Traditional surgical implantation of Tenckhoff catheters involves immediate exteri-orization of the external segment through the skin, so that the catheter can be used for supportive peritoneal dialysis or for intermittent infusions during the "break-in" period. To prevent blockage and to confirm function, the catheter is flushed weekly with saline or dialysate; each exchange carries the same risk of peritonitis as in continuous ambulatory peritoneal dialysis therapy to avoid bacterial contamination of the exit site. The catheter must also be bandaged and the skin exit site must be kept clean in the weeks after placement. The patient must, therefore, be trained in some techniques of catheter care. It has always been difficult to decide when to place a peritoneal dialysis catheter in a patient with chronic renal insufficiency. If the catheter is placed too early, the patient may spend weeks to months caring for a catheter that is not used for dialysis. If the catheter is placed after the patient becomes uremic, it is often used for peritoneal dialysis therapy without a "break-in" period.
Moncrief et al. devised a placement technique in which the entire peritoneal catheter can be buried under the skin some weeks to months before it is used (63). The catheter-burying technique was first described for the placement of a modified Tenckhoff catheter with a 2.5 cm-long superficial cuff, but the technique has been adopted for standard dual-cuff Tenckhoff catheters (64-66). In the original technique, the external portion of the catheter was brought through a 2 to 3 cm skin exit site (much larger than the usual 0.5 cm incision). The catheter was then tied off with silk suture then coiled and placed into a "pouch" created under the skin. The skin exit site was then closed. Weeks to months later, the original skin exit site was opened, and the free end of the catheter was brought through the original skin large exit site (63,64).
The goal of burying the peritoneal dialysis catheter was to allow ingrowth of tissue into the cuffs of the catheter to prevent bacterial colonization and to allow ingrowth and anchoring of the deep and subcutaneous cuffs. Burying the catheter effectively eliminated early peri-catheter leaks and decreased the incidence of peritonitis rate. In 66 months of follow-up, patients with the buried Tenckhoff catheter had peritonitis infection rates of 0.017 to 0.37 infections per year, versus 1.3 to 1.9 infections per year in control patients (63). In a study of 26 buried Tenckhoff catheters, incidence of infectious complications during peritoneal dialysis was 0.8 infections per year and catheter-related peritonitis was only 0.036 per patient-year (64). A retrospective study confirmed a significantly lower catheter infection and peritonitis rate in patients having had buried catheters and a significantly longer catheter life (67,68), although the procedure was not effective when used for single-cuff catheters.
Exit site infections were not decreased in catheters that were buried, but this is understandable, because a large exit site was created when the catheter was buried, and a similarly large site was recreated when the catheter was exteriorized. Creating the "pouch" under the skin requires a considerable amount of dissection and trauma near the exit site. The size of the pocket limits the length of catheter that can be coiled and buried under the skin, limiting the external length of the catheter after exteriorization. The exit site must be opened widely to remove the catheter, because the coil rests in a position distant from the skin exit site. Subcutaneous adhesions to the silk suture around the catheter further restrict removal. Increased trauma near the exit site during placement and exteriorization of the catheter may have caused an increased incidence of early exit infection with this technique. In one study of "embedded" catheters in 26 adult patients (with mean subcutaneous residence of 79.5 days), 2 patients developed local seromas and 12 developed subcutaneous hematomas (5 of which were revised surgically) (69). At catheter "activation," there were a number of flow problems: nine patients developed fibrin thrombi (two requiring operative clearance) and four patients had omental catheter obstruction (four requiring omentectomy). When burying the Tenckhoff catheter by standard techniques, there were a total of 27 complications in 26 catheter placements, with 13 of these complications requiring corrective surgery.
When catheters are placed by the Y-Tec procedure, the quill and cannula of the system can be reassembled and used to bury the external portions of dual-cuff Tenckhoff and Advantage catheters (12). The catheter exit site is made slightly larger than the standard exit site. The quill and cannula are inserted through this exit site to create a long, straight tunnel for the external end of the catheter. The catheter is blocked with an internal plug, rather than an external silk suture. This technique has been used to bury and then remove over 40 Tenckhoff and Advantage catheters. There have been few early complications of insignificant hematoma (3%), seroma (0%), exit infection (3%), or outflow failure (0%) and all catheters have functioned after exteriorization (12). Nephrologists can bury and exteriorize peritoneal dialysis catheters with greater ease and lesser trauma than surgical procedures and obtain results and benefits that are at least as positive.
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