Peritoneoscopic placement of Swan neck peritoneal dialysis catheters

Peritoneoscopic placement of peritoneal dialysis catheters, although accomplished in only about 10% of dialysis centers, is a nonsurgical technique that fulfills requirements for safety and dependability. Over a 40-month period, 136 catheters were placed with the peritoneoscope, 135 of which were double-cuffed, Swan neck curled catheters, with a uniform radiopaque stripe. Patients were followed longitudinally for outcome. Catheters were placed in 44 diabetic patients, 1 human immunodeficiency virus (HIV)-positive patient, and 18 morbidly obese patients. No complications occurred as a direct result of placement. Catheters were used, on average, nine days after placement (many on days 1 to 4) usually with 1.5 to 2 L exchanges. With 1183 patient-months' experience, complications were few: 28 patients experienced catheter-related infections, and there were five leaks that resolved with supine, low-volume dialysis for several days. Leakage did not correlate with time of usage after placement. Of ten outflow/mechanical problems that required catheter removal, nine involved catheter migration, probably due to lack of attention during placement to orientation of the radiopaque stripe. One was due to a preperitoneal placement early in this institution's experience with the peritoneoscope. Five of the migrated catheters were removed and then successfully replaced with the peritoneoscope at the same sitting. Four patients requested surgical removal and replacement. Sixteen catheters were removed because of catheter-related infections: five refractory Staphylococcus aureus, six Pseudomonas aeruginosa, two fungal, two Serratia species, and one Mycobacterium chelonei. Actuarial life-table analysis showed that at the end of the 40-month follow-up, 62% of the catheters were expected to survive. Because more than 50% survived, median catheter survival could not be calculated. The adverse responses were removal because of infection or catheter migration. Peritoneal dialysis catheter implantation with the peritoneoscope represents a safe and dependable method for catheter placement. Literature review and comparison indicate that catheter-related complications are fewer and catheter longevity is better with peritoneoscopic placement than with surgical placement. Our experience with prompt postplacement utilization suggests the need for further evaluation of catheter break-in procedure with the peritoneoscope.