Ultrasound‐guided percutaneous peritoneal dialysis catheter insertion using multifunctional bladder paracentesis trocar: A modified percutaneous PD catheter placement technique

Abstract Background To evaluate the efficacy and safety of ultrasound‐guided percutaneous peritoneal dialysis catheter insertion using multifunctional bladder paracentesis trocar. Methods A retrospective review of 103 ESRD patients receiving percutaneous PD catheter insertion using a multifunctional bladder paracentesis trocar under ultrasound guidance at a single center between May 2016 and May 2018. Mechanical complications and catheter survival were evaluated over a 12‐month follow‐up. Result Catheterization using this technique required only 10‐30 minutes from the beginning of local anesthesia to the end of skin suture at the puncture site (mean 18 ± 7 minutes) and an incision length of 2‐4 cm. Moreover, only four of 103 cases required catheter removal due to poor drainage within one month after surgery, with a success rate of 96.19%. Among failures, omentum wrapping was cause in two cases, catheter displacement in one case, and protein clot blockage in one case, while there were no instances of organ injury, severe hemorrhage, peritubular leakage, hernia, peritonitis, or exit infection within one month of PD catheter insertion. Catheter survival at 1 year was 92.2%. Conclusion Percutaneous PD catheter insertion using a multifunctional bladder paracentesis trocar and ultrasound guidance is a feasible technique for ESRD patients.

surgery time and accelerates postoperative recovery. Also, simultaneous intra-abdominal adhesiolysis can be done in cases with abdominal adhesion due to previous surgery. 7 However, laparoscopic surgery requires general anesthesia and the creation of two or three holes in the abdominal wall by surgeons experienced in laparoscopic surgery, thus increasing the technical difficulty and limiting its applicability.
Alternatively, percutaneous puncture is a bedside operative technique conducted mainly by nephrologists based on Seldinger technology. It is a simple procedure with confirmed efficacy and so is attracting increasing attention from nephrologists. 8 Further, percutaneous placement of PD catheters is performed under local anesthesia with minimal transcutaneous access, thereby facilitating rapid recovery. 9 However, using the blind Seldinger technique, it is impossible to look directly into the pelvic cavity, and difficult to accurately place the dialysis catheter in the appropriate position based on feel. Thus, the catheter may be placed too deeply, stimulating the rectum and causing discomfort to the lower abdomen, or too superficially, increasing the risk of displacement and omentum wrapping. Therefore, the Seldinger technique is generally not suitable for obese patients or patients with a history of abdominal surgery. Further, the relatively expensive puncture components with avulsion sheath are not readily available in some small centers, that also hinders the wider application of this technique.
To enhance the technical ease and safety of PD catheter placement, we have improved the blind Seldinger technique by incorporating ultrasound guidance and the use of a multifunctional cystostomy paracentesis trocar for percutaneous puncture. The multifunctional cystostomy paracentesis trocar component has integrated functions of sharp-headed trocar core puncture, blunt-headed trocar core guidance, and semi-ring outer sheath blunt dilation by pulling out the built-in trocar core. The guidewire and catheter are placed through the semi-ring sheath without the need for a separate dilator or the assistance of an avulsion sheath. This new technique can be easily performed by a nephrologist and is safe for PD patients. In this study, we report our experience with percutaneous PD catheter insertion using a multifunctional bladder paracentesis trocar and ultrasound guidance. China) consisting of an semi-ring outer sheath, an inner trocar sheath, a sharp-headed trocar core and a blunt-headed trocar core (Figure 1), which is originally designed as a puncture kit for a bladder ostomy for patients with blocked urethra and inability to urinate normally.

| Study sample and protocol
This study was conducted with the approval of the institutional ethics committee. Prior to the procedure, we obtained informed consent from all patients to review their documents for research purposes.

| Postoperative treatment
After surgery, low-dose heparin saline was injected into the abdomen, and 1.5% peritoneal dialysis solution was used to wash the abdominal cavity every day (four times, 500 mL each time). Routine Continuous ambulatory peritoneal dialysis (CAPD) treatment was started from 7 days after catheterization. The surgical dressing was changed every three days after surgery until the stitches were removed, and routine maintenance of the exit site was performed daily. During hospitalization, patients were provided with relevant knowledge for home PD treatment, including the early identification and treatment of peritonitis and exit site infection.

| Indications for catheter removal
Conditions requiring catheter removal included difficult drainage, failure of manual reduction due to omentum wrapping and displacement, refractory peritonitis, recurrent peritonitis, fungal peritonitis, refractory exit and tunnel infection, reproducible peritonitis, mycobacterial peritonitis, and multiple intestinal bacterial infectious peritonitis. Catheters were reinserted following relief of peritonitis.

| Data collection and definition
Data recorded during the catheterization procedure included incision length, catheterization time, and intraoperative complications.

| Statistical analysis
Continuous variables are expressed as mean ± standard deviation and categorical data as number (%). Categorical variables were compared using chi-square test or Fisher exact test. Catheter survival rate was calculated from the day of insertion to the day of removal.
A P < .05 was considered statistically significant. Statistical analysis was performed using SPSS version 23.
Procedural and postprocedural details are summarized in    Figure 3. The one-year survival rate was 92.20%. group. 16