A prospective randomized study of the effect of a subcutaneously "buried" peritoneal dialysis catheter technique versus standard technique on the incidence of peritonitis and exit-site infection. One-dose cefuroxime i.v. and i.p. reduces microbial growth in PD patients after catheter insertion. Peritoneoscopic versus surgical placement of peritoneal dialysis catheters: a prospective randomized study on outcome. Prophylactic antibiotics in the insertion of Tenckhoff catheters. Role of preoperative antibiotic prophylaxis in preventing postoperative peritonitis in newly placed peritoneal dialysis catheters. Effect of prolonged subcutaneous implantation of peritoneal catheter on peritonitis rate during CAPD: a prospective randomized study. Peritoneal dialysis access: prospective randomized comparison of the Swan neck and Tenckhoff catheters. Role of intraperitoneal urokinase in acute peritonitis and prevention of catheter loss in peritoneal dialysis patients. Peritoneal dialysis access: prospective randomized comparison of single-cuff and double-cuff straight Tenckhoff catheters. Catheter configuration and outcome in patients on continuous ambulatory peritoneal dialysis: a prospective comparison of two catheters. Cefazolin plus ceftazidime versus imipenem/cilastatin monotherapy for treatment of CAPD peritonitis--a randomized controlled trial. Paramedian versus midline incision for the insertion of permanent peritoneal dialysis catheters. A randomized clinical trial. Percutaneous endoscopic gastrostomy (PEG): comparison of push and pull methods and evaluation of antibiotic prophylaxis. Randomized prospective comparison of laparoscopic and open peritoneal dialysis catheter insertion.
A new method for implantation of peritoneal dialysis (PD) catheters was described in 1991. The distal part of the catheter is buried subcutaneously and exteriorized at the start of PD. This study was designed to evaluate the effect of such a subcutaneous rest period on the incidence of peritonitis and exit-site infections (ESI).
                Sixty patients were randomized to either the new method (B group; n = 30) or to not having the distal part buried subcutaneously (NB group; n = 30). Sixty-five patients (NS group) were not randomized as they had to start PD within 1-2 weeks after implantation. The Moncrief-Popovich catheter was used in the B and NB groups and a standard Tenckhoff catheter was used in the NS group.
                Patients scheduled for PD treatment, judged not in need of PD for at least 6 weeks after implantation.
                There was no statistically significant difference in the cumulative probability of not developing peritonitis during the first 6, 12, and 24 months. The incidence of the first episode of peritonitis was 1/40, 1/26, and 1/33 treatment-months in the B, NB, and NS groups, respectively. The incidence of ESI was 1/103 and 1/95 treatment-months in the B and NS groups, respectively. The cumulative probability of not developing ESI was similar in both groups. There were no episodes of ESI in the NB group. The difference in the number of ESI between the NB and NS groups was significant (p < 0.05).
                Subcutaneous burying of the distal catheter segment prior to starting PD does not reduce the risk of contracting peritonitis or exit-site infection. When a peritoneal dialysis catheter is inserted intra-abdominally in a patient starting peritoneal dialysis (PD) there is always a risk for postoperative wound infection and peritonitis. At our centre, PD is started immediately after the dialysis catheter is inserted. This may increase the postoperative risk for peritonitis and wound infection. The aim of this prospective, randomized, study was to evaluate whether the incidence of microbial growth postoperatively (within 10 days) after catheter insertion could be reduced by prophylactic antibiotic therapy.
                During a period of 27 months, 38 patients, who consecutively entered the PD programme, (11 women and 27 men, mean age 57 years) were included in the study. Eighteen patients were given cefuroxime 1.5 g i.v. preoperatively and 250 mg i.p. in the first dialysis bag (containing 1 litre fluid) as prophylaxis. Twenty patients were not given prophylactic antibiotics (control group). All catheter insertions were performed in an operating theatre by the same surgeons using the same technique.
                In the test group, none of the patients showed microbial growth in the dialysis fluid during the post-operative period, while in the control group six of 20 patients (30%) suffered from such growth (P = 0.021).
                Prophylactic treatment by cefuroxime i.v. pre- and i.p. perioperatively may reduce the risk for microbial growth and peritonitis after insertion of a Tenckhoff catheter. The most commonly used technique for insertion of peritoneal dialysis (PD) catheters is open surgical approach by minilaparotomy. Percutaneous implantation via the peritoneoscopic technique is expanding. Studies have suggested that PD catheters placed peritoneoscopically have longer survival rate than surgically placed ones. However, these studies were not randomized, where the surgical group had more patients who were obese or had prior abdominal surgery, and therefore, the selection of patients may have biased the results. We conducted a prospective randomized study in which patients underwent PD catheter placement by either the surgical or the peritoneoscopic technique. In the period from October 1992 through October 1995, 148 double-cuff, curled-end, swan-neck PD catheters were placed in 148 patients. The outcome of the 76 patients in whom the PD catheters were placed peritoneoscopically was compared with that of the 72 patients in whom the catheters were placed surgically. Early peritonitis episodes (within 2 weeks of catheter placement) occurred in 9 of 72 patients (12.5%) in the surgical group, versus 2 of 76 patients (2.6%) in the peritoneoscopy group (P = 0.02). This higher rate of infection was most likely related to a higher exit site leak in the surgical group (11.1%) as compared with the peritoneoscopy group (1.3%). Moreover, peritoneoscopically placed catheters were found to have better survival (77.5% at 12 months, 63% at 24 months, and 51.3% at 36 months) than those placed surgically (62.5% at 12 months, 41.5% at 24 months, and 36% at 36 months) with P = 0.02, 0.01, and 0.04, respectively. We conclude that peritoneoscopically placed PD catheters have a longer survival rate than surgically placed ones. Furthermore, the rate of exit site leak and early infection is lower in the peritoneoscopic method. We assessed the efficacy of preoperative antibiotic prophylaxis in a prospective trial for patients undergoing insertion of Tenckhoff catheters for continuous ambulatory peritoneal dialysis (CAPD). The prophylactic regimen was a single dose of cefazolin (500 mg) and gentamicin (80 mg) given intravenously half an hour before surgery. There was no significant difference in the number of exit site infections (8 in the antibiotic group vs. 8 in the controls) and the number of episodes of peritonitis (5 in the antibiotic group vs. 2 in the controls). Our study showed that prophylactic preoperative antibiotics did not reduce the number of exit site infections and peritonitis after the insertion of Tenckhoff catheters. The role of vancomycin and other antibiotics in the treatment of acute peritonitis in peritoneal dialysis (PD) patients is well established. However, the role of preoperative vancomycin or cephalosporins in preventing early infection in newly placed PD catheters remains controversial. We performed a prospective randomized study to examine the role of vancomycin or cefazolin prophylaxis in decreasing the incidence of postoperative peritonitis. Over a 6-year period, 221 patients undergoing 254 permanent peritoneal catheter placement procedures were randomized into three groups. Group I patients (86 procedures) were administered a single intravenous (IV) dose of vancomycin, 1,000 mg, 12 hours before peritoneal catheter placement procedures, whereas group II patients (85 procedures) were administered a single IV dose of cefazolin, 1,000 mg, 3 hours before the procedure. Group III patients (83 procedures) were not administered antibiotics preoperatively for at least 1 week before the procedure. Patients were monitored for peritonitis in the following 14 days. Peritonitis developed in 1 patient (1%) in group I (vancomycin group) and 6 patients (7%) in group II (cefazolin group) compared with 10 patients (12%) in group III (control group); P = 0.02. We conclude that the use of preoperative single-dose IV vancomycin prophylaxis for permanent PD catheter placement reduces the risk for postoperative peritonitis. Single-dose vancomycin is superior to single-dose cefazolin in reducing the risk for postoperative peritonitis. Absence of prophylaxis is associated with a high risk for developing postoperative peritonitis. We conducted a prospective randomized controlled study to confirm our earlier observation that prolonged subcutaneous implantation of peritoneal catheter reduced peritonitis rate when compared to retrospective data from patients with catheters placed by conventional access technique. A total of 60 patients were randomized into two groups: 30 patients had catheters left implanted subcutaneously for 6 weeks (I) and the other 30 patients had catheters inserted by conventional technique and had 6 weeks of break-in period (C). Subgroups of 15 patients each with new and conventional techniques used Y-connector (IY, CY) and remaining patients used standard spikes (IS, CS). Mean age was 47.7 years (range 16-71); 61.0% were male and 44.1% diabetics. Peritonitis, exit site infection, simultaneous peritonitis and exit site infection, and complication related to Staphylococcus or Pseudomonas infections were observed for up to 2 years in each patient after initiation of bag exchange or until termination of CAPD by transfer to hemodialysis or by death. Total duration of observation was 493.2 patient-months for new access technique and 409.6 patient-months for conventional technique. Patients in IY group had the lowest incidence of peritonitis (1/14.9 patient-months) and exit site infection (1/16.8 patient-months) among four subgroups. Peritonitis rate in IY was significantly lower compared to CY or CS. The total peritonitis-free period in those patients who did not experience peritonitis during the observation period was also significantly longer in IY (120 patient-months) than in CY (26 patient-months), IS (10.6 patient-months), or CS (10.4 patient-months). Simultaneous peritonitis and exit site infection was observed in none of IY group but 3 episodes in CY, 4 episodes in IS, and 3 episodes in CS. The rates of complications related to Staphylococcus aureus and Pseudomonas infections were also significantly lower in IY than in CY, IS, or CS. Technique survival did not differ between the two groups. The present results confirm our previous observation that the new access technique reduces the incidence of peritonitis probably by reducing infection via periluminal route. The Y-connector system further reduces peritonitis rate by reducing infection via intraluminal route. To examine the impact of peritoneal catheter configuration on mechanical complications, catheter survival, probability of episodes of peritonitis, and probability of exit-site infections associated with the use of catheters for continuous ambulatory peritoneal dialysis (CAPD).
                Prospective randomized trial.
                CAPD unit in one university hospital, serving a population of 1.2 million.
                Forty consecutive patients requiring their first dialysis catheter for future CAPD were randomized to receive either a two-cuff permanently bent Swan neck catheter or a two-cuff straight Tenckhoff catheter. The skin exit was downward-directed in the Swan neck group and upward-directed in the Tenckhoff group.
                Dialysate leak, catheter migration, or tunnel infection did not occur in any of the patients. Three outer cuff extrusions needing cuff shaving occurred, all in the Tenckhoff group (p = 0.1). No significant differences could be demonstrated in catheter survival at 2 years, probability of episodes of peritonitis, or probability of exit-site infections.
                Catheter configuration did not influence the catheter-related mechanical or infectious complications, and equally good results were obtained with both catheter types studied. Some studies have demonstrated the efficacy and safety of intraperitoneal (i.p.) urokinase in the resolution of recurrent or relapsing peritonitis, while others have not. Most studies were small, and they varied in methodology. Furthermore, the role of i.p. urokinase in shortening the duration of peritonitis or in preventing recurrence after initial peritonitis has not been examined. In addition, no previous studies have examined the role of i.p. urokinase in preventing, after first infection, catheter loss due to unresolving (resistant) peritonitis. Over a period of 3 years, we prospectively randomized into two groups all peritoneal dialysis (PD) patients who developed a first episode of peritonitis. Group I (n = 40) received i.p. urokinase on the first day of diagnosis (5000 IU intraluminally in the peritoneal catheter and left for 4 hours before next exchange). Group II (n = 40) received no urokinase. The duration of peritonitis was assessed by daily PD fluid white blood cell (WBC) count. Indications for catheter removal were: persistent peritonitis after four days from initiation of antibiotic therapy, or peritonitis with multiple organisms, suggesting bowel perforation. No statistically significant difference was seen between the two groups in regard to primary cause of end-stage renal disease (ESRD), age, sex, race, weight, type of dialysis [continuous ambulatory peritoneal dialysis (CAPD), automated peritoneal dialysis (APD), continuous cycling peritoneal dialysis (CCPD)], or duration of dialysis prior to first peritonitis. No statistically significant difference was seen between the two groups in the duration of peritonitis or in the severity of symptoms and signs of peritonitis. Neither was any difference seen in the peritonitis recurrence or relapse rate (10% in the urokinase group vs 7.5% in the control group). Nine patients lost their catheters (3 in the urokinase group: 1 Pseudomonas aeruginosa and 2 Candida tropicalis; 6 in the control group: 1 Klebsiella pneumonia, 1 enterococcus, 2 Pseudomonas aeruginosa, and 2 Candida tropicalis). The difference in the rate of catheter loss between the two groups was not statistically significant; it appeared to relate to the type of organism rather than to the response to urokinase. In conclusion, i.p. urokinase plays no significant role in shortening the course of peritonitis or in preventing recurrence or loss of the PD catheter. Loss of PD catheters in patients having their first peritonitis appears to be related primarily to the type of organism causing the infection. A prerequisite to the technical success of chronic peritoneal dialysis is a functioning peritoneal catheter. The option of using Tenckhoff catheters with single or double Dacron cuffs has been available for almost 3 decades, but still there is no consensus as to which is the preferable type.
                Sixty consecutive patients requiring a catheter for CAPD were randomized to receive either a straight deep single-cuff Tenckhoff catheter or a double-cuff Tenckhoff catheter. The catheters were surgically inserted.
                There were no early failures. Two subcutaneous cuff extrusions were treated with shaving of the cuff. In the long term, eight patients in both groups required transfer to haemodialysis (5 and 3 prolonged peritonitis, 1 and 0 exit-site infection, 2 and 5 unable to cope or inadequacy of dialysis). There was no significant difference in the probability of developing first episode of peritonitis or exit site infection between the groups. Overall probability of catheter survival was 95.5 and 96.7% at 1 year, 82.7 and 79.9% at 2 in the two groups respectively.
                There was no significant difference between catheters with single or double cuffs with respect to catheter survival, episodes of peritonitis and exit-site infections. To examine the impact of peritoneal catheter configuration on mechanical complications, catheter survival, probability of episodes of peritonitis, and probability of exit-site infections associated with the use of catheters for continuous ambulatory peritoneal dialysis (CAPD).
                Prospective randomized trial.
                CAPD unit in one university hospital.
                Forty consecutive patients requiring a dialysis catheter for future CAPD were randomized to receive either a single-cuff straight Tenckhoff catheter or a permanently bent single-cuff Swan neck catheter. The skin exit was upward-directed in the Tenckhoff group and downward-directed in the Swan neck group.
                Dialysate leak occurred in one patient and symptomatic catheter tip migration in 3 patients with the Tenckhoff catheter but in none with the single-cuff Swan neck catheter (p = 0.5, p = 0.12). No significant differences in catheter survival at 2 years, probability of episodes of peritonitis, or probability of exit-site infections could be demonstrated.
                Catheter configuration did not influence the catheter-related mechanical or infectious complications. We were unable to demonstrate any advantage of the newer, permanently bent single-cuff Swan neck catheter over the conventional straight type. Peritonitis is a serious complication of peritoneal dialysis (PD). We studied the efficacy of imipenem/cilastatin monotherapy in the treatment of PD-related peritonitis.
                We performed an open-label, randomized control study comparing imipenem/cilastatin monotherapy (treatment group) versus cefazolin plus ceftazidime (control group) in the treatment of PD peritonitis. The result was further compared to a historic group treated with cefazolin plus netilmycin. Outcome measures were primary response rate at day 10 and complete cure rate.
                We enrolled 51 patients in the treatment group, 51 in the control group, and identified 96 in the historic group. The primary response rate to the assigned antibiotics was 49.0%, 51.0%, and 49.0% for the treatment, control, and historic groups, respectively (p = 0.97). The primary response rate allowing for change in antibiotic was 82.4%, 90.2%, and 82.3%, respectively, for the three groups (p = 0.41). The complete cure rate was 72.5%, 80.4%, and 82.3%, respectively (p = 0.60). Tenckhoff catheter removal was needed in 6 cases in the treatment group, 6 cases in the control group, and 13 cases in the historic group (p = 0.90).
                We concluded that monotherapy of imipenem/cilastatin has similar efficacy compared to the two standard regimens of cefazolin plus ceftazidime or netilmycin in the treatment of PD peritonitis. A randomized trial was conducted to examine the influence of the site of catheter insertion on the mechanical complications associated with the use of peritoneal dialysis catheters (pericatheter leakage/herniation and tip migration). 37 patients requiring a dialysis catheter for future CAPD were randomized to insertion by either a midline (prior standard approach) or a lateral incision (new approach). Thirteen catheters (6 midline, 7 lateral) failed for mechanical reasons--mainly irreversible tip migration. The one year estimated catheter survival without mechanical failure was found to be similar in the two groups: midline (59%) and lateral (51%), (0.4 less than p less than 0.5). Infection of the gastrostomy opening after placement of a percutaneous endoscopic gastrostomy (PEG) catheter has been reported to occur quite often, especially when the pull method is used. We therefore compared complications occurring with the pull and push methods, and evaluated the role of antibiotic prophylaxis.
                In a prospective study, 100 consecutive patients were randomly assigned to group A (pull plus antibiotic prophylaxis: amoxycillin-clavulanic acid 3 x 1.2 g i.v. over 24 hours; 37 patients), group B (pull without antibiotic prophylaxis; 34 patients) and group C (push without antibiotic prophylaxis; 29 patients). The indications for PEG placement were dysphagia due to oropharyngeal tumors (56%), neurological disease (32%), or other (12%). Patients were evaluated twice weekly for one month after the PEG placement.
                PEG catheters were successfully placed in 96% of the patients. The total procedure-related complication rate was significantly lower in group A than in groups B and C (28%, 58%, and 70%, respectively; p < 0.01). Major complications occurred in one patient in group A (seeding metastasis of a hypopharyngeal carcinoma in the gastrostomy tract), and in four patients in group B (three cases of peritonitis and one aspiration, resulting in two deaths), but in none of the group C patients. Group A patients experienced fewer peristomal infections than the other two groups (14%, 30%, and 41%, respectively: p = 0.05). The risk of peristomal pain was similar (11%, 15%, and 11%, respectively; p = n.s.). In three patients in group C, the PEG catheter had to be replaced by the pull method, due to repeated dislocation of the balloon catheter.
                The complication rate with PEG placement is high with both the push and pull methods. The complication rate with the pull method is significantly reduced when antibiotic prophylaxis is used. To compare laparoscopic and conventional peritoneal dialysis catheter insertion with respect to post operative discomfort, complication rates, and catheter survival.
                Randomized prospective study.
                Tertiary referral renal unit.
                Fifty patients commencing peritoneal dialysis.
                Catheters were implanted laparoscopically or by a conventional surgical technique.
                The duration of surgery, hospital stay, pain scores, and analgesic requirements were recorded. Complications (early/late) and catheter survival were compared.
                The conventional procedure was faster than the laparoscopic (14.3 vs 21.9 minutes, p < 0.0001). There was no difference in any other parameter assessed.
                The data suggest that the insertion techniques are equivalent, and that laparoscopic insertion does not reduce early complication rates.
No major advantages from any of the catheter-related interventions which have been purported to reduce the risk of PD peritonitis could be demonstrated in this review. The frequency and quality of available trials are suboptimal.