預先植管 階段式開始之腹膜透析 Stepwise Initiation of PD by Using Subcutaneously Embedded PD Catheter Technique 張勝勛醫師 成大醫院移植外科

Kidney international (2006) 70,S38~S43

11% of inserted catheters were never exteriorized : improved renal function died pre-emptive transplant Six catheters (2% of total) were removed for complications before being exteriorized Kidney international (2006) 70,S38~S43

Complications initial catheter function (85%) VS 23% malfunction rate (European catheter outcomes) primary non-function (7%) is low rate of exit-site leaks (3%) is also very low peritonitis rate during this period was one per 34 patient-months four incisional hernias no cases of serious abdominal wall hematomas Kidney international (2006) 70,S38~S43

PDI 2001,vol.21(3) ; p205~208

PDI 2002,vol.22(2) ; p211~219

Moncrief Popovich catheter : new method (B group; n = 30), (NB group; n = 30), randomized Standard Tenckhoff catheter : (NS group; : n = 65) start PD within 1 2 weeks after implantation Subcutaneous burying of the distal catheter segment prior to starting PD does not reduce the risk of contracting peritonitis or exit-site infection PDI 2002,vol.22(2) ; p211~219

埋放在皮下的導管可以放置多久? 導管可長時間埋放於皮下, 最好大於 4-5 週, 等到需要透析時再做出口製作術 國外最久的埋放時間是 835 天 ( 平均 50 天 ) 2041 天

349 first PD were exteriorized and total observation period was 5624 patient-months Days between insertion of the catheter and exteriorization : early (group 1, 11 47 days), mid (group 2, 48 133 days) and late (group 3, 134 2041 days) exteriorization Nephrol Dial Transplant (2008) 23: 2299 2303

Mechanical complications and catheter loss are associated with the length of time a catheter is embedded. We recommend insertion 6 weeks to 5 months ahead of the need for PD to maximize catheter survival. Nephrol Dial Transplant (2008) 23: 2299 2303

How to tie the catheter? Tie-Band No import license in Taiwan? 替代品 (license OK): 2-0 suture line-nylon Clip (Johnson-Johnson LT-300) 1-0 Silk ( B Braun)-suture line The 2 nd wound location? Turn over wound Future exit site

Skin Design before Operation 2.Turn Over Wound Future Exit Site 1.Incision Wound 3.Ending Wound

surgery kit and accessories Blockade Catheter accessories a. Tie-Band tie on Future Exit Site

a. Tie-Band tie on Future Exit Site Benefits Blockade Catheter 效果佳 製作導管出口時, 容易辨識 Exit Site 的位置 製作導管出口時, 可保護導管不被手術刀劃傷 Shortcoming 無登記衛署輸入許可證 Tie-Band 材質堅硬, 植入皮下時, 病人會有異物感 將 Catheter 植入皮下時, 比較困難 Moncrief JW, Popovich RP et al. ASAIO J. 39, 62-65, 1993

surgery kit and accessories Blockade Catheter accessories b. Clip LT 300 tie on Future Exit Site

b. Clip LT 300 tie on Future Exit Site Benefits 有登記衛署輸入許可證 Blockade Catheter 時, 操作容易 製作導管出口時, 容易辨識 Exit Site 的位置 Shortcoming Blockade Catheter 效果不穩定, 曾有病人發生拉出導管時,Clip 鬆脫情形

surgery kit and accessories Blockade Catheter accessories c. 1-0 Silk or 2-0 Nylon suture linetie on Catheter Terminal Silk 綁在導管末端

c. 1 Silk or 2 Nylon suture line tie on Catheter Terminal Benefits 有登記衛署輸入許可證 Blockade Catheter 效果佳 將 Catheter 植入皮下時, 操作容易 Silk 植入皮下時, 病人不會有異物感 Shortcoming 製作導管出口時, 不容易辨識 Exit Site 的位置 先找出 Cuff 位置, 向下沿著 Catheter 2~3 cm 處, 定為 Exit Site 的位置

How I Do The Operation

Idea Reference from this paper :

Canada paper Exteriorization of the Embedded Catheter

surgery kit and accessories 1 2 3 4 5000u Heparin in 5ml NS

Instill heparin (5ml/5000µ) into catheter. Tighten silk suture line. Confirm complete blockade. And, the catheter is automatically embedded.

健保批碼 :62009C 皮下異物取出術 2300 點

SMAP Exteriorization of the Embedded Catheter Removed Tie band tool 1 2 3

NCKUH Exteriorization of the Embedded Catheter

Why, Who and When? Shorter hospital stay and less healthcare costs Patients with expected problems of wound healing, such as diabetic, obese, or steroid therapy Prepare for peritoneal dialysis in a more stable condition of preuremia

腹膜透析部分 : 接受透析治療時機 ( 一 ) 植入腹膜透析導管 (58012 58012B) 之時機 : 預期開始長期腹膜透析前至少兩週或以上至少兩週或以上 ( 二 ) 糖尿病腎病變患者 : 肌酸酐清除率 (CCr CCr) 小於 15 ml/min, 或肌酸酐 (Cr) 大於 6 mg/dl, 且預期在 三個月後 需要透析者 三個月後 ( 三 ) 非糖尿病腎病變患者 : 肌酸酐清除率 (CCr CCr) 小於 10 ml/min, 或肌酸酐 (Cr) 大於 8 mg/dl, 且預期在後需要透析者 且預期在 三個月 後需要透析者 ( 四 ) 體重低於 30 公斤以下兒童 : 肌酸酐 (Cr) 大於 6 mg/dl 4 歲以下之兒童 : 肌酸酐 (Cr) 大於 5 mg/dl

Requirement for two procedures (insertion then exteriorization) : local anesthesia, short OP time no serious complications of exteriorization do not need a double-lumen

Mechanical complications one-way obstruction and omental entrapment Overall, 6% (21 of 349) of catheters were complicated by primary mechanical failure The proportion of catheters with primary failure varied significantly with time embedded Nephrol Dial Transplant (2008) 23: 2299 2303

預先植管能讓你 適時準備透析通路 減少緊急透析及其合併症 並有時間學習腹膜透析的知識順利進入透析

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