Peritoneal Dialysis Access: The Surgeon’s Perspective

Abstract

Chronic kidney disease (CKD) is prevalent throughout the world, and peritoneal dialysis (PD) has been a growing mode of renal replacement therapy (RRT) for over four decades. Peritoneal dialysis has several advantages in cost, patient satisfaction, and quality of life, despite accounting for only one in ten patients on dialysis in the United States. In spite of some contraindications and barriers to effective PD, the vast majority of renal failure patients are candidates, especially when in a high-volume program with surgical expertise readily available. Reliable access via an intraabdominal PD catheter is paramount for managing end-stage renal disease patients. Surgical approaches for PD catheter insertion have evolved substantially alongside innovations in catheter design. Recent data suggests that the advanced laparoscopic catheter placement offers the best results and long-term survival. However, image-guided fluoroscopic insertion can be performed without general anesthesia, is highly effective, and is growing in usage. Being able to start PD urgently is vital in avoiding hemodialysis (HD) and its complications, and this is a growing theme worldwide, despite slightly higher morbidity. Infectious and mechanical complications are relatively common and are frustrating to PD patients and the physicians who care for them. Peritonitis and exit site infections require antibiotic coverage and sometimes, surgical intervention. Catheter dysfunction is a frequent mechanical issue requiring a multidisciplinary approach: medical treatment, nurse-administered flushing and clot dissolvers, interventional radiology evaluation and wire manipulation, and surgical laparoscopy for catheter salvage.

1. Introduction

Using the peritoneal membrane to clear toxins from the blood has been a work in progress for over a century. In 1923, George Ganter performed the first peritoneal dialysis (PD) on a guinea pig using hypertonic saline [1]. Several attempts were made in humans to no avail until Frank, Siegelman, and Fine, in 1946, reported the first successful use of peritoneal dialysis in a renal failure patient in Boston [2]. Over the next two decades, PD did not see widespread use due to poor clearance, catheter problems, and infections. However, a significant breakthrough occurred in 1968 when Henry Tenckhoff developed a permanent implantable silastic catheter with multiple holes in the tip to improve drainage and cuffs to prevent infection [3]. The late 1970s and 1980s saw the birth of CAPD, cycling machines, plastic solution bags, the Y connector, and several adaptations of the implantable peritoneal dialysis catheter [4], ushering PD into the mainstream as a viable form of renal replacement therapy. Over the last four decades, peritoneal dialysis has evolved as a proven mode of dialysis worldwide.

While its adoption has experienced fluctuations within the United States healthcare system, there has been a consistent upward trend in utilization globally, especially in Hong Kong, Mexico, New Zealand, Thailand, and Australia [5]. This modality offers several advantages over traditional hemodialysis (HD), particularly in areas of patient quality-of-life enhancement. These benefits include substantially improved patient autonomy through self-administration capabilities, superior preservation of residual kidney function, and less hemodynamic instability [6,7,8,9,10,11]. From an economic perspective, home-based dialysis modalities like PD present considerable cost advantages compared to in-center hemodialysis [12,13,14]. Recognizing these benefits, the Centers for Medicare and Medicaid Services (CMS) implemented the End-Stage Renal Disease (ESRD) Treatment Choices Model in 2021, actively promoting peritoneal dialysis and kidney transplantation as preferred interventions [15]. This policy shift aimed to simultaneously enhance the quality of care while reducing the substantial Medicare expenditures associated with chronic kidney disease management. As a result of these initiatives, peritoneal dialysis is experiencing renewed growth within the United States as a primary renal replacement modality. However, despite these positive trends, PD currently accounts for only approximately 12% of the total ESRD population in the US [16]. Patient selection for PD remains heavily influenced by nephrologist recommendations, which are shaped by multiple factors, including the physician’s fellowship training experiences, established group practice patterns, personal biases regarding modality selection, and the robustness of existing PD programs within their practice environment.

2. Contraindications and Barriers to PD

Several conditions preclude the use of peritoneal dialysis, the first of which is documented ultrafiltration failure of the peritoneal membrane, indicating an inability to effectively filter waste through the peritoneal surface. Severe protein malnutrition and/or proteinuria exceeding 10 g per day, which can be exacerbated by PD and represents another absolute contraindication. Active intraabdominal infectious processes, including but not limited to Crohn’s disease flares, acute diverticulitis, or ischemic bowel conditions, also completely preclude PD initiation due to infection risk. Other conditions present significant challenges but do not entirely rule out PD as an option. The first is the loss of abdominal domain or irreparable abdominal wall hernias that compromise the integrity of the peritoneal cavity, making PD technically challenging. Reduced functional peritoneal volume due to dense abdominal adhesions from previous surgeries or inflammatory conditions may also limit effectiveness. In these cases, surgical intervention may restore candidacy for PD if appropriate surgical expertise is available. It is worth noting that preoperative assessment often cannot definitively determine whether surgical correction will enable successful PD implementation [17,18]. Therefore, an aggressive surgical approach may be warranted. Beyond formal contraindications, numerous factors have traditionally been considered barriers to successful PD implementation. Advanced age was once considered prohibitive, but is now recognized as a manageable factor with proper support. Obesity presents technical challenges to the surgeon and requires modified exit site planning. However, specialized placement techniques, such as omentopexy and upper abdominal exit site, can allow obese patients to achieve similar success rates to the non-obese [19]. Polycystic kidney disease requires careful catheter positioning but is no longer considered a significant barrier. The presence of an ostomy necessitates strategic exit site planning, but can be accommodated. Prior liver transplantation, congestive heart failure, and portal hypertension with ascites all require specialized management but do not automatically exclude patients from PD consideration. Visual impairment and cognitive limitations, including dementia or memory deficits, may require caregiver assistance but need not prevent PD utilization. Suboptimal home environments can often be modified to accommodate PD equipment and supplies. Employment circumstances requiring frequent travel or limited flexibility may present logistical challenges, but creative scheduling solutions can typically be developed. Many barriers can be overcome with appropriate patient selection, comprehensive nephrology team education, access to surgeons with specialized expertise in PD catheter placement, and engagement of family members or dedicated caregivers [20].

The typical pathway to PD begins with detailed discussions between the patient and their nephrologist, followed by referral to a surgeon for preoperative evaluation. This surgical consultation focuses on assessing specific risk factors that may contribute to catheter dysfunction. A detailed history of previous abdominal surgical procedures helps anticipate potential adhesions. Evaluation for the presence of abdominal wall hernias, both symptomatic and asymptomatic, is essential as these may require simultaneous or staged repair. Assessment of obesity and its potential impact on catheter function guides the selection of optimal catheter configuration and placement technique. Patients are counseled regarding the importance of preoperative education through their outpatient dialysis provider such as DaVita™ or Fresenius™. The optimal timing for initiating this training process is approximately 10 days prior to the scheduled catheter insertion procedure, allowing sufficient time for knowledge acquisition without excessive delay [21].

Given the elevated anesthetic and surgical risks in this medically complex population, comprehensive preoperative risk stratification is essential. This typically involves a complete blood count, comprehensive metabolic profile, thorough evaluation by the primary care physician, and when indicated, consultation with a cardiologist to optimize the patient’s condition prior to the procedure. To minimize infection of the implanted device, antibiotics should be administered at least 30 min before incision [22]. A first-generation cephalosporin is most common, but Vancomycin should be considered in high-risk patients [23]. Other preoperative considerations include: having the patient shower on the day of surgery with a chlorhexidine soap wash of the abdomen/chest, removal of body hair in the preoperative holding area, preferably with electric clippers, and an empty bladder before surgery [22]. It has also been recommended in the 2019 update of the International Society of Peritoneal Dialysis (ISPD) guideline that a bowel regimen such as enema, stimulant suppository, or PEG solution be administered the night before surgery [22]. In addition, before image-guided percutaneous insertion, in nonurgent placements, bowel preparation is recommended to reduce colonic distension and postoperative constipation that might affect catheter function. If patients have chronic constipation, oral laxatives could also be administered several days before the procedure. Post-procedure instructions to avoid constipation are also delivered [24].

3. Surgical Techniques and Catheter Configurations

Surgical approaches for PD catheter insertion have evolved substantially alongside innovations in catheter design. The current literature regarding infection prevention and catheter functionality supports using catheters with either straight or coiled tips that ultimately position within the deep pelvis for optimal dialysate flow. Modern PD catheters incorporate two “cuffs” adhered to the mid-portion of the device. A “deep cuff” is positioned within the abdominal wall, between the anterior and posterior sheaths, while a “superficial cuff” is located in the subcutaneous tissue approximately 2 cm from the skin exit site. These cuffs facilitate rapid tissue ingrowth following insertion, which serves two critical purposes: preventing accidental catheter displacement and creating a barrier against retrograde bacterial migration from the skin along the catheter tract [22]. Currently, three primary catheter configurations are widely available, each designed to position the exit site optimally in relation to anatomical landmarks, most importantly, the belt line. The straight catheter design allows a more superior angled path through the subcutaneous tissue to the exit site. The swan neck configuration creates an angled pathway that helps direct the exit site downward, below the belt line. The extended two-piece catheter system allows for customized positioning in challenging anatomical situations. These include presternal or subcostal exit site locations to avoid the pannus, or existing ostomies.

The surgical technique used for insertion was first described as blind percutaneous by Tenckoff and Schechter in 1968 [3]. Unfortunately, this technique was plagued by complications such as bowel injury and poor function, so it was soon replaced by open insertion through a mini laparotomy. The open insertion through a paramedian incision subsequently became the mainstay for PD access for over three decades until the laparoscopic approach crept into the scene [25]. The initial laparoscopic procedure was described to allow intraabdominal visualization of the catheter as it was inserted, and this is now known as basic laparoscopic (BL) insertion [26]. Next, surgeons around the globe added adjunct procedures to help decrease catheter dysfunction. These included lysis of adhesions, omentopexy to keep the omentum out of the pelvis, and suture fixation or rectus sheath tunnel to prevent catheter migration [27,28]. After these publications were released, the technique became known as advanced laparoscopic (AL) insertion. Additional large series followed, supporting AL insertion [29,30], as well as a recent systematic review and meta-analysis by Shrestha in 2018 comparing AL to open and BL insertion [31]. They defined AL insertion as using rectus sheath tunnel, omentopexy, and lysis of adhesions and found that compared with BL, catheter obstruction and migration were significantly lower in the AL group, whereas catheter survival was similar in both groups. All other outcomes were similar between the AL and BL groups, including infectious complications such as peritonitis and exit-site infection. Furthermore, they found that AL insertion was associated with superior outcomes compared to open insertion. Specifically, a significant reduction was observed in the incidence of catheter obstruction, catheter migration, pericannular leak, and pericannular and incisional hernias. In addition, 1- and 2-year catheter survival was better in the AL group [31].

Comparing insertion techniques was a primary focus of the 2023 Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Peritoneal Dialysis Access Guideline Update [32]. For this clinical practice guideline, key questions compared AL to BL, AL to open, and AL to image-guided percutaneous insertion. The working group performed abstract screening, full-text review, evidence grading, data extraction, and analysis. Finally, evidence-to-decision panels reviewed the evidence and placed a final vote on the condition and strength of the recommendations [33]. Key question 5 asked: Should advanced laparoscopic insertion techniques or open insertion be used for adult patients needing renal replacement therapy? The panel suggested that advanced laparoscopic insertion be used as opposed to open insertion (conditional recommendation, very low certainty evidence). This was based on favorable outcomes of bowel injury, early and late catheter dysfunction, hernia occurrence, exit site infection, leakage, mortality, and peritonitis. A consideration favoring open insertion is the ability to perform the procedure under local anesthesia and sedation, while AL requires general anesthesia and CO₂ insufflation, which carries a higher risk of cardiopulmonary complications [34]. The panel did note that there could be issues with access to the requisite training and equipment to perform laparoscopic surgery worldwide. However, with the widespread adoption of laparoscopy, the equipment required for AL placement should hopefully be easily accessible to most surgeons. Regarding the appropriate training, the panel noted the importance of surgical societies and the ISPD in both presenting and publishing educational videos of the technique and training new generations of surgeons in AL placement. Key question 4 asked: Should advanced laparoscopic insertion techniques or basic laparoscopic insertion techniques be used for adult patients needing renal replacement therapy? For adult patients, the panel suggests advanced laparoscopic insertion as opposed to basic laparoscopic insertion (conditional recommendation, very low certainty of evidence). This was based on significantly lower late catheter dysfunction. Currently, both the International Society for Peritoneal Dialysis (ISPD) and the Society of American Gastrointestinal and Endoscopic Surgeons guidelines support the use of AL as offering a lower risk of PD catheter dysfunction over open and BL [22,32].

Over the last two decades, an increasing number of PD catheters have been inserted by interventional radiologists and nephrologists using an image-guided percutaneous approach, usually under ultrasound and fluoroscopic guidance. Advantages include increased availability by avoiding the need for an operating room and better patient safety since general anesthesia is not required. Ultrasound, to facilitate avoidance of the inferior epigastric vessels and bowel loops, and fluoroscopy, to confirm catheter tip placement in the pelvis, have made this a safe and efficacious insertion technique [35,36,37,38,39]. A systematic review and meta-analysis was published in 2021, including 24 studies and over 6000 patients, comparing infectious and mechanical complications between surgical PD catheter insertion and percutaneous catheter insertion. They did not differentiate between the three surgical insertion options, and they included patients who underwent percutaneous insertion using the Seldinger technique with or without image guidance. They found that percutaneous insertion was associated with a lower risk of both exit-site infections and peritonitis within 1 month of the procedure. In addition, the two techniques had no difference in mechanical complication rates [39]. They concluded that results may have significant implications on the direction of PD programs in terms of maximizing operating room resources. They did agree that large RCTs should be conducted to help improve the quality of these findings [40].

Comparing image-guided percutaneous (IGP) insertion to advanced laparoscopic insertion was the focus of another key question on the recent SAGES Updated Guidelines for Peritoneal Dialysis Access Surgery. It should be noted that the data regarding IGP was extracted from papers that did not exclude patients who were obese or had prior abdominal surgery. The panel concluded that either AL insertion or ultrasound-guided percutaneous insertion should be used for patients needing PD catheter insertion (conditional recommendation, very low certainty evidence). The advantages of the percutaneous technique found in this analysis included a lower risk of dialysate leakage, hernia, exit-site infection, and late catheter dysfunction. However, there was a higher risk of bleeding and bowel injury, and this may have been magnified in patients with prior abdominal operations [32]. The panel concluded that further research, including randomized controlled trials, are necessary to best compare these techniques. In the meantime, image-guided percutaneous insertion is a viable and growing modality for catheter insertion.

4. Post-Insertion Management

Regardless of the insertion technique employed, certain fundamental principles should guide post-procedure management as established by the ISPD [22]. The catheter should be thoroughly flushed and capped with a transfer set immediately after placement. Sterile dressing application and securing of the catheter is essential to prevent accidental displacement. The catheter and dressing should remain undisturbed for one week to allow initial tissue integration with the cuffs. The first catheter flushing procedure should be performed one-week post-insertion to maintain patency. Finally, The International Society for Peritoneal Dialysis recommends a minimum “break-in” period of two weeks before initiating actual dialysis treatments to allow for adequate healing of the insertion site and the formation of a biological barrier around the catheter cuffs [22].

5. Urgent-Start PD Protocols

Despite recommendations encouraging early specialist enrollment for patients with advancing chronic kidney disease, many individuals present with urgent or emergent dialysis requirements due to fluid overload or life-threatening hyperkalemia. Approximately 30–40% of patients (in North America and Europe) start dialysis without functioning permanent access, such as an arteriovenous fistula or a PD catheter [41]. These are usually patients who were not under the care of a nephrologist or were non-compliant with recommendations and presented with a sudden deterioration in renal function due to superimposed acute kidney injury with subsequent non-recovery. Historically, these patients received temporary venous catheters for inpatient hemodialysis despite the increased morbidity related to temporary catheters, such as infection, thrombosis, and venous stenosis [42]. They were then discharged with planned outpatient HD regimens. Once established on this routine, patients rarely transitioned to peritoneal dialysis.

There has recently been increasing momentum toward implementing “urgent-start” PD protocols to avoid temporary hemodialysis and increase overall PD utilization. Initiating PD earlier than the traditional two-week waiting period offers several significant advantages, such as the preservation of vascular access sites for potential future needs and improved outcomes following kidney transplantation. Patients managed exclusively with PD also experience a reduced risk of hepatitis B and C infections associated with hemodialysis [43].

Several studies worldwide have shown the success of “Urgent PD start” using low-volume exchanges in the supine position without waiting for the traditional 2-week catheter break-in period [44,45,46]. Although peritoneal catheter leaks and mechanical obstruction continue to be hurdles to the success of this modality, several centers have shown close to 18–30% increase in PD utilization after implementing an “Urgent Start” program [47]. In the USA, more programs are adapting to the idea of “Transitional Care Units” where patients are stabilized on HD and their families are educated about the advantages and disadvantages of home-based therapies, resulting in increased uptake of PD [48].

In a recent systematic review and meta-analysis by Xu et al., they analyzed 27 studies and found that the overall risk of post-procedure infection was comparable for both PD initiation methods. Similarly, the risks for peritonitis and exit site infections did not differ significantly. However, urgent-start PD correlated with a significantly higher risk of overall mechanical complications. Specifically, the risk for leaks was notably higher in the urgent-start group compared to the conventional-start PD group. Urgent-start PD correlated with significantly increased mortality rates and there was no difference in the likelihood of technique survival and transfer to hemodialysis. Both urgent-start and conventional-start PD correlated with similar risks of overall infectious complications. Because Urgent-start PD resulted in significantly increased risks of mechanical complications and mortality, their findings emphasize the need for meticulous planning and consideration when opting for PD initiation [49].

According to the SAGES guideline panel, urgent initiation of PD before the conventional two-week break-in period is associated with increased risks of dialysate leakage, early catheter dysfunction, and bleeding complications. Therefore, the recommendation was as follows: for adult patients, the panel suggests traditional start as opposed to urgent start when initiating peritoneal dialysis (conditional recommendation, very low certainty evidence). However, this risk assessment specifically addressed scenarios where patients have the option to delay PD initiation. The guideline acknowledged that for certain patients, the benefits of avoiding HD-related procedures and interim hemodialysis treatments may outweigh the risks associated with urgent PD initiation. This decision requires individualized consideration between the patient and their healthcare team, with further research indicated to refine approaches to urgent-start protocols [32]. Successful urgent-start protocols require rapid medical stabilization by the nephrology team and immediate availability of surgical or interventional radiology resources for catheter placement. Coordinated discharge planning to ensure continuity of care is also essential for program success.

6. Complications and Management Strategies

Complications related to peritoneal dialysis access are relatively uncommon but pose significant challenges for both patients and healthcare providers when they do occur. Both infectious and mechanical complications can jeopardize the viability of continued PD and must be addressed promptly to prevent the need for conversion to hemodialysis.

Peritonitis is relatively common in PD patients and presents with varying severity, ranging from mild abdominal discomfort to life-threatening sepsis. The incidence varies globally, but the ISPD recommends that the overall peritonitis rate in a program should be no more than 0.40 episodes per year at risk and the percentage of patients free of peritonitis per unit time should be targeted at >80% per year [50]. The most common presentation includes observation of cloudy peritoneal dialysis fluid effluent accompanied by abdominal pain, often severe in nature. Patients typically exhibit abdominal tenderness during physical examination. The constellation of symptoms may mimic surgical emergencies, necessitating careful differentiation. Diagnosis is confirmed through PD fluid cell count and microbiological culture. Treatment begins with empiric broad-spectrum intravenous antibiotics pending culture results, ensuring coverage of Gram-positive and Gram-negative organisms. The ISPD guidelines specifically recommend intraperitoneal antibiotic administration as the preferred route unless the patient exhibits features of systemic sepsis [50]. Symptom improvement typically occurs within 72 h of appropriate therapy. If the dialysate effluent does not clear within five days despite treatment, there is a high probability that catheter removal will be necessary, requiring a temporary transition to hemodialysis. However, it is essential to note that PD catheter reinsertion remains an option once the infection has been completely resolved.

Exit site infections represent another challenging complication for PD patients. Erythema surrounding the exit site may indicate early infection, while drainage from the exit site, particularly purulent material, strongly suggests infection. Fluctuance or tenderness along the catheter tract may indicate a deeper collection requiring drainage. Purulent drainage specifically indicates tunnel infection extending along the subcutaneous portion of the catheter. When these signs are present, evaluation by a nephrologist and referral to a surgeon is indicated. In complex cases, infectious disease consultation may be warranted. Diagnostic evaluation typically includes ultrasound assessment of the catheter tract to identify fluid collections and a trial of appropriate antibiotics if peritonitis is absent. Incision and drainage procedures may be necessary for purulent collections. Cuff shaving has been described as a way of salvaging the catheter in instances where the cuff is visible or extruded and in some cases of refractory peritonitis [22,51]. If these interventions fail to resolve the infection, catheter removal and replacement at a separate site represent the definitive management approach.

Catheter dysfunction is another significant complication requiring urgent attention. This problem is classified as either one-way (outflow) obstruction or two-way (inflow and outflow) obstruction, with different management approaches required for each. Two-way obstruction typically indicates a fibrin plug within the catheter or a mechanical kink in the tubing, particularly when occurring immediately after surgical placement. Outflow obstruction manifests as poor or slow drainage of dialysate from the abdomen and commonly results from colonic distension due to constipation. More challenging causes of drainage dysfunction include omental wrapping around the catheter, which physically blocks flow and sometimes works like a one-way valve, allowing fluid to instill but not drain. Catheter migration out of the optimal position in the deep pelvis is another leading cause since the catheter no longer lies where dialysate pools. Entrapment within bowel loops creates mechanical obstruction through external compression or a one-way valve, and the formation of inflammatory adhesions can similarly restrict catheter function by external compression or by forming a loculated small cavity.

The initial management approach includes vigorous flushing procedures at the dialysis center to dislodge potential fibrin plugs or debris. Aggressive treatment of constipation with appropriate laxatives often relieves outflow obstruction by reducing colonic distension. Because PD patients maintain residual renal function and urine output, bladder distension from urinary retention may be the problem and should be managed aggressively. Radiographic assessment to evaluate catheter position guides further intervention planning. This usually begins with a plain abdominal series, but computed tomography can provide better anatomical information.

If these measures prove inadequate, the next steps may include the installation of tissue plasminogen activator to dissolve fibrin and blood clots that resist mechanical flushing. Interventional radiology evaluation with contrast injection can identify specific areas of obstruction and wire manipulation under fluoroscopic guidance may reposition displaced catheters in selected cases [52,53]. While these interventions may provide temporary improvement, operative management with exploratory laparoscopy and catheter revision typically yields superior long-term results and this should be undertaken promptly to avoid the need for temporary hemodialysis. The recent SAGES guideline addressed operative versus nonoperative treatment of PD catheter dysfunction. After a review of the literature, the two were compared using several outcomes, including the following: bleeding, infection, short-term survival, and long-term survival of the catheter. The data did not favor either technique as non-operative IR manipulation showed lower risk of bleeding, exit site infection, and peritonitis. At the same time, operative intervention via laparoscopy led to a lower rate of early and late catheter dysfunction. The panel suggested that in patients with PD catheter malfunction, either nonoperative or operative salvage may be attempted (conditional recommendation, very low certainty evidence). Additionally, they recommended that nonoperative strategies such as interventional radiology wire manipulation are low risk and should probably be attempted first if time permits. However, operative intervention with exploratory laparoscopy and catheter revision has better long-term results and should be undertaken in a timely manner so temporary HD may be avoided [32].

Our unpublished data revealed that out of 41 patients undergoing laparoscopic revision, the cause in 32% was adhesions, 29% migration, 12% adhesions plus fibrin plug, and 10% fibrin plug. We utilized lysis of adhesions, Proline suture sling to reposition the catheter in the pelvis, vigorous flushing of fibrin plugs, and omentopexy as operative techniques to salvage the function of the catheter. Short- and long-term follow-ups revealed a 30-day success rate of 83%, and the catheters were used in one or two days to avoid hemodialysis. Unfortunately, the long-term survival rate was 29%, and the average survival time was just over 5 months. These results indicate that patients with primary catheter dysfunction, despite salvage, are at high risk for subsequent failure and the need to switch modes of renal replacement therapy. This calls attention to the importance of appropriate counseling for patients who have dysfunction before salvage procedures to manage long-term expectations.

7. Conclusions

Peritoneal dialysis represents a valuable renal replacement therapy option with distinct advantages over hemodialysis for appropriately selected patients. With continued advancements in catheter design, insertion techniques, and management protocols, PD continues to evolve as an increasingly accessible modality in the United States and abroad. A comprehensive understanding of contraindications, preoperative considerations, surgical approaches, and complication management is essential for all healthcare providers caring for end-stage renal disease patients.