Fallopian tube wrapping as a cause of catheter malfunction in peritoneal dialysis: a report of two cases and management strategies

Introduction

Peritoneal dialysis (PD) is gaining popularity as it offers a more comfortable dialysis option for patients with end-stage renal disease (ESRD) and has a beneficial impact on preserving residual renal function. However, catheter malfunction remains a significant issue in PD patients, commonly stemming from catheter migration, catheter kinking, omental wrapping, and fibrin obstruction. Additionally, constipation and intestinal bloating can also lead to the catheter displacement with problematic drainage. Among these, omental wrapping is considered to be the primary cause of catheter flow restriction. Nevertheless, several rare causes contributing to catheter dysfunction should not be ignored. For example, appendix entrapment was discovered as a unique cause of catheter-related obstruction in a 4-year-old boy undergoing continuous ambulatory peritoneal dialysis (CAPD), which was resolved through appendectomy and catheter replacement (1). Similarly, in 2021, a case of catheter dysfunction caused by migration into the right inguinal hernia sac was also reported (2). Another example was a 45-year-old man experiencing recurrent catheter obstruction accompanied by stomach pain, a laparoscopic examination found that the PD catheter was encircled by the sigmoid mesocolon. The catheter was eventually withdrawn, and the patient was switched to hemodialysis (3). Furthermore, the hemorrhagic corpus luteum was also discovered to be an uncommon cause of catheter obstruction, which was reabsorbed and the catheter resumed function following the next menstrual cycle (4). In female PD patients who experience bidirectional catheter obstruction, we should also consider the possibility of fallopian tube wrapping as a cause of catheter dysfunction. Herein, we present two cases of PD catheter dysfunction caused by fallopian tube wrapping that were effectively resolved through laparoscopic surgery and catheter fixation. Our aim is to raise awareness of this potential cause in order to make an accurate diagnosis and provide timely intervention. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-23-201/rc).

Case presentation

Case 1

On April 24, 2023, a 28-year-old lady was admitted to the Department of Nephrology at the Second Affiliated Hospital of Xi’an Jiaotong University, complaining of decrease dialysate flow rates for the previous 2 days. Three years ago, she experienced a cesarean section, but there were no specific documents regarding her medical and family history. Two months ago, she underwent implantation of a straight double-cuffed Tenckhoff catheter and initiated low-dose intermittent peritoneal dialysis (IPD) due to ESRD resulting from chronic glomerulonephritis. Approximately 1 month after catheter implantation, she started encountering difficulties with dialysate drainage, which initially improved with defecation and catheter flushing. However, her symptoms worsened 2 days prior to admission, making it more difficult to drain or infuse the dialysate, prompting her hospitalization for further management. Physical examination revealed slight swelling of the upper eyelid. An abdominal X-ray revealed catheter displacement from the pelvis (Figure 1A), but the ultrasound examination could not detect whether the catheter was wrapped by the omentum. Attempts to restore the catheter patency using flushing, gravity reduction, and tube sealing with urokinase were all unsuccessful. To determine the existence of omentum wrapping, a laparoscopic examination was performed under general anesthesia. During the surgery, it was discovered that the left fallopian tube, rather than the omentum, was tightly wrapped around the PD catheter (Figure 1B). As visible in the abdominal X-ray, the catheter tip was located outside of the pelvis rather than the entire intraperitoneal portion, suggesting fixation of the catheter by the left fallopian tube (Figure 1B). The fimbriae of the fallopian tube protruded into the lateral holes of the catheter, causing the blockage (Figure 1C). Although relatively rare, the cause of catheter dysfunction can lead to PD failure. The wrapped fallopian tube was then carefully peeled away from the catheter, and a leftover tissue fragments in the lumen were removed using dissecting forceps (Figure 1D), followed by repeated flushing. A laparoscopic salpingectomy was not performed on this patient, as it could raise the risk of infertility in women of reproductive age. Finally, the PD catheter was positioned in the uterine rectal fossa, with its tip fixing to the posterior wall of the bladder using a non-absorbable suture to prevent migration out of the small pelvis (Figure 1E). Following surgery, the catheter was unobstructed, and a follow-up abdominal X-ray showed appropriate placement (Figure 1F). Up to now, the patient is successfully undergoing CAPD, with no abdominal bleeding or peritoneal dialysate leakage.

Figure 1 The peritoneal dialysis catheter was wrapped by the fallopian tube in case 1. (A) Abdominal X-ray image prior to the laparoscopic manipulation, the red arrow points to the tip of the displaced peritoneal dialysis catheter; (B,C) fimbriae of the left fallopian tube tightly wrapped around the catheter and intruded into the drainage holes; (D) fimbriae were peeled off from the catheter; (E) the catheter tip was fixed to the posterior wall of the bladder; (F) abdominal X-ray image after the laparoscopic manipulation, the red arrow points to the tip of the peritoneal dialysis catheter.

Case 2

On March 30, 2023, a 49-year-old female underwent insertion of a straight double-cuffed Tenckhoff PD catheter due to acute renal failure (ARF) caused by minimal change disease (MCD) complicated with acute tubular necrosis (ATN). Within 1 month of PD initiation, the patient received low-dose IPD therapy, and both the dialysate infusion and drainage were unimpeded. However, after 40 days of catheter insertion, the patient began experiencing problems with dialysate drainage and infusion. Despite employing catheter flushing, gravity reduction, and tube sealing with urokinase, the catheter dysfunction continued. On May 10, a laparoscopic examination revealed that the right fallopian tube was tightly wrapped around the PD catheter, with fimbriae protruding into the lateral holes (Figure 2A). The catheter was retrieved from the fallopian tube fimbriae (Figure 2B) and flushed to ensure its patency (Figure 2C). To prevent displacement, the catheter tip was also fixed to the posterior wall of the bladder to prevent its migration (Figure 2D). Since the laparoscopic intervention, the patient has experienced successful PD without any subsequent difficulties.

Figure 2 The peritoneal dialysis catheter was wrapped by the fallopian tube in case 2. (A) The right fallopian tube tightly wrapped around the catheter; (B) the fimbriae of the fallopian tube blocked the drainage holes of the catheter; (C) catheter flushing was performed to check its patency; (D) catheter fixation was implemented to prevent the recurrence of migration.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the two patients for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

A PD catheter is an artificially implanted conduit facilitating dialysate infusion and outflow from the abdominal cavity. Proper placement and function of the PD catheter are critical for a successful PD process, whereas catheter malfunction can cause challenges with dialysate infusion and drainage, ultimately resulting in technique failure in PD patients. In a retrospective study involving 700 individuals who experienced catheter problems, displacement accounted for 67.1% of cases, omental wrapping for 25.2%, and a combination of migration and omental wrapping for 7.7%. Patients experiencing catheter malfunctions exhibited considerably lower catheter survival durations than those without malfunction (5). Non-invasive approaches for restoring catheter function include catheter flushing, purgative enemas, gravity reduction, and manipulative techniques (6). However, if these conservative techniques fail, more invasive approaches such as X-ray-guided wire manipulation, open surgery, or laparoscopic surgery may be necessary (7,8).

The fallopian tubes, which are positioned on both sides of the uterine floor, are a pair of elongated, curved myogenic ducts responsible for transporting the egg into the uterus (9). In previous reports, fallopian tube wrapping has been traditionally regarded as a rare cause of catheter malfunction (10,11), but its significance in technique failure and PD discontinuation may be underestimated (12). Firstly, fallopian tube wrapping was observed primarily within the first two months after PD onset, whereas catheter displacement occurred frequently within the first two weeks after catheter implantation. The coexistence of catheter displacement and fallopian tube wrapping in the first case indicates a close relationship between the two events. Secondly, ultrasound or X-ray examinations could not effectively distinguish the fallopian tube from the omentum when bidirectional flow restriction occurs in the early stages of PD initiation. Furthermore, if a mini-laparotomy is performed to restore catheter function, the fallopian tube may inadvertently be torn when the catheter is retrieved through a small incision, making it difficult to distinguish between the fallopian tube and the omentum. As a result, it is critical to consider the possibility of fallopian tube wrapping as a cause in female PD patients experiencing catheter malfunction.

The laparoscopic technique facilitates the identification and diagnose of fallopian tube wrapping, as well as the rescue of a faulty PD catheter. In our cases, laparoscopy revealed that the displaced catheter was tightly wrapped by the fallopian tube, with drainage holes blocking by the fimbriae. To restore the catheter patency, the catheter should be released from the fimbriae, and a salpingectomy was previously used as a strategy to prevent the recurrence (13). However, the use of laparoscopic salpingectomy to manage fallopian tube wrapping remains a topic of debate and controversy due to concerns about potential infertility in women of childbearing age. Therefore, the decision to perform a salpingectomy should be carefully considered, weighing the potential benefits against the risk of jeopardizing future fertility (14). Additionally, laparoscopic fixation of the catheter to the anterior abdominal wall or the lower abdominal wall using a non-absorbable suture is regarded as a simple, safe, and effective method to prevent catheter displacement (15,16). In our cases, we chose to remove the fallopian tube and fimbriae from the catheter and fix the catheter tip to the bladder’s posterior wall to prevent the migration from occurring again and to maintain future fertility. To avoid excessive pulling and potential damage to the bladder, we sutured the catheter tip to the bladder peritoneum or subserosal zone, ensuring a suitable gap between the catheter tip and the bladder wall to allow for some catheter mobility. This approach minimizes discomfort for patients during CAPD or automated peritoneal dialysis (APD). Furthermore, due to the shallow depth of the sutures, most patients experience the suture knots naturally falling off within 1–2 months after the surgery. This not only prevents early catheter displacement, but also avoids difficulties during catheter extubation and minimizes the risk of bladder damage. In some cases, we opt for absorbable sutures to further enhance patient comfort and safety. During postoperative follow-up, both patients reported that laparoscopic surgery under general anesthesia was less painful, resulted in faster postoperative recovery, and efficiently resolved catheter-related issues, enabling them to continue PD rather than converting to hemodialysis.

However, the particular causes for the catheter being wrapped by the fallopian tube in these two cases remain unclear. Several factors could potentially contribute to this phenomenon warranting further investigation. These may include variations in the menstrual cycle during the operation, hormonal fluctuations in the body, a history of previous abdominal surgery, or catheter displacement after the operation. Further research and exploration are needed to elucidate the underlying mechanism and contributing factors involved in fallopian tube wrapping around PD catheters.

Conclusions

Fallopian tube wrapping around PD catheters may represent an under-reported issue that warrants consideration in case of catheter dysfunction. Utilizing of laparoscopy with catheter fixation can be beneficial in restoring catheter function and enhancing patient outcomes. However, the decision to perform a salpingectomy should be carefully considered, taking into account potential risks and benefits. Further research and clinical experience are needed to better understand and manage the uncommon but clinically significant complications.

Acknowledgments

The authors express their gratitude to Dr. Liu Yang from the General Surgery Department of the Second Affiliated Hospital of Xi’an Jiaotong University for his assistance in laparoscopic surgery operations.

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-23-201/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-23-201/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-23-201/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the two patients for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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