Perit Dial Int
29(1):
119-120
2009
© 2009 International Society for Peritoneal Dialysis
Another Peritoneal Dialysis Catheter Encapsulated in Peritoneal Tissue
F.C. Prischl*,
F. Knoll and
R. Kramar
Nephrology 3rd Department of Medicine Klinikum Wels-Grieskirchen Wels,
Austria
*
e-mail:
friedrich.prischl{at}klinikum-wegr.at
Editor:
We read with interest the short report by Kazory and co-workers on primary
malfunction of a peritoneal dialysis (PD) catheter found in a thick
encapsulated sheath 1 month after catheter insertion
(1). We would like to add our
experience with a similar observation in a 60-year-old male with diabetic
nephropathy as the cause of end-stage renal disease.
Our patient had his first PD catheter implanted using a technique described
previously (2) in which the
catheter (Quinton swan neck Tenckhoff PD catheter; Tyco Healthcare, Mansfield,
MA, USA) was surgically placed below the umbilicus in a typical manner. The
outer part of the swan-neck catheter was embedded in the subcutaneous tissue.
Prior to suture of the skin, the catheter was filled with heparin solution as
in the report by Kazory et al. The period of wound healing was
uneventful. After 67 days, when clinical symptoms indicated beginning renal
replacement therapy, the outer part of the PD catheter was exteriorized via a
small skin incision under local anesthesia. When connecting the catheter to
the PD fluid bag, very poor inflow of fluid was recognized and an attempt to
drain fluid from the peritoneal cavity exhibited no outflow.
Radiological examination with contrast medium showed contrast medium
spilling into the peritoneal cavity from the tip of the catheter but not from
the side holes, as would be expected
(Figure 1). The catheter was in
a normal position but with the tip at the entry to the small pelvis. An
attempt was made to mobilize the catheter using a guidewire but was
unsuccessful.
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Figure 1 — X ray with contrast medium of the peritoneal dialysis catheter. As
indicated by the arrows, contrast medium spilled from the catheter tip into
the abdominal cavity only, but no flow is seen from the many side holes of the
catheter, as would be expected.
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The next day laparoscopy was performed with the expectation of finding
omental wrapping. Surprisingly, the catheter was found to be completely
surrounded by connective-tissue-like material on the frontal inner abdominal
wall (Figure 2). The sheath
appeared vascularized, clearly distinguishing the tissue from a simple fibrin
sheath. Inspection of the abdominal cavity revealed no other abnormalities,
especially no adhesions or inflammation. The catheter was surgically cut out
of this sheath. No fibrin clots were seen within the catheter lumen. A
specimen was taken from the sheath for histological examination and the
operation was finished successfully. Immediate dialysate inflow and drainage
was possible without problems. Histological examination of the sheath specimen
revealed granulation tissue, as seen in scars, with no signs of
inflammation.
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Figure 2 — Operational site at laparoscopic intervention. The whole catheter
was encapsulated in an apparently vascularized granulomatous sheath. This
sheath had to be cut off, as shown here, after the first incisions at the
distal part of the sheath.
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A recent clinical commentary on noninfectious complications in PD
(3) did not mention the
complication seen by Kazory et al.
(1) or that in our patient.
Both patients have in common the relatively long period between catheter
placement and start of PD (1 and 2 months respectively.) In our patient, we
thought the observation of a vascularized granulation tissue sheath might be
related to our method of catheter implantation
(2). However, one of the
largest series on subcutaneously embedded PD catheters in recent time (304
embedded catheters in 303 patients) reported an initial rate of 15% having
either one- or two-way obstruction to dialysate flow
(4). Seven percent of their
patients never achieved adequate inflow and drainage function, but an
encapsulating sheath was not described in their series as the cause of
catheter dysfunction.
Therefore, we follow the possible explanations of Kazory et al.
that the catheter itself, that is, the mechanical movements of the catheter
along the peritoneum, or catheter material, or the saline and/or heparin
solution leaking out the catheter side holes may induce a local inflammatory
process, followed by mesothelial cell proliferation and growth of a sheath.
Finally, with granulation tissue, as documented histologically in our patient,
surgical intervention, preferably laparoscopy, is the only method to
successfully activate catheter function.
ACKNOWLEDGMENTS
The authors thank Dr. Wolfgang Fröhler, 1st Department of Radiology,
for radiological examination, and Hans Kalchmair and Walter Schauer, 2nd
Department of Surgery, all Klinikum Wels-Grieskirchen, for successful
laparoscopic intervention.
REFERENCES
- Kazory A, Cendan JC, Hollen TL, Ross EA. Primary malfunction of a
peritoneal dialysis catheter due to encasement in an encapsulating sheath.
Perit Dial Int 2007;27
: 707-9.[Abstract/Free Full Text]
- Prischl FC, Wallner M, Kalchmair H, Povacz F, Kramar R. Initial
subcutaneous embedding of the peritoneal dialysis catheter—a critical
appraisal of this new implantation technique. Nephrol Dial
Transplant 1997; 12:1661
-7.[Abstract/Free Full Text]
- McCormick BB, Bargman JM. Noninfectious complications of peritoneal
dialysis: implications for patient and technique survival. J Am Soc
Nephrol 2007; 18:3023
-5.[Abstract/Free Full Text]
- McCormick BB, Brown PA, Knoll G, Yelle JD, Page D, Biyani M, et
al. Use of the embedded peritoneal dialysis catheter: experience and
results from a North American center. Kidney Int Suppl2006; 70:S38
-43.
