Page 4 - WJOLS - Laparoscopic Journal

Amir Keshvari

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then returned it to the peritoneal cavity by pushing it back formation. Without consideration of the cause of clot
through tissue tract and put it again into the deep pelvis formation, clot removal by a safe method, may avoid catheter
under vision of laparoscopy. Catheter function is tested using removal or replacement.
a 0.5-L bag of normal saline to demonstrate rapid inflow Rapid flushing of the catheter by normal saline mixed
and out flow. After drainage of insufflated gas, removal of with heparin and push-and-suck maneuver often used in
the laparoscopic ports is delayed until a satisfactory irrigation attempting to push the intraluminal clot but do not always
test of the catheter has been achieved. The fascia of the reliably clear PD catheter of fibrin deposited in the lumen.
port sites is not ordinarily repaired. Skin wounds are closed Streptokinase is used to clear obstructed catheters by
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with nonabsorbable sutures material. Peritoneal dialysis is clot from 1969 and there is many reports about it, 19,20 but
generally started at second postoperative day. streptokinase is not usable for many patients like those having
a predisposition to bleeding, a platelet count less than
RESULTS 100,000/cu mm, prolonged prothrombin or partial
thromboplastin times, serious infection around the catheter,
A total of 14 laparoscopic ECCE procedures for clot removal
were performed for 14 consecutive patients. The mean known allergy to streptokinase, recent Streptococcal
infection, or streptokinase therapy in the previous six
patient age was 57.64 years (rang 21 to 75) and male to months. Urokinase is also effective in clearing clotted
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female ratio was 4:3. All catheters were swan-neck, coiled- 4
tip. Previous implantation procedures in 9 patients were catheters. It lacks the risk of allergic reactions that may
laparoscopic and in 5 patients was open surgery. The occur with streptokinase. Manipulation of the catheter using
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procedure was possible in 5 cases by one trocar and other malleable stainless steel wire under fluoroscopic guidance
have been reported as a successful procedure which achieved
cases need to another additional trocar. In 6 patients, the
pathologic problem of the catheter was just intraluminal 48 to 65% catheter function success rate, however, this
fibrin clot (IFC). Five patients had intestinal entrapment technique required sedation of patients because the stiff
(IE), 2 patients had adhesion of the catheter to the fallopian wire caused discomfort, and there is potential risk of bowel
tube and 1 patient has tip migration as well as IFC. damage with the stiff wire.
Clot removal using endoscopic channel—cleaning brush
In all cases, the clot was successfully extracted using 9,10
the method described herein. Inflow and outflow of all the under fluoroscopic control is suggested. Although, it is
catheters was excellent at the end of operation. One patient smoothly rounded tip would be unlikely to cause trauma to
was dead at day 6 due to sepsis and in another patient the the abdominal contents, but it is a possibility, particularly if
catheter was removed due to nontolerance at day 20. Eight the brush was accidentally advanced beyond the end of the
catheter into the peritoneal cavity. The other concern is the
of catheters were nonfunctional before day 20. Long-term
function of the catheter was achieved in 4 patients. possibility of dislodgement of bristles of the brush in to the
peritoneal cavity. According to our experience for clot
removal in our first patient with endoscopy brush, under
DISCUSSION
vision of laparoscopy intracorporeal clot extrusion was very
In a review of literatures which published from 1999 to difficult and time wasting.
2008, about rescue procedure for malfunctioning peritoneal Laparoscopic clot extrusion has many advantages: It
dialysis catheters, the rate of intraluminal fibrin clot as a allow direct examination of the catheter and whole peritoneal
cause of mechanical obstruction, was reported between cavity.
0 to 60%. 14-18 In our experience according to this study, It is highly accurate to confirm the diagnosis of
the rate is 30% (15 from 50). intraluminal fibrin clot as a cause of malfunction of the
It is not clearly determined the exact causes of fibrin catheter before using any procedure for rescue it and prevent
clot formation in the lumen of the peritoneal dialysis catheter. performance of unnecessary interventions. It enable
Peritonitis, intraperitoneal bleeding, visceral entrapment or diagnosis of other accompanying pathology and treatment
adhesion to the catheter, delay in the use of the catheter other surgical problems in the same operations.
after its implantation and compression of the catheter by Some disadvantages for using laparoscopy in PD catheter
adjacent organs are described as predisposing factor of clot implantation or management of malfunctioning catheters

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JAYPEE