|LETTER TO EDITOR
|Year : 2016 | Volume
| Issue : 2 | Page : 262-265
Peritoneal dialysis catheter kinking: Description of laparoscopic management and a synopsis of related complications
Amanda Gifford1, Robert S Gayner2, Stanislaw P Stawicki3, John J Lukaszczyk3
1 Temple University School of Medicine, St. Luke's University Hospital Campus, Bethlehem, Pennsylvania, USA
2 Department of Internal Medicine, Division of Nephrology, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
3 Department of Surgery, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
|Date of Web Publication||28-Dec-2016|
John J Lukaszczyk
Estes Surgical Associates, 801 Ostrum Street, Bethlehem, Pennsylvania 18015
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Gifford A, Gayner RS, Stawicki SP, Lukaszczyk JJ. Peritoneal dialysis catheter kinking: Description of laparoscopic management and a synopsis of related complications. Int J Acad Med 2016;2:262-5
|How to cite this URL:|
Gifford A, Gayner RS, Stawicki SP, Lukaszczyk JJ. Peritoneal dialysis catheter kinking: Description of laparoscopic management and a synopsis of related complications. Int J Acad Med [serial online] 2016 [cited 2022 Jan 19];2:262-5. Available from: https://www.ijam-web.org/text.asp?2016/2/2/262/196879
To the Editor,
Peritoneal dialysis catheters (PDCs) offer an important therapeutic option for patients who exhausted their vascular access options, are not candidates for hemodialysis (HD), or prefer the peritoneal dialysis (PD) approach. Numerous placement options for PDC are available, including open surgery, laparoscopy, and percutaneous techniques.,,, Many patients find it easier and more comfortable to undergo PD than HD. For some, PDC equates to the freedom to undergo overnight dialysis treatments at home, as opposed to spending multiple hours per week at a dedicated HD center. Other advantages of PD over HD include lower costs, avoidance of radical intravascular fluid shifts, and fewer hemodynamic sequelae (e.g., lower risk of hypotension or intravascular volume depletion).,, However, it is important to recognize that PDCs can be associated with major morbidity [Table 1]. Infection (peritonitis) is the number one cause of discontinuation of PD. Mechanical malfunction of the catheter is also quite common, occurring in up to 20% of patients. Sclerosing encapsulating peritonitis may occur with chronic PDC use, especially in the setting of recurrent infections [Figure 1].,,, Collectively, these complications may mandate temporary or permanent transition to HD.
|Table 1: Summary of complications associated with peritoneal dialysis catheters|
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|Figure 1: (a and b) Computed tomography scan showing sclerosing encapsulating peritonitis as evidenced by diffuse thickening of parietal peritoneum, mesenteric thickening with vascular engorgement, and associated ascites. Source: Jung JI, Cho JT. A case of fulminant sclerosing peritonitis presented such as acute culture-negative peritonitis and successfully treated with corticosteroid therapy. J Korean Med Sci 2013;28:620-3. Used under the creative commons attribution-noncommercial license (http://www.creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited|
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PDC malfunction can manifest by failure to either fill or drain instilled peritoneal dialysate fluid. Malfunction can be due to both placement-related (e.g., suboptimal location, tip migration, and omental wrap) and usage-related (e.g., repeated manipulation, kinking, peritoneal adhesions, intraluminal sediment buildup, encapsulation, and device migration) factors., Of note, the omentum is involved in approximately 15% of PDC malfunction cases. In the era of minimally invasive surgery, nonfunctioning PDCs due to omental entanglement can be successfully managed by “untangling” the catheter from the omentum using laparoscopy.
In this brief communication, we would like to describe a case of PDC malfunction, diagnosed with peritoneography and treated entirely with laparoscopy. A middle-aged patient with long-standing history of end-stage renal failure elected to abandon traditional HD and transition to PD mainly due to lifestyle-related considerations. The patient's PDC was placed approximately 8 months before the current presentation and it was functioning well until approximately 1 month prior.
On the day of the current presentation, the patient reported an inability to drain the dialysate and sought help at the ambulatory office. After the PDC malfunction was confirmed during an outpatient visit, an interventional radiologist was consulted to perform a peritoneogram, which showed the catheter malpositioned in the right upper abdominal quadrant [Figure 2]. At this time, it was not known if other factors such as intraperitoneal adhesions, omental encasement, or fibrin sheath formation around the distal catheter contributed to the malfunction.
|Figure 2: Peritoneogram showing likely fibrin encasement of the peritoneal dialysis catheter. (a) preinjection film, (b) immediate postinjection film, (c) image obtained after failing to evacuate the injected fluid. The catheter is seen looping in the lower abdominal midline. Its distal end is coiled in the right upper abdomen, consistent with omental involvement|
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Given that the patient's only previous abdominal intervention involved a minimally invasive placement of the PDC, there were no contraindications to laparoscopic management of the current presentation. Consequently, the patient was taken to the operating room for diagnostic laparoscopy with the intent to either reposition or replace the existing catheter. Intraoperatively, the PDC was easily located in the right upper quadrant. The catheter was found to be coiled and held in place by several adhesions between the omentum and the anterior abdominal wall [Figure 3]a. Using laparoscopic scissors and targeted electrocautery application, two dense adhesive bands were taken down uneventfully [Figure 3]b. The PDC was then freed from the surrounding omentum, uncoiled, and placed in the pelvis (posterior to the bladder, not shown). Several months postoperatively, the catheter continues to work properly. The patient did not experience any procedure-related complications.
|Figure 3: (a) Intraoperative images from diagnostic laparoscopy show the Moncrief–Popovich peritoneal dialysis catheter coiled and trapped between the omentum (†) and anterior abdominal wall adhesions (*). (b) After the anterior abdominal wall adhesions were lysed, the tip of the catheter was liberated from the omentum (†). The peritoneal dialysis catheter was then placed in the pelvis, posterior to the urinary bladder (not shown)|
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Intraperitoneal catheter migration may be involved in as many as 85%–90% of PDC failures. Migration combined with outflow obstruction typically indicates omental wrapping  as exemplified in the current case. When a laparoscopic procedure is performed to remedy the malfunction, a majority of cases (>80%) are able to be resolved initially, although recurrence rates vary. Advanced placement techniques such as rectus sheath tunneling, prophylactic adhesiolysis, and omentopexy may reduce the incidence of problems related to outflow obstruction.
Omental stripping and omentopexy may be preferred as the initial approaches when dealing with omental wrapping of the PDC, mainly due to short operative times in the traditionally high-risk, end-stage renal failure population. From a surgical perspective, omental stripping is a procedure that “frees up” side openings (e.g., used primarily for drainage) of the PDC. Omentopexy entails securing the omentum to the parietal peritoneum, usually using the anterior abdominal wall. This theoretically prevents the omentum from “wrapping around” the PDC.
Long-term success of PD depends heavily on the ability to maintain adequate PDC function and the avoidance of complications. Proper anatomic placement of the catheter is a very simple, yet often underappreciated factor. The optimal location of the catheter tip is in the pelvis, well below the lower extent of the omentum. Accordingly, the length of the catheter and its relation to the cutaneous exit site are of critical importance during preoperative planning and intraoperative decision-making. Optimally placed PDC will reliably facilitate proper dialysate drainage while preventing omental wrapping and the associated catheter malfunction. Reduction in PDC-associated infections is also very important. Various technical approaches and catheter designs have been proposed to reduce the incidence of peritoneal infections.,, However, the problem of PDC-associated peritonitis continues to be a significant barrier to wider implementation of PD, and there is no substitute for sterile technique during catheter placement and meticulous attention to catheter maintenance in accordance to the best practices for reducing the risk of subsequent infections.,,
In conclusion, PDCs may be susceptible to a variety of complications, most of which are due to the anatomic positioning of the catheter and the inherently elevated risk of infection related to the catheter itself being a “bridge” between intraperitoneal and extracorporeal environments. This report described a case of PDC malfunction related to the migration of the catheter tip into the right upper abdomen, its entrapment involving peritoneal adhesions and the omentum, and the subsequent failure to drain the dialysate fluid. Laparoscopic approach was successfully utilized to restore adequate PDC function.
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[Figure 1], [Figure 2], [Figure 3]