比較移除腹膜透析導管時置入腹腔引流管的有無，是否可減少難治性腹膜透析相關之腹膜炎的腹內併發症風險：單一醫學中心之經驗
曾文歆1、劉建良1、黃志強2、王憲奕2、甘偉志2、黃冠華1
奇美醫療財團法人奇美醫學中心 1外科部 泌尿外科
2內科部 腎臟科
Comparison of Pelvic Drainage Insertion During Removal of Dialysis Catheter Decreases the Risk of Complications in Refractory Peritoneal Dialysis-related Peritonitis: A Single Center Experience
Wen-Hsin Tseng 1、Chien-Liang Liu 1 、Jyh-Chang Hwang2、Hsien-Yi Wang2、Wei-Chin Kan2、Steven K. Huang1
1Division of Urology, Department of Surgery, 2Division of Nephrology, Department of Internal Medication, Chi Mei Medical Center, Tainan, Taiwan
Purpose:
Peritoneal dialysis (PD) is a method of renal replacement therapy in patients with end-stage kidney disease, and the most common type is continuous ambulatory peritoneal dialysis. Peritonitis is the leading complication of PD and the major predisposing factor is PD catheter-related infection.1-3 Removal of the PD catheter is often required when patients have refractory PD-related peritonitis.4 Some reports reveal that more than 10% of patients with refractory peritonitis experience loculated ascites requiring percutaneous drainage and up to 30% of them die within 6 weeks of follow-up.5 This information provides evidence that pelvic drainage occurs during removal of the dialysis catheter. In this study, we compared the outcome whether inserted pelvic drainage during the removal of the dialysis catheter.
Materials and Methods:
Between Jan 2011 and Mar 2018, total 100 patients underwent the removal of dialysis catheter at the Chi Mei Medical Center. Subsequently, 21 patients were excluded for recurrence PD insertion, removing dialysis catheter not for refractory PD-related peritonitis. Then 39 patients accept insertion of pelvic drainage during the removal of the dialysis catheter as group1 and another 40 patients didn’t insert pelvic drainage during the removal of the dialysis catheter as group2. We compared the outcome between these two groups including intra-abdominal complications, PD reimplantation, length of hospital stay and condition of infection control.
Results:
In group1, the mean duration of PD was 5.9 years, and the mean number of previous peritonitis episodes was 2.5. The average of operation lasted for 65.2 min and the length of hospital stay was 21.6 days, and the pelvic drainage were removed 14 days after the operation. There were only one perioperative complications which had subcutaneous hematoma over the wound and 3 patients expired for uncontrollable sepsis .
In group2, the mean duration of PD was 3.72 years, and the mean number of previous peritonitis episodes was 2.8. The average of operation lasted for 65.3 min and the length of hospital stay was 19.4 days. There were 7 patient s was found abnormal fluid accumulation, then accept percutaneous drainage and 3 patients suffered from recurrence peritonitis. Finally, 6 patients expired for uncontrollable sepsis.
There are 6 patients accept PD reimplantation in group1 and 7 patients accept reimplantation in group2. And 30 patients shift to hemodialysis in group1 and 27 patients shift to hemodialysis in group2.
Discussion:
1. In the previous study, patients had refractory peritonitis with symptomatic ascites requiring percutaneous drainage shortly after the removal of the catheter, and this led to prolonged hospitalization.5-7But in our study, there was 7 patients (17.5%) in group 2 need percutaneous drainage for abnormal fluid accumulation, and there was no difference for length of hospital stay.
2. The development of ascites shortly after catheter removal might result in many intra-abdominal complications, such as abscess, persistent infection, bowel adhesion, and obstruction. Pelvic drainage can not only decrease possible peritoneal complications but can also be used to check intra-abdominal conditions through the drainage ascites.
3. Insertion for pelvic drainage under direct view by scopy during removal of the dialysis catheter was more safely and easily performed than a sono- or CT-guided percutaneous approach after surgery.8,9
Conclusion:
Insertion for pelvic drainage during the removal of the dialysis catheter decreases the risk of complications in refractory PD-related peritonitis.