Outcomes of dialysis catheters positioned by the Y-TEC peritoneoscopic approach: a single-center surgical expertise

Results from the Dialysis Outcomes and Practice Patterns Study
May 16, 2021 0 Comments

Clin Kidney J. 2016 Feb; 9(1): 158–161.

Summary

Background

In the previous couple of years, peritoneal dialysis (PD) catheter placement strategies and outcomes have change into necessary due to the rising inhabitants of PD sufferers. Though there are a rising variety of catheters positioned by the minimally invasive Y-TEC peritoneoscopic approach, there are nonetheless restricted knowledge on outcomes for these catheters, particularly these positioned by a surgeon. We aimed to conduct a retrospective examine of our expertise with PD catheters positioned by the Y-TEC peritoneoscopic approach in our establishment.

Strategies

We reviewed sufferers with peritoneoscopic PD catheter insertion during the last decade and described their issues and outcomes. In a secondary evaluation, we in contrast the outcomes and issues of those catheters with these with open placement positioned by the identical surgeon.

Outcomes

We had full knowledge on 62 sufferers with peritoneoscopic catheter placement through the examine interval. The imply age was 55 years, 48.4% have been females and the commonest explanation for end-stage renal illness was diabetes mellitus (33%). Surgical issues have been seen in solely 6/62 (9.6%) and peritonitis in 16/62 (26%) of peritoneoscopic catheters. Most catheters have been used after 2 months of placement, whereas 12.3% have been used inside 2 months. When put next with 93 sufferers with open placement of catheters as a secondary evaluation, peritoneoscopic catheters have been discovered to have a better 2-year survival.

Conclusion

Our giant collection of peritoneoscopically positioned catheters by a surgeon exhibit low surgical issues and peritonitis charges in addition to superior 2-year survival in contrast with open placement of catheters.

Key phrases: CAPD, catheter, peritoneal dialysis, peritoneal membrane, peritoneoscopy

Introduction

Peritoneal dialysis (PD) has change into a modality of alternative for renal alternative remedy (RRT) for a lot of end-stage renal illness (ESRD) sufferers requiring autonomy and having a busy life-style [1–6]. The PD catheter is the cornerstone of PD and its correct operate and survival are essential.

In the previous couple of years, PD catheter placement strategies and outcomes have been the topic of a number of publications within the medical literature. Meta-analyses and systematic evaluations have advised that straight catheters are likely to have much less migration than coiled catheters [7–9]. One other necessary challenge described within the current literature is the improved outcomes with fewer malfunctions and longer catheter survival discovered when performing the process with a traditional laparoscopic approach utilizing the a number of ports strategy beneath common anesthesia [10]. Nevertheless, there are nonetheless restricted knowledge on the outcomes of catheters positioned by the minimally invasive Y-TEC peritoneoscopic approach. Within the current examine, we overview our expertise with these catheters over the previous decade in a big inhabitants of PD sufferers. We additionally in contrast outcomes for these catheters with these positioned by the traditional open approach.

Supplies and strategies

Information assortment

We carried out a retrospective chart overview of all ESRD sufferers who had a PD catheter inserted at Mount Sinai Hospital from 2004 to 2014. We solely included the primary occasion of catheter placement for every affected person. We carried out a complete chart overview and abstracted demographics, comorbidities together with diabetes mellitus and whether or not PD was the primary RRT modality. We reviewed the operative notes and abstracted data on the surgical strategy (peritoneoscopic versus open) and the time for first use after insertion. We additionally collected data on issues (mechanical/infectious/different), total catheter survival and complete time of follow-up (together with when the affected person discontinued PD because of incapacity/transplant/desire). The institutional overview board of our establishment authorised the examine.

Methods of catheter implantation

Y-TEC peritoneoscopy approach

Underneath native anesthesia with delicate sedation, a 2-cm paraumbilical paramedian incision is made within the pores and skin and subcutaneous tissue, exposing the anterior rectus fascia. A 0 Prolene purse-ring sew is positioned within the fascia. Via the middle of this purse-ring sew, a Varis needle is launched and three L of nitrous oxide is insufflated into the peritoneal cavity. This fuel is used as an alternative of CO2 as a result of it’s painless within the peritoneal cavity and permits for the process to be carried out beneath native anesthesia. As soon as pneumoperitoneum is obtained, the Varis needle is eliminated and a Y-TEC trocar is launched by the middle of the purse ring. This trocar has a metallic cannula/peeling sheath that accepts the Y-TEC scope. Peritoneoscopy is finished and the tip of the cannula/peeling sheath is directed towards the pelvis. The metallic cannula is eliminated, leaving the peeling sheath in place. The PD catheter, which is mounted on a inflexible metallic rod, is launched by the peeling sheath and because the catheter is being launched, the rod is progressively eliminated. Earlier than eradicating the peeling sheath, the distal Dacron cuff is pressured into the rectal sheet. The purse-ring suture is tightened snugly across the catheter. The exterior facet of the catheter is introduced out by a small superior lateral pores and skin opening, leaving the proximal Dacron cuff subcutaneously.

Open approach

Underneath common anesthesia, a 5–10 cm lengthy paraumbilical paramedian incision is made within the pores and skin and subcutaneous layers. The anterior rectus muscle fascia is opened in the identical course and extension. The muscle fibers are cut up, exposing the posterior fascia/peritoneal membrane. A 0 Prolene purse-ring sew is positioned on this layer and within the heart of it, a small opening is made. The PD catheter is launched by this opening, directing the tip of the catheter to the pelvic space. The distal Dacron cuff is positioned exterior of the posterior fascia/peritoneal membrane and the purse-ring suture is tightly tied across the catheter. The anterior rectus fascia is closed with a steady 0 Prolene suture. The catheter is exited by a small pores and skin incision superior/lateral, leaving the proximal Dacron cuff within the subcutaneous layer.

Statistical evaluation

We summarized variations in steady variables utilizing imply/median values relying on their distribution and categorical variables utilizing percentages. We utilized t-test/Wilcoxon rank-sum check for steady and χ2 check for categorical variables to evaluate variations between sufferers who misplaced their catheters versus those that didn’t. As a secondary evaluation, we analyzed the impartial impact of the peritoneoscopic versus open placement approach utilizing Cox proportional hazard modeling after adjusting for demographics and comorbidities. We censored follow-up time at loss of life, switch to hemodialysis (with a functioning PD catheter) or loss to follow-up. We constructed Kaplan–Meier curves to plot catheter survival over the follow-up interval. We used a two-tailed P-value ≤0.05 to find out statistically important variations. All statistical analyses have been carried out utilizing STATA 12 SE (StataCorp, School Station, TX, USA).

Outcomes

Baseline traits

From February 2004 to June 2014, a complete of 155 ESRD sufferers had their first PD catheters inserted on the Icahn College of Drugs at Mount Sinai. Desk summarizes sufferers’ baseline traits each total in addition to stratified by the kind of catheter placement. The imply age was 55 years, 51% have been males and 63.2% of sufferers have been white. Diabetes mellitus was the commonest explanation for ESRD in our inhabitants, adopted by hypertension and power glomerulonephritis/HIV-associated nephropathy (HIVAN). PD was the primary modality of RRT in 103 (66.5%) sufferers. In 130 (83.9%) sufferers, catheters have been used after 2 months of insertion, whereas in 19 (12.3%) sufferers, catheters have been used <2 months, largely within the setting of urgent-start PD. Three catheters had major nonfunction, one was by no means used as a result of the affected person expired 5 days after PD catheter placement and one was by no means used as a result of the affected person was by no means began on PD. Except decrease physique mass index in sufferers with peritoneoscopic placement, there have been no important variations in baseline traits by catheter placement approach.

Desk 1.

Baseline traits of sufferers total and stratified by catheter loss (n = 155)

Total Sufferers with Y-TEC peritoneoscopic catheter placement (n = 62) Sufferers with open catheter placement (n = 93) P-value
Age (years), imply (SD) 55.1 (17.1) 56.5 (17.9) 54.2 (16.6) 0.42
Male, n (%) 79 (51) 36 (59) 42 (45.2) 0.09
Race, n (%) 0.39
 White 98 (63.2) 36 (59) 58 (62.4) 0.68
 African American/different 57 (36.8) 24 (41) 35 (37.6)
Physique mass index, median (IQR) 26 (23–30) 25 (22–28) 27.5 (24–32) 0.02
Explanation for ESRD, n (%) 0.10
 Diabetes 50 (32.3) 13 (21.3) 37 (39.8)
 Hypertension 35 (22.6) 18 (29.5) 16 (17.2)
 Glomerulonephritis/HIVAN 37 (23.9) 17 (27.9) 20 (21.5)
 Different 33 (21.3) 14 (21.5) 20 (21.5)
PD as first modality 103 (66.5) 42 (67.7) 60 (64.5) 0.58
Time to first use, n (%) 0.10
 ≥2 months 130 (83.9) 48 (77.4) 82 (88.1)
 <2 months 19 (12.3) 10 (16.1) 9 (9.7)
 Unknown/by no means used 6 (3.8) 4 (6.5) 2 (2.2)
Prior stomach surgical procedure, n (%) 3 0 (0) 3 (3.2) 0.17

Problems and outcomes

The infectious and noninfectious issues of sufferers with catheters positioned by Y-TEC peritoneoscopic strategies are proven in Desk . The most typical infectious complication was peritonitis, which occurred in 26% of sufferers. The most typical noninfectious complication was scrotal leak, occurring in 4.8% of sufferers. There have been no issues of hernias or catheter migration seen within the Y-TEC peritoneoscopically positioned catheters. Throughout follow-up, 8 (13%) sufferers misplaced their catheters. The most typical motive for catheter loss was peritonitis in three sufferers. Different causes included mechanical dysfunction in two sufferers, stomach wall leak in a single affected person and pleuroperitoneal fistula in a single affected person. One affected person had a malposition; nonetheless, a brand new catheter was positioned instantly. When evaluating survival of Y-TEC positioned catheters with these positioned by open approach in a secondary evaluation, though this distinction was not statistically important (Desk ).

Desk 2.

Infectious and noninfectious catheter issues with related catheter loss

Complete, n Sufferers with Y-TEC peritoneoscopic catheter placement (n = 62), n (%) Sufferers with open catheter placement (n = 93), n (%) P-value
Infectious issues
 Solely peritonitis 55 16 (26) 39 (42) 0.05
 Exit web site an infection 27 10 (16.1) 17 (18.3) 0.45
 Tunnel an infection 11 3 (5) 8 (8.6) 0.80
Noninfectious issues
 Scrotal leak 7 3 (4.8) 4 (4.3) 0.34
 Hernias 3 0 (0) 3 (3.2) 0.55
 Catheter migration 2 0 (0) 2 (2.2) 0.90
 Subcutaneous hematoma 2 1 (1.6) 1 (1.1) 0.54
 Adhesions 2 1 (1.6) 1 (1.1) 0.54
 Omental adherence 2 1 (1.6) 1 (1.1) 0.54
 Pleuroperitoneal fistula 1 0 (0) 1 (1.1) 0.90

In a secondary evaluation, evaluating the survival of Y-TEC-placed catheters with these positioned by the open approach, there was no distinction in hazard ratios in catheter survival after adjusting for demographics, diabetes standing and the variety of earlier catheter placements for total follow-up. Nevertheless, at 2 years of follow-up, open placement of catheters had a better adjusted hazard ratio for catheter loss in contrast with Y-TEC peritoneoscopic placement [2.53 (95% CI 0.98–6.68), P = 0.06], which was near statistical significance (Desk .) That is doubtless since a majority of catheters have been misplaced inside 24 months, with the imply time to catheter loss being 18 months. The Kaplan–Meier curves for time to catheter loss are proven in Determine .

Desk 3.

Multivariable Cox proportional hazards for catheter loss

Hazard ratio (95% CI) P-value
Peritoneoscopic placement 1 (Ref) NA
Open placement 2.53 (0.98–6.68) 0.06
Age 0.99 (0.96–1.02) 0.79
Feminine 1 (Ref)
Male 1.02 (0.42–2.46) 0.82
White 1 (Ref) NA
African/American or different 0.65 (0.25–1.72) 0.39
Diabetes mellitus 1.06 (0.41–2.71) 0.91
Physique mass index 1.07 (0.99–1.16) 0.08

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Catheter cumulative survival stratified by placement approach. This determine exhibits Kaplan–Meier curves for catheter loss by catheter placement approach. The stable pink line denotes open placement of catheters, whereas the dotted inexperienced line denotes peritoneoscopic placement over the follow-up interval in months. The 2 vertical maroon strains denote time intervals of 1 and a pair of years of follow-up.

Dialogue

On this article we current one of many largest collection of Y-TEC peritoneoscopically positioned PD catheters by a surgeon. We report an total catheter survival fee comparable with earlier studies of laparoscopic or open placement [8, 11–13], with a mean of 80% survival at 2 years. Gadallah et al. [12] confirmed {that a} peritoneoscopically positioned catheter (utilizing Y-TEC) had fewer issues and better survival charges in contrast with these positioned by an open approach. A current meta-analysis confirmed that peritoneoscopically positioned catheters had a greater 1-year survival and likewise much less catheter migration than these positioned through an open strategy [10]. We additionally noticed catheter leak occurring in 4.9% of sufferers, which is way decrease than beforehand described [11, 14]. Additionally, our fee of mechanical issues was 11%, in contrast with 17.8% in a current examine by Ouyang et al. [8]. Our report exhibits that Y-TEC peritoneoscopically positioned catheters had a low complication fee and the same survival fee in contrast with these positioned surgically by an open approach.

As regards to the kind of catheter used, a current systematic overview and meta-analysis by Hagen et al. [9] favored survival of straight versus coiled PD catheters. Since all of our sufferers, besides one, had coiled PD catheters, we’re unable to check variations in consequence between the 2 varieties of catheters. Nevertheless, the truth that we didn’t discover variations in consequence in our catheters in contrast with different revealed experiences with a larger use of straight catheters means that coiled catheters is likely to be as secure.

A majority of the PD catheters within the USA are positioned by surgeons and by an open or laparoscopic approach. The peritoneoscopic approach has the benefit that it’s performed beneath native sedation, versus a laparoscopic strategy that’s performed with common anesthesia. Furthermore, this system permits acute use of the catheter versus laparoscopy, which requires a therapeutic time of a minimum of 2 weeks. This report supplies proof that peritoneoscopically positioned PD catheters could possibly be utilized as a process of alternative amongst surgeons offering entry for PD.

In abstract, this decade-long, single-center expertise with peritoneoscopically positioned PD catheters by a surgeon demonstrated comparable catheter survival charges however decrease mechanical issues charges in contrast with earlier reported research utilizing open or laparoscopic placement. Additionally of curiosity, coiled PD catheters confirmed no important distinction in consequence in contrast with straight catheters.

Battle of curiosity assertion

The authors report no battle of curiosity. The outcomes introduced on this article haven’t been revealed beforehand in entire or partially, besides in summary format.

References

1. Fenton SS, Schaubel DE, Desmeules M, et al.
Hemodialysis versus peritoneal dialysis: a comparability of adjusted mortality charges. Am J Kidney Dis
1997; 30: 334–342 [PubMed] [Google Scholar]
2. Vonesh EF, Snyder JJ, Foley RN, et al.
The differential influence of threat elements on mortality in hemodialysis and peritoneal dialysis. Kidney Int
2004; 66: 2389–2401 [PubMed] [Google Scholar]
3. Merkus MP, Jager KJ, Dekker FW, et al.
High quality of life in sufferers on power dialysis: self-assessment 3 months after the beginning of remedy. The Necosad Research Group. Am J Kidney Dis
1997; 29: 584–592 [PubMed] [Google Scholar]
4. Coles GA, Williams JD.
What’s the place of peritoneal dialysis within the built-in remedy of renal failure?
Kidney Int
1998; 54: 2234–2240 [PubMed] [Google Scholar]
5. Rubin HR, Fink NE, Plantinga LC, et al.
Affected person rankings of dialysis care with peritoneal dialysis vs hemodialysis. JAMA
2004; 291: 697–703 [PubMed] [Google Scholar]
6. Saxena R.
Peritoneal dialysis: a viable renal alternative remedy choice. Am J Med Sci
2005; 330: 36–47 [PubMed] [Google Scholar]
7. Xie J, Kiryluk Okay, Ren H, et al.
Coiled versus straight peritoneal dialysis catheters: a randomized managed trial and meta-analysis. Am J Kidney Dis
2011; 58: 946–955 [PubMed] [Google Scholar]
8. Ouyang C-J, Huang F-X, Yang Q-Q, et al.
Evaluating the incidence of catheter-related issues with straight and coiled Tenckhoff catheters in peritoneal dialysis sufferers—a single-center potential randomized trial. Perit Dial Int
2015; 35: 443–449 [PMC free article] [PubMed] [Google Scholar]
9. Hagen SM, Lafranca JA, IJzermans JNM, et al.
A scientific overview and meta-analysis of the affect of peritoneal dialysis catheter kind on complication fee and catheter survival. Kidney Int
2014; 85: 920–932 [PubMed] [Google Scholar]
10. Hagen SM, Lafranca JA, Steyerberg EW, et al.
Laparoscopic versus open peritoneal dialysis catheter insertion: a meta-analysis. PLoS One
2013; 8: e56351. [PMC free article] [PubMed] [Google Scholar]
11. Singh N, Davidson I, Minhajuddin A, et al.
Danger elements related to peritoneal dialysis catheter survival: a 9-year single-center examine in 315 sufferers. J Vasc Entry
2010; 11: 316–322 [PMC free article] [PubMed] [Google Scholar]
12. Gadallah MF, Pervez A, el-Shahawy MA, et al.
Peritoneoscopic versus surgical placement of peritoneal dialysis catheters: a potential randomized examine on consequence. Am J Kidney Dis
1999; 33: 118–122 [PubMed] [Google Scholar]
13. Medani S, Hussein W, Shantier M, et al.
Comparability of percutaneous and open surgical strategies for first-time peritoneal dialysis catheter placement within the unbreached peritoneum. Perit Dial Int
2015; 35: 576–585 [PMC free article] [PubMed] [Google Scholar]
14. Al-Hwiesh AK.
Percutaneous versus laparoscopic placement of peritoneal dialysis catheters: simplicity and favorable consequence. Saudi J Kidney Dis Transpl
2014; 25: 1194–1201 [PubMed] [Google Scholar]

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