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Will V, Rodrigues SG, Berzigotti A. Current treatment options of refractory ascites in liver cirrhosis - A systematic review and meta-analysis. Dig Liver Dis 2022; 54:1007-1014. [PMID: 35016859 DOI: 10.1016/j.dld.2021.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 10/24/2021] [Accepted: 12/11/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Refractory ascites is a severe complication of liver cirrhosis and treatment options consist in large volume paracentesis, transjugular intrahepatic portosystemic shunt, alfapump®, peritoneovenous shunt and permanent indwelling peritoneal catheter. AIM Our aim was to assess the efficacy, mortality and complications of each treatment. METHODS We performed a systematic review using Pubmed and Embase. Frequencies were summarized with Comprehensive Meta-Analysis Software. RESULTS Seventy-seven studies were included. In patients with transjugular intrahepatic portosystemic shunt, 1-year mortality was 33% (95% CI 0.29-0.39, I2=82.1; τ2 = 0.37; p<0.001) with lower mortality in newer studies (26% vs. 44%). At 6 months, mortality in patients with alfapump® was 24% (95% CI 0.16-0.33, I2=0.00; τ2 = 0.00; p = 0.83), 31% developed acute kidney injury (95% CI 0.18-0.48, I2=44.0; τ2 = 0.22; p = 0.15). Mortality at 12 months was 44% (95% CI 32%-58%, I2=76.7, τ2 = 0.44, p<0.001) in peritoneovenous shunts and 45% (95% CI 38%-53%, I2=61.4, τ2 = 0.18, p = 0.003) in large volume paracentesis, respectively. Overall mortality in patients with permanent indwelling catheters was 66% (95% CI 33%-89%, I2=82.5, τ2 = 1.57, p = 0.001). DISCUSSION Mortality in patients with transjugular intrahepatic portosystemic shunt was lower in newer studies, probably due to a better patient selection. Acute kidney injury was frequent in patients with alfapump®. Permanent indwelling catheters seemed to be a good option in a palliative setting.
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Affiliation(s)
- Valerie Will
- Department for Visceral Surgery and Medicine, Inselspital, University Hospital of Bern, University of Bern, BHH D115, Freiburgstrasse 10, CH-3008 Bern, Switzerland; Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Susana G Rodrigues
- Department for Visceral Surgery and Medicine, Inselspital, University Hospital of Bern, University of Bern, BHH D115, Freiburgstrasse 10, CH-3008 Bern, Switzerland; Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Annalisa Berzigotti
- Department for Visceral Surgery and Medicine, Inselspital, University Hospital of Bern, University of Bern, BHH D115, Freiburgstrasse 10, CH-3008 Bern, Switzerland; Department of Biomedical Research, University of Bern, Bern, Switzerland.
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Jain A, Scavo L, Cross D, Marra SP, Nimgaonkar A. Exploring a New Management Option for Patients With Refractory Ascites: The PeriLeve Device. J Med Device 2020. [DOI: 10.1115/1.4048616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Abstract
Cirrhosis of the liver is often accompanied by refractory ascites, a condition characterized by fluid buildup in the peritoneal cavity that does not respond to diuretics or recurs shortly after therapeutic paracentesis. There are several management strategies in practice including large-volume paracentesis, transjugular intrahepatic portosystemic shunts, peritoneovenous shunting, and liver transplant. However, each of these options come with limitations such as high cost, poor efficacy, and increased risk of complications. This article explores a new management strategy with a novel biopowered shunt, the PeriLeve device, that moves fluid from the peritoneal cavity to the urinary bladder using natural changes in intra-abdominal pressure (IAP). By doing so, PeriLeve shifts the current paradigm of care from the hospital to the home which reduces costs to healthcare providers and patients while improving quality of life. The basic design of the pump consists of two check (i.e., one-way) valves on either side of a fluid filled cavity which is separated from an air cavity by an elastomeric membrane. This article presents benchtop testing results of a prototype PeriLeve pump. The performance of the pump was analyzed along six parameters: change in intra-abdominal pressure, valve opening pressure, membrane thickness, membrane stiffness, membrane surface area, and air cavity volume. Initial results indicate that, with future optimizations, the pump can ultimately move a clinically significant volume of fluid.
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Affiliation(s)
- Aseem Jain
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD 21287
| | - Laura Scavo
- Center for Bioengineering Innovation & Design, Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD 21287
| | - Damian Cross
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD 21287
| | - Steven P. Marra
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD 21287
| | - Ashish Nimgaonkar
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medicine, Baltimore, MD 21287; Center for Bioengineering Innovation & Design, Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD 21287
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Huang Y, Gloviczki P, Duncan AA, Fleming MD, Driscoll DJ, Kalra M, Oderich GS, Bower TC. Management of refractory chylous ascites with peritoneovenous shunts. J Vasc Surg Venous Lymphat Disord 2017. [DOI: 10.1016/j.jvsv.2017.03.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
Included among the most important renal complica tions of liver disease is progressive sodium retention leading to the formation of edema and ascites and the hepatorenal syndrome (HRS). When ascites is refractory to conventional treatment, the use of invasive proce dures such as reinfusion or dialytic ultrafiltration of as cites or the peritoneovenous shunt may be indicated. The possibility that continuous arteriovenous hemo filtration may be useful in removing fluid in patients who would not otherwise tolerate traditional hemodialysis has, because of its recent availability, been raised. Ther apy of HRS continues to be one of the most intriguing and vexing problems in clinical medicine. The use of hemodialysis with polyacrylonitrile membranes may be helpful in certain patients with HRS, especially in those with acute reversible liver injury. Although the peri toneovenous shunt has been reported to correct the renal functional disturbance, the results of the only two controlled studies available are inconclusive. Liver disease is frequently accompanied by a variety of alterations in renal function and electrolyte me tabolism [1]. These complications of liver disease range in severity from the clinically unimportant to problems requiring prompt and vigorous thera peutic intervention. In the present review, empha sis is placed on the management of the abnor malities of renal sodium handling and on acute intrinsic renal failure (ATN) and the hepatorenal syndrome (HRS), which often supervene in patients with severe liver disease. The reader is referred to Epstein [1,2] and Perez and colleagues [3] for more detailed expositions of the use of dialysis and ultrafiltration in treating renal complications of liver disease.
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Affiliation(s)
- Murray Epstein
- Nephrology Section, Veterans Administration Medical Center, and the Department of Medicine, University of Miami School of Medicine, Miami, FL
| | - Guido Perez
- Nephrology Section, Veterans Administration Medical Center, and the Department of Medicine, University of Miami School of Medicine, Miami, FL
| | - James R. Oster
- Nephrology Section, Veterans Administration Medical Center, and the Department of Medicine, University of Miami School of Medicine, Miami, FL
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5
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Thomas MN, Sauter GH, Gerbes AL, Stangl M, Schiergens TS, Angele M, Werner J, Guba M. Automated low flow pump system for the treatment of refractory ascites: a single-center experience. Langenbecks Arch Surg 2015; 400:979-83. [PMID: 26566989 DOI: 10.1007/s00423-015-1356-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 11/02/2015] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Ascites is a common complication of liver cirrhosis and represents the main cause of hospitalization among patients with cirrhosis. First-line therapy for those patients is the use of diuretics and dietary sodium restriction. However, 10 % of patients per year become therapy refractory to diuretic treatment with the need of repeated high-volume paracentesis or transjugular intrahepatic portosystemic shunt (TIPS). For these patients, an automated pump system (Alfapump/Sequana Medical) was developed. Here, we describe our single-center experience of ten consecutively implanted pump systems. PATIENTS AND METHODS Between 08/13 and 11/14, ten Alfapump systems were implanted in patients with refractory ascites all suffering from liver cirrhosis. Those patients were treated as a bridge to transplant (4/10) or as an end-stage therapy (6/10). Median follow-up was 165 days (23-379 days). RESULTS Postimplant, the need of paracentesis could be markedly reduced to a mean of 0.45 (0-4/month) per month. In eight patients, paracentesis was not needed after implantation of the pump system. The median daily output volume was 1000 ml/day (450-2000 ml/day). Prerenal insufficiency was a recurrent complication in the postoperative period. DISCUSSION The Alfapump system is a useful system in the treatment of patients suffering from therapy refractory ascites. However, due to the high level of comorbidities, careful patient selection and postoperative monitoring are required.
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Affiliation(s)
- M N Thomas
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, L.M., University of Munich, Campus Großhadern, Marchioninistrasse 15, 81375, München, Deutschland, Germany.
| | - G H Sauter
- Department of Medicine II, Klinikum Großhadern, L.M., University of Munich, Munich, Germany
- Liver Center Munich, Klinikum Großhadern, L.M., University of Munich, Munich, Germany
| | - A L Gerbes
- Department of Medicine II, Klinikum Großhadern, L.M., University of Munich, Munich, Germany
- Liver Center Munich, Klinikum Großhadern, L.M., University of Munich, Munich, Germany
| | - M Stangl
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, L.M., University of Munich, Campus Großhadern, Marchioninistrasse 15, 81375, München, Deutschland, Germany
| | - T S Schiergens
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, L.M., University of Munich, Campus Großhadern, Marchioninistrasse 15, 81375, München, Deutschland, Germany
| | - M Angele
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, L.M., University of Munich, Campus Großhadern, Marchioninistrasse 15, 81375, München, Deutschland, Germany
| | - J Werner
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, L.M., University of Munich, Campus Großhadern, Marchioninistrasse 15, 81375, München, Deutschland, Germany
| | - M Guba
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, L.M., University of Munich, Campus Großhadern, Marchioninistrasse 15, 81375, München, Deutschland, Germany
- Liver Center Munich, Klinikum Großhadern, L.M., University of Munich, Munich, Germany
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Won JY, Choi SY, Ko HK, Kim SH, Lee KH, Lee JT, Lee DY. Percutaneous peritoneovenous shunt for treatment of refractory ascites. J Vasc Interv Radiol 2008; 19:1717-22. [PMID: 18948021 DOI: 10.1016/j.jvir.2008.09.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2007] [Revised: 07/07/2008] [Accepted: 09/04/2008] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To evaluate the usefulness of a percutaneously placed peritoneovenous shunt (PVS) in patients with refractory ascites. MATERIALS AND METHODS Under fluoroscopic and ultrasonographic (US) guidance, the authors placed a PVS in 55 patients (39 men and 16 women; mean age, 56 years) with refractory ascites and symptomatic abdominal distention. The cause of ascites was liver cirrhosis (n = 36), carcinomatosis (n = 17), ruptured cysts with polycystic kidney disease (n = 1), and idiopathic refractory ascites (n = 1). The authors retrospectively evaluated technical feasibility, shunt patency, complications, and clinical outcomes of each patient. RESULTS The technical success rate was 100%, and symptomatic improvement was achieved in all but one patient. Complications occurred in 17 of the 55 patients (31%): five patients had variceal bleeding; three patients had ascites leakage; two patients each had disseminated intravascular coagulopathy, transient abdominal pain, shunt infection, and venous thrombosis; and one patient had pulmonary thromboembolism. Thirty patients (54%) died 2-690 days after the procedure (mean, 117 days), and their lifetime shunt patency was 84%. Eight patients were lost to follow-up. Seventeen patients were alive for 60-1,200 days, and their shunt patency was 71%. There was no significant difference in shunt patency between the two groups with benign and malignant ascites. CONCLUSIONS The percutaneous placement of a PVS was a technically feasible and effective method for symptomatic relief of refractory ascites.
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Affiliation(s)
- Jong Yun Won
- Departments of Radiology, Yonsei University College of Medicine, #134 Shinchon-dong, Seodaemun-gu, 120-752, Seoul, Korea
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7
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Dumortier J, Pianta E, Le Derf Y, Bernard P, Bouffard Y, Boucaud C, Sagnard P, Delafosse B, Boillot O. Peritoneovenous shunt as a bridge to liver transplantation. Am J Transplant 2005; 5:1886-92. [PMID: 15996235 DOI: 10.1111/j.1600-6143.2005.00959.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Intractable ascites carries great morbidity. The aim of this study was to determine the efficacy of peritoneovenous shunt (PVS) in patients listed for liver transplantation (LT). Between January 1999 and January 2004, PVS was inserted in 36 (30 males and 6 females) cirrhotic patients, 50.3 years of median age (range: 30-66), who failed multiple large-volume paracenteses and diuretic therapy, when listed for LT. Data were collected until LT or the present time, and were compared to an historical cohort (1997-1998) as control. No operative death occurred. Four patients died before LT in a median delay of 9 months after PVS insertion. PVS provided palliation for intractable ascites in 30 patients (83%). Renal function significantly improved (glomerular filtration rate (GFR) improved from 0.642 to 0.987 mL/s, p<0.05). Eighteen patients were transplanted in a median delay of 6 months (range: 3-12 months) after PVS insertion. When compared to the historical cohort of 18 patients, the occurrence of post-LT acute renal failure was significantly lower in the PVS group (3/18 vs. 13/18, p<0.05). Our results suggest that PVS might be beneficial in patients with refractory ascites waiting for LT and could prevent postoperative acute renal failure.
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Affiliation(s)
- Jérôme Dumortier
- Unité de Transplantation Hépatique, Fédération des Spécialités Digestives, Hôpital Edouard Herriot, Lyon, France.
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8
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Chen JH, Liu HD, Yu JC, Chen CJ, Shih ML, Liu YC, Hsieh CB. Modified saphenous-peritoneal shunt in refractory ascites: new technique. ANZ J Surg 2005; 75:128-31. [PMID: 15777390 DOI: 10.1111/j.1445-2197.2005.03315.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Refractory ascites is a serious complication for patients with decompensated liver cirrhosis. Saphenous-peritoneal shunting is a possible surgical treatment for its relief, but tends to lead to higher groin infections. The purpose of the present paper was to determine whether a modified procedure could resolve the problem and offer potential advantages over a peritoneo-venous shunt. METHODS Sixteen patients with refractory ascites who received modified saphenous-peritoneal shunts were studied. Clinical data such as bodyweight, abdominal girth, indocyanine green 15-min retention rate (ICG-15), serum bilirubin concentrations, Child-Pugh Score, creatinine clearance (C(Cr)), daily urinary output, urine sodium (U(Na)) and operative complications were recorded before, and 3 months after, surgery. RESULTS Three months after the operation, the urinary output, nutritional status and Child-Pugh scores had improved, but ICG-15 and total bilirubin output had not changed significantly. The C(Cr), U(Na) bodyweight and abdominal girth tended to decrease, but not significantly. No groin infections were noted following this procedure. CONCLUSIONS This modified procedure not only improved the nutritional status of cirrhotic patients with refractory ascites but also improved their quality of life. Infections and obstructions decreased in the short term. However, long-term follow up is mandatory. This new technique requires more practice and experience.
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Affiliation(s)
- Jia-Hui Chen
- Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defence Medical Centre, Taipei, Taiwan
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9
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Arroyo V, Colmenero J. Ascites and hepatorenal syndrome in cirrhosis: pathophysiological basis of therapy and current management. J Hepatol 2003; 38 Suppl 1:S69-89. [PMID: 12591187 DOI: 10.1016/s0168-8278(03)00007-2] [Citation(s) in RCA: 168] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Vicente Arroyo
- Liver Unit, Institute of Digestive Diseases, Hospital Clínic, Villarroel, 170, University of Barcelona, 08036 Barcelona, Spain.
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10
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Thuluvath PJ, Bal JS, Mitchell S, Lund G, Venbrux A. TIPS for management of refractory ascites: response and survival are both unpredictable. Dig Dis Sci 2003; 48:542-50. [PMID: 12757168 DOI: 10.1023/a:1022544917898] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Refractory ascites is a serious complication of advanced cirrhosis with a 1-year transplant-free survival of 20-50%. The aim of our study was to investigate the short- and long-term effects of transjugular intrahepatic portosystemic shunt (TIPS) in the management of refractory ascites. In all 65 patients (39 M, 26 F; Child B 55%, Child C 45%, mean MELD score 14.8 +/- 6.6) with liver disease (alcoholic 40%, cryptogenic 20%, HCV 14%, others 26%) and refractory ascites were included in this study. Forty-eight (74%) patients had no signs of hepatic encephalopathy (HE), 16 (24%) had mild and 1 (2%) had moderate HE before TIPS; 28 (43%) had mild (> 1.2 and < 2.4 mg/dl) and 6 patients (9%) had moderate (> 2.4 mg/dl) renal dysfunction. Mean follow-up was 55.5 +/- 70.2 weeks. Treatment success, defined as complete response, partial response, and no response, and survival was determined at 3 weeks, and 3, 6, 12, 24, and 36 months after TIPS. TIPS was successful in all patients. Mean portal venous pressure gradient improved significantly after TIPS (24 +/- 8 to 10 +/- 4). During follow-up, 40 (58%) patients died and 17 (27%) patients had liver transplantation (OLT); 20 (31%) patients had 38 shunt revisions due to lack of initial response or recurrence of ascites. The response was assessed in patients who were alive, without OLT, at each time point. Complete response was seen in 10%, 23%, 17%, 11%, 22% and 33%; partial response was seen in 46%, 46%, 40%, 44%, 28%, and 8%; and no response was seen in 44%, 31%, 43%, 41 %, 39%, and 50% at 3 weeks, and 3, 6, 12, 24, and 36 months respectively. There were no pre-TIPS variables that could predict the response at 3 weeks, 3 months, or 6 months. Mild HE was seen in 8 (12%) patients and severe HE was seen in 16 (25%) immediately after TIPS. The mortality at 3 weeks, and 3, 6, 12, 24, and 36 months was 26%, 38%, 46%, 51%, 57%, and 58%, respectively. Three-week (P = 0.01) and 3-month (P = 0.04) mortality was higher in Child C patients compared to Child B. However, there were no independent predictors of survival on multivariate analysis at 3 or 6 months. Child-Pugh score 3 weeks after TIPS was a strong predictor of mortality. In conclusion, in patients with refractory ascites, TIPS was associated with a high mortality and morbidity. The response and the mortality were both unpredictable on the basis of pretransplant variables.
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Affiliation(s)
- Paul J Thuluvath
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA
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11
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Vadeyar HJ, Doran JD, Charnley R, Ryder SD. Saphenoperitoneal shunts for patients with intractable ascites associated with chronic liver disease. Br J Surg 1999; 86:882-5. [PMID: 10417558 DOI: 10.1046/j.1365-2168.1999.01156.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Ascites is a common complication in patients with chronic liver disease. Some patients are resistant to diuretics and need therapeutic paracentesis on a regular basis. This is inconvenient in the long term and also has resource implications. Alternatively, these patients may be treated by peritoneovenous shunts, which require insertion of a foreign body into a central vein and are prone to occlusion. A new technique for peritoneovenous shunting without the use of foreign material is described. METHODS Eight patients with chronic liver disease and diuretic-resistant ascites underwent this procedure. During operation, the long saphenous vein was divided at the mid-thigh level and inverted towards the inguinal canal, where it was anastomosed directly to the peritoneum at the internal inguinal ring using non-absorbable suture material. RESULTS Seven patients had successful shunt formation; the remaining patient had to have the shunt removed because of ascitic leakage. In those who underwent successful shunt formation, the need for paracentesis and the dose of diuretic was significantly reduced over a median follow-up of 8 months. Hospital stay in the month after discharge was significantly less than that in the month before operation. Three patients died during follow-up from causes unrelated to the operation. One patient underwent successful liver transplantation. CONCLUSION This study suggests that saphenoperitoneal shunting is potentially a safe and effective therapy for patients with diuretic-resistant ascites. It retains the benefits of peritoneovenous shunting without the adverse effects of insertion of foreign material.
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Affiliation(s)
- H J Vadeyar
- Department of Gastroenterology, Queen's Medical Centre, Nottingham, UK
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12
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McGuire BM, Bloomer JR. Complications of cirrhosis. Why they occur and what to do about them. Postgrad Med 1998; 103:209-12, 217-8, 223-4. [PMID: 9479317 DOI: 10.3810/pgm.1998.02.361] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Cirrhosis is a chronic disease of the liver in which dense bands of fibrosis enclose regenerative hepatocellular nodules. Clinical and radiologic features of advanced liver disease provide presumptive evidence for the presence of cirrhosis. Major complications are related to the increased hepatic resistance, increased sodium and water retention, and hyperdynamic changes of the circulatory system. Patient management should consist of appropriate prophylaxis for the life-threatening complications of variceal bleeding and spontaneous bacterial peritonitis and treatment of other complications as signs and symptoms develop.
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Affiliation(s)
- B M McGuire
- Liver Center, University of Alabama at Birmingham 35294-0005, USA.
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13
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Katoh S, Kojima T, Itoh K, Yoneyama S, Ida K, Nakaji S. Usefulness of a nonmachinery based system for the reinfusion of cell-free and concentrated autogenous ascitic fluid. Artif Organs 1997; 21:1232-8. [PMID: 9423974 DOI: 10.1111/j.1525-1594.1997.tb00483.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
A nonmachinery based system using gravity dependent flow for the treatment and reinfusion of ascitic fluid was developed, and its usefulness was assessed. In a preliminary study using bovine plasma, samples with protein concentrations below 5.0 g/dl were found to be treatable with this system. Bovine plasma containing blood, prepared to 0.5% hematocrit and with a protein concentration of 3.0 g/dl, was also treatable. We conducted a clinical study of 1,799 treatment sessions (1,495 using a machinery based system and 304 using a nonmachinery based system) of 343 patients with ascites refractory to various treatments. The recovery ratio of protein from the original ascitic fluid was 96% using the nonmachinery based system and 77% with the machinery based system (p < 0.01). Of 253 continuous reinfusions of ascitic fluid using the nonmachinery based system, the original ascitic fluid at protein concentrations below 2.5 g/dl was treatable. Original ascitic fluid below a hematocrit of 0.7% (protein concentration, 1.4 g/dl) was also treatable. This new procedure was simple and time and labor saving; the high recovery ratio of protein also demonstrated the usefulness of the new system.
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Affiliation(s)
- S Katoh
- Department of Internal Medicine, Murakami Memorial Hospital, Asahi University, Gifu, Japan
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14
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Stanley MM, Reyes CV, Greenlee HB, Nemchausky B, Reinhardt GF. Peritoneal fibrosis in cirrhotics treated with peritoneovenous shunting for ascites. An autopsy study with clinical correlations. Dig Dis Sci 1996; 41:571-7. [PMID: 8617138 DOI: 10.1007/bf02282343] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Of 554 cirrhotics autopsied during 1975-1993, 69 had had peritoneovenous shunts. Generalized peritoneal fibrosis with cocoon formation was found in 26 (38%) of those with shunts but in only one of 485 without shunts (P = 0.00002). In 14/26 the fibrosis was asymptomatic, an incidental autopsy finding. Intestinal obstruction in 12/26 (46%), the only symptomatic manifestation, was fatal in five. The etiology of peritoneal fibrosis in shunted patients is unknown. The 26 patients with fibrosis had more prior abdominal operations, complicated abdominal wall hernias, and active biliary tract inflammations; the features differentiated them from the 43 patients without fibrosis. Scores in a 'peritoneal complication index,' that considered multiple risks in the same patients, were significantly higher in those with fibrosis. In addition to these peritoneal injuries or inflammations, the faster ascitic fluid circulation in shunted patients may have increased deposition of fibrin upon the peritoneum. Fibrogenic cytokines, thus spread throughout the abdomen from local sites, may have converted fibrinous adhesions to generalized peritoneal fibrosis.
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Affiliation(s)
- M M Stanley
- Department of Medicine, Hines Veterans Administration Hospital, Illinois, USA
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15
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Ginès A, Planas R, Angeli P, Guarner C, Salerno F, Ginès P, Saló J, Rodriguez N, Domènech E, Soriano G. Treatment of patients with cirrhosis and refractory ascites using LeVeen shunt with titanium tip: comparison with therapeutic paracentesis. Hepatology 1995; 22:124-31. [PMID: 7601403 DOI: 10.1002/hep.1840220120] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
It has recently been suggested that insertion of a titanium tip at the venous end of the LeVeen shunt drastically reduces the rate of shunt obstruction. To assess whether the LeVeen shunt with titanium tip improves the results obtained with therapeutic paracentesis, 81 patients with cirrhosis and refractory ascites were randomly assigned to therapy with paracentesis plus intravenous albumin (42 patients) or LeVeen shunt with titanium tip (39 patients). If patients were readmitted for ascites during follow-up, those in the first group were treated with paracentesis, and those in the LeVeen shunt group by the insertion of a new valve or a new shunt if obstruction was demonstrated. During first hospitalization, both treatments were equally effective in removing ascites. Complications were similar in both groups except for a higher rate of severe bacterial infection in the LeVeen shunt group. The mean duration of hospitalization was shorter in the paracentesis group than in the shunt group. During follow-up, the total number of readmissions and the number of readmissions for ascites were higher in the paracentesis group than in the shunt group (252 vs. 99, P < .001; and 193 vs. 43, P < .001, respectively). The total time in hospital, however, was similar (38 +/- 38 vs. 39 +/- 43 days, P = NS). Three patients had obstruction of the shunt during first hospitalization and 14 patients had a total of 22 obstructions during follow-up. Long-term survival was similar in both groups. The insertion of a titanium tip at the venous end of the LeVeen shunt does not prevent obstruction.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- A Ginès
- Department of Medicine, Hospital Clínic i Provincial, Barcelona, Spain
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16
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Oyer RA, Finch IJ. Use of a LeVeen shunt as a percutaneously placed abdominal drainage catheter for malignant ascites. J Vasc Interv Radiol 1995; 6:253-4. [PMID: 7787359 DOI: 10.1016/s1051-0443(95)71108-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- R A Oyer
- Department of Hematology and Oncology, John Muir Medical Center, Walnut Creek, CA 94598, USA
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17
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Bosch J, Bruix J, Mas A, Navasa M, Rodés J. Rolling review: the treatment of major complications of cirrhosis. Aliment Pharmacol Ther 1994; 8:639-57. [PMID: 7696453 DOI: 10.1111/j.1365-2036.1994.tb00342.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- J Bosch
- Liver Unit, Hospital Clínic i Provincial, University of Barcelona, Spain
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18
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Elcheroth J, Vons C, Franco D. Role of surgical therapy in management of intractable ascites. World J Surg 1994; 18:240-5. [PMID: 8042329 DOI: 10.1007/bf00294408] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Almost 10% of patients with cirrhosis and ascites develop intractable ascites. When large-volume paracentesis fails to relieve ascites, patients may be submitted to one of the three following surgical options: portosystemic shunting, peritoneovenous shunting, or liver transplantation. Portosystemic shunting is efficient in clearing ascites, but it is associated with a high rate of encephalopathy and liver failure. The indications for portosystemic shunting are therefore limited for treatment of intractable ascites and should be performed only in patients with good liver function in whom all other treatments failed. Peritoneovenous shunting has been associated with a high rate of early complications and valve obstruction. Improvements in perioperative care and in the material used have greatly reduced the operative risks and increased the patency rate. Mortality remains high in patients with severe liver failure or with a history of spontaneous bacterial peritonitis or variceal bleeding. Peritoneovenous shunting should not be done when these risk factors are present. In the absence of such risk factors, peritoneovenous shunting is a good procedure and may provide definitive relief of ascites and long-term survival in more than 50% of the operated patients. In patients with poor risk factors liver transplantation may be preferable, and the onset of intractable ascites in a patient with a severely compromised liver should trigger the indication of liver replacement.
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Affiliation(s)
- J Elcheroth
- Groupe de Recherche sur la Chirurgie du Foie et de l'Hypertension Portale, Université Paris XI, Clamart, France
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19
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Cooper SG, Iannone JP. LeVeen shunt insertion with use of a percutaneous translumbar approach to the inferior vena cava. J Vasc Interv Radiol 1993; 4:667-8; discussion 669-72. [PMID: 8219562 DOI: 10.1016/s1051-0443(93)71943-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Affiliation(s)
- S G Cooper
- Department of Radiology, St Vincent's Medical Center, New York, NY 10310
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20
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Rossaro L, Graziotto A, Bonato S, Plebani M, van Thiel DH, Burlina A, Naccarato R, Salvagnini M. Concentrated ascitic fluid reinfusion after cascade filtration in tense ascites. Dig Dis Sci 1993; 38:903-8. [PMID: 8482189 DOI: 10.1007/bf01295918] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
A new method for concentrated ascitic fluid reinfusion using a double ultrafiltration device is reported as 22 procedures in 20 cirrhotic patients (6 females, 14 males; median age 55 years, range 33-69) with tense, refractory ascites. Eight of the 20 patients had elevated creatinine levels. The mean time for each procedure was 189 +/- 82 min, during which a mean of 7.7 liters (1.3-13.3) of ultrafiltered ascitic fluid was removed and 613 ml (140-1700) of concentrated ascitic fluid rich in albumin (mean: 60 g, range 14-175) was reinfused. The procedure resulted in a mean weight loss of 8.1 kg (2.2-14.0) and a mean increase of 163 ml in urine output (24 hr). A reduction in the serum creatinine level (P < 0.05) and an increase in the plasma atrial natriuretic factor level (P < 0.02) 24 hr after reinfusion, while no changes in serum albumin, plasma and urinary electrolytes, plasma renin activity, aldosterone, and antidiuretic hormone levels were noted. Although minor evidence for a disturbance in coagulation was observed, there were no episodes of clinical bleeding. Four patients (20%) had transient chills or fever. Based upon this experience, it can be concluded that reinfusion of cascade filtered and concentrated ascitic fluid is a rapid, safe, and effective treatment for patients with tense ascites; it appears to have less side effects than more traditional methods and importantly does not require administration of heterologous plasma derivatives.
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Affiliation(s)
- L Rossaro
- Divisione di Gastroenterologia R. Farini, Universitá di Padova, Italy
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21
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Lewis WD, Sanchez H, Jenkins RL. Indications and technique for the use of the porto-renal shunt in the treatment of variceal hemorrhage. Am J Surg 1993; 165:336-40. [PMID: 8447538 DOI: 10.1016/s0002-9610(05)80838-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Although hepatic replacement has emerged as the most definitive treatment for patients with chronic liver disease with variceal hemorrhage, a significant number of patients remain better served by porto-systemic shunting. Historically, for those patients with coexisting ascites requiring side-to-side shunting, synthetic or autogenous graft material has been interposed between the portal vein and inferior vena cava when the two veins could not be brought into direct apposition. The porto-renal shunt, described in 1964 but rarely used, allows shunt construction without the use of synthetic materials. Six patients who recently underwent porto-renal shunting are described in order to clarify the indications for the use of this technique and to describe the technical aspects of its construction.
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Affiliation(s)
- W D Lewis
- Department of Surgery, New England Deaconess Hospital, Boston, Massachusetts
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22
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Elcheroth J, Franco D. Le cirrhotique face à la chirurgie : rôle de la dénutrition dans les complications infectieuses. NUTR CLIN METAB 1993. [DOI: 10.1016/s0985-0562(05)80193-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
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23
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Ngô Y, Messing B, Marteau P, Nouël O, Pasquiou A, Lavergne A, Rambaud JC. Peritoneal sarcoidosis. An unrecognized cause of sclerosing peritonitis. Dig Dis Sci 1992; 37:1776-80. [PMID: 1425080 DOI: 10.1007/bf01299875] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In a Caucasian woman with a history of ocular and pulmonary sarcoidosis, the occurrence of sclerosing peritonitis with exudative ascites but without any of the well-known causes of this syndrome prompts us to consider that sclerosing peritonitis is a manifestation of sarcoidosis. The dramatic improvement that occurred on corticosteroid therapy adds credibility to this previously unreported association.
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Affiliation(s)
- Y Ngô
- Service de Gastroentérologie, Hôpital Saint Lazare, Paris, France
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24
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Ginès P, Arroyo V, Vargas V, Planas R, Casafont F, Panés J, Hoyos M, Viladomiu L, Rimola A, Morillas R. Paracentesis with intravenous infusion of albumin as compared with peritoneovenous shunting in cirrhosis with refractory ascites. N Engl J Med 1991; 325:829-35. [PMID: 1875966 DOI: 10.1056/nejm199109193251201] [Citation(s) in RCA: 223] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND There is no satisfactory treatment for refractory ascites in patients with cirrhosis. Both peritoneovenous shunts and paracentesis have been used, but there is uncertainty about their relative merits. METHODS We studied 89 patients with cirrhosis and refractory ascites who were randomly assigned to receive either repeated large-volume paracentesis plus intravenous albumin or a LeVeen peritoneovenous shunt. Patients in the paracentesis group in whom recurrent tense ascites developed during follow-up were treated with paracentesis, and those in the peritoneovenous-shunt group with diuretic agents or by the insertion of a new shunt if there was shunt obstruction. RESULTS During the first hospitalization, ascites was removed in all 41 patients in the paracentesis group and in 44 of the 48 patients in the peritoneovenous-shunt group. The mean (+/- SD) duration of hospitalization in the two groups was 11 +/- 5 and 19 +/- 9 days, respectively (P less than 0.01). There were no significant differences in the number of patients who had complications or died. During follow-up, 37 patients in each group were hospitalized again. In the paracentesis group, the number of rehospitalizations for any reason (174 vs. 97 in the peritoneovenous-shunt group) or for ascites (125 vs. 38) was significantly higher, and the median time to a first readmission for any reason (1 +/- 1 vs. 2 +/- 2 months) or for ascites (2 +/- 2 vs. 8 +/- 17 months) was significantly shorter than in the peritoneovenous-shunt group. The total times in the hospital during follow-up, however, were similar in the two groups (48 +/- 49 and 44 +/- 39 days, respectively). Three patients had obstructions of their peritoneovenous shunts during their first hospitalizations, and 15 patients had a total of 20 obstructions during follow-up. Survival was similar in both groups. CONCLUSIONS The LeVeen shunt and paracentesis are equally effective in relieving refractory ascites. The former may provide better long-term control of ascites, but shunt occlusion is common and survival is not improved.
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Affiliation(s)
- P Ginès
- Liver Unit, Hospital Clínic i Provincial, Barcelona, Spain
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25
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Abstract
The presence of ascites may indicate a number of hepatic and extra-hepatic disorders. This situation requires comprehensive evaluation to determine the underlying cause. The evaluation and management of ascites in patients with known cirrhosis is very important since this manifestation of portal hypertension has a detrimental effect on the prognosis for such patients.
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Affiliation(s)
- J L Herrera
- Department of Medicine University of South Alabama, Mobile
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26
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27
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Stanley MM, Ochi S, Lee KK, Nemchausky BA, Greenlee HB, Allen JI, Allen MJ, Baum RA, Gadacz TR, Camara DS. Peritoneovenous shunting as compared with medical treatment in patients with alcoholic cirrhosis and massive ascites. Veterans Administration Cooperative Study on Treatment of Alcoholic Cirrhosis with Ascites. N Engl J Med 1989; 321:1632-8. [PMID: 2586565 DOI: 10.1056/nejm198912143212403] [Citation(s) in RCA: 158] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The optimal management of severe ascites in patients with alcoholic cirrhosis has not been defined. in a 5 1/2-year study, we randomly assigned 299 men with alcoholic cirrhosis, who had persistent or recurrent severe ascites despite a standard medical regimen, to receive either intensive medical treatment or peritoneovenous (LeVeen) shunting. We identified three risk groups: Group 1 had normal or mildly abnormal results on liver-function tests, Group 2 had more severe liver dysfunction or previous complications, and Group 3 had severe prerenal azotemia without kidney disease. For the patients who received the medical treatment and those who received the surgical treatment combined, the median survival times were 1093 days in Group 1, 222 days in Group 2, and 37 days in Group 3 (P less than or equal to 0.01) for all comparisons). For all the groups combined, the median time to the resolution of ascites was 5.4 weeks for medical patients and 3.0 weeks for surgical patients (P less than 0.01). Within each risk group, mortality during the initial hospitalization and median long-term survival were similar among patients receiving either treatment. However, the median time to the recurrence of ascites in Group 1 was 4 months in medical patients, as compared with 18 months in surgical patients (P = 0.01); in Group 2 it was 3 months in medical patients as compared with 12 months in surgical patients (P = 0.04). The median duration of hospitalization was longer in medical patients than in surgical patients (6.1 vs. 2.4 weeks in Group 1 [P less than 0.001] and 5.0 vs. 3.1 weeks in Group 2 [P less than 0.01]). Group 3 was too small to permit a meaningful comparison. During the initial hospitalization, the incidence of infections, gastrointestinal bleeding, and encephalopathy was similar among the medical and surgical patients. We conclude that peritoneovenous shunting alleviated disabling ascites more rapidly than medical management. However, survival was closely related to the severity of the illness at the time of randomization and was not altered by shunting.
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28
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Holm A, Halpern NB, Aldrete JS. Peritoneovenous shunt for intractable ascites of hepatic, nephrogenic, and malignant causes. Am J Surg 1989; 158:162-6. [PMID: 2757146 DOI: 10.1016/0002-9610(89)90368-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
A retrospective analysis of 54 patients with a peritoneovenous shunt inserted to control massive ascites refractory to conventional medical treatment is presented. The cause of ascites was hepatic in 29 patients (Group 1, 54 percent), malignant in 13 (Group 2, 24 percent), and nephrogenic in 12 (Group 3, 22 percent). The peritoneovenous shunt failed in 11 patients (20 percent): 6 in Group 1, 3 in Group 2, and 2 in Group 3. Shunt outflow obstruction (thrombosis) was the principal cause. Systemic sepsis in five patients and variceal hemorrhage in three were the factors responsible for most of the deaths (22 percent). Of the 42 patients who survived operation, the peritoneovenous shunt was effective in controlling the massive ascites in 37 (86 percent). Eight patients (15 percent), four with hepatic and four with nephrogenic ascites, survived 3 years or more without ascites. Removal of at least 50 to 70 percent of ascitic fluid at the time of shunt insertion was considered an important factor in decreasing morbidity and mortality. A peritoneovenous shunt can be effective for a long-term period in controlling massive ascites with an hepatic or nephrogenic cause in a selected group of patients; however, in patients with malignant ascites, although the benefit was substantial in half, the survival period did not exceed 6 months.
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Affiliation(s)
- A Holm
- Department of Surgery, University of Alabama School of Medicine, Birmingham
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29
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Yersin B, Glauser MP, Guze PA, Guze LB, Freedman LR. Experimental Escherichia coli endocarditis in rats: roles of serum bactericidal activity and duration of catheter placement. Infect Immun 1988; 56:1273-80. [PMID: 3281906 PMCID: PMC259807 DOI: 10.1128/iai.56.5.1273-1280.1988] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Studies were undertaken to investigate the relationship of the sensitivity of Escherichia coli to the bactericidal properties of serum and the ability of different strains to induce and sustain endocardial infection in rats. Strains of E. coli demonstrated different degrees of serum sensitivity, as determined by a method which employed concentrations of serum from 10 to 95% and periods of incubation as long as 24 h. The greater the serum sensitivity of the E. coli strain, the less able it was to initiate infection and the more rapidly it was spontaneously eliminated from established infections. Endocardial infection with E. coli was established by intravenous challenge in rats with polyethylene catheters passing through the aortic valve into the left ventricle. An E. coli strain of low serum sensitivity was used; the initiation of infection depended upon the length of time the catheter had been in place and, in addition, whether the catheter was in place at the time of bacterial challenge. Removal of the catheter permitted spontaneous sterilization of the endocardial vegetations. The time necessary for sterilization was in direct proportion to the length of time the catheter remained in place following bacterial challenge. If the catheter was not removed, sterilization of the endocardial vegetations did not take place. These studies suggest that serum bactericidal activity is an important host defense mechanism, acting to prevent the initiation of endocarditis in the case of highly serum-sensitive E. coli and to sterilize experimentally induced endocarditis in the case of less-serum-sensitive bacteria. The catheter used to induce nonbacterial endocardial vegetations favored the colonization of vegetations by E. coli, and it delayed the spontaneous sterilization of infected vegetations which occurred in relation to the susceptibility of the strain to the bactericidal properties of the serum. This effect of the catheter was not attributable to bacteria remaining viable in its lumen, nor was it attributable to inhibition of the bactericidal capacity of the serum as measured in vitro. Whatever the mechanism responsible for the catheter effect, experimental studies of the evolution of infections established with this technique must take into consideration the duration of catheter placement and whether and for how long it was present before or after inoculation with test bacteria.
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Affiliation(s)
- B Yersin
- Research Services, Veterans Administration West Los Angeles Medical Center, California
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30
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Abstract
Early obstruction of the venous tubing is a frequent complication after peritoneovenous (PV) shunting for ascites in cirrhosis and results in a high incidence of shunt failure. A titanium catheter tip, developed because of this material's thromboresistance, was employed in 13 consecutive cirrhotic patients receiving a LeVeen shunt for intractable ascites. While the mean interval before shunt occlusion was 4 +/- 3 months in our previous studies, none of the patients in the present series had venous catheter occlusion during follow-up, which averaged 8 +/- 2 months. The use of titanium in the venous tubing of PV shunts may significantly prolong the patency and function of these devices.
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Affiliation(s)
- D Franco
- Groupe de Recherche sur la Chirurgie du Foie, Hôpital Paul Brousse
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31
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Eriksen CA, Cuschieri A. [Peritoneovenous shunt in the treatment of therapy-refractory ascites]. LANGENBECKS ARCHIV FUR CHIRURGIE 1988; 373:47-56. [PMID: 3282133 DOI: 10.1007/bf01263261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- C A Eriksen
- Department of Surgery, Ninewells Hospital, Dundee, UK
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32
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Mestres CA, de Lacy AM, Pomar JL. Massive right atrial and ventricular thrombosis after peritoneovenous shunting treated by thrombectomy and tricuspid valvectomy. Ann Thorac Surg 1987; 44:205-6. [PMID: 3619545 DOI: 10.1016/s0003-4975(10)62045-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Intractable recurrent ascites usually is treated by peritoneovenous shunting. Several complications can occur after shunt implantation. One such complication, right ventricular thrombosis, was managed with atrioventricular thrombectomy and tricuspid valvectomy.
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33
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Arroyo V, Ginés P, Rodés J. Treatment of ascites in patients with cirrhosis of the liver. Intensive Care Med 1987; 13:154-61. [PMID: 3584645 DOI: 10.1007/bf00254698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Söderlund C. Denver peritoneovenous shunting for malignant or cirrhotic ascites. A prospective consecutive series. Scand J Gastroenterol 1986; 21:1161-72. [PMID: 3809991 DOI: 10.3109/00365528608996438] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
A Denver peritoneovenous (PV) shunt was inserted in 54 consecutive patients for relief of malignant (24 patients) or cirrhotic (30) refractory ascites. The median age of both groups was 58 years, and the most frequent diagnoses were gastrointestinal (15) or ovarian (7) cancers and alcoholic cirrhosis (25). Median survival time was 1.7 and 3.5 months (range, 0.1-15.5 and 0.1-50.5), and the 1-month mortality 42% and 27%, respectively. Postoperative 24-h urinary output increased by 2-31, and the 1-week weight reduction was 8 and 11 kg, respectively, compared with before shunting. Complete shunt failure was encountered early in two patients, due to catheter malposition and clotting. Four more patients experienced transient failure, for an early dysfunction rate of 11%. A shunt-related operative mortality of 6% was caused by pulmonary oedema (two patients) and sepsis (one patient). Shunt malfunction intervened in almost half (6 of 14) of the cancer patients surviving 1 month but was relieved in all but 1. In 3 of 22 cirrhotic 1-month survivors, the Denver shunt had to be removed owing to clotting or sepsis (2 patients) or revised because of blockage. Seven patients with cirrhosis are alive a median of 18 months (range, 2-51) after PV shunt surgery. Side effects were detected in 22 patients (41%): thromboembolism (9 patients), sepsis (7), initially bleeding oesophageal varices (3), DIC syndrome (2), postoperative hepatic coma (2), ascitic leakage (2), and pulmonary oedema (2). Patients with gastrointestinal cancers or severe cardiac disease did not benefit from the procedure. A history of hepatic encephalopathy or a serum bilirubin level above about 100 mumol/l was a bad prognostic sign. We could confirm the reported considerable morbidity and mortality after PV shunting, but also its efficiency in certain cases. Careful patient selection and follow-up study, timing of operation, and adherence to technical details are mandatory to improve the results.
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35
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