02/27/2018. About half million people in the US with ESRD. HD is currently more prevalent than PD

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1 Anil S. Paramesh, MD, FACS Professor of Surgery, Urology and Pediatrics Tulane University School of Medicine Transplant Advisor, ESRD Network 13 First described in the 1920s Chronic PD initiated in 1960s Stalwarts of PD Tenckhoff Moncrief/Popovich Toronto & Missouri groups By the end of 2010, >120,000 pts on PD worldwide 1

2 About half million people in the US with ESRD HD is currently more prevalent than PD Studies have shown short term benefit with PD, likely due to preservation of kidney function, and ability to do home dialysis Cheaper than HD Patient/family personal responsibilities Better transplant candidates? 2

3 Overall catheter survival is about 88%/yr (regardless of type) Previous large randomized prospective trials have really failed to show difference in survival or complication rates based on catheter type Gokal R, et al. PDI 1998;18:11 Strippoli GF, et al. J Am Soc Nephrol 2004; 15: 2735 Johnson DW, et al. Am J Kid Dis 2006; 48: meta analysis that showed straight catheters had high function rate at 2 yrs vs coiled tip (79% vs 55%) Double cuffed caths have longer survival and less peritonitis episodes Some evidence that weighted tip catheters may function better Hagen SM Kidn Int 2014; 85:920 Flanigan M. Perit Dial Int 2005; 25:132 Sanchez Canel, Perit Dial Int 2016; 36;52 3

4 Percutaneous technique Flouroscopy (interventional radiology) Surgery Open Laparoscopic Offers complete sinus tract healing to reduce peritonitis episodes Conflicting studies regarding actual decrease in peritonitis rates Prolonged burial has higher rates of primary non function (up to 10%) Brown PA, Nephrol Dial Transpl 2008;23:2299 4

5 Implantation method Author Catheters (n) Prior surgery Leak (%) Flow dysfunction Percutaneous guidewire Ozener et al. (2001) Moon et al. (2008) Open surgery Y TEC laparoscopy Surgical laparoscopy Rosenthal et al. (2008) Gadallah et al. (1999) Ozener et al. (2001) Soontrapornchai et al. (2005) Tiong et al. (2006) Chen et al. (2007) Gadallah et al. (1999) Soontrapornchai et al. (2005) Maio et al. (2008) Keshvari et al. (2009) Crabtree et al. (2009) Ability to visualize placement Ability to perform lysis of adhesions Ability to diagnose small hernias Ability to perform omentopexy Ability to revise catheters Shown to be cost effective Allows Quick Start Crabtree JH, et al. Adv Per Dial 2001; 17: 88 Gajjar A, et al. Am J Surg 2007; 194: 872 Attaluri V, et al. J Am Coll Surg 2010; 211: 699 Success in Establishing Peritoneal Dialysis Access in the Hostile Abdomen Using Laparoscopic Techniques W. Devin Seale, Anil S. Paramesh, MD, FACS Dept. of Surgery, Tulane University School of Medicine Introduction Peritoneal dialysis access may be difficult to establish in patients with previous abdominal surgeries. There is paucity of data regarding successful PD access rates among these patients. Laparoscopic placement of catheters (LPD) may provide better success rates with this modality of dialysis. The aim of this study is to review success rates of PD catheter placement among patients that have had previous major abdominal surgery Patients and Methods All patients who received LPD at our center during the period of September September 2012 were included in this study. From hospital medical records patient information as to gender, age, BMI and previous major abdominal surgery was obtained. Review of operative reports allowed for assessment of performance of additional procedures during LPD such as omentopexy, adhesiolysis, and hernia repair. Complications, revisional procedures, and failure rates of PD during this 3 year period was analyzed. Results A total of 60 patients undergoing 87 operations were included in this study. 26 patients had previous major abdominal surgery. A total of 51 additional procedures were performed at the time of LPD surgery. 27 revision surgeries were performed on 19 patients in the follow up period. 10(16.7%) patients had peritoneal dialysis failure at a mean of 8.7(1-24) months. Overall one year catheter survival rate was 89.6%. One year catheter survival rates were 92% for patients with previous abdominal surgery vs. 88.6% without (p = NS). During the three years covered by this research, 3 patients have received transplants and are no longer on PD. Results Patient Demographics Mean age (years) 49.2 (22-83) Male/Female 30/30 Mean BMI 29.5 (16-53) Prior abdominal surgery 26 Additional Procedures on Initial Placement Adhesiolysis 15 (25%) Omentopexy 32 (53.3%) Hernia Repair 4 (6.7%) Reason for Revision Infection 2 (7.4%) Malpositioning 12 (44.4%) Mechanical Obstruction 13 (48.1%) Causes of PD Failure Peritoneal Failure 2 (20%) Infection 7 (70%) Intractable Pleural Effusion 1 (10%) Conclusions Laparoscopic techniques allow for successful placement and maintenance of peritoneal dialysis catheters in a patient with prior abdominal surgery. With the opportunity for lysis of adhesions, the possibility of omentopexy, and the ability to place the catheter low in the pelvis, the laparoscopic approach to catheter placement offers many safeguards to prevent catheter failure. 5

6 Previous abdominal surgery Decision if PD feasible or not 6

7 Policeman of the abdomen Tacking to upper abdominal wall prevents it from reaching pelvis 7

8 Not commonly performed For patients with recurrent malpositioning Caution on the bowstring effect! 8

9 Look for pre existing hernias if present likely will worsen once PD started! Hernias can be fixed (may need mesh) Consider switching to temporary HD while hernia heals 9

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13 Not that uncommon Usually from retrograde menstruation Significant blood may require imaging and/or surgical eval Paramesh AS. JLSMS 2016;168:141 13

14 Men vs. women What side they sleep on Morbidly obese Colostomies Small children 14

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17 CAPD more physiologic In supine position, catheter can float CAPD empties by gravity, cycler empties by active suction Patients on PD tend to do better immediately post transplant In cases of DGF, may need to temporarily do HD Typically, PD cath removed 6 8 weeks post transplant, but often removed earlier 17