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Abstract
Peritoneal dialysis (PD) is used in children with end-stage renal disease (ESRD) for renal replacement therapy. However, it can be associated with the risk of post-surgical complications. The objectives of this study were to report our experience with the placement of PD catheters for 14 years and to assess the incidence of PD malfunction and other PD-related complications, including the effect of adopting minimally invasive techniques for catheter placement. The objectives of this study were to report our experience with placement of PD catheters for 14-year period and to assess the incidence of PD-related complications and the effect of adopting minimally invasive techniques for catheter placement. It is a retrospective cohort study at the department of pediatric surgery and pediatric nephrology, dialysis, and transplant in Jeddah, Saudi Arabia. We reviewed the records of all children who had PD catheter placements between 2005 and 2019. The data included demographics, the surgical technique, the performance of omentectomy, duration of PD catheter, and complication rates. Sixty-five patients had PD catheter insertion during the study period; 16 (24.6%) of them were placed in other institutions then referred to us. Thirty-five patients had no complications. Omentectomy during the first procedure was performed in 53 patients (81.54%). Early dialysate leaking occurred in six patients (9.3%); none were treated with surgical revisions. Four leaks resolved spontaneously, and hemodialysis (HD) was needed in two patients. The median PD catheter duration was 29 months (25th–75th percentiles: 21–41). Sixteen patients required revision (24.62%), and mortality occurred in five patients (7.69%). PD is a safe option in children with ESRD. Open placement with omentectomy in a specialized center could reduce leakage,help to start dialysis early, and decrease the conversion to HD.
Introduction 
Peritoneal dialysis (PD) was introduced as an option for the management of patients with renal disease,[1],[2] and it is used as a bridge to transplant in the pediatric population.[3] PD offers several advantages over hemodialysis (HD), including easy mobility of the patient and no blood access; in addition, it is safer in hemodynamically unstable patients.[4],[5],[6] The cornerstone for successful PD is a working catheter.[7]
Despite the recent improvement of surgical techniques and the catheter quality, complications are still high, especially in infants.[8] This can be partially attributed to the difficulty of catheter insertion in infants and the mismatch between catheter and patient’s size.[9] Other complications can lead to treatment failure, such as site infections and peritonitis, which occur in 25% of the patients within the first six months following insertion.[10] In addition, PD catheter is prone to obstruction, displacement, leakage, and reduced longevity of the catheter.[11],[12],[13] Several techniques and modifications have been proposed to reduce catheter-related complications, including amendments in the exit site and the use of various dressings to reduce catheter-site infection.[14],[15] In addition, omentectomy has been advocated to minimize catheter obstruction. Recently, laparoscopic PD catheter insertion and its impact on the complications have been evaluated.[16]
The objectives of this study were to report our experience with placement of PD catheters for 14-year period and to assess the incidence of PD-related complications and the effect of adopting minimally invasive techniques for catheter placement.
Patients and Methods Design and patients
This research is a retrospective cohort study performed on patients who had PD catheters in the department of pediatric surgery and were treated with PD in the unit of pediatric nephrology, dialysis, and transplant in Jeddah, Saudi Arabia, from January 2005 to August 2019. Data were collected from medical charts including demographics, indications for catheter placement, surgical technique, omentectomy, the longevity of PD catheter, and reason for catheter failure, ultimate renal replacement, and complication rates. Infants with nontunneled temporary PD catheters and patients with acute renal failure were excluded. Peritonitis is suspected if the peritoneal dialysis fluid is not clear or when abdominal pain occurs. Forty-nine patients had primary PD insertion at our institution, and 16 patients were referred to us from other hospitals with PD catheters already inserted. The Institutional Review Board has approved the study, and patients’ consent was waved.
Surgical technique
We used a right paramedian transverse incision (2–3 cm), then we opened the anterior rectus sheath transversely. We split the rectus muscle and placed a purse-string suture with polyproline 3-0 on the posterior sheath. Afterward, we opened the posterior sheath in the middle and performed omentectomy by ligation or LigaSure, and we removed as much as we can from the omentum. We used a loop catheter and pushed it to the pelvic with stylet; the purse-string suture was tightened just below the proximal cuff, then mattress suture was applied on the rectus muscle to encase the cuff. We closed the anterior sheath tightly around the catheter. Finally, we brought the catheter out from the exit site on the lateral aspect leaving the distal cuff 2 cm proximal to the exit site. We tested the catheter in the operation room by flashing and draining of 300–500mL saline 2–3 times. We checked the catheter to ensure good inflow and backflow, no bleeding in the fluid, or leak. Usually, we use a catheter with a curved shape of the intraperitoneal portion, straight subcutaneous tunnel configuration, and two cuffs.
For malfunction or obstructed catheters, a 5 mm laparoscopy port was used to explore and relive the obstruction and perform omentectomy.
Statistical Analysis Data analysis was performed using Stata 16 (StataCorp, College Town, Texas, USA). Continuous variables were presented as median, 25th and 75th percentiles, and categorical variables as number and percentage. Continuous variables were compared using the Mann-Whitney test and categorical variables using Chi-square or Fisher’s exact test when appropriate. Spearman correlation was used to test the correlation between age and duration of PD catheters. Linear regression analysis was used to identify factors affecting the duration of PD catheters.
Results Initiation of peritoneal dialysis
PD was started as primary therapy in 49 patients (75.4%) and as secondary therapy following HD in 16 patients (24.6 %) [Table 1]. Indications for insertion are listed in [Table 2].
Technique failure
Thirty patients (46.15%) were shifted to HD over the study period; seven (10.8%) of these patients had refractory peritonitis, and eight (12.3%) had catheter malfunction. Thirteen patients (20%) were shifted to HD due to inadequate clearance on PD, while in two (3%) patients, PD was discontinued due to lack of patient’s compliance.
Indications for access revision
The reasons for access revision included mechanical dysfunction in one (1.5%) patient, peritonitis in three (4.6%) patients, and exit site or tunnel infection in one (1.5%) patient. In one (1.5%) patient, the reason was not reported.
Overall, and within the 1st year of PD, the need for access revision was most commonly associated with mechanical problems [Figure 1], whereas infectious complications were the predominant cause for revision at one year after PD initiation.
Frequency of access revision
A total of 16 (24.6%) patients experienced 24 access revisions. Sixteen patients were referred to our center; 11 of them (68.75%) experienced 17 access revisions. In children with the primary procedure done in our institution, five (10%) patients experienced seven access revisions.
Catheter-related complications
The PD catheter was surgically removed and re-inserted in three (4.6%) patients. In one case, it was due to refractory multi-bacterial peritonitis, and the catheter was re-inserted after an interval of two months following the resolution of peritonitis. In one (1.6%) patient, the catheter was removed due to leakage of fluid from the exit site, following catheter insertion by laparoscopy. It was treated by surgical repositioning. In the third patient, there was an outflow obstruction not relieved by non-invasive means, and the catheter was replaced. Two patients presented with decreased fluid removal and abdominal discomfort. Abdominal X-ray showed catheter tip migration above the pelvis. The predisposing factor in both cases was constipation, and the problem was relieved using laxatives and patient education about diet, bowel habits, and ambulation. Complications are presented in [Table 3]. The duration of PD catheter was not significant between patients who had PD in our institution and the referred patients (P =0.053); however, the overall complications were higher in the referred patients (P = 0.044).
Mortality
A total of five patients died during the study period; all of them were on HD, yielding an overall mortality rate of 7.6% for the study period. The cause of death was a systemic infection and cardiovascular causes in three (4.6%) patients and unknown in two (3.07%)patients. There was no difference in mortality between the patients with PD catheters in our institution and the referred patients (P = 0.59).
Peritoneal dialysis outcome
At the end of the study, 35 (53%) patients were continuing on PD, seven (10.7%) patients underwent renal transplantation, 30 (46%) were shifted to HD, and five (7.6%) patients died. The duration of PD catheter was positively correlated with the age at the time of insertion [Figure 2]. The duration of PD catheters was not significantly associated with the gender (P = 0.236) or referred patient (P = 0.791) [Table 4].
Discussion The study included pediatric patients who had a peritoneal catheter during a 14-year period. The main goal of this study was to investigate complications of PD at our hospital. Successful PD requires reliable access to the peritoneal cavity with a well-functioning dialysis catheter. Several factors could influence the catheter performance and the incidence of mechanical and infectious complications, including the catheter type, insertion technique, exit site, and postoperative care.
Mechanical complications of PD catheters are obstruction, leakage, displacement, and hernia. Failure of fluid drainage can happen due to blockage of catheter lumen, migration of catheter tip, and omental wrapping.[17],[18] Management of this condition can be either through a conservative approach orcatheter repositioning either surgical or through laparoscopic revision.[19],[20],[21]
Survival in our cohort was similar to what was reported in the literature.[22] The survival after PD insertion was found to be age related, and children older than 15 years had a more prolonged catheter life.[13] Older children are less susceptible to infection, and catheter management is easier in this age group compared to younger children.
Infectious complications were reported to be the most common cause of mortality.[23]Staphylococcus aureus was the most common organism isolated in catheter-related peritonitis.[24] We used a double-cuff curved catheter in our patients, the distal cuff, which is closer to the exit site, could increase the incidence of infection. In such cases, the subcutaneous cuff had to be removed (cuff shaving). We should stress that the second cuff should be proximal to the exit site at least 1–2 cm.
Urgent dialysis is usually needed to correct the electrolyte disturbance and the nutritional state.[25],[26],[27] Children with renal failure have vascular access problems with high rates of infection, thrombosis, central venous stenosis, and inflammatory stress, which lead to increased morbidity.[28]’[29] The risk of early dialysate leakage was considered the main reason to delay the use of PD catheter for the first 14 days after placement.[6],[9],[30]
In our experience’ the reported complications had a lower frequency compared to other studies (16% vs. 27%).[13] Most of these complications are related to the surgical technique. Omentectomy seems to prevent catheter obstruction, especially in younger children.[11] Other studies showed that omentectomy was associated with lower obstruction and peritonitis.[31]
Study Limitations The study is retrospective in nature with its inherent biases; however, this study design is suitable for studying an infrequent technique. Other limitations include small patients’ number and single-center experience.
Conclusion PD is an effective and safe method of dialysis for pediatric patients with end-stage renal disease. Open placement with omentectomy in a specialized center appears to have benefits in starting dialysis immediately and reducing the complications and conversion to HD. Laparoscopic catheter revision techniques could improve PD catheter outcomes.
Conflict of interest: None declared.
References 
Correspondence Address:
Osama Bawazir
Department of Surgery, Faculty of Medicine, Umm Al-QuraUniversity, P.O. Box 715, Makkah 21955, Saudi Arabia.
Saudi Arabia
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/1319-2442.352419
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