PD catheter implantation (double-cuff straight Tenckhoff catheter) 基隆長庚一般外科卓世川

PD catheter implantation (double-cuff straight Tenckhoff catheter) 基隆長庚一般外科卓世川

Successful assess of PD Various techniques for various designs of peritoneal catheters. Access of catheter placement is the key of receiving peritoneal dialysis. ( 植管才是接受腹膜透析的關鍵 ) A survey by Ash (overview 70 studies): success of peritoneal dialysis depended more on placement technique than on their catheter design. ( 而成功的腹膜透析依賴於植管的技術更勝於透析管的設計 )

Access of catheter placement Open or laparoscopic surgery?

Current methods for catheter placement 1) Beside insertion or percutaneous implantation: Risk of visceral injury (1.3% to 2.5%). 2) Surgical insertion or open dissection: Overall complication rates up to 56% have been reported. 3) Peritoneoscopic insertion: Y-TEC peritoneoscope with limited visualization, first introduced by Ash et al. 4) Laparoscopic insertion: Adhesiolysis or more sophisticated surgery is possible during catheter placement.

Laparoscopic catheter placement Broadcast use in many fields due to mini-invasion. Superior to open surgery in direct vision. Reduce catheter morbidities and increase catheter survival. Many reports: fewer failed-insertion rate (0-2.4%), lower short-term complication rate (0-9.5%), higher long-term catheter survival rate (63-85%). Advocated by Nijhuis, Crabtree, Lu, Giannattasio, Brandt et al. Controversial by Draganic, Wright, Daschner, Batey et al. Comparative studies lack consensus.

Our experience We satisfied with the results of open surgical catheter placement. To clarify the superiority of laparoscopic surgery in PD catheter placement. Design prospective randomized study to compare laparoscopic with open surgical catheter placement in patients requiring primary PD to treat ESRD.

Our paper J Surg Res 2010; 159: 489 496. {SCI}

Materials and Methods Prospective randomized study From 2002 to 2006, 77 patients First PD catheter Tolerate spinal/general anesthesia Willing to receive randomized trial Assigned to open (40) or laparoscopic (37) group randomly

Technique of catheter placement Open surgery

Technique of catheter placement Laparoscopic group

Data record (1) Patient s demographics: sex, age, body height, body weight, body mass index, causes of renal failure, underlying medical diseases, disease severity of APACHE II, history of previous abdominal surgery. (2) Operation-related data: operative type, operative time, postoperative pain, usage of analgesic, cosmetic wound length, length of hospital stay, hospital costs, incidence of overall/early/late procedural complications, delay in start of peritoneal dialysis and mean catheter longevity. (3) Procedural complications: catheter migration, dialysate leak, exit site infection, peritonitis, bleeding and hernia. (4) Clinical outcomes: patient mortality, catheter dropout, overall catheter survival rate, true catheter survival rate.

Statistical analysis Statistical Package for Social Science V11.5 (SPSS, Chicago, Illinois, USA.) was utilized. Independent sample T-test was used in continuous variable. Pearson chi-square or Fisher exact test was used in nominal variable. Overall / true cumulative catheter survival was expressed by Kaplan-Meier curve and the difference was compared by log-rank test. P value < 0.05 was statistically significant.

Literature review English literatures from Medline update to Feb 2008. Comparison study of laparoscopic with open catheter placement for the patients with ESRD

Results

Summary

Laparoscopic placement: longer operative time (P<0.001), shorter wound length (P<0.001), more expensive cost (P<0.001). Similar results were obtained when patients with laparoscopic adhesiolysis were excluded (operative time, 65.85 6± 30.03 versus 46.68 ± 15.99 minutes, P =0.0008; wound length, 1.69 ± 0.45 versus 2.34 ± 0.84 cm, P = 0.0002; cost, 10928.79 ± 2984.19 NTD versus 8577.05 ± 1884.48 NTD, P = 0.0001) ; or when patients with previous surgery were excluded from both groups (operative time, 65.85 ± 30.03 versus 47.29 ± 16.25 minutes, P = 0.0021; wound length, 1.69 ± 0.46 versus 2.19 ± 0.56 cm, P = 0.0002; cost, 10928.79 ± 2984.19 NTD versus 8481.63 ± 1834.51 NTD, P = 0.0001). A trend to have higher incidence of pericannular bleeding (21.6% versus 7.5%) and lower rate of early catheter migration (2.7% versus 15.0%), but not statistically significant.

Dialysate leak and late stage infectious complications were not significantly different. Early/ late/ overall complication rate also not significantly different. Catheter survival is equivalent. All infectious complication occurred in late stage-- related to contaminated usage or impaired defense of patients. Pain score/requirement of pain control have no difference. Postoperative hospital stay is not different.

DISCUSSION

Superiority and drawback of the present study A prospective randomized design to eliminate selection bias. All operations by one senior surgeon. Although patient number of the present study is larger than that of most previous studies. It would be better to increase this number in future studies to avoid type II statistical error.

Obvious advantages of laparoscopic placement Accurate catheter position under direct vision. Simultaneous intra-abdominal interventions. Crabtree et al. further classified laparoscopic catheter placement into basic laparoscopy and advanced laparoscopy according to accessory procedures of rectus sheath tunneling, selective prophylactic omentopexy, and selective adhesiolysis. The overall complication rate showed that basic laparoscopy = open surgery > advanced laparoscopy.

Base on this study laparoscopic technique using percutaneous puncture assisted by direct laparoscopic vision is similar to basic laparoscopy and the most usage in previous studies showed no superiority in complication rate or catheter survival but required a longer operative time and higher operative costs than the open group. No evidence that basic laparoscopic technique should be used as a routine for all primary catheter placements. In fact, open surgery: shorter operative time, simpler equipment requirement had more cost-effective. It, with easily-improved techniques decreasing complications rate, is commonly used in our unit.

We recommend Conventional open surgery for most patients with primary catheter placement. Advanced laparoscopy using more sophisticated procedures may be further investigated for selected patients with other abdominal management simultaneously or relapsing complications during catheter placement.

Laparoscopic adhesinolysis due to previous OP for pelvic abscess

Photos of procedures for open surgery in PD catheter implantation {additive video (8.5 minutes)}

Preoperative mark Cauda Cepha

Small wound Cauda Cepha

Longitudinal incision Cauda Cepha

Peritoneum exposure Cepha Cauda

Create a small peritoneal inlet Cepha Cauda

Catheter with styllette Cepha Cauda

Purse string suture Cepha Cauda

Bury internal cuff into rectus muscle Cepha Cauda

External cuff 2 cm away from exit site Cepha Cauda

Troca curve to exit site Cepha Cauda

Finish procedure Cepha Cauda

The guideline of Baxter 1998 Create peritoneal incision lateral or paramedian for deep cuff fixation to minimize herniation and/or fluid leaks. Place intra-abdominal segment of catheter between visceral and parietal peritoneum, avoiding bowel or omental tissue. Position deep cuff in musculature of abdominal wall or in preperitoneal space. Close peritoneum below level of deep cuff with purse string absorbable sutures. Position subcutaneous cuff 2 cm from exit site. Tunnel from cuff to exit site with diameter same as catheter. Position exit site downward. Sutures at exit site not recommended.

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