There are two problems with this patient's PD catheters. Migration out of the pelvic cavity and omental wrapping. I would ask a surgeon to laparoscopically reposition the catheter in the pelvic cavity and do an omentopexy. In addition, our surgeons put an anchoring stitch that holds the straight segment of the catheter to the abdominal wall and prevents it from migrating. This anchoring stitch technique is shown in the ASDIN Peritoneal Dialysis Curriculum.

I wonder if in addition to Omentoplexy, if a partial omentectomy might not be indicated in this case- depending on how much omentum there was. It would seem omental entrapment with resultant migration out of the pelvis with encapsulation of the catheter coil is rather aggressive in this case. Agree with Ken, that an anchoring suture sling might be helpful. I also wonder if perhaps a straight catheter might be better, given data on migration being less with the a straight catheter.

Regardless of what is done, my experience is that in patients like this with such rapid PD catheter failure, their time on PD is limited. Sometimes I find that even after omentoplexy the small bowel decides to get into the action and decides to wrap itself around the catheter.

I agree with Raj, an omentopexy or omentectomy is needed. The first pictures almost look like the catheter was in a space that did not really communicate with the rest of the abdomen. The other two show movement of the catheter out of the pelvis. At least, what I have read is that an anchoring stitch may help keep the catheter in the pelvis, it does not improve function. It also means that if there is a problem with the catheter, it will almost always need to be addressed surgically.

Thanks to Ken, Raj and Wes for the comments. I agree with them. All three of the outflow failures in this patient were accompanied by a pocket of omentum that prevented dye from communicating with the rest of the peritoneum. This is formed, I believe, from omentum covering the catheter like a sheet and plastering it against the parietal peritoneum. With this limited space around the catheter, reposition is almost always a failure. I agree that an omentectomy or omentoplasty done laparoscopically might have allowed a fourth catheter to work (though there are failures of this invasive procedure, as mentioned above). We offered this to the patient as an option. She decided against it and decided to discontinue PD and continue on hemodialysis. I removed the final PD catheter without difficulty. Nice comments, you all.