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Poisson C, Sampetrean A, Renard P, Khoury-Abboud RM, Scotté F, Vigouret-Viant L, Bonnet B, Tselikas L, Deschamps F, Mateus C. Palliative semi-permanent abdominal drain for the management of refractory malignant ascites: a retrospective study in a comprehensive cancer center. Support Care Cancer 2025; 33:496. [PMID: 40411695 PMCID: PMC12103333 DOI: 10.1007/s00520-025-09551-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2024] [Accepted: 05/13/2025] [Indexed: 05/26/2025]
Abstract
PURPOSE Refractory malignant ascites in the advanced palliative phase significantly impacts patients' quality of life (QoL), causing pain, respiratory difficulties, digestive issues, and impaired mobility. While iterative drainages can effectively relieve symptoms, frequent hospital visits and the significant volume of fluid requiring removal pose considerable challenges. A semi-continuous approach using a permanent bedside drain may offer more frequent drainages of smaller volumes. This study aimed to examine the feasibility, reliability, and safety of a semi-permanent bedside abdominal drain for patients in advanced palliative care with refractory malignant ascites. METHODS This is a retrospective study, with cases identified through computerized queries of digital patient records. Data collected included patient characteristics, biological parameters, procedure details, and end-of-life outcomes. RESULTS Between 2019 and 2024, this drain was proposed to 25 palliative care patients. They had received a median of three lines of oncological treatment, with 60% of them receiving exclusively palliative care at the time of drainage. Drain placement had a beneficial impact on disabling symptoms in over 92% of cases, allowing 60% of patients to return to home hospitalization, without requiring additional hospital visits for paracentesis. The median time between drain placement and end of life was 36.5 days [4;147], while the median time from the diagnosis of refractory ascites to death was 93.7 days [14;263]. CONCLUSION A non-tunneled semi-permanent catheter, easily implanted at the patient's bedside, may improve QoL. This study serves as a pilot for a prospective cohort that will analyze QoL improvements and economic costs.
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Affiliation(s)
- Caroline Poisson
- Palliative Care Unit, Interdisciplinary Department for the Organization of Patient Course (Supportive Care Department), Gustave Roussy, Paris-Saclay University, 114, Rue Edouard-Vaillant, 94800, Villejuif, France.
| | - Anda Sampetrean
- Palliative Care Unit, Interdisciplinary Department for the Organization of Patient Course (Supportive Care Department), Gustave Roussy, Paris-Saclay University, 114, Rue Edouard-Vaillant, 94800, Villejuif, France
| | - Perrine Renard
- Palliative Care Unit, Interdisciplinary Department for the Organization of Patient Course (Supportive Care Department), Gustave Roussy, Paris-Saclay University, 114, Rue Edouard-Vaillant, 94800, Villejuif, France
| | - Rita-Maria Khoury-Abboud
- Palliative Care Unit, Interdisciplinary Department for the Organization of Patient Course (Supportive Care Department), Gustave Roussy, Paris-Saclay University, 114, Rue Edouard-Vaillant, 94800, Villejuif, France
| | - Florian Scotté
- Palliative Care Unit, Interdisciplinary Department for the Organization of Patient Course (Supportive Care Department), Gustave Roussy, Paris-Saclay University, 114, Rue Edouard-Vaillant, 94800, Villejuif, France
| | - Laurence Vigouret-Viant
- Palliative Care Unit, Interdisciplinary Department for the Organization of Patient Course (Supportive Care Department), Gustave Roussy, Paris-Saclay University, 114, Rue Edouard-Vaillant, 94800, Villejuif, France
| | - Baptiste Bonnet
- Interventional Radiology Unit, Anesthesiology, Surgery and Interventional Department, 94805, Villejuif, France
| | - Lambros Tselikas
- Interventional Radiology Unit, Anesthesiology, Surgery and Interventional Department, 94805, Villejuif, France
| | - Frédéric Deschamps
- Interventional Radiology Unit, Anesthesiology, Surgery and Interventional Department, 94805, Villejuif, France
| | - Christine Mateus
- Palliative Care Unit, Interdisciplinary Department for the Organization of Patient Course (Supportive Care Department), Gustave Roussy, Paris-Saclay University, 114, Rue Edouard-Vaillant, 94800, Villejuif, France
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Vierra MA, Morgan RB, Bhutiani N, White MG, Eng OS. Contemporary Management of Malignant Ascites. J Surg Res 2025; 307:157-175. [PMID: 40037156 DOI: 10.1016/j.jss.2025.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2024] [Revised: 12/08/2024] [Accepted: 01/26/2025] [Indexed: 03/06/2025]
Abstract
INTRODUCTION Malignant ascites (MA) develops when malignant disease of the peritoneum causes excess fluid to accumulate in the abdominal cavity. It portends a poor prognosis and is associated with debilitating symptoms. While several palliative therapies exist, none have proven curative or free from side effects and complications. This review article describes experimental therapies on the horizon and the contemporary management of MA. MATERIALS AND METHODS A literature review was performed using MEDLINE/PubMed, in which studies of emerging or experimental therapies under investigation for the management of MA were reviewed. Current therapies were also reviewed to provide important context. Data, including study design, sample size, primary and secondary outcomes, and side effects were recorded and described. Studies were then categorized into distinct sections and subsections, with tables corresponding to each section. RESULTS Five current therapies, including paracentesis, diuretics, peritoneovenous shunting, permanent catheters, and intraperitoneal chemotherapy, are described. Their limitations in effectively managing MA are highlighted. The "Experimental therapies" section is subsectioned into several categories, with the major studies corresponding to each section thoroughly described regarding methods, results, and validity. A final section describes treatments for mucinous ascites, which has distinct characteristics. CONCLUSIONS While each of the experimental therapies described offers unique benefits and has demonstrated some promise in managing MA, they all have limitations that have thus far prevented any one of them from being routinely used in practice. MA remains a challenging condition to treat, warranting further research into novel therapies.
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Affiliation(s)
- Mason A Vierra
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Ryan B Morgan
- Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Neal Bhutiani
- Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Michael G White
- Department of Colon & Rectal Surgery, MD Anderson Cancer Center, Houston, Texas
| | - Oliver S Eng
- Department of Surgery, University of California Irvine, Orange, California
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Abbott J, Verma S, Saksena S. Effective palliation of refractory ascites in cirrhosis is challenging. Int J Palliat Nurs 2024; 30:286-293. [PMID: 38913640 DOI: 10.12968/ijpn.2024.30.6.286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
BACKGROUND Palliative care is often suboptimal for patients with end-stage liver disease (ESLD). Ascites remains the most common complication in ESLD. Though long-term abdominal drains (LTAD) are commonly used in refractory malignant ascites, the standard care for ESLD is hospital drainage (large volume paracentesis (LVP)). There is an ongoing National Institute for Health and Care Research (NIHR) funded trial (REDUCe 2 Study) (ISRCTN269936824) comparing palliative LTAD to LVP in ESLD. This 35-site trial is being conducted in England, Scotland and Wales. AIM To understand the views and experience of healthcare professionals (HCP) on the use of palliative LTAD in ESLD. METHODS An electronic survey comprised of seven questions with fixed quantitative options and three exploratory questions was used between August-December 2019. The survey was distributed electronically via the British Association for Study of Liver newsletter and to relevant hospital departments in Southeast England and Northeast London. An email reminder was sent at 4 and 8 weeks after the initial invitation to the survey. RESULTS There were 211 respondents (hepatologists (36.5%), specialist nurses (24.6%), gastroenterologists (16.6%), trainees (17%) and others (5.2%)). All respondents had access to LVP, 86% to a transjugular intrahepatic portosystemic shunt procedure for patients, 67% to LTADs and 10% to other options, such as the automated low-flow ascites (ALFA) pump. The majority of respondents to the survey (68%) reported their experience of using LTAD. Almost all respondents (91%) were willing to consider LTAD in ESLD. However, the main deterrents of this were the perceived risk of infection (90%), followed by LTAD management in community (57%). Some 51% of those with prior experience of using LTAD reported clinical complications for patients (including bleeding, infection and renal impairment), 41% reported technical issues and 35% inadequate community support. CONCLUSIONS Almost all HCPs are willing to consider palliative LTAD in refractory ascites due to ESLD, but the main deterrents are the perceived infection risk and lack of published data to guide community management. The REDUCe 2 trial will clarify if these concerns are real and provide conclusive evidence on role, if any, of palliative LTADs in this vulnerable and under researched cohort with ESLD.
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Affiliation(s)
- Jane Abbott
- Gastroenterology Registrar, Department of Hepatology, Royal London Hospital, Barts Health NHS Trust; Department of Immunobiology, Blizard Institute, Queen Mary University of London
| | - Sumita Verma
- Professor and Honorary Consultant in Hepatology; Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School; Department of Gastroenterology and Hepatology, University Hospitals Sussex NHS Foundation
| | - Sushma Saksena
- Consultant Hepatologist, Department of Hepatology, Royal London Hospital, Barts Health NHS Trust
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Kaur S, Motta RV, Chapman B, Wharton V, Collier JD, Saffioti F. Palliative long-term abdominal drains vs large volume paracenteses for the management of refractory ascites in end-stage liver disease. World J Hepatol 2024; 16:428-438. [PMID: 38577536 PMCID: PMC10989306 DOI: 10.4254/wjh.v16.i3.428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/25/2024] [Accepted: 02/29/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Long-term abdominal drains (LTAD) are a cost-effective palliative measure to manage malignant ascites in the community, but their use in patients with end-stage chronic liver disease and refractory ascites is not routine practice. The safety and cost-effectiveness of LTAD are currently being studied in this setting, with preliminary positive results. We hypothesised that palliative LTAD are as effective and safe as repeat palliative large volume paracentesis (LVP) in patients with cirrhosis and refractory ascites and may offer advantages in patients' quality of life. AIM To compare the effectiveness and safety of palliative LTAD and LVP in refractory ascites secondary to end-stage chronic liver disease. METHODS A retrospective, observational cohort study comparing the effectiveness and safety outcomes of palliative LTAD and regular palliative LVP as a treatment for refractory ascites in consecutive patients with end-stage chronic liver disease followed-up at our United Kingdom tertiary centre between 2018 and 2022 was conducted. Fisher's exact tests and the Mann-Whitney U test were used to compare qualitative and quantitative variables, respectively. Kaplan-Meier survival estimates were generated to stratify time-related outcomes according to the type of drain. RESULTS Thirty patients had a total of 35 indwelling abdominal drains and nineteen patients underwent regular LVP. The baseline characteristics were similar between the groups. Prophylactic antibiotics were more frequently prescribed in patients with LTAD (P = 0.012), while the incidence of peritonitis did not differ between the two groups (P = 0.46). The incidence of acute kidney injury (P = 0.014) and ascites/drain-related hospital admissions (P = 0.004) were significantly higher in the LVP group. The overall survival was similar in the two groups (log-rank P = 0.26), but the endpoint-free survival was significantly shorter in the LVP group (P = 0.003, P < 0.001, P = 0.018 for first ascites/drain-related admission, acute kidney injury and drain-related complications, respectively). CONCLUSION The use of LTAD in the management of refractory ascites in palliated end-stage liver disease is effective, safe, and may reduce hospital admissions and utilisation of healthcare resources compared to LVP.
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Affiliation(s)
- Senamjit Kaur
- Oxford Liver Unit, Department of Gastroenterology and Hepatology, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, United Kingdom
| | - Rodrigo V Motta
- Oxford Liver Unit and Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford OX3 9DU, United Kingdom
| | - Bryony Chapman
- Oxford Liver Unit, Department of Gastroenterology and Hepatology, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, United Kingdom
| | - Victoria Wharton
- Oxford Liver Unit, Department of Gastroenterology and Hepatology, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, United Kingdom
| | - Jane D Collier
- Oxford Liver Unit, Department of Gastroenterology and Hepatology, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, United Kingdom
| | - Francesca Saffioti
- Oxford Liver Unit, Department of Gastroenterology and Hepatology, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, United Kingdom.
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Zhang J, Qi Z, Ou W, Mi X, Fang Y, Zhang W, Yang Z, Zhou Y, Lin X, Hou J, Yuan Z. Advances in the treatment of malignant ascites in China. Support Care Cancer 2024; 32:97. [PMID: 38200158 DOI: 10.1007/s00520-023-08299-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024]
Abstract
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.
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Affiliation(s)
- Junzi Zhang
- Changchun University of Chinese Medicine, Changchun, Jilin, China
| | - Zhaoxue Qi
- Department of Secretory Metabolism, The First Hospital of Jilin University, Changchun, China
| | - Wenjie Ou
- Changchun University of Chinese Medicine, Changchun, Jilin, China
| | - Xuguang Mi
- Department of Central Laboratory, Jilin Provincial People's Hospital, Changchun, China
| | - Yanqiu Fang
- Department of Tumor Comprehensive Therapy, Jilin Provincial People's Hospital, Changchun, China
| | - Wenqi Zhang
- Changchun University of Chinese Medicine, Changchun, Jilin, China
| | - Zhen Yang
- Changchun University of Chinese Medicine, Changchun, Jilin, China
| | - Ying Zhou
- Department of Tumor Comprehensive Therapy, Jilin Provincial People's Hospital, Changchun, China
| | - Xiuying Lin
- Department of Tumor Comprehensive Therapy, Jilin Provincial People's Hospital, Changchun, China
| | - Junjie Hou
- Department of Tumor Comprehensive Therapy, Jilin Provincial People's Hospital, Changchun, China.
| | - Zhixin Yuan
- Department of Emergency Surgery, Jilin Provincial People's Hospital, Changchun, China.
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Haddadin Y, Macken L, Ufere NN, Verma S. Antibiotic prophylaxis in palliative patients with cirrhosis: Stewardship or gatekeeping? Hepatol Commun 2023; 7:e0309. [PMID: 37994503 PMCID: PMC10666976 DOI: 10.1097/hc9.0000000000000309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 09/15/2023] [Indexed: 11/24/2023] Open
Affiliation(s)
- Yazan Haddadin
- Brighton and Sussex Medical School and University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Lucia Macken
- Brighton and Sussex Medical School and University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Nneka N Ufere
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sumita Verma
- Brighton and Sussex Medical School and University Hospitals Sussex NHS Foundation Trust, Brighton, UK
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Siefen AC, Eilers L, Baltin CT, Kron F. Cost Comparison of Treatment Alternatives for Pleural Effusion and Ascites from a Payer Perspective: Are There Cost Savings from Indwelling Catheters? J Palliat Med 2023; 26:1510-1520. [PMID: 37352428 PMCID: PMC10658739 DOI: 10.1089/jpm.2022.0592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2023] [Indexed: 06/25/2023] Open
Abstract
Background: The presence of pleural effusions and ascites in patients is often considered a marker of illness severity and a poor prognostic indicator. This study aims to compare inpatient and outpatient costs of alternative invasive treatments for ascites and pleural effusions. Methods: The retrospective single-institution study included inpatient cases treated for pleural effusion (J90 and J91) or ascites (R18) at the University Hospital Cologne (UHC) in Germany between January 01, 2020, and December 31, 2021. Costs for punctures and indwelling catheter systems (ICSs) as well as pleurodesis were analyzed in different comparator treatment pathways. Real-world data from the UHC tertiary care center were based on diagnosis-related group fees from 2020 to 2021. A simulation of outpatient expenses was carried out to compare inpatient and outpatient costs for each pathway from a payer perspective. Results: A total of 4323 cases (3396 pleural effusions and 1302 ascites) were analyzed. For ascites, inpatient implantation with home care drainage was found to be the most expensive option, with total costs of €1,918.58 per procedure, whereas outpatient puncture was the least expensive option at €60.02. For pleural effusions, the most expensive treatment pathway was pleurodesis at €8,867.84 compared with the least costly option of outpatient puncture resulting in total costs per procedure of €70.03. A break-even analysis showed that outpatient puncture remains the most inexpensive treatment option, and the ICS comprises a cost-saving potential. Longevity of several months with the use of ICSs results in both enhanced quality of life for patients and increased cost savings.
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Affiliation(s)
| | - Leonie Eilers
- VITIS Healthcare Group, Cologne, Germany
- KCM KompetenzCentrum für Medizinoekonomie, FOM University of Applied Sciences, Essen, Germany
| | - Christoph T. Baltin
- VITIS Healthcare Group, Cologne, Germany
- KCM KompetenzCentrum für Medizinoekonomie, FOM University of Applied Sciences, Essen, Germany
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Florian Kron
- VITIS Healthcare Group, Cologne, Germany
- Department I of Internal Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- Faculty of Medicine and University Hospital Cologne, Centre for Integrated Oncology (CIO ABCD), University of Cologne, Cologne, Germany
- KCM KompetenzCentrum für Medizinoekonomie, FOM University of Applied Sciences, Essen, Germany
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Han MY, Borazanci EH. Malignant ascites in pancreatic cancer: Pathophysiology, diagnosis, molecular characterization, and therapeutic strategies. Front Oncol 2023; 13:1138759. [PMID: 37007072 PMCID: PMC10060830 DOI: 10.3389/fonc.2023.1138759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 03/06/2023] [Indexed: 03/18/2023] Open
Abstract
Malignant ascites is the accumulation of fluid in the peritoneum as a result of advanced cancer and often signifies the terminal phase of the disease. Management of malignant ascites remains a clinical challenge as symptom palliation is the current standard of cure. Previously, studies examining malignant ascites largely focused on ovarian and gastric cancer. In recent years, there has been a significant increase in research on malignant ascites in pancreatic cancer. Malignant ascites is usually diagnosed based on positive cytology, but cytology is not always diagnostic, indicating the need for novel diagnostic tools and biomarkers. This review aims to summarize the current understanding of malignant ascites in pancreatic cancer and the recent advances in the molecular characterization of malignant ascites fluid from patients with pancreatic cancer including analysis of soluble molecules and extracellular vesicles. Current standard of care treatment options such as paracenteses and diuretics are outlined along with new emerging treatment strategies such as immunotherapy and small-molecule based therapies. New potential investigative directions resulting from these studies are also highlighted.
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Affiliation(s)
- Margaret Y. Han
- Department of Biosciences, Rice University, Houston, TX, United States
| | - Erkut H. Borazanci
- Department of Oncology, HonorHealth Research Institute, Scottsdale, AZ, United States
- *Correspondence: Erkut H. Borazanci,
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Demarest K, Lavu H, Collins E, Batra V. Comprehensive Diagnosis and Management of Malignant Bowel Obstruction: A Review. J Pain Palliat Care Pharmacother 2023; 37:91-105. [PMID: 36377820 DOI: 10.1080/15360288.2022.2106012] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Malignant bowel obstruction is a common complication of advanced gastrointestinal, gynecologic, and genitourinary tumors. Patients present with nausea, vomiting, abdominal pain, and constipation. Cross-sectional imaging is essential to make a diagnosis of bowel obstruction. Initial management is conservative with fluid replacement, electrolyte replacement, bowel rest and sometimes nasogastric decompression. Numerous advanced options exist for definitive management, though none are overly promising but nevertheless may improve quality and quantity of life. Surgical bypass, endoscopic stenting, and endoscopic decompression are some of the options with variable efficacy and are employed in select patients. Chemotherapy may be utilized if the bowel obstruction resolves to reduce tumor burden in a limited number of patients. Parenteral nutrition is an option and should typically be used in surgical patients with good functional and nutritional status with limited tumor burden or curative intent. Palliative care and hospice should be discussed in patients with advanced malignancy who present with peritoneal carcinomatosis or multiple levels of obstruction. Overall prognosis of malignant bowel obstruction is poor, and median survival ranges from 26 to 192 days.
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Affiliation(s)
- Kaitlin Demarest
- Kaitlin Demarest, MD, is with, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA; Harish Lavu, MD, is with the Department of Surgery, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA; Elizabeth Collins, MD, is with the Department of Family & Community Medicine, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA; Vivek Batra, MD, is with the Department of Medical Oncology, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Harish Lavu
- Kaitlin Demarest, MD, is with, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA; Harish Lavu, MD, is with the Department of Surgery, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA; Elizabeth Collins, MD, is with the Department of Family & Community Medicine, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA; Vivek Batra, MD, is with the Department of Medical Oncology, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Elizabeth Collins
- Kaitlin Demarest, MD, is with, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA; Harish Lavu, MD, is with the Department of Surgery, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA; Elizabeth Collins, MD, is with the Department of Family & Community Medicine, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA; Vivek Batra, MD, is with the Department of Medical Oncology, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Vivek Batra
- Kaitlin Demarest, MD, is with, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA; Harish Lavu, MD, is with the Department of Surgery, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA; Elizabeth Collins, MD, is with the Department of Family & Community Medicine, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA; Vivek Batra, MD, is with the Department of Medical Oncology, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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10
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Seah DS, Wilcock A, Chang S, Sousa MS, Sinnarajah A, Teoh CO, Allan S, Chye R, Doogue M, Hunt J, Agar M, Currow DC. Paracentesis for cancer-related ascites in palliative care: An international, prospective cohort study. Palliat Med 2022; 36:1408-1417. [PMID: 36113139 DOI: 10.1177/02692163221122326] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Davinia Se Seah
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.,Sacred Heart Health Service, Sydney, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Andrew Wilcock
- Hayward House Specialist Palliative Care Unit, School of Clinical Oncology, University of Nottingham, Nottingham, England
| | - Sungwon Chang
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Mariana S Sousa
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Aynharan Sinnarajah
- Division of Palliative Medicine, Department of Medicine, School of Medicine, Queen's University, Kingston, ON, Canada
| | | | | | - Richard Chye
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.,Sacred Heart Health Service, Sydney, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Matthew Doogue
- University of Otago - Christchurch & Canterbury District Health Board, Christchurch, New Zealand
| | - Jane Hunt
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Meera Agar
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - David C Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
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Türk Y, Devecioğlu İ, Yıldızhan İ, Arslan BC, Arıbaş BK. Tunneled Uncuffed Pigtail Drainage Catheter Placement in Patients with Refractory Ascites or Pleural Effusion: A Single-Center Experience. Cardiovasc Intervent Radiol 2022; 45:1735-1741. [PMID: 35945349 DOI: 10.1007/s00270-022-03248-2] [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: 01/18/2022] [Accepted: 08/01/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE No evidence exists to support the use of tunneled non-cuffed pigtail drainage catheters in patients with refractory ascites or pleural effusion. The purpose of this study was to determine the feasibility of non-cuffed tunneled pigtail drainage catheters in patients with refractory ascites or pleural effusions. MATERIALS AND METHODS Between October 5, 2020 and May 25, 2021, 34 pigtail catheters were implanted in 27 patients (17 males, 10 females; average age: 65.66 ± 12.04 years) under either ultrasound or computed-tomography guidance (19 catheters for ascites, 15 catheters for pleural effusion). Twenty-eight catheters (82.35%) were implanted for malignant etiologies, and 6 catheters (17.65%) were implanted for benign etiologies. The catheters (size: 8-14 French) were implanted through a subcutaneous tunnel. Complication rate and factors related to complications were analyzed. Catheter lifetime was analyzed with Kaplan-Meier method. RESULTS Patency ranged from 3 to 211 days. None of the patients experienced a major complication (e.g., peritonitis and empyema). Meanwhile, 8 minor complications were observed including 3 catheter occlusion, 3 ascites leakage, 1 peri-catheter local skin infection, 1 peri-catheter local skin reaction. None of the etiologies were related to the catheter complications. However, the 8-F catheter was associated with a significantly higher complication rate (odds = 5.5, p = 0.044). The estimated mean [CI] dwelling time of a catheter was 59.18 [32.97, 85.39] days. CONCLUSIONS Image-guided insertion of tunneled peritoneal or pleural pigtail external drainage catheters achieved with a 100% technical success rate and resulted in an acceptable complication rate and catheter lifetime for the management of refractory ascites or pleural effusion.
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Affiliation(s)
- Yaşar Türk
- Radiology Department, Medical Faculty, Bulent Ecevit University, İbni Sina Kampüsü, 67600, Esenköy-Kozlu, Zonguldak, Turkey.
- Radiology Department, Medical Faculty, Biruni University Hospital, Beşyol Mahallesi Eski Londra Asfaltı No: 10 Küçükçekmece, Istanbul, Turkey.
| | - İsmail Devecioğlu
- Biomedical Engineering Department, Çorlu Engineering Faculty, Tekirdağ Namık Kemal University, NKU Corlu Muhendislik Fakultesi, Silahtaraga Mh., Çorlu, Tekirdağ, Turkey
| | - İshak Yıldızhan
- Radiology Department, Medical Faculty, Bulent Ecevit University, İbni Sina Kampüsü, 67600, Esenköy-Kozlu, Zonguldak, Turkey
| | - Barış Can Arslan
- Radiology Department, Medical Faculty, Bulent Ecevit University, İbni Sina Kampüsü, 67600, Esenköy-Kozlu, Zonguldak, Turkey
| | - Bilgin Kadri Arıbaş
- Radiology Department, Medical Faculty, Bulent Ecevit University, İbni Sina Kampüsü, 67600, Esenköy-Kozlu, Zonguldak, Turkey
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12
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Macken L, Corrigan M, Prentice W, Finlay F, McDonagh J, Rajoriya N, Salmon C, Donnelly M, Evans C, Ganai B, Bedlington J, Steer S, Wright M, Hudson B, Verma S, the British Association for the Study of the Liver/British Society of Gastroenterology (BASL/BSG) End of Life Special Interest Group. Palliative long-term abdominal drains for the management of refractory ascites due to cirrhosis: a consensus document. Frontline Gastroenterol 2022; 13:e116-e125. [PMID: 35812034 PMCID: PMC9234735 DOI: 10.1136/flgastro-2022-102128] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 05/15/2022] [Indexed: 02/06/2023] Open
Abstract
Palliative care remains suboptimal in advanced cirrhosis, in part relating to a lack of evidence-based interventions. Ascites remains the most common cirrhosis complication resulting in hospitalisation. Many patients with refractory ascites are not candidates for liver transplantation or transjugular intrahepatic portosystemic shunt, and therefore, require recurrent palliative large volume paracentesis in hospital. We review the available evidence on use of palliative long-term abdominal drains in cirrhosis. Pending results of a national trial (REDUCe 2) and consistent with recently published national and American guidance, long-term abdominal drains cannot be regarded as standard of care in advanced cirrhosis. They should instead be considered only on a case-by-case basis, pending definitive evidence. This manuscript provides consensus to help standardise use of long-term abdominal drains in cirrhosis including patient selection and community management. Our ultimate aim remains to improve palliative care for this under researched and vulnerable cohort.
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Affiliation(s)
- Lucia Macken
- Gastroenterology and Hepatology, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Margaret Corrigan
- Hepatology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Wendy Prentice
- Department of Palliative Care Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Fiona Finlay
- Palliative Medicine, Queen Elizabeth University Hospital Campus, Glasgow, UK
| | | | - Neil Rajoriya
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Claire Salmon
- Hepatology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | | | - Bhaskar Ganai
- Gastroenterology and Hepatology, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | | | - Shani Steer
- Patient and Public involvement, Brighton, UK
| | - Mark Wright
- Hepatology, University Hospital Southampton, Southampton, UK
| | - Ben Hudson
- Hepatology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Sumita Verma
- Gastroenterology and Hepatology, University Hospitals Sussex NHS Foundation Trust, Brighton, UK,Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK
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13
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Lim LY, Loneragan R, Lee J, Chan C. Long-Term Peritoneal Indwelling Catheters for Malignant Ascites: A Retrospective Case Series of PleurX and Peritoneal Port. J Palliat Med 2022; 25:1127-1131. [PMID: 35333615 DOI: 10.1089/jpm.2021.0504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Liang Yik Lim
- Department of Palliative Care and Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Robert Loneragan
- Department of Interventional Radiology, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Jessica Lee
- Department of Palliative Care and Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Camilla Chan
- Department of Palliative Care and Concord Repatriation General Hospital, Concord, New South Wales, Australia
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14
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Murray FR, Gnehm F, Schindler V, Morell B, Gubler C, Kretschmer EM, Bütikofer S. Permanent Tunneled Drainage of Ascites in Palliative Patients: Timing Needs Evaluation. J Palliat Med 2022; 25:1132-1135. [PMID: 35325569 DOI: 10.1089/jpm.2021.0506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Treatment of refractory ascites remains challenging. We evaluated the safety and efficacy of permanent tunneled peritoneal catheters (PTPC) in this condition. Methods: We retrospectively analyzed consecutive patients in palliative situations in a tertiary referral center. Safety parameters, symptom relief, and survival were assessed. Results: Seventy patients were included from February 2012 to January 2021. Ninety percent had ascites due to malignancy, 10% due to end-stage liver disease. The technical procedure was successful in all cases; no deaths occurred. Procedure-related infections were rare and only observed in patients without peri-interventional antibiotics. Most patients experienced symptom relief (76%) and were satisfied with the device (83%). Survival after PTPC was relatively short (median 19 days). Discussion: PTPC is a safe option for refractory ascites in palliative settings with symptom relief in the majority of patients and should be considered early after onset of ascites. Periprocedural antibiotic prophylaxis may be considered to avoid procedure-related infections.
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Affiliation(s)
- Fritz Ruprecht Murray
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Florian Gnehm
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Valeria Schindler
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Bernhard Morell
- Division of Gastroenterology and Hepatology, Stadtspital Zurich, Zurich, Switzerland
| | - Christoph Gubler
- Division of Gastroenterology and Hepatology, Stadtspital Zurich, Zurich, Switzerland
| | - Eva-Maria Kretschmer
- Department of Radiation Oncology and Competence Centre for Palliative Care, University Hospital Zurich, Zurich, Switzerland
| | - Simon Bütikofer
- Gastroenterology and Hepatology Unit, Luzerner Kantonsspital, Lucerne, Switzerland
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15
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Indwelling Peritoneal Catheter for Ascites Management in a UK District General Hospital: A Cohort Study. Healthcare (Basel) 2021; 9:healthcare9101254. [PMID: 34682934 PMCID: PMC8536105 DOI: 10.3390/healthcare9101254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/16/2021] [Accepted: 09/17/2021] [Indexed: 11/17/2022] Open
Abstract
Background: There is no national or local guidance for management of malignancy-related ascites (MRA). Modalities can include large volume paracentesis (LVP) and indwelling peritoneal catheter (IPeC) insertion. Objectives: We set up a local IPeC service and performed a retrospective review with local ethical (Caldicott) approval. We hypothesized that an IPeC service would reduce inpatient stay related to MRA management, would be acceptable to patients, and have minimal complications. Methods: Notes of all patients requiring IPeC insertion were reviewed. Descriptive statistical methodology was applied with continuous data presented as mean (standard deviation (SD); range) and categorical variables as frequencies or percentages. Integrated Palliative Care Outcome Scale (IPOS) scores were collected for IPeC patients. Results: Thirty-four patients were identified. They were predominantly female, with a mean age of 66.6 years and a wide range of cancer diagnoses. Twenty-nine were inserted as day case procedures, and 31 had preceding paracenteses (mean 2). Main complications were leakage (6(17%)), peritonitis (2(5.8%)), and skin infection (1(3%)). IPOS scores showed consistent improvement in symptoms. Conclusions: An IPeC service for malignant-related ascites is acceptable to patients and is associated with manageable complication rates. We present the development of our service and hope for widespread application.
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16
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Zhang S, Xie B, Wang L, Yang H, Zhang H, Chen Y, Wang F, Liu C, He H. Macrophage-mediated vascular permeability via VLA4/VCAM1 pathway dictates ascites development in ovarian cancer. J Clin Invest 2021; 131:140315. [PMID: 33295887 DOI: 10.1172/jci140315] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 11/25/2020] [Indexed: 12/14/2022] Open
Abstract
The development of ascites correlates with advanced stage disease and poor prognosis in ovarian cancer. Vascular permeability is the key pathophysiological change involved in ascites development. Previously, we provided evidence that perivascular M2-like macrophages protect the vascular barrier through direct contact with endothelial cells (ECs). Here, we investigated the molecular mechanism and its clinical significance in the ovarian cancer setting. We found that upon direct coculture with the endothelium, M2 macrophages tuned down their VLA4 and reduced the levels of VCAM1 in ECs. On the other hand, ectopically overexpressing VLA4 in macrophages or VCAM1 in ECs induced hyperpermeability. Mechanistically, downregulation of VLA4 or VCAM1 led to reduced levels of RAC1 and ROS, which resulted in decreased phosphorylation of PYK2 (p-PYK2) and VE-cadherin (p-VE-cad), hence enhancing cell adhesion. Furthermore, targeting the VLA4/VCAM1 axis augmented vascular integrity and abrogated ascites formation in vivo. Finally, VLA4 expression on the macrophages isolated from ascites dictated permeability ex vivo. Importantly, VLA4 antibody acted synergistically with bevacizumab to further enhance the vascular barrier. Taking these data together, we reveal here that M2 macrophages regulate the vascular barrier though the VCAM1/RAC1/ROS/p-PYK2/p-VE-cad cascade, which provides specific therapeutic targets for the treatment of malignant ascites.
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Affiliation(s)
- Shibo Zhang
- Guangdong Provincial Key Laboratory of Biomedical Imaging and Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
| | - Bingfan Xie
- Department of Gynaecology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Lijie Wang
- Guangdong Provincial Key Laboratory of Biomedical Imaging and Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
| | - Hua Yang
- Department of Gynaecology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Haopei Zhang
- Guangdong Provincial Key Laboratory of Biomedical Imaging and Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
| | - Yuming Chen
- Guangdong Provincial Key Laboratory of Biomedical Imaging and Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
| | - Feng Wang
- Department of Gynaecology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Changqing Liu
- Department of Gynaecology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Huanhuan He
- Guangdong Provincial Key Laboratory of Biomedical Imaging and Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
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17
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Cooper M, Pollard A, Pandey A, Bremner S, Macken L, Evans CJ, Austin M, Parnell N, Steer S, Thomson S, Hashim A, Mason L, Verma S. Palliative Long-Term Abdominal Drains Versus Large Volume Paracentesis in Refractory Ascites Due to Cirrhosis (REDUCe Study): Qualitative Outcomes. J Pain Symptom Manage 2021; 62:312-325.e2. [PMID: 33348031 DOI: 10.1016/j.jpainsymman.2020.12.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 12/06/2020] [Accepted: 12/08/2020] [Indexed: 12/14/2022]
Abstract
CONTEXT Palliative care remains suboptimal in end-stage liver disease (ESLD). OBJECTIVES We report qualitative outcomes from the REDUCe study. We aimed to explore and contrast experiences/perceptions/care pathways of patients with refractory ascites due to ESLD randomized to either palliative long-term abdominal drains (LTADs) (allow home drainage) vs. large volume paracentesis (LVP) (hospital drainage). METHODS Concurrent embedded qualitative study in a 12-week feasibility randomized controlled trial. Telephone interviews were conducted, data being recorded, transcribed verbatim, and analyzed using applied thematic analysis, considered in terms of a pathway approach toward accessing health care. Quantitative outcomes were collected (integrated palliative outcome scale, short-form liver disease quality of life, EQ-5D-5 L, Zarit Burden Interview-12). RESULTS Fourteen patients (six allocated LTAD and eight LVP) and eight nurses participated in the qualitative study. The patient journey in the LVP group could be hindered by challenges along the entire care pathway, from recognizing the need for drainage to a lengthy wait in hospital for drainage and/or to be discharged. These issues also impacted upon caregivers. In contrast, LTADs appeared to transform this care pathway at all levels across the patient's journey by removing the need for hospital drainage. Additional benefits included personalized care, improved symptom control of ascites, being at home, and regular support from community nurses. Nurses also viewed the LTAD favorably, though expressed the need for additional support should this become standard of care. CONCLUSION Patients and nurses expressed acceptability of palliative LTAD in ESLD and preference for this approach in enabling care at home. Proceeding to a definitive trial is feasible. TRIAL REGISTRATION ISRCTN30697116, date assigned: 07/10/2015.
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Affiliation(s)
- Max Cooper
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, UK
| | - Alex Pollard
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, UK
| | - Aparajita Pandey
- Research & Development Department, Sussex Partnership NHS Foundation Trust, Brighton, UK
| | | | - 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 Trust, Brighton, UK
| | - Catherine J Evans
- Kings College, Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, London, UK; Sussex Community NHS Foundation Trust, Brighton, UK
| | - Mark Austin
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals Trust, Brighton, UK
| | - Nick Parnell
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals Trust, Brighton, UK
| | - Shani Steer
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals Trust, Brighton, UK
| | - Sam Thomson
- Department of Gastroenterology and Hepatology, Western Sussex NHS Foundation Trust, Worthing, 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 Trust, Brighton, UK
| | - Louise Mason
- Department of Palliative Medicine, Brighton and Sussex University Hospitals 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 Trust, Brighton, UK.
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18
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Aithal GP, Palaniyappan N, China L, Härmälä S, Macken L, Ryan JM, Wilkes EA, Moore K, Leithead JA, Hayes PC, O'Brien AJ, Verma S. Guidelines on the management of ascites in cirrhosis. Gut 2021; 70:9-29. [PMID: 33067334 PMCID: PMC7788190 DOI: 10.1136/gutjnl-2020-321790] [Citation(s) in RCA: 225] [Impact Index Per Article: 56.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 08/27/2020] [Accepted: 09/04/2020] [Indexed: 12/15/2022]
Abstract
The British Society of Gastroenterology in collaboration with British Association for the Study of the Liver has prepared this document. The aim of this guideline is to review and summarise the evidence that guides clinical diagnosis and management of ascites in patients with cirrhosis. Substantial advances have been made in this area since the publication of the last guideline in 2007. These guidelines are based on a comprehensive literature search and comprise systematic reviews in the key areas, including the diagnostic tests, diuretic use, therapeutic paracentesis, use of albumin, transjugular intrahepatic portosystemic stent shunt, spontaneous bacterial peritonitis and beta-blockers in patients with ascites. Where recent systematic reviews and meta-analysis are available, these have been updated with additional studies. In addition, the results of prospective and retrospective studies, evidence obtained from expert committee reports and, in some instances, reports from case series have been included. Where possible, judgement has been made on the quality of information used to generate the guidelines and the specific recommendations have been made according to the 'Grading of Recommendations Assessment, Development and Evaluation (GRADE)' system. These guidelines are intended to inform practising clinicians, and it is expected that these guidelines will be revised in 3 years' time.
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Affiliation(s)
- Guruprasad P Aithal
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Naaventhan Palaniyappan
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Louise China
- Institute of Liver Disease and Digestive Health, University College London, London, UK
| | - Suvi Härmälä
- Institute of Health Informatics, University College London, London, UK
| | - 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
| | - Jennifer M Ryan
- Institute of Liver Disease and Digestive Health, University College London, London, UK
- Royal Free London NHS Foundation Trust, London, UK
| | - Emilie A Wilkes
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Kevin Moore
- Institute of Liver Disease and Digestive Health, University College London, London, UK
| | - Joanna A Leithead
- Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Peter C Hayes
- Hepatology Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Alastair J O'Brien
- Institute of Liver Disease and Digestive Health, University College London, London, 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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19
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Macken L, Bremner S, Gage H, Touray M, Williams P, Crook D, Mason L, Lambert D, Evans CJ, Cooper M, Timeyin J, Steer S, Austin M, Parnell N, Thomson SJ, Sheridan D, Wright M, Isaacs P, Hashim A, Verma S. Randomised clinical trial: palliative long-term abdominal drains vs large-volume paracentesis in refractory ascites due to cirrhosis. Aliment Pharmacol Ther 2020; 52:107-122. [PMID: 32478917 DOI: 10.1111/apt.15802] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/12/2020] [Accepted: 04/28/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Palliative care remains suboptimal in end-stage liver disease. AIM To inform a definitive study, we assessed palliative long-term abdominal drains in end-stage liver disease to determine recruitment, attrition, safety/potential effectiveness, questionnaires/interview uptake/completion and make a preliminary cost comparison. METHODS A 12-week feasibility nonblinded randomised controlled trial comparing large-volume paracentesis vs long-term abdominal drains in refractory ascites due to end-stage liver disease with fortnightly home visits for clinical/questionnaire-based assessments. Study success criteria were attrition not >50%, <10% long-term abdominal drain removal due to complications, the long-term abdominal drain group to spend <50% ascites-related study time in hospital vs large-volume paracentesis group and 80% questionnaire/interview uptake/completion. RESULTS Of 59 eligible patients, 36 (61%) were randomised, 17 to long-term abdominal drain and 19 to large-volume paracentesis. Following randomisation, median number (IQR) of hospital ascitic drains (long-term abdominal drain group vs large-volume paracentesis group) were 0 (0-1) vs 4 (3-7); week 12 serum albumin (g/L) and serum creatinine (μmol/L) were 29 (26.5-32.5) vs 30 (25-35) and 104.5 (81-115.5) vs 127 (63-158) respectively. Total attrition was 42% (long-term abdominal drain group 47%, large-volume paracentesis group 37%). Median (IQR) fortnightly community/hospital/social care ascites-related costs and percentage study time in hospital were lower in the long-term abdominal drain group, £329 (253-580) vs £843 (603-1060) and 0% (0-0.74) vs 2.75% (2.35-3.84) respectively. Self-limiting cellulitis/leakage occurred in 41% (7/17) in the long-term abdominal drain group vs 11% (2/19) in the large-volume paracentesis group; peritonitis incidence was 6% (1/17) vs 11% (2/19) respectively. Questionnaires/interview uptake/completion were ≥80%; interviews indicated that long-term abdominal drains could transform the care pathway. CONCLUSIONS The REDUCe study demonstrates feasibility with preliminary evidence of long-term abdominal drain acceptability/effectiveness/safety and reduction in health resource utilisation. TRIAL REGISTRATION ISRCTN30697116, date assigned: 07/10/2015.
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20
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Ramamoorthy V, Rubens M, Saxena A, Bhatt C, Das S, Appunni S, Veledar E, McGranaghan P, Shehadeh N, Viamonte-Ros A, Linhares Y, Odia Y, Kotecha R, Mehta MP. Prevalence and Inpatient Hospital Outcomes of Malignancy-Related Ascites in the United States. Am J Hosp Palliat Care 2020; 38:47-53. [PMID: 32462883 DOI: 10.1177/1049909120928980] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Malignancy-related ascites (MRA) is the terminal stage of many advanced cancers, and the treatment is mainly palliative. This study looked for epidemiology and inpatient hospital outcomes of patients with MRA in the United States using a national database. METHODS The current study was a cross-sectional analysis of 2015 National Inpatient Sample data and consisted of patients ≥18 years with MRA. Descriptive statistics were used for understanding demographics, clinical characteristics, and MRA hospitalization costs. Multivariate regression models were used to identify predictors of length of hospital stay and in-hospital mortality. RESULTS There were 123 410 MRA hospitalizations in 2015. The median length of stay was 4.7 days (interquartile range [IQR]: 2.5-8.6 days), median cost of hospitalization was US$43 543 (IQR: US$23 485-US$82 248), and in-hospital mortality rate was 8.8% (n = 10 855). Multivariate analyses showed that male sex, black race, and admission to medium and large hospitals were associated with increased hospital length of stay. Factors associated with higher in-hospital mortality rates included male sex; Asian or Pacific Islander race; beneficiaries of private insurance, Medicaid, and self-pay; patients residing in large central and small metro counties; nonelective admission type; and rural and urban nonteaching hospitals. CONCLUSIONS Our study showed that many demographic, socioeconomic, health care, and geographic factors were associated with hospital length of stay and in-hospital mortality and may suggest disparities in quality of care. These factors could be targeted for preventing unplanned hospitalization, decreasing hospital length of stay, and lowering in-hospital mortality for this population.
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Affiliation(s)
| | - Muni Rubens
- Department of Radiation Oncology, 455694Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Anshul Saxena
- 7403Baptist Health South Florida, Miami, FL, USA.,1782Florida International University, Miami, FL, USA
| | | | - Sankalp Das
- 7403Baptist Health South Florida, Miami, FL, USA
| | | | - Emir Veledar
- 7403Baptist Health South Florida, Miami, FL, USA.,1782Florida International University, Miami, FL, USA
| | - Peter McGranaghan
- Department of Radiation Oncology, 455694Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | | | - Ana Viamonte-Ros
- 7403Baptist Health South Florida, Miami, FL, USA.,1782Florida International University, Miami, FL, USA
| | - Yuliya Linhares
- Department of Radiation Oncology, 455694Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Yazmin Odia
- Department of Radiation Oncology, 455694Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA.,1782Florida International University, Miami, FL, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, 455694Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA.,1782Florida International University, Miami, FL, USA
| | - Minesh P Mehta
- Department of Radiation Oncology, 455694Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA.,1782Florida International University, Miami, FL, USA
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21
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Weston M, Soyer P, Barral M, Dohan A, Pierre S, Rabei R, Garcia-Reyes K, Kohi MP. Role of Interventional Procedures in Obstetrics and Gynecology. Radiol Clin North Am 2020; 58:445-462. [PMID: 32044017 DOI: 10.1016/j.rcl.2019.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Radiological guided intervention techniques are discussed in obstetric and gynecologic patients. Fallopian tube recanalization, postpartum hemorrhage control, techniques of treating uterine leiomyomas, pelvic congestion treatment, and the use of percutaneous and transvaginal ultrasonography-guided aspirations and biopsy are covered. These techniques use basic radiological interventional skills and show how they are adapted for use in the female pelvis.
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Affiliation(s)
- Michael Weston
- Department of Radiology, St James's University Hospital, Leeds LS9 7TF, UK.
| | - Philippe Soyer
- Department of Radiology, Service de Radiologie A, Hopital Cochin, APHP & Université de Paris-Descartes Paris 5, 27 rue du Faubourg Saint-Jacques, Paris 75014, France
| | - Matthias Barral
- Department of Radiology, Service de Radiologie A, Hopital Cochin, APHP & Université de Paris-Descartes Paris 5, 27 rue du Faubourg Saint-Jacques, Paris 75014, France
| | - Anthony Dohan
- Department of Radiology, Service de Radiologie A, Hopital Cochin, APHP & Université de Paris-Descartes Paris 5, 27 rue du Faubourg Saint-Jacques, Paris 75014, France
| | - Sacha Pierre
- Department of Radiology, St James's University Hospital, Leeds LS9 7TF, UK
| | - Rana Rabei
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Avenue, M-361, San Francisco, CA 94143, USA
| | - Kirema Garcia-Reyes
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Avenue, M-361, San Francisco, CA 94143, USA
| | - Maureen P Kohi
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Avenue, M-361, San Francisco, CA 94143, USA
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22
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Fiscal Idrobo LM, Salazar VE, Oviedo Segura CP, Gavilán Martínez DM, Carmona Montoya X. Drenaje peritoneal como tratamiento de la ascitis maligna, una revisión de la literatura. REVISTA CUIDARTE 2020. [DOI: 10.15649/cuidarte.919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
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
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Kietpeerakool C, Rattanakanokchai S, Jampathong N, Srisomboon J, Lumbiganon P, Cochrane Gynaecological, Neuro‐oncology and Orphan Cancer Group. Management of drainage for malignant ascites in gynaecological cancer. Cochrane Database Syst Rev 2019; 12:CD007794. [PMID: 31825525 PMCID: PMC6953277 DOI: 10.1002/14651858.cd007794.pub3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Chumnan Kietpeerakool
- Khon Kaen UniversityDepartment of Obstetrics and Gynaecology, Faculty of Medicine123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
| | - Siwanon Rattanakanokchai
- Khon Kaen UniversityDepartment of Epidemiology and Biostatistics, Faculty of Public Health123 Mittraphap Rd. Nai‐MuangMuang DistrictKhon KaenThailand40002
| | | | - Jatupol Srisomboon
- Faculty of Medicine, Chiang Mai UniversityDepartment of Obstetrics and Gynecology110 Intawaroros RoadMuangChiang MaiThailand50200
| | - Pisake Lumbiganon
- Khon Kaen UniversityDepartment of Obstetrics and Gynaecology, Faculty of Medicine123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
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Zhang F, Feng Z, Zhang Y, Liu Z, Sun X, Jin S. Determination of the optimal volume of ascitic fluid for the precise diagnosis of malignant ascites. Saudi J Gastroenterol 2019; 25:327-332. [PMID: 30900607 PMCID: PMC6784429 DOI: 10.4103/sjg.sjg_547_18] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND/AIMS The aim of this study was to determine the optimal volume of peritoneal effusion required to diagnose malignant ascites. PATIENTS AND METHODS The authors recruited 123 patients with shifting dullness and obtained 123 peritoneocentesis fluid samples. The samples were divided into seven aliquots of 10, 50, 100, 150, 200, 250, and 300 mL for cytopathological examination. The sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were calculated for each aliquot. RESULTS The sensitivity for the diagnosis of malignant ascites gradually increased as the sample volume increased and reached a constant value at a volume of 200 mL. The sensitivity and NPV for the 10-, 100-, and 150-mL volumes were significantly different from those for the 200-mL sample. However, the sensitivity and NPV for the 250- and 300-mL volumes were not significantly different. The sensitivity for the diagnosis of malignant ascites is closely related to the volume of peritoneal fluid that is extracted by peritoneocentesis. CONCLUSION We suggest a volume of 200 mL as the optimal minimum volume to confirm malignant ascites in patients with shifting dullness.
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Affiliation(s)
- Feifei Zhang
- Department of Gastroenterology and Hepatology, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Zhenning Feng
- Department of Gastroenterology and Hepatology, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Yichi Zhang
- Department of Gastroenterology and Hepatology, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Zishuai Liu
- Department of Gastroenterology and Hepatology, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Xiaoli Sun
- Department of Gastroenterology and Hepatology, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Shizhu Jin
- Department of Gastroenterology and Hepatology, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China,Address for correspondence: Dr. Shizhu Jin, Department of Gastroenterology and Hepatology, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China. E-mail:
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25
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Hodge C, Badgwell BD. Palliation of malignant ascites. J Surg Oncol 2019; 120:67-73. [PMID: 30903617 DOI: 10.1002/jso.25453] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 03/03/2019] [Indexed: 12/17/2022]
Abstract
Malignant ascites (MA) carries a poor prognosis. It can have a significant impact on quality of life (QOL), with increasing abdominal distention, pain, and dyspnea. Diuretics typically do not work well for MA. Paracentesis is effective in providing temporary symptom relief but requires frequent repeat procedures. Options for durable symptom management include indwelling catheters, peritoneal ports, peritoneovenous shunts, intraperitoneal (i.p.) catumaxomab, and hyperthermic i.p. chemotherapy. These interventions do not necessarily improve overall survival but may improve QOL.
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Affiliation(s)
- Caitlin Hodge
- Department of General Surgery, Abington Memorial Hospital, Abington, Pennsylvania
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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26
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Quality of life improves after palliative placement of percutaneous tunneled drainage catheter for refractory ascites in prospective study of patients with end-stage cancer. Palliat Support Care 2019; 17:677-685. [PMID: 30880658 DOI: 10.1017/s1478951519000051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Percutaneous tunneled drainage catheter (PTDC) placement is a palliative alternative to serial paracenteses in patients with end-stage cancer and refractory ascites. The impact of PTDC on quality of life (QoL) and long-term outcomes has not been prospectively described. The objective was to evaluate changes in QoL after PTDC. METHOD Eligible adult patients with end-stage cancer undergoing PTDC placement for refractory ascites completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire and McGill Quality of Life instruments before PTDC placement and at 2 to 7 days and 2 to 4 weeks after PTDC. Catheter function, complications, and laboratory values were assessed. Analysis of QoL data was evaluated with a stratified Wilcoxon signed-rank test. RESULT Fifty patients enrolled. Survey completion ranged from 65% to 100% (median 88%) across timepoints. All patients had a Tenckhoff catheter, with 98% technical success. Median survival after PTDC was 38 days (95% confidence interval = 32, 57 days). European Organization for Research and Treatment of Cancer scores showed improvement in global QoL (p = 0.03) at 1 week postprocedure (PP). Significant symptom improvement was reported for fatigue, nausea/vomiting, pain, dyspnea, insomnia, and appetite at 1 week PP and was sustained at 3 weeks PP for dyspnea (p < 0.01), insomnia (p < 0.01), and appetite loss (p = 0.03). McGill Quality of Life demonstrated overall QoL improvement at 1 (p = 0.03) and 3 weeks (p = 0.04) PP. Decline in sodium and albumin values pre- and post-PTDC slowed significantly (albumin slope -0.43 to -0.26, p = 0.055; sodium slope -2.50 to 1.31, p = 0.04). Creatinine values increased at an accelerated pace post-PTDC (0.040 to 0.21, p < 0.01). Thirty-eight catheter-related complications occurred in 24 of 45 patients (53%). SIGNIFICANCE OF RESULTS QoL and symptoms improved after PTDC placement for refractory ascites in patients with end-stage malignancy. Decline in sodium and albumin values slowed postplacement. This study supports the use of a PTDC for palliation of refractory ascites in cancer patients.
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27
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Chen BS, Wong SHC, Hawkins S, Huggins L. Permanent peritoneal ports for the management of recurrent malignant ascites: a retrospective review of safety and efficacy. Intern Med J 2018; 48:1524-1528. [PMID: 30517990 DOI: 10.1111/imj.14137] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 06/08/2018] [Accepted: 06/13/2018] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Benson S Chen
- Palliative Care Services, Counties Manukau District Health Board, Middlemore Hospital, Auckland, New Zealand
| | - Stephen H C Wong
- Palliative Care Services, Counties Manukau District Health Board, Middlemore Hospital, Auckland, New Zealand
| | - Stewart Hawkins
- Interventional Radiology, Counties Manukau District Health Board, Middlemore Hospital, Auckland, New Zealand
| | - Linda Huggins
- Palliative Care Services, Counties Manukau District Health Board, Middlemore Hospital, Auckland, New Zealand
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28
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Abstract
Despite advances in the management of peritoneal carcinomatosis, morbidity remains high with survival often measured in weeks to months. Patients are often subjected to symptoms and complications that impact quality of life. Much of the management revolves around palliation of symptoms and providing support and resources to address emotional and existential concerns. This article reviews surgical and nonsurgical palliative treatments for the symptoms and complications associated with advanced, incurable peritoneal carcinomatosis. It is important that providers caring for patients with peritoneal carcinomatosis be knowledgeable in the palliative management of this condition, including the usefulness of early palliative care referral.
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Affiliation(s)
- Laura A Lambert
- Surgical Oncology, Huntsman Cancer Institute, 2000 Circle of Hope Drive, Salt Lake City, UT 84112, USA.
| | - Ryan J Hendrix
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, 55 Lake Avenue N., Worcester, MA 01608, USA
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29
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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: 1.0] [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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30
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Caldwell J, Edriss H, Nugent K. Chronic peritoneal indwelling catheters for the management of malignant and nonmalignant ascites. Proc AMIA Symp 2018; 31:297-302. [PMID: 29904292 PMCID: PMC5997061 DOI: 10.1080/08998280.2018.1461525] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 04/01/2018] [Accepted: 04/02/2018] [Indexed: 12/14/2022] Open
Abstract
Ascites is a debilitating condition affecting patients with end-stage liver disease and advanced abdominal malignancies. Serial paracentesis can reduce symptoms in these patients; indwelling peritoneal catheters provide an alternative approach that allows patients to manage their symptoms at home. A literature search was conducted to identify studies with at least 20 patients published in the last 15 years that reported indwelling catheter placement in patients with chronic ascites. Fourteen studies with 957 patients (687 with malignancy and 270 with cirrhosis) were reviewed. Symptom improvement was reported in all studies. The most common complication in patients with malignant ascites was catheter dysfunction (39/687). Infection rates for patients with malignancy and patients with nonmalignant ascites were 5.4% (37/687) and 12.2% (33/270), respectively. Infection risk significantly increased with devices in place for >12 weeks. The average survival time after catheter placement was 7.2 weeks for patients with malignancy and 164 weeks for patients without malignancy. In conclusion, indwelling peritoneal catheters are an effective alternative to paracentesis for palliation in patients with refractory ascites. Peritonitis is a definite risk in patients with nonmalignant ascites in whom prolonged use is expected.
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Affiliation(s)
- Joseph Caldwell
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Hawa Edriss
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Kenneth Nugent
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
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31
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Lambert LA, Wiseman J. Palliative Management of Peritoneal Metastases. Ann Surg Oncol 2018; 25:2165-2171. [PMID: 29383612 DOI: 10.1245/s10434-018-6335-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Indexed: 02/06/2023]
Abstract
Despite significant recent advances in the management of peritoneal carcinomatosis, this diagnosis still is accompanied frequently by a grim survival prognosis, often measured in weeks to months. The poor prognosis also is accompanied often by complications and symptoms that have a dramatic impact on quality of life and are challenging to the managing health care provider and devastating to loved ones caring for the person who is suffering. Consequently, management of carcinomatosis often revolves around palliation of symptoms such as bowel obstruction, nausea, pain, fatigue, and cachexia as well as emotional and existential concerns. This article reviews several palliative treatment options for some of the more common symptoms and complications associated with advanced, incurable peritoneal carcinomatosis. Although readers should recognize that carcinomatosis is no longer an imminent death sentence, providers caring for patients with peritoneal carcinomatosis also must be well-versed in the palliative management of this condition and recognize the utility of early palliative care referral in this setting.
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Affiliation(s)
- Laura A Lambert
- Surgical Oncology, Huntsman Cancer Institute, University of Utah, 2000 Circle of Hope, Salt Lake City, UT, USA.
| | - Jason Wiseman
- Division of Surgical Oncology, University of Massachusetts Medical School, Worcester, MA, USA
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32
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Safety and Effectiveness of Palliative Tunneled Peritoneal Drainage Catheters in the Management of Refractory Malignant and Non-malignant Ascites. Cardiovasc Intervent Radiol 2018; 41:753-761. [DOI: 10.1007/s00270-017-1872-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 12/29/2017] [Indexed: 10/18/2022]
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33
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Palliative care in ovarian carcinoma patients-a personalized approach of a team work: a review. Arch Gynecol Obstet 2017; 296:691-700. [PMID: 28803353 DOI: 10.1007/s00404-017-4484-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 08/01/2017] [Indexed: 01/06/2023]
Abstract
Most ovarian cancer patients are diagnosed in an advanced stage; and after the initial treatment experience disease recurrence, which eventually becomes palliative. Many questions arise in this setting including how to address patients in the palliative setting, how to discuss end-of-life issues, and how to manage symptoms. In this review, we discuss the timing and setting of end-of-life discussion in the context of end-stage ovarian cancer. We review the approach to relieving disease burden by improving and decreasing symptoms. These symptoms include recurrent ascites, bowel obstruction, pain, pulmonary effusion, and deep vein thrombosis.
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Macken L, Joshi D, Messenger J, Austin M, Tibble J, Mason L, Verma S. Palliative long-term abdominal drains in refractory ascites due to end-stage liver disease: A case series. Palliat Med 2017; 31:671-675. [PMID: 27707955 DOI: 10.1177/0269216316671281] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Ascites, the commonest complication of cirrhosis, leads to frequent hospitalisations. Refractory ascites confers a median survival of 6 months without liver transplantation. In many, the management remains palliative (large-volume paracentesis). Despite calls for improvement, palliative and end-of-life care is not yet integrated into end-stage liver disease. Long-term abdominal drains are a palliative strategy in malignant ascites, but not end-stage liver disease. CASE PRESENTATION A retrospective, single centre, case series review was performed of patients undergoing long-term abdominal drain placement for refractory ascites secondary to end-stage liver disease at a large teaching hospital between August 2011 and March 2013. Case management: Patients with end-stage liver disease and refractory ascites, where liver transplantation was not an option, were considered for long-term abdominal drains. Seven patients underwent successful long-term abdominal drain insertion after multi-professional assessment. Case outcome: Following long-term abdominal drain insertion, mean hospital attendances reduced to 1 (0-4) from 9 (4-21), with none for ascites management. Median survival after long-term abdominal drain insertion was 29 days (8-219). The complication rate was low and none life threatening. CONCLUSION Palliative and end-of-life care needs in end-stage liver disease remain under-addressed. Our data suggest that long-term abdominal drains may be a safe and effective palliative intervention in end-stage liver disease. Prospective randomised controlled trials comparing large-volume paracentesis versus long-term abdominal drains in refractory ascites secondary to end-stage liver disease are warranted.
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Affiliation(s)
- Lucia Macken
- 1 Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.,2 Department of Medicine, Brighton and Sussex Medical School, Brighton, UK
| | - Deepak Joshi
- 3 Institute of Hepatology, King's College Hospital NHS Foundation Trust, London, UK
| | - Jenny Messenger
- 4 Department of Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Mark Austin
- 1 Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Jeremy Tibble
- 1 Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Louise Mason
- 5 Department of Palliative Care, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Sumita Verma
- 1 Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.,2 Department of Medicine, Brighton and Sussex Medical School, Brighton, UK
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Home-based drainage of refractory ascites by a permanent-tunneled peritoneal catheter can safely replace large-volume paracentesis. Eur J Gastroenterol Hepatol 2017; 29:539-546. [PMID: 28350743 DOI: 10.1097/meg.0000000000000837] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Refractory ascites has a poor prognosis. Recurrent large-volume paracentesis is the current standard of care; however, it results in circulatory dysfunction and renal dysfunction, and hospitalization is commonly required. Transjugular intrahepatic portosystemic shunt placement is not an option in a substantial number of patients because of contraindications. The placement of a tunneled peritoneal drainage catheter has been shown to be effective in patients with malignant ascites. However, data in patients with nonmalignant refractory ascites are rare. PATIENTS AND METHODS We followed 24 consecutive patients in whom tunneled peritoneal drainage catheters were placed in the Endoscopy Unit at Hannover Medical School between June 2013 and December 2014. RESULTS Catheters were placed in 24 patients with refractory ascites in end-stage liver disease and with a contraindication to transjugular intrahepatic portosystemic shunt placement. Placement was technically successful in all patients. The dosage of diuretics could be reduced significantly. The number of paracentesis decreased from 2.2±1 to 0 per week, although the volume of daily ascites removal remained stable (2 l). Despite frequent drainage of ascites, kidney function, serum sodium, and serum albumin remained stable. Seven adverse events occurred in six (25%) patients. Five patients listed for liver transplantation underwent successful transplantation without a negative impact. CONCLUSION The tunneled peritoneal drainage catheter placement is a viable and effective treatment alternative in patients with refractory ascites because of end-stage liver disease, reducing diuretic intake and the need for paracentesis. The procedure avoids hyponatremia, worsening kidney function, and albumin infusions without an increased risk of spontaneous bacterial peritonitis.
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Abstract
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.
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Affiliation(s)
- Maciej Stukan
- Department of Gynecologic Oncology, Gdynia Oncology Center, Szpitale Wojewodzkie w Gdyni Sp. z o.o., Gdynia, Poland
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Abstract
Given the severe shortage of physicians in Israel, the Ministry of Health issued a decree that offered advanced authority and responsibilities to experienced nurses; thus, the status of the nurse specialist (NS) was created. The role of NS in Israel is truly varied, incorporating many different facets that range from stabilizing to changing the existing palliative care (PC) orders, including those involving dosages and methods of care provision, issuing of repeat prescriptions, suspending drug treatment, and prescribing new drugs for a patient according to a protocol issued by a physician. The NS is also authorized to perform many clinical duties that frequently involve direct patient care. According to the different needs of the patients, he/she coordinates with the different members of the interdisciplinary team, who may be suitable to offer further help and support to the client and/or his/her significant others. His/her work keeps him/her in a constant dialogue with other health-care professionals, and as questions arise, he/she answers them and offers support to staff, patients, and family members. In the Middle East, the whole issue of PC is relatively new, and due to cultures, traditions, and religions, a number of difficulties have to be resolved.
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Affiliation(s)
- Suzanne Csorba
- Oncology Department, Hadassah Hospital, Jerusalem, Israel
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Hicks AM, Chou J, Capanu M, Lowery MA, Yu KH, O'Reilly EM. Pancreas Adenocarcinoma: Ascites, Clinical Manifestations, and Management Implications. Clin Colorectal Cancer 2016; 15:360-368. [PMID: 27262896 PMCID: PMC5099112 DOI: 10.1016/j.clcc.2016.04.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Revised: 03/28/2016] [Accepted: 04/27/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND Ascites develops in a subset of patients with pancreatic adenocarcinoma (PAC) at presentation or as the disease advances. Limited data exist on the prognostic importance of malignant ascites in PAC. Our hypothesis is that this information will provide an understanding of the natural history and facilitate management decisions. METHODS We conducted a retrospective analysis of 180 patients treated at Memorial Sloan Kettering Cancer Center diagnosed between January 1, 2009 and December 31, 2014, with PAC and with ascites either at presentation or that developed during the disease course. RESULTS For the 180 patients, the overall survival was 15 months. The time from diagnosis to ascites presentation was 11 months, and the survival time after ascites development was 1.8 months (range, 1.6-2.3 months; 95% confidence interval). Of 62 patients (34%) who had ascitic fluid analyzed, 36 (58%) had positive cytology. Fifty-one (82%) patients had a serum ascites albumin gradient ≥ 1, and 11 (18%) had serum ascites albumin gradient < 1. Sixty-four (36%) patients had their ascites managed solely by serial paracenteses. A total of 116 patients required a catheter; of these, 108 (93%) had a Tenckhoff catheter, 4 (3%) a Pleurx catheter, 4 (3%) a pigtail catheter, and 1 (1%) a Denver catheter. Eight (7%) patients required 2 catheters to be placed, and in 6 (5%), Tenckhoff catheters had to be removed. The main observed complications were spontaneous bacterial peritonitis in 7 (11%) managed with paracenteses versus 26 (23%) who had a catheter placed, catheter malfunction in 8 (7%), and acute renal failure in 6 (3%). After ascites development, 79 (44%) patients received active anti-cancer therapy, and 101 (56%) patients were managed with supportive care alone. CONCLUSIONS In patients with PAC who presented with or developed ascites, serial paracenteses and indwelling catheters are common methods used for providing symptomatic relief. The complication rate was higher with indwelling catheters, primarily related to infection (eg, bacterial peritonitis). Overall, ascites has a significantly negative prognostic import with a short median survival.
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Affiliation(s)
- Angel Mier Hicks
- Department of Medicine, Icahn School of Medicine at Mount Sinai/St. Luke's Roosevelt Hospital Center Program, New York, NY
| | - Joanne Chou
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Marinela Capanu
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Maeve A Lowery
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kenneth H Yu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Eileen M O'Reilly
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.
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Meyer L, Suidan R, Sun C, Westin S, Coleman RL, Mills GB. The management of malignant ascites and impact on quality of life outcomes in women with ovarian cancer. EXPERT REVIEW OF QUALITY OF LIFE IN CANCER CARE 2016; 1:231-238. [PMID: 30906877 PMCID: PMC6425954 DOI: 10.1080/23809000.2016.1185369] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Malignant ascites is one of the most common sequela of epithelial ovarian cancer. It causes significant symptoms and can have a detrimental impact on patient quality of life, especially in women with recurrent ovarian cancer. The management of symptomatic ascites consists of both mechanical treatments that aim to drain the peritoneal cavity, and medical therapies that prevent and diminish the development of ascites. Mechanical options include serial paracentesis, peritoneal catheters, and peritoneovenous shunts. Pharmaceutical treatments include diuretics, angiogenesis inhibitors, and other targeted agents. There is a perception, without formal analysis, that intractable ascites is less common in the taxane era of therapy. In this review paper, we highlight current and emerging therapeutic strategies, complications and contraindications, and their effects on patient quality of life.
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Affiliation(s)
- Larissa Meyer
- The University of Texas MD Anderson Cancer Center, Houston Texas, United States
| | - Rudy Suidan
- The University of Texas MD Anderson Cancer Center, Houston Texas, United States
| | - Charlotte Sun
- The University of Texas MD Anderson Cancer Center, Houston Texas, United States
| | - Shannon Westin
- The University of Texas MD Anderson Cancer Center, Houston Texas, United States
| | - Robert L Coleman
- The University of Texas MD Anderson Cancer Center, Houston Texas, United States
| | - Gordon B Mills
- The University of Texas MD Anderson Cancer Center, Houston Texas, United States
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Gu X, Zhang Y, Cheng M, Liu M, Zhang Z, Cheng W. Management of non-ovarian cancer malignant ascites through indwelling catheter drainage. BMC Palliat Care 2016; 15:44. [PMID: 27103467 PMCID: PMC4839130 DOI: 10.1186/s12904-016-0116-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 04/13/2016] [Indexed: 02/07/2023] Open
Abstract
Backgrounds Intra-abdominal placement of the Central Venous Catheter (CVC) was conducted to manage the ascites-related symptoms of non-ovarian cancer patients. The aim of this study is to document the efficacy of symptom relief and conduct survival analysis of non-ovarian cancer patients with malignant ascites who received paracentesis and indwelling catheter drainage. Methods Seventy eight patients received paracentesis and drainage. All patients who met the inclusion criteria were included in this study. The overall survival (OS) was defined as the interval between initial diagnosis and death. Since-paracentesis survival (SP-Survival) was defined as the interval between initial paracentesis and death. Results Hepatic cancer was the most frequent original cancer in this study. Peritoneal catheters remained in situ for a median of 13 days. No immediate complications, such as perforation of a viscus or excessive bleeding, were encountered during placement. All ascites-related symptoms improved after drainage compared with the baseline. There was a statistically significant improvement in the mean score for abdominal swelling (p < 0.001), anorexia (p = 0.023) and constipation (p = 0.045). Cancer type was shown to be an independent prognostic factor for overall survival length (p = 0.001). Serum albumin was an independent prognostic factor for SP-survival (p = 0.02). Conclusions Paracentesis and indwelling catheter drainage through CVC set is a useful method for improving painful symptom. Further research is needed to validate the findings.
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Affiliation(s)
- Xiaoli Gu
- Department of Integrated Therapy, Fudan University Shanghai Cancer Center, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Yuanyuan Zhang
- Department of Integrated Therapy, Fudan University Shanghai Cancer Center, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Menglei Cheng
- Department of Integrated Therapy, Fudan University Shanghai Cancer Center, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Minghui Liu
- Department of Integrated Therapy, Fudan University Shanghai Cancer Center, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Zhe Zhang
- Department of Integrated Therapy, Fudan University Shanghai Cancer Center, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Wenwu Cheng
- Department of Integrated Therapy, Fudan University Shanghai Cancer Center, Shanghai, 200032, China. .,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China. .,, #270, DongAn Road, Shanghai, 200032, People's Republic of China.
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Potosek J, Curry M, Buss M, Chittenden E. Integration of palliative care in end-stage liver disease and liver transplantation. J Palliat Med 2015; 17:1271-7. [PMID: 25390468 DOI: 10.1089/jpm.2013.0167] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Patients with end-stage liver disease (ESLD) have a life-limiting illness that causes multiple distressing symptoms and negatively affects quality of life (QOL). This population traditionally has not had much attention within the palliative care community. DISCUSSION This article provides an evidence-based review of palliative care issues that patients with ESLD and those awaiting liver transplant face, including approaches to prognosis, symptom management, advance care planning, and end-of-life care. CONCLUSION Tremendous opportunity exists to integrate palliative medicine into the care of these patients.
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Affiliation(s)
- Jamie Potosek
- 1 Department of Hematology/Oncology, Providence Regional Cancer Center , Lacey, Washington
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Meier M, Mortensen FV, Madsen HHT. Malignant ascites in patients with terminal cancer is effectively treated with permanent peritoneal catheter. Acta Radiol Open 2015; 4:2058460115579934. [PMID: 26346641 PMCID: PMC4548747 DOI: 10.1177/2058460115579934] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 03/10/2015] [Indexed: 02/01/2023] Open
Abstract
Background Malignant ascites is a pathological condition caused by intra- or extra-abdominal disseminated cancer. The object of treatment is palliation. In search of an effective and minimally invasive palliative treatment of malignant ascites placement of a permanent intra peritoneal catheter has been suggested. Purpose To evaluate our experiences with treatment of malignant ascites by implantation of a permanent PleurX catheter. Material and Methods A retrospective study was conducted, comprising 20 consecutive patients with terminal cancer, who had a permanent PleurX catheter implanted because of malignant ascites in the period from February to November 2014. Using the patients’ medical records, we retrieved data on patients and procedures. Results The technical success rate was 100%. Catheter patency was 95.2%, one catheter was removed due to dislocation. Ten patients (50.0%) experienced minor adverse events. No procedural difficulties were reported and there was no need for additional treatment of malignant ascites after catheter implantation. Median residual survival after catheter implantation was 27 days. Conclusion Implantation of a permanent PleurX catheter is a minimally invasive and effective procedure with only minor adverse events and a high rate of catheter patency in patients with malignant ascites caused by terminal cancer disease.
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Affiliation(s)
- Michelle Meier
- Department of Surgery, Section for Upper Gastrointestinal and Hepato-pancreatico-biliary Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Frank V Mortensen
- Department of Surgery, Section for Upper Gastrointestinal and Hepato-pancreatico-biliary Surgery, Aarhus University Hospital, Aarhus, Denmark
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Lawrance N, Kibriya N, Mullan D, Laasch HU. Fibrinolysis in the management of malignant ascites and nonfunctioning intraperitoneal tunneled catheters. GASTROINTESTINAL INTERVENTION 2015. [DOI: 10.1016/j.gii.2015.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Khirfan K, Hanson J, Alcorn J. Portal hypertension in alcoholic liver disease: can it be fixed? Dig Dis Sci 2015; 60:838-40. [PMID: 25647760 DOI: 10.1007/s10620-015-3562-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 01/22/2015] [Indexed: 12/09/2022]
Affiliation(s)
- K Khirfan
- Division of Gastroenterology and Hepatology, University of New Mexico School of Medicine, Albuquerque, NM, USA,
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45
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Stukan M, Leśniewski-Kmak K, Wróblewska M, Dudziak M. Management of symptomatic ascites and post-operative lymphocysts with an easy-to-use, patient-controlled, vascular catheter. Gynecol Oncol 2015; 136:466-71. [DOI: 10.1016/j.ygyno.2014.11.073] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 11/17/2014] [Accepted: 11/19/2014] [Indexed: 10/24/2022]
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Hahn KY, Kim HJ, Park HJ, Kim SW, Chang SY, Kim BK, Han KH, Hong SP. [A case of successful endoscopic clipping for iatrogenic colon perforation induced by peritoneal catheter insertion]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2014; 63:373-7. [PMID: 24953616 DOI: 10.4166/kjg.2014.63.6.373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Advanced cancer patients with refractory ascites often do not respond to conventional treatments including dietary sodium restriction, diuretics, and repeated large volume paracentesis. In these patients, continuous peritoneal drainage by an indwelling catheter may be an effective option for managing refractory ascites with a relative low complication rate. Peritoneal catheter-induced complications include hypotension, hematoma, leakage, cellulitis, peritonitis, and bowel perforation. Although bowel perforation is a very rare complication, it can become disastrous and necessitates emergency surgical treatment. Herein, we report a case of a 57-year-old male with refractory ascites due to advanced liver cancer who experienced iatrogenic colonic perforation after peritoneal drainage catheter insertion and was treated successfully with endoscopic clipping.
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Affiliation(s)
- Kyu Yeon Hahn
- Institute of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemungu, Seoul 120-749, Korea
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Lungren MP, Kim CY, Stewart JK, Smith TP, Miller MJ. Tunneled peritoneal drainage catheter placement for refractory ascites: single-center experience in 188 patients. J Vasc Interv Radiol 2013; 24:1303-8. [PMID: 23876552 DOI: 10.1016/j.jvir.2013.05.042] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Revised: 05/16/2013] [Accepted: 05/17/2013] [Indexed: 01/28/2023] Open
Abstract
PURPOSE To assess the success and safety of tunneled peritoneal drainage catheters for the management of ascites refractory to medical management. MATERIALS AND METHODS A total of 188 consecutive patients (83 male, 105 female; average age 59 y) with refractory ascites were treated with tunneled peritoneal drainage catheters from January 1, 2006, to August 10, 2012. A combination of fluoroscopic and ultrasound guidance was used to insert all catheters. Patient history, procedural records, and clinical follow-up documents were retrospectively reviewed. Clinical data (malignancy, renal disease, chemotherapy, neutropenia, albumin levels) were compared with respect to patency and complication rates with the use of odds ratios. Catheter survival curves were generated with the Kaplan-Meier method and life-table analysis for the cumulative and infection-free survival of primary and secondary catheters. RESULTS A total of 193 catheter placements or interventions were performed in 188 patients with refractory ascites: 170 catheters (93%) were placed for malignant etiologies and 13 (7%) for nonmalignant etiologies. The most common malignancies were ovarian (22%), pancreatic (12%), and breast (11%). The most common nonmalignant etiologies were end-stage liver disease (n = 7) and heart failure (n = 6). There was a 100% technical success rate for catheter insertion; no procedure-related deaths or major placement complications were identified. Catheter survival ranged from 0 to 796 days (mean, 60 d), with a total of 11,936 cumulative catheter-days. Fourteen postplacement complications were identified: five patients experienced catheter malfunction, four had leakage of ascites at the incisional site requiring suture placement, three had cellulitis of the tunnel tract, and two developed peritonitis. The annual complication event rate was 0.43 events per year (ie, 0.12 events per 100 catheter-days). Pancreatic malignancy was associated with a significantly increased rate of catheter malfunction (ie, occlusion). CONCLUSIONS Radiologic insertion of tunneled peritoneal drainage catheters demonstrated a 100% technical success rate for insertion and an acceptable complication rate for the management of refractory ascites.
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Affiliation(s)
- Matthew P Lungren
- Department of Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710, USA.
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Coupe NA, Cox K, Clark K, Boyer M, Stockler M. Outcomes of permanent peritoneal ports for the management of recurrent malignant ascites. J Palliat Med 2013; 16:938-40. [PMID: 23734592 DOI: 10.1089/jpm.2012.0535] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Ascites complicates many advanced malignancies, resulting in abdominal pain, discomfort, anorexia, nausea, and dyspnea. Percutaneous drainage relieves symptoms in the vast majority of patients. The aim of this study was to determine the course and outcomes in a consecutive series of patients with recurrent ascites managed with permanent peritoneal ports. METHODS A prospective longitudinal descriptive study from 2006 to 2011, involving patients treated at the Sydney Cancer Center (New South Wales, Australia). RESULTS AND CONCLUSIONS A total of 155 drainages were performed in 24 patients; 26% of drainages (n=40) in the patient's home and the remainder in the ambulatory care clinic. Grade 3 or higher adverse events occured in less than 25% of all draining procedures. An improvement in symptoms was demonstrated in almost half of all individual drainage procedures. Our findings suggest that peritoneal ports are efficacious, safe, and are associated with symptomatic relief in most patients.
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Kipps E, Tan DSP, Kaye SB. Meeting the challenge of ascites in ovarian cancer: new avenues for therapy and research. Nat Rev Cancer 2013; 13:273-82. [PMID: 23426401 PMCID: PMC4673904 DOI: 10.1038/nrc3432] [Citation(s) in RCA: 422] [Impact Index Per Article: 35.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Malignant ascites presents a considerable clinical challenge to the management of ovarian cancer, but also provides a wealth of opportunities for translational research. The accessibility of ascitic fluid and its cellular components make it an excellent source of tumour tissue for the investigation of prognostic and predictive biomarkers, pharmacodynamic markers and for molecular profiling analysis. In this Opinion article, we discuss recent advances in our understanding of its pathophysiology, the development of new methods to characterize its molecular features and how these findings can be used to improve the treatment of malignant ascites, particularly in the context of ovarian cancer.
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Affiliation(s)
- Emma Kipps
- The Institute of Cancer Research/Royal Marsden Hospital, Medicine, Downs Road, Sutton SM2 5PT, UK
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50
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Abstract
Ovarian cancer affects approximately 21,880 women and accounts for over 13,000 deaths annually in the United States. Although survival rates have improved over the past several decades, directly as a result of advances in chemotherapy and surgery, ovarian cancer continues to have high mortality rates. Understanding the multiple roles of surgery throughout the disease course is the focus of this review.
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