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Stolzberg N, Paramanandam G, Myers SR, Abreu S, Volk-Craft BE. A Tunneled Catheter Placement Program for Community Hospices. J Pain Symptom Manage 2024; 67:e163-e168. [PMID: 37992847 DOI: 10.1016/j.jpainsymman.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 11/24/2023]
Abstract
CONTEXT The symptoms associated with the excessive fluid accumulation of ascites or pleural effusions can be intractable to medical management and can have a significant negative impact on quality of life of hospice patients. Hospice of the Valley, a community-based, nonprofit hospice agency has historically referred patients to outpatient providers for paracentesis, thoracentesis, and placement of tunneled drainage catheters. OBJECTIVES To describe an in-house pilot program of tunneled catheter placement to provide immediate and longer-term symptom relief for selected hospice patients. METHODS The logistics and cost of the pilot program are described. Key data elements, including select demographics, patient eligibility screening, and incidence of procedure-related or late complications are reported. RESULTS A total of 135 drainage procedures completed on 127 unique hospice patients over 27 months (2020-2023) were reviewed. The rate of procedure-related complications (<4%) and late complications (<3%) are low. The average cost per procedure ($1030) compares favorably with outpatient providers' fees. The program was well-accepted by the interdisciplinary hospice team, patients, and families. CONCLUSIONS An in-house program of tunneled catheter placement is a feasible option for hospice providers with low-cost exposure and high potential for improved quality of life and symptom relief for selected patients.
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Affiliation(s)
- Ned Stolzberg
- Hospice of the Valley (N.S., S.M., S.A.), Phoenix, Arizona, USA.
| | | | - Shelly R Myers
- Hospice of the Valley (N.S., S.M., S.A.), Phoenix, Arizona, USA.
| | - Shawn Abreu
- Hospice of the Valley (N.S., S.M., S.A.), Phoenix, Arizona, USA.
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Will V, Rodrigues SG, Berzigotti A. Current treatment options of refractory ascites in liver cirrhosis - A systematic review and meta-analysis. Dig Liver Dis 2022; 54:1007-1014. [PMID: 35016859 DOI: 10.1016/j.dld.2021.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 10/24/2021] [Accepted: 12/11/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Refractory ascites is a severe complication of liver cirrhosis and treatment options consist in large volume paracentesis, transjugular intrahepatic portosystemic shunt, alfapump®, peritoneovenous shunt and permanent indwelling peritoneal catheter. AIM Our aim was to assess the efficacy, mortality and complications of each treatment. METHODS We performed a systematic review using Pubmed and Embase. Frequencies were summarized with Comprehensive Meta-Analysis Software. RESULTS Seventy-seven studies were included. In patients with transjugular intrahepatic portosystemic shunt, 1-year mortality was 33% (95% CI 0.29-0.39, I2=82.1; τ2 = 0.37; p<0.001) with lower mortality in newer studies (26% vs. 44%). At 6 months, mortality in patients with alfapump® was 24% (95% CI 0.16-0.33, I2=0.00; τ2 = 0.00; p = 0.83), 31% developed acute kidney injury (95% CI 0.18-0.48, I2=44.0; τ2 = 0.22; p = 0.15). Mortality at 12 months was 44% (95% CI 32%-58%, I2=76.7, τ2 = 0.44, p<0.001) in peritoneovenous shunts and 45% (95% CI 38%-53%, I2=61.4, τ2 = 0.18, p = 0.003) in large volume paracentesis, respectively. Overall mortality in patients with permanent indwelling catheters was 66% (95% CI 33%-89%, I2=82.5, τ2 = 1.57, p = 0.001). DISCUSSION Mortality in patients with transjugular intrahepatic portosystemic shunt was lower in newer studies, probably due to a better patient selection. Acute kidney injury was frequent in patients with alfapump®. Permanent indwelling catheters seemed to be a good option in a palliative setting.
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Affiliation(s)
- Valerie Will
- Department for Visceral Surgery and Medicine, Inselspital, University Hospital of Bern, University of Bern, BHH D115, Freiburgstrasse 10, CH-3008 Bern, Switzerland; Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Susana G Rodrigues
- Department for Visceral Surgery and Medicine, Inselspital, University Hospital of Bern, University of Bern, BHH D115, Freiburgstrasse 10, CH-3008 Bern, Switzerland; Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Annalisa Berzigotti
- Department for Visceral Surgery and Medicine, Inselspital, University Hospital of Bern, University of Bern, BHH D115, Freiburgstrasse 10, CH-3008 Bern, Switzerland; Department of Biomedical Research, University of Bern, Bern, Switzerland.
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Kulkarni AV, Rabiee A, Mohanty A. Management of Portal Hypertension. J Clin Exp Hepatol 2022; 12:1184-1199. [PMID: 35814519 PMCID: PMC9257868 DOI: 10.1016/j.jceh.2022.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/07/2022] [Indexed: 12/12/2022] Open
Abstract
Portal hypertension is the cause of the clinical complications associated with cirrhosis. The primary complications of portal hypertension are ascites, acute variceal bleed, and hepatic encephalopathy. Hepatic venous pressure gradient measurement remains the gold standard test for diagnosing cirrhosis-related portal hypertension. Hepatic venous pressure gradient more than 10 mmHg is associated with an increased risk of complications and is termed clinically significant portal hypertension (CSPH). Clinical, laboratory, and imaging methods can also aid in diagnosing CSPH non-invasively. Recently, deep learning methods have been demonstrated to diagnose CSPH effectively. The management of portal hypertension is always individualized and is dependent on the etiology, the availability of therapies, and the degree of portal hypertension complications. In this review, we discuss the diagnosis and management of cirrhosis-related portal hypertension in detail. Also, we highlight the history of portal hypertension and future research areas in portal hypertension.
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Key Words
- ACLF, acute-on-chronic liver failure
- AKI, acute kidney injury
- APRI, AST to platelet ratio
- AST, aspartate transaminase
- BB, Beta blocker
- BRTO, balloon occluded retrograde transvenous obliteration
- CKD, chronic kidney disease
- CSPH, clinically significant portal hypertension
- CT, computed tomography
- GFR, glomerular filtration rate
- GOV, gastrpoesopahegal varices
- HE, hepatic encephalopathy
- HRS, hepatorenal syndrome
- HVPG, hepatic venous pressure gradient
- ICG, indocyanine green
- LOLA, l-ornithine l-aspartate
- NAFLD, Non-alcoholic fatty liver disease
- SBP, spontaneous bacterial peritonitis
- SGLT2I, sodium glucose co-transporter 2 inhibitors
- SSM, splenic stiffness measurement
- TE, transient elastography
- TIPS, transjugular intrahepatic portosystemic shunt
- VITRO, von Willebrand factor to platelet counts
- acute kidney injury
- ascites
- hemodynamics
- history
- vasoconstrictors
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Affiliation(s)
- Anand V. Kulkarni
- Department of Hepatology, AIG Hospitals, Hyderabad, India,Address for correspondence: Dr. Anand V. Kulkarni, MD, DM., Department of Hepatology and Liver Transplantation, Asian Institute of Gastroenterology, Hyderabad, India.
| | | | - Arpan Mohanty
- Boston University School of Medicine, Boston, MA, USA
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Corrigan M, Thomas R, McDonagh J, Speakman J, Abbas N, Bardell S, Thompson F, Holt A, Jones R, Willis A, Karkhanis S, Rajoriya N. Tunnelled peritoneal drainage catheter placement for the palliative management of refractory ascites in patients with liver cirrhosis. Frontline Gastroenterol 2020; 12:108-112. [PMID: 33613941 PMCID: PMC7873544 DOI: 10.1136/flgastro-2019-101332] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/22/2019] [Accepted: 02/04/2020] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Refractory ascites is an established indication for liver transplantation. While transplantation is regarded as the definitive therapy for this condition, many patients are unsuitable due to comorbidity or frailty. Alternatives such as transjugular intrahepatic portosystemic shunt (TIPSS) and large-volume paracentesis can lead to complications, including encephalopathy, circulatory and renal dysfunction, and protein-calorie deficiency that may accelerate sarcopenia. Cost and complication rates limit therapies such as alfapump. While there are data to support the use of indwelling catheters in the management of patients with malignant ascites, there is limited evidence to support their routine use in the context of end-stage liver cirrhosis. Here we describe our centres' experience using indwelling tunnelled ascitic drains over a 6-year period. METHODS A retrospective review of data (January 2012-May 2018) was undertaken for all patients with refractory ascites who underwent a tunnelled ascitic drain. Demographics, disease aetiology, procedure data and follow-up data were obtained through interrogation of electronic records and reports. RESULTS Twenty-five drains were placed. All procedures were technically successful with no immediate complications. Six patients were readmitted following their index admission with abdominal pain and suspected infected ascites (although only two had a positive ascitic fluid culture). There were three cases of abdominal wall cellulitis and three of leakage around the tunnel site; all managed conservatively. CONCLUSION Indwelling drains appear an effective strategy for palliative management of select patients with liver cirrhosis complicated by refractory ascites who are not amenable to undergo TIPSS or transplantation. While complications can occur, these are most usually minor and can be managed on an outpatient basis.
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Affiliation(s)
| | - Rhodri Thomas
- Interventional Radiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Joanne McDonagh
- Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - John Speakman
- Supportive and Palliative Care, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Nadir Abbas
- Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Sara Bardell
- Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Fiona Thompson
- Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Andrew Holt
- Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Robert Jones
- Interventional Radiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Andrew Willis
- Interventional Radiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Salil Karkhanis
- Interventional Radiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Neil Rajoriya
- Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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Macken L, Hashim A, Mason L, Verma S. Permanent indwelling peritoneal catheters for palliation of refractory ascites in end-stage liver disease: A systematic review. Liver Int 2019; 39:1594-1607. [PMID: 31152623 DOI: 10.1111/liv.14162] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 05/26/2019] [Accepted: 05/28/2019] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS The incidence and mortality from end-stage liver disease is increasing, with a minority eligible for liver transplantation. Ascites is the commonest complication of end-stage liver disease and large volume paracentesis (LVP) the accepted management strategy where refractory to medical treatment. In malignant ascites, permanent indwelling peritoneal catheters (PIPC) are an established palliative intervention. The aims are to describe available data using permanent indwelling peritoneal catheters in refractory ascites due to end-stage liver disease. METHODS Using systematic review methodology, databases were searched (MEDLINE, EMBASE, CINAHL [The Cumulative Index to Nursing and Allied Health Literature], Google Scholar and Cochrane Database of Systematic Reviews from inception-March 2018), for studies combining ascites and palliative care. Inclusion and exclusion criteria were applied to results. RESULTS Following initial and updated searches, 225 studies were identified for full text review, 18 were eligible for final analysis. The studies displayed heterogeneity in design, reported on different indwelling catheters and were overall of low quality. Only one pilot randomised controlled trial was identified, of PIPC versus LVP, recruiting one patient into each arm. Technical insertion success was 100%, with low rates of non-infectious complications (<12%), none life threatening. Rates of bacterial peritonitis were not unacceptably high (12.7%), considering this was an end-stage liver disease population and only a minority utilising long-term prophylactic antibiotics. Only one study attempted quality-of-life assessments; none addressed potential health economic benefits. CONCLUSIONS Despite lack of well-designed studies, preliminary data suggests low significant complication rates; however safety and efficacy of permanent indwelling peritoneal catheters in end-stage liver disease remains to be confirmed. Further prospective randomised controlled trials are warranted, potentially translating permanent indwelling peritoneal catheters into improved palliative care in end-stage liver disease.
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Affiliation(s)
- Lucia Macken
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK.,Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Ahmed Hashim
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK.,Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Louise Mason
- Department of Palliative Care, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Sumita Verma
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK.,Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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Macken L, Mason L, Evans C, Gage H, Jordan J, Austin M, Parnell N, Cooper M, Steer S, Boles J, Bremner S, Lambert D, Crook D, Earl G, Timeyin J, Verma S. Palliative long-term abdominal drains versus repeated drainage in individuals with untreatable ascites due to advanced cirrhosis: study protocol for a feasibility randomised controlled trial. Trials 2018; 19:401. [PMID: 30053891 PMCID: PMC6062920 DOI: 10.1186/s13063-018-2779-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 06/29/2018] [Indexed: 01/28/2023] Open
Abstract
Background UK deaths due to chronic liver diseases such as cirrhosis have quadrupled over the last 40 years, making this condition now the third most common cause of premature death. Most patients with advanced cirrhosis (end-stage liver disease [ESLD]) develop ascites. This is often managed with diuretics, but if refractory, then the fluid is drained from the peritoneal cavity every 10–14 days by large volume paracentesis (LVP), a procedure requiring hospital admissions. As the life expectancy of patients with ESLD and refractory ascites (if ineligible for liver transplantation) is on average ≤ 6 months, frequent hospital visits are inappropriate from a palliative perspective. One alternative is long-term abdominal drains (LTADs), used successfully in patients whose ascites is due to malignancy. Although inserted in hospital, these drains allow ascites management outside of a hospital setting. LTADs have not been formally evaluated in patients with refractory ascites due to ESLD. Methods/design Due to uncertainty about appropriate outcome measures and whether patients with ESLD would wish or be able to participate in a study, a feasibility randomised controlled trial (RCT) was designed. Patients were consulted on trial design. We plan to recruit 48 patients with refractory ascites and randomise them (1:1) to either (1) LTAD or (2) current standard of care (LVP) for 12 weeks. Outcomes of interest include acceptability of the LTAD to patients, carers and healthcare professionals as well as recruitment and retention rates. The Integrated Palliative care Outcome Scale, the Short Form Liver Disease Quality of Life questionnaire, the EuroQol 5 dimensions instrument and carer-reported (Zarit Burden Interview) outcomes will also be assessed. Preliminary data on cost-effectiveness will be collected, and patients and healthcare professionals will be interviewed about their experience of the trial with a view to identifying barriers to recruitment. Discussion LTADs could potentially improve end-of-life care in patients with refractory ascites due to ESLD by improving symptom control, reducing hospital visits and enabling some self-management. Our trial is designed to see if such patients can be recruited, as well as to inform the design of a subsequent definitive trial. Trial registration ISRCTN, ISRCTN30697116. Registered on 7 October 2015. Electronic supplementary material The online version of this article (10.1186/s13063-018-2779-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lucia Macken
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Main Teaching Building, North South Road, University of Sussex, Falmer, Brighton, East Sussex, BN1 9PX, UK.,Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals Trust, Royal Sussex County Hospital, Eastern Rd, Brighton, East Sussex, BN2 5BE, UK
| | - Louise Mason
- Department of Palliative Medicine, Brighton and Sussex University Hospitals Trust, Royal Sussex County Hospital, Eastern Rd, Brighton, East Sussex, BN2 5BE, UK
| | - Catherine Evans
- King's College, Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK.,Sussex Community NHS Foundation Trust, Brighton General Hospital, Elm Grove, Brighton, BN2 3EW, UK
| | - Heather Gage
- Surrey Health Economics Centre, School of Economics, Faculty of Arts and Social Sciences, University of Surrey, Guildford, Surrey, GU2 7XH, UK
| | - Jake Jordan
- Surrey Health Economics Centre, School of Economics, Faculty of Arts and Social Sciences, University of Surrey, Guildford, Surrey, GU2 7XH, UK
| | - Mark Austin
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals Trust, Royal Sussex County Hospital, Eastern Rd, Brighton, East Sussex, BN2 5BE, UK
| | - Nick Parnell
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals Trust, Royal Sussex County Hospital, Eastern Rd, Brighton, East Sussex, BN2 5BE, UK
| | - Max Cooper
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Main Teaching Building, North South Road, University of Sussex, Falmer, Brighton, East Sussex, BN1 9PX, UK
| | - Shani Steer
- Brighton & Sussex Clinical Trials Unit, Room 204 Bevendean House, University of Brighton, Falmer, BN1 9PH, UK
| | - Justine Boles
- Brighton & Sussex Clinical Trials Unit, Room 204 Bevendean House, University of Brighton, Falmer, BN1 9PH, UK
| | - Stephen Bremner
- Brighton & Sussex Clinical Trials Unit, Room 204 Bevendean House, University of Brighton, Falmer, BN1 9PH, UK.,Department of Primary Care and Public Health, Brighton and Sussex Medical School, Mayfield House, Brighton, BN1 9PH, UK
| | - Debbie Lambert
- Brighton & Sussex Clinical Trials Unit, Room 204 Bevendean House, University of Brighton, Falmer, BN1 9PH, UK
| | - David Crook
- Brighton & Sussex Clinical Trials Unit, Room 204 Bevendean House, University of Brighton, Falmer, BN1 9PH, UK
| | - Gemma Earl
- Brighton & Sussex Clinical Trials Unit, Room 204 Bevendean House, University of Brighton, Falmer, BN1 9PH, UK
| | - Jean Timeyin
- Brighton & Sussex Clinical Trials Unit, Room 204 Bevendean House, University of Brighton, Falmer, BN1 9PH, UK
| | - Sumita Verma
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Main Teaching Building, North South Road, University of Sussex, Falmer, Brighton, East Sussex, BN1 9PX, UK. .,Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals Trust, Royal Sussex County Hospital, Eastern Rd, Brighton, East Sussex, BN2 5BE, UK.
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