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Surgical management of PD
complications(double-cuff straight Tenckhoff catheter)
基隆長庚一般外科卓世川
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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
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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
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Management
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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.
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Case 1. catheter migration treated by
conservative methods•57y/o male
•2008/12/26
On PD
•KUB:
migration
•Conservative
treat
–Enema
–Massage
abdomen
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Case 2. catheter migration corrected by Lunderquist guidewire
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Revision with styllette correction after retrieval from
subcutaneous tunnel when diagnostic laparoscopy was not
feasible in patient with poor condition
Cauda
Cepha
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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
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Case 3. early stage omentum wrapping
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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
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Case 4. late stage omentum wrapping
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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
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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
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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
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Case4
Case 6. catheter-related peritonitis with I/O obst.
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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
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Case 7. catheter-related peritonitis with abscess
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Case 7. Re-on PD catheter 3 weeks later
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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)
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Case 8. catheter-related peritonitis with S.P
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Encapsulated sclerosing peritonitis- treated by peeling
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Encapsulated sclerosing peritonitis with Candida infection
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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
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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
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Case 10. secondary peritonitis due to ischemic bowel
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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
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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
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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
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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
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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
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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
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• 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
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What’s your action when seen in diagnostic laparoscopy?
Conversion to laparotomy?
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Irrigation with lots of saline, checking appendix, cecum, terminal ileum,
pelvis, sigmoid-rectum, GB, Morison’s pouch, duodenum, stomach, S.B.
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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
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Peri-catheter leak
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Subcutaneous leaks
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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
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Hydrothorax (水胸)
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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
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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)
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Outcome of pleurodesis of hydrothorax in PD
Mak et al. Ann Thorac Surg 2002;74:218-221
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Bleeding
• Subcutaneous hematoma:
• Bloody dialysate (hemoperitoneum):
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Case 11. subcutaneous ecchymosis
• 47y/o female
• General edema, low
albumin & Hct, prolonged
BT/APTT
• 2010/05/24 PD insertion
• Subcutaneous ecchymosis
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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
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Case 12. bloody dialysate
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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
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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
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Hernia
• Umbilical: herniorrhaphy with/without mesh
• Inguinal: herniorrhaphy with/without mesh
• Ventral: herniorrhaphy with/without mesh
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Umbilical hernia Inguinal hernia
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Others
• Pre-peritoneal catheter placement
• Peritoneal penetration when creating curve
subcutaneous tunnel
• Abdominal discomfort during infusion and
drain
• Pneumoperitoneum (shoulder pain)
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已把尖銳處磨鈍了
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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
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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
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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
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Removal of PD catheter
CephaCauda
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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.
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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}
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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)
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Thank you for your attention!