改良腹膜透析置管方法的临床研究

Clinical study on the modified catheterization method for peritoneal dialysis

目的探讨改进的腹膜透析（PD）置管方法对PD导管功能障碍的影响。方法收集2011年11月~2013年11月安徽省阜阳市第二人民医院肾内科手术置管腹膜透析患者。手术置管后存活时间大于4周;用双卡夫Tenckhoff天鹅颈直管,与Tenckhoff直管。采用局部麻醉下置管,改进如下：1PD置管点选择在耻骨联合上缘水平垂直向上7.0~9.0cm、左或右旁开1.0~2.0cm;2PD导管腹内管置入腹腔前,先用肝素盐水冲洗,使其内外壁,侧孔＂肝素化＂;3用导丝置入PD导管的过程中有脱空感或无阻力。结果手术置管133例患者。其中男82例,女51例,平均年龄49.2±14.6岁。基础病：慢性肾小球肾炎87例,糖尿病21例,多囊肾6例,其他19例。使用Tenckhoff鹅颈直管131例,Tenckhoff直管2例。中位随访时间11.0（6.0~16.5）个月。随访期间发生引流不畅5例次（均为使用Tenckhoff鹅颈直管）,其中因血凝块堵管2例次,经使用肝素盐水冲洗、尿激酶封管后改善;仅1例患者发生导管移位,经保守处理（包括冲洗、腹部揉压、通便、下床活动等）后腹内管复位,引流良好;1例置管行CAPD6个月后出现大网膜包裹,经手术解除PD导管包裹,引流通畅;1例置管35天后出现引流不畅,摄片示PD管腹内段位置良好,经保守治疗2周无效,遵患者意愿改为血液透析治疗。1年导管完好率（98.0%）。结论本中心应用改良的PD置管方法后引流不畅特别是导管移位发生率低。较高的导管功能完好率是确保PD患者腹膜透析治疗顺利实施的基本条件。由血凝块堵管引起的引流不畅可通过保守处理解除,漂管所致的引流不畅可通过规范的保守处理或等待自然复位恢复引流通畅。只有大网膜包裹所致的导管引流不畅经过规范的保守处理才会无效;只能通过再次手术才可恢复导管引流通畅;手术复位引流通畅后可保持较长时期引流良好。PD液引流不畅的发生也可能与引流时间过长,腹腔残留腹膜透析液过少,致＂虹吸现象＂吸引腹膜有关。

Objective To observe the improved peritoneal dialysis （PD） catheter implantation technique on PD catheter dysfunction. Method Patients surviving at least 4 weeks after operative catheter insertion be- tween November 2011 and November 2013 in our center were included in this study. The operation was per- formed by our physicians using swan-neck or straight double-cuffed Tenckhoff catheter. The implantation technique was modified as follows： （1） catheters were placed at 7~9.0em upper the symphysis pubis and 1- 2.0cm to the left or right side; （2） catheters were flushed with heparin to make it heparinization before place- ment; and （3） hollow sensation without resistance existed during the catheter placement utilizing a guide-wire. Results Of the 133 PD patients enrolled in the study, 82 were females, and 51 were males. The mean age was 49.2±14.6 years and the median follow-up vintage was 11.0 （6.0-16.5） months. The primary diseases includ- ed chronic glomerulonephritis （n=87）, diabetic nephropathy （n=21）, and others （n=25）. Swan-neck （n=131） or straight （n=2） double-cuffed Tenckhoff catheters were used. During the follow-up period, catheter migration was found in one case, and was successfully relieved by conservative treatment including flushing, abdominal massage, laxatives, and ambulation; poor drainage of the tubes were present in 5 cases using swan neck Tenck- hoff catheters, and two of them were blocked by blood clots that were cleared by use of heparin saline and uro- kinase; tube wrapped by omentum was found in one case after the operation and CAPD for 6 months, and re-gained patency after operation; one case had poor drainage 35 days after the insertion, the location of the tube was adequate by X-ray examination, the problem remained after conservative treatment for two weeks, and the patient was then changed to hemodialysis. The one year catheter survival was 98%. Conclusion The inci- dence of catheter dysfunctional problems became lower in our PD center after the application of the modified PD catheter implantation technique.