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1.  Laparoscopic versus open catheter placement in peritoneal dialysis patients: a systematic review and meta-analysis 
BMC Nephrology  2012;13:69.
Peritoneal dialysis has been proven to be a safe and effective mode of renal replacement therapy for patients with end-stage renal disease. The usage of laparoscopic catheter placement technique was increased in recent years. But the advantages and disadvantages between the laparoscopic catheter placement technique and open laparotomy technique were still http://in controversy. The objective of this study is to access the operation-related data and complications of catheter placement for peritoneal dialysis (PD) patients, Then to determine the better method for catheter insertion.
We performed a systematic review and meta-analysis on published studies identified by the databases PubMed, EMBASE, Highwire, and the Cochrane Library. Analysis was performed using the statistical software Review Manager Version 5.0.
We assessed the operation-related data and complications of four randomized controlled trials (RCTs) and ten observational studies. The available data showed that laparoscope prolonged the time for catheter insertion in PD patients, however, the two groups did not significantly differ in hospital stays, early and late complications, including infection, dialysate leaks, catheter migration, pericannular bleeding, blockage and hernia.
The data showed that Laparoscopic catheter placement had no superiority to open surgery. However, this treatment still needs to be confirmed in a large, multi-center, well-designed RCT.
PMCID: PMC3439683  PMID: 22839745
Laparoscopic catheter placement; Peritoneal dialysis; Complications
2.  Randomised Controlled Trial to determine the appropriate time to initiate peritoneal dialysis after insertion of catheter to minimise complications (Timely PD study) 
BMC Nephrology  2010;11:11.
The most appropriate time to initiate dialysis after surgical insertion of Tenckhoff catheters is not clear in the literature. There is the possibility of peritoneal dialysis (PD) complications such as leakage and infection if dialysis is started too soon after insertion. However, much morbidity and expense could be saved by reducing dependency on haemodialysis (HD) by earlier initiation of PD post catheter insertion. Previous studies are observational and mostly compare immediate with delayed use. The primary objective is to determine the safest and shortest time interval between surgical placement of a Tenckhoff catheter and starting PD.
This is a randomised controlled trial of patients who will start PD after insertion of Tenckhoff catheter at Royal Brisbane and Women's Hospital (RBWH) or Rockhampton Base Hospital (RBH) who meet the inclusion criteria. Patients will be stratified by site and diabetic status. The patients will be randomised to one of three treatment groups. Group 1 will start PD one week after Tenckhoff catheter insertion, group 2 at two weeks and group 3 at four weeks. Nurses and physicians will be blinded to the randomised allocation. The primary end point is the complication rate (leaks and infection) after initiation of PD.
The study will determine the most appropriate time to initiate PD after placement of a Tenckhoff catheter.
Trial Registration
PMCID: PMC2898765  PMID: 20565984
3.  Laparoscopic versus Open Peritoneal Dialysis Catheter Insertion: A Meta-Analysis 
PLoS ONE  2013;8(2):e56351.
Peritoneal dialysis is an effective treatment for end-stage renal disease. Key to successful peritoneal dialysis is a well-functioning catheter. The different insertion techniques may be of great importance. Mostly, the standard operative approach is the open technique; however, laparoscopic insertion is increasingly popular. Catheter malfunction is reported up to 35% for the open technique and up to 13% for the laparoscopic technique. However, evidence is lacking to definitely conclude that the laparoscopic approach is to be preferred. This review and meta-analysis was carried out to investigate if one of the techniques is superior to the other.
Comprehensive searches were conducted in MEDLINE, Embase and CENTRAL (the Cochrane Library 2012, issue 10). Reference lists were searched manually. The methodology was in accordance with the Cochrane Handbook for interventional systematic reviews, and written based on the PRISMA-statement.
Three randomized controlled trials and eight cohort studies were identified. Nine postoperative outcome measures were meta-analyzed; of these, seven were not different between operation techniques. Based on the meta-analysis, the proportion of migrating catheters was lower (odds ratio (OR) 0.21, confidence interval (CI) 0.07 to 0.63; P = 0.006), and the one-year catheter survival was higher in the laparoscopic group (OR 3.93, CI 1.80 to 8.57; P = 0.0006).
Based on these results there is some evidence in favour of the laparoscopic insertion technique for having a higher one-year catheter survival and less migration, which would be clinically relevant.
PMCID: PMC3574153  PMID: 23457554
4.  A Modified Method in Laparoscopic Peritoneal Catheter Implantation: The Combination of Preperitoneal Tunneling and Pelvic Fixation 
ISRN Surgery  2013;2013:248126.
Introduction. Continuous ambulatory peritoneal dialysis (CAPD) is widely accepted for the management of end-stage renal disease (ESRD). Although not as widely used as hemodialysis, CAPD has clear advantages, especially those related to patient satisfaction and simplicity. Peritoneal dialysis (PD) catheter insertion can be accomplished by several different techniques. In this study, we aimed to evaluate our results obtained with peritoneal dialysis catheter placement by combination of pelvic fixation plus preperitoneal tunneling. Material and Methods. Laparoscopic peritoneal catheter implantation by combining preperitoneal tunneling and pelvic fixation methods was performed in 82 consecutive patients with end-stage renal disease. Sex, age, primary disease etiology, complications, mean duration of surgery, mean duration of hospital stay, morbidity, mortality, and catheter survival rates and surgical technique used were assessed. Analysis of catheter survival was performed using the Kaplan-Meier method. Results. Mean follow-up period was 28.35 ± 14.5 months (range of 13–44 months). Mean operative time was 28 ± 6 minutes, and mean duration of hospital stay was 3 ± 1 days. There were no conversions from laparoscopy to other insertion methods. None of the patients developed serious complications during surgery or the postoperative period. No infections of the exit site or subcutaneous tunnel, hemorrhagic complications, abdominal wall hernias, or extrusion of the superficial catheter cuff was detected. No mortality occurred in this series of patients. Catheter survival was found to be 92% at 3 years followup. Conclusions. During one-year followup, we had seven patients of migrated catheters due to separation of pelvic fixation suture from peritoneal surface, but they were reimplanted and fixated again laparoscopically with success. Over a three-year followup period, catheter survival was found to be 92%. In the literature, similar catheter survival rates without combination of the two techniques are reported. As a conclusion, although laparoscopic placement of PD catheters avoids many perioperative and early complications, as well as increasing catheter free survival period and quality of life, our results comparing to other studies in the literature indicate that different laparoscopic placement methods are still in debate, and further studies are necessary to make a more accurate decision.
PMCID: PMC3671265  PMID: 23762625
5.  Comparing the outcomes of open surgical procedure and percutaneously peritoneal dialysis catheter (PDC) insertion using laparoscopic needle: A two month follow-up study 
This study was performed to compare the outcomes of open surgical procedure and percutaneously peritoneal dialysis catheter (PDC) insertion using laparoscopic needle.
This randomized clinical trial study was conducted in the Nephrology Department in Noor Hospital, Isfahan, Iran between 2009 and 2010. 64 uremic patients were randomized into two study groups using random allocation software. Thirty four catheters were inserted percutaneously (P group) and 30 catheters were placed surgically (S group). Collected information included demographic data, body mass index, and cause of renal disease, duration of operation and length of hospitalization. Outcomes were considered as mechanical and infectious complications.
There were no significant differences in age, gender, the mean of body mass index, having history of hemodialysis, diabetes mellitus, hypertension, ischemic heart disease, and length of hospitalization. Hemopenitoneom was more frequent in S group than P group (13.3% versus 3.2%; p < 0.0001). There was no significant difference between two groups in early peritonitis, early leakage, hernia, hollow viscous perforation, catheter obstruction, and malpositioning and the time of peritoneal dialysis onset. Outflow failure and the exit site infection were more frequent in S group than P group (p < 0.0001). Mean of the operative time was longer in S group than P group (27.70 ± 2.79 minutes versus 10.48 ± 1.91 minutes, p < 0.001).
Percutaneous catheter insertion has fewer rate of complications and is less time consuming in comparison with surgical method.
PMCID: PMC3214349  PMID: 22091260
Laparoscopy; Needles; Catheter Ablation; Peritoneal Dialysis
6.  A Brief Recap of Tips and Surgical Manoeuvres to Enhance Optimal Outcome of Surgically Placed Peritoneal Dialysis Catheters 
Background. Peritoneal dialysis (PD) is an effective option of renal replacement therapy for ESRF, offering advantages over haemodialysis. Peritoneal dialysis catheter (PDC) placement is thought to be the key to successful PD and the economic advantages are lost if a patient switches to HD in the 1st year. This paper is a brief document elaborating a recap of published literature, looking at various surgical tips and manoeuvres to enhance optimal outcome of PDC placement. Methods. A search strategy assessing for access team, preoperative antibiotic prophylaxis, type of catheter, catheter exit site, intraoperative catheter trial, optimal time to commence PD, hernia repairs, number of cuffs, catheter-embedding procedures, rectus sheath tunnelling, laparoscopic fixing, omentopexy, omentectomy, the “Y”-Tec system, resection of epiploic appendages, adhesiolysis, a trained surgeon, and perioperative catheter care protocol was used looking at various databases. Findings. The complications of catheterrelated dysfunction can be reduced with advanced planning of access placement, immaculate surgery, and attention to catheter insertion techniques. Conclusion. The success of a peritoneal dialysis programme depends upon functional and durable long term access to the peritoneal cavity; this depends on placement techniques and competent surgeons and psychosocial support to the patient. The various technical tips and manoeuvres elaborated here should be considered options carried out to improve outcome and reduce catheter dysfunction.
PMCID: PMC3408654  PMID: 22888425
7.  Laparoscopic Peritoneal Dialysis Catheter Insertion Using a Quinton Percutaneous Insertion Kit 
We assessed a unique technique of laparoscopic peritoneal dialysis (PD) catheter insertion which can minimize catheter dysfunction.
We performed a retrospective review of patients undergoing laparoscopic PD catheter placement with a Quinton percutaneous insertion kit between July 2000 and December 2004.
Thirty-one catheters were placed laparoscopically. The mean operating time was 52 minutes. Adhesiolysis was required in 9 (29%) and omentectomy or omen-topexy in 3 (10%) cases. Late complications included catheter dysfunction in 2 patients (6.5%), debilitating abdominal pain requiring catheter removal in 1 patient, and 1 trocar-site hernia. The mean follow-up was 17 months.
Laparoscopic PD catheter insertion using a Quinton percutaneous insertion kit is safe, reproducible, and effective. It facilitates placement of the catheter tip into the pelvis and allows adhesiolysis, omentectomy, or omentopexy when necessary. Utilization of this technique results in a low rate of PD catheter dysfunction.
PMCID: PMC3015720  PMID: 17761082
Minimally invasive surgery; Laparoscopy; Continuous ambulatory peritoneal dialysis; Catheter; In-dwelling; Catheter dysfunction
8.  Laparoscopic internal fixation is a viable alternative option for continuous ambulatory peritoneal dialysis catheter insertion 
One of the major drawbacks of peritoneal dialysis (PD) is catheter migration and dysfunction. Preventing catheter migration is one of the main concerns. We compared laparoscopic internal fixation method with open surgical method for catheter migration rates.
From January 2008 to August 2009, PD catheters were inserted by laparoscopic fixation (LF) method in 22 patients and by open surgery (OS) in 32 patients. Clinical data were reviewed retrospectively. The frequency of migration, peritonitis, and other complications were compared. Catheter and patient survival rates were also compared.
The mean age and sex ratio were not different between groups. Mean follow-up duration was 29.1 months in LF group and 26.1 months in OS group. More patients in LF group (27.3%) had history of laparotomy than in OS group (3.1%) (P = 0.01). The mean operation time was significantly longer in LF group (101.6 ± 30.4 minutes) than in OS group (72.4 ± 26.03 minutes) (P = 0.00). The cumulative incidence of catheter migration was 65.6% in OS group and 13.6% in LF group (P = 0.00). Migration-free catheter survival was higher in LF group (P = 0.001). There were no differences in complication rates between groups. Overall catheter survival was similar (P = 0.93). Patient survival rate at 2 years was not different (P = 0.13).
Laparoscopic internal fixation of continuous ambulatory peritoneal dialysis catheter significantly reduces migration rates without any addition of complications. Also, laparoscopic technique did not incur patient morbidity or mortality despite the requirement for general endotracheal anesthesia and longer operation time. Therefore, internal fixation can be afforded safely in patients with previous abdominal surgery as either a salvage or preventive measure in patients with repeated catheter migration.
PMCID: PMC3514481  PMID: 23230557
CAPD; Catheter; Laparoscopy; Fixation; Migration
9.  Continuous ambulatory peritoneal dialysis catheter placement: Is omentectomy necessary? 
Urology Annals  2010;2(3):107-109.
There are different methods of continuous ambulatory peritoneal dialysis (CAPD) catheter placement. Open surgical technique is a widely followed method. The complication rate following catheter placement varies and catheter blockage due to omental plugging is one of the main reasons.
To analyze the need for routine omentectomy during CAPD catheter placement.
Materials and Methods:
This was a retrospective analysis of 58 CAPD catheter placements performed between July 2002 and June 2007. Tenckhoff double cuffed catheter was used in all. The postoperative complications were analyzed.
There were 44 males and 14 females. The mean age was 51 years ranging from 15 to 76 years. Of these, 40 (69%) patients underwent omentectomy (group A) and 18 (31%) did not (group B). Laparoscopic and open techniques were performed in 5 and 53 patients, respectively. Omentectomy was not performed in 13 patients with open technique and all the five in the laparoscopic group. One patient in group A developed hemoperitoneum which was treated conservatively. None from group A developed catheter blockage, whereas five (27.8%) from group B developed catheter blockage postoperatively. The median time interval between the primary procedure and development of catheter blockage was 45 days (ranged from 14 to 150 days).
Omentectomy during CAPD catheter placement prevents catheter blockage and secondary interventions.
PMCID: PMC2955224  PMID: 20981197
Chronic renal failure; dialysis; omentectomy
10.  Rationale and design of the HEALTHY-CATH trial: A randomised controlled trial of Heparin versus EthAnol Lock THerapY for the prevention of Catheter Associated infecTion in Haemodialysis patients 
BMC Nephrology  2009;10:23.
Catheter-related bacteraemias (CRBs) contribute significantly to morbidity, mortality and health care costs in dialysis populations. Despite international guidelines recommending avoidance of catheters for haemodialysis access, hospital admissions for CRBs have doubled in the last decade. The primary aim of the study is to determine whether weekly instillation of 70% ethanol prevents CRBs compared with standard heparin saline.
The study will follow a prospective, open-label, randomized controlled design. Inclusion criteria are adult patients with incident or prevalent tunneled intravenous dialysis catheters on three times weekly haemodialysis, with no current evidence of catheter infection and no personal, cultural or religious objection to ethanol use, who are on adequate contraception and are able to give informed consent. Patients will be randomized 1:1 to receive 3 mL of intravenous-grade 70% ethanol into each lumen of the catheter once a week and standard heparin locks for other dialysis days, or to receive heparin locks only. The primary outcome measure will be time to the first episode of CRB, which will be defined using standard objective criteria. Secondary outcomes will include adverse reactions, incidence of CRB caused by different pathogens, time to infection-related catheter removal, time to exit site infections and costs. Prospective power calculations indicate that the study will have 80% statistical power to detect a clinically significant increase in median infection-free survival from 200 days to 400 days if 56 patients are recruited into each arm.
This investigator-initiated study has been designed to provide evidence to help nephrologists reduce the incidence of CRBs in haemodialysis patients with tunnelled intravenous catheters.
Trial Registration
Australian New Zealand Clinical Trials Registry Number: ACTRN12609000493246
PMCID: PMC2738669  PMID: 19691852
11.  Comparison of temporary and permanent catheters for acute peritoneal dialysis. 
Archives of Disease in Childhood  1988;63(7):827-831.
The records of 64 children who underwent acute peritoneal dialysis in the Hospital for Sick Children, Toronto, between 1 January 1982 and 31 December 1985 were reviewed. Rigid Trocath catheters were used in 33 patients and silastic Tenckhoff catheters in 34. The groups were comparable for age, weight, primary disease, duration of dialysis, and outcome. There were no significant differences in the incidences of leakage of dialysate, two way obstruction, bleeding, or peritonitis. Among those who had Trocath catheters there were significantly more episodes of outflow obstruction, and significantly more patients required two or more catheter insertions (12 of 33 compared with one of 34 among those who had Tenckhoff catheters). Furthermore, more catheters were removed because of complications (19 of 33 compared with five of 34 respectively). One patient who had a Tenckhoff catheter died of peritonitis directly related to insertion of the catheter. Overall, the Tenckhoff catheter was associated with fewer complications and is recommended for most patients.
PMCID: PMC1779093  PMID: 3415301
12.  Dialysis-associated peritonitis in children 
Peritonitis remains a frequent complication of peritoneal dialysis in children and is the most common reason for technique failure. The microbiology is characterized by a predominance of Gram-positive organisms, with fungi responsible for less than 5% of episodes. Data collected by the International Pediatric Peritonitis Registry have revealed a worldwide variation in the bacterial etiology of peritonitis, as well as in the rate of culture-negative peritonitis. Risk factors for infection include young age, the absence of prophylactic antibiotics at catheter placement, spiking of dialysis bags, and the presence of a catheter exit-site or tunnel infection. Clinical symptoms at presentation are somewhat organism specific and can be objectively assessed with a Disease Severity Score. Whereas recommendations for empiric antibiotic therapy in children have been published by the International Society of Peritoneal Dialysis, epidemiologic data and antibiotic susceptibility data suggest that it may be desirable to take the patient- and center-specific history of microorganisms and their sensitivity patterns into account when prescribing initial therapy. The vast majority of patients are treated successfully and continue peritoneal dialysis, with the poorest outcome noted in patients with peritonitis secondary to Gram-negative organisms or fungi and in those with a relapsing infection.
PMCID: PMC2810362  PMID: 19190935
Antibiotics; Children; Infection; Peritonitis; Peritoneal dialysis
13.  Laparoscopic Management of Malfunctioning Peritoneal Dialysis Catheters 
Oman Medical Journal  2011;26(3):171-174.
Continuous ambulatory peritoneal dialysis (CAPD) is an established alternative method to hemodialysis for treating end-stage renal disease patients. Malfunction of the peritoneal catheter is a frequent complication in peritoneal dialysis (PD). Laparoscopy is a minimal invasive technique that allows rescue therapy of malfunctioning catheters and consecutive immediate resumption of PD. The purpose of this study is to present our experiences with laparoscopic repair of peritoneal catheter dysfunction
Between April 2006 and March 2010, 21 cases of laparoscopic interventions were performed for the salvage of malfunctioning CAPD catheter. Two trocars (5 mm) were used. Recorded data included patient demographics, catheter implantation method, date of malfunction, cause of dysfunction, procedure performed and complications.
The primary etiology of dysfunction was omentum and/or small bowel wrapping with adhesions in fifteen cases, malpositioning in four cases, and tunnel infection in the remaining two cases. Adhesiolysis was performed in cases with adhesions. In the cases with malpositioning but no adhesions, the catheters were repositioned in the pelvic cavity. Two catheters had to be withdrawn and exchanged because of infection. There were no mechanical or infection problems. The overall success rate of catheter function (>30 days after laparoscopy) was 100%, except for two cases in which the catheters had to be removed.
Laparoscopy is a safe, highly effective and successful method for the evaluation and management of peritoneal dialysis catheter dysfunction.
PMCID: PMC3191690  PMID: 22043409
Peritoneal dialysis; Catheter malfunction; Laparoscopy
14.  Laparoscopic-assisted catheter insertion for continuous ambulatory peritoneal dialysis: A case report of simple technique for optimal placement 
A 40-year-old male underwent tube placement surgery for continuous ambulatory peritoneal dialysis (CAPD). A 2-cm skin incision was made, and the peritoneum was reflected enough to perform secure fixation. A swan-necked, double-felted silicone CAPD catheter was inserted, and the felt cuff was sutured to the peritoneum to avoid postoperative leakage. An adequate gradient for tube fixation to the abdominal wall was confirmed. The CAPD tube was passed through a subcutaneous tunnel. Aeroperitoneum was induced to confirm that there was no air leakage from the sites of CAPD insertion. Two trocars were placed, and we confirmed that the CAPD tube led to the rectovesical pouch. Tip position was reliably observed laparoscopically. Optimal patency of the CAPD tube was confirmed during surgery. Placement of CAPD catheters by laparoscopic-assisted surgery has clear advantages in simplicity, safety, flexibility, and certainty. Laparoscopic technique should be considered the first choice for CAPD tube insertion.
PMCID: PMC3812441  PMID: 24179625
Continuous ambulatory peritoneal dialysis; Dialysis catheter; Tube insertion; Surgical technique
15.  Laparoscopic Placement of Peritoneal Dialysis Catheter (Same Day Dialysis) 
Background and Objective:
Peritoneal dialysis (PD) remains the generally accepted method for management of renal failure in chronic and acute renal failure. Despite the rapidly increasing use of continuous ambulatory peritoneal dialysis (CAPD) since its introduction, controversy persists as to the efficacy and exact role of the modality in the treatment of end stage renal failure. The aim of this paper is to present the experience with laparoscopic placement of a peritoneal dialysis catheter and starting the peritoneal dialysis on the same day.
The laparoscopic placement of a peritoneal dialysis catheter was performed on 11 patients (10 males and 1 female) with an average age of 35 years, over a 12-month period. The procedure was done using two 5 mm abdominal trocars. The precise position of the catheter on the pelvis was ensured laparoscopically. One to two liters exchange dialysis was used for every patient, and no leakage was recorded.
The patients tolerated the procedure well. The peritoneal dialysis was started immediately. Patients were discharged after an overnight stay, and PD was carried out routinely.
The results of laparoscopic placement of a peritoneal dialysis catheter show the following advantages: minimal incision; less surgical trauma; the procedure hastens the early start of peritoneal dialysis and has no complications.
PMCID: PMC3015362  PMID: 10694081
Lkaparoscopy; Peritoneal dialysis; Catheter
16.  Needleoscopic Placement of Tenckhoff Catheters 
Minimally invasive techniques are being developed for the placement of peritoneal dialysis catheters. A needleoscopic technique that utilizes only two punctures is described.
Twelve patients underwent 13 needleoscopic Tenckhoff catheter placement procedures between November 1995 and May 1998. An additional six patients underwent the same procedure using a standard 10 mm laparoscope. The patients were followed prospectively for type of anesthesia and operative time for the procedure, whether the procedure was performed as an inpatient or an outpatient, and for any complications or leakage following the procedure.
The needleoscopic procedure was able to be performed with an average operative time of 12 minutes. Twenty-three percent (23%) were performed under local anesthesia and thirty-eight (38%) were treated as outpatients.
Needleoscopic Tenckhoff catheter placement is very simple to perform and can be performed under local anesthesia with minimal discomfort, secure catheter placement, and no leakage.
PMCID: PMC3015322  PMID: 10444018
Needleoscopy; Peritoneal dialysis; Ascites
17.  Clinical application of right low-position modified peritoneal dialysis catheterization 
The aim of this study was to investigate peritoneal dialysis catheter malposition following low-position modified peritoneal dialysis catheterization and its clinical application value. A total of 48 patients receiving traditional peritoneal dialysis catheterization (the traditional group) and 95 patients receiving right low-position modified peritoneal dialysis catheterization (the modified group) from 2006 to 2011 were selected. The inflow time, outflow time, ultrafiltration volume of peritoneal dialysis solution and rate of peritoneal dialysis catheter malposition in the two groups of patients following surgery were compared and analyzed. There were no significant differences of inflow time, outflow time and ultrafiltration volume of the peritoneal dialysis solution between the two groups. In the modified group, no post-operative peritoneal dialysis catheter malposition occurred, therefore the incidence rate was 0. However, 9 patients in the traditional group presented peritoneal dialysis catheter malposition, an incidence rate of 18.75% (9/48). Among them, 6 patients required a second surgery. There was a statistically significant difference in the incidence rate of catheter malposition between the two groups (P<0.01). Right low-position modified peritoneal dialysis catheterization significantly reduced the incidence rate of peritoneal dialysis catheter malposition following peritoneal dialysis, and was shown to be significantly more effective than the traditional peritoneal dialysis catheterization and is therefore worth promoting for clinical use.
PMCID: PMC3570151  PMID: 23404635
peritoneal dialysis; catheterization; peritoneal dialysis catheter malposition
18.  Percutaneous CAPD catheter insertion by a nephrologist versus surgical placement: A comparative study 
Peritoneal dialysis catheter (PDC) for continuous ambulatory peritoneal dialysis is inserted into the abdominal cavity either by a surgeon, interventional radiologist or nephrologist. Various innovations have been made in the methodology adopted in the placement of the PDC. We compared the percutaneous approach for PDC insertion with the open surgical technique. From January 2006 to May 2007, 25 of the 46 catheters were successfully inserted using the percutaneous Seldinger technique. The incision size (2.6 ± 0.7 vs 7.3 ± 0.6 cm) and the length of hospital stay (11.9 ± 5.9 vs 17.3 ± 6.8 d) were considerably less in the percutaneously placed group compared to the surgically placed group. Early initiation of exchanges and reduction in the expenses were other important advantages of this method.
PMCID: PMC2847731  PMID: 20368912
Continuous ambulatory peritoneal dialysis; interventional nephrologists; percutaneous insertion; peritoneal dialysis catheter
19.  Factors influencing peritoneal catheter survival in continuous ambulatory peritoneal dialysis. 
The success of continuous ambulatory peritoneal dialysis (CAPD) is to a great extent determined by the survival of the peritoneal catheter. The aim of this study was to identify technical factors which influence CAPD catheter survival. A total of 453 CAPD catheters inserted into 310 patients over an 8-year period were analysed. Access to the peritoneum was gained either by an open surgical technique (n = 290) or by a closed technique using a trocar and introducer (n = 163). Data relating to a number of potentially significant risk/benefit factors were analysed using multiple regression analysis (proportional hazards method of Cox). Three factors were found to be independently associated with improved catheter survival. They were: using an open surgical insertion technique, performing a partial omentectomy at the time of catheter insertion and the procedure being performed by a consultant.
PMCID: PMC2499290  PMID: 2241055
20.  Laparoscopic Placement and Revision of Peritoneal Dialysis Catheters 
Chronic peritoneal dialysis is an option for many patients with end stage renal disease. Laparoscopy offers an alter-native approach in the management of dialysis patients. Over an 18-month period, laparoscopy was used for placement or revision of seven peritoneal dialysis catheters. All were placed in patients with end stage renal disease for chronic dialysis. Two catheters were initially placed using the laparoscope, and in five other patients, the position of the catheter was revised. Of the two patients who had their catheters placed initially, one patient had a previous lower mid-line incision and underwent laparoscopic placement of a catheter and lysis of pelvic adhesions. The second patient had hepatitis C and chronically elevated liver function tests. He underwent laparoscopic placement of a peritoneal dialysis catheter and liver biopsy. Five patients had laparoscopic revision for non-functional catheters. Four were found to have omental adhesions surrounding the catheter. Three patients were found to have a fibrin clot within the catheter, and in one patient the small bowel was adhered to the catheter. All seven patients had general endotracheal anesthesia. There were no operative or anesthetic complications. The average operative time was 56 minutes. Four patients had their procedure in an ambulatory setting and were discharged home the same day. One patient was admitted for 23-hour observation, and two patients had their procedure while in the hospital for other reasons. In follow-up, there was one early failure at two weeks, which required removal of the catheter for infection. One catheter was removed at the time of a combined kidney/pancreas transplant eight months after revision. The other five catheters are still functional with an average follow-up of ten months. These results suggest that laparoscopy is another method for placement of peritoneal dialysis catheters and more importantly for revision in patients with nonfunctional catheters secondary to adhesions. It also provides an opportunity to evaluate the abdomen and perform concomitant procedures.
PMCID: PMC3015335  PMID: 10323172
Laparoscopy; Dialysis catheter; Renal Disease
21.  Low concentration of heparin used for permanent catheters canal locking is effective and diminishes the risk of bleeding 
There is an increasing number of patients being dialyzed with permanent catheters (PC). In the majority of cases, heparin is used to maintain PC patency. This practice causes clotting disturbances due to heparin leakage and may predispose the patient to bleeding episodes. It has not been well studied whether lowering heparin concentration for canal locking decreases short-term bleeding complications after PC placement.
This was a prospective single-center randomized open-label trial conducted in hemodialyzed patients undergoing PC insertion. Low concentration of heparin (LCH) 2,500 IU/ml versus high concentration of heparin (HCH) 5,000 IU/ml was randomly used for catheter lumens locking. The primary endpoint was the occurrence of bleeding within 24 h after catheter placement. The effects of clinical and laboratory data on bleeding events were analyzed as secondary endpoints.
Seventy-five patients (37 in LCH) were enrolled in the study. Only in the HCH group we found a significant prolongation of activated partial thromboplastin time (APTT) 2 h after PC placement (p < 0.001). There was a higher number of bleeding episodes in the HCH group (n = 16; 42.1%) than in the LCH group (n = 7; 18.9%) (χ2 = 4.74; p = 0.029). In univariate analysis, assignment to HCH, baseline APTT, use of low molecular weight heparin, and femoral localization were associated with bleeding events. In multivariate analysis, the use of HCH (odds ratio [OR] 3.64; 95% confidence interval [95% CI] 1.10–12.05) and baseline APTT (OR 1.12; 95% CI 1.002–1.250) predicted bleeding after PC insertion.
LCH used for canals locking decreases bleeding events in the first 24 hours after permanent catheter placement, compared to HCH.
PMCID: PMC3689468  PMID: 22418764
Bleeding; Hemodialysis; Heparin; Permanent catheter
22.  Technique of Peritoneal Catheter Placement under Fluroscopic Guidance 
Peritoneal catheters are mainly used for peritoneal dialysis in patients with end-stage renal disease. Other uses of this catheter include intraperitoneal chemotherapy and gene therapy for ovarian cancer and draining of uncontrolled refractory ascites in patients with liver cirrhosis. Traditionally, surgeons place most of these peritoneal catheters either by laparoscopy or open laparotomy. We detail our percutaneous approach to placing peritoneal catheters using fluoroscopic guidance. We emphasize the use of additional ultrasound guidance, including gray scale and color Doppler ultrasound, to determine the safest puncture site and to guide the initial needle puncture in order to avoid bowel perforation and injury to epigastric artery. We present our experience in placing peritoneal catheters using this technique in 95 patients with various indications. Fluoroscopic guided percutaneous placement of peritoneal catheters is a safe, minimally invasive, and effective alternative to open surgical or laparoscopic placement.
PMCID: PMC3196249  PMID: 22091373
23.  Peritonitis in children on peritoneal dialysis in Cape Town, South Africa: epidemiology and risks 
Pediatric Nephrology (Berlin, Germany)  2010;25(10):2149-2157.
Peritonitis is a frequent complication of peritoneal dialysis (PD) in children as well in adults. Data on PD and peritonitis in pediatric patients are very scarce in developing countries. A retrospective cohort study was performed between 2000 and 2008 with the aim to evaluate PD treatment and peritonitis epidemiology in pediatric patients in South Africa and identify risk factors for peritonitis. Baseline characteristics and potential risk factors of peritonitis were recorded, including housing, socio-economic circumstances, distance to PD center, type of PD, mode of catheter placement, race, presence of gastrostomy tube, weight, and height. Outcome indices for peritonitis were peritonitis rate, time to first peritonitis, and number of peritonitis-free patients. The patient cohort comprised 67 patients who were on PD for a total of 544 months. The total number of peritonitis episodes was 129. Median peritonitis rate was one episode every 4.3 patient months (2.8 episodes/patient-year, range 0–21.2). Median time to first infection was 2.03 months (range 0.1–21.5 months), and 28.4% of patients remained free from peritonitis. Patients with good housing and good socio-economic circumstances had a significantly lower peritonitis rate and a longer time to first peritonitis episode. Peritonitis rate was high in this cohort, compared to numbers reported for the developed world; the characteristics of causative organisms are comparable. The most important risk factors for the development of peritonitis were poor housing and poor socio-economic circumstances. More intensive counseling may be beneficial, but improvement of general socio-economic circumstances will have the greatest influence on PD success.
PMCID: PMC2923710  PMID: 20645111
Peritonitis; Pediatric; Risk factors; Socio-economic circumstances; Outcome
24.  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.
PMCID: PMC3569939  PMID: 23431443
25.  Inflammation and the Peritoneal Membrane: Causes and Impact on Structure and Function during Peritoneal Dialysis 
Mediators of Inflammation  2012;2012:912595.
Peritoneal dialysis therapy has increased in popularity since the end of the 1970s. This method provides a patient survival rate equivalent to hemodialysis and better preservation of residual renal function. However, technique failure by peritonitis, and ultrafiltration failure, which is a multifactorial complication that can affect up to 40% of patients after 3 years of therapy. Encapsulant peritoneal sclerosis is an extreme and potentially fatal manifestation. Causes of inflammation in peritoneal dialysis range from traditional factors to those related to chronic kidney disease per se, as well as from the peritoneal dialysis treatment, including the peritoneal dialysis catheter, dialysis solution, and infectious peritonitis. Peritoneal inflammation generated causes significant structural alterations including: thickening and cubic transformation of mesothelial cells, fibrin deposition, fibrous capsule formation, perivascular bleeding, and interstitial fibrosis. Structural alterations of the peritoneal membrane described above result in clinical and functional changes. One of these clinical manifestations is ultrafiltration failure and can occur in up to 30% of patients on PD after five years of treatment. An understanding of the mechanisms involved in peritoneal inflammation is fundamental to improve patient survival and provide a better quality of life.
PMCID: PMC3323921  PMID: 22547910

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