Stephen Haggerty Editor Surgical Aspects of Peritoneal Dialysis 123 Surgical Aspects of Peritoneal Dialysis [email protected] Stephen Haggerty Editor Surgical Aspects of Peritoneal Dialysis [email protected] Editor Stephen Haggerty Division of Gastrointestinal and General Surgery NorthShore University HealthSystem Evanston, IL USA ISBN 978-3-319-52820-5 ISBN 978-3-319-52821-2 (eBook) DOI 10.1007/978-3-319-52821-2 Library of Congress Control Number: 2017937373 © Springer International Publishing AG 2017 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. 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Printed on acid-free paper This Springer imprint is published by Springer Nature The registered company is Springer International Publishing AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland [email protected] I dedicate this book to my lovely wife Pride Turner Haggerty and my three children Peter, Charlie, and Pridie. I appreciate their love and support during this process. [email protected] Foreword Surgeons and Surgical technology have always been an integral part of peri- toneal dialysis evolution because infusion of solution into the peritoneal cav- ity needs a conduit. Christopher Warrick from England in 1740 used the surgical technique to insert a leather pipe in the peritoneal cavity and three years later, Stephen Hale, again from England used two surgical trocars for infusion and drainage of fluids from the peritoneal cavity. Georg Ganter from Germany in 1923 performed peritoneal exchanges in human subjects, using a simple needle to instill and drain one to three liters of specially prepared ster- ile PD solution that contained appropriate amount of electrolytes and dex- trose. He observed that needle allowed free inflow but drainage was very cumbersome. Peritonitis was a frequent complication. To the modern nephrol- ogists involved in peritoneal dialysis, Ganter’s observations would be a “loud music”! In the ensuing nearly a century, many innovators including surgeons and nephrologists have worked on designing a dedicated peritoneal dialysis access. In the process, they have used surgical materials like, glass cannulas, trocars, gall bladder trocars, rubber cannulas, Foley catheter, and surgical drains. The disadvantages of these devices were rigidity of the material caus- ing pressure-trauma to the internal organs, air suction and entrapment in the system, fluid leaks and inadequate fixation of devices to the abdominal wall. The result of all these inadequacies was inevitable peritonitis. Innovations in 1950s and 1960s gave us PD catheters that were biocompatible, flexible, less rigid and easily anchored to the abdominal wall. The Tenckhoff catheter, introduced in 1968, was the major breakthrough that saw the peritoneal dialy- sis become an alternative therapy for ESRD. This catheter has stood the test of time Based on our 40+ years of clinical experience, I feel the outcome of PD catheters depends upon the experience and technical skills of the operator, including surgeon, interventional nephrologist or radiologist. An ideal cath- eter insertion would place the catheter tip deep in the pelvis and prevent it from migrating out of pelvis. In order to accomplish this, the operator has to be familiar with the simple but most important component of providing the pelvic tilt to the cuff at the peritoneal entry site. Positioning the catheter ter- minal segment in the deep pelvis has an additional benefit; keeping the side holes farther away from the omentum. The small amount of intra-peritoneal fluid containing protein bathes the catheter and over-time forms a thin coating outside and inside the catheter. This protein coating of the catheter makes it less likely to be captured by the omentum. It is my observation that omental vii [email protected] viii Foreword capture of the terminal segment of the catheter occurs mostly during the first few days after insertion. The second most important step is for the surgeon to ensure that he or she creates an appropriate length of sinus track at the exit site. Too short, too long or too wide a sinus track exposes the higher risk of cuff extrusion or exit site infection. Based on our observations of several hundred cases, Zbylut Twardowski, MD, my respected colleague now retired, concluded that in most human peritoneal dialysis catheter tunnels, during the healing process, the epithelium does not reach to the level of cuff, but grows only for a few millimeters from the exit in the sinus tract. We observed that there are fast healing exits, where the epidermis starts entering into the sinus after 2-3 weeks; and slow healing exits, where the epidermis starts entering into the sinus after 4-6 weeks. The healing process is complete in 4-8 weeks when the epidermis covers approximately half of a visible sinus tract. My goal is to see every sinus tract look like an umbilicus! The third important principle is to preserve the natural shape of the catheter during insertion. The catheter material is a silicone rubber and has its elastic property. When cath- eter is placed in its unnatural shape, it tends to create opposing forces to get back to its original shape. These forces could cause delayed wound healing, and slowly cause cuff extrusion and catheter tip migration. Lastly and equally important is the care of the catheter by the dialysis nurse, especially during the catheter healing process. The dialysis nurse should ensure at the exit site, the catheter is kept completely immobilized during the entire period of heal- ing. Unintended mobility around the catheter exit site promotes trauma at the site and increase granulation tissue. Consequently, minor bleeding could occur and promote infection. Constricting stitches to immobilize the catheter should be discouraged. When the sinus tract heals completely, the exit site is amazingly resistant to infection. To accomplish excellent results requires a well-coordinated team of surgeons, nephrologists and dialysis nurses. Complications like, catheter tip migration out of pelvis, omental capture, exit infection, cuff extrusion, tunnel infection and ultimately peritonitis can be eliminated or for sure can be minimized. The process of PD catheter place- ment is an art that has to be seen and cultivated from an expert! Our PD program is fortunate to have had the expertise of a surgeon, W. Kirt Nichols MD. For over forty years, he collaborated with us both clinically and academically. One of the unique features about our long-term relation- ship is the open and free communication. In the OR, a Post-op a KUB is performed after every PD catheter placement. Such imaging study provides us a baseline catheter position and a talking point for our discussion for each other’s learning. Frequently we discuss whether the surgery met our stan- dards of placement. We have learned a lot from these discussions and have established our own standards. I am sure, during his days at the University of Missouri, Dr. Stephen Haggerty learned from Kirt’s experience and long established teamwork approach with nephrology. Not only that Stephen has established a top class PD catheter placement program, it is only fitting that he embarked on writing a book on the surgical aspect of peritoneal dialysis. At the outset, it might raise a question “A book on peritoneal dialysis by a surgeon?” It is my strong conviction that surgeons make or break the func- tioning and longevity of a PD catheter and the success of the PD program. [email protected] Foreword ix Sharing experiences of surgical pioneers like Kirt Nichols, John Crabtree, Stephen Haggerty, and innumerable other surgeons and interventionists through a book is long overdue! The tradition in medical world is to learn from a mentor. A surgeon teaching a colleague surgeon has more impact than any other approach. It is no accident that in this book, 10 of the 15 chapters are dedicated to surgical aspects of peritoneal dialysis. Several world- renowned expert authors have extensively described the pre-op preparation of patients, surgical and laparoscopic insertion technique of different catheter types. Chapters on diagnosis and management of catheter dysfunction and mechanical complications would be well appreciated by all dealing with peri- toneal dialysis There appears to be a resurgence of peritoneal dialysis in the United States and of course, globally its penetration keeps increasing. Training on the sur- gical aspects of PD should be a part of the overall training related to perito- neal dialysis. Haggerty’s book on the Surgical Aspects of Peritoneal Dialysis, a unique treasure. With vast amount of expert knowledge poured in it, would find a niche in the peritoneal dialysis community. As Sir William Osler said “The art of the practice of medicine is to be learned only by experience; ‘tis not an inheritance; it cannot be revealed.