+

Non-Infectious

Catheter/Mechanical

ComplicationsZoe Parr, MD, FRCSC, FACS

ADC, February 27, 2016, Seattle, WA

+OBJECTIVES

To review common catheter complications

To review considerations for catheter salvage

To discuss the importance of surgical technique for

prevention

+Background

Work in a multi-disciplinary team

General Surgeons – UWMC and HMC

Nephrologists – UWMC and HMC

Nurses – UWMC, HMC, Northwest Kidney Center

Place PD catheters laparoscopically according to a technique

taught to us by Dr. John Crabtree (Kaiser Permanente, CA)

+Catheter complications

Many techniques to place catheters (laparoscopic, open, peritoneoscopic, percutaneous) and many differently trained providers placing them

Infectious complications

Exit site infections (2-41%)

Peritonitis (2-30%)

Non-infectious complications

Catheter-related

Abdominal-wall hernias

+Non-infectious complications

Catheter-related

Problems with flow – obstruction, migration, kinking

Peri-catheter leak

Abdominal wall hernias

Umbilical > Inguinal > Incisional, Epigastric

Peri-catheter hernias

+

Complication Laparoscopic

(%)

Open (%)

Obstruction* 4.7 12.2

Pericatheter Leak 4.6 8.1

Migration* 1.3-5.4 7.6-17.1

Intervention 7.9 23.4

Removal 13.3 19.3

Survival at 1 year* 94 75

Survival at 2 years* 71 49.2

+Mechanical Flow

Confirm the diagnosis – Hx, PE, radiology

Consider peri-catheter leakage

Outflow >> inflow

Obstruction – extra-luminal (constipation, bladder distension,

organs) or intra-luminal (fibrin plugging, omental intrusion)

Catheter kinking

Catheter malposition – migration

+Work-up of Issues with Flow

Rule out constipation, bladder distension, fibrin plugging

Initial diagnostics – AXR, bladder scan, catheter study

AXR – constipation, tube displacement (suggestive of omental

entrapment or adhesions)

Catheter study – rule out catheter leakage, may suggest

evidence for entrapment or adhesions

Fibrin plugging – urokinase, alteplase

+Images of Malpositioned/Migrated

catheters

+

+

+Catheter salvage

Techniques utilized for de-plugging or for re-direction of

catheters

Endoluminal brushes, fogarty balloons, fluoroscopic guide wire

manipulation

Laparoscopy

Extra-luminal obstruction

Intra-luminal obstruction from omental intrusion

Catheter-tip migration

Kinking (replacement)

+My Approach to Laparoscopy

Review their pre-operative Hx, PE, imaging studies, existing

operative reports

Supine positioning with both arms tucked

Access the abdomen opposite the side the catheter was

inserted on

Achieve pneumoperitoneum via the technique one most

comfortable with/most appropriate for the case

Consider using the existing PD catheter to insufflate

+Findings

Omental wrapping +- tip migration

Perform or re-do omentopexy

Adhesions +- tip migration

Adhesions from bowel, fallopian tubes, epiploicea etc.

Try to leave the adhesions in place and reposition the catheter

Angulation through the abdominal wall or related to tube memory

May be best to replace the catheter

Fibrin plugging

Catheter stripping, use of fogarty balloons or brushes

+

40/197 pts (20.3%) evaluated for catheter malfunction and 46 laparoscopic procedures performed to attempt catheter salvage

16 pts – tip migration alone; 12 pts – tip migration + omental/bowel adhesions; 4 pts – adhesions alone; 8 pts – other

3 pts required catheter removal, 3 required replacement and the remaining were corrected laparoscopically

Catheter malfunction recurred in 12 patients of 37 patients (32.4%) at a mean time of 12.4 months.

97.2% catheter patency at 3 months for the 37 patients, 62% at 12 months.

Mean catheter survival 19.9 months.

+Pericatheter leaks

Pericatheter leakage – outflow < inflow with signs of leakage from the exit site, subQ swelling, peripheral or genital edema

Highly variable reported incidence due to varying techniques, though rates tend to be less with embedded catheters

Tends to occur early after surgery in the setting of high dialysate volumes

Late leaks are more often associated with factors predisposing to a weak abdominal wall (pericannular hernias) or are caused by occult tunnel track infections

Hydrothorax – (1-2% of PD pts), less likely to resolve with disruption of PD and best success rates with thorascopic pleurodesis (3)

Diagnosis – CT peritoneography or peritoneal scintigraphy

Treatment – Typically will seal with temporary disruption of PD

+

+Hernias

PD is a known risk factor for the development of hernias, with reported incidences of 2-25% (4-6). ESRD pts will also have pre-existing hernias. This is considered a contraindication to PD and therefore must be fixed prior to starting PD.

General principles:

Reduce the peritoneal sac without entering it

Mesh repairs in a tension-free manner with mesh placed outside the peritoneal cavity and with wide overlap

Onlay, intraparietal, pre-peritoneal

Alternative?: IPOM w/ Zenapro

Hernia repairs are done at the same time as PD catheter placement (7)

If needed, can start PD immediately at low volumes w/ apparent good outcomes (8-10)

+Umbilical hernias

Most common acquired hernia in PD patients (11-16)

< 1 cm – My practice - primary repair at time of procedure

with an Endoclose

1 - 3 cm – Onlay mesh hernioplasty (17) versus pre-

peritoneal or H mesh hernioplasty (11)

> 3 cm – Retro-rectus type repair (8)

+

+

+Incisional hernias

Less data regarding this specific complication

A number of different techniques have been reported to

successfully repair incisional hernias

Intraparietal (antemuscular) (8)

Onlay (9)

+Inguinal

Open repair with mesh concurrently with PD catheter

placement

Avoid intra-parietal mesh and making rents in the

peritoneum with a TEP or TAPP

Avoid disrupting the space used for catheter tunneling

+Pericatheter hernias

These catheters must be replaced and the hernia fixed

according to the principles discussed

+Low Volume PD for Early Starts

Has been suggested by authors to wait a period of time after

hernia repair to start PD. However, in those patients currently

on PD where the decision was made not to wait, results have

been favorable without dialysate leaks using a low volume

protocol (11, 18)

“Our” protocol:

Supine, low volume PD (~1L) 3-5 times per week for 2 weeks

prior to transitioning to home

+Prevention!!!

Utilize a technique developed and taught by Dr. John Crabtree –adopted by all surgeons at UWMC/HMC

Preoperatively mark creases/pants line, check handedness

Laparoscopic approach using 5 mm camera and 2nd 5 mm port

Check for hernias initially and repair concurrently if found

Perform an omentopexy for every patient

Place the catheter with a preperitoneal tunnel using a 7/8 mm Versaport

Downward facing exit site

Check inflow/outflow and additionally flush with heparinized saline

+References

1. Hagen SM, Lafrana JA, Steyerberg EW, IJzermans JN, Dor FJ. Laparoscopic versus open

peritoneal dialysis catheter insertion: a meta-analysis. PLoS One. 2013; 8(2):e56351.

2. Yilmazlar T, Kirdak K, Bilgin S, Yavuz M, Yurtkuran M. Laparoscopic findings of

peritoneal dialysis catheter malfunction and management outcomes. Perit Dial Int.

2006; 26:374-9.

3. Xu T, Xie J, Wang W, Ren H, Chen N. Peritoneal-pleural leaks demonstrated by CT

peritoneography. Case Rep Nephrol Dial. 2015; 5(2):135-9.

4. Nelson H, Lindner M, Schuman ES, Gross GF, Hayes JF. Abdominal wall hernias as a

complication of peritoneal dialysis. Surg Gynecol Obstet. 1983; 157(6):541-4.

5. Hussain SI, Bernardini J, Piraino B. The risk of hernia with large exchange volumes. Adv

Perit Dial. 1998; 14:105-7.

6. O’Connor JP, Rigby RJ, Hardie IR. Abdominal hernias complicating continuous

ambulatory peritoneal dialysis. Am J Nephrol. 1986; 6(4):271-4.

+References

7. Sodo M, Bracale, U, Argentino G, Merola G, Russo R, Sannino, G, Strazzullo T, Russo D. Simultaneous abdominal wall defect repair and Tenckhoff catheter placement in candidates for peritoneal dialysis. J Nephrol. 2015; Nov 13, epub

8. Guzman-Valdivia G, Zaga I. Abdominal wall hernia repair in patients with chronic renal failure and a dialysis catheter. Hernia 2001; 5:9-11.

9. Imvrios G, Tsakiris D, Gakis D, Takoudas D, Koukoudis P, Papadimitriou M et a. Prosthetic mesh repair of multiple recurrent and large abdominal hernias in continuous ambulatory peritoneal dialysis patients. Perit Dial Int. 1994; 14:338-43.

10. Gianetta E, Civalleri D, Serventi A, Floris F, Marianai F, Aloisi F et al. Anterior tension-free repair under local anaesthesia of abdominal wall hernias in continuous ambulatory peritoneal dialysis patients. Hernia. 2004; 8:354-7.

11. Garcia-Urena MA, Remon Rodriguez C, Vega Ruiz V, Carnero Hernandez FJ, Fernandez-Ruiz E, Vazquez Gallego JM, et al. Prevalence and management of hernias in peritoneal dialysis patients. Perit Dial Int. 2006; 26:198-202

12. Afthentopoulos IE, Panduranga RS, Mathews R, Oreopoulos DG. Hernia development in CAPD patient and the effect of 2.5 L dialysate volume in selected patients. Clin Nephrol. 1998; 9:307-8

+References

13. Lupo A, Tarchini R, Gegoloni GP, Gentile MG, Cancarini G, Gellin G et al. Abdominal hernia in CAPD patients: incidence, risk factors and outcome. Adv Perit Dial. 1988; 4:107-9

14. Suh H, Wadhwa NK, Cabralda T, Sokunbi D, Pinard B. Abdominal wall hernias in ESRD patients receiving peritoneal dialysis. Adv Perit Dial. 1994; 10:85-5.

15. Cherney DZI, Siccion Z, Chu M, Bargman JM, Natural history and outcome of incarcerated abdominal hernias in peritoneal dialysis patients. Adv Perit Dial. 2004; 20:86-9.

16. Del Paso G, Bajo MA, Costero O, Hevia C, Gil F, Diaz C et al. Risk factors for abdominal wall complications in peritoneal dialysis patient. Peri Dial Int. 2003; 23:249-54.

17. Crabtree JH. Hernia repair without delay in initiating or continuing peritoneal dialysis. Peri Dial Int. 2006; 26:178-182.

18. Shah H, Chu M, Bargman J. Perioperative management of peritoneal dialysis patients undergoing hernia surgery without the use of interim hemodialysis. Peri Dial Int. 2006; 26:684-7.