Peritoneovenous shunting for nongynecologic malignant ascites

Chronological Course and Clinical Features after Denver Peritoneovenous Shunt Placement in Decompensated Liver Cirrhosis

BACKGROUND

Refractory ascites affects the prognosis and quality of life in patients with liver cirrhosis. Peritoneovenous shunt (PVS) is a treatment procedure of palliative interventional radiology for refractory ascites. Although it is reportedly associated with serious complications (e.g., heart failure, thrombotic disease), the clinical course of PVS has not been thoroughly evaluated.

OBJECTIVES

To evaluate the relationship between chronological course and complications after PVS for refractory ascites in liver cirrhosis patients.

MATERIALS AND METHODS

This was a retrospective study of 14 patients with refractory ascites associated with decompensated cirrhosis who underwent PVS placement between June 2011 and June 2023. The clinical characteristics, changes in cardiothoracic ratio (CTR), and laboratory data (i.e., brain natriuretic peptide (BNP), D-dimer, platelet) were evaluated. Follow-up CT images in eight patients were also evaluated for ascites and complications.

RESULTS

No serious complication associated with the procedure occurred in any case. Transient increases in BNP and D-dimer levels, decreased platelet counts, and the worsening of CTR were observed in the 2 days after PVS; however, they were improved in 7 days in all cases except one. In the follow-up CT, the amount of ascites decreased in all patients, but one patient with a continuous increase in D-dimer 2 and 7 days after PVS had thrombotic disease (renal and splenic infarction). The mean PVS patency was 345.4 days, and the median survival after PVS placement was 474.4 days.

CONCLUSIONS

PVS placement for refractory ascites is a technically feasible palliative therapy. The combined evaluation of chronological changes in BNP, D-dimer, platelet count and CTR, and follow-up CT images may be useful for the early prediction of the efficacy and complications of PVS.

Advances in the treatment of malignant ascites in China

PURPOSE

Malignant ascites (MA) often occurs in recurrent abdominal malignant tumors, and the large amount of ascites associated with cancerous peritonitis not only leads to severe abdominal distension and breathing difficulties, but also reduces the patient's quality of life and ability to resist diseases, which usually makes it difficult to carry out anti-cancer treatment. The exploration of MA treatment methods is also a key link in MA treatment. This article is going to review the treatment of MA, to provide details for further research on the treatment of MA, and to provide some guidance for the clinical treatment of MA.

METHOD

This review analyzes various expert papers and summarizes them to obtain the paper.

RESULT

There are various treatment methods for MA, including systemic therapy and local therapy. Among them, systemic therapy includes diuretic therapy, chemotherapy, immunotherapy, targeted therapy, anti angiogenic therapy, CAR-T, and vaccine. Local therapy includes puncture surgery, peritoneal vein shunt surgery, acellular ascites infusion therapy, radioactive nuclide intraperitoneal injection therapy, tunnel catheter, and intraperitoneal hyperthermia chemotherapy. And traditional Chinese medicine treatment has also played a role in enhancing efficacy and reducing toxicity to a certain extent.

CONCLUSION

Although there has been significant progress in the treatment of MA, it is still one of the clinical difficulties. Exploring the combination or method of drugs with the best therapeutic effect and the least adverse reactions to control MA is still an urgent problem to be solved.

Clinical practice guideline for the treatment of malignant ascites: section summary in Clinical Practice Guideline for peritoneal dissemination (2021)

Patients with peritoneal dissemination (PD) caused by abdominal malignancies are often associated with massive ascites, which shows extremely dismal prognosis because of the discontinuation of systemic chemotherapy mostly due to poor performance status. Many treatment methods, such as simple drainage, peritoneovenous shunting (PVS) and cell-free and concentrated reinfusion therapy (CART), have been used for symptom relief. However, the clinical efficacies of these methods have not been fully investigated yet. Recently, we developed the Clinical Practice Guideline for PD caused by various malignancies according to "Minds Clinical Practice Guideline Development Guide 2017". In this guideline, we systematically reviewed information on clinical diagnosis and treatments for PD using PubMed databases (2000 – 2020), and clarified the degree of recommendation for clinical questions (CQ). The evidence level was divided into groups by study design and quality. The literature level and a body of evidence were evaluated in reference to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Based on the results of systematic review, the strength of the recommendations was evaluated at a consensus meeting of the Guideline Committee. This is the English synopsis of the part of treatment of malignant ascites in Clinical Practice Guideline for PD, 2021 in Japanese. The guidelines summarize the general aspect of the treatment of malignant ascites and statements with recommendation strengths, evidence levels, agreement rates and future perspective for four raised clinical questions.

The influence of a peritoneovenous shunt for cirrhotic and malignant intractable ascites on renal function

Background

Peritoneovenous shunts (PVS) are widely used for palliation of intractable ascites caused by peritoneal carcinomatosis (PC) or liver cirrhosis (LC). Some patients who need PVS have renal dysfunction. However, renal dysfunction is considered a relative contraindication. Therefore, it is important to assess renal function before PVS placement.

Purpose

To evaluate the relationship between PVS and renal function.

Material and Methods

Between October 2007 and July 2015, 60 patients (PC = 47; LC = 10; others = 3) underwent PVS placement for intractable ascites. Changes in estimated glomerular filtration rate (eGFR) and other adverse events (AEs) were retrospectively analyzed.

Results

Changes in eGFR before, one day after, and one week after PVS placement could be evaluated in 46 patients. The median eGFR before, one day after, and one week after was 56.5, 59.1, and 64.7 mL/min/1.73 m², respectively (P < 0.05). These values were 61.6, 72, and 67.1 mL/min/1.73 m², respectively, in PC patients (n = 34; P < 0.05) and 28.5, 27, and 37.2 mL/min/1.73 m², respectively, in LC patients (n = 10; P < 0.05). In 17 patients with moderate to severe renal dysfunction (eGFR < 45), these values were 23.4, 23.7, and 30.5 mL/min/1.73 m², respectively. The most frequent AE was PVS catheter obstruction, which occurred in 12 patients (20.7%). Clinical disseminated intravascular coagulation occurred in six patients (10.3%) and caused death in three patients (5.2%).

Conclusion

PVS placement for intractable ascites is associated with various AEs. However, PVS appeared to promote renal function, especially in patients with renal impairment.

Symptomatic Fluid Drainage: Peritoneovenous Shunt Placement

Ascites causes significant discomfort and has negative impact on patient's quality of life. Medical therapies including dietary restriction and diuretics are successful in only 40 to 44% of patients with malignant ascites and repeated paracentesis only provides temporary symptomatic relief. Therefore, a more permanent solution is necessary. Indwelling catheters or peritoneovenous shunt placement can provide more permanent symptomatic relief and improve patients' quality of life. Unlike indwelling catheters, peritoneovenous shunts do not limit patients' life style and therefore should be offered as first option in patients who are good candidates. Denver shunt (CareFusion-BD Worldwide) is the current available peritoneovenous shunt. In this article, the indications, contraindications, technical aspects of shunt placement, and techniques to prevent postprocedure complications will be discussed.

Palliative Interventional Oncology

Interventional oncologists are playing an ever greater role in improving the quality of life of their patients through minimally invasive procedures, many of which can be performed on an outpatient basis. Some of the most common palliative procedures currently performed will be discussed including management of intractable ascites and pleural effusions, neurolytic plexus blocks, and palliation of pain and bleeding associated with metastatic tumors.

Denver peritoneovenous shunts for the management of malignant ascites: a review of the literature in the post LeVeen Era

Most case series describing peritoneovenous (PV) shunts for malignant ascites include both LeVeen and Denver shunts. Conclusions based on these studies are no longer clinically relevant since the LeVeen shunt has been discontinued. The purpose of this study was to identify outcomes specific to Denver shunts to establish expected results in the modern era. Case series describing PV shunts for malignant ascites between 1980 and 2008 were identified through a keyword PUBMED search. Whenever possible, results attributable to Denver shunts were abstracted and analyzed. Nineteen series describing 341 patients undergoing 353 Denver PV shunts for malignant ascites were identified. The primary indications for PV shunts were unspecified or cancers of unknown origin (40%), ovarian cancer (16%), and pancreatic cancer (8%). Primary patency averaged 87 ± 57 days. Seventy-four per cent of patients died with functioning shunts. Complications occurred in 38% of patients including occlusion (24%) and disseminated intravascular coagulation (9%). Average survival of all patients was 3.0 ± 1.7 months and shunts provided effective palliation in 75.3%. One and a half per cent of 133 patients who had autopsies were reported to have hematologic dissemination. These results are not statistically different than overall results reported for both shunts combined or LeVeen shunts alone. Studies that report combined outcomes with Denver and LeVeen shunts for malignant ascites are neither negatively, nor positively influenced by one specific shunt. Expectations following PV shunting for malignant ascites do not have to be revised because LeVeen shunts are no longer available.

[Pathogenesis and management of refractory malignant ascites]

Malignant ascites are the cancer-associated accumulation of fluids in the peritoneal cavity. The neoplasms most frequently associated with ascites are ovarian, breast, colon, stomach and pancreas adenocarcinomas. Symptoms are abdominal distention, nausea, vomiting, anorexia, dyspnea and limbs oedemas. Several pathophysiological mechanisms might be implicated such as peritoneal carcinomatosis, lymphatic vessels' obstruction, portal hypertension or heart failure. Its diagnosis is most often performed in a context of already known neoplasia. Malignant ascites are associated with a pejorative evolution. Ascites which cannot be mobilized or show early recurrence and cannot be prevented by medical treatment are defined as refractory ascites. Therefore, management of refractory malignant ascites takes place in the context of palliative care and aims at improving the quality of life of these patients. This review lists the current data reported on the pathophysiology of malignant ascites and describes the present and future options for refractory malignant ascites management.

Feasibility of externalized peritoneovenous shunt (EPVS) for malignant ascites

PURPOSE

To evaluate a new modified peritoneovenous shunt therapy, the externalized peritoneovenous shunt (EPVS) system placement, used to treat patients with malignant ascites.

METHODS

We retrospectively reviewed 10 patients, who were not suited for conventional peritoneovenous shunts (PVS), with malignant ascites, which was refractory to medical therapies. Patient characteristics, technical success, efficacy, duration of EPVS placement, adverse events, and outcome were evaluated. Clinical efficacy of the EPVS was evaluated by the change in subjective symptoms.

RESULTS

The primary reasons for applying EPVS were severe anasarca in 4 patients, potential PVS dysfunction in 3 patients, poor performance status in 2 patients, and a history of PVS occlusion in 1 patient. EPVS was successfully placed in all patients, and it provided clinical efficacy in 8 patients (80%). Early death occurred within 7 days after EPVS placement in 2 patients because of renal failure. The median duration of EPVS placement was 10.4 days (range, 2-28 days). In 6 patients (60%), the EPVS was exchanged to conventional PVS sequentially, since the initial EPVS placement resulted in an improvement of the subjective symptoms of the patients, without serious complications.

CONCLUSION

EPVS placement may be an option for patients with malignant ascites who may not be appropriate for conventional PVS placement.

Radiological insertion of Denver peritoneovenous shunts for malignant refractory ascites: a retrospective multicenter study (JIVROSG-0809)

PURPOSE

Peritoneal venous shunts (PVSs) are widely used for palliating symptoms of refractory malignant ascites and are recognized as one of the practical methods. However, reliable clinical data are insufficient because most previous reports have been small studies from single centers. We conducted a retrospective, multicenter study to evaluate the safety and efficacy of radiologically placed PVSs in patients with malignant refractory ascites.

METHODS

A total of 133 patients with malignant ascites refractory to medical therapies were evaluated for patient characteristics, technical success, efficacy, survival times, adverse events, and changes in laboratory data.

RESULTS

PVSs were successfully placed in all patients and were effective (i.e., improvement of ascites symptoms lasting 7 days or more) in 110 (82.7%). The median duration of symptom palliation was 26 days and median survival time was 41 days. The most frequent adverse event was PVS dysfunction, which occurred in 60 (45.1%) patients, among whom function was recovered with an additional minimally invasive procedure in 9. Abnormalities in coagulation (subclinical disseminated intravascular coagulation) occurred in 37 (27.8%) patients, although only 7 (5.3%) developed clinical disseminated intravascular coagulation. Other major adverse events were gastrointestinal bleeding (9.8%), sepsis (3.8%), and acute heart failure (3.0%). PVS was least effective in patients with elevated serum creatinine, bloody ascites, or gynecologic tumor.

CONCLUSIONS

Radiological PVS is a technically feasible and effective method for palliating the symptoms from refractory malignant ascites, but preoperative evaluation and monitoring the postprocedural complications are mandatory to preclude severe adverse events after PVS.

Treatment of malignant ascites in patients with advanced cancer: peritoneovenous shunt versus paracentesis

BACKGROUND

Malignant ascites in patients with advanced cancer is often difficult to treat and effective palliation is not achieved.

METHODS

We performed peritoneovenous shunt (PVS) placement in patients with malignant ascites, who were admitted to our institution between January 2000 and March 2005. The outcome of PVS placement was compared with paracentesis as a treatment option during the same period. Comparisons included changes in abdominal girth, hematocrit (Hct), blood urea nitrogen (BUN) and creatinine (Cr) measurements before and after PVS placement. The number of procedures, changes in the postoperative performance score, the median survival, possibility of discharge, and complications were compared between the two groups.

RESULTS

Twenty patients underwent PVS placement and 49 patients were subjected to paracentesis. After PVS, abdominal girth and Hct decreased significantly. BUN and Cr tended to decrease. The median number of procedures was less in the PVS group than in the paracentesis group (one vs two, respectively; P < 0.0001). The postoperative performance score showed a significant improvement following PVS placement (P = 0.0026). Median survival was significantly longer for patients undergoing PVS placement than for those undergoing paracentesis (42 days vs 18 days, respectively; P = 0.003). The rate of possible discharge was significantly higher for patients undergoing PVS placement (P = 0.0076). Severe complications were observed in one patient in the PVS group and in seven patients in the paracentesis group.

CONCLUSIONS

PVS placement provides an effective treatment option for patients with refractory malignant ascites in advanced cancer, and yields a higher likelihood of discharge compared with conventional paracentesis.

Surgical Management of Metastatic Peritoneal or Pleural Disease

The surgeon's role in the treatment of malignant peritoneal disease has expanded over time, stemming from a better understanding of tumor biology. For the majority of patients, carcinomatosis is a terminal process with surgical intervention being reserved for palliation of bowel obstruction or symptomatic ascites. However, for select patients with favorable tumor biologies, aggressive surgical approaches may result in long-term survival. This review describes the patterns of peritoneal tumor dissemination, surgical palliation of malignant bowel obstruction or ascites, and the principles, indications, toxicities, and overall results of cytoreductive surgery with intraperitoneal hyperthermic chemotherapy. On the other hand, long-term survival is rarely expected for malignant pleural disease unless the causal tumor is highly responsive to systemic chemotherapy. There are controversies and considerable geographic variations in the management of malignant pleural effusions. However, less invasive ambulatory palliative treatments for patients so afflicted are gaining popularity.

Malignant ascites: systematic review and guideline for treatment

A guideline on the management of symptomatic malignant ascites by abdominal paracentesis, diuretics and peritoneovenous shunting, based on a systematic review of the literature is presented. Thirty-two relevant studies were identified. None were randomized control trials, one was a non-randomized open controlled trial, five were cohort studies or prospective uncontrolled trials, 26 studies were non-analytic studies like case series. Although paracentesis, diuretics and shunting are commonly used procedures, the evidence is weak. Available data show good, although temporary effect of paracentesis on symptom relief. Fluid withdrawal speed and concurrent intravenous hydration is not sufficiently studied. Peritoneovenous shunts can control ascites in patients with malignant ascites, but have to be balanced by the potential risks of this procedure. The available data about diuretics in treatment of malignant ascites are controversial. The use of diuretics therefore should be considered in all patients, but has to be evaluated individually.

Modified saphenous-peritoneal shunt in refractory ascites: new technique

BACKGROUND

Refractory ascites is a serious complication for patients with decompensated liver cirrhosis. Saphenous-peritoneal shunting is a possible surgical treatment for its relief, but tends to lead to higher groin infections. The purpose of the present paper was to determine whether a modified procedure could resolve the problem and offer potential advantages over a peritoneo-venous shunt.

METHODS

Sixteen patients with refractory ascites who received modified saphenous-peritoneal shunts were studied. Clinical data such as bodyweight, abdominal girth, indocyanine green 15-min retention rate (ICG-15), serum bilirubin concentrations, Child-Pugh Score, creatinine clearance (C(Cr)), daily urinary output, urine sodium (U(Na)) and operative complications were recorded before, and 3 months after, surgery.

RESULTS

Three months after the operation, the urinary output, nutritional status and Child-Pugh scores had improved, but ICG-15 and total bilirubin output had not changed significantly. The C(Cr), U(Na) bodyweight and abdominal girth tended to decrease, but not significantly. No groin infections were noted following this procedure.

CONCLUSIONS

This modified procedure not only improved the nutritional status of cirrhotic patients with refractory ascites but also improved their quality of life. Infections and obstructions decreased in the short term. However, long-term follow up is mandatory. This new technique requires more practice and experience.