PDI
january 2014 – Vol. 34, No. 1 correspondence
Department of Medicine3 Department of Pathology and Laboratory Medicine4 Schulich School of Medicine and Dentistry London, Ontario, Canada *email: [email protected] REFERENCES
doi:10.3747/pdi.2012.00077
Intestinal Obstruction—An Unusual Complication of Peritoneoscopic Tenckhoff Catheter Insertion Editor: Continuous ambulatory peritoneal dialysis (CAPD) is a widely accepted and effective method of renal replacement therapy (RRT) in end-stage renal disease. The Tenckhoff catheter can be inserted by various means. In our center, we use the peritoneoscopic method, performed by the physician. There are a number of well-recognized complications of Tenckhoff catheter insertion—namely, peritonitis, catheter migration, hemoperitoneum, and rarely, intestinal obstruction (1). Here, we share our experience of an instance of acute intestinal obstruction after Tenckhoff catheter insertion. A 54-year-old man had presented with stage 5 chronic kidney disease (estimated glomerular filtration rate: 6 mL/min) secondary to diabetic nephropathy. He opted
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1. Nomoto Y, Suga T, Nakajima K, Sakai H, Osawa G, Ota K, et al. Acute hydrothorax in continuous ambulatory peritoneal dialysis—a collaborative study of 161 centers. Am J Nephrol 1989; 9:363–7. 2. Szeto CC, Chow KM. Pathogenesis and management of hydrothorax complicating peritoneal dialysis. Curr Opin Pulm Med 2004; 10:315–19. 3. Chow CC, Sung JY, Cheung CK, Hamilton–Wood C, Lai KN. Massive hydrothorax in continuous ambulatory peritoneal dialysis: diagnosis, management and review of the literature. N Z Med J 1988; 101:475–7. 4. Kawaguchi AL, Dunn JC, Fonkalsrud EW. Management of peritoneal dialysis–induced hydrothorax in children. Am Surg 1996; 62:820–4. 5. Lew SQ. Hydrothorax: pleural effusion associated with peritoneal dialysis. Perit Dial Int 2010; 30:13–18. 6. Yim AP, Lee TW, Wan IY, Ng C. Images in cardiothoracic surgery. Pleuroperitoneal fistula. Ann Thorac Surg 2002; 73:1327. 7. Gagnon RF, Thirlweil M, Arzoumanian A, Mehio A. Systemic amyloidosis involving the diaphragm and acute massive hydrothorax during peritoneal dialysis. Clin Nephrol 2002; 57:474–9. 8. Van Dijk CM, Ledesma SG, Teitelbaum I. Patient characteristics associated with defects of the peritoneal cavity boundary. Perit Dial Int 2005; 25:367–73. 9. Saillen P, Mosimann F, Wauters JP. Hydrothorax and endstage chronic renal failure. Chest 1991; 99:1010–1. 10. Chow KM, Szeto CC, Wong TY, Li PK. Hydrothorax complicating peritoneal dialysis: diagnostic value of glucose concentration in pleural fluid aspirate. Perit Dial Int 2002; 22:525–8. 11. Juergensen PH, Rizvi H, Caride VJ, Kliger AS, Finkelstein FO. Value of scintigraphy in chronic peritoneal dialysis patients. Kidney Int 1999; 55:1111–19. 12. Mestas D, Wauquier JP, Escande G, Baguet JC, Veyr A. Diagnosis of hydrothorax complicating CAPD and demonstration of successful therapy by scintigraphy. Perit Dial Int 1991; 11:283–4. 13. Cho Y, D’Intini V, Ranganathan D. Acute hydrothorax complicating peritoneal dialysis: a case report. J Med Case Rep 2010; 4:355. 14. Tang S, Chui WH, Tang AW, Li FK, Chau WS, Ho YW, et al. V ideo-assisted thoracoscopic talc pleurodesis is effective for maintenance of peritoneal dialysis in acute hydrothorax complicating peritoneal dialysis. Nephrol Dial Transplant 2003; 18:804–8.
15. Kechrid MC, Malik GH, Shaikh JF, Al-Mohaya S, Al-Wakeel JS, El Gamal H. Acute hydrothorax complicating continuous ambulatory peritoneal dialysis: a case report and review of literature. Saudi J Kidney Dis Transpl 1999; 10:163–6. 16. Chow KM, Szeto CC, Li PK. Management options for hydrothorax complicating peritoneal dialysis. Semin Dial 2003; 16:389–94. 17. Gibbons GD, Baumert J. Unilateral hydrothorax complicating peritoneal dialysis. Use of radionuclide imaging. Clin Nucl Med 1983; 8:83–4. 18. Rajnish A, Ahmad M, Kumar P. Peritoneal scintigraphy in the diagnosis of complications associated with continuous ambulatory peritoneal dialysis. Clin Nucl Med 2003; 28:70–1. 19. Pankaj P, Pathak V, Sen IB, Verma R, Bhalla AK, Marwaha A, et al. Use of radionuclide peritoneography in the diagnosis of pleuroperitoneal communication as a complication of continuous ambulatory peritoneal dialysis. Ind J Nucl Med 2005; 20:4–8. 20. Goh AS, Lee GS, Kee SG, Ang ES, Sundram FX. Radionuclide detection of dialysate leakage in patients on continuous ambulatory peritoneal dialysis. Ann Acad Med Singapore 1994; 23:315–18. 21. Huang JJ, Wu JS, Chi WC, Lan RR, Yang LF, Chiu NT. Hydrothorax in continuous ambulatory peritoneal dialysis: therapeutic implications of Tc-99m MAA peritoneal scintigraphy. Nephrol Dial Transplant 1999; 14:992–7. 22. Krishnan RG, Ognjanovic MV, Crosier J, Coulthard MG. Acute hydrothorax complicating peritoneal dialysis. Perit Dial Int 2007; 27:296–9.
CORRESPONDENCE
january 2014 – Vol. 34, No. 1
PDI
The patient continued to have excessive upper gastrointestinal fluid loss. A nasogastric tube was inserted, draining 1000 mL on the 3rd postoperative day. He was reviewed by the surgical team and kept under observation. He was regularly hemodialyzed using an internal jugular catheter. Against medical advice, the patient opted to be discharged on the 8th postoperative day. Unfortunately, he returned 2 days after discharge, with florid features of intestinal obstruction. He had had no bowel opening, and he was vomiting profusely and experiencing abdominal pain and distention. Abdominal radiography revealed gross dilation of the small bowel (Figure 2). The catheter was in situ. Subsequent abdominal computed tomography revealed small-bowel obstruction secondary to coiling of the Tenckhoff catheter in the lower abdomen (Figure 3). Laparotomy was performed on the 14th postoperative day. Intraoperatively, the proximal small bowel was noted to be grossly dilated, with the transition zone found at 100 cm from the duodenojejunal junction because of internal herniation through the mesosigmoid colon defect. The Tenckhoff catheter was looping around a
Figure 1 — Initial abdominal radiograph on the 3rd postoperative day shows a small loop of dilated small bowel (arrow).
Figure 2 — Repeat abdominal radiograph on the 10th postoperative day shows features of small-bowel obstruction.
144
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for CAPD and underwent peritoneoscopic insertion of a Tenckhoff catheter (double-cuffed, coiled) using the Y-Tec peritoneoscope (CardioMed, Lindsay, ON, Canada) with the use of the VP-210 STD Disposable Pac (CardioMed). The placement site for the Tenckhoff catheter was well visualized using the peritoneoscopic method. Intraoperatively, no complications were encountered, and good inflow and outflow of dialysate was achieved. The patient experienced a short period of leakage from the exit site in the immediate postoperative period that settled after 3 days. He was given a week’s course of oral cephalosporin to prevent peritonitis. However, he became unwell 2 days after catheter insertion, experiencing abdominal discomfort beginning on the 2nd postoperative day. The frequency of bowel opening declined, but he refused stool softeners and enemas. He also experienced vomiting. On examination, the patient’s vital signs were stable, with no abdominal tenderness and audible bowel sounds. A rectal examination revealed an empty rectum. On the 3rd postoperative day, abdominal radiography (Figure 1) showed the Tenckhoff catheter in situ, with no gross features of intestinal obstruction save for a short loop of prominent small bowel.
PDI
january 2014 – Vol. 34, No. 1 correspondence
DISCLOSURES
Figure 3 — Computed tomography shows the Tenckhoff catheter (white arrow) entwining the small bowel, with dilated small bowel proximal to the obstruction (large black arrow) and collapsed small bowel distal (small black arrow).
section of strangulated small bowel. The affected bowel appeared dusky. A serosal tear was also noted in the small bowel 95 cm from the duodenojejunal junction. The internal herniation was released, and the obstructed small bowel decompressed. On assessment, the small bowel was deemed viable. The mesosigmoid defect and serosal tear were repaired, and the Tenckhoff catheter was removed. The patient recovered well postoperatively. He was no longer vomiting, and he was tolerating oral intake and experiencing normal bowel openings. He was discharged well on the 2nd post-laparotomy day, and he continued performing regular hemodialysis using his internal jugular catheter. On follow-up at the nephrology clinic, the patient opted to perform hemodialysis as long-term renal replacement therapy. Complications after Tenckhoff catheter implantation can be categorized as early or late. Early complications are those that occur within 30 days after implantation, and they include peritonitis, catheter malfunction, leak,
The authors have no financial conflicts of interest to declare. S. Sivathasan* L. Mushahar W.S. Yusuf Department of Nephrology Hospital Tuanku Ja’afar Seremban Seremban, Malaysia *email: [email protected] REFERENCES 1. Shenouda AN, Puckett W, Burns R, Miller FJ. Acute intestinal obstruction complicating CAPD. Perit Dial Int 1982; 1:49. 2. Asif A. Peritoneal dialysis access–related procedures by nephrologists. Semin Dial 2004; 17:398–406. 3. Cooles P, Power DA, Krukowski ZH. Small bowel obstruction secondary to recurrent peritonitis. A fatal complication of chronic ambulatory peritoneal dialysis. J R Coll Surg Edinb 1985; 30:206–7. 4. Madden MA, Beirne GJ, Zimmerman SW, Sollinger H. Acute bowel obstruction: an unusual complication of chronic peritoneal dialysis. Am J Kidney Dis 1982; 1:219–21.
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145
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and perforated viscus (2). Late complications (more than 30 days after implantation) include infections, catheter migration, and hernias (2). Acute intestinal obstruction after Tenckhoff insertion is by no means a common complication. Reported causes include severe peritoneal adhesions (3) and occasionally an incisional hernia at the site of catheter insertion (4,5). The mechanism described in this case, with the Tenckhoff catheter entwining the small bowel, has thus far not been extensively reported. Intestinal obstruction after insertion of an Oreopoulos catheter by the open method has previously been reported (6), but that complication occurred after a year on CAPD. We believe that the present case is the first reported of acute obstruction after peritoneoscopic insertion of a double-cuffed coiled catheter. This case is presented for its rarity and to highlight the need to keep all potential complications in mind and to take necessary precautions to prevent them, even though peritoneoscopic catheter insertion is safe. Despite the rarity of intestinal obstruction as a complication, our case illustrates that, after initial conservative measures have been unsuccessful, surgical intervention can prevent untoward incidents.
CORRESPONDENCE
january 2014 – Vol. 34, No. 1
5. Jorkasky D, Goldfarb S. Abdominal wall hernia complicating chronic ambulatory peritoneal dialysis. Am J Nephrol 1982; 2:323–4. 6. Kanagasundaram NS, Fletcher S, Gupta S, Davison AM.
PDI
Acute small bowel obstruction following mesenteric perforation by CAPD catheter. Nephrol Dial Transplant 1997; 12:599–600. doi:10.3747/pdi.2012.00332
Downloaded from http://www.pdiconnect.com/ at CLAUDE MOORE HEALTH SCIENCES LIBRARY on December 9, 2015
146
This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]
january 2014 – Vol. 34, No. 1 correspondence
Department of Medicine3 Department of Pathology and Laboratory Medicine4 Schulich School of Medicine and Dentistry London, Ontario, Canada *email: [email protected] REFERENCES
doi:10.3747/pdi.2012.00077
Intestinal Obstruction—An Unusual Complication of Peritoneoscopic Tenckhoff Catheter Insertion Editor: Continuous ambulatory peritoneal dialysis (CAPD) is a widely accepted and effective method of renal replacement therapy (RRT) in end-stage renal disease. The Tenckhoff catheter can be inserted by various means. In our center, we use the peritoneoscopic method, performed by the physician. There are a number of well-recognized complications of Tenckhoff catheter insertion—namely, peritonitis, catheter migration, hemoperitoneum, and rarely, intestinal obstruction (1). Here, we share our experience of an instance of acute intestinal obstruction after Tenckhoff catheter insertion. A 54-year-old man had presented with stage 5 chronic kidney disease (estimated glomerular filtration rate: 6 mL/min) secondary to diabetic nephropathy. He opted
This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]
143
Downloaded from http://www.pdiconnect.com/ at CLAUDE MOORE HEALTH SCIENCES LIBRARY on December 9, 2015
1. Nomoto Y, Suga T, Nakajima K, Sakai H, Osawa G, Ota K, et al. Acute hydrothorax in continuous ambulatory peritoneal dialysis—a collaborative study of 161 centers. Am J Nephrol 1989; 9:363–7. 2. Szeto CC, Chow KM. Pathogenesis and management of hydrothorax complicating peritoneal dialysis. Curr Opin Pulm Med 2004; 10:315–19. 3. Chow CC, Sung JY, Cheung CK, Hamilton–Wood C, Lai KN. Massive hydrothorax in continuous ambulatory peritoneal dialysis: diagnosis, management and review of the literature. N Z Med J 1988; 101:475–7. 4. Kawaguchi AL, Dunn JC, Fonkalsrud EW. Management of peritoneal dialysis–induced hydrothorax in children. Am Surg 1996; 62:820–4. 5. Lew SQ. Hydrothorax: pleural effusion associated with peritoneal dialysis. Perit Dial Int 2010; 30:13–18. 6. Yim AP, Lee TW, Wan IY, Ng C. Images in cardiothoracic surgery. Pleuroperitoneal fistula. Ann Thorac Surg 2002; 73:1327. 7. Gagnon RF, Thirlweil M, Arzoumanian A, Mehio A. Systemic amyloidosis involving the diaphragm and acute massive hydrothorax during peritoneal dialysis. Clin Nephrol 2002; 57:474–9. 8. Van Dijk CM, Ledesma SG, Teitelbaum I. Patient characteristics associated with defects of the peritoneal cavity boundary. Perit Dial Int 2005; 25:367–73. 9. Saillen P, Mosimann F, Wauters JP. Hydrothorax and endstage chronic renal failure. Chest 1991; 99:1010–1. 10. Chow KM, Szeto CC, Wong TY, Li PK. Hydrothorax complicating peritoneal dialysis: diagnostic value of glucose concentration in pleural fluid aspirate. Perit Dial Int 2002; 22:525–8. 11. Juergensen PH, Rizvi H, Caride VJ, Kliger AS, Finkelstein FO. Value of scintigraphy in chronic peritoneal dialysis patients. Kidney Int 1999; 55:1111–19. 12. Mestas D, Wauquier JP, Escande G, Baguet JC, Veyr A. Diagnosis of hydrothorax complicating CAPD and demonstration of successful therapy by scintigraphy. Perit Dial Int 1991; 11:283–4. 13. Cho Y, D’Intini V, Ranganathan D. Acute hydrothorax complicating peritoneal dialysis: a case report. J Med Case Rep 2010; 4:355. 14. Tang S, Chui WH, Tang AW, Li FK, Chau WS, Ho YW, et al. V ideo-assisted thoracoscopic talc pleurodesis is effective for maintenance of peritoneal dialysis in acute hydrothorax complicating peritoneal dialysis. Nephrol Dial Transplant 2003; 18:804–8.
15. Kechrid MC, Malik GH, Shaikh JF, Al-Mohaya S, Al-Wakeel JS, El Gamal H. Acute hydrothorax complicating continuous ambulatory peritoneal dialysis: a case report and review of literature. Saudi J Kidney Dis Transpl 1999; 10:163–6. 16. Chow KM, Szeto CC, Li PK. Management options for hydrothorax complicating peritoneal dialysis. Semin Dial 2003; 16:389–94. 17. Gibbons GD, Baumert J. Unilateral hydrothorax complicating peritoneal dialysis. Use of radionuclide imaging. Clin Nucl Med 1983; 8:83–4. 18. Rajnish A, Ahmad M, Kumar P. Peritoneal scintigraphy in the diagnosis of complications associated with continuous ambulatory peritoneal dialysis. Clin Nucl Med 2003; 28:70–1. 19. Pankaj P, Pathak V, Sen IB, Verma R, Bhalla AK, Marwaha A, et al. Use of radionuclide peritoneography in the diagnosis of pleuroperitoneal communication as a complication of continuous ambulatory peritoneal dialysis. Ind J Nucl Med 2005; 20:4–8. 20. Goh AS, Lee GS, Kee SG, Ang ES, Sundram FX. Radionuclide detection of dialysate leakage in patients on continuous ambulatory peritoneal dialysis. Ann Acad Med Singapore 1994; 23:315–18. 21. Huang JJ, Wu JS, Chi WC, Lan RR, Yang LF, Chiu NT. Hydrothorax in continuous ambulatory peritoneal dialysis: therapeutic implications of Tc-99m MAA peritoneal scintigraphy. Nephrol Dial Transplant 1999; 14:992–7. 22. Krishnan RG, Ognjanovic MV, Crosier J, Coulthard MG. Acute hydrothorax complicating peritoneal dialysis. Perit Dial Int 2007; 27:296–9.
CORRESPONDENCE
january 2014 – Vol. 34, No. 1
PDI
The patient continued to have excessive upper gastrointestinal fluid loss. A nasogastric tube was inserted, draining 1000 mL on the 3rd postoperative day. He was reviewed by the surgical team and kept under observation. He was regularly hemodialyzed using an internal jugular catheter. Against medical advice, the patient opted to be discharged on the 8th postoperative day. Unfortunately, he returned 2 days after discharge, with florid features of intestinal obstruction. He had had no bowel opening, and he was vomiting profusely and experiencing abdominal pain and distention. Abdominal radiography revealed gross dilation of the small bowel (Figure 2). The catheter was in situ. Subsequent abdominal computed tomography revealed small-bowel obstruction secondary to coiling of the Tenckhoff catheter in the lower abdomen (Figure 3). Laparotomy was performed on the 14th postoperative day. Intraoperatively, the proximal small bowel was noted to be grossly dilated, with the transition zone found at 100 cm from the duodenojejunal junction because of internal herniation through the mesosigmoid colon defect. The Tenckhoff catheter was looping around a
Figure 1 — Initial abdominal radiograph on the 3rd postoperative day shows a small loop of dilated small bowel (arrow).
Figure 2 — Repeat abdominal radiograph on the 10th postoperative day shows features of small-bowel obstruction.
144
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for CAPD and underwent peritoneoscopic insertion of a Tenckhoff catheter (double-cuffed, coiled) using the Y-Tec peritoneoscope (CardioMed, Lindsay, ON, Canada) with the use of the VP-210 STD Disposable Pac (CardioMed). The placement site for the Tenckhoff catheter was well visualized using the peritoneoscopic method. Intraoperatively, no complications were encountered, and good inflow and outflow of dialysate was achieved. The patient experienced a short period of leakage from the exit site in the immediate postoperative period that settled after 3 days. He was given a week’s course of oral cephalosporin to prevent peritonitis. However, he became unwell 2 days after catheter insertion, experiencing abdominal discomfort beginning on the 2nd postoperative day. The frequency of bowel opening declined, but he refused stool softeners and enemas. He also experienced vomiting. On examination, the patient’s vital signs were stable, with no abdominal tenderness and audible bowel sounds. A rectal examination revealed an empty rectum. On the 3rd postoperative day, abdominal radiography (Figure 1) showed the Tenckhoff catheter in situ, with no gross features of intestinal obstruction save for a short loop of prominent small bowel.
PDI
january 2014 – Vol. 34, No. 1 correspondence
DISCLOSURES
Figure 3 — Computed tomography shows the Tenckhoff catheter (white arrow) entwining the small bowel, with dilated small bowel proximal to the obstruction (large black arrow) and collapsed small bowel distal (small black arrow).
section of strangulated small bowel. The affected bowel appeared dusky. A serosal tear was also noted in the small bowel 95 cm from the duodenojejunal junction. The internal herniation was released, and the obstructed small bowel decompressed. On assessment, the small bowel was deemed viable. The mesosigmoid defect and serosal tear were repaired, and the Tenckhoff catheter was removed. The patient recovered well postoperatively. He was no longer vomiting, and he was tolerating oral intake and experiencing normal bowel openings. He was discharged well on the 2nd post-laparotomy day, and he continued performing regular hemodialysis using his internal jugular catheter. On follow-up at the nephrology clinic, the patient opted to perform hemodialysis as long-term renal replacement therapy. Complications after Tenckhoff catheter implantation can be categorized as early or late. Early complications are those that occur within 30 days after implantation, and they include peritonitis, catheter malfunction, leak,
The authors have no financial conflicts of interest to declare. S. Sivathasan* L. Mushahar W.S. Yusuf Department of Nephrology Hospital Tuanku Ja’afar Seremban Seremban, Malaysia *email: [email protected] REFERENCES 1. Shenouda AN, Puckett W, Burns R, Miller FJ. Acute intestinal obstruction complicating CAPD. Perit Dial Int 1982; 1:49. 2. Asif A. Peritoneal dialysis access–related procedures by nephrologists. Semin Dial 2004; 17:398–406. 3. Cooles P, Power DA, Krukowski ZH. Small bowel obstruction secondary to recurrent peritonitis. A fatal complication of chronic ambulatory peritoneal dialysis. J R Coll Surg Edinb 1985; 30:206–7. 4. Madden MA, Beirne GJ, Zimmerman SW, Sollinger H. Acute bowel obstruction: an unusual complication of chronic peritoneal dialysis. Am J Kidney Dis 1982; 1:219–21.
This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]
145
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and perforated viscus (2). Late complications (more than 30 days after implantation) include infections, catheter migration, and hernias (2). Acute intestinal obstruction after Tenckhoff insertion is by no means a common complication. Reported causes include severe peritoneal adhesions (3) and occasionally an incisional hernia at the site of catheter insertion (4,5). The mechanism described in this case, with the Tenckhoff catheter entwining the small bowel, has thus far not been extensively reported. Intestinal obstruction after insertion of an Oreopoulos catheter by the open method has previously been reported (6), but that complication occurred after a year on CAPD. We believe that the present case is the first reported of acute obstruction after peritoneoscopic insertion of a double-cuffed coiled catheter. This case is presented for its rarity and to highlight the need to keep all potential complications in mind and to take necessary precautions to prevent them, even though peritoneoscopic catheter insertion is safe. Despite the rarity of intestinal obstruction as a complication, our case illustrates that, after initial conservative measures have been unsuccessful, surgical intervention can prevent untoward incidents.
CORRESPONDENCE
january 2014 – Vol. 34, No. 1
5. Jorkasky D, Goldfarb S. Abdominal wall hernia complicating chronic ambulatory peritoneal dialysis. Am J Nephrol 1982; 2:323–4. 6. Kanagasundaram NS, Fletcher S, Gupta S, Davison AM.
PDI
Acute small bowel obstruction following mesenteric perforation by CAPD catheter. Nephrol Dial Transplant 1997; 12:599–600. doi:10.3747/pdi.2012.00332
Downloaded from http://www.pdiconnect.com/ at CLAUDE MOORE HEALTH SCIENCES LIBRARY on December 9, 2015
146
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