Raj; I can't seem to get to the video. Did the surgeon use staples to fix the catheter in position? SRa

Dr. Ash, he did use staples. The video is at:

https://youtu.be/AxSEmtsts5Q

Raj.

I have seen torn catheters before but the way this behaves is very unique. If it was complete tear then it would be contrast spill without such dramatic "catheter movement". Here the "catheter" line seems to be moving after the leak which leads me to think this was peristaltic movement from the gut attached to the catheter, tickled by the contrast leak. Power injector is out of question i hope. How much contrast was that?
Would be looking forward to the laparoscopic exam results.

Hi Raj,
Very impressive video. Agree with encasement of catheter by ?bowel as nothing come out from the coiled end of the catheter. The back pressure caused the catheter to rupture. Could this be as a result of a manufacturing defect? How was the intra-peritoneal fixation done? Isn't it odd to use staples??

It looks more to me that the catheter pulled out (or more so sprang out) of the encasement, under pressure, rather than breaking. U can still see that there is contrast lining up the catheter as it is filling up the peritoneal cavity. I cannot imagine that it would be this easy to break.
Tony Samaha

Dr. Jalandhra, I was also wondering if this was peristaltic movement, but since the catheter coil portion remained in place while the rest of the catheter moved backwards, I am concerned about catheter breakage. I used about 5cc of contrast and it was not power injected.

Adrian and Dr. Samaha, the contrast injection was slow and even if it was rapid, it should not have caused the catheter to break- I suspect if it was broken, that happened as a result of other factors- i.e. perhaps rubbing up against the staples. The intra-peritoneal fixation is done by creating a "suture sling" held in place by staples, and the catheter lies in the sling.

I will update this once I get follow up from the surgeon.

Raj,
Great case -- can we add it to the ASDIN teaching file? Should add it to the test tool

Raj,
It almost looks like the catheter was wrapped up in omentum and the injection caused it to free itself. Essentially, the contrast had no where to go except that confined little cavity, so it repulsed the catheter out of the location and across midline. I wonder if you took another injection through the now freed catheter to confirm the coil was still attached?

I've never done this with an injection, however, several times I have done so while trying to reposition a catheter with a stiff glidewire. All of a sudden, the catheter flicks out of the omental wrap and into another quadrant. Left behind is a contrast impregnated 'cast' of the catheter coil in the omentum. The first two times this happened, I was sure the catheter had transected from my forcing the wire through it. However, after removing the wire and reinjecting, I saw that the coil was still there, in the new position There also remained a coiled contrast outline/shadow where the coil had been previously.

Not sure if that is what happened here or not.

Some interesting asides, regarding 'broken' catheters.

Catheters are pretty tough, however, I have caused a rent in at least two by pulling too hard while tunneling, if the cuff wasn't popping through the SQ tissue. It usually happens at the leading edge of the superficial cuff. Both catheters had exit site leaks which were + glucose during flushing/training. After confirming the tear by injecting contrast, I cut down and repaired using presternal extension kits. I now use a larger tunnelor which allows room for the diameter of the cuff. These were both Merit catheters, I don't know if they are weaker than the others or not. Probably just my overdoing it.

If you're using the Merit catheter, the plastic end adapter will consistently erode through the tubing at about 1 year. It's a known problem and you should get the rep to give you the titanium connectors for free because they won't erode.

A few weeks ago, I saw a patient who recently had a PD catheter removed by a general surgeon in the hospital. He does alot of PD access. He told her that he was only able to remove part of her catheter because, "her peritoneum digested the rest"! I read his OP report and he stated that the catheter was unable to be freed from omentum/casing and therefore he cut the catheter as far down as possible and left the rest behind. I wonder if the deep cuff was inadvertantly placed in an intra-peritoneal position during insertion....

Many years ago, we had a patient in AZ who presented with persistent drainage from an exit site several months s/p PD catheter removal. To everyone's surprise, fluoroscopy revealed a complete catheter in place. The surgeon pulled on the catheter and just transected it at the exit site, allowing it to retract out of sight!

Thanks for the PD cases / discussions. Look forward to the feedback from the laparoscopy.

Hi Ryan,
Interesting comment. I have to warn others that the retained catheter can erode into the bowel. This has been reported many times.

Ryan and Adrian; The Merit PD catheter (previously Medigroup) does have a thinner wall than the Argyle (previously Quinton). The Merit catheter is also identified by a blue strip instead of a white one. However, it is still tough though not indestructible. I grab the body of the catheter with a pair of hemostats lightly applied and pull the hemostats into the tunnel ahead of the cuff while tunneling. The I expand the hemostats widely. The cuff enters easily to the tunnel then.

By the way, I really can't figure out the cause of the video picture for this catheter.

Adrian,
Right-I'm wondering when that catheter that was left behind is either going to erode or cause an abscess. Or maybe a lead to a bowel obstruction.

Stephen,
Thanks for the tips. I have been treating non-resolving ESI and extruded cuffs by placing a presternal extension to allow for a new tunnel tract and exit site without disturbing the intra-peritoneal portion of the catheter or deep cuff. The repaired catheter can then be used immediately. However, as mentioned, there is a blue line and a white line catheter. They have differing internal diameters, so the correct presternal extension connector must be used. Otherwise it will be too loose or not fit.

Very interesting Case.! To avoid tension when tunneling the catheter I use a 16F peel away introducer sheath dilator combo (same way as Scanlan tunneler) towards the exit site once across the exit site I remove the inner dilator and feed the catheter through the peel away sheath. I find this less cumbersome, ensures the integrity of the catheter and I can ensure the cuff is buried where I want. At the center I use the Argyle catheter.