Perit Dial Int
30(1):
41-45
2010
© 2010 International Society for Peritoneal Dialysis
THE EFFECTS OF PREVIOUS ABDOMINAL OPERATIONS AND INTRAPERITONEAL ADHESIONS ON THE OUTCOME OF PERITONEAL DIALYSIS CATHETERS
Amir Keshvari1,
Mohammad Sadegh Fazeli1,
Alipasha Meysamie2,
Sepideh Seifi3 and
Mohammad Kazem Nouri Taromloo1
Departments of Surgery,1 Community &
Prevention Medicine,2 and
Nephrology,3 Tehran University of Medical Sciences,
Tehran, Iran
Correspondence to: A. Keshvari, Surgical Ward 3, Imam Khomeini Hospital,
Keshavarz Blvd., Tehran, Iran.
keshvari{at}sina.tums.ac.ir
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ABSTRACT
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Background: Patients with previous history of abdominal
operations are sometimes excluded from consideration for peritoneal dialysis
because of concerns for increased risk of complications during the
implantation procedure and inadequate dialysis due to reduced peritoneal
surface area. Employing a laparoscopic approach, we compared the outcome of
peritoneal dialysis catheters in 2 groups of patients with and without
intra-abdominal adhesions.
Methods: All data in this report were recorded
prospectively. Revision-free and overall survival of catheters, the incidence
of mechanical and infectious complication, and surgical revision rates were
compared between the 2 groups.
Results: In 217 successful catheter implantations,
there was a history of previous abdominal surgery in 42.9% of procedures; only
26.9% of them had intraperitoneal adhesions; 2.8% of patients without history
of previous abdominal surgery had intraperitoneal adhesions. There were no
significant differences between the 2 groups for 1- and 2-year revision-free
and overall catheter survival, mechanical dysfunction, infectious
complications, or surgical revision rates.
Conclusion: History of previous abdominal surgery
should not be used to judge the eligibility of patients for peritoneal
dialysis. Laparoscopic placement is the best way to ensure optimal catheter
outcomes equivalent to patients without previous abdominal surgery.
KEY WORDS: Peritoneal dialysis catheter; intraperitoneal adhesion; abdominal operation; laparoscopy.
Peritoneal dialysis (PD) is an established form of therapy in the
management of the end-stage renal disease. Concern over intraperitoneal
adhesions from previous abdominal surgery is often used to judge patient
eligibility for PD. Peritoneal adhesions have been reported to form after 70%
– 90% of abdominal operations
(1). Catheter implantation
using conventional approaches in patients with intra-abdominal adhesions has
been associated with an increased incidence of post-operative complications
(2). In the presence of
adhesions, catheter insertion can be complicated by visceral injury,
hemorrhage, and catheter malposition with flow dysfunction. Visualization of
the peritoneal cavity during implantation of PD catheters using laparoscopic
methods can determine the presence and extent of intra-abdominal adhesions and
help direct the placement of catheters. The purpose of the present study is to
investigate how the use of a laparoscopic modality for catheter placement may
affect differences in catheter outcomes in patients with and without
intra-abdominal adhesions.
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MATERIALS AND METHODS
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All data in this report were recorded prospectively in a database of
patients that underwent laparoscopic implantation of PD catheters from March
2004 to February 2008. Catheter implantation was performed using a
laparoscopic approach previously described in detail
(3). The peritoneal catheter
was inserted at a paramedian site through a port conduit that was tunneled
under laparoscopic control in a cranial-caudal direction through the rectus
muscle and sheath. The 4 cm rectus sheath tunnel promoted pelvic orientation
of the catheter tip. The deep catheter cuff was positioned in the rectus
muscle below the anterior rectus sheath. The catheter was tunneled
subcutaneously from the insertion site in an arcuate configuration to produce
a downward skin exit site.
Revision-free and overall catheter survival probabilities were estimated
using the method of Kaplan and Meier. Comparison of probability curves was
performed with the log-rank test. Catheter failure was defined as removal of
the catheter for some mechanical and infectious complications such as
pericannular leak, flow obstruction, and severe peritonitis. Catheter loss due
to death or transplantation was censored although counted as survived
catheters because these catheters had no problems and were working when
removed. Infectious complications included exit-site/tunnel infection and
peritonitis and were summarized as the total number of patients having an
infectious event during the study period. Surgical revisions were performed
for catheter flow dysfunction when conservative management could not eliminate
the problem and they were recorded as the total number of cases requiring
operative intervention.
Chi-square was used to compare nominal data and t-test to compare
continuous data. All results were considered significant at p <
0.05. For descriptive purposes, cumulative rates of mechanical complications,
infections, and catheter loss were calculated from the total number of
episodes of an event divided by the total patient-years on dialysis for each
group.
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RESULTS
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Successful laparoscopic implantation of 217 catheters was achieved in 218
consecutive procedures in 207 patients. One patient with extensive adhesions
could not be implanted. All but 16 catheters were two cuff, swan neck,
coiled-tip Tenckhoff catheters (Medionics International, Markham, Ontario,
Canada). No catheters were lost to follow-up. Mean patient age was 50.9
± 16.8 (range 3 – 84) years and 51.2% were female. There was a
history of previous abdominal surgery in 93 of 217 procedures (42.9%). Only 25
(26.9%) patients with previous surgery were noted to have intraperitoneal
adhesions. Previous abdominal surgery in patients with adhesions included
caesarian section, hysterectomy, cholecystectomy, renal transplantation,
nephrectomy, previous PD catheter implantation, abdominal wall hernia, and
laparotomy for bowel obstruction (due to extensive intraperitoneal adhesions)
or intraperitoneal bleeding following blunt abdominal trauma. In addition, 6
patients (2.8%) without previous abdominal surgery were noted to have
adhesions between the omentum and the umbilical region (2 had umbilical
hernias).
Laparoscopic adhesiolysis for extensive adhesions in order to permit
catheter implantation was required in only 3 patients. In 7 patients with
extensive adhesions limited to one side of the abdomen, the site of catheter
insertion was selected on the uninvolved side. In 1 patient with extensive
adhesions in the lower abdomen, a window was created through the omentum to
permit positioning of the catheter tip in the open deep pelvis. The adhesions
in the remainder of the patients did not require any special intervention or
modification of our standard implantation technique.
The results of the comparative analysis between the 31 patients with
adhesions and the remaining 186 patients without intraperitoneal adhesions are
summarized in Table 1. There
were no differences in the types of mechanical complications or revisional
interventions following catheter insertion in the groups with and without
intraperitoneal adhesions. The numbers of catheters lost due to mechanical
complications were 2 of 6 (33.3%) and 11 of 42 (26.2%) in the groups with and
without intraperitoneal adhesions respectively. Catheter flow dysfunction
accounted for 27 of the 48 total mechanical complications and included 7
omental wraps, 5 intestinal entrapments, 3 fibrin clots, 2 catheter tip
migrations, 1 adherent uterine tube, and 9 temporary outflow obstructions
remedied by conservative means. The remainder of the mechanical complications
included 17 leaks (15 pericannular, 1 inguinal hernia, 1 subcutaneous tubing
damage), 3 cuff extrusions, and 1 postoperative hemorrhage. The 18 surgical
revisions for catheter flow obstruction included clot removal alone,
repositioning with/without clot removal, adhesiolysis plus repositioning
(with/without clot removal), and repositioning plus omentopexy. The remainder
of the revisions included hernia repair, catheter repairs (cuff, tubing,
pericatheter leak), and surgical control of bleeding.
There were no significant differences between the two groups with and
without adhesions for 1- and 2-year revision-free and overall catheter
survival, mechanical dysfunction, infectious complications, or surgical
revision rates (Table 1).
Survival curves for the two groups of catheters are shown in
Figure 1.
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Figure 1 — Overall catheter survival was not significantly different for
patients with and without intraperitoneal adhesions.
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DISCUSSION
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Continuous ambulatory PD is an increasingly popular treatment modality for
patients with renal failure; however, despite widespread acceptance of this
therapy, patients with a history of abdominal operations are frequently
excluded from consideration. Abdominal surgery can lead to the formation of
adhesions. Adhesive scarring within the peritoneal space can complicate
catheter placement. Compartmentalization of the peritoneal cavity by adhesions
can impede insertion of the catheter, produce kinking or malpositioning of the
tubing, block the side drainage holes resulting in flow dysfunction, and limit
the available dialyzable space
(4). It is not unreasonable to
surmise that intraperitoneal adhesions would not only increase the difficulty
and risk of catheter insertion but also would adversely affect catheter
survival.
History of previous major abdominal surgery is considered a
contraindication for blind and fluoroscopically assisted Seldinger
needle-guidewire approaches to catheter insertion due to placement failure and
risk of bowel perforation
(5–10).
While open placement permits direct visual confirmation of entry into the
peritoneal cavity, insertion of the catheter is still performed mostly by
feel, and therefore blindly. Tiong et al.
(2), using a conventional open
approach for catheter placement, noted a 41.9% incidence of early
post-implantation complications in patients with previous abdominal
operations, compared to 26.4% in those without prior surgery (p =
0.02). The types of complications, however, were not specified for each group.
Chen et al. (11),
also using conventional open catheter insertion, noted significantly longer
procedure time (85 vs 65 minutes, p < 0.05) due to increased
procedural difficulties from adhesions in patients with a history of abdominal
surgery. The incidence of catheter malfunction tended to be higher in patients
with prior operations (16.7% vs 12.5%), although the difference did not reach
statistical significance, most likely due to small sample size.
Laparoscopy, on the other hand, provides a relatively noninvasive method to
fully investigate the peritoneal cavity
(12,13).
Under laparoscopic vision, adhesions that interfere with catheter placement or
that may impede dialysate drainage can be divided. Alternatively, as
demonstrated in the present study, the necessity for adhesiolysis may be
avoided using laparoscopic vision to select an uninvolved site for catheter
placement on the opposite side of the abdomen or permit advancement of the
catheter through a window in the adhesions to reach an open area.
According to our findings, 63.1% of the patients with previous surgery had
no intraperitoneal adhesions. In the remainder of the patients, modification
of our standard implantation technique was required in 3 groups: (1)
laparoscopic adhesiolysis (in 3 patients); (2) selection of the left side of
abdomen for catheterization due to extensive adhesion in the right; and (3)
window creation through the omentum (in 1 patient).
The 43% incidence of previous abdominal surgery in our study population
reflects our policy of not excluding patients because of a history of previous
abdominal operations. This prevalence rate of previous abdominal surgery is
similar to the 45.8% – 55.1% rate of other series that did not restrict
potential PD candidates
(14–16).
Our observed incidence of intraperitoneal adhesions was lower than that noted
in studies that specifically looked for postoperative adhesions
(1,17).
Based on autopsy studies, intra-abdominal adhesions were found in 75% –
90% of patients with a history of abdominal surgery and in 10% of patients
without previous surgery. We noted a 27% incidence of adhesions in patients
with prior surgery and a 2.2% incidence in those without a history of
abdominal operations. This difference may be due to the practicability of a
more complete and vigorous search for adhesions in autopsy series, whereas we
were more concerned with the clinically obvious lesions.
It should be noted that 63% of our patients with a history of abdominal
operations had no clinically apparent intraperitoneal adhesions. This
emphasizes that the occurrence of adhesions is unpredictable and has great
individual variability. Scars on the abdomen from previous surgery do not
predict the existence and extent of adhesions and should not be used to judge
eligibility for PD.
Gender differences in our study were due to operations on the female
reproductive tract. When operations on the female reproductive tract were
excluded, there was no difference in the incidence of intraperitoneal
adhesions in males and females.
In summary, the present study shows that the laparoscopic modality can
eliminate the differences in PD catheter outcomes that accompany conventional
catheter insertion methods when intraperitoneal adhesions are present.
Patients should not be deprived the opportunity to pursue PD because of a
history of abdominal operations. Currently, laparoscopy is the only practical
way to reliably investigate the suitability of the peritoneal cavity for
dialysis in these patients. Laparoscopic vision enables adhesiolysis when
needed and permits insertion of the catheter into a position of most favorable
function. Conventional catheter placement techniques are suboptimal approaches
for patients with prior abdominal surgery.
According to our current policy, there is no contraindication for doing
peritoneal dialysis in patients with previous surgical operation unless there
is the impossibility of insufflation of the peritoneum for laparoscopy or when
we cannot eliminate peritoneal compartmentalization laparoscopically.
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DISCLOSURE
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The authors declare that no financial conflict of interest exists.
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ACKNOWLEDGMENTS
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The authors thank Mrs. Akram Safari, the nurse of the PD Clinic of Imam
Khomeini Hospital, and the PD nurses in other medical centers of Iran for
helping us with data collection.
Received 7 May 2008;
accepted 6 February 2009.
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ABSTRACT
MATERIALS AND METHODS
