Can a tenckoff catheter be implanted for 5 mos, being dormant, then be surgically released for us?

Answer 1

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Tenckhoff catheters post-renal transplantation: the ‘pull’ technique?
Isabel M. Quiroga, Ram Baboo, Rozanne H. Lord and Christopher R. Darby

University Hospital of Wales, Heath Park, Cardiff, UK

Abstract

Background. Tenckhoff catheters are used widely for the provision of continuous ambulatory peritoneal dialysis. Traditionally these catheters are removed surgically under anaesthesia. We set out to introduce and monitor prospectively a technique for removal of the Tenckhoff catheter by a ‘pull’ technique. The intention was to avoid the discomfort, risk and cost of traditional surgery.

Methods. Over a 1-year period all renal transplant patients having their Tenckhoff catheter removed by this technique were monitored prospectively. All patients were followed for a minimum 2-year period after removal. In the pull technique steady non-jerky traction is applied to the catheter. Complications such as catheter breakage and cuff related sepsis were recorded.

Results. Sepsis related to a retained cuff occurred in only one patient early in the series. There were no other complications. The procedure was well tolerated. Use of local anaesthesia used initially, was largely phased out over the course of study and the procedure moved from the theatre to the ward.

Conclusions. The pull technique is safe and well tolerated. The technique has significant advantages in selected patients without a history of recent peritonitis or exit site infection, in reducing risk to the patients, the pain of abdominal wall surgery and reduced usage of costly theatre time and in-patient beds.

Keywords: anaesthesia; complications; cost; pull technique; removal; surgery; Tenckhoff; transplantation

Introduction

Tenckhoff catheters (Quinton, Seattle, WA, USA) are used widely for the provision of continuous ambulatory peritoneal dialysis (CAPD). These catheters are implanted surgically and are retained in the patient by tissue in-growth into two cuffs. After successful transplantation these catheters can be removed. Traditionally this has been by surgical exposure, dissection of the cuffs from the scar tissue and removal in entirety. This procedure can be accomplished in the operating theatre under a general anaesthetic or with more difficulty under local anaesthetic. This activity exposes the patient to the pain of surgery to the abdominal wall and risks of anaesthesia. This activity also takes up precious beds, medical, nursing and theatre time. In our unit we have not performed this surgery for years. However, we can find little reference to alternatives in the literature and on enquiry find that almost all units continue to remove Tenckhoff catheters surgically. Therefore, we chose to review our technique for removal of catheters prospectively and follow a group of patients for some years to assess the efficacy of a pull technique.

Subjects and methods

Over a 1-year period all renal transplant patients having their Tenckhoff catheter removed by this technique were monitored prospectively. All patients received triple therapy immunosuppression consisting of cyclosporin, azathioprine, and prednisolone. Data were recorded for prior history of infection, time catheter in situ, time catheter in situ post-transplantation, place where the procedure was performed, anaesthesia used, technique used, and complications. All patients were followed for a minimum 2-year period after removal.

The commonest catheters have two cuffs bonded to the catheter itself. However, this bond is not particularly strong. This provides a safe guard as the catheter will always shear from the cuff rather than break in the event of an accident. In the pull technique, steady non-jerky traction is applied to the catheter. Anaesthesia or sedation is not usually required (see below). The catheter will stretch and pressure will be felt by the patient at the outer cuff. After a few moments the catheter will begin to move out again as the cuff shears off and is retained in the patient. Tension is now transferred to the inner cuff. Traction is maintained as before and the inner cuff will separate from the catheter. The intra-peritoneal section of the catheter is drawn through the cuff and the intact catheter removed from the patient.

The technique is modified in some situations. If there is a history of recent exit site infection local anaesthesia is injected at the exit site. The exit site is enlarged a little. Traction brings the cuff to the base of this small wound. Local anaesthetic is injected around the outer cuff and the cuff dissected from the surrounding tissues. The rest of the catheter is removed by traction leaving the inner cuff as before. In the absence of infection, if the outer cuff on traction is found to be right next to the skin it is removed as above.

Results

Thirty-one patients (17 male and 14 female) underwent removal of their Tenckhoff catheter by this technique and have been followed for a minimum of 2 years.

The mean age was 44 years. The mean time catheter was in situ prior to removal was 24 months while the mean time in situ post-transplant was 4 months. Anaesthetic techniques used included: 15 local alone; three local plus sedation; eight no anaesthetic; three general anaesthetic (in patients undergoing another procedure); two sedation for anxiety. Twenty-five catheters were removed in the operating theatre and six on the ward. The inner cuff was retained in 31 patients. The outer cuff was retained in 26 and removed in five patients. Mean time in hospital was 0.5 days. Complications included late outer cuff related infection in one patient. Neither deep cuff sepsis nor catheter breakage occurred