Introduction:
Catheter malfunction, defined as a mechanical failure in dialysate inflow or drainage.(1)Peritoneal dialysis catheters have undergone various modifications over the past years to reduce technique failure. Complications resulting from catheter insertion techniques can contribute significantly to technique failure (2). Careful surgical insertion ensuring proper catheter placement to avoid blind insertion, especially in patients with previous abdominal surgeries and obese patients to prevent outflow failure, which is common in obese patients (3) (4). Here, we report a case of an unusual migration of PD catheter into the inguinal canal.
Case Report:
A 1-year-old boy who is a product of full-term pregnancy and an elective C-section. He developed end-stage renal disease and pulmonary hypoplasia secondary to obstructive uropathy (posterior urethral valve) which was diagnosed antenatally. He had posterior urethral valve ablation and circumcision in the 1st week of life. His renal function did not recover and his creatinine kept rising up to 146, 548 and 499 before PD catheter insertion (Chronic kidney disease stage 4). He was followed by pediatric Nephrology and as his renal function continued to worsen, he had peritoneal dialysis (PD) catheter inserted at 2 weeks of age (12 days) (9-4-2016). He had his PD catheter inserted by the team of pediatric surgery using an open technique through transverse skin and rectus fascia incision using single cuff straight PD catheter. Omentectomy was not performed during the initial procedure. He was started on PD ??? weeks post-operatively and there was no issues with dialysis initially.
The PD catheter stopped working (seven weeks/ almost 2 months) (7-6-2016) after the insertion and multiple attempts to flush it but failed.
He was admitted and he underwent to diagnostic laparoscopy, omentectomy and repositioning of his PD catheter. Laparoscopy showed distended sigmoid, multiple small bowel adhesions forming multiple pockets in the lower abdomen. The PD catheter was found going through a left patent processus vaginalis going through the inguinal canal (Figure). The PD catheter was repositioned in the Douglas pouch and fixed to the anterior abdominal wall with a non-absorbable suture to avoid migration. Last follow was on 9-4-2017, two months post the revision surgery and his PD catheter is working well, patient doing fine with a history of febrile UTI. PD revision was on 9-2-2017
Discussion:
Outflow failure is a significant PD catheter malfunction. In the case reported here, migration of the PD catheter from the pelvis into the inguinal canal resulted in an unusual complication. Mechanical obstruction of the catheter usually results from misplacement, migration out of the pelvis, omental wrapping, adhesions or encasement by fibrin (intraluminal and extraluminal) (5). Omental wrapping usually develops early after catheter placement, unlike catheter tip migration, tend to happen at any time after insertion, some of the patients experienced constipation, with the consequent eventually leading to up-ward the catheter as a result of sigmoid colon bulging. Laxatives and enemas considered as initial management but the definitive management is the manual correction for repositioning the catheter.(1) If the failure happened as quickly as possible, a rapid differential diagnosis is the first important step to restore the function of the catheter (6) The rate of success insertion and the possibility to be considered as failure vary between methods because of differences in the procedures.(1)A laparoscopic approach, with omentectomy or omentopexy reported being efficacious in omental wrapping treatment as well prevent recurrence (7,8,9,10). Catheter failure rate when using the open technique mentioned to vary between 10% up to 35% (11,12) while laparoscopic insertion technique range from 2.8 to 13% (13,14).Laparoscopic fixation also considered being valuable for prevention the migration.(1) in case-series the migration reported to be 1.3–5.4% of the laparoscopically inserted.(13,15,16) on the other hand open technique range from 7.6 to 17.1%.(17,18,19). In Meta-Analysis published in 2013 showed laparoscopic technique of PD catheters insertion is having a higher one-year catheter survival and less migration compared with open technique (20)