Continuous Ambulatory Peritoneal Dialysis (CAPD) has been a beneficial treatment option for patients with End-Stage Renal Disease (ESRD) since 1976. In the United States, CAPD is utilized in 13% of patients who need long-term renal replacement, while CAPD is used in more than 50% of ESRD patients in developing nations. Peritoneal dialysis is preferred over hemodialysis due to several factors such as hemodialysis unit limitations, lower cost and difficulty accessing dialysis units. The process of placing a CAPD involves implanting a double-cuff peritoneal. This procedure then causes the tissue to ingrown into the cuffs and the fibrous sheath to cover the inter-cuff tunnel section, forming a tunnel with a short sinus tract, a shallow peritoneal recess and a 5-7 cm long tunnel proper [1].

Achieving secure and permanent access to the peritoneal cavity can determine the success of peritoneal dialysis. It is important to maintain the consistency and optimality of hydraulic function of the catheter and to place it in a stable position with the body. Good peritoneal dialysis access techniques can prevent dialysis leakage and bacterial migration, so peritoneal access has a critical role. Twenty percent of patients transferred to undergo hemodialysis are permanently caused by catheter-related and infectious. Catheter-related complications are a substantial worry, especially with the lower incidence of peritonitis complications. Peritoneal access, catheter type, catheter insertion procedures, infections and mechanical issues are all investigated in this study [2].

Surakarta is a major city with a diversified population. In Surakarta, no published data on the complications of Continuous Ambulatory Peritoneal Dialysis (CAPD), particularly complication related access, are currently available. As a result, we looked into the incidence, technique and clinical outcomes of CAPD-access related complication in all CAPD patients at Dr. Moewardi General Hospital between January 2015 and December 2020.  

This study has received approval from the ethics committee. This study analyzed patients carrying out CAPD procedures performed by urology staff at Dr. Moewardi hospital with one or laparoscopic peritoneal dialysis catheter placement technique. This is a cross sectional study of CAPD patients who had access related complication between January 2015 and January 2020 and were treated in the urology department of Dr. Moewardi hospital in Surakarta, Indonesia. 

In this investigation, non-probability sampling was employed with purposive sampling approaches based on pre-determined inclusion and exclusion criteria. The rule of thumb formula was used to compute the sample size in this study, which was set at 80 people. Data with a normal distribution (p>0.05) against data with an aberrant distribution (p<0.05). The t-test is used on normally distributed data, while the Mann-Whitney test is used on irregularly distributed data. The association between two variables is investigated using bivariate analysis.

Percutaneous procedures, laparoscopic techniques and open surgical measures are among the catheter installation techniques that each have their own risks of early and late complications as well as failure rates.

Age, gender, BMI, operation risk assessment, surgery time, hospitalization length and death rate were the variables used in the study. The length of hospitalization, the appearance of postoperative problems and the use of laparoscopic procedures versus open-to-need re-surgery are all evaluated in this study (catheter migration, catheter leakage, catheter damage and infection).

Laparoscopic Technique

Transverse incisions with a size of 1 cm are made inferiorly and laterally from the umbilicus. Through this incision, we inserted a cuff catheter on the anterior part of the posterior rectus sheath. The cuff catheter enters peritoneum caudally into Douglas arcuate line. Laparoscopic graspers are used to place the catheter on the pelvis near the superior and posterior part of the bladder. This technique does not use stitches on the skin.

Open Surgery Technique

To recognize and make an incision in the anterior rectus fascia, we made a transverse incision in the posteriorly elevated umbilicus rectus muscle. The posterior rectus fascia is exposed by separating the rectus muscle fibers. Pursestring stitching using Prolene 30-0 was used on this fascia. The access to the peritoneal cavity is achieved through the pursestring fascia which is opened in the midline. A single cuff catheter is bent into the pelvis and wrapped in a pursestring. The catheter is stitched to the skin. 

Both techniques are performed using general anesthesia. At intra-operative time it is given 1-2 L of gravitationally drained dialysate to ensure the catheter is functioning properly. The catheter works well if 75% of the dialysate volume can be drained. Incisions in the fascia and skin are covered with absorbable seams. In both techniques given as much as 5000 units of heparin (in 20 cc 0.9% NS) used to rinse catheters and also act as sterile dressings.

Data analysis in this study consists of three types: univariate, bivariate and multivariate analyses. The data for this study was collected using IBM's Statistical Product and Service Solution (SPSS) statistics 26.

Between January 2015 and January 2020, two urology surgeons at Dr. Moewardi hospital in Surakarta performed peritoneal catheter dialysis on 83 patients. The majority of patients (53 percent) are female. 60-year-old average age (SD) (81.5). 29.2 (2.1kg/m²) is the average body mass index (SD). The ASA score is 3.3 on average (0.46). There were no issues throughout the operation. For the index procedure (n = 83), the total postoperative complication rate was 10.84% (n = 9). Catheter infections accounted for 44.44 percent (n = 4), catheter migrations 33.33 percent (n = 3) and catheter malfunctions 22.22 percent (n = 2) of those with complications: fibrin deposition, omental/adhesional blockage and one leaked around the catheter (Table 1,2).

Table 1: Peritoneal Dialysis Index and Subsequent Operations Outcomes

* BMI: Body Mass Index, **ASA: American Society of Anesthesiologist, ***OT: Operative Time

Table 2: Index Operations Outcomes

* BMI: Body Mass Index, **ASA: American Society of Anesthesiologist, ***OT: Operative Time

Patients with ESRD are classed as ASA grade 3 or higher and research by Tiret et al. found that ASA scores were closely associated to the rate of postoperative surgical complications. The Prause et al. study looked at 16,000 patients who were having elective surgery and found that 30-day mortality was 0.4 percent in ASA patients in grades 1 and 2 and 7.3 percent in ASA class 4 patients. 

CAPD catheter installation surgery approaches have advantages. Catheter installation with open surgery takes less time and uses less surgical equipment, resulting in cheaper operating expenses and perhaps lower anesthetic risks. Direct viewing, adhesion lysis, tethering, or resecting the omental are all possible using laparoscopic methods, reducing the risk of intestinal damage and allowing for precise catheter placement. The number of samples used in this investigation was too little and the follow-up period was too short. The selection of operations, according to Xie et al. and Wright et al., is suited to the surgeon's expertise and previous surgical history [3,4]. 

The incidence of complications was examined separately by type of complication, rather than by cumulative complication rates, in this study. A comprehensive meta-analysis by Hagen et al. analyzing complication rates of open cases and laparoscopy utilizing the results of up to nine investigations showed that many patients have had multiple procedures for various diseases, injuries and kidney transplants in the past. Keeping the catheter free of adhesion and blockage can be difficult due to the presence of prior adhesions as well as changes in anatomical structure. There are various literary disagreements of opinion: According to Chen et al., postoperative complications are not affected by having a history of abdominal surgery 17 percent catheter damage and 33 percent peritonitis with previous abdominal surgery versus 13 percent and 29 percent, respectively - without prior surgery). According to Tiong et al., previous abdominal surgery had an effect on the occurrence of early complications (42 percent with previous abdominal surgery, 26 percent without), but had no effect on late complications (42 percent with previous abdominal surgery, 26 percent without). Both investigations had a sample size of 122 patients (Chen) and 139 patients (Tiong) [5]. 

The presence of fibrin accumulation and catheter calcification causes catheter malfunction in CAPD. According to Hamada et al., prolonged exposure to improper PD fluid results in morphological and functional alterations in the peritoneal cavity, resulting in a decline in catheter function (fibrin deposition, peritoneal turbidity and calcification). In addition, Hamada employs a grading system to assess the link between morphological and clinical data. Although he was unable to assess the severity of each discovery, the macroscopic change score grew in tandem with the length of PD. After more than 12 months of use, Cho et al. indicate that pH neutral, low glucose levels such as icodextrin promote peritoneal ultrafiltration and lead to higher residual kidney function without causing extra difficulties. There are certain drawbacks to this research. The investigation was based on a single institutional experience [6].

CAPD is one of the treatment options for patients with end-stage renal disease and it is becoming more popular as a result of the prospect of patient independence, as well as other benefits. However, CAPD use results in a temporary or permanent reduction in dialithic function, which leads to debility or death. Surgical procedures for insertion of CAPD catheters in ESRD patients, both open surgery and laparoscopic approaches, are generally safe. According to our findings, 10.84% of CAPD patients require surgery due to infection or catheter damage.

Acknowledgment

The Department of Urology Dr. Moewardi general hospital Surakarta supported this work.

Conflict of Interest

data This study has no possible conflicts of interest that have been disclosed.

Funding

There are no financial conflicts of interest for the authors.

Ethical Approval

The ethics committees at Dr. Moewardi General Hospital and the head of surgery department Faculty of Medicine, Sebelas Maret University accepted the study protocol and waived the requirement for written informed consent.

Author Contribution

All contributors worked together to write and improve this article. All contributors worked together to write and improve this article.

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