Importance of the creation of a short musculofascial tunnel in peritoneal dialysis catheter placement

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 character istics 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.

不同类型腹膜透析导管临床应用体会

目的观察不同类型腹膜透析导管的近期并发症的发生率情况及防治体会。方法68例终末期肾衰竭行维持性腹膜透析治疗患者分为两组。组1:28例患者采用Tenckhoff曲管;组2:40例患者采用鹅颈直管。两组患者随访时间均大于6个月。观察两组患者的腹膜透析液引流速度、隧道感染、出口感染、导管移位、腹膜透析液渗漏等发生情况。结果两组患者腹膜透析液引流速度的隧道感染率和出口感染率无差别(P>0.05).Tenckhoff管组5例患者出现导管移位(17.8%),而swan-neck导管组仅2例(5%),两组相比有显著性差异(P<0.05)。进一步分析发现前组患者漂管发生于第一周3例(60%),第二周2例(40%),而鹅颈直管发生漂管多于1周内。另外鹅颈直管组有3例患者于术后第一周出现引流不畅,拔管时发现导管内均有大量蛋白凝块阻塞。结论不同类型导管各有优缺点,鹅颈直管的导管移位率明显低于Tenckhoff导管,但易发生透析液引流不畅,而Tenckhoff导管不容易发生堵管。在置管过程中调整swan-neck腹膜透析管外段与腹正中线的角度后能明显改观引流速度。

三种腹膜透析导管相关并发症的比较

目的:比较Tenckhoff卷曲管、Tenckhoff直管、鹅颈直管相关并发症的差异,为临床选择不同腹透管提供依据。方法:回顾性分析2008年3月～2011年7月在我中心行腹膜透析置管术的157例终末期肾病患者资料,按导管形态不同分Tenckhoff卷曲管组(n=53),Tenckhoff直管组(n=54)和鹅颈直管组(n=50)。观察三组导管功能障碍、出口感染、腹膜透析相关性腹膜炎发生情况及对腹膜透析效率的影响。结果:各组共发生导管功能障碍21例,A组11例(13.21%),B组8例(16.67%),C组2例(4%),各组比较差异有统计学意义(P<0.05);共发生出口感染和腹膜透析相关性腹膜炎分别为12例和42例,各组比较差异均无统计学意义(P>0.05);三种腹透管对透析效率的影响差异无统计学意义(P>0.05)。结论:鹅颈直管相对Tenckhoff卷曲管和直管可减少导管功能障碍的发生率,三种导管在出口感染、腹膜透析相关性腹膜炎及对透析效率的影响方面差异无统计学意义。

两种腹膜透析管的相关并发症比较

目的 :比较腹膜透析卷曲管与直接管在临床使用上的优缺点 ,以利于腹膜透析的开展。方法 :对行腹膜透析置管术的 12 4例成人慢性肾衰竭病例进行回顾性分析 ,根据其所使用的腹透管类型不同 ,将病人分为直管组(4 6例 )和卷曲管组 (78例 )两组 ,统计其并发症并进行比较。结果 :行腹膜透析插管术后 ,发生漂管移位的共 11例(8.87% ) ,其中直管 8例 (17.39% ) ,卷曲管 3例 (3.85 % ) ,两组比较有统计学差异 ;拔管重置的 4例 (3.2 3% ) ,均为直管 ;病人出现腹痛的共 9例 (7.2 6 % ) ,直管 7例 (15 .2 2 % ) ,卷曲管 2例 (2 .5 6 % ) ,两组比较也有统计学差异。结论 :卷曲管组漂管、拔管率及并发疼痛的发生率显著低于直管组。而在渗漏、出水不畅、血性透出液等方面 。

重症急性肾损伤患者行床边开放式解剖法留置腹膜透析导管的安全性研究

目的:探讨重症急性肾损伤(AKI)患者行床边开放式解剖法留置腹膜透析导管的安全性。方法:广州市第一人民医院2010年1月-2011年12月期间所有行床边开放式解剖法留置腹膜透析导管的重症患进行前瞻性观察,时间为置管后一个月至病人死亡或因各种原因拔除腹膜透析导管,观察置管术后出现的各急性并发症如手术伤口感染、出血、渗液,腹透液引流障碍,腹膜炎等。结果:入组23名患者均为多器官功能竭并AKI,置管术后有发生导管功能不良2例,出现手术伤口脓肿(表面葡萄球菌)、导管出口处感染(表面葡球菌)、同时出现血性腹水和导管出口处出血各1例,无并发腹膜炎。结论:重症AⅪ行床边开放式解剖法留腹膜透析导管安全。

Mechanical Complications of Peritoneal Dialysis

Introduction: The key to a successful chronic peritoneal dialysis is a permanent and safe access to the peritoneal cavity. The mechanical complications of peritoneal dialysis (MCPD) are a major cause of the failure of the technique. The aim of the study was to define the prevalence of peritoneal dialysis (PD) mechanical catheter complications, to determine the time and the factors associated with their occurring. Materials and Methods: A retrospective study was conducted between January 2009 and January 2014 at the nephrology, dialysis and renal transplants department of Ibn Sina university hospital in Rabat. We included all patients who were on peritoneal dialysis and presented mechanical complications. These mechanical catheter complications are represented by catheter migration or obstruction, inguinal or umbilical hernias, early and late peritoneal dialysate leakage, subcutaneous cuff extrusion and hemoperitoneum. Results: MCPD were noted in 23 of the 62 patients (37% of cases). Onset time of complications was 24.8 ± 18.9 months [3 - 60 months]. Among these complications, we noted a catheter migration (65.2%), postoperative hematoma (21.7%), cracking or perforation of catheter (17.4%), epiploic aspiration (17.4%), sleeve externalization (17.4%), catheter obstruction (13%), hemoperitoneum (13%), hernia (22%;13% umbilical and 8.7% inguinal), early dialysate leakage (13%), and pleuroperitoneal leakage (8.7%). The average age of our patients was 54.9 ± 15.5 years [21 - 81 years old], with a male predominance and a sex ratio of 2.28. The average body mass index (BMI) was 25.4 kg/m2. Diabetic patients represent 48.7% of our series. In our study, MCPD represent 13% of causes of transfer to hemodialysis (HD). Conclusion: Prevention of MCPD remains crucial. It is based on good patient education on hygiene and handling errors but also periodic retraining of patients and caregivers.

初发卵巢上皮性癌子宫切除术后的复发形式

背景:子宫及双侧附件切除是治疗晚期原发性卵巢上皮性癌(epithelial ovarian cancer,EOC)的标准手术方式。目前认为,即便膈下、腹腔内有肿瘤病变残留,对盆腔病变进行积极的手术干预也是有益的。方法:收集子宫切除术后复发性卵巢癌患者的二次肿瘤细胞减灭术(cytoreductive surgery,CRS)资料。在二次CRS中,腹盆腔所有肿瘤肉眼可见。所有患者复发病灶至少23处,均予以详细记录。结果:共计20例复发性/进展期卵巢上皮性癌患者接受了二次CRS。肿瘤的复发部位比例:右膈下为70%,残留大网膜65%,直肠乙状结肠交界65%,前腹壁切口55%,膀胱浆膜面50%,左侧输尿管远端50%,阴道穹隆50%,右侧输尿管远端35%。结论:EOC患者行子宫切除术后,肿瘤转移复发最常见的是右膈下、中腹部的肿瘤病变,及已实施肿瘤减灭部位的肿瘤病变复发。子宫切除术可能会增加肿瘤细胞包裹的风险,除非膈下、腹腔及盆腔的病灶能够通过手术全部切除,否则单纯子宫切除术并不可取。

双涤纶套鹅颈管与Tenckhoff管在腹膜透析患者中的疗效比较

目的比较双涤纶套鹅颈管与Tenckhoff管在持续性非卧床腹膜透析（CAPD）患者中的临床疗效。方法前瞻性入选首次植管并接受CAPD治疗的终末期肾脏病（ESRD）患者110例，随机分为鹅颈管组（A组）和Tenckhoff管组（B组），各55例。腹透管末端均为直型，以常规手术法植入，随访1年。记录并发症、生存时间、退出透析或死亡等结局。采用Kaplan—Meier法、Log—Rank柃验进行生存分析。结果随访结束时，110例CAPD患者中17例死亡，3例转为肾移植，8例转为血液透析治疗，3例转至其他医院，79例（71．8％）继续在我院腹透治疗。两组患者共发生腹膜炎26例（35例次），总腹膜炎发生率为0．32次／病人年，A组为0．35次／病人年和B组为0．29次／病人年（P〉0．05）。植管距离首次腹膜炎时间分别为A组（30~29）周和B组（29±4）周（P〉0．05）。12个月时两组发生腹膜炎的风险同为26．97％。两组共发生隧道感染2次，出口感染9次，隧道及出口感染的发生率为0．1次／病人年。与A组比较，B组隧道感染（0．036次／病人年比0）和出口感染（0．11次／病人年比0．06次／病人年）发生率较高，但差异无统计学意义（P〉0．05）。两组间导管机械并发症（导管移位、大网膜包裹、腹透液渗漏、外涤纶套滑出）、腹股沟疝及腹痛的发生率差异均无统计学意义（P〉0．05）。两组各有4例拔管，12个月技术生存率两组同为92．73％。两组共17例死亡（15．45％），其中A组死亡7例，B组死亡10例（P〉0．05），死亡原因主要为心脑血管并发症（47．1％）和感染（23．5％）。患者12个月生存率A组为86．34％，B组为80．68％（P〉0．05）。结论鹅颈管与Tenckhoff管应用于CAPD患者，在感染并发症与机械并发症的发生率、12个月技术生存率及患者生存率等方面的差异均无统计学意义，两种腹透管的疗效相近。