Surgical management of PD

complications(double-cuff straight Tenckhoff catheter)

基隆長庚一般外科卓世川

Advantages and disadvantage of PD

• Popvich and Moncrief in 1976

• Better blood pressure control

• Fewer dietary restrictions

• Lower costs

• Greater simplicity

• Superior patient mobility

• Independence

• Outflow obstruction, catheter-related infection,

dialysate leak remain troublesome

PD complications

• Outflow obstruction, catheter-related infection, dialysate leak remain troublesome

• Others are rare

• Common issues in surgery: (1). I/O obstruction: migration, omentum wrapping(2). Infection: exit site/wound infection, peritonitis(3). Dialysate leakage: exit site/wound, gential, thorax(4). Bleeding: subcutaneous hematoma, bloody dialysate(5). Hernia: umbilical, inguinal, ventral

Management

I/O obstruction

• Migration: enema, saline flushing, change

body position, jumping, massage, guide-

wire correction, revision with styllette,

laparoscopic salvage.

• Omentum wrapping: guide-wire correction,

revision with styllette, laparoscopic

salvage.

Case 1. catheter migration treated by

conservative methods•57y/o male

•2008/12/26

On PD

•KUB:

migration

•Conservative

treat

–Enema

–Massage

abdomen

Case 2. catheter migration corrected by Lunderquist guidewire

Revision with styllette correction after retrieval from

subcutaneous tunnel when diagnostic laparoscopy was not

feasible in patient with poor condition

Cauda

Cepha

Case 3. early stage omentum wrapping

• 67 y/o female

• 2010/01/10 laparoscopic surgery for uterine

myoma

• 2010/06/11 open surgery PD implantation

• 2010/06/17 started PD: Outflow obstruction

• 2010/06/18 laparoscopy: Omentum wrapping

Case 3. early stage omentum wrapping

Case 4. late stage omentum wrapping

• 71y/o liver cirrhosis female

• Appedectomy and cholecystectomy 14 years ago

• Laparoscopic PD placement 3 months ago

• Persist chylous effluent and low abd discomfort

– Abd CT

– Effluent study not special finding

• G(-) Bacteria peritonitis treat failure

– Lock PD

– Consult surgical doctor

Case 4. late stage omentum wrapping

Infection

• Exit site/subcutaneous tunnel: topical/oral/IV

antibiotics, un-roofing tunnel, cuff shaving

• Catheter-related peritonitis: associated with

flow obstruction, abscess, sclerosing

peritoneum (encapsulated sclerosing

peritonitis)

• Secondary peritonitis

• The role of diagnostic laparoscopy

Case 5. Cuff extrusion with infection

• 23 y/o male

• 1991 open surgery PD catheter implantation

• Cuff extrusion with exit site infection

• Tx: cuff shaving

Case 6. Catheter-related peritonitis with I/O

flow obstruction

• 54 y/o female

• PD for 3 years, open surgery PD catheter

implantation

• Fail to treat bacterial peritonitis

• I/O flow obstruction

• Consult surgical doctor

Case4

Case 6. catheter-related peritonitis with I/O obst.

Case 7. pelvic abscess• 69 y/o male

• 2008/03/07 open surgery PD catheter implantation

• Bacteria peritonitis (9 episodes)

2010/3/12 Removed catheter due to refractory candida peritonitis

• 2010/4/17 Laparoscopy for intra-abdominal abscess

• 2008/3/07 on PD2010/3/12 remove PD2010/4/17 abdominal abscess OP2010/5/07 re-on PD

Case 7. catheter-related peritonitis with abscess

Case 7. Re-on PD catheter 3 weeks later

Case 8. catheter-related peritonitis with

initial sclerosing change• 41y/o female

• 2005/12/01 open surgery PD catheter implantation

• 2008/09/14~2009/01/19: 2 bacteria peritonitis

• 2010/04/27 bacteria peritonitis

• 2010/05/11 recurrent candida peritonitis

– Consult surgical doctor

– Diagnostic laparoscopy with peritoneal lavage

– Removed catheter (initial sclerosing change)

Case 8. catheter-related peritonitis with S.P

Encapsulated sclerosing peritonitis- treated by peeling

Encapsulated sclerosing peritonitis with Candida infection

Case 9. secondary peritonitis due to

rectosigmoid perforation

• 41 y/o male

• 2007.5.11 open surgery PD catheter implantation

• CAPD indwelling: 1 year (2007.5.18~2008.6.4)

• APD indwelling: 1 year (2008.6.5~2009.6.29)

• 2009.6.29~2009.7.8:

1st peritonitis / B. fragilis & E. coli & Strepto. constellatus

• 2009.7.9:

laparoscopy & remove PD tube

• 2009.7.10:

revision

Case 10. secondary peritonitis due to ischemic

bowel perforation

• 84 y/o male

• Long-term bed-ridden, poor general

condition

• 2009/12/04 open surgery PD catheter

implantation

• 2009/12/12 started PD training

– UF unstable

– Dyspnea

– Combined with HD

• Equivocal peritonitis

– Consult surgeon for diagnostic laparoscopy

– Ischemic small bowel with perforation

Case 10. secondary peritonitis due to ischemic bowel

D/D catheter-related peritonitis from

secondary peritonitis

• Secondary bacterial peritonitis: peritonitis

caused by intraabdominal disease

– Appendicitis

– Diverticulitis

– Cholecystitis

– Hollow organ perforation

– Pancreatitis

– Ischemic bowel

– < 6% of peritonitis in PD patient

D/D catheter-related peritonitis from

secondary peritonitis• How to differentiate?

– Similar PE and laboratory findings

– Symptoms related to Dx (shifting pain, postprandial

RUQ pain, GB stones history, hunger pain, PUD

history)

– Multiple enteric organisms in ascites culture

– Unusual enteric organism (bacteroides) in ascites

culture

– Stool in the dialysate

– Peritoneal fluid amylase and lipase levels

Amylase >50 IU/L: intraabdominal disease

Elevated lipase: pancreatitis

Why D/D important?

• Different treatment modality

– Catheter-related peritonitis: medical Tx

– 2nd peritonitis: usually operation

• PPU: operation

• Appendecitis: operation

• Cholecystitis: operation vs drainage

• Ischemic bowel: operation

• Diverticulitis: medical Tx vs. operation

• Pancreatitis: medical Tx

Indication for catheter removal

• 2005 guidelines

– Relapsing peritonitis:

• episode of peritonitis with the same pathogen

as previous episode within four weeks after

completing the course of Abx

– Refractory peritonitis:

• fail to respond to antibiotics within 5 days

– Refractory catheter infections:

• purulent drainage from exit site with multiple

Gr(+) infection

Indication for catheter removal

• 2005 guidelines

– Fungal peritonitis

– Fecal peritonitis

– Associated with other intra-abdominal pathology

– Mechanical failure: occlusion or dysfunction

• 2005 guidelines

– Not mentioned about irrigation, lavage, or

drainage

Conclusion• Peritonitis in a PD patient

– D/D catheter-related peritonitis from 2nd

peritonitis

• 2nd peritonitis: operation considered

• Catheter-related peritonitis: antibiotics first

• Treatment failure: >5 days antibiotics or fungal

peritonitis

– Consider surgical treatment to remove catheter

(diagnostic laparoscopy if necessary)

• Re-insert catheter 2-3 weeks later

• Patient category: acute nonspecific abdominal pain, trauma,

acute abdomen in critical patient

• Acute abdominal pain, less than 7 days, uncertain diagnosis

after exam and tests

• To prevent treatment delay (poorer patient outcomes); to avoid

unnecessary laparotomy (Relatively high morbidity rates 5–

22%)

• high accuracy (70–99%; levels 1–3); early DL improved

diagnostic accuracy then observation (81% vs 36%; p<0.001)

• should be considered in patients without a specific diagnosis

after exams; may be superior to observation alone; for selected

patients, DL may be preferable to exploratory laparotomy

What’s your action when seen in diagnostic laparoscopy?

Conversion to laparotomy?

Irrigation with lots of saline, checking appendix, cecum, terminal ileum,

pelvis, sigmoid-rectum, GB, Morison’s pouch, duodenum, stomach, S.B.

Dialysate leakage

• Exit site/wound (pericatheter and

subcutaneous leaks ) reduce to low dose

PD

• Genital: hydrocele surgical repair,

scrotum edema or lymphedema increased

glucose conc in dialysate or change to APD

• Thorax: hydrothorax VATS, pleurodesis

Peri-catheter leak

Subcutaneous leaks

40

Genital edema (外生殖器水腫)

導 因 處 理

•經由腹部缺陷滲漏所致

診斷方法：

1、電腦斷層腹膜造影術

2、核子醫學檢查

•暫停CAPD或改成APD

•增加透析液葡萄糖濃度

•改成HD

•外科手術

Hydrothorax (水胸)

Diagnosis of hydrothorax (水胸)

• Symptoms:

• 肺部呼吸音減弱(好發右側)

• 呼吸短促,平躺時咳嗽加劇

• 若引流液減少,須注意是否使用高濃度藥水後呼吸短促情形加劇

• Signs:

• Chest X-ray -- pleural effusion

• 核醫 -- pleural-peritoneal communication

• 胸腔引流液呈現高葡萄糖,低蛋白

Treatment of hydrothorax (水胸)

• 保守性療法 (peritoneal rest and intermittent low

volume dialysis) 鮮少有成功的機率

• 胸管引流以及胸腔灑粉法 [pleurodesis with

talc slurry, autologous blood, OK-432 (Picibanil),

minocycline] 成功機率有限

• 在外科手術之後,短暫使用血液透析3-4 週,有助於腹膜橫隔相通處的黏合

• Thoracoscopic visualization of pleuro-peritoneal

communication and direct surgical obliteration

• Video –assisted thoracic surgery (VATS)

Outcome of pleurodesis of hydrothorax in PD

Mak et al. Ann Thorac Surg 2002;74:218-221

Bleeding

• Subcutaneous hematoma:

• Bloody dialysate (hemoperitoneum):

Case 11. subcutaneous ecchymosis

• 47y/o female

• General edema, low

albumin & Hct, prolonged

BT/APTT

• 2010/05/24 PD insertion

• Subcutaneous ecchymosis

Case 12. bloody dialysate

• 70 y/o female

• 2009/04/10: open surgery PD

catheter implantation

• 2009/12/14: 1st G(-) bacteria

peritonitis & treated successful

• 2010/02/15: 2nd bacteria

peritonitis – Treated failure

• Lock PD & resumption

• Bloody effluent & outflow

obstruction were noted

– Consult surgical doctor for evaluation

Case 12. bloody dialysate

Bloody dialysate (血性透析液 )

• 手術中或術後即時

• 常見於女性月經或排卵期

• 內臟器官或血管自發、發炎、外傷破裂出血

• 輕微出血可能原因: 導管引起,劇烈運動,腹膜沾黏

• 任何形式的出血都需密切觀察,探討潛在因素

Cause of bloody dialysate

• Surgical causes: cholecystitis, rupture of the

spleen or pancreatitis

• Medical causes: coagulation disorder, PKD,

leakage, hematoma ESWL, rupture of ovarian

or hepatic cysts, EPS

• Recent Exam: enema, colonoscopy

• Recent use of IP tPA

Hernia

• Umbilical: herniorrhaphy with/without mesh

• Inguinal: herniorrhaphy with/without mesh

• Ventral: herniorrhaphy with/without mesh

Umbilical hernia Inguinal hernia

Others

• Pre-peritoneal catheter placement

• Peritoneal penetration when creating curve

subcutaneous tunnel

• Abdominal discomfort during infusion and

drain

• Pneumoperitoneum (shoulder pain)

已把尖銳處磨鈍了

Abdominal discomfort during infusion and drain

(灌注和引流引起的腹部不適)

• 減慢灌注速度,避免快速增加大量的劑量

• 避免透析液溫度過冷或過熱

• 避免導管移位

• 須排除腹膜炎

• 藥物的使用

• Training for APD

Pneumoperitoneum (腹膜腔空氣)

• 肩痛須排除心臟不適原因

• 評估疼痛程度和時間

• 詢問最近換液程序是否有誤

• 評估是否有出現腹膜炎的症狀

• 評估是否有胃腸破裂的可能

Causes of catheter dropout• Catheter-related peritonitis

• Secondary peritonitis

• Intractable dialysate leakage

• Catheter dysfunction

• Inadequate peritoneal dialysis

• Renal transplantation

• Renal recovery

• Volunteered for HD

• Patient mortality

Removal of PD catheter

CephaCauda

My course in PD catheter implantation• Principle acquired from PD nurse (pelvic direction,

subcutaneous curve down, and external cuff 2 cm

away from exit site).

• Design Lunderquist guidewire to correct catheter

migration.

• Use laparoscopy to salvage catheter.

• Modify and simplify surgical procedures- small

wound, paramedian incision, longitudinal

intramuscular catheter position (trans-rectus muscle

tunneling), reduce suture stitches, create inverse U-

shape tunnel without additive incision, etc.

• Happy to have colleagues’ support: research projects,

paper writing and publications.

My related publications Chi-Ming Lee, Shu-Hang Ng, Shyh-Chuan Jwo, Sheung-Fat Ko, Chang-

Huang Tsai: Malpositioned Tenckhoff Peritoneal Dialysis Catheter

Correction Using Guide Wire. Chin J Radiol 1999; 24:119–121.

Shyh-Chuan Jwo, Chi-Ming Lee, Chi-Jen Tsai. Correction of a Migrated

Tenckhoff Peritoneal Dialysis Catheter using a Lunderquist guidewire: Report

of two cases. Chang Gung Med J 2000; 23: 360–365.

Shyh-Chuan Jwo, Kuo-Su Chen, Chi-Ming Lee, Chieh-Yu Huang.

Correction of Migrated Peritoneal Dialysis Catheters using Lunderquist

guidewire: a preliminary report. Peri Dial Int 2001; 21(6): 619–621. {SCI}

Shyh-Chuan Jwo, Kuo-Su Chen, Yu-Ying Lin, Video-assisted laparoscopic

procedures in peritoneal dialysis. Surg Endosc 2003; 17: 1666–1670. {SCI}

Shyh-Chuan Jwo, Kuo-Su Chen. Correction of Migrated Peritoneal Dialysis

Catheters by a GuideWire. JNNA 2004; 3(1): 11–16. (invited)

Shyh-Chuan Jwo, Kuo-Su Chen, Chin-Chan Lee, Huang-Yang Chen.

Prospective Randomized Study for Comparison of Open Surgery with

Laparoscopic-assisted Placement of Tenckhoff Peritoneal Dialysis Catheter–A

Single Center Experience and Literature Review. J Surg Res 2010; 159: 489–

496. {SCI}

Q&A

• 1-1如何決定手術切口及導管出口？以利後續之導管出口之良好照護

• 1-2放置導管在腹腔內的方向是否需注意甚麼事？以利後續導管之良好位置

• 1-3如何於建立隧道及出口時，使其導管出口朝下？建立隧道及出口時是否需注意甚麼事？對於側面出口及朝下出口，是否在後續之導管出口之照護造成影響(能否請卓醫師提供建議)

• 1-4如何測試導管功能是否良好？(除PDN的判斷外，外科醫師是否有何建議)

• 1-5於KUB上何處為理想的導管末端

• 1-6對於腹側線及腹中線的植管，可否請卓醫師提供想法？

• 1-7 腹膜處第一個CUFF縫合的方式或縫線密度是否影響leakage?

• 2-1當導管出現網膜包覆時，會建議如何處理？(以外科角度)

• 2-2若反覆的導管移位或網膜包覆，會建議如何處理？(以外科角度)

• 2-3若以腹腔鏡處理導管移位或網膜包覆，其復發率高嗎？(請問卓醫師的經驗)

Thank you for your attention!