Permanent catheters for recurrent ascites-a critical and systematic review of study methodology

Paracentesis for cancer-related ascites in palliative care: An international, prospective cohort study

BACKGROUND

Paracentesis is commonly undertaken in patients with cancer-related ascites.

AIM

To systematically investigate the symptomatic benefits and harms experienced by patients with cancer undergoing paracentesis using real-world data in the palliative care setting.

DESIGN

Prospective, multisite, observational, consecutive cohort study. Benefits and harms of paracentesis were assessed between 01/07/2018 and 31/02/2021 as part of routine clinical assessments by treating clinicians at four timepoints: (T0) before paracentesis; (T1) once drainage ceased; (T2) 24 h after T1 and (T3) 28 days after T1 or next paracentesis, if sooner.

SETTING/PARTICIPANTS

Data were collected from 11 participating sites across five countries (Australia, England, Hong Kong, Malaysia and New Zealand) on 111 patients undergoing paracentesis via a temporary (73%) or indwelling (21%) catheter: 51% male, median age 69 years, Australia-modified Karnofsky Performance Score 50.

RESULTS

At T1 (n = 100), symptoms had improved for most patients (81%), specifically abdominal distension (61%), abdominal pain (49%) and nausea (27%), with two-thirds experiencing improvement in ⩾2 symptoms. In the remaining patients, symptoms were unchanged (7%) or worse (12%). At least one harm occurred in 32% of patients, the most common being an ascitic leak (n = 14). By T3, 89% of patients had experienced some benefit and 36% some harm, including four patients who experienced serious harm, one of which was a fatal bowel perforation.

CONCLUSION

Most patients obtained rapid benefits from paracentesis. Harms were less frequent and generally mild, but occasionally serious and fatal. Our findings help inform clinician-patient discussions about the potential outcomes of paracentesis in this frail population.

Long-Term Peritoneal Indwelling Catheters for Malignant Ascites: A Retrospective Case Series of PleurX and Peritoneal Port

Objectives: To compare outcomes of PleurX and peritoneal port for malignant ascites. Design: Retrospective review of medical records was conducted. Setting/Subjects: Subjects were consecutive patients receiving PleurX or peritoneal port for malignant ascites in a center in Sydney, Australia. Measurements: Demographic data, complication rates, hospitalization rates, and survival were measured. Results: Sixteen cases were analyzed: 6 had peritoneal port (170 catheter days) and 10 had PleurX (477 catheter days). Complication rates were low with both drainage systems. Cellulitis rate was 33% (1.2 events/100 catheter days) for peritoneal port and 10% (0.2 events/100 catheter days) for PleurX. Hospital admission days were 27 days/100 catheter days for peritoneal port and 5.2 days/100 catheter days for PleurX. Conclusions: Both PleurX and peritoneal port seem feasible options in draining malignant ascites. Further research is needed to ascertain whether there are true differences in cellulitis/admission rates. Patient quality of life, experience, and preference should be included in future studies.

Drenaje peritoneal como tratamiento de la ascitis maligna, una revisión de la literatura

Introducción: La ascitis maligna es la acumulación anormal de fluido en la cavidad peritoneal como consecuencia de patologías como el cáncer, además es un factor desencadenante de clúster de síntomas (dolor, disnea, pérdida de apetito, náuseas, reducción a la movilidad y cambios en el aspecto físico) que se convierten en un problema clínico de difícil manejo. Dentro de los tratamientos encaminados al mejoramiento de esta condición se encuentra la paracentesis terapéutica, procedimiento médico cuya técnica se hace mediante drenaje y que en ocasiones se requiere practicar de manera repetitiva, pudiendo ser un síntoma refractario que conlleva al requerimiento de la implantación de un catéter peritoneal como una medida paliativa para el mejoramiento de la calidad de vida del paciente y su familia. Materiales y Métodos: Se realiza una revisión de la literatura existente, estableciéndose una búsqueda inicial donde se obtuvieron 747 artículos de los cuales se incluyen 277 potencialmente relevantes, a los que se le verificaron el cumplimiento de los criterios de inclusión, y posterior a la depuración de la información y de eliminar artículos duplicados y se incluyeron en la revisión los 8 estudios que cumplieron la totalidad de estos parámetros. Resultados: La técnica del catéter peritoneal es 100% exitosa, no presenta complicaciones inmediatas, óptima medida paliativa para los pacientes con ascitis refractaria permitiendo más de 30 días de durabilidad del dispositivo, además, de un fácil uso por profesionales, paciente y familia, permitiendo un manejo ambulatorio que disminuye costos, reingresos por complicaciones tardías potencialmente prevenibles e identificables como lo son filtración, desplazamiento, infecciones, oclusión del dispositivo hospitalarios y proporcionando confort y control de síntomas de manera inmediata. Discusión y Conclusiones: Con los resultados expuestos en la presente revisión se define el catéter peritoneal óptimo en el manejo de la ascitis maligna como medida paliativa. En el tratamiento de esta y de los demás síntomas desencadenados en pacientes con patologías oncológicas avanzadas, permitiendo un mejoramiento en la calidad de vida de las personas. Como citar este artículo: Fiscal LM, Salazar VE, Oviedo CP, Gavilán DM, Carmona X. Drenaje peritoneal como tratamiento de la ascitis maligna, una revisión de la literatura. Rev Cuid. 2020; 11(1): e919. http://dx.doi.org/10.15649/cuidarte.919  

Role of Interventional Radiology in Complications of Portal Hypertension

Portal hypertension, a consequence of end-stage liver disease and liver cirrhosis can lead to significant morbidity and mortality for patients through abnormal fluid accumulation as well as the formation of portosystemic shunts and varices. Treatment of the sequelae of portal hypertension can be achieved through endovascular management by referral to an interventional radiologist on an outpatient or emergent basis as required. Current techniques include the placement of peritoneovenous shunts and tunneled peritoneal drains, the creation of transjugular intrahepatic portosystemic shunts, or the obliteration of shunts via balloon-occluded retrograde transvenous obliteration (BRTO). In addition, newer procedural techniques utilizing vascular plugs and coils have reduced risks of the traditional BRTO procedure. Modified-BRTO procedures, known as plug-assisted and coil-assisted retrograde transvenous obliteration (PARTO and CARTO, respectively) have become the standard of care at many institutions for the treatment of gastric varices and portosystemic shunt-induced hepatic encephalopathy. This review examines the most recent literature of the management of portal hypertension by interventional radiologists, evaluating treatment options as well as the clinical and technical outcomes of TIPS, peritoneovenous shunts, tunneled peritoneal drains, BRTOs, and modified-BRTOs as well as future directions in the development of procedural techniques.

Permanent peritoneal ports for the management of recurrent malignant ascites: a retrospective review of safety and efficacy

Large volume paracentesis is effective in relieving the symptoms of malignant ascites, but frequent procedures are often required. Permanent peritoneal ports are an alternative to repeated procedures. We describe our experience with the use of peritoneal ports in patients at Middlemore Hospital (Auckland, New Zealand) who had a port inserted for the drainage of malignant ascites. Twenty-eight ports were inserted in 26 patients and accessed a total of 257 times with acceptably low rates of complications including cellulitis, peritonitis and wound dehiscence.

Endoscopic ultrasound-guided placement of plastic pigtail stents for the drainage of refractory malignant ascites

Endoscopic ultrasound (EUS)-guided drainage is now the treatment of choice in cases of pancreatic pseudocysts and walled-off necrosis, especially in the absence of luminal bulging and in patients with portal hypertension. Malignant refractory ascites usually heralds a poor prognosis and substantially impairs the quality of life of patients because of the symptoms experienced and the need for repeated paracentesis. EUS-guided placement of lumen-apposing, fully covered, self-expandable metal stents (FCSEMS) has been reported for the drainage of malignant ascites. Herein, we present the results of EUS-guided placement of plastic pigtails stents for the drainage of refractory malignant ascites in three patients. The aim was to improve symptoms and minimize the possible drawbacks of large-caliber FCSEMS. In this preliminary experience, EUS-guided placement of plastic stents was feasible and avoided further paracentesis.