|Year : 2019 | Volume
| Issue : 1 | Page : 27-30
Role of chemoports in children with hematological/solid tumor malignancies - Technical implications and complications: An institutional experience
Rajeev Redkar, Anant Bangar, Janani Krishnan, Vinod Raj, C Swathi, Shirin Joshi
Department of Pediatric Surgery, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India
|Date of Web Publication||19-Dec-2018|
Dr. Rajeev Redkar
Consultant Pediatric Surgeon, 14, Buildarch Terrace, Sitladevi Temple Road, Mahim (West), Mumbai - 400 016, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: The aim of this retrospective analysis was to identify the variously related complications and to study preventive and therapeutic measures for these complications.
Materials and Methods: A total of 72 catheters were inserted in 69 patients (mean follow-up of 1140 days) from December 2002 to May 2017. Sixty-four children were diagnosed to have hematological malignancies, and five children had solid tumors. The youngest child was 2 months of age, and the oldest was 15 years, 5 months. Records were analyzed retrospectively for the age, indication, route of insertion, and postoperative complications. A protocol-based insertion and postinsertion handling by trained nursing staff/doctors were instituted, including a periodic training program for those concerned.
Results: Chemoport-related complications were infection in 3 (4.16%), necessitating port removal in one patient. The rest were managed by antibiotic-lock therapy. The other problems were catheter tip occlusion in 1 (1.38%) and extravasation in two patients (2.77%) leading to a sterile collection around the port chamber. An unsightly scar in 4 (5.55%) and granuloma formation at scar site in 1 (1.38%) patient were noted.
Conclusion: Totally implantable chemoports are preferred in children with solid and hematological malignancies because of decreased pain, the rate of infection, and ability to maintain patency for the long term. Despite significant advantages over other types of central venous access, chemoports have their own complications. It was also noted that the rate of complications could be minimized by periodic training of all the personnel concerned and following protocol-based handling of ports.
Keywords: Chemoports, hematological malignancies, pediatric
|How to cite this article:|
Redkar R, Bangar A, Krishnan J, Raj V, Swathi C, Joshi S. Role of chemoports in children with hematological/solid tumor malignancies - Technical implications and complications: An institutional experience. J Indian Assoc Pediatr Surg 2019;24:27-30
|How to cite this URL:|
Redkar R, Bangar A, Krishnan J, Raj V, Swathi C, Joshi S. Role of chemoports in children with hematological/solid tumor malignancies - Technical implications and complications: An institutional experience. J Indian Assoc Pediatr Surg [serial online] 2019 [cited 2019 Jan 18];24:27-30. Available from: http://www.jiaps.com/text.asp?2019/24/1/27/247902
| Introduction|| |
Chemoports are implantable vascular access devices, which have facilitated the administration of chemotherapy in children with hematological/ solid tumor malignancies. The physical and psychological impact of multiple punctures involved in a peripheral line, with the risk of extravasation of toxic chemotherapeutic drugs, makes it the least preferred access in children receiving chemotherapy. However, ports are also associated with their share of complications which can be minimized with proper insertion techniques and strict protocols for handling ports, periodic training of concerned nursing staff and doctors.
We describe our institutional experience with chemoports regarding insertion techniques, complications and protocols for handling a port and its advantages.
| Materials and Methods|| |
A total of 72 chemoports were inserted in 64 children with hematological malignancies and 5 children with solid tumors. Chemoports were inserted twice in three children requiring chemotherapy due to relapse. These chemoports, analyzed retrospectively, were inserted between December 2002, and May 2017 in a tertiary care center. Before 2002 we inserted partially externalized central venous catheters for children requiring long-term intravenous access. Owing to the increased rate of infection, thrombosis, and discomfort experienced by the children, chemoports became our access of choice from 2004 onward. Those with a platelet count <50,000 cells/cu mm or deranged coagulation profile (international normalized ratio >1.25) on preoperative evaluation, were corrected to ensure safe port insertion. Those patients who had a central line previously inserted in the right internal jugular vein (IJV) underwent ultrasound Doppler scan of the neck to confirm patency of the right IJV. The nonavailability of the right IJV is usually suspected with a history of multiple line insertion in right IJV. In this situation, a venous Doppler is done to assess and plan for the choice of the vein for cannulation. Usually, left IJV, right subclavian vein, left subclavian vein, or even external jugular veins are the next options. The decision is reached only after reviewing the venous anatomy and patency by radiological investigations.
Technique of insertion
Under general anesthesia, the child was placed in supine position with the adequate extension of the neck and rotation toward the contralateral side. The right IJV was isolated by the open technique. An appropriate-sized preconnected, single lumen, open-ended chemoport was flushed adequately with dilute gentamicin solution (20 mg in 200 ml of normal saline). The chamber was fixed with 4/0 polypropylene sutures in the right infraclavicular region in the subcutaneous plane, taking care not to encroach the mammary region, especially in female children. The catheter was tunneled in the subcutaneous plane into the neck and tip was inserted into the right IJV under direct vision and fixed. Intraoperatively while positioning the catheter, we always take care to confirm the orientation of catheter position in the neck to avoid acute curvature and kinking which may result in difficulties in achieving free flow of infusions or withdrawal of blood for sampling. The position of the catheter tip at the junction of superior vena cava and right atrium was confirmed under fluoroscopy as shown in [Figure 1]. Strict asepsis was maintained throughout the procedure. The port was activated with a 22G/20G noncoring Huber needle, flushed with heparin saline (10 U/ml) and secured as shown in [Figure 2].
The chemoports were flushed with heparin saline every 4 weeks to avoid blockage. Every time a port would be handled by a doctor/nursing staff, appropriate sterile precautions were taken. A local anesthetic cream was applied to the skin overlying the chamber, to decrease the pain during puncture. After every blood collection through the port or after every cycle of chemotherapy, it was flushed with 10 cc of heparin saline (10U/ml).
A training program of the nursing staff and doctors was conducted as and when new personnel were inducted.
| Results|| |
From December 2002, to May 2017, there were 69 children from 2 months to 15 years 5 months of age who underwent chemoport insertion. The mean age at insertion was 5 years 11 months. Hematological malignancies accounted for 92.75% and five solid tumors for 7.24% of the patients.
All port catheters were inserted in the right IJV. There were no immediate postoperative complications. There were three culture-proven infections, Staphylococcus aureus in one, Staphylococcus epidermidis in one, and Candida albicans in one patient. All staphylococcal infections were managed by antibiotic lock therapy. One port was removed due to candidal infection. The total infection rate was 4.16%, which occurred between September and December 2012. Hence, a training session was conducted for all the nursing staff and doctors concerned with port handling to reiterate the importance of absolute sterile precautions during port handling.
Extravasation of flushing solution and chemotherapeutic drug solution around the port chamber was seen in two children. The collection pocket was drained by compression in both and the fluid sent for culture was sterile.
There was one case of catheter tip occlusion due to delay in port flushing by 25 days. It was managed conservatively by flushing of the catheter with 10 ml of 10 U/ml of heparin saline under low-graded pressure.
The other difficulties faced during the port activation were the inability to confirm a backflow on aspiration, which was managed by positional changes and difficulty in the location of a slim chamber of 6.6 Fr in a child who had gained subcutaneous fat. On long-term follow-up (mean = 1140 days), postchemoport removal, the unsightly scar was found in four patients (5.55%), which are being managed with topical creams and silicone gel sheeting (cica care). One of the child, who had extravasation of flushing solution, developed a granuloma at the scar site which was managed with topical silver nitrate cauterization.
| Discussion|| |
Tunneled silicon catheters are attributed to Broviac et al. and Hickman et al. Their external exit site acts as a portal for infection and restricts the routine activities in children. Tunneled external central venous catheters have a 3–7 times higher rate of catheter-associated bloodstream infections than totally implantable devices (Ports) in children with cancer. Hence, it is quite apparent that ports, by being totally implanted have lesser implications for infection, cosmesis and improve the comfort in performing daily activities in children.,
Complications in central venous access devices have been reported to be as high as 40%. The complications in ports have ranged from 5.1% to 31%. Percutaneous insertion of the guide wire has high complication rate in pediatric age due to high dome/apex resulting in pneumothorax. In addition, in our series, we have done the procedure in patients with hematological malignancies who have nutritional deficiencies, low platelets, and coagulation issues, and a percutaneous puncture has a risk of a hematoma formation. This high complication rate has been validated by a comprehensive review by Di Carlo et al. Hence, we prefer insertion of the catheter by open technique at our institute. We report an overall complication rate of 11/72 (15.27%). Port infection occurred in 3/72 which was culture positive. Microbiological data suggestive of bloodstream infection rather than contamination include the following: multiple positive blood culture results, quantitative cultures of blood samples drawn from a catheter with 100 cfu/mL, and isolation of the same organism from quantitative catheter cultures and percutaneous blood cultures. In uncomplicated infections, although there are no data that support the use of specific empirical antibiotic therapy for device-related bloodstream infection, vancomycin is usually recommended in those hospitals or countries with an increased incidence of methicillin-resistant staphylococci, because of its activity against coagulase-negative staphylococci and S. aureus. In the absence of methicillin-resistant S. aureus, penicillinase-resistant penicillins, such as nafcillin or oxacillin, should be used. In salvage approach for ports, antibiotic lock therapy is recommended for 2 weeks in addition to the systemic antibiotics for 7 days. Antibiotic solutions that contain the desired antimicrobial agent in a concentration of 1–5 mg/mL are usually mixed with 50–100 U of heparin (or normal saline) in sufficient volume to fill the catheter lumen (usually 2–5 mL) and are installed or “locked” into the catheter lumen during periods when the catheter is not being used (e.g., for a 12 h period each night). In case of complicated infections such as port abscess, sepsis or endocarditis, port removal is recommended. Furthermore, any fungal infection (Candida spp.) mandates port removal as salvage therapy does not work.
Catheter occlusion is usually managed by flushing with heparin saline though there is a small risk of embolism. For a catheter thrombus, current recommendations include administration of a thrombolytic agent into the catheter lumen with a dwell time of at least 30 min and a repeated dose if needed. If catheter patency is not restored, a low dose of alteplase can be infused over 6–8 h. An ultrasound, venogram, or other diagnostic study is warranted if venous thrombosis is suspected. Different thrombolytics can be used such as reteplase, recombinant urokinase, and alfimeprase.
Prophylaxis for prevention of thrombosis has conflicting guidelines. In our experience, port flushing with heparin saline of 10 ml of 10 U/ml on a monthly basis has been safe as there have been no complications in our patients over a follow-up of 1140 days. Furthermore, a delay by 25 days in port flushing in one patient led to catheter tip occlusion, possibly implying a positive role of flushing with heparin saline on a monthly basis. Fracture of catheters may result in serious complications due to migration and embolization. This complication may need extraction of the fractured/embolized catheter by interventional radiological procedure or open surgery. To prevent this complication occurring due to slippage of the catheter from its hub, at our institute we use exclusively preconnected catheters. The close relationship between the clavicle and first rib may lead to crimping and intermittent positional or permanent occlusion of compressible catheters placed in subclavian vein. This complication has been referred to as the subclavian pinch-off syndrome. The resulting occlusion will render infusion and possibly aspiration through the line difficult or impossible. Over time, repeated crimping of the catheter may weaken its mechanical integrity, eventually resulting in fracture and catheter embolus. For this reason, pinch-off syndrome should be treated with catheter removal and insertion of a catheter in a new site. Some suggest subclavian pinch-off syndrome can be avoided by puncture of the subclavian vein at a relative lateral position.
Scar-related complications though rare, do occur. Most often, an unsightly scar is seen in lean children. The chamber is placed against the bony cage and overlying skin is stretched leading to a broad scar and sometimes a hypertrophic scar. Topical silicone gel is a safe and effective treatment for hypertrophic scars. It has been reported to be effective and produces 86% reduction in texture, 84% in color, and 68% in the height of scars. Scar granuloma in one patient is being treated with silver nitrate cauterization over the granuloma. In this research paper, we have critically analyzed a large series from a single center. There is a paucity of papers on this subject, especially in children and in our country. Through this paper, we have tried to stress the importance of protocol-based insertion technique and handling of the port by nursing staff and doctors.
| Conclusion|| |
Totally implantable chemoports are preferred in children withsolid and hematological malignancies because of decreased pain, the rate ofinfection, and ability to maintain patency for the long term. Despite significantadvantages over other types of central venous access, chemoports have their owncomplications. It was also noted that the rate of complicationscould be minimizedby periodic training of all the personnel concerned and following protocol-based handling of ports.
The authors would like to thank Pediatric Haemato-oncologist Dr. M. R. Lokeshwar and Dr. S. Kanakia.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Broviac JW, Cole JJ, Scribner BH. A silicone rubber atrial catheter for prolonged parenteral alimentation. Surg Gynecol Obstet 1973;136:602-6.
Hickman RO, Buckner CD, Clift RA, Sanders JE, Stewart P, Thomas ED, et al.
A modified right atrial catheter for access to the venous system in marrow transplant recipients. Surg Gynecol Obstet 1979;148:871-5.
Alexander N. Question 3. Do Portacaths or Hickman lines have a higher risk of catheter-related bloodstream infections in children with leukaemia? Arch Dis Child 2010;95:239-41.
Krul EJ, van Leeuwen EF, Vos A, Voûte PA. Continuous venous access in children for long-term chemotherapy by means of an implantable system. J Pediatr Surg 1986;21:689-90.
Babu R, Spicer RD. Implanted vascular access devices (ports) in children: Complications and their prevention. Pediatr Surg Int 2002;18:50-3.
Mermel LA, Allon M, Bouza E, Craven DE, Flynn P, O'Grady NP, et al.
Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America. Clin Infect Dis 2009;49:1-45.
Dillon PA, Foglia RP. Complications associated with an implantable vascular access device. J Pediatr Surg 2006;41:1582-7.
Di Carlo I, Pulvirenti E, Mannino M, Toro A. Increased use of percutaneous technique for totally implantable venous access devices. Is it real progress? A 27-year comprehensive review on early complications. Ann Surg Oncol 2010;17:1649-56.
Rosovsky RP, Kuter DJ. Catheter-related thrombosis in cancer patients: Pathophysiology, diagnosis, and management. Hematol Oncol Clin North Am 2005;19:183-202, vii.
Baskin JL, Pui CH, Reiss U, Wilimas JA, Metzger ML, Ribeiro RC, et al.
Management of occlusion and thrombosis associated with long-term indwelling central venous catheters. Lancet 2009;374:159-69.
Puri N, Talwar A. The efficacy of silicone gel for the treatment of hypertrophic scars and keloids. J Cutan Aesthet Surg 2009;2:104-6.
] [Full text]
[Figure 1], [Figure 2]