Adequate and permanent access to the peritoneal

Peritoneal Dialysis International, Vol. 23, pp. 242 248 Printed in Canada. All rights reserved. 0896-8608/03 $3.00 +.00 Copyright 2003 International Society for Peritoneal Dialysis EXPERIENCE USING PRESTERNAL CATHETER FOR PERITONEAL DIALYSIS IN POLAND: AMULTICENTER PEDIATRIC SURVEY Stanislaw Warchol, 1 Maria Roszkowska Blaim, 2 Joanna Latoszynska, 3 Tomasz Jarmolinski, 4 and Jacek Zachwieja 5 Department of Cardiac Surgery and General Pediatric Surgery, 1 Department of Pediatrics and Nephrology, 2 Medical University of Warsaw; Department of Nephrology and Kidney Transplantation, 3 Children s Memorial Health Institute, Warsaw; Department of Nephrology and Dialysis, 4 District Children s Hospital, Szczecin; Department of Pediatric Nephrology, 5 Karol Marcinkowski University of Medical Sciences, Poznan, Poland Correspondence to: S. Warchol, 24 Marszalkowska St., 00 576 Warsaw, Poland. swarchol@poczta.onet.pl Received 12 August 2002; accepted 18 November 2002. 242 Objectives: Permanent and adequate access to the peritoneal cavity is the key to successful chronic peritoneal dialysis (PD). A variety of catheter designs and implantation techniques have been developed to achieve optimal peritoneal access. One such new and modified PD catheter is the presternal catheter [swan neck presternal catheter (SNPC)], with the exit site located on the chest wall. Design: A multicenter survey was undertaken to summarize 10 years of experience with the presternal catheter in children in Poland. Setting: Four pediatric institutions using the SNPC in children: (1) Medical University of Warsaw, Warsaw; (2) Children s Memorial Health Institute, Warsaw; (3) District Children s Hospital, Szczecin; (4) University of Medical Sciences, Poznan. Patients: During the past 10 years, 20 presternal catheters were implanted in 19 children, aged 0.2 17.7 years (mean 8 ± 5.8 years), with end-stage renal failure. The main indications for the SNPC include urinary diversion (ureterocutaneostomy or vesicostomy), use of diapers, young age, obesity, abdominal wall weakness, and recurrent exitsite infections (ESI) with previous abdominal PD catheters. Intervention: In all children the presternal catheter was implanted surgically under general anesthesia by one surgeon. Uniform operative technique and uniform perioperative management were used. Results: The mean observation time for the 20 presternal catheters was 24.8 ± 25 months (range 1 83 months). The ESI rate was 1/70.9 patient-months (0.17 episodes per year), tunnel infection rate was 1/248 patient-months (0.05 episodes per year), and the overall peritonitis rate was 1/26.6 patient-months (0.51 episodes per year). Noninfectious complications associated with the SNPC included disconnection of both sections (2 children) and trauma to the exit site located on the chest wall (4 children). Mean survival time of the presternal catheter, as calculated by the Kaplan Meier method, was 57.5 ± 8.5 months; 50% catheter survival reached 72 months. Conclusions: The good outcome in patients with a SNPC validates the rationale for the presternal catheter design and should encourage its more widespread use. The SNPC seems to be suitable for any patient on PD; however, this catheter is particularly useful in patients with specific indications (i.e., higher tendency to ESI). The SNPC allows safe and long-term chronic PD in very young children using diapers and in patients with urinary diversion. Perit Dial Int 2003; 23:242 248 www.pdiconnect.com KEY WORDS: Presternal catheter; peritoneal dialysis catheter; exit-site infection; peritonitis; children. Adequate and permanent access to the peritoneal cavity allows for successful performance of chronic peritoneal dialysis (PD) (1 4). During the recent decade, new types of PD catheters have been designed (5 8) and a variety of implantation techniques have been developed (1 4,9 12) to improve catheter survival and to reduce the incidence of catheter-related complications. One of these new PD catheters is the presternal catheter [swan neck presternal catheter (SNPC)], with the exit site located on the chest wall, and which was introduced into clinical practice in 1991 (13,14). The aim of the present study was to summarize our experience with the SNPC in children in Poland. To achieve this goal a multicenter survey was undertaken. MATERIAL AND METHODS From December 1991 to June 2002, 20 SNPCs (previously produced by Accurate Surgical Instruments,

PDI MAY 2003 VOL. 23, NO. 3 PRESTERNAL CATHETER FOR PD IN CHILDREN Indication TABLE 1 Indications for Insertion of the Swan Neck Presternal Catheter Patients (n) Urinary diversion Ureterocutaneostomy 6 Vesicostomy 2 Use of diapers 7 Young age 6 Recurrent ESI with previous Tenckhoff catheter 6 Obesity 4 Abdominal wall weakness 3 Fecal incontinence 1 ESI = exit-site infection. Toronto, Ontario, Canada, and recently by Sherwood Medical Company, St. Louis, Missouri, USA and EC Rep Sherwood Davis & Geck, Gosport, UK) were implanted in 19 children, aged 0.2 17.7 years (mean 8 ± 5.8 years), with end-stage renal failure (ESRF). Eight children were under 5 years of age, including 3 under 1 year, 3 between 1 and 3 years, and 2 between 3 and 5 years. Thirteen patients were treated at the Medical University of Warsaw, 4 at the Children s Memorial Health Institute in Warsaw, 1 at District Children s Hospital in Szczecin, and 1 at the University of Medical Sciences in Poznan. Their original renal diseases were as follows: congenital urinary tract anomalies in 13 children (obstructive uropathy in 10, reflux nephropathy in 1, renal dysplasia in 1, and polycystic kidney disease in 1), amyloidosis during the course of juvenile rheumatoid arthritis in 3, interstitial nephritis in 1, focal segmental glomerulosclerosis in 1, and antenatal irreversible renal ischemia in 1. Before insertion of the SNPC, 6 children had not been dialyzed; the other 13 experienced previous renal replacement therapy (hemodialysis and/or chronic PD), lasting from 1 to 38 months (mean 13 ± 12.3 months). The criteria for using the presternal catheter are listed in Table 1. More than one indication was present in some patients. In 12 of the 19 children, the SNPC was the first PD catheter used. In one girl with amyloidosis and recovery of renal function after her first course of PD, a second SNPC was inserted after a 2-year period without dialysis. In all children, the SNPC was composed of presternal and abdominal sections joined by a titanium connector, and was implanted surgically under general anesthesia by one surgeon using uniform operative technique. There was also uniform perioperative management. Twelve coiled and seven Missouri coiled catheters were used as the abdominal section of the SNPC. The choice depended on the size of the abdominal tube. Generally, the coiled catheter was used in younger and smaller patients, whereas the Missouri coiled catheter was used in older children, especially those with abdominal stomas. In one child, transfer to the SNPC was performed, which consisted of insertion of the presternal tube and its connection with the preserved intraperitoneal section of the previous Tenckhoff catheter. Our operative technique in children [a modification of the technique described by Twardowski et al. for adults (13)] was reported earlier (14,15). Table 2 presents details of the presternal catheter implantation technique, and Figure 1 is a schematic drawing of the operative procedure. Perioperative antibiotic prophylaxis (three consecutive doses of second-generation cephalosporin given intravenously) was used in all cases and PD was started routinely 2 weeks after catheter implantation. In a majority of children, the Y-type system was used. The Kaplan Meier method was used to calculate survival rates of the SNPCs. TABLE 2 Presternal Catheter Implantation Technique Peritoneal cavity is opened through midline incision Subtotal omentectomy is performed Coiled abdominal catheter with one peritoneal cuff is inserted through a small opening in the left rectus muscle Alternative Transverse skin incision is made over the rectus muscle Missouri coiled abdominal catheter with bead, flange, and cuff is inserted through the rectus muscle Peritoneal cuff is fixed A small transverse incision is made in the epigastrium Using a trocar the same size as the catheter tubing, a subcutaneous tunnel is created between two abdominal incisions The external section of the abdominal catheter is placed in the subcutaneous tunnel (with extra tube length) A vertical incision is made above the upper part of the sternum, creating two subcutaneous pockets, one on each side, to accommodate the bent section of the presternal tube with two cuffs Using a trocar, a long subcutaneous presternal tunnel is created with the exit site located on the left side of the chest wall (at the level of the second or third rib) The presternal tube is placed in the tunnel (with extra tube length) The presternal and abdominal tubes are connected, with a titanium connector, in the epigastrium (two additional nonabsorbable ligatures are applied to the connection) Catheter function is checked before final wound closure 243

WARCHOL et al. MAY 2003 VOL. 23, NO. 3 PDI Figure 1 Diagram of the swan neck presternal catheter implantation technique. Left figure: coiled type peritoneal catheter as the abdominal section. Right figure: Missouri coiled peritoneal catheter as the abdominal section. 1 = coiled intraperitoneal section of the abdominal tube; 2 = peritoneal cuff; 3 = titanium connector; 4 = presternal tube; 5 = subcutaneous cuffs; 6 = Missouri coiled intraperitoneal section of the abdominal tube; 7 = peritoneal cuff with bead and flange; arrow = exit site on the chest wall. RESULTS The total observation time for the 20 SNPCs was 496 patient-months (range 1 83 months, mean 24.8 ± 25 months). As the present study is a 10-year follow-up of our experience with the SNPC, many of the cases presented in this paper were reported in a 5-year review published in 1998 (15). Nine new patients were included in the present study and 3 other previously described patients had considerably longer observation periods. The observed complications are presented in Table 3. New data regarding complications compared with the 1998 report (15) include 6 episodes of exitsite infection (ESI), 1 of tunnel infection (TI), and 1 new trauma. Seven episodes of ESI were noted in 5 children. The mean time to occurrence of the first episode was 37.2 ± 24.8 months (range 6 64 months). Staphylococcus aureus and methicillin-resistant Staphylococcus epidermidis were cultured. Five episodes of ESI were successfully treated conservatively with antibiotics; in one case, it was necessary to remove the distal subcutaneous cuff. In the same child, TI due to Candida albicans along the bent section of the presternal tube appeared after 9 months. Operative treatment in this case consisted of a two-stage procedure: removal of only the presternal section, with preservation of the abdominal section and, after 6 weeks, insertion of a new presternal tube and connection with the embedded abdominal section. One episode of ESI was followed immediately by TI near the exit site on the chest wall, and the decision to remove the SNPC was undertaken (this child was treated in one of the contributing centers). In a subgroup of 6 children in whom recurrent ESI with a standard Tenckhoff catheter was the predominant indication for the SNPC, the ESI rate with the Tenckhoff catheter was 2.7 episodes per year, whereas, with the presternal catheter, there were only 0.3 episodes per year (signed rank test p < 0.05; W = 2.15). In 11 children with the SNPC, 21 episodes of bacterial peritonitis were observed. The time to the occurrence of the first episode ranged from 2 to 80 months (mean 25.2 ± 29.2 months). Thirteen episodes occurred in 5 children on continuous ambulatory peritoneal dialysis (CAPD) and 8 in 6 children on automated peritoneal dialysis (APD). In four cases it was necessary to remove the presternal catheter because of recurrent peritonitis due to S. epidermidis. Noninfectious complications associated with the presternal catheter included disconnection of both sections and trauma to the exit site located on the chest wall. Disconnection was observed in 2 children: in the first case after 7 months of catheter use (the SNPC was removed because of concomitant peritonitis) and, in the second case, after 33 months (a new abdominal section was implanted and joined with the presternal section). Trauma to the exit site was noted 244 TABLE 3 Complications of the Swan Neck Presternal Catheter Episodes/patients Rate Rate Complication (n/n) (per patient-months) (episodes per year) Exit-site infection 7/5 1/70.9 0.17 Tunnel infection 2/2 1/248 0.05 Peritonitis (CAPD+APD) 21/11 1/26.6 0.51 Peritonitis (APD) 8/6 1/41 0.29 Disconnection 2/2 1/248 0.05 Exit-site trauma 5/4 1/99.2 0.12 CAPD = continuous ambulatory peritoneal dialysis; APD = automated peritoneal dialysis.

PDI MAY 2003 VOL. 23, NO. 3 PRESTERNAL CATHETER FOR PD IN CHILDREN in 4 children. The mechanism of trauma, consequences, and treatment modalities are presented in Table 4. Most of the observed complications (2 episodes of ESI, TI, disconnection, and 2 episodes of trauma) occurred in the patient with one of the longest observation periods, which reached 6 years (16). Follow-up was ended under the following circumstances: renal transplantation (3 patients), patient s death (1), removal of the catheter because of complications (5), and elective removal of the SNPC because of recovery of renal function (1) or transfer to hemodialysis (2). Seven SNPCs are still in use and have been in place for 83, 77, 26, 26, 25, 16, and 8 months, respectively. The mean survival time for the presternal catheter, as calculated by the Kaplan Meier method, was 57.5 ± 8.5 months; 50% catheter survival reached 72 months. DISCUSSION The rationale for placing the PD catheter exit site on the chest wall was described in the first papers on the subject (13,14,17,18). The classic indications for the use of the presternal catheter in adults include obesity, abdominal stomas, and previous problems with abdominal PD catheters (13,17,19). An increasing number of adult patients also choose this type of catheter for other reasons, such as the desire to use a bathtub or whirlpool (17,19,20); some patients prefer the exit location on the chest wall for psychological or body image reasons (17,19). In children, additional reported criteria for the use of the SNPC include young age, the use of diapers, and the presence of ureterocutaneostomies (14,15,18). We can add two new indications: abdominal wall weakness and vesicostomy, found in 3 and 2 of our patients respectively. An exit site located on the chest wall also allowed for the performance of PD in newborns with renal aplasia/dysplasia associated with intestinal and cloacal malformations and colostomy, as described recently by the Kansas City Group (21), and in children with ESRF and fecal incontinence after repair of anal atresia (15). It was our choice to reserve the SNPC for patients with specific indications; however, our experience shows there are no special difficulties associated with this type of catheter that would preclude its more widespread use. No problems with patient discomfort or body image were observed in our patients and the presternal catheter was well accepted by patients and families. Also, Twardowski et al. stated that adult patients acceptance is excellent and no specific contraindications to using the SNPC have been identified (17,19). In our opinion, the only limitations for more common use of SNPCs are availability of such catheters and, eventually, the costs compared with the standard Tenckhoff catheter. A group from Kansas City (21) proposed for use in newborns an alternative to the multipiece presternal catheter, a conventional swan neck catheter (of a size larger than typically required), with its exit site located on the chest wall to avoid potential technical problems in such small patients. We found no difficulties in implanting the SNPC, even in the youngest and smallest children the youngest of our patients was 2 months old at the time of catheter insertion and had a body weight of 3.2 kg; 42% of our patients were less than 5 years of age (8 of 19 children). Decreased frequency of ESI has been described as the most important advantage of the presternal catheter (14,15,17,19). The ESI rate in our 19 children with the SNPC was 0.17 episodes per year and compares favorably with the published ESI rates in children on chronic PD with standard peritoneal catheters, which has reached 0.35 0.77 episodes per year (22 25). During the same observation period, the ESI rate in children with standard Tenckhoff catheters treated at our institution reached 0.7 episodes per year (26). It is also worth noting that the first episode of ESI was observed after relatively long-term use of the SNPC: in 2 patients after almost 2 and 3 years respectively, and in the other 2 after 5 years of use. In these cases, the occurrence of ESI was attributed mainly to the fatigue of the patient/family due to long-lasting disease and dialysis treatment. Furthermore, we found a statistically significant decrease in TABLE 4 Exit-Site Trauma in Children with the Swan Neck Presternal Catheter Trauma mechanism Trauma consequences Treatment modality Jerk of catheter Extrusion of the distal subcutaneous cuff Removal of the distal cuff Use of school rucksack Skin damage above the bent section of Replacement of the bent section of the presternal tube the presternal tube Direct trauma Posttraumatic hematoma/abscess Replacement of the bent section of the presternal tube Posttraumatic hematoma/abscess Removal of the distal cuff Partial tear of the exit site Conservative management 245

WARCHOL et al. MAY 2003 VOL. 23, NO. 3 PDI the incidence of ESI before and after SNPC insertion in our patients in whom recurrent ESI with a standard Tenckhoff catheter was the predominant indication for chest localization of the exit site. In 1998, our reported incidence of ESI was as low as 0.07 episodes per year (15) in patients using SNPCs. The factors potentially contributing to the change in the ESI rate to 0.17 episodes per year in the current report include a larger number of patients, longer observation periods, and longer duration of PD, as well as observed caregiver burnout. A few patients with recurrent ESI accounted for the increased ESI rate. There was no institutional variation accounting for the ESI rate. Only one SNPC was removed because of ESI (followed by TI); this was in a child with a history of multiple ESIs with previous Tenckhoff catheters. This patient was treated in one of the contributing centers and probably the decision to remove the catheter was made too early. In another patient, a TI along the bent section of the presternal tube was treated successfully using a two-stage operative procedure (16). In this case, to salvage the catheter we used the idea of initial subcutaneous embedding of the PD catheter with delayed externalization, as proposed by Moncrief and Popovich (5). The Moncrief technique was employed recently by Japanese authors for implantation of the presternal catheter in adults to achieve better results in reducing catheter-related complications (20). Recently reported peritonitis rates in children vary from 0.66 to 0.92 episodes per year (23 25,27,28), and the only lower incidence (0.40 episodes per year) was reported in Japan (29). Peritonitis occurred at the rate of 0.51 episodes per year in our patients with the SNPC; however, two-thirds of the episodes were observed during the first 3 years of the study period (all in children on CAPD). Recently, all children with the SNPC have been placed on APD; in this subgroup, only a few episodes of peritonitis have been noted and the peritonitis rate is lower (0.29 episodes per year). The incidence of peritonitis in our children with conventional PD catheters was 0.59 episodes per year (26). Similarly to the late occurrence of the first ESI, the first and single peritonitis episode in 4 children with the SNPC was noted after 2.7, 4.6, 5.8, and 6.7 years, respectively. In adults with the SNPC, the reported peritonitis rate was 1 episode per 37.4 patient-months (19). Four presternal catheters had to be removed because of recurrent peritonitis, but in one case, peritonitis was associated with disconnection of both sections of the SNPC, and in a second case, dialysate leakage around the peritoneal cuff was found to be the cause of persistent infection. 246 Since our last report in 1998 (15), we have not observed any new episodes of disconnection, a potential complication that can be attributed strictly to the presternal catheter design and that would appear to be a pediatric-specific complication. To avoid such a possibility, at the time of implantation in each child, an extra length of both sections of the SNPC is left within the subcutaneous tunnel ( S shape), and the connection site within the titanium connector is reinforced with nonabsorbable suture ligatures. In an adult population, such a complication was neither expected nor observed (13,19,30). In one of our patients, both sections of the SNPC became disconnected almost 3 years after its use, due probably to rapid growth during human growth hormone therapy. Based on our observations, we stated that, in children, the problem of disconnection exists (15); however, we feel now that strict monitoring of growing children with an SNPC, especially those treated with growth hormone, can help to resolve this potential problem at the appropriate moment by operative intervention, that is, insertion of an extra section of tube between the two sections of the SNPC to elongate the catheter, or replacement of the abdominal section with a longer one. Such monitoring should include both estimation of the catheter s shape within the tunnel by physical examination (any straightening of the tube) as well as checking by x ray the position of the abdominal section (any elevation of the tube). None of our patients have had their tube electively lengthened so far; however, one of them is now under observation regarding the necessity to perform this procedure. Avoidance of trauma to the exit site located on the chest wall was thought to be an advantage of the presternal catheter design (13,14,18), and this is true for adults (17,19). In children, trauma was found to be the most common noninfectious complication. However, we have observed only one new case since our last report (15). In those children that underwent trauma with the main mechanism being jerk of the catheter or a direct blow to the chest wall, we have observed that the occurrence of trauma was strictly related to patient/family compliance and behavioral environments. More attention is now being devoted to this problem during the patient/family teaching program. One of the specific indications for the use of the SNPC is the presence of abdominal stomas, such as ureterocutaneostomy, which represent a threatening source of contamination. The use of the presternal catheter enabled long-term PD in 8 of our boys with obstructive uropathy, including 5 as young as 0.2, 0.8, 2.2, 4, and 4.3 years old at the time of catheter implantation. No infectious complications were noted in this group. Similar good results in infants with colos-

PDI MAY 2003 VOL. 23, NO. 3 PRESTERNAL CATHETER FOR PD IN CHILDREN tomy and chest wall PD catheter have also been published (21). The favorable changes since our last report (15) include a growing number of patients (especially the youngest patients), a larger number of institutions using the SNPC, and improved catheter survival with a relatively low complication rate. A considerable increase in the ESI rate is one unfavorable complication, but in light of the fact that our SNPC group represents the biased high-risk population (i.e., those with higher risk of infectious complications), our results seem to be even more significant. Based on our 10-year experience with the SNPC in children, we can issue the following conclusions: (1) The good outcomes in patients with SNPCs validate the rationale for the presternal catheter design and should promote its more widespread use. (2) The SNPC seems to be suitable for any patient on PD; however, this type of catheter is particularly useful in patients with specific indications (i.e., higher tendency to ESI). (3) The SNPC allows safe and longterm chronic PD in very young children using diapers and in patients with urinary diversion. REFERENCES 1. Gokal R, Alexander S, Ash S, Chen TW, Danielson A, Holmes C, et al. Peritoneal catheters and exit-site practices toward optimum peritoneal access: 1998 update. International Society for Peritoneal Dialysis. Perit Dial Int 1998; 18:11 33. 2. Harvey EA. Peritoneal access in children. Perit Dial Int 2001; 21(Suppl 3):S218 22. 3. Lee HB, Park MS, Cha MK, Kim JH, Song KI, Moon C. The peritoneal access. Perit Dial Int 1996; 16(Suppl 1): S322 6. 4. Cruz C. Implantation techniques for peritoneal dialysis catheters. Perit Dial Int 1996; 16(Suppl 1):S319 21. 5. Moncrief JW, Popovich RP. Moncrief Popovich catheter: implantation technique and clinical results. 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WARCHOL et al. MAY 2003 VOL. 23, NO. 3 PDI 2):S479 83. 28. Furth SL, Donaldson LA, Sullivan EK, Watkins SL. Peritoneal dialysis catheter infections and peritonitis in children: a report of the North American Pediatric Renal Transplant Cooperative Study. Pediatr Nephrol 2000; 15:179 82. 29. Honda M. The 1997 report of the Japanese National Registry data on pediatric peritoneal dialysis patients. Perit Dial Int 1999; 19(Suppl 2):S473 8. 30. Twardowski ZJ, Nichols WK, Nolph KD, Khanna R. Swan neck presternal peritoneal dialysis catheter. Perit Dial Int 1993; 13(Suppl 2):S130 2. EUROPEAN MASTER IN BIOETHICS Several eminent European universities offer joint postgraduate training in bioethics to educate professionals in health care in a multidisciplinary approach to bioethics. The courses combine issues from daily health care praxis with the study of moral theories. The learning methods aim to stimulate participants to exchange and learn more about typical European approaches to ethical dilemmas in health care. The second edition of the European Master in Bioethics will begin in March 2002 in Nijmegen, The Netherlands. On successful completion, the program leads to a recognized European master s degree in bioethics. 16 courses will be offered in 4 residential periods during the 2-year training period: March 2002 September 2002 March 2003 September 2003 Nijmegen, The Netherlands (Professor Henk ten Have) Basel, Switzerland (Professor Stella Reiter Theil) Leuven, Belgium (Professor Paul Schotsmans) Padova, Italy (Dr. Renzo Pegoraro) The course fee of 15,000 Euro includes registration, all course materials, tuition, and full board and lodging for 4 months at the participating European universities. Each application should be accompanied by a curriculum vitae and a written motivation for choosing to apply for the program. For more information, please contact the coordinators: Katrien Ruytjens Centre for Biomedical Ethics and Law Faculty of Medicine University of Louvain Kapucijnenvoer 35 8-3000 Leuven, Belgium Tel: +32 16 33 69 51 Fax: +32 16 33 69 52 Katrien.ruytjens@med.kuleuvan.ac.be Inez Uerz Dept. of Ethics, Philosophy and History of Medicine Faculty of Medical Sciences University of Nijmegen PO Box 9101 6500 HB Nijmegen, The Netherlands Tel: +31 24 361 53 20 Fax: +31 24 354 02 54 i.uerz@efg.kun.nl www.masterbioethics.org 248