Risk Factors and Management of Catheter Malfunction During Urgent-Start Peritoneal Dialysis

Background: Catheter malfunction is a common complication of peritoneal dialysis (PD). This study aimed to retrospectively analyze the risk factors and management of catheter malfunction in urgent-start PD.Methods: Patients who underwent urgent-start PD were divided into catheter-malfunction and control groups. Baseline demographic and laboratory data of the two groups were compared, and the risk factors for catheter malfunction were analyzed. Primary outcome measure was catheter survival, and the secondary outcomes were surgical complications and malfunction treatment.Results: Total of 700 patients was analyzed, among whom 143 (20.4%) experienced catheter malfunctions, specifically catheter migration (96, 67.1%), omental wrapping (36, 25.2%), and migration plus omental wrapping (11, 7.7%). Catheter survival time in the malfunction group (202.5 ± 479.4 days) was significantly shorter than that in the control group (1295.3 ± 637.0 days) (P < 0.001). Multivariate analysis revealed higher body mass index [hazard ratio (HR), 1.061; 95% confidence intervals (CI), 1.010–1.115; P = 0.018], lower surgeon count (HR, 1.083; 95% CI, 1.032–1.136; P = 0.001), and higher serum potassium (HR, 1.231; 95% CI, 1.041–1.494; P = 0.036) as independent risk factors for catheter malfunction, while older age (HR, 0.976, 95% CI, 0.962–0.991; P = 0.002) and colonic dialysis (HR, 0.384; 95% CI, 0.254–0.581; P < 0.001) as protective factors. Further subgroup analysis revealed a shorter catheter survival time in patients with younger age ( ≤ 40 years), higher serum potassium levels (≥5 mmol/L), while a longer catheter survival time in patients with colonic dialysis. PD tube and subcutaneous tunnel preservation was successful in 41 out of 44 patients with omental wrapping. All patients had good post-incision prognoses.Conclusions: Urgent-start PD is safe and effective for unplanned PD patients. Adequate pre-operative colonic dialysis and serum potassium level control are conducive in preventing catheter malfunction. Conservative treatment is effective in managing catheter migration alone, while preservation of the PD tube and the subcutaneous tunnel is effective for omental wrapping.

Our experience in laparoscopic ureterolysis and omental wrapping as a definitive surgical management of ureteric obstruction related to retroperitoneal fibrosis

Introduction and Objectives: Retroperitoneal fibrosis (RPF) is a rare fibro-inflammatory disease and a cause of ureteric obstruction that leads to obstructive uropathy. Although the mainstay of RPF treatment is medical, ureterolysis becomes a necessity if medical treatment fails or if patients are unable to tolerate side effects of conservative/medical management, including those of ureteric stents. We aimed to investigate our experience of laparoscopic ureterolysis (LU) and omental wrapping as a definitive surgical treatment for RPF. Patients and methods: We conducted a retrospective analysis of 17 patients who underwent LU between September 2009 and October 2018 in a single institution. Mode of presentation, investigation and interventions were reviewed. Outcome measures were stent or nephrostomy-free rates, post-ureterolysis change in estimated glomerular filtration rate (eGFR), operative time, estimated blood loss, length of hospital stay, complications and need for additional procedures. MAG3 renography was performed to assess ureteral patency. Results: Among 17 patients, a total of 23 LU procedures were performed in 20 operative sessions. Median (IQR) length of hospital stay was 4 (2–6) days. Median length of follow-up was 23.5 months (range 4–92 months), where 14 patients completed at least 15 months of follow-up. All patients were either stent ( n=9) or nephrostomy ( n=8) dependent before ureterolysis. Some 82.4% patients ( n=14) remain stent/nephrostomy free after LU. Renal function remains stable after ureterolysis with a median (IQR) change in eGFR at latest follow-up of: +7.5 (−8 to +23), ( P=0.74). Conclusions: LU is safe and effective at halting decline in renal dysfunction secondary to RPF. It has reliably avoided internal or external ureteric drainage in most patients. Consideration should be given to early referral to a specialised centre for ureterolysis in the context of multi-disciplinary management of benign RPF, to preservation of renal function and to render patients stent or nephrostomy free. Level of Evidence: 4 (case series).

Diagnostic capability of ultrasound in peritoneal catheter malfunction compared to videolaparoscopy

Background: The approach to peritoneal catheter malfunction consists usually in a diagnostic and therapeutic sequence of laxative prescription, abdominal radiography, brushing of the catheter, guide-wire manipulation or fluoroscopy and in the end of a videolaparoscopy (VLS) rescue intervention. Ultrasound (US) is able to find out major causes of peritoneal catheter malfunction, however without a clearly defined diagnostic value. The aim of the study was to validate the diagnostic capability of US in catheter malfunction compared to the diagnostic reference of VLS. Methods: US scans of the subcutaneous and intraperitoneal segment of the catheter were performed prior to a VLS intervention in 40 adult patients presenting persistent catheter malfunction within a prospective multicentre study. Laxative prescription and brushing of the catheter lumen were undertaken prior to US scan. US diagnosis was compared to the corresponding at VLS, kappa coefficient calculated and the causes of mismatch analysed. Results: In US, causes of persistent malfunction were catheter dislocation combined with omental wrapping in 21 cases, omental wrapping without dislocation in 11 cases, dislocation only in 4 cases, adherences to non-omental structures in 3 cases and entrapment in the lateral inguinal fossa in 1 case. The US diagnosis corresponded to the respective at VLS in 36 of 40 cases, resulting in a kappa coefficient of 0.89 (95% CI: 0.78–1.00). The discrepancies were due to improper visualization of the catheter between omentum and intestinal loops, resulting in an erroneous US diagnosis of omental wrapping. Conclusions: This study suggests that US might have a pivotal role in the diagnostic approach to peritoneal catheter dysfunction.

Omental wrap: Radiographic diagnosis confirmed surgically – Report of two cases in Grenada

Omental wrapping is a common cause of peritoneal catheter malfunction. This diagnosis should be confirmed by radiography before proceeding with surgical omentectomy. We report two cases of peritoneal dialysis (PD) catheter outflow obstruction from our developing PD program in Grenada, in which contrast studies accurately diagnosed omental wrap, allowing for prompt surgical correction. In both cases, the contrast study indicated the presence of omental wrapping, confirmed at time of surgical correction. Radiographic features of omental wrap are distinctive, which allows for reliable differentiation from other causes of obstruction. Radiographic contrast study reliably diagnoses the cause of peritoneal catheter obstruction, permitting prompt diagnosis and treatment. This is vital for regions with limited access to haemodialysis.

The efficacy and safety of a novel method of peritoneal dialysis catheter insertion from the McBurney point

Background Catheter dysfunction, especially omental wrapping, is a serious complication of peritoneal dialysis (PD). Although catheter implantation at a lower site was reported to prevent omental wrapping, this method could induce insufficient drainage of the PD solution and cause pain or a persistent desire to defecate, when the intraperitoneal catheter is of insufficient length or when its tip is in direct contact with the pelvic floor, respectively. The aim of this study was to assess the efficacy and safety of a novel PD catheter insertion method of approaching from the McBurney point, from the outer side of the abdomen. Methods This retrospective study included 23 patients with end-stage renal disease who were started on PD from January 2017 to July 2018 at Ashikaga Red Cross Hospital, Tochigi, Japan. Among them, 16 patients underwent a PD catheter insertion using a conventional method, whereas 7 patients underwent a novel method of approaching from the McBurney point. Infectious and mechanical complications were evaluated until August 2020. Results There were 18 men and 5 women, with a mean age of 63.1 ± 13.6 years. All patients were followed up postoperatively for a mean duration of 27.2 ± 13.4 months. No patient experienced omental wrapping, insufficient drainage of the PD solution, and pain or persistent desire to defecate in both groups. Both the incidence of infectious and mechanical complications (times per patient-year) were not statistically different between patients undergoing a conventional and a novel PD catheter insertion (0.18 vs. 0.24; p = 0.79 and 0.03 vs. 0.16; p = 0.16, respectively). Conclusions This novel method of PD catheter insertion from the McBurney point was safe, caused less discomfort, and was effective in preventing catheter dysfunction.

P1147SEQUENTIAL ULTRASOUND BASED APPROACH IN PERITONEAL CATHETER MALFUNCTION: THE COMBINATION OF B-MODE AND DOPPLER ULTRASOUND

Background and Aims The clinical approach to peritoneal catheter malfunction consists usually in laxative prescription, abdominal radiography, brushing of the catheter lumen, guide-wire manipulation or catheter fluoroscopy. Only specialized centers apply videolaparoscopy for catheter rescue interventions. Up to now, limited experience is present regarding the evaluation of the intraperitoneal tract of the peritoneal catheter in adult patients. The aim of the study was to evaluate the diagnostic capability of B-mode ultrasound (US) followed by colour Doppler US (Doppler US) in persistent peritoneal catheter malfunction. Method US followed by Doppler US of the intraperitoneal part of the catheter was performed prior to videolaparoscopy intervention in 40 adult patients presenting persistent peritoneal catheter malfunction despite non-invasive therapy such as laxative prescription and brushing of the catheter lumen. US and Doppler US diagnosis were compared to the corresponding at videolaparoscopy intervention, and the causes of mismatch analyzed. In all patients US was performed after filling of the abdominal cavity with peritoneal dialysis solution of at least one liter. Doppler US along the intraperitoneal segment of the catheter was performed by flushing with dialysis fluid. Results In US, causes of persistent malfunction were catheter dislocation combined with omental wrapping in 21 cases, omental wrapping without dislocation in 11 cases, dislocation only in 4 cases, adherences to non-omental structures in 3 cases and entrapment in the lateral inguinal fossa in one case. The correspondence of US and videolaparoscopy diagnosis was 90%, respectively in 36 of 40 cases. The discrepancies were due to improper visualization of the catheter caused by constipation and embedding of the catheter between intestinal loops, resulting in an erroneous US diagnosis of omental wrapping, whereas videolaparoscopy showed encasement of the catheter between intestinal loops in three cases and presence of adherences to tubal structures in one case. Doppler US clarified the functional aspects of the catheter, thus increasing the correspondence to videolaparoscopy up to 39 out of 40 cases (97.5%) Conclusion US combined with Doppler US is helpful in making a correct pre-operative diagnosis of persistent peritoneal catheter malfunction and in planning of the videolaparoscopy rescue intervention.

PS01.111: STAGED PEDICLED JEJUNAL TRANSFER AFTER AORTOESOPHAGECTOMY FOR AORTOESOPHAGEAL FISTULA

Background Aortoesophageal fistula(AEF) had been a critical and life-threatening disease. The surgical strategy which consist of aortic graft replacement with omental wrapping, esophagectomy, and staged esophageal reconstruction achieve circulatory recovery, infection control and long term survival. The objective of this study is to evaluate surgical outcomes of pedicled jejunal transfer with microvascular augmentation as esophageal reconstruction for AEF. Methods 14 patients with aortoesophageal fistula who underwent aortic graft replacement and esophagectomy between 2010 and 2017 at Kobe University Hospital and affiliate hospitals were enrolled in this study. Patient characteristics, operative method and clinical outcomes were obtained by retrospective chart review. Results All 14 patients underwent aortic graft replacement with omental wrapping, esophagectomy and staged esophageal reconstruction. 10 patients (71.4%) successfully underwent staged esophageal reconstruction of pedicled jejunal transfer with microvascular augmentation and showed no leakage and no graft loss. Median survival time in the patients who underwent esophageal reconstruction was 20.3 months from initial operation. Nine of 10 patients were alive but one patient died of sepsis ten months after esophageal reconstruction. Conclusion Aortic graft replacement with omental wrapping and esophaegcotomy play crucial role in the treatment of AEF. Omentum is pedicled by right epiploic artery and vein to prepare good blood flow and sufficient volume of omental wraping and, consequently, stomach without right epiploic artery and vein becomes inappropriate for esophageal conduit. Pedicled jejunal transfer with microvascular augmentation contributes good post-operative outcome. The surgical strategy for AEF, which includes aortic graft replacement with omental wrapping, esophagectomy, and staged esophageal reconstruction by pedicled jejunal transfer microvascular augmentation is feasible and promising. Disclosure All authors have declared no conflicts of interest.