Radiologically placed tunneled peritoneal catheter in palliation of malignant ascites

A safe and effective treatment for refractory malignant ascites: the use of pigtail catheters

Purpose

Recurrent malignant ascites is a common and challenging condition in cancer patients, often lacking a standardized treatment protocol. Small-scale studies in the literature have been insufficient to establish a treatment standard. The aim of our study was to investigate the effectiveness and safety of pigtail peritoneal catheter application in the treatment of malignant ascites.

Material and methods

We conducted a retrospective analysis of patients who had pigtail catheters inserted between January 2017 and December 2022. The study focused on the success rate of the procedure, catheter dwell time, complication rates, and the factors influencing these outcomes.

Results

A total of 196 patients, 102 of whom were female, with malignant ascites were included in the study. The median age was 65.5 years. The procedure had a 100% success rate, with no procedure-related deaths or major complications. The overall minor complication rate, including bleeding, minor cellulitis, leakage, and blockage, was 52%. Patients with comorbidities experienced statistically significantly more complications (p < 0.05). The median catheter dwell time was 31 days (range: 3-181 days).

Conclusions

Pigtail peritoneal catheters provide effective and safe minimally invasive fluid drainage for the treatment of malignant ascites. The most critical factors for preventing procedure-related complications and ensuring procedural success include proper indication, correct timing, procedural expertise, and the involvement of well-trained patients and caregivers.

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  

Management of drainage for malignant ascites in gynaecological cancer

BACKGROUND

Ascites is the accumulation of fluid within the abdominal cavity. Most women with advanced ovarian cancer and some women with advanced endometrial cancer need repeated drainage for ascites. Guidelines to advise those involved in the drainage of ascites are usually produced locally and are generally not evidence-based. Managing drains that improve the efficacy and quality of the procedure is key in making recommendations that could improve the quality of life (QoL) for women at this critical period of their lives.

OBJECTIVES

To evaluate the effectiveness and adverse events of different interventions for the management of malignant ascites drainage in the palliative care of women with gynaecological cancer.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase to 4 November 2019. We checked clinical trial registries, grey literature, reports of conferences, citation lists of included studies, and key textbooks for potentially relevant studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of women with malignant ascites with gynaecological cancer. If studies also included women with non-gynaecological cancer, we planned to extract data specifically for women with gynaecological cancers or request the data from trial authors. If this was not possible, we planned to include the study only if at least 50% of participants were diagnosed with gynaecological cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data, evaluated the quality of the included studies, compared results, and assessed the certainty of the evidence using Cochrane methodology.

MAIN RESULTS

In the original 2010 review, we identified no relevant studies. This updated review included one RCT involving 245 participants that compared abdominal paracentesis and intraperitoneal infusion of catumaxomab versus abdominal paracentesis alone. The study was at high risk of bias in almost all domains. The data were not suitable for analysis. The median time to the first deterioration of QoL ranged from 19 to 26 days in participants receiving paracentesis alone compared to 47 to 49 days among participants receiving paracentesis with catumaxomab infusion (very low-certainty evidence). Adverse events were only reported among participants receiving catumaxomab infusion. The most common severe adverse events were abdominal pain and lymphopenia (157 participants; very low-certainty evidence). There were no data on the improvement of symptoms, satisfaction of participants and caregivers, and cost-effectiveness.

AUTHORS' CONCLUSIONS

Currently, there is insufficient evidence to recommend the most appropriate management of drainage for malignant ascites among women with gynaecological cancer, as there was only very low-certainty evidence from one small RCT at overall high risk of bias.

Tunneled Peritoneal Catheter Placement in Palliation of Malignant Ascites: A Study with Two Different Types of Catheters

Objective(s)

Malignant ascites (MA) is abnormal accumulation of fluid in the peritoneal cavity and has negative effects on the quality of life. The purpose of this retrospective study is to explore feasibility, safety and efficacy of tunneled peritoneal catheter placement using both peritoneal dialysis and hemodialysis catheters in the palliation of MA.

Methods

Between October 2013-June 2016, thirty patients with resistent MA underwent tunneled peritoneal catheterisation in our interventional radiology department. Tunneled peritoneal catheter (TPC) was placed in 22 (n=22/30; %73) patients, tunneled hemodialysis catheter (THC) was placed in 8 patients (n=8/30; %27). Routine visits were scheduled for months 1, 3, 6, 9, and 12 of the catheterization, and the records were evaluated retrospectively.

Results

The overall duration of catheterization varied from 2 to 334 days (mean 66.4 ± 68.5, median: 57 days). Catheters remained intact in 29 patients (96.7%) until the endpoint. There was one (3.3%) malfunctioning catheter among both groups. Overall, four patients developed infection, which were classified into major (n=2/30, %6.7) and minor (n=2/30, %6.7) complications according to SIR criteria.

Conclusion

Tunneled peritoneal catheterization using both TPCs and THCs provided a safe method with relatively high patency, and low infection and systemic complication rates in the palliation of MA.

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.

Drainage of malignant ascites: patient selection and perspectives

Malignant ascites (MA) is a sign of advanced cancer and poor prognosis. MA can result in impairment in quality of life (QOL) and significant symptoms. As a supportive treatment, ascites can be drained by paracentesis (PC), percutaneously implanted catheters (tunneled, untunneled, central venous catheters), or peritoneal ports, or peritoneovenous shunts. The aim of this study was to evaluate the effectiveness, safety, and patient-reported outcomes (PRO) of different drainage methods for the management of MA. A systematic review of the literature was performed, and 32 original articles met the inclusion criteria. Patients selected for permanent drain insertion demonstrated symptoms related to MA and had undergone repeated PC. The primary focus of the reviewed articles was procedural safety issues. The rate of technical success of drainage device installation was 100%. Most patients experienced improvements in symptom control after ascites drainage. When analyzed together, 19.7% (255/1297) of patients experienced any complication and 6.2% (81/1297) experienced serious adverse events during MA drainage. Complications were reported for every drainage method; however, the least occurred after PC or central venous catheter, while the most serious occurred after peritoneovenous shunts. Adverse events were as follows: catheter obstruction: 4.4%, infection: 4.1%, leakage: 3.5%, catheter dislodgment: 2.3%, hypotension: 0.6%, injuries during device insertion: 0.6%, renal impairment: 0.5%, electrolyte imbalance: 0.2%, other: 3.6%. PRO and QOL endpoints were available for 12 studies. When PRO were measured using an interview, a significant improvement in symptom control and QOL was reported in almost all patients. Once standardized questionnaires were used, improvements in symptomatic scores and role functioning were observed. Deterioration was observed in cognitive and emotional subscales. MA drainage is a safe and effective method to control symptoms associated with ascites, and should be perceived as a supportive care, that can be applied for those who need it at any time of their cancer trajectory. Patient selection should be performed using a thorough assessment of symptoms and QOL, and should not be delayed.

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

PURPOSE

Management of refractory ascites traditionally includes medical treatment with diuretics or intermittent paracentesis. Patients with recurrent ascites may benefit from the use of permanent intra-abdominal catheters with more frequent drainage without hospitalization. The objective was to systematically asses the methodology of factors and endpoints reported in studies investigating permanent catheters for recurrent ascites treatment.

METHODS

Using a systematic search strategy, we critically assessed the methodology when treating refractory ascites using a permanent catheter. Studies critically assessed included both retro- and prospective studies.

RESULTS

A total of 715 unique articles were found via PubMed, The Cochrane Library and Embase. Twenty-nine studies (tunnelled catheter = 12, peritoneal ports = 6 and peritoneovenous shunts = 11) with three distinct types of permanent catheters fulfilled the inclusion criteria. Only three studies reported technical success less than 100 %. Data on complications and treatment were not available in all papers; peritonitis (48 %), cellulitis (41 %), prophylactic antibiotics (48 %) and complications to catheter insertion were difficult to distinguish from advanced co-morbidity of patients. Thirteen studies (45 %) reported some type of evaluating patient experience or functional outcome, but only three studies used validated reproducible scales when assessing outcomes. Fifteen of the 29 studies included 30 patients or less.

CONCLUSION

Knowledge is limited because complications and outcomes are poorly defined. The expected increase in catheter treatment of refractory ascites necessitates comparative studies, using validated patient-related outcomes, and the reporting of unambiguous complications. A proposal of variables to include in future studies is presented.

Tenckhoff tunneled peritoneal catheter placement in the palliative treatment of malignant ascites: technical results and overall clinical outcome

Background

To assess the technical and clinical outcome of percutaneous insertion of tunneled peritoneal catheters in the palliative treatment of refractory malignant ascites and to determine the safety and feasibility of intraperitoneal administration of cytotoxic drugs through the tunneled catheter.

Materials and methods

Consecutive patients palliatively treated with a tunneled peritoneal catheter to drain the malignant ascites were identified. Patients’ medical history, procedural and clinical follow-up data, including complications and estimated survival, were reviewed. Additionally, a sub analysis of the patients with widespread ovarian cancer and refractory ascites treated with or without intraperitoneal administration of cytotoxic drugs was made.

Results

In all 94 patients it was technically feasible to insert the peritoneal drainage catheter and to drain a median of 3260 cc (range 100 cc – 8500 cc) of malignant ascitic fluid. Post procedural complications included catheter infection (n = 2; 2%), fluid leakage around the entry site (n = 4; 4%), catheter occlusion (n = 2; 2%), sleeve formation around the catheter tip (n = 1; 1%) and accidental loss of the catheter (n = 1; 1%). There was no increase in catheter infection rate in patients treated with or without intraperitoneal administration of cytotoxic drugs. Median overall survival after catheter insertion is 1.7 months.

Conclusions

Percutaneous insertion of a tunneled Tenckhoff catheter for the palliative drainage of malignant ascites and intraperitoneal infusion of cytotoxic drugs is feasible and associated with a very low complication rate, including catheter infection. These tunneled peritoneal lines are beneficial for symptomatic palliative treatment of refractory ascites and allow safe intraperitoneal chemotherapy.

Repeat Large-Volume Paracentesis Versus Tunneled Peritoneal Catheter Placement for Malignant Ascites: A Cost-Minimization Study

OBJECTIVE

The objective of this study was to determine the point in time at which tunneled peritoneal catheter placement becomes less costly than repeat large-volume paracentesis (LVP) for patients with malignant ascites.

MATERIALS AND METHODS

Procedure costs were based on 2013 Medicare reimbursement rates. Rates for specific complications were obtained from the literature and were assigned costs. A decision tree-based Markov chain Monte Carlo model was designed with 11 cycles of 10 days, to simulate 4000 subjects per trial. Patients were grouped according to initial treatment decision (LVP vs catheter placement), and the total cost at the end of each 10-day cycle was calculated. The point at which catheter placement became less costly than LVP was determined. Additional simulations were used for bivariate analyses of all cost and probability variables and for trivariate analysis of cycle length and volume of fluid drained per cycle.

RESULTS

Individual input probabilities were not significantly different from corresponding simulation outcomes (p value range, 0.068-0.95). When complications were included in the model, the cost curves crossed at a mean (± SD) of 82.8 ± 3.6 days (range, 75.8-89.6 days), corresponding to a time between the performance of the ninth and 10th LVP procedures. Intersection occurred earlier in simulations with a shorter cycle length and less fluid per cycle, but it was minimally affected by changing individual complication probabilities and costs.

CONCLUSION

For patients with malignant ascites, LVP becomes more costly once the procedure is performed nine or 10 times or at approximately 83 days, if paracentesis is repeated every 10 days, with 5 L of fluid removed each time. Use of a tunneled peritoneal catheter improves the cost advantage for patients who receive LVP more frequently or patients who have less than 5 L of fluid drained per procedure.

Interventional radiology in paediatric palliative care

Paediatric palliative care is a distinct subspecialty that offers treatment to children with many types of illness, including oncological, neurological and respiratory problems. Paediatric interventional radiologists can make a useful contribution to symptom management as part of a multidisciplinary team. Interventions for pain management include local ablation or other treatment of painful lesions, image-guided nerve blocks and the insertion of devices for the delivery of analgesic drugs. Various techniques are also available for the management of ascites, pleural effusions and other symptomatic complications of the underlying disease process.