The use of mini-invasive surgical techniques to treat refractory exit-site and tunnel infections in peritoneal dialysis patients: a clinical approach.

Peritoneal dialysis-(PD) related infections continue to be a major cause of morbidity and mortality in patients on PD. Although great advances have been made in the prevention and treatment of infectious complications over the past two decades, catheter-related infections represent a significant cause of technical failure in PD. Recent studies support the role of exit-site/tunnel infections in causing peritonitis. Peritonitis secondary to tunnel infection led to catheter loss in most cases. Thus, removing the catheter when exit-site/tunnel infection is refractory to medical therapy has been recommended. This approach requires interrupting PD and, after the placement of a central venous catheter, and transferring the patient to haemodialysis. In order to continue PD, simultaneous catheter removal and replacement of the PD catheter has been suggested. Although simultaneous catheter removal and replacement avoids temporary haemodialysis, it implies the removal/reinsertion of the catheter and the immediate initiation of PD with the risk of mechanical complications, such as leakage and malfunction. Hence, several mini-invasive surgical techniques, such as curettage, cuff-shaving, removal of the superficial cuff, and partial reimplantation of the catheter, have been proposed as rescue treatments. These procedures may allow the rescue of the catheter with a success rate of 70-100%. Therefore, in case of refractory exit-site/tunnel infection, a mini-invasive surgical revision should be considered before removing the catheter.