwent dialysis catheter placing using an original technique. All procedures were finished laparoscopically using two 12 mm-sized ports. Our technique bases on placing Oreopoulos- Zellerman catheter along with straight Guyon's guide with atraumatic tip, visually guaranting optimal placement. Catheter can be repositioned if desired by reentering the guide. Median follow-up was 25 months. Results: Mean operating time was 32 minutes (range 15-55 minutes). One patient suffered an immediate postoperative catheter obstruction that required surgical repositioning. No other technical intra or early postoperative problems related to technique were reported. Mean time to discharge 1.02 ± 2.2 days. Catheter outflow failure rate was 7.6%. Conversion to haemodialysis due to peritonitis 13%. Peritonitis per patient / year was 0.27. Catheter 6 mo, 1 year and 2 year survival rate was 94%, 87% and 72%. Catheter migration rate was 4%. There was no peritoneal dialysis liquid leakage. Conclusions: The two ports technique described is an easy and rapid procedure, with several complications and early discharge. Due to its reliability, offers good catheter function outcome.
Summary

Objective: To study the viability, efficacy and safety of our technique of two ports of peritoneal dialysis catheter placement by laparoscopy. Material and methods: From January 2006 to July 2009, 51 patients underwent peritoneal dialysis catheter placement using a new technique. All procedures were completed laparoscopically using two 12 mm ports. Our technique is based on the placement of an Oreopoulos-Zellerman type catheter on a straight Guyon guide with atraumatic tip, and guarantees the optimal placement of the catheter. If necessary, it can be replaced by repositioning the guide. The average follow-up was 25 months. Results: Average surgical time: 32 minutes (range 15-55 minutes). One patient presented an obstruction of the catheter in the immediate postoperative period, which required surgical repositioning. No other technical complications have occurred during surgery or the immediate postoperative period. Mean time to discharge: 1.02 ± 2.2 days. Rate of catheter obstruction: 7.6%. Conversion rate to hemodialysis secondary to peritonitis: 13%. Episodes of peritonitis per patient-year: 0.27. Survival of the catheter at 6 months, one year and 5 years: 94, 87 and 72%, respectively. Catheter migration rate: 4%. No cases of peritoneal fluid fistula have been reported. Conclusions: The two-port technique described is a simple and rapid procedure, with few complications and immediate hospital discharge. Due to its reliability, it offers good results in the function of the catheter.
Key words: Surgical technique
Palabras Clave: Surgical technique

INTRODUCTION

Peritoneal dialysis (PD) is a valid alternative to hemodialysis, which has some advantages compared to it. With regard to patients, PD allows better mobility, greater freedom in the diet, better hemodynamic control and less technical complexity1. From an economic point of view, PD presents a lower cost compared with hemodialysis. In short, patients with PD have greater satisfaction than patients on dialysis2-8. On the other hand, PD has some disadvantages, most of them related to the catheter, such as catheter infection, obstruction or migration of the catheter, cuff extrusion, eventrations and leakage of fluid5,9-12.


Catheter placement techniques have evolved from open surgery to minimally invasive procedures during the last two decades. In parallel, percutaneous placement of dialysis catheters has been used using the Seldinger technique13. Currently, catheter placement can be carried out by open surgery, percutaneous insertion or laparoscopic surgery.

Open surgery is a simple procedure that requires minimal laparotomy, which is why it has been the most widely used election procedure2,7,14-16. However, open surgery allows limited vision, which is especially important in patients with a history of abdominal surgery, in whom intestinal adhesions can hinder the procedure17-19. For this reason, the rate of obstruction of catheters placed by open surgery reaches 22% 3,15,16,20.

These technical problems with open surgery led, two decades ago, to the development of new strategies for the placement of PD catheters. Laparoscopic surgery, carried out mostly with three trocars, was developed at this point21,22. By facilitating an optimal vision of the peritoneal cavity, and therefore improving the obstruction of the catheter and related infections, the laparoscopic approach gained wide acceptance23-25. Laparoscopic surgery presents a series of clear benefits, especially in the reduction of postoperative pain. The lower postoperative pain allows an earlier discharge and an early normalization of social life4,26. In addition, laparoscopy offers better cosmetic results.

In the present study we describe a new surgical technique for the placement of the DP catheter, using a laparoscopic approach with two ports. This initial experience examines its viability, effectiveness and safety.

MATERIAL AND METHODS

We prospectively analyzed 51 consecutive patients who underwent PD catheter placement in our center from January 2006 to July 2009. The demographic, clinical, preoperative and postoperative data were collected prospectively.

Demographics

The patients were 19 women and 32 men, with a mean age of 56 ± 18 years. All procedures were carried out under general anesthesia. The mean body mass index was 24.5 ± 3.5 kg / m2. The mean anesthetic risk (ASA) was III (40% ASA II, 48% ASA III, 12% ASA IV).

Surgical technique

We describe a new surgical technique using two 12 mm ports for the placement of the DP catheter; for this, an atraumatic tip Guyon guide is used (figure 1). After lubricating the Guyon guide, the catheter is placed over it and a rigid tutoring catheter is obtained. The employee was the Oreopoulos-Zellerman catheter.

We performed the pneumoperitoneum using a minimal periumbilical laparotomy and placed a 12-mm trocar. Under direct vision, a left pararectal 12-mm trocar is placed. The optics are placed in it and the catheter is placed with the guide through the periumbilical trocar. Next, the catheter tip is installed in the Douglas pouch and the Guyon guide is removed. We check visually that the catheter is properly placed, after which both trocars are removed. A subcutaneous tunnel is created between both trocars and the catheter is externalized through the orifice of the left pararectal trocar (Figure 2).

RESULTS

All procedures were completed laparoscopically with two 12 mm ports. The mean surgical time was 32 minutes (range, 15-55 minutes). One patient presented catheter obstruction in the first 24 hours after placement and required revision and surgical re-placement. There were no other intraoperative complications or during the immediate postoperative period. The mean follow-up was 25 months.

The mean stay was 1.02 ± 2.2 days. Approximately two thirds of the patients (65%) were discharged the same day of the intervention, and up to 80% within the first 24 postoperative hours. The patients who remained in the hospital after 24 hours of the procedure did so due to medical problems not related to the procedure.


There have been no leaks of peritoneal fluid or infections of surgical wounds during the immediate postoperative period (<48 h). No extrusions of the cuff or eventrations have occurred. The rate of catheter obstruction was 7.8%, and the catheter migration rate was 4% (2 patients). One of these patients required catheter removal due to severe peritonitis. In the other case, the catheter has not presented obstruction or peritonitis, and currently works correctly.

A total of 3 patients died, at an average of 16 months, after catheter placement (2.35 deaths per 1,000 patients and month of exposure). The causes of death were cardiovascular complications secondary to terminal renal failure. Mortality was not related to PD or to the catheter.

The survival curve of the patients in the DP program is shown in figure 3, and the survival curve of the catheters, in figure 4. A total of three catheters (5.9%) had to be removed due to peritonitis. , all of them working correctly. In our experience, we had 0.27 episodes of peritonitis per patient per year.

Two catheters were removed due to technical complications in the late postoperative period. In the first case, the patient presented a picture of abdominal pain that required exploratory laparotomy, and decubitus of the catheter was noticed in a bowel loop. After checking that the handle was viable, the catheter was removed and a new one was placed. The patient is currently in the DP program. The second patient, 9 months after surgery, presented permeabilization of the vaginal peritoneal duct and a hydrocele appeared. The patient rejected the correction of the latter and was transferred to the hemodialysis program (table 1).

DISCUSSION

The PD is a safe and effective option for the patient with terminal renal failure. In addition, there is evidence of better preservation of residual renal function when compared with hemodialysis27,28. Although open surgery has been the method of choice, the laparoscopic approach has been widely accepted29-31.

Our technique, described above, is a simple procedure through two 12-mm trocars. In addition, it is a fast procedure, with a short surgical time. Regarding the intraoperative advantages, laparoscopy allows optimal vision and evaluation of the peritoneal cavity, and allows accurate placement of the catheter. In addition, laparoscopy allows the release of peritoneal adhesions if necessary.

The use of a Guyon guide has been of great help for the precise placement of the catheter, since its atraumatic tip and its rigidity make it possible both to guide the catheter to the bottom of the sac and reposition it if necessary. The incidence of catheter obstruction varies in the literature between 10 and 22% in procedures for open surgery with blind placement. On the other hand, laparoscopic surgery has much lower obstruction rates, between 4 and 13%. In our experience, the obstruction rate was 3.9%. Despite this low rate, our limited follow-up must be taken into account.

The peritoneal fluid leak rate varies between 2.6 and 22%. In our experience, we have not had any case of flight. This complication is not only associated with open surgery, but also with the laparoscopic approach. Paramedial placement and the creation of a long subcutaneous tunnel are strategies to try to reduce this complication32,33 and could explain the absence of a fistula in our series.

When analyzing our technique in comparison with other laparoscopic techniques of three ports, our experience is comparable in terms of surgical time, time of admission and rate of obstruction of the catheter30,34,35. Peritoneal fluid fistula rates with three-port techniques range from 0 to 4.7%. Accepting our limited follow-up, our results would be at least equal.25,30. We have not had cases of infection of the surgical incisions. It could be argued that a short surgical time is important to limit wound infections, but other centers with similar surgical times report infections of the ports of up to 21% 35.

We did not have peritonitis in the early postoperative period (two first weeks) after the catheter implantation, but there was one episode of peritonitis per patient every 32.4 months (0.27 episodes per patient per year), which is lower than recommended in the literature36. We need more follow-up to determine the risk of peritonitis associated with our technique.

In summary, we believe that our technique is a simple and fast procedure, with few complications and short entry, which due to its reliability offers excellent results regarding the function of the catheter.

Oropoulos-zellerman catheter with guyon guide atraumatic tip.

Figure 1. Oreopoulos-Zellerman catheter with Guyon guide atraumatic tip.

position of the ports. periumbilical port of 12 mm for the catheter and left pararectal port of 12 mm for the optics.

Figure 2. Position of the ports. Periumbilical port of 12 mm for the catheter and left pararectal port of 12 mm for the optics.

km curve showing the survival of patients on peritoneal dialysis.

Figure 3. KM curve showing the survival of patients on peritoneal dialysis.

catheters removed or replaced due to technical problems (obstruction, peritonitis or migration).

Figure 4. Catheters removed or replaced due to technical problems (obstruction, peritonitis or migration).

patients excluded from the dpac program. cause of exclusion, time from onset, current treatment and condition of the catheter at the time of exclusion

Table 1. Patients excluded from the CAPD program. Cause of exclusion, time from onset, current treatment and catheter status at the time of exclusion