PDI MARCH 2010 – VOL. 30, NO.

2 CORRESPONDENCE

Saunders; 1990: 224–6.

9. De Bree E, Zoetmulder FA, Christodoulakis M, Aleman BM,
Tsiftsis DD. Treatment of malignancy arising in pilonidal
disease. Ann Surg Oncol 2001; 8:60–4.
10. Atkinson RC, Rubin J. Complications of Tenckhoff cath-
eters post removal. ASAIO Trans 1990; 36:M501–2.
doi: 10.3747/pdi.2009.00122

Abdominal Wall Skin Pressure Ulcer

Due to a Peritoneal Catheter

Editor:
We read with interest the letter by Tapiawala and
Bargman (1) about an unusual cause of skin ulceration Figure 1 — The new ulcer appeared on the external cuff after
in a very long-term peritoneal dialysis (PD) patient. We the suture of the first ulceration.
would like to add our experience with a similar situation

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of a skin ulcer on the peritoneal catheter subcutaneous
portion in a polycystic patient.
Our patient, a 64-year-old man with end-stage renal
disease due to polycystic kidney disease, had been on
continuous ambulatory PD for 3 years. The patient’s
underlying problems included severe hypertensive myo-
cardiopathy, ischemic heart disease, and a severe periph-
eral vascular disease. During a routine visit after 3 years
and 6 months on PD, physical examination showed se-
rous drainage from the exit site, cutaneous redness on
the external catheter cuff, and a little skin ulcer local-
ized 3 – 4 cm from the exit site on the catheter tunnel
(almost identical to Tapiawala’s patient). The catheter
was visible through this ulcer but communication be-
Figure 2 — Aspect after incision between exit site and the first
tween the sore and the exit site was not apparent. The
ulcer, relocation of the external cuff, and creation of a new
skin around the ulceration was normal in appearance
exit site.
with no discharge. Exit-site cultures were positive for
Staphylococcus aureus and therapy with appropriate an- is approximately 25 mmHg in healthy people. Compres-
tibiotics was indicated. Initially, we tried to suture the sion with pressures > 30 mmHg will eventually occlude
ulceration but the wound healing was bad and a new ul- the blood vessels so that the surrounding tissues become
ceration appeared on the external cuff (Figure 1). We anoxic and cell death occurs. The necrotic tissue breaks
proceeded to make an incision between the exit site and down, revealing an ulcer. Reduced tissue oxygenation
the skin ulcer, exteriorizing and removing the superfi- induced by pressure is the main determinant of ulcer for-
cial cuff, and establish a new exit site at the low medial mation but the amount of pressure and time necessary
side of the wound (Figure 2). No major complication was for damage may be shortened by a number of identified
noted postoperatively and PD continued uneventfully. risk factors, such as immobility or limited activity, in-
Among the uncommon complications of PD, delayed creased age, poor nutritional status, affected tissue per-
decubitus perforation of a viscus is explained by the in- fusion, and diminished pain sensation (5). Our patient
timate contact between the peritoneal catheter and the suffered some of these risk factors. The skin pressure
viscus (2–4). This continuous pressure causes localized ulcer staging systems (5) will not help the clinician in
ischemia, leading to the formation of a decubitus ero- situations such as that presented here because, in this
sion or a frank perforation. Theoretically, the same case, the lesion progressed upward and a reddened area
pathogenic mechanism may occur at the PD catheter tun- can be the sign of deep tissue damage. Moreover, al-
nel, where the immobility of the subcutaneous segment though the initial general management of skin decubi-
causes prolonged pressure. Mean skin capillary pressure tus ulcers uses local treatment, in the PD setting, surgical

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CORRESPONDENCE MARCH 2010 – VOL. 30, NO. 2 PDI

intervention must be indicated due to the high risk of REFERENCES

tunnel and/or intraperitoneal infection.
It is important therefore to suspect a pressure ulcer 1. Tapiawala S, Bargman JM. An unusual cause of skin ulcer-
of the subcutaneous portion of the catheter through the ation in a very long-term peritoneal dialysis patient. Perit
abdominal wall when a trophic dermal change on the Dial Int 2009; 29:120–1.
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the bowel is a sword of Damocles in patients on perito-
DISCLOSURES neal dialysis. Nephron 1996; 74:232–3.
3. Balaji V, Digard N, Wise MH. Delayed bowel erosion due to
None. functioning chronic ambulatory peritoneal dialysis cath-
eter. Nephrol Dial Transplant 1996; 11:368–9.
M. Moreiras–Plaza 4. Miller R, Dennan R, Saltissi D, Healy H, Muller M, Fleming
S. Erosion of a mesenteric vessel by a Tenckhoff catheter.
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Department of Nephrology
5. Leigh IH, Bennett G. Pressure ulcers: prevalence, etiol-
C.H.U. Xeral-Cies
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Vigo, Spain 1994; 167:25s–29s.
doi: 10.3747/pdi.2009.00128
e-mail: mercedes.moreiras.plaza@sergas.es

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258 This single copy is for your personal, non-commercial use only.
For permission to reprint multiple copies or to order presentation-ready copies
for distribution, contact Multimed Inc. at marketing@multi-med.com