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INTRODUCTION: Ultrasound has been found to facilitate early identification of peritonitis in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). METHODS: A retrospective analysis was carried out to evaluate the effectiveness of ultrasonography-guided removal of the Tenckhoff catheter in reducing complications like a shift to hemodialysis or death in CAPD patients. RESULTS: The "peritonitis rescue plan" supported timely decision-making for the removal of the infected catheter and resulted in a lower peritonitis episode per patient per month ratio (from 1:36 to 1:122) in 2021, a lower death rate (from 19% to 6.6%) and lower incidences of shifts to hemodialysis (from 2%-9% to 0%) as compared to that before the implementation of the plan in 2019. CONCLUSION: The implementation of the "peritonitis rescue plan" and the removal of the infected catheter within 3 days of peritonitis being detected was successful in improving the standard of care for patients undergoing CAPD.

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BACKGROUND: Dialysate leakage, a major complication in peritoneal dialysis (PD), causes difficulty in continuing PD. However, literature evaluating risk factors for leakage in detail and the appropriate break-in period to avoid leakage in pediatric patients is scarce. METHODS: We conducted a retrospective study on children aged < 20 years who underwent Tenckhoff catheter placement between April 1, 2002, and December 31, 2021, at our institution. We compared clinical factors between patients with and without leakage within 30 days of catheter insertion. RESULTS: Dialysate leakage occurred in 8 of 102 (7.8%) PD catheters placed in 78 patients. All leaks occurred in children with a break-in period of < 14 days. Leaks were significantly more frequent in patients with low body weight at the catheter insertion, single-cuffed catheter insertion, a break-in period ≤ 7 days, and a long PD treatment time per day. Only one patient who had leakage with a break-in period > 7 days was neonate. PD was suspended in four of the eight patients with leakage and continued in the others. Two of the latter had secondary peritonitis, one of whom required catheter removal, and leakage improved in the remaining patients. Three infants had serious complications from bridge hemodialysis. CONCLUSIONS: A break-in period of > 7 days and if possible 14 days is recommended to avoid leakage in pediatric patients. Whereas infants with low body weight are at high risk of leakage, their difficulty in inserting double-cuffed catheter, hemodialysis complications, and possible leakage even under long break-in period make prevention of leakage challenging.

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OBJECTIVE: Evaluate the impact of peritoneal dialysis catheter (PDC) tail-end design variations on PDC-related complications. METHOD: Effective data were extracted from databases. The literature was evaluated according to the Cochrane Handbook for Systematic Reviews of Interventions, and a meta-analysis was conducted. RESULTS: Analysis revealed that the straight-tailed catheter was superior to the curled-tailed catheter in minimizing catheter displacement and complication-induced catheter removal (RR = 1.73, 95%CI:1.18-2.53, p = 0.005). In terms of complication-induced PDC removal, the straight-tailed catheter was superior to the curled-tailed catheter (RR = 1.55, 95%CI: 1.15-2.08, p = 0.004). CONCLUSION: Curled-tail design of the catheter increased the risk of catheter displacement and complication-induced catheter removal, whereas the straight-tailed catheter was superior to the curled-tailed catheter in terms of reducing catheter displacement and complication-induced catheter removal. However, the analysis and comparison of factors such as leakage, peritonitis, exit-site infection, and tunnel infection did not reveal a statistically significant difference between the two designs.

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Richter's hernia is a rare type of hernia that occurs when the antimesenteric intestinal wall protrudes through a defect in the abdominal fascia leading to ischaemia, gangrene, bowel perforation and enterocutaneous fistulae. In this article, we describe a rare case of enterocutaneous fistula due to a Richter's hernia after a Tenckhoff catheter removal. This type of complication has not been previously reported in the literature. An 82-year-old man presented with a 1-day history of enteric content at the Tenckhoff catheter insertion site. Seven weeks earlier, the catheter was removed due to peritonitis. Removal was performed using open technique, and the fascia was not closed. Computed tomography revealed a small incarcerated hernia and subcutaneous fluid collection at the previous catheter insertion site. He underwent laparoscopy, which showed a Richter's hernia with perforation of the ileum causing an enterocutaneous fistula. A laparoscopic enterectomy was performed using a primary mechanical anastomosis. The hernia was repaired by primary suture without a mesh because of wound enteral contamination and the small size of the hernia. Richter's hernia has a misleading clinical presentation and contributes to high rates of morbidity and mortality. A secure myofascial closure during catheter removal may reduce the chances of this complication.

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BACKGROUND: The removal techniques for peritoneal dialysis (PD) catheters are open surgical dissection (OD) and the 'pull technique' (PT). The latter is limitedly used because of uncertainty about its feasibility and safety. This study aimed to compare the outcomes and complications between the two techniques. METHODS: This retrospective study included patients who underwent PD catheter removal from January 2015 to January 2021 in four PD centres in China. The patients were grouped according to the different removal techniques and were followed up to observe the potential complications. RESULTS: The demographic characteristics of patients in the PT (n = 68) and OD (n = 44) groups showed no significant difference. The indications for PD catheter removal were similar between the two groups, except for a higher frequency of peritonitis in the OD group (p = 0.010). In the PT group, the main complications were broken catheter (7.4%), superficial cuff infection (4.8%) and subcutaneous bleeding (4.8%). In the OD group, the main complications were death (9.1%) and subcutaneous bleeding (4.6%). CONCLUSION: PT might be a safe and reliable technique for PD catheter removal compared to OD. Considering its simple and non-invasive nature, PT should be recommended as the alternative to OD in suitable PD patients.

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Urachus is a tubular connection between the umbilical cord and the bladder of developing foetus and tends to degenerate during perinatal period to form an impatent median umbilical ligament. Failure to degenerate results in patent canal between the bladder and the umbilicus called "patent urachus" which may lead to serious of symptoms such as umbilical discharge, dermatitis, umbilical infection, abdominal pain or recurrent urinary tract infections. The Tenckhoff catheter is a tube used to perform peritoneal dialysis that is inserted through abdominal wall into peritoneum either by open surgery, minilaparotomy, laparoscopy or needle-guidewire technique. A CASE REPORT: A 57-years old man was admitted to the hospital after implantation of Tenckhoff catheter by percutaneous technique in order to start peritoneal dialysis treatment. His medical history was: endstage chronic kidney disease (diabetic nephropathy), type 2 diabetes and hypertension. After the infusion of dialysate the patient experienced sudden urine pressure and passed significant amount of urine. The CT scan showed the tip of catheter being placed inside the urinary bladder. The catheter was introduced through the abdominal wall into the canal of previously undiagnosed patent urachus. The decision about re-surgery was made to stitch urachal remnants and place new the Tenckhoff catheter. Awaiting the surgery patient temporary started hemodialysis. In ongoing observation patient did not present any complications associated with peritoneal dialysis treatment.

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BACKGROUND: Minimally invasive insertion of catheters for peritoneal dialysis can be performed laparoscopically or percutaneously under image guidance. In Geelong (Victoria, Australia) both methods are used. Our aim was to analyse the outcomes of all catheters inserted by both laparoscopic and percutaneous techniques and compare them against published studies from tertiary referral centres. METHODS: Data were collected retrospectively on all patients who had their catheter inserted (since 2006) within the Geelong regional service. We compared the outcomes of percutaneous catheter insertion under image guidance (percutaneous group, n = 29) with the laparoscopic catheter placement technique (laparoscopic group, n = 61). Perioperative, follow-up and catheter outcome data were collected. There were no exclusion criteria. Analysis was performed using the unpaired student t-test and chi-squared test. RESULTS: Ninety catheters were inserted between 2006 and 2017 in mostly male patients (63%) with a mean age of 60 ± 0.4 years. The most common aetiology of chronic kidney disease was diabetic nephropathy (34%). Percutaneous insertion required less operative time, shorter hospital stay and earlier initiation of peritoneal dialysis. In the longer term, percutaneous catheters were more likely to migrate and laparoscopic catheters were more durable but more often associated with peritonitis. Thirty-day complication rates did not differ between both groups. No Clavien-Dindo grade 3 or 4 complication was reported. CONCLUSIONS: Laparoscopic insertion of peritoneal dialysis catheters at our centre is performed safely and with patient outcomes comparable to published literature. Percutaneous insertion represents a safe and effective alternative based on the study findings.

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BACKGROUND: Peritoneal dialysis (PD) catheter migration impedes the efficacy of dialysis. Therefore, several techniques involving additional sutures or incisions have been proposed to maintain catheter position in the pelvis. AIM: To evaluate the efficacy of creating a short musculofascial tunnel beneath the anterior sheath of the rectus abdominis during PD catheter implantation. METHODS: Patients who underwent PD catheter implantation between 2015 and 2019 were included in this retrospective study. The patients were divided into two groups based on the procedure performed: Patients who underwent catheter implantation without a musculofascial tunnel before 2017 and those who underwent the procedure with a tunnel after 2017. We recorded patient characteristics and catheter complications over a two-year follow-up period. In addition, postoperative plain abdominal radiographs were reviewed to determine the catheter angle in the event of migration. RESULTS: The no-tunnel and tunnel groups included 115 and 107 patients, respectively. Compared to the no-tunnel group, the tunnel group showed lesser catheter angle deviation toward the pelvis (15.51 ± 11.30 vs 25.00 ± 23.08, P = 0.0002) immediately after the operation, and a smaller range of migration within 2 years postoperatively (13.48 ± 10.71 vs 44.34 ± 41.29, P < 0.0001). Four events of catheter dysfunction due to migration were observed in the no-tunnel group, and none occurred in the tunnel group. There was no difference in the two-year catheter function survival rate between the two groups (88.90% vs 84.79%, P = 0.3799). CONCLUSION: The musculofascial tunnel helps maintain catheter position in the pelvis and reduces migration, thus preventing catheter dysfunction.

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BACKGROUND: There is currently no consensus regarding the optimal type of peritoneal dialysis catheter (PDC). We compared the outcomes of PDCs according to the number of cuffs, intercuff and intraperitoneal segment shape, and presence of a weighted tip. METHODS: A systematic review of the literature was performed using the MEDLINE and Cochrane Library databases (end-of-search date: October 16th, 2019). We included studies comparing double-cuff vs. single-cuff, swan-neck vs. straight-neck, coiled-tip vs. straight-tip, and weighted vs. non-weighted PDCs for the outcomes of interest. We performed meta-analyses using the random-effects model. We assessed the risk of bias using the Newcastle-Ottawa scale and the Cochrane Collaboration's Tool. RESULTS: In total, 38 studies were identified, of which 20 were randomized controlled trials (RCTs) and 18 were observational studies. No statistically significant differences were detected between double-cuff vs. single-cuff, swan-neck vs. straight-neck, and coiled-tip vs. straight tip PDCs in any of the outcomes of interest. Weighted catheters were associated with significantly lower rates of tunnel infection (relative risk [RR] 0.52, 95% confidence interval [CI] 0.31-0.95, p = 0.03), migration (RR 0.07, 95% CI 0.03-0.16, p < 0.001), drainage failure (RR 0.62, 95% CI 0.39-0.96, p = 0.03), cuff extrusion (RR 0.40, 95% CI 0.21-0.74, p < 0.001), and complication-related removal (RR 0.53, 95% CI 0.44-0.64, p < 0.001). DISCUSSION: Among the different types of PDCs, weighted catheters result in lower complication rates and superior long-term outcomes compared to non-weighted catheters. Other aspects of the catheter design do not significantly affect PDC outcomes. PROTOCOL REGISTRATION: PROSPERO 2020 CRD42020158177.

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INTRODUCTION AND IMPORTANCE: Endometrial cancer may disseminate through lymphatic channels to pelvic and retroperitoneal lymph nodes, through the bloodstream to the lungs, or through the peritoneal space to peritoneal surfaces. However, not all endometrial cancers involve all 3 sites for metastatic disease. CASE PRESENTATION: A patient with large volume of symptomatic recurrence of peritoneal metastases from endometrial cancer was subjected to additional surgery and both regional and systemic chemotherapy. All aspects of her disease and its treatment were studied. CLINICAL DISCUSSION: The primary malignancy was treated by a laparoscopic hysterectomy and bilateral salpingo-oophorectomy followed by intravaginal radiation. Large volume recurrent disease limited to the abdomen and pelvis was treated by complete cytoreductive surgery (CRS), hyperthermic intraperitoneal chemotherapy (HIPEC) and early postoperative intraperitoneal chemotherapy (EPIC). After recovery from surgery, systemic chemotherapy with cisplatin and paclitaxel was administered. The patient is now 25 months following treatment for recurrent cancer and free of disease. CONCLUSIONS: The possibility of complete resection of recurrent endometrial cancer combined with HIPEC, EPIC and systemic chemotherapy is a treatment option for selected patients.

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Peritoneal dialysis (PD) related infections continue to be a major cause of morbidity and mortality in patients undertaking renal replacement therapy with PD. Nevertheless, despite the great effort invested in the prevention of PD infective episodes, almost one third of technical failures are still caused by peritonitis. Recent studies support the idea that there is a direct role of exit-site (ESIs) and tunnel infections (TIs) in causing peritonitis. Hence, both the prompt ESI/TI diagnosis and correct prognostic hypothesis would allow the timely start of an appropriate antibiotic therapy decreasing the associated complications and preserving the PD technique. The ultrasound exam (US) is a simple, rapid, non-invasive and widely available procedure for the tunnel evaluation in PD catheter-related infections. In case of ESI, the US possesses a greater sensibility in diagnosing a simultaneous TI compared to the clinical criterions. This peculiarity allows to distinguish the ESI episodes which will be healed with antibiotic therapy from those refractories to medical therapy. In case of TI, the US permits to localize the catheter portion involved in the infectious process obtaining significant prognostic information; while the US repetition after two weeks of antibiotic allows to monitor the patient responsiveness to the therapy. There is no evidence of the US usefulness as screening tool aimed to the precocious diagnosis of TI in asymptomatic PD patients.

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Bullous pemphigoid (BP), a chronic autoimmune subepidermal blistering skin disease, has been described in end-stage renal disease patients requiring dialysis after the placement of an artero-venous fistula. We report a case of a novel onset of BP following a peritoneal dialysis abdominal Tenckhoff catheter placement. The 3-month treatment with systemic doxycycline and topical clobetasol propionate allowed a rapid disappearing of the blisters and left the patient free of symptoms in the follow-up. To our knowledge, this is the first case describing a new BP onset after a peritoneal dialysis catheter placement.

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BACKGROUND: With the introduction of laparoscopic Tenckhoff catheter insertion in the early 1990s, catheter malposition resulting in malfunction remains a frequent complication, often requiring surgical or radiological intervention. In this pioneer study, we describe the technique of suturing the Tenckhoff catheter using an EndoClose (Medtronic, Macquarie Park, NSW, Australia) device to the anterior abdominal wall during laparoscopic insertion and compare its outcomes with those not sutured. METHODS: This is a retrospective study of all patients who underwent laparoscopic Tenckhoff catheter insertion at Western Health from January 2013 to June 2018. All procedures were undertaken or supervised by one surgeon. The primary outcome was catheter malposition requiring surgical revision. Secondary outcomes were time to malposition and complications. Peri- and post-operative factors were analysed to adjust for confounders using the Cochran-Mantel-Haenszel test. RESULTS: There were 82 patients in the sutured group and 63 patients in the non-sutured group. Catheter malposition occurred in 7.32% in the sutured group and 19.05% in the non-sutured group (P = 0.034; 95% confidence interval for the difference 0.007-0.237). There was an overall reduction in the odds of catheter malposition of 63% in favour of the sutured group. The median time-to-malposition was 128 and 182 days for the non-sutured and sutured group, respectively, but not statistically different. No differences were found for the number of post-operative complications. CONCLUSION: Suturing of Tenckhoff catheter with an EndoClose device to the anterior abdominal wall during laparoscopic insertion is a simple, safe and useful method of reducing catheter malposition.

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RATIONALE & OBJECTIVE: Despite a recent meta-analysis favoring straight catheters, the clinical benefits of straight versus coiled peritoneal dialysis catheters remain uncertain. We conducted a randomized controlled study to compare the complication rates associated with these 2 types of double-cuffed peritoneal dialysis catheters. STUDY DESIGN: Multicenter, open-label, randomized, controlled trial. SETTING & PARTICIPANTS: 308 adult continuous ambulatory peritoneal dialysis patients. INTERVENTION: Participants were randomly assigned to receive either straight or coiled catheters. OUTCOMES: The primary outcome was the incidence of catheter dysfunction requiring surgical intervention. Secondary outcomes included time to catheter dysfunction requiring intervention, catheter migration with dysfunction, infusion pain measured using a visual analogue scale, peritonitis, technique failure, and peritoneal catheter survival. RESULTS: 153 patients were randomly assigned to straight catheters; and 155, to coiled catheters. Among randomly assigned patients who underwent peritoneal dialysis, during a mean follow-up of 21 months, the primary outcome of catheter dysfunction or drainage failure occurred in 9 (5.8%) patients who received a coiled catheter and 1 (0.7%) patient who received a straight catheter. Straight catheters had 5.1% lower risk for catheter dysfunction (95% CI, 1.2%-9.1%; P=0.02). The HR of the primary outcome for coiled versus straight catheters was 8.69 (95% CI, 1.10-68.6; P=0.04). Patients who received a coiled catheter had similar risk for peritonitis but reported higher infusion pain scores than those who received straight catheters. LIMITATIONS: Generalizability to other peritoneal dialysis centers with lower volumes and other races and nationalities. CONCLUSIONS: Use of straight Tenckhoff catheters compared with coiled catheters reduced the rate of catheter dysfunction requiring surgical intervention. FUNDING: Funded by the Chinese University of Hong Kong. TRIAL REGISTRATION: Registered at ClinicalTrials.gov with study number NCT02479295.

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Background:In severe peritoneal dialysis (PD)-related peritonitis, patients' response to antibiotic can be poor. We postulated that adjunctive lavage may improve the outcome in severe cases by enhancing the removal of bacteria and inflammatory cells from the peritoneum.Methods:Severe PD peritonitis was defined as poor clinical response to empirical cefazolin/ceftazidime and a PD effluent (PDE) leukocyte count > 1,090/mm3 on day 3. Enrolled patients were randomized into either the lavage group (n = 20) or control group (n = 20). In the lavage group, continuous lavage by an automated PD machine from day 3 to 5 or 6 was performed, whereas the usual PD schedule was maintained in the control group. The primary outcome was treatment success. Post hoc analysis was also performed to compare the outcome between subgroups with different severity.Results:Baseline parameters were similar in the lavage and control groups, including PDE leukocyte count on day 3 (4,871/mm3 vs 4,143/mm3, p = 0.46). Treatment success rates were high in both groups (75% vs 70%, p = 0.72). C-reactive protein (CRP) on day 3 was found to be the only predictor of treatment failure and was used to stratify all patients into tertiles of severity. Whilst a significant decline in treatment success was evident across the tertiles of increasing CRP in the control group (100% vs 85.7% vs 28.6%, p = 0.005), treatment success was relatively maintained in the lavage group (85.7% vs 71.4% vs 66.7%, p = 0.43).Conclusions:Adjunctive lavage did not improve the overall outcome, although it may be beneficial for the more severe peritonitis patients who have high CRP.

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Background:Exit-site infection (ESI) and tunnel infection (TI) of the peritoneal dialysis (PD) catheter are significant causes of catheter or even method loss as well as patient morbidity. Among the methods that have been in use thus far, the removal and replacement of the catheter often needs to be followed by switching temporarily to hemodialysis, whereas catheter splicing or unroofing of the tunnel tract and shaving/removal of the superficial catheter cuff have not gained universal acceptance thus far.Methods:We treat chronic ESI with exit-site relocation under local anesthetic with removal of the external cuff. For the purposes of this study, we conducted a retrospective cohort analysis of all exit-site relocations performed using that technique over a 5-year period.Results:Twenty-seven patients (16 male, mean age 58 years, range 23 - 81 years) with chronic ESI underwent exit-site relocation under local anesthetic as a day-case procedure. Follow-up was 47.5 ± 22.4 months (range 10.8 - 79.4 months). No dialysate leaks occurred following the procedure. Peritoneal dialysis was resumed immediately. The procedure resulted in long-term resolution of the infection in 20 of the 27 patients (74%). In 7 patients (26%), the catheter had to be removed eventually, either because of ESI recurrence (5 patients) or TI (2 patients), which in 2 cases was subsequently complicated by PD peritonitis, and the patients were switched to hemodialysis.Conclusion:The technique described herein is a safe, straightforward, and effective method for the treatment of chronic ESI while the patient remains on PD and avoids switching to hemodialysis.

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BACKGROUND: Evidence regarding volume-outcome effects on peritoneal dialysis (PD) catheter implantation is limited. This study aimed to investigate associations between hospital volume (annual caseload of catheter implantation) and perioperative outcomes. METHODS: Clinical data for patients who underwent PD catheter implantation from 2007 to 2012 were extracted from the Japanese nationwide Diagnosis Procedure Combination database. Hospital volume was divided into tertiles: low-volume (1 - 6 cases/year), medium-volume (7 - 13 cases/year), and high-volume (≥ 14 cases/year). Multivariate logistic regression analysis for the occurrence of any adverse events and blood transfusion, and gamma-distributed log-linked linear regression analysis for postoperative length of stay were conducted with explanatory variables of hospital volume, age, sex, Charlson comorbidity index, history of hemodialysis, type of anesthesia, and type of hospital. RESULTS: Among 906, 855, and 744 cases in the low-volume, medium-volume, and high-volume groups, overall adverse events were 10.0%, 7.6%, and 6.0%, transfusion rates were 1.3%, 1.1%, and 0.9%, and median postoperative stays were 12, 10, and 9 days, respectively. In multivariate analyses, compared with the low-volume group, medium-volume and high-volume groups were associated with a lower incidence of overall adverse events (odds ratio [OR] = 0.71, p = 0.058, and OR = 0.59, p = 0.013, respectively) and shorter postoperative stay (% difference = -10.5%, p = 0.023, and % difference = -18.5%, p = 0.001, respectively), while no significant association was detected for transfusion. CONCLUSIONS: Less frequent adverse events and shorter stays were observed in higher-volume centers. Inverse volume-outcome relationships in PD catheter implantation were confirmed.

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Percutaneous insertion of a peritoneal dialysis (PD) catheter has inherent risks of complications, more so if done "blind" (without fluoroscopy and ultrasound guidance). Despite the perceived disadvantages, there are very few reported cases of mechanical complications after PD catheter insertion. We present an 81-year-old man who underwent percutaneous insertion of dual-cuffed coiled Tenckhoff PD catheter under local anesthesia by a trained nephrologist. The procedure was uneventful, and the patient was discharged 45 min later in a stable state. A day later, he noticed a decline in the urine output. A week later at a scheduled clinic visit, upon unclamping the PD catheter, there was a sudden gush of amber colored fluid. A diagnostic CT scan confirmed the presence of PD catheter entering the abdominal cavity inferior to the umbilicus and the distal end coiled in the urinary bladder. This case illustrates the need for prophylactic Foley catheterization in individuals at high risk for a distended bladder either as a consequence of a mechanical obstruction from an enlarged prostate or due to a neurogenic bladder while undergoing "blind" percutaneous placement.