Christopher Crawford, MD, Daniel Lomelin, MPH, Bradley Hall, MD, Vishal Kothari, MD. University of Nebraska Medical Center
INTRODUCTION: Peritoneal dialysis (PD) catheters are utilized worldwide for patients with end-stage renal disease, but usage is plagued with complications including inability to drain or catheter occlusion. Use of laparoscopy to facilitate placement has been found to improve the rates of primary function as well as salvage of existing catheters. This improvement in outcomes has previously been associated with an increase in the cost of the operation, raising the question of whether it is more economical to place a catheter with open technique, even if it requires subsequent revision versus placing it laparoscopically at the outset.
METHODS: Records were obtained from the University HealthSystem Consortium’s (UHC) Clinical Database/Resource Manager tool from December 2011 to June 2015. UHC’s database represents the majority of nonprofit academic medical centers and affiliated hospitals in the USA. Records were selected as those patients 19+ years old with the International Classification of Diseases – 9th revision (ICD-9) codes for chronic kidney disease, as well as procedure codes for laparoscopic (54.98 and 54.21) or open PD catheter placement (54.98, excluding those with laparoscopy code: 54.21). Direct cost, length of stay (LOS), demographics, and complication rates were reviewed. Statistical analysis was conducted using SPSS v22.214.171.124. Median tests were utilized for cost to better account for skew.
RESULTS: Selection criteria identified a total of 22,364 open PD catheters and 157 laparoscopic PD catheters among inpatient cases. Median cost for open PD catheter placement was $10,371 (IQR: 7,357-15,226), compared to $12,741 (7,755.75-23,176.75) for laparoscopic PD catheter placement, (p<0.001).
Within inpatients, mortality rates (open: 3.44%, lap: 2.55%) did not significantly differ. However, the open operations had significantly higher patient disease severity (68.51% major/extreme) compared to the laparoscopic group (65.61%, p=0.001). The LOS was shorter in the open group (open: 5 days, lap: 6 days, p=0.003), and the complication rate was lower in the open group (open 10.10%, lap: 17.18%, p=0.003).
CONCLUSION: The use of laparoscopy in PD catheter placement has been found to have better primary patency and salvage rates, but its cost has been a limiting factor in recommending its use. This data registry review confirmed that laparoscopy remains significantly more expensive. For patients with good physiologic reserve, the trade-off with increased cost may be worth the improved patency. Patients with a laparoscopic PD catheter had lower disease severity than the open group, which may be secondary to the fact that very ill patients may not tolerate laparoscopy.