Percutaneous Versus Surgical Insertion of Peritoneal Dialysis Catheters: A Systematic Review and Meta-Analysis

Abstract

Background: Home-based peritoneal dialysis (PD) is an alternative to facility-based hemodialysis and has lower costs and greater freedom for patients with kidney failure. For a patient to undergo PD, a safe and reliable method of accessing the peritoneum is needed. However, different catheter insertion techniques may affect patient health outcomes. Objective: To compare the risk of infectious and mechanical complications between surgical (open and laparoscopic) PD catheter insertion and percutaneous catheter insertion. Design: Systematic review and meta-analysis. Setting: We searched for observational studies and randomized controlled trials (RCTs) in CENTRAL, EMBASE, MEDLINE, PubMed, and SCOPUS from inception until June 2018. Data were extracted by 2 independent reviewers based on a preformed template. Patients: Adult (aged 18+) patients with kidney failure who underwent a PD catheter insertion procedure. Measurements: We analyzed leak, malfunction, and bleed as early complications (occurring within 1 month of catheter insertion). Infectious complications (exit-site infections, tunnel infections, and peritonitis) were presented as both early complications and with the longest duration of follow-up. Methods: Random effects meta-analyses with the generic inverse variance method to estimate pooled rate ratios and 95% confidence intervals. We quantified heterogeneity by using the I2 statistic for inconsistency and assessed heterogeneity using the χ2 test. Sensitivity analysis was performed by removing studies at high risk of bias as measured with the Newcastle-Ottawa Scale and the Cochrane Risk of Bias tool. Results: Twenty-four studies (22 observational, 2 RCTs) with 3108 patients and 3777 catheter insertions were selected. Data from 2 studies were unable to be extracted and were qualitatively assessed. In the remaining 22 studies, percutaneous insertion was associated with a lower risk of both exit-site infections (risk ratio [RR] = 0.36, 95% confidence interval [CI] = 0.24-0.53, I2 = 0%) and peritonitis (RR = 0.52, 95% CI = 0.36-0.77, I2 = 3%) within 1 month of the procedure. There was no difference in mechanical complication rates between the 2 techniques. Limitations: Lack of consistency in the time periods for the various outcomes reported, risk of bias concerns with respect to population comparability, and the inability to analyze individual component causes of primary nonfunction (catheter obstruction, catheter migration, and leak). Conclusions: Our meta-analysis suggests differences in early infectious complications in favor of percutaneous insertion and no significant differences in mechanical complications compared with surgical insertion. These findings have implications on the direction of PD programs in terms of maximizing operating room resources.

Catheter placement by the nephrologist: a safe and effective method for improving access to peritoneal dialysis

“…This discrepancy might be attributed to the absence of antibiotic prophylaxis administered to patients undergoing percutaneous placement, unlike those undergoing surgical placement. Another meta-analysis by Anirudh Agarwal and al (15) comparing percutaneous insertion and surgical insertion (both laparoscopy and open surgery)…”

Outcomes of Percutaneous Peritoneal Dialysis Catheters Insertion by Interventional Radiologists: A Single-Institution Experience

“…20 There are various means of PD catheter placements (e.g., percutaneous, laparoscopic, and open/surgical catheter placement), varying in their invasiveness, postoperative pain, and recovery time. Agarwal et al 21 conducted a meta-analysis to compare the rates of complications among surgical and percutaneous insertion methods. They meta-analyzed two RCTs and 20 observational studies that found percutaneous insertion had significantly lower incidences of early infectious complications compared to surgical option.…”

ISPD Catheter-related Infection Recommendations: 2023 Update

“…28 More recently, a systematic review and meta-analysis that included both observational (non-randomised) studies and RCTs found that, in low certainty evidence, percutaneous PD catheter insertion may have been associated with lower risks of early (within 1 month) exit site infection (7 studies; RR 0.36, 95% CI 0.24-0.53) and overall exit infection (16 studies; RR 0.61, 95% CI 0.46-0.82), but little or no difference in tunnel infection (7 studies; RR 0.76, 95% CI 0.38-1.51) compared with surgical (open and laparoscopic) PD catheter insertion. 29 Prior to catheter insertion, it is advisable to carefully identify the optimal location of the exit site that will allow the patient to be able to see their exit site, clean it and avoid inadvertently traumatising it (e.g. by the belt).…”