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Meta-Analysis
. 2023 Feb 22;2(2):CD012478.
doi: 10.1002/14651858.CD012478.pub2.

Catheter insertion techniques for improving catheter function and clinical outcomes in peritoneal dialysis patients

Victoria R Briggs  1 , Richard M Jacques  2 , James Fotheringham  3 , Ravi Maheswaran  2 , Michael Campbell  2 , Martin E Wilkie  3
Affiliations
Meta-Analysis

Catheter insertion techniques for improving catheter function and clinical outcomes in peritoneal dialysis patients

Victoria R Briggs et al. Cochrane Database Syst Rev. .

Abstract

Background: Peritoneal dialysis (PD) relies on the optimal functionality of the flexible plastic PD catheter present within the peritoneal cavity to enable effective treatment. As a result of limited evidence, it is uncertain if the PD catheter's insertion method influences the rate of catheter dysfunction and, thus, the quality of dialysis therapy. Numerous variations of four basic techniques have been adopted in an attempt to improve and maintain PD catheter function. This review evaluates the association between PD catheter insertion technique and associated differences in PD catheter function and post-PD catheter insertion complications OBJECTIVES: Our aims were to 1) evaluate if a specific technique used for PD catheter insertion has lower rates of PD catheter dysfunction (early and late) and technique failure; and 2) examine if any of the available techniques results in a reduction in post-procedure complication rates including postoperative haemorrhage, exit-site infection and peritonitis.

Search methods: We searched the Cochrane Kidney and Transplant Register of Studies up to 24 November 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

Selection criteria: We included randomised controlled trials (RCTs) examining adults and children undergoing PD catheter insertion. The studies examined any two PD catheter insertion techniques, including laparoscopic, open-surgical, percutaneous and peritoneoscopic insertion. Primary outcomes of interest were PD catheter function and technique survival. DATA COLLECTION AND ANALYSIS: Two authors independently performed data extraction and assessed the risk of bias for all included studies. Main outcomes in the Summary of Findings tables include primary outcomes - early PD catheter function, long-term PD catheter function, technique failure and postoperative complications. A random effects model was used to perform meta-analyses; risk ratios (RRs) were calculated for dichotomous outcomes, and mean differences (MD) were calculated for continuous outcomes, using 95% confidence intervals (CIs) for effect estimates. The certainty of the evidence was evaluated using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach. MAIN RESULTS: Seventeen studies were included in this review. Nine studies were suitable for inclusion in quantitative meta-analysis (670 randomised participants). Five studies compared laparoscopic with open PD catheter insertion, and four studies compared a 'medical' insertion technique with open surgical PD catheter insertion: percutaneous (2) and peritoneoscopic (2). Random sequence generation was judged to be at low risk of bias in eight studies. Allocation concealment was reported poorly, with only five studies judged to be at low risk of selection bias. Performance bias was judged to be high risk in 10 studies. Attrition bias and reporting bias were judged to be low in 14 and 12 studies, respectively. Six studies compared laparoscopic PD catheter insertion with open surgical insertion. Five studies could be meta-analysed (394 participants). For our primary outcomes, data were either not reported in a format that could be meta-analysed (early PD catheter function, long-term catheter function) or not reported at all (technique failure). One death was reported in the laparoscopic group and none in the open surgical group. In low certainty evidence, laparoscopic PD catheter insertion may make little or no difference to the risk of peritonitis (4 studies, 288 participants: RR 0.97, 95% CI 0.63 to 1.48; I² = 7%), PD catheter removal (4 studies, 257 participants: RR 1.15, 95% CI 0.80 to 1.64; I² = 0%), and dialysate leakage (4 studies, 330 participants: RR 1.40, 95% CI 0.49 to 4.02; I² = 0%), but may reduce the risk of haemorrhage (2 studies, 167 participants: RR 1.68, 95% CI 0.28 to 10.31; I² = 33%) and catheter tip migration (4 studies, 333 participants: RR 0.43, 95% CI 0.20 to 0.92; I² = 12%). Four studies compared a medical insertion technique with open surgical insertion (276 participants). Technique failure was not reported, and no deaths were reported (2 studies, 64 participants). In low certainty evidence, medical insertion may make little or no difference to early PD catheter function (3 studies, 212 participants: RR 0.73, 95% CI 0.29 to 1.83; I² = 0%), while one study reported long-term PD function may improve with peritoneoscopic insertion (116 participants: RR 0.59, 95% CI 0.38 to 0.92). Peritoneoscopic catheter insertion may reduce the episodes of early peritonitis (2 studies, 177 participants: RR 0.21, 95% CI 0.06 to 0.71; I² = 0%) and dialysate leakage (2 studies, 177 participants: RR 0.13, 95% CI 0.02 to 0.71; I² = 0%). Medical insertion had uncertain effects on catheter tip migration (2 studies, 90 participants: RR 0.74, 95% CI 0.15 to 3.73; I² = 0%). Most of the studies examined were small and of poor quality, increasing the risk of imprecision. There was also a significant risk of bias therefore cautious interpretation of results is advised.

Authors' conclusions: The available studies show that the evidence needed to guide clinicians in developing their PD catheter insertion service is lacking. No PD catheter insertion technique had lower rates of PD catheter dysfunction. High-quality, evidence-based data are urgently required, utilising multi-centre RCTs or large cohort studies, in order to provide definitive guidance relating to PD catheter insertion modality.

Trial registration: ClinicalTrials.gov NCT01023191 NCT02347592.

PubMed Disclaimer

Conflict of interest statement

  1. Victoria R Briggs: no relevant interests were disclosed

  2. Richard M Jacques: no relevant interests were disclosed

  3. James Fotheringham: Baxter Healthcare Corporation (Grant / Contract), Fresenius Medical Care Deutschland GmbH (Independent Contractor ‐ Consultant)

  4. Michael Campbell: no relevant interests were disclosed

  5. Martin E Wilkie: Baxter Healthcare Corporation, Vifor Fresenius Medical Care Renal Pharma Ltd. (Grant / Contract)

  6. Ravi Maheswaran: no relevant interests were disclosed

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
1.1
1.1. Analysis
Comparison 1: Laparoscopic versus open surgical PD catheter insertion, Outcome 1: Postoperative death
1.2
1.2. Analysis
Comparison 1: Laparoscopic versus open surgical PD catheter insertion, Outcome 2: Exit‐site infection
1.3
1.3. Analysis
Comparison 1: Laparoscopic versus open surgical PD catheter insertion, Outcome 3: Peritonitis
1.4
1.4. Analysis
Comparison 1: Laparoscopic versus open surgical PD catheter insertion, Outcome 4: PD catheter removal (any cause)
1.5
1.5. Analysis
Comparison 1: Laparoscopic versus open surgical PD catheter insertion, Outcome 5: Haemorrhage
1.6
1.6. Analysis
Comparison 1: Laparoscopic versus open surgical PD catheter insertion, Outcome 6: Catheter tip migration
1.7
1.7. Analysis
Comparison 1: Laparoscopic versus open surgical PD catheter insertion, Outcome 7: Dialysate leakage
2.1
2.1. Analysis
Comparison 2: Medical versus open surgical PD catheter insertion, Outcome 1: Early PD catheter function
2.2
2.2. Analysis
Comparison 2: Medical versus open surgical PD catheter insertion, Outcome 2: Long‐term PD catheter function
2.3
2.3. Analysis
Comparison 2: Medical versus open surgical PD catheter insertion, Outcome 3: Mechanical catheter failure
2.4
2.4. Analysis
Comparison 2: Medical versus open surgical PD catheter insertion, Outcome 4: Postoperative death
2.5
2.5. Analysis
Comparison 2: Medical versus open surgical PD catheter insertion, Outcome 5: Exit‐site infection
2.6
2.6. Analysis
Comparison 2: Medical versus open surgical PD catheter insertion, Outcome 6: Peritonitis
2.7
2.7. Analysis
Comparison 2: Medical versus open surgical PD catheter insertion, Outcome 7: Haemorrhage
2.8
2.8. Analysis
Comparison 2: Medical versus open surgical PD catheter insertion, Outcome 8: PD catheter tip migration
2.9
2.9. Analysis
Comparison 2: Medical versus open surgical PD catheter insertion, Outcome 9: Dialysate leakage
2.10
2.10. Analysis
Comparison 2: Medical versus open surgical PD catheter insertion, Outcome 10: Hernia formation
2.11
2.11. Analysis
Comparison 2: Medical versus open surgical PD catheter insertion, Outcome 11: Catheter obstruction
2.12
2.12. Analysis
Comparison 2: Medical versus open surgical PD catheter insertion, Outcome 12: Omental wrapping
See this image and copyright information in PMC

Update of

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