© Springer International Publishing AG 2017
Stephen Haggerty (ed.)Surgical Aspects of Peritoneal Dialysis10.1007/978-3-319-52821-2_1212. Diagnosis and Management of Catheter Dysfunction
(1)
University of Akdeniz, Faculty of Medicine, General Surgery Department, Antalya, Turkey
Introduction
Catheter malfunction, defined as mechanical failure in dialysate inflow or outflow, is not uncommon in peritoneal dialysis(PD) patient. Outflow failure occurs in 4–34.5% of PD patients [1]. Ever since the first permanent silicone catheter was introduced in 1968, a wide variety of catheters and placement techniques have been developed to attempt to eliminate catheter malfunction. However, catheter-related problems are not fully resolved [2–6].
Catheter Flow Obstruction
The most common causes of catheter malfunction are omental wrapping and catheter tip migration. Catheter obstruction due to fibrin or blood clots within the catheter lumen, kinking of the catheter, small bowel wrapping, occlusion by fimbriae and intraperitoneal adhesions are other occlusive catheter problems in CAPD patients [7–9]. Prevention of these problems during the primary insertion has been a primary goal of surgeons who insert PD catheters. Our insertion technique, which is long tunelling and routine omentopexy, is significantly effective in preventing catheter-related problems, such as omental wrapping, catheter tip migration, pericatheter leakage and drain pain [10]. Since the laparoscopic technique was introduced and used for the placement of catheters and also salvage procedures for malfunctioning CAPD catheters in the early nineties of the last century, it has proven to be superior to the open surgical technique in many medical centers [11–14]. The advantages of laparoscopy over every other techniques are the adjunctive procedures enabled by this method, principally rectus sheath tunelling, omentopexy, adhesiolysis, epiploectomy, salpigectomy, and colopexy. When these techniques are applied effectively, the laparoscopic approach can both prevent and resolve most of the common mechanical problems that complicate insertion of PD catheters [15]. Omentopexy is employed selectively since it may be unnecessary when the omentum is short or adherent to previous upper abdominal surgical site. An additional argument supporting preservation of the omentum by using omentopexy as opposed to its resection is that omental milky spots (clusters of leukocytes) appear to have a role in the peritoneal cavity immune response, especially in the pediatric age population [15].
Diagnosis and Management
In many cases, the diagnosis of outflow failure may be difficult because of a lack of noninvasive methods. Change in body position, rapid saline infusion, cathartics, enemas, the classic use of fibrinolytics, and fluoroscopic manipulation are conservative measures often used in attempting to restore drainage in patients with poorly functioning catheters. However, laparoscopy is highly accurate in its diagnosis of CAPD complications caused by obstruction and is also therapeutic. Due to the need for continuous renal replacement therapy, the rescue procedures should not be delayed beyond a few days after noticing the alfunction if concervative treatments are ineffective.
Ideally, salvage surgery should be safe, with a high success rate, ease of performance, ability to prevent recurrence, and short recovery time. Open rescue surgery can lead to new adhesion formation and, therefore, restrictions in fluid distribution in the peritoneal cavity, as well as the development of incision-related complications and the additional stress of surgery for patients. In contrast, laparoscopic rescue procedures have many advantages: they leave smaller wounds with less tissue disturbance; they allow direct examination of the catheter and whole peritoneal cavity through the scope, allowing accurate identification of the cause of catheter malfunction as well as immediate intervention to restore its function; they enable diagnosis of other intra-abdominal pathology and treatment of other surgical problems such as symptomatic cholecystolithiasis and abdominal wall/inguinal hernia in the same operation; they avoid the need to replace the catheter; they enable immediate testing for overall peritoneal catheter function; they leave the patient with diminished postoperative pain, a shorter stay in hospital, and a quicker recovery of social and professional activities; they facilitate early resumption of PD and beter functional survival; and the operation recordings can be used to share our knowledge and experience with nephrologists, our assistants, and our students. There are also a few disadvantages: the need for general anesthesia in most patients; requirement of an operating theater; the cost of equipment and instrumentation; the long duration of the operative procedure and the adverse physiologic effects of CO2 pneumoperitoneum [11]. Cosmetic problems related to port site incisions which can be eliminated with using the single port laparoscopc surgical technique by expert surgeons [1].
Technique of Laparoscopic Catheter Salvage
In our instiution, laparoscopic rescue procedures were performed under general anesthesia. The peritoneal cavity was emptied before surgery. Prophylactic antibiotic therapy (cefazolin sodium 1 g) was administired before surgery. A nasogastric tube was inserted. A 1-cm long slightly lateral subumbilical incision was made through the subcutaneous tissue, and the anterior rectus sheath. The rectus muscle fibers were then dissected bluntly down to the posterior rectus sheath. A 10-mm trocar was inserted on the opposite side of the previous catheter placement location. A pneumoperitoneum was established via this trocar, inflating to a pressure of 12 mmHg. If the patient was mobidly obese pneumoperitoneum was established through the existing PD catheter. If the catheter was completely obstructed pneumoperitoneum was established usind the Veress needle in left upper quadrant on subcostal site in morbidly obese patients with slightly reverse Trendelenburg and slightly right side position. Two 5-mm working ports were used. Once the diagnosis of catheter dysfunction was made, corrective measures were undertaken.
Omental Wrapping
Peritoneal dialysis catheter obstruction is frequently caused by omentum blocking the side holes of the catheter tubing. Omental wrapping usually develops early after catheter placement. The incidence of omental wrapping of CAPD catheters has been reported from 4.5% to 15% [16]. Clinically, the inflow of dialysate decreases slightly, and drainage is obviously blocked. Wrapping may be a result of a bulky omentum [17]. Using laparoscopic salvage, the incidence of outflow failure by omental wrapping ranged between 57% and 92% in some series [18]. Advantages of laparoscopic surgery include direct visualization of the state of obstruction and ability to lyse adhesions, and perform omental fixation after the stripping if necessary [11].
When omental wrapping is diagnosed at laparoscopy, usually only stripping is performed. This procedure can be easly done without the need for complicated laparoscopic instruments or advanced laparoscopic surgical experience. Reported series show that this simple laparoscopic stripping of the omentum from the catheter usually resolves a catheter obstruction due to omental wrapping with a high rate of success [19–21]. Some authors advocate omental fixation after the stripping procedure to prevent further omental wrapping [11, 22]. Laparoscopic partial omental resection has also been performed for recurrent catheter dysfunction due to omental wrapping [23, 24]. In our observation, the omentum was more likley to cause catheter obstruction in emaciated patients which can be related to the omentum being very thin in these individuals in contrast in obese patients. The omentum must be preserved in PD salvage procedures. The omentum possesses an inherent motility that allows it to seek out and arrest trouble that may arise within the peritoneal cavity. It has been referred to as the “police officer of the abdomen”. The potent lympatic system of the omentum can absorb enormous amounts of edema fluids and remove metabolic wastes and toxic substances. The omentum is also widely used for the treatment of some pathologies in full surgical fields if necessary [25]. To completely overcome this problem related to omental wrapping prophylactic laparoscopic omental fixation is routinely performed during CAPD catheter placement in our series [10].
Catheter Tip Migration
Catheter tip migration still accounts for a substantial number of catheter failures in blind, open and laparoscopically placed CAPD catheters [3, 17]. Mechanical obstruction usually results from either misplacement during the initial insertion or catheter migration out of the pelvis. A coiled intra-abdominal segment is generally belived to reduce catheter tip migration; however, the results of previous prospective randomized studies comparing straight and coiled catheters have been controversial [26]. Catheter tip migration is easily determined with abdominal x ray. Various noninvasive management techniques, including changing body position, enemas, and saline flushing, increase physical activity as much as possible have been described; however, the success rate is only about 25%. If such noninvasive techniques fail, before surgical revision, fluoroscopically guided manipulations using a rigid canulla, stiff metal rod, tip-deflecting wire, Lunderquist guidewire or double guidewire method may be used to reposition the catheter [7]. Different success rates of fluoroscopy-guided wire manipulation have been reported, ranging from 27% to 67% [27]. Advantages of fluoroscopy-guided wire manipulation are that it is relatively easy and safe, simple, does not require anesthesia, can be performed in radiology suite, can be attempted repeatedly, and has a relatively lower cost compared to laparoscopic surgery. Disadvantages of fluoroscopy-guided wire manipulation include a lower success rate and inapplicability of difficulty with certain special catheter design [27].
The rate of catheter misplacement has been dramatically reduced because in recent years it has been possible to place catheters more accurately under direct vision with laparoscopic insertion [10]. Surgical revision is mandatory in the treatment of peritoneal catheter malfunction due to catheter tip migration when conventional methods fail. Open repositioning of the catheter is not only more invasive, but may result in the creation of adhesions. In addition, open catheter revision inhibits immediate use of the catheter because the abdominal incision must first heal. A secondary means of dialysis is required, that is, hemodialysis (HD) which involves further cost, inconvenience, and the risks associated with HD catheters.
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