Page 5 - WALS Journal

Najeeb H Mir

omentopexy in 3 (10%) cases. Late complications DISCUSSION
included catheter dysfunction in two patients (6.5%), Peritoneal dialysis is a safe and effective alternative for the
debilitating abdominal pain requiring catheter removal patients with ESRD, especially children. The preservation
9
in one patient, and one trocar-site hernia. The mean of residual renal function when compared with hemodialysis
follow-up was 17 months. Laparoscopic PD catheter 10,11
insertion is safe, reproducible and effective. It facilitates is much better with PD. The laparoscopic approach has
placement of the catheter tip into the pelvis and allows been widely accepted as an effective alternative to open
12-14
adhesiolysis, omentectomy or omentopexy when surgery. The open method requires a painful incision
necessary. Utilization of this technique results in a low followed by blind insertion and carries a high potential for
rate of PD catheter dysfunction. 4 adhesions, incisional hernia and delay in instituting full
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5. Ahmed M Al-Hashemy et al evaluated nine patients. volume peritoneal dialysis. The technique of two port
The mean operating time was 41 minutes (range 30-75 laparoscopic placement of PD catheter is gaining wide
min). The mean postoperative hospital stay was 4.5 days acceptance in terms of reliability, efficacy and long-term
(range 2-15 days). Two patients (22.2%) developed usage, with minimal complications. The conversion to open
leakage of dialysate from the 5 mm port and one patient in 6% of patients compares favorably with a 5.2%
(11.1%) had migration of the PDC. Our study suggests conversion rate for laparoscopic cholecystectomy and 21%
that this new modified technique appears to be safe and conversion rate for laparoscopic colectomy. 16,17 Catheter
simple and is associated with rapid postoperative malfunction can be caused by kinking, catheter
recovery. 3 displacement, omental wrapping, catheter-fibrin coating and
adhesions caused by abdominal infections. Besides exit-
RESULTS site and subcutaneous tract infections, peritonitis is a feared
1. Mean operative time: In three of our study groups the complication responsible for the catheter failures. Peritonitis
mean operative time was ranging from 32 to 52 can be recurrent, with a rate of relapse of ± 0.27 episodes/
minute. 3,4,7 patient/year. 7
2. Surgical revision: The conversion to laparotomy was Catheter migration is a common complication associated
about 6% (2/33) in one of the trials. 6 with all techniques of catheter placement. In one of the
18
3. Catheter survival: In one of the randomized controlled series, one patient required laparoscopic insertion of a new
trials catheter 6 months, 1 and 2 years survival rate was catheter due to migration. Dialysate leak remains a problem
94, 87 and 72%. 7 with catheter placement for continuous ambulatory
4. Catheter leakage: Four studies reported the rate of peritoneal dialysis. The leakage rate following placement
catheter leakage ranging from 0% (0/51) to 22.2% of the PD catheter through an abdominal incision has been
(2/9). 3,7,8 reported to be between 13 and 27%, especially with
5. Catheter outflow failure: Two studies reported catheter institution of early peritoneal dialysis. 15,19,20
outflow failure rates between 0% (0/38) and 7.6% (4/51) None of the patients in our series had any catastrophic
of procedures. 7,8 hemorrhage.
Another study showed malfunction of catheter
in 6.5% (2/31) of patients after a mean follow-up of CONCLUSION
17 months. 4
6. Catheter migration: The three randomized controlled Two port laparoscopic PD catheter insertion is a safe,
trials reported that the catheter migration occurred reproducible, and effective technique. It allows inspection
between 2.6% (1/38) and 4% (2/51) of the patients. 7,8 of the abdominal cavity and adhesiolysis, omentectomy, or
7. Hemorrhage: All the studies did not report any catastro- omentopexy when necessary. It facilitates exact placement
phic bleeding related to the two ports laparoscopic of the catheter tip into the pelvis where it functions best.
procedure. 1-8 This technique is a simple and rapid procedure with few
8. Infection: Two randomized controlled trials reported that complications due to its reliability and excellent results in
peritonitis occurred between 6.5% (2/33) and 13% terms of catheter function.
(7/51) of patients. 4,7 A successful PD program depends on the knowledge of
One nonrandomized controlled trial reported exit site the placement techniques and complications. A multi-
infection in 3% (1/33) of laparoscopic procedures. 4 disciplinary approach with great enthusiasm from the health
9. Mean follow-up: In three of our study groups the mean care team will improve the catheter outcome and long-term
follow-up was between 17 months and 2 years. 4,7,8 results.
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