Percutaneous vs surgical insertion of PDcatheters in dialysis patients: a meta-

analysis

February 20th 2016

Micah Chan MD MPH FACP FASDIN

Clinical Chief, Division of Nephrology

University of Wisconsin Hospitals and Clinics

Madison, WI

PD catheters

The key to successful PD and avoidance of urgent hemodialysis isaccess to timely insertion of a well-functioning PDC

The potential advantages of percutaneous PDC implantation over opensurgery and laparoscopic techniques include its simplicity, avoidance ofgeneral anesthesia (GA), quicker recovery and ambulation, efficient useof resources as well as minimization of delays associated with surgicalconsultation and operating room scheduling.

Various meta-analyses have demonstrated no specific advantage oflaparoscopic vs open surgical placement.

Several small studies have suggested that the percutaneous method ofPD catheter insertion is effective and has a lower complication rate thansurgical techniques (open, laparoscopic or peritoneoscopic), though norandomized, controlled study has compared percutaneous and surgicalmethods

Objective

Our objective was to compare percutaneousPD catheter insertion versus surgicalplacement in terms of 1-year catheter survival,catheter dysfunction, fluid leak and incidence ofperitonitis.

Types of PD catheters

Interventional Nephrology: Principles and Practice, Yevzlin,etal

We used combinations of terms related to peritoneal dialysis(peritoneal dialysis, end stage renal disease and ESRD)and peritoneal access (catheter, percutaneous,laparoscopic, peritoneoscopic, fluoroscopic, open orlaparotomy, laparoscopy or fluoroscopy).

Further, we hand-searched the reference lists of all articlesidentified in the search. We also reviewed the abstracts ofthe American Society of Nephrology and National KidneyFoundation annual scientific meetings from 2008 through2012.

J Vasc Access 2015; 16(6):498-505

Search strategy

Inclusion criteria were a measure of one or more of the followingoutcomes: catheter survival at 1 year, catheter dysfunction, peritonitisrate per patient-month and fluid leak.

It was decided, a priori, to exclude any of the following categories ofarticles: editorials, practice guidelines, pediatric studies, non-Englishlanguage studies, review articles, case reports, and duplicatepublications.

From among 417 citations, we reviewed all relevant articles (Figure 1).Of those, 20 were abstracts or articles appropriate for detailed review. Ofnote, there were 2 studies identified from national conferenceproceedings.

Included studies

Study outcomes

Statistical analysis

The primary outcomes of interest (1-year catheter survival,peritonitis, leak, and catheter dysfunction) were assessedusing random effects models.

Publication bias was assessed using funnel plots.

Heterogeneity across studies was assessed using the Qstatistic and I2 index.

Kappa scores were used to evaluate inter-observeragreement between the two independent reviewers.

Results

We identified 13 studies with a total of 2681subjects published between 1993 and 2012

Ten of them are retrospective studies while threeare prospective studies. Only one prospectivestudy is randomized.

There was no significant difference in 1-yearcatheter survival in percutaneous vs surgical PDcatheter placement (relative risk [RR]=0.81; 95%CI: 0.59-1.11, p=0.19). (Fig. 2).

Results

We found that catheter dysfunction did not differsignificantly between percutaneous versus surgicalcatheter placement (pooled odds ratio [OR]=0.86;95% CI: 0.57-1.29, p=0.46)

The prevalence of peritoneal fluid leak also wassimilar for the two groups (OR=1.10; 95% CI: 0.58-2.09, p=0.77)

However, there was a significant lower incidence ofperitonitis among those with percutaneousplacement (incidence rate ratio [IRR]=0.77; 95%CI: 0.62-0.96, p=0.02)

PD catheter survival

PD catheter dysfunction

Catheter leak

Peritonitis

Peritonitis

Peritonitis remains a significant problem in the utilization ofPD and the rates of patients returning back to hemodialysis.

It is particularly interesting that the percutaneous method ofPD catheter insertion is associated with a lower rate ofperitonitis based on our meta-analysis.

Perhaps, the less invasive technique results in less traumato the bowel and surrounding tissues, or there may be lessinflammation associated with the percutaneous method thanlaparoscopic or open surgical methods.

Nevertheless, this association offers a clear advantage forthe future success of PD programs and utilization of PD inacute and urgent starts.

Limitations

The predominance of non-randomized studies could lead tobias due to unrecognized differences between groups. Wealso recognize that a variety of different types of catheterswere used and there may be inherent biases towardsoperator dependent difficulties in placement based on onecatheter versus another.

We recognize that surgical placement does offeradvantages of direct visualization and therefore surgicaltechniques of improving the functionality of the catheterplacement, ie adhesiectomy, omentectomy, tacking downcatheter, etc. just to name a few have certain advantagesover the percutaneous method.

We used random effects models based on momentmethods, which detect within-study and between-studyvariation to derive the pooled risk ratios.

Future trials

Conclusions

Our meta-analysis suggests that there is no significantdifference in catheter survival, dysfunction or peritoneal fluidleak between percutaneous and surgical placement of PDcatheters.

The improved peritonitis rates in the percutaneous PDcatheter group suggest that this method may be preferred incertain patients and that nephrologists should be trained toperform these procedures.

These findings have significant implications for the futuredesign of clinical trials in the placement of PD catheters andthe delivery of dialysis-related services.

Thank You