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Complications after Tenckhoff Catheter Insertion: A Single-Centre Experience

using Multiple Operators over Four Years

Article in Peritoneal Dialysis International · March 2010

DOI: 10.3747/pdi.2009.00083 · Source: PubMed

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Wen J. Liu Lai Seong Hooi

Hospital Sultanah Aminah Hospital Sultanah Aminah Johor Bahtu, Malaysia
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Peritoneal Dialysis International, Vol. 30, pp. 509-512
doi: 10.4737/pdi.2009.00083
COMPLICATIONS AFTER TENCKHOFF CATHETER INSERTION: A SINGLE-CENTRE
EXPERIENCE USING MULTIPLE OPERATORS OVER FOUR YEARS
Wen Jiun Liu and Lai Seong Hooi
Haemodialysis Unit, Department of Medicine, Sultanah Aminah Hospital, Johor Bahru, Johor, Malaysia
♦ Objective: To analyze the complications after Tenckhoff
catheter insertion among patients with renal failure need-
ing dialysis.
♦ Patients and Methods: The open, paramedian approach is
the commonest technique to insert the 62-cm coiled double-
cuffed Tenckhoff peritoneal catheter. All patients with
catheters inserted between January 2004 and November
2007 were retrospectively analyzed for demographics and
followed for up to 1 month for complications. We excluded
patients whose catheters had been anchored to the bladder
wall and who underwent concurrent omentectomy or read-
justment without removal of a malfunctioning catheter (n =
7). Intravenous cloxacillin was the standard preoperative
antibiotic prophylaxis.
♦ Results: Over the 4-year study period, 384 catheters
were inserted under local anesthetic into 319 patients [201
women (62.8%); mean age: 49.4 ± 16.7 years (range: 13 –
89 years); 167 (52.2%) with diabetes; 303 (95%) with end-
stage renal disease] by 22 different operators. All Tenckhoff
catheters were inserted by the general surgical (n = 223) or
urology (n = 161) team. There were 29 cases (7.6%) of cath-
eter migration, 22 (5.7%) of catheter obstruction without
migration, 24 (6.3%) of exit-site infection, 12 (3.1%) of
leak from the main incision, 14 (3.6%) of culture-proven
wound infection, 11 (2.9%) post-insertion peritonitis, and
1 (0.3%) hemoperitoneum. No deaths were attributed to
surgical mishap.
♦ Conclusions: The most common complication was catheter
migration. The paramedian insertion technique was safe,
with low complication rates.
Perit Dial Int 2010; 30:509-512 www.PDIConnect.com
epub ahead of print: 17 May 2010 doi: 10.3747/pdi.2009.00083
KEY WORDS: Continuous ambulatory peritoneal dialy-
sis; Tenckhoff catheter; paramedian.
Correspondence to: W.J. Liu, Haemodialysis Unit, Depart-
ment of Medicine, Sultanah Aminah Hospital, Johor Bahru,
Johor 80100 Malaysia.
drliuwenjiun@johr.moh.gov.my
Received 20 April 2009; accepted 16 September 2009.
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Copyright © 2010 International Society for Peritoneal Dialysis
A continuous ambulatory peritoneal dialysis (CAPD)
unit was first established in Sultanah Aminah Hos-
pital, Johor Bahru, Malaysia, in 1997. By December 2007,
our unit was supporting 164 adult patients. Historically,
coiled double-cuffed silicon Tenckhoff catheters were
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the only type used. Early complications such as wound
­infection, migration, or catheter obstruction prolong
hospitalization days, require repeat insertion proce-
dures, and subsequently affect patient morbidity. The
present study retrospectively analyzes complications
after Tenckhoff catheter insertion in patients with renal
failure needing peritoneal dialysis at our CAPD unit.
PATIENTS AND METHODS
We retrospectively analyzed demographics and
complications for all patients who underwent catheter
insertion between January 2004 and November 2007
and who were followed for up to 1 month. All data were
captured prospectively in nursing and clinical records at
the CAPD unit. Information from surgical procedures was
counterchecked with records in the operating theater.
Preoperatively, patients received povidone scrub 2 days
before the procedure. Intravenous cloxacillin was the
standard preoperative antibiotic prophylaxis. The open
paramedian approach was used to insert a 62-cm coiled
double-cuffed Tenckhoff peritoneal catheter.
Under local anesthesia, a 5-cm sagittal skin incision
is made starting at the level of the umbilicus 3 cm lateral
to the midline going downward. Dissection is performed
layer by layer to expose the anterior rectus sheath. The
rectus muscle fibers are bluntly separated until the
posterior sheath, and the peritoneum is then incised to
create a small opening. A malleable introducer is used to
position the intraperitoneal segment of the Tenckhoff
catheter in the pelvic cavity. The inner cuff is fixed onto
the peritoneal membrane by absorbable suture, followed
by another stitch to anchor it to the rectus sheath. Peri-
toneal dialysis fluid is introduced into the abdominal
cavity to test flow. Once the surgeon is ­satisfied with
509
LIU and HOOI
the flow, the catheter is then tunneled through the
subcutaneous plane with the outer cuff buried 2 cm
from the designated exit. The outer rectus sheath is
closed by continuous polypropylene sutures. The skin is
then closed with subcuticular absorbable sutures. Low-
volume peritoneal dialysis using an automated cycler may
commence immediately depending on patient’s uremic
status. Otherwise, CAPD using 2-L exchanges can begin
on postoperative day 10.
We excluded from the study patients whose catheters
had been anchored to the bladder wall and who had
undergone concurrent omentectomy or readjustment
without removal of a malfunctioning catheter (n = 7).
RESULTS AND DISCUSSION
Over the 4-year-study period, 384 catheters were
inserted into 319 patients [mean age: 49.4 ± 16.7 years
(range: 13 – 89 years)] under local anesthesia. Table 1
shows patient characteristics. All Tenckhoff catheters
were inserted by the general surgical (n = 223) or urology
(n = 161) team. The minor operating theatre was used
for 335 catheter insertions, and the major operating
theatre, for 49. The procedures were performed by 22
doctors (including 4 consultant urologists), of whom 4
had worked in both departments during the study period.
Table 2 shows the complications that occurred. No deaths
were due to surgical mishap.
In 11 cases, culture-proven episodes of peritonitis
occurred: Candida (n = 1), enterococcal species (n = 1),
Klebsiella pneumoniae (n = 1), methicillin-resistant
Staphylococcus aureus (n = 1), methicillin-sensitive S. epi-
dermidis (n = 2), and methicillin-sensitive S. aureus(n = 5).
TABLE 1
Baseline Characteristics of 319 Patients Who Underwent
Tenckhoff Catheter Insertions
Characteristic Patients
(n) (%)
Female sex 201 62.8
End-stage renal failure 303 95.0
Diabetes mellitus (types 1 and 2) 167 52.4
Tenckhoff catheter insertions attempted cloxacillin in our study yielded a very low 2.9% incidence
First 307 79.9
Second 69 18.0
Third 7 1.8
Fourth 1 0.3
Our analysis was performed on a 4-year series of Tenck-
hoff catheter insertions using the paramedian approach
under local anesthesia. Being that this analysis is ret-
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SEPTEMBER 2010 - Vol. 30, No. 5 PDI
TABLE 2
Types of Complications Post Tenckhoff Catheter Insertion
Complication type Occurrences
(n) (%)
Catheter migration 29 7.6
Catheter obstruction without migration 22 5.7
Exit-site infection 24 6.3
Leak from main incision 12 3.1
Culture-proven wound infection 14 3.6
Post-insertion peritonitis 11 2.9
Hemoperitoneum 1 0.3
rospective, we lack detailed information on abdominal
scars in the subjects. From clinical experience, fewer
than 5% of patients had history of abdominal surgery;
those with a history of extensive peritoneal contamina-
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tion were excluded from Tenckhoff catheter insertions
in view of potential bowel adhesions. The most common
early complications of catheter migration and catheter
obstruction without migration did not occur excessively
in comparison with other series (Table 3) that included
the use of dedicated surgeons and a randomized con-
trolled trial setting. Gadallah et al. (1) showed a lower
catheter malfunction rate of 8.3% (including migration
and obstruction), but those complications occurred
within a shorter period of 2 weeks as compared with
the 1 month in our series.
In large randomized controlled trial by Gadallah et al.
(4) comparing intravenous vancomycin 1 g, cefazolin
1 g, and placebo, administration of an antibiotic just
before Tenckhoff catheter insertion was shown to be
useful. At 2 weeks, the incidence of peritonitis was
significantly lower in patients who received antibiot-
ics (1%, 7%, and 12% incidence for the vancomycin,
cefazolin, and placebo groups respectively). The 2005
guidelines from the International Society for Perito-
neal Dialysis (5) also suggested that a single dose of
a first- or second-generation cephalosporin should
be given intravenously. Cefazolin was not available in
the Malaysian Ministry of Health formulary; cloxacillin
was readily available and was therefore used as the
prophylactic antibiotic. Use of prophylactic intravenous
of peritonitis at 4 weeks and, hence, is worthwhile to
continue.
The occurrence of post-Tenckhoff catheter ­peritonitis
at 2 weeks in the study by Gadallah and colleagues
(1) showed a difference between surgical and perito-
neoscopic placement: 2.6% with the peritoneoscopic
­approach as compared with 12.5% in the surgical arm (a
factor of almost 5). The peritonitis occurrence in our study
PDI SEPTEMBER 2010 - Vol. 30, No. 5 COMPLICATIONS AFTER TENCKHOFF CATHETER INSERTION

TABLE 3
Comparisons with Other Studies
Variable Current study Gadallah et al. (1) Johnson et al. (2) Tiong et al. (3)

Country Malaysia U.S.A. Australia Singapore

Year 2009 1999 2006 2006
Study type Case Randomized Randomized Case
series controlled controlled series
Tenckhoff catheter
384 72 62 164
insertions (n)
Catheter type Coiled Coiled Coiled Straight
Surgeons involved (n) 22 3 4 3
Complications Within Within Within Within
recorded 1 month 2 weeks 3 years 1 month

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Complication subtype (%)
Migration 7.6 16
8.3 24
Obstruction 5.7 —
Exit-site infection 6.3 5.5 37 11
Wound leakage 3.1 11.1 — —
Wound infection 3.6 — — 38
Peritonitis 2.9 12.5 6 6

was low and is comparable even with the incidence in the
peritoneoscopic approach. Our historical (since 1997)
routine practice of povidone body scrub 2 days before cath-
eter insertion at our center may have a role in preventing
peritonitis episodes. The solution is given to improve
skin hygiene in patients, especially those in chronic ill
health, confined to bed, and unfit even for a proper
bath. This practice was not described in the other
studies in the literature (1–3). Various techniques for
inserting a Tenckhoff catheter have been described (6),
but no particular technique has consistently proved to
be superior in the prevention of peritonitis (7). The
open surgical method remains the most common ap-
proach (8,9), with lower risk of visceral injury afforded
by direct visualization of the peritoneal cavity during
the procedure.
With a high staff turnover within the department
of surgery, our center relied on the services of two
teams of doctors. A new operator would begin learn-
ing by assisting in insertion procedures at least twice
before becoming a main operator (assisted by a more
experienced operator). Knowledge of the procedure is
handed down to subsequent generations of operators,
who are mostly junior medical officers who have just
completed their internships. Success depends on the
learning curve of the doctors embarking on this new
skill. However, the overall outcome of this surgical
procedure has remained satisfactory and compatible
with the results shown by other authors (1–3) involving
a small number of dedicated surgeons.
CONCLUSIONS
Our most common complication was catheter migra-
tion. The paramedian technique of insertion was safe,
with low complication rates.
DISCLOSURES
The authors declare that they have no financial
­conflict of interest in the conduct of this study.
ACKNOWLEDGMENT
The authors thank the Director General of Health, Min-
istry of Health of Malaysia, for supporting the publication
of this paper. The continuing efforts of all CAPD nurses in
collecting data for this analysis are greatly appreciated.
REFERENCES
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This single copy is for your personal, non-commercial use only. 511
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for distribution, contact Multimed Inc. at marketing@multi-med.com
 LIU and HOOI SEPTEMBER 2010 - Vol. 30, No. 5 PDI

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