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계속적 외래복막투석에서 도관기능부전시 도관제거에 앞서 도관기능 회복을 위한 처치
방종효(Jong Hyoo Bang),김준홍(Jun Hong Kim),조성(Seong Cho),권태환(Tae Hwan Kwon),김용림(Yong Lim Kim),조동규(Dong Kyu Cho) 대한내과학회 1996 대한내과학회지 Vol.50 No.4
N/A Objectives: The peritonitis and peritoneal catheter malfunction remained as two major causes for the failure of chronic peritoneal dialysis. Extensive quantitative data on the nonoperative technique alternative to surgical placement of a new catheter in catheter malfunction due to dislodgment and obstruction are not available. Methods: From January 1991 through February 1993, thirteen fluoroscopy guided brushings and twelve laparoscopy guided manipulations were performed for 15 adult patients with catheter malfunction due to dislodgment and obstruction in an effort to prolong catheter life. Results : 1) The causes of catheter malfunction were four omental wrapping with secondary migration, four obstruction by fibrin deposits or blood clots, and seven dislodgment and obstruction. 2) With fluoroscopy guided brushing and/or laparoscopy manipulation, catheter malfunction were restored in 11 patients(73%). Among 11 patients, catheter malfunction were restored in 4 patients with fluoroscopy guided brushing, 4 patients with laparoscopic manipulation, and 3 patients with combination of two procedures. However, the remaining four patients, even after repeated manipulations, ended with catheters removal due to persistent malfunction. Eight patients had immediately successful restoration of catheter malfunction at the time of the procedure, two patients in the first week, and one patient in the third week. 3) There were four complications followed by the procedure : two were CAPD peritonitis and exit site infection and leakage followed by fluoroscopy guided brushing, and the other were laparoscopy related leakage from puncture site which was recovered by resting for two weeks and a broken catheter tip within peritoneal cavity which could be removed safely by laparoscopy. Conclusion: Fluoroscopy or laparoscopy guided manipulation of catheter was considered as re- commendable techniques in the catheter malfunction and could also be a desirable alternative to surgical placement of a new catheter.
계속적 외래복막투석에서 여러가지 도관에 따른 도관관련합병증의 비교
김성호 ( Kim Seong Ho ),방종효 ( Bang Jong Hyo ),김동희 ( Kim Dong Hui ),임종우 ( Im Jong U ),조동규 ( Jo Dong Gyu ) 대한내과학회 1993 대한내과학회지 Vol.44 No.4
연구배경 : 계속적외래복막투석에서 도관출구감염, 누출, 전위 및 폐쇄 등의 고관관련합병증은 복막염과 같은 내과적 합병증과 함께 고관생존에 중대한 영향을 미친다. 1985년 Twardowski 등^(2)) 이 기존 straight Tenckhoff도관의 약점이었던 cuff돌출과 전위를 줄이기 위해 소위 swan neck 도관의 사용을 제시한 이래 swan neck도관은 현재 계속적외래복막투석에서 널리 사용되고 있다. 한편 도관의 피부 출구부분은 swan neck도관과 같이하되 도관의 복강내 끝부분을 또라이모양(curl) 으로 만들면 도관전위를 줄일 것으로 생각하여 curl bent neck도관이 고안되었으나 아직 그 효과에 대해서는 정설이 없다. 방법 : 103명의 환자를 대상으로 115예의 도관(straight Tenckhoff도관 56예, swan neck도관 30예, curl bent neck도관 19예)에서 도관생존율과 합병증의 발생율을 비교하였다. 결과 : 각 도관의 1개월, 3개월, 6개월, 12개월의 누적생존율은 straight Tenckhoff도관이 0.93, 0.91, 0.87, 0.83, swan neck도관이 0.87, 0.80, 0.73, 0.73, curl bent neck도관이 0.90, 0.90, 0.86, 0.79로 각 도관간의 누적생존율의 차이는 통계학적으로 유의하지 않았다. 합병증으로 인한 도관 제거는 모두 33예(straight Tenckhoff도관 20예, swan neck도관 8예, curl bent neck도관 5예)였으며 원인별로 보면 straight Tenckhoff도관에서는 복막염으로 12예, 전위 4예, 누출 및 폐쇄 각 1예, 기타 2예 모두 20예가 제거되었고, swan neck도관에서는 복막염 4예, 전위 2예, 출구감염 2예 모두 8예가 제거되었고, curl bent neck 도관에서는 복막염 2예, 누출, 전위 및 폐쇄 각각 1예 모두 5예가 제거되었다. 각 도관에서 도관관련합병증들의 발생율을 비교해보면 출구감염의 발생율은 straight Tenckhoff 도관, swan neck 도관, curl bent neck 도관에서 patient-month당 각각 0.044회, 0.051회, 0.036회, 도관전위는 0.024회, 0.032회, 0.046회, 누출은 0.008회, 0.009회, 0.021회, 도관 폐쇄 0.003회, 0회, 0.015회, 터널감염 0.002회, 0.003회, 0회, 탈장은 0.002회, 0.032회, 0회로 각각의 합병증의 발생율은 세가지 도관사이에 유의한 차이가 없었다. 복막염의 발생율은 patient-month 당 straight Tenckhoff도관 0.201회, swan neck도관 0.136회, curl bent neck도관 0.143회로 각 군간에 역시 유의한 차이가 없었다. 결론 : 도관생존율이나 도관관련합병증발생율에 있어서 어떤 도관이 더 유리하다고 보기는 어려울 것 같다. Background: The key to succeful chronic peritoneal dialysis is a permament and safe access to the peritoneal cavity. Despite of improvement in catheter suuvival over the last several years with reduction in the incidence of peritonitis, catheter-related complications still occur, causing significant morbidity and often forcing removal of the catheter. Methods: This study analysed the experience of 115 peritoneal dialysis catheters (56 straight Tenckhoff(ST), 30 swan neck(SN), and 29 curl bent neck (CBN) cateters) retrospectively, and compared 3 catheters with respect to catheter survival and catheter-related complication rate. Results: By life table analysis, the cumulative survival rate of each catheters was as follows: ST catheter were 0.93, 0.91, 0.87, and 0.83 at 1, 3, 6, and 12 month respectively, those of SN catheter 0.87, 0.80, 0,73, and 0,72, and CBN catheter 0.90, 0.90, 0.86, and 0,79. There was no significant difference among 3 types of catheter with respect to catheter survival. There were 33 catheter failuters (22 ST, 8 SN, and 5 CBN) due to peritonitis and catheter-related complications. The causes of catheter removal among 3 types of catheter are not different statistically. The exit site infection rate was 0.044case/patient-month in ST, 0.051 in SN, and 0.035 in CBN catheters. Dislocation rate was 0.024 in ST, 0.032 in SN, and 0.046 in CBN catheters. Leakage rate was 0.008 in ST, 0.009 in SN, and 0.021 in CBN catheter. Obstruction rate was 0.003 in ST, none in SN, and 0.015 in CBN catheters Tunnel infection rate was 0.002 in ST, 0.032 in SN, and 0.143 in CBN catheters. The peritonitis rate was not significant among 3 types of catheter. Conclusion: These results indicate that there is no difference among 3 types of peritoneal catheter with respect to catheter survival and catheter-related complications.
지속성 외래복막투석환자에서 조기 및 후기 복강 관류액 누출
김진홍,조동규,권태환,김용림,방종효,조성 대한신장학회 1995 Kidney Research and Clinical Practice Vol.14 No.3
Continuous ambulatory peritoneal dialysis(CAPD) is now a well-established mode of therapy for end- stage rena@l disease. Dialysate leaks as well as other technical complications, however, still remain as an important complication of CAPD. The dialysate leaks may develop early after catheter implantation(early leaks), or months or even years later(late leaks). In either case, the leak may stop if peritoneal dialysis is discontinued for a period ranging from two days to three weeks. From January 1988 through August 1994, 201 CAPD patients were analyzed retrospec- tively. Twenty six patients developed early leaks (within 30 days of catheter insertion) and 9 patients late leaks(beyond 30 days of catheter insertion). The incidences of early and late leaks were 12.9% and 4.5% respectively. Most early leaks were manifested externally through the exit site, but late leaks usually by poor dialysate outflow, localized edema and/or subucutaneous fluid collection. Concurrent complications of the early and late leaks were mainly CAPD peritonitis and exit site infection. The catheter removal rates of early and late leaks were 3.8% and 33.3% respectively. Early leaks were su- ccessfully managed by 2 weeks' discontinuation of CAPD alone in most cases. In late leaks, our experience does suggest that catheter removal will be required if leakage continues beyond 96 hours. Early leaks differ from late leaks in some clinical manifestations and are successfully managed by temporary discontinuation of CAPD. Late leaks are an uncommon and unpredictable complication of CAPD and resulted frequently in replacement of peritoneal catheters. Excessive exercise or mechani- cal manipulation of catheter might result in the occurrence of late leaks.