MODIFIED ULTRASOUND-GUIDED PERCUTANEOUS BEDSIDE PD CATHETER INSERTION BY NEPHROLOGISTS WITHOUT FLOUROSCOPY IN RESOURCE-LIMITED SETTINGS - EXPERIENCE FROM A TERTIARY CARE CENTRE IN SOUTH INDIA

Introduction:

Peritoneal dialysis (PD) catheter insertion by laparotomy or laparoscopy is associated with high costs as well as high morbidity rate and require general anaesthesia with increased risk, leading to delays. Percutaneous insertion of PD catheter by nephrologists, usually guided by fluoroscopy, has been shown to be a safe alternative. However, in developing countries, financial constraints and access to fluoroscopy are limiting factors. Hence, bedside ultrasound-guided percutaneous catheter insertion can be a game changer.

Methods:

End-stage kidney disease patients opting for PD underwent catheter insertion by this procedure. Patients who had undergone major abdominal surgery other than appendicectomy or caesarean section were excluded. Tenckhoff double-cuffed swan-neck catheter was used. The technique was protocolised based on the Seldinger technique and was performed by nephrologists under local anaesthesia with mild intravenous sedation used in some patients. It was modified from the traditional “blind” technique as iatrogenic ascites was created and the needle position was confirmed by ultrasound prior to guidewire and sheath insertion. Blunt dilator was progressed along the guidewire sparing the rectus sheath from an incision. Guidewire was also traced by ultrasound into the pelvis and X-ray KUB was done bedside immediately after catheter insertion to confirm position of the catheter. Data was collected retrospectively on 25 patients who underwent this procedure between 2021 and 2023 with a minimum 1 year of follow-up.

Results:

Among the study population, 80% had diabetes, 60% had coronary artery disease (CAD), 28% had history of cerebrovascular accident. 23/25 patients had successful catheter placement on initial attempt with no complications. In 2 patients, iatrogenic ascites could not be confirmed and the procedure performed successfully after repeat bowel preparation with use of an acute PD catheter. Tip in pelvis was confirmed by X-ray KUB bedside in 23 out of 25 patients. All 25 patients had good inflow and outflow and were initiated on urgent- or early start PD. Pericatheter leak and hemorrhagic drain were noted in one patient each, both of which resolved within 1 week and PD was continued. Bowel perforation was not noted in any patient. PD peritonitis occurred in 8/25 patients within 1 year, with one episode occurring within 1 month. Catheter was salvaged in all these patients. Patient survival was 100% at months 1 and 12 and technique survival was 100% and 96% at months 1 and 12 respectively with one patient requiring hemodialysis due to ultrafiltration failure at 8 months.

Conclusions:

Modified ultrasound-guided percutaneous bedside CAPD catheter insertion is a safe, effective and cost-effective alternative to the traditional fluoroscopic catheter insertions without any increased risk of mechanical or infective complications in patients without prior major abdominal surgery. Although no such episodes were noted in our population, the possibility of an abdominal viscera puncture is a concern with percutaneous “blind” implantation. The study showed that this risk may be reduced by creation of iatrogenic ascites in all cases with use of ultrasound-guidance for needle insertion and guidewire tracing. This technique can be utilised in resource-limited setting for CAPD initiation in a timely manner, in centres without availability of fluoroscopy and precludes the need for general anaesthesia in these high-risk patients.

I have no potential conflict of interest to disclose.

I did not use generative AI and AI-assisted technologies in the writing process.