Use of cyanoacrylate glue to seal an early pericatheter leak.

Dialysate leaks early after peritoneal dialysis (PD) initiation constitute a common mechanical complication, with incidence varying between 5% and 10%, more so in patients with chronic liver disease with pre-existing ascites. We describe the successful use of cyanoacrylate glue in the management of early and persistent pericatheter PD leak in a patient with liver cirrhosis and end-stage renal disease. The index case is a 61-year-old male patient, with diabetic end-stage renal disease and decompensated liver disease with ascites. The patient underwent percutaneous straight Tenckhoff catheter insertion via median infraumbilical incision, with complete drainage of peritoneal fluid post-insertion and thrice in the first 2 weeks. Upon initiating PD on day 15, the patient developed a pericatheter dialysate leak at the catheter insertion site, which persisted despite PD discontinuation and fluid drainage over next 2 weeks. Thereafter, under ultrasound guidance, the catheter cuff was located in the pre-peritoneal plane, surrounded by a hypoechoic collection, up to 1 cm in thickness (Figure 1). Using a 24G needle, up to 8–10 ml of clear straw-coloured fluid was drained from around the cuff. With the needle in the same location, 1 ml of 1-butyl N-cyanoacrylate (Endocryl; Samarth Life Sciences, Mumbai, Maharashtra, India) was injected in the peri-cuff area. Two days later, PD was re-initiated successfully and continuing without leaks as on the last follow-up on day 102. Temporary discontinuation of PD, surgical repair and transfer to automated peritoneal dialysis using a cycler are the most commonly practised approaches for handling leaks. In adults, Joffe and Herbrig described two cases of percutaneous fibrin glue use, in an external and a subcutaneous leak, respectively. However, the cost of fibrin glue is quite high and, in the Indian scenario, matches the cost of a straight Tenckhoff catheter. Cyanoacrylate glue, on the other hand, costs up to 20 times lesser, has demonstrated excellent tissue adhesive properties and we have used this glue safely earlier to seal post paracentesis site leaks in patients with cirrhosis. There are theoretical concerns with regard to degradation of silicone material upon prolonged contact to cyanoacrylates; however, clinical experience with cyanoacrylate used in closure of urinary fistulas in adults on silicone urinary catheters did not report any damage to the catheter. Also, utilising a paramedian catheter insertion site and prophylactic glue injection might have prevented the development of the leak. To the best of our knowledge, this is the first case to describe the successful use of cyanoacrylate glue in the management of external dialysate leak in a patient on PD. With further experience, cyanoacrylate glue could be considered as an alternate to fibrin glue for sealing post-insertion leaks when fibrin glue is not available or where the cost is prohibitive.