J Huazhong Univ Sci Technol [Med Sci] 35(1):71-75,2015 DOI 10.1007/s11596-015-1391-8 J Huazhong Univ Sci Technol [Med Sci] 35(1):2015

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Superiority of Laparoscopy in the Peritoneal Dialysis Catheter Reset Surgery Wen-li CHEN (陈文莉)1, Guo-hua DING (丁国华)1#, Zhi ZHENG (郑 直)2, Chang-xuan LIU (刘昌璇)3 Department of Nephrology, Renmin Hospital of Wuhan University, Wuhan 430060, China 2 Department of Hepatopancreatobiliary Surgery, 3Department of Nephrology, Wuhan Central Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430014, China

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© Huazhong University of Science and Technology and Springer-Verlag Berlin Heidelberg 2015

Summary: Peritoneal dialysis catheter surgery has been used in clinical treatment for nearly 40 years, and open surgery under local anesthesia is the conventional method. However, catheter displacement after open surgery is still the thorny issue during our clinical practice. Then the reset surgery is often required to be taken again. Nowadays, laparoscopic peritoneal dialysis catheter draws our attention due to its advantages of accurate positioning, smaller incision, and less pain, and its clinical application has been limited. While laparoscopic surgery is recognized, there are few relevant studies on whether there is difference during the catheter reset process between the two surgical approaches. In this study, we mainly discussed the rate of secondary catheter migration, the incidence of complications after catheter reset for two surgical approaches and the hospital stay as well as the total clinical cost for the two surgical approaches. In this study, we retrospectively analyzed 25 cases of end-stage renal disease, who received catheterization for peritoneal dialysis and regular peritoneal dialysis in our hospital from March 2010 to December 2013, and had a medical history of catheter migration. We collected the relevant clinical data for all patients. Fifteen patients selected laparoscopic catheter reset, and 10 patients selected the traditional surgical method for catheter reset by themselves. For all patients enrolled, we analyzed the incidence of secondary catheter migration and postoperative complications, hospitalization time, and total cost for different methods of reset. Through the studies above, we found that laparoscopic peritoneal dialysis catheter surgery offered accurate catheter location and a small incision that was easy to heal. Besides, the incidence of postoperative complications for the laparoscopic surgery was lower than that for traditional surgical approach for catheter reset. The average hospitalization time for laparoscopic surgery was shorter than that for the traditional surgical approach. The total cost of laparoscopic surgery was more than that of the traditional surgery. Therefore, the rational application of a laparoscopic peritoneal dialysis catheter and reset surgery can increase the success rate of peritoneal dialysis, reduce the complications, shorten hospitalization time of patients, and thus enhance patient’s confidence to stick it out. Key words: laparoscope; peritoneal dialysis catheter; catheter migration

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Peritoneal dialysis (PD) is one of the important approaches to treat end-stage renal failure. In comparison with hemodialysis, it has the advantages of simple operation without special equipment, home treatment, low impact on the cardiovascular system, and protection of residual renal function. In 1978, Nolph reported that the treatment of continuous ambulatory peritoneal dialysis (CAPD) on the end-stage renal failure achieved good results, and it was gradually widely applied in clinical practice due to its simplicity and safety[1]. Traditional catheter placement is an open surgery that usually uses local anesthesia. The catheter placement can be achieved through an abdominal incision and guiding wire. It is difficult to visually determine if the placement of the catheter is correct during the surgery, and some patients’ catheters are prone to migrating after the surgery. Laparoscopic catheterization has precise positioning and makes it possible to secure the catheter onto the ab

Wen-li CHEN, E-mail: [email protected] Corresponding author, E-mail: [email protected]

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dominal wall or the visceral peritoneum, making catheter migration more difficult. However, although Park et al[2] proved that laparoscopic surgery does not have obvious advantages in comparison with open surgery, and the one-time hospitalization cost is relatively expensive, there have been no relevant reports on the advantages and disadvantages of catheter reset between traditional surgical and laparoscopic approaches. In this study, we studied 25 patients undergoing regular peritoneal dialysis in our hospital, who all had a medical history of primary catheter migration, and detected the impact of the means of surgical replacement on the rate of secondary catheter migration, the impact of the surgical approach to catheter reset on the postoperative complications, and the influence of the surgical approach to catheter reset on the cost and hospitalization time. By analyzing these data, we can understand the advantages and disadvantages of the traditional open surgical approach and the laparoscopic surgical approach when applied to peritoneal patients so that we can create a basis of reliable data to provide better medical services to patients.

72 1 MATERIALS AND METHODS 1.1 Data of Enrolled Patients We collected 25 patients who received PD in our hospital from March 2010 to December 2013, and all of them were readmitted due to catheter migration. The relevant information was collected, including the age, gender, primary disease and clinical biochemical indices of the patients (table 1 and 2). All of these 25 patients had accepted open surgery under local anesthesia, and the catheters used were all crimp catheters (the full length of the COVIDIEN PD catheter was 62 cm). No bacteria were detected growing in patients’ peritoneal dialysate, so peritonitis was excluded. All the patients still suffered impeded flow of PD fluids after the conservative treatment of conventional cathartics and sports. From the abdominal plain film, the shift or improper position of catheter could be identified; the patients experiencing the continued migration of conduits (fig. 1) required surgical reset.

J Huazhong Univ Sci Technol [Med Sci] 35(1):2015

of the umbilicus and established the pneumoperitoneum by puncture. Next, we implanted a 10-mm Trocar so as to place the laparoscopic monitoring device to know the situation in the abdominal cavity. Then, at 2–3 cm below the outer edge of the umbilicus, we inserted 5-mm Trocars into both the left and right lateral rectus to place the laparoscopic operation device (fig. 2A). The patient was adjusted to the Trendelenburg position, and the head was tilted downward by 20°–30°. For the patients with simple catheter migration, directed by laparoscopic observation, we placed the peritoneal dialysis catheter to the bladder or uterine rectal fossa (fig. 2B) and used a non-absorbable suture to fix the catheter to the adjacent abdominal wall (fig. 2C), to prevent the secondary migration. For catheter migration accompanied by omental wrapping (fig. 2D), we separated the omentum and the catheter using a blunt dissection technique. If the omentum was overlong, the redundant would be cut away and the remaining procedures were the same as above. When the catheter was fixed in place, the patient was returned to the horizontal position, and 100–200 mL normal saline was injected from the dialysis catheter mouth into the abdominal cavity. Under the laparoscope, we observed the condition of patency of the main holes and each side hole of the dialysis catheter, then we discharged the pneumoperitoneum when the drainage was convinced to be effective; at last, we removed the laparoscopic device and sutured and closed all the incisions to finish the surgery.

Fig. 1 Catheter migration in X-ray There was a peritoneal dialysis Tenckhoff tube indicated by a white arrow.

1.2 Operation Approach After communication with the patients before surgery, the patients chose the surgical approach by themselves. A total of 15 patients selected the laparoscopic surgical reset, and 10 patients selected the traditional open surgical reset. For the 25 patients, preoperative routine chest X-rays and electrocardiograms were applied to examine the cardiopulmonary condition. There was no significant enhancement in the cardiothoracic ratio and no significant arrhythmia. Besides, there were no obvious differences between the two groups in age and clinical biochemical indices (P>0.05, table 1). All of these 25 patients exhibited hypertension, and the preoperative systolic blood pressure was controlled under 160 mmHg. And all patients’ preoperative serum potassium and coagulation functions were normal, and platelets were more than 100×109/L. The patients who selected laparoscopic catheter reset surgery all underwent general anesthesia and tracheal intubation. STORZ image 1 hub laparoscopic apparatus was employed, and the patients were in supine position during the surgery. After anesthesia was successfully completed, we made a 1-cm incision on the upper edge

Fig. 2 A: Insertion of 5-mm Trocars into both the left and right lateral rectus to place the laparoscopic operation device; B: Simple catheter migration; C: Fixation of the catheter to the adjacent abdominal wall; D: Catheter migration accompanied by omental wrapping

Patients who chose the traditional open surgical replacement with dorsal position were sterilized on their abdominal skin. We chose the place next to the original peritoneal dialysis catheter incision (roughly 0.5 cm) as the reset position. Next, the skin was cut open under local anesthesia with 2% lidocaine solution, the subcutaneous tissues were isolated to the anterior rectus sheath, the dialysis tube was probed with a finger to keep the dialysis tube off, and the anterior sheath was carefully cut open. After separation of the muscle tissue from the posterior rectus sheath, the sheath was lifted and a 2-cm

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incision was made and the peritoneum was shown. The peritoneum was opened, and the abdominal cavity was fingered into to find the tube along the location of the purse string suture for placement of original peritoneal dialysis catheter. Then, the dialysis tube was carefully pulled out through the new peritoneal incision. If it was simple catheter migration, the oval duct was clamped and the catheter was inserted slowly into the rectovesical ponch or the Douglas’ Pouch by the new incision. If it was wrapped in omentum, we separated the omentum and the catheter using a blunt dissection technique, then the catheter abdominal section was washed with sterile saline repeatedly followed by putting the catheter into the abdominal cavity. Normal saline (100–200 mL) was injected through the peritoneal dialysis tube to the abdominal cavity; if the fluid flowed fluently, the reset operation was successful, and we could finally suture and close all the incisions to finish the surgery. 1.3 Data and Statistical Analyses Data analysis was performed using SPSS version 18.0 software (SPSS, Inc., USA) and categorical variables were expressed as frequency and proportion, while continuous variables were expressed as ±s. The former were analyzed using the chi-squared test, and the latter were analyzed by the one-way ANOVA. A probability value of less than 0.05 was considered statistically significant. 2 RESULTS 2.1 Laparoscopic Position Fixing and Incidence of Catheter Migration for Peritoneal Dialysis Catheters For the 25 patients with primary catheter migration, the group of laparoscopic catheter placement had 11 cases of simple catheter migration, and 4 cases of catheter migration with omental wrapping. While the group of opening surgical approach had 9 cases of simple catheter migration, and only 1 case of catheter migration with omental wrapping. For all patients, there was no obstruction on the peritoneal dialysis fluid after the replacement surgery, and it was identified by abdominal plain film that all the catheters were located in the pelvic cavity on the first postoperative day. From the above we could come to the conclusion that the reset operation was successful. As shown in table 3, for the 15 patients who selected laparoscopic catheter reset surgery, there was no occurrence of secondary catheter migration during the follow-up period from three months to four years. How-

ever, for the 10 patients with catheter reset using conventional open surgery, the rate of secondary catheter migration during the follow-up period was 20%, which was significantly higher than that for the patients who selected laparoscopic catheter reset surgery (P<0.05). 2.2 Incidence Rate of Complications in Laparoscopic Catheter Reset Surgery vs. Open Surgery On the first day after the surgery, the catheters of the patients were locked, and we did not perform peritoneal dialysis treatment on the patients to promote the healing of tissues around the incision and to avoid exudation and leakage. In order to avoid leakage of dialysate caused by excessive intra-abdominal pressure, small doses of peritoneal dialysis (500 mL per time) were given on the second day after the surgery. For the patients with successful replacement using the laparoscopic technique, the operating time was 30–45 min, and the average blood loss was 5–10 mL. During the operation, there were no significant complications. After the operation, the patient recovered well from the anesthesia, and the removal of tube of the tracheal intubation was smooth. The postoperative mortality rate was lower for the laparoscopic approaches than for traditional approaches (table 3). There were 6 cases of bloody dialysate: 1 in the laparoscopic surgery group (6.7%), and the rest 5 in the traditional surgery group (50%) (P<0.05). The wound infection rate after the open surgical catheter reset was higher than that after the laparoscopic surgery [3 (30%) vs. 0 (0%), P<0.05]. Local dressings of the patients were changed once every two days. Wound infection occurred 4–6 days after the operation, characterized by local skin redness, minor swelling and pain, but no purulent secretion, dressings were changed once a day after infection, other than using antibiotics. There was no significant difference in incidence of peritonitis between the open surgical catheter reset and laparoscopic catheter reset. 2.3 Comparison of Hospital Stay and Hospitalization Expenses between Open Surgical Reset and Laparoscopic Catheter Reset Surgery The hospitalization expenses in traditional open reset surgery (0.93±0.17 ten thousand RMB) were less than those in laparoscopic catheter reset surgery (1.31±0.15 ten thousand RMB), and the hospital stay in the former (8.3±1.9 days) was longer than that of the latter (5.6±1.1 days). The differences between two groups were statistically significant (P<0.05).

Table 1 Comparison of the primary diseases between the two groups Laparoscopic group Traditional surgery group Cases (n) 15 10 Diabetic nephropathy 5 4 Chronic glomerulonephritis 4 1 Hypertensive kidney lesion 1 3 Interstitial nephritis 2 0 Obstructive nephropathy 2 1 Anaphylatic purpura nephritis 1 0 Lupus nephritis 0 1

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Table 2 Comparison of the patients’ general conditions before surgery Laparoscopic group Traditional surgery group Cases (n) 15 10 Gender (male/female) 9/6 7/3 Age (years) 59.4±7.1 51.7±10.5 Blood urea nitrogen (mmol/L) 26.3±5.9 27.5±4.7 Creatinine (μmol/L) 718.3±105.1 695.4±88.1 Hemoglobin (g/L) 89±10.6 94±11.2 Albumin (g/L) 31±8.3 32±7.9

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Table 3 Comparison of various indicators between two surgical procedures Laparoscopic group Traditional surgery group Cases (n) 15 10 Bloody dialystate 1 (6.7%) 5 (50%)* Wound infection 0 (0%) 3 (30%)* Peritonitis 0 (0%) 0 (0%) 0 (0%) 2 (20%)* Secondary catheter migration Hospital stay (days) 5.6±1.1 8.3±1.9* Hospitalization expenses (ten thousand RMB) 1.31±0.15 0.93±0.17* Operation expenses (ten thousand RMB) 0.71±0.11 0.13±0.03*

P<0.05

3 DISCUSSION PD uses the peritoneal membrane as the dialysis membrane and dialysis fluid is injected into the abdominal cavity. Using a solute concentration gradient and osmotic gradient, the plasma inside the capillary on the one side of peritoneum and the dialysate in the abdominal cavity on the other side clear the retention of metabolic water and excess water in the body through the principle of diffusive convection and ultra-filtration. Meanwhile, the necessary substances are supplemented through the dialysate. By constantly changing the fresh dialysis solution, we can achieve the goal of removing toxins, removing excess water, and correcting acidosis and electrolyte imbalance[3]. PD catheter surgery has the following three options: the blind bedside insertion, which has nearly been eliminated from the clinic and is only used for emergency rescue now because it is easy to damage adjacent organs, the traditional open reset surgery, and laparoscopic catheter reset surgery. Traditional PD catheter surgery requires an abdominal incision and is the most common method. However, the field of abdominal observation through a small incision is limited, and the positioning of the dialysis catheter is not accurate. The incidence of complications, such as catheter migration, is relatively high. After the surgical catheter reset, there can be secondary catheter migration, which might eventually cause the patients to lose confidence in PD and therefore quit dialysis. Therefore, a good dialysis catheter surgery is an important step in the successful PD treatment of patients. In recent years, the laparoscopic technique has been relatively widely applied to PD catheter reset surgery[4–6], as its advantages include the following five points: (1) The laparoscope method only requires three incisions of 0.5–1.0 cm in the abdomen, and the wounds are easy to heal; the postoperative recovery is fast, and the hospitalization time is significantly shortened[7]. (2) The posi-

tioning is accurate, and it is possible to rapidly reset a catheter or find a displaced catheter under direct observation, avoiding serious damage to internal organs and blood vessels, and there is essentially no postoperative displacement, ensuring the smooth implementation of PD. (3) Laparoscopic PD surgery can also suture the far end of the dialysis catheter and fix it to the excavatio rectovesicalis, Douglas’ pouch, round ligament of uterus, parietal peritoneum or visceral layer, bladder and the uterus rear, further reducing the incidence of peritoneal catheter migration[8–10]. The study by Numanoglu et al[11] indicated that the suture and fixation of the far end of the dialysis catheter can extend the lifetime of the dialysis catheter by 8.4 months on average. (4) Omentum can be mended by direct visual operation[12]. During the laparoscopic catheter reset surgery, surgeons can have a clear vision of the omentum. For patients with a overlong omentum, the neoplasty of omentum can be implemented and the redundant will be cut away to avoid wrapping or blocking of the catheter, which will affect the overflow of PD fluids[13, 14]. Four cases in 15 patients had wrapped omentum, and one of the four patients underwent the omentum mending surgery and developed bloody dialysate after the operation, but this kind of condition fell away after repeated dialysate rinse. (5) It is a surgery under general anesthesia, during which the patient experiences no pain, and the surgical approach fully embodies humanization; the postoperative physical recovery is relatively fast. In this study, 15 patients underwent the laparoscopic approach for a successful catheter reset. The long-term follow-up of PD went smoothly, which further indicates that this technique has its advantages. By observing the incidence rate of complications after the reset with open surgery and laparoscopic surgery, such as the rates of bloody dialysate, wound infection, peritonitis, secondary catheter migration, and the hospitalization time, it demonstrates the advantages of the laparoscopic technique in

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PD replacement in several aspects. Under direct visualization through the laparoscopic technique, we can fix the catheter on site and suture the curve side of the catheter to the nearby parietal peritoneum. In order to avoid the stimulus of the catheter to pelvic organs, we often reserve some sutures to allow the catheter to move on a small scale. Some foreign scholars inserted the looped end of a folded nylon suture into the abdominal cavity by the means of a 16-gauge needle, and then let the Tenckhoff catheter pass through the nylon loop by adjusting the catheter. At the last, the loop-introducing needle is removed and the nylon is sutured (with the help of a free needle on a needle holder) on the subcutaneous fascia of Scarpa or on the anterior rectus sheath and tied. The Tenckhoff catheter is in this way fixed at the lower anterior abdominal wall[15]. Of course, in comparison with traditional surgeries, there are also some shortcomings[16] in laparoscopic PD surgery, such as the relatively high risk of general anesthesia, influence on cardio-pulmonary function. Before the surgery, the risk of patients’ regarding toleration of the general anesthesia needs to be estimated again by the anesthesiologist. At the same time, anemia and blood clotting abnormalities need to be actively corrected, hypertension needs to be controlled, and the serum electrolytes should be maintained at a normal level. During the operation, we should shorten the surgical time as much as possible and reinforce the postoperative monitoring. The measurement of dialysis from small dose and all of the above means are keys to ensure the success of operation for patients. However, laparoscopic technique needs to be performed by demanding surgeons, supported by some devices, and has a higher hospitalization expenses, so in our hospital, we only apply this technique to patients in cases of PD catheter reset or obesity and to patients with a history of abdominal surgery or who have high medical requirements, and good results have been achieved. Especially in patients with previous history of abdominal surgery, traditional open surgery often cannot put the catheter in place due to its peritoneal adhesions, so that patients have an impeded flow of PD fluids postoperatively and even catheter blockage. With the laparoscopic catheter, ultrasonic scalpel can be used to separate the adhesions and expand the abdominal cavity volume. Besides, the laparoscopic technique can fix the catheter even more accurate. All of this can increase the success rate of PD[17]. Due to the small samples in this study, the conclusion does not have a strong representation, so more cases are needed to deeply investigate the advantages of the laparoscopic techniques. Conflict of Interest Statement We declare that we have no financial and personal relationships with other people or organizations that can inappropriately influence our work, and there is no professional or other personal interest of any nature or kind in any product, service and/or company that could be construed as influencing the position presented in or the review of the manuscript entitled.

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