Indwelling Peritoneal Catheters for Managing Malignancy-Associated Ascites

Advances in the treatment of malignant ascites in China

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.

Exploring the Therapeutic Potential of Peritoneal Dialysis (PD) in the Treatment of Neurological Disorders

Peritoneal dialysis (PD) is a well-established renal replacement therapy commonly employed in clinical practice. While its primary application is in the treatment of kidney disease, its potential in addressing other systemic disorders, including neurological diseases, has garnered increasing interest. This study provides a comprehensive overview of the related technologies, unique advantages, and clinical applications of PD in the context of neurological disorders. By exploring the mechanism underlying PD, its application in neurological diseases, and associated complications, we addressed the feasibility and benefits of PD as an adjunct therapy for various neurological conditions. Our study aims to highlight its role in detoxification and symptom management, as well as its advantages over other universally accepted methods of renal replacement therapy. Our goal is to bring to the spotlight the therapeutic potential of PD in neurological diseases, such as stroke, stimulate further research, and broaden the scope of its application in the clinical setting.

Home-based, tunnelled peritoneal drainage system as an alternative treatment option for patients with refractory ascites

BACKGROUND

Onset of refractory ascites is the hallmark of end-stage liver disease. If liver transplantation (LTx) is not available and contraindications for a transjugular portosystemic shunt (TIPS) are present, repeated paracentesis remains the standard of care (SOC). Home-based, tunnelled peritoneal catheters (PeCa) have been suggested as an alternative treatment option. However, data on patients with cirrhosis are scarce.

AIM

To evaluate the safety of PeCa in these patients compared to SOC.

METHODS

Overall, 223 patients with cirrhosis, a contraindication for TIPS and refractory ascites were included in this retrospective study. PeCa implant was performed in 152 patients, whereas 71 were treated with SOC. Analysed end points included device explant-free survival, mortality, acute kidney injury (AKI) and hyponatraemia. In the second approach, propensity score matching (PPSM) was performed to adjust for confounding factors.

RESULTS

In patients with PeCa, median device explant-free survival was 74 days and 52 explants were recorded within the first 90 days. Within 90 days, patients with PeCa had lower mortality than SOC (p = 0.11), and spontaneous bacterial peritonitis (SBP) incidence did not differ (p = 0.82). Regarding AKI and hyponatraemia, there was a trend towards a higher incidence in the PeCa group (p = 0.13 and p = 0.08), and the risk for rehospitalisation was higher in those with a PeCa (HR: 2.11, p = 0.04). After PPSM, mortality was lower in the PeCa group (HR:0.40; p = 0.03), whereas the incidence of SBP and hyponatraemia was comparable (p = 0.80 and p = 0.28) and AKI was more frequent in those with a PeCa (p = 0.08).

CONCLUSION

The implant of PeCa allows home-based therapy of patients with cirrhosis and refractory ascites and a contraindication for TIPS. However, the risk for complications has to be considered and prospective studies are needed.

A Palliative Approach to Management of Peritoneal Carcinomatosis and Malignant Ascites

In addition to severe, life-limiting complications such as malignant bowel obstruction, fistulae, and malignant ascites, peritoneal carcinomatosis frequently causes life-impacting symptoms such as pain, nausea, anorexia, cachexia, and fatigue. A variety of medical, interventional, and surgical therapies are now available for management of both complications and symptoms. Although surgery in this population is often associated with a relatively high risk of morbidity and mortality, operative intervention can offer effective palliative treatment in appropriately selected patients. Early involvement of palliative care specialists as part of a multidisciplinary team is essential to providing optimal, holistic care of patients with peritoneal carcinomatosis.

Use of indwelling pleural/peritoneal catheter in the management of malignant ascites: a retrospective study of 48 patients

BACKGROUND

Patients suffering from malignant ascites usually require repeated large volume paracentesis (LVP) for symptomatic relief. This often requires hospital admission and has inherent risks.

AIMS

To report the first Australian experience of placing tunnelled indwelling peritoneal catheters (IPeC) for management of recurrent malignant ascites.

METHODS

A retrospective study was conducted of tunnelled IPeC use in patients with symptomatic malignant ascites in four hospitals in Western Australia (from 2010 to 2018). Procedure data, success rate and safety profile were collected from a database.

RESULTS

Forty-eight patients (median age 65 years; female 56%) underwent 51 peritoneal catheter insertion procedures that were performed mostly by pleural specialists. The majority of patients (96%) had prior LVP (median two drainages, interquartile range (IQR) 1-4) before IPeC insertion. The IPeC was inserted successfully under ultrasound guidance in all patients. The median length of hospital stay for IPeC insertion and initial ascites drainage was 2 days (IQR 2-3 days) and most patients (96%) did not require further paracentesis after IPeC placement. The majority (96%) of patients experienced relief from ascites symptoms after catheter insertion. Most IPeC-related adverse events were self-limiting, including pain (in 25% cases), transient hypotension after initial fluid drainage (10%), peritoneal fluid leakage (10%), bacterial peritonitis (8%), fluid loculation (2%) and catheter dislodgement (2%). Six (12%) patients had IPeC removed. All patients with bacterial peritonitis responded to antibiotics and one required catheter removal.

CONCLUSIONS

Use of tunnelled IPeC improves symptoms and can minimise further invasive drainage procedures in patients with symptomatic malignant ascites. Placement of IPeC was associated with a low rate of adverse events, most of which could be managed conservatively.

Management of Refractory Ascites Due to Portal Hypertension: Current Status

Refractory ascites is a costly and debilitating condition that occurs most frequently in the setting of substantial cirrhotic portal hypertension, where it portends a poor prognosis. Many treatment options are available, among them medical management, serial large volume paracenteses, transjugular intrahepatic portosystemic shunts, and implanted drainage devices. Although the availability of multiple therapies ensures that most patients will achieve satisfactory results, it can be challenging for the provider to select the appropriate treatment for each specific patient. This article reviews the available therapeutic options for refractory ascites and incorporates available data and clinical experience to suggest a linear stepwise management approach to enhance patient outcomes.

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

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

Permanent indwelling peritoneal catheters for palliation of refractory ascites in end-stage liver disease: A systematic review

BACKGROUND & AIMS

The incidence and mortality from end-stage liver disease is increasing, with a minority eligible for liver transplantation. Ascites is the commonest complication of end-stage liver disease and large volume paracentesis (LVP) the accepted management strategy where refractory to medical treatment. In malignant ascites, permanent indwelling peritoneal catheters (PIPC) are an established palliative intervention. The aims are to describe available data using permanent indwelling peritoneal catheters in refractory ascites due to end-stage liver disease.

METHODS

Using systematic review methodology, databases were searched (MEDLINE, EMBASE, CINAHL [The Cumulative Index to Nursing and Allied Health Literature], Google Scholar and Cochrane Database of Systematic Reviews from inception-March 2018), for studies combining ascites and palliative care. Inclusion and exclusion criteria were applied to results.

RESULTS

Following initial and updated searches, 225 studies were identified for full text review, 18 were eligible for final analysis. The studies displayed heterogeneity in design, reported on different indwelling catheters and were overall of low quality. Only one pilot randomised controlled trial was identified, of PIPC versus LVP, recruiting one patient into each arm. Technical insertion success was 100%, with low rates of non-infectious complications (<12%), none life threatening. Rates of bacterial peritonitis were not unacceptably high (12.7%), considering this was an end-stage liver disease population and only a minority utilising long-term prophylactic antibiotics. Only one study attempted quality-of-life assessments; none addressed potential health economic benefits.

CONCLUSIONS

Despite lack of well-designed studies, preliminary data suggests low significant complication rates; however safety and efficacy of permanent indwelling peritoneal catheters in end-stage liver disease remains to be confirmed. Further prospective randomised controlled trials are warranted, potentially translating permanent indwelling peritoneal catheters into improved palliative care in end-stage liver disease.

Palliation of malignant ascites

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.

Quality of life improves after palliative placement of percutaneous tunneled drainage catheter for refractory ascites in prospective study of patients with end-stage cancer

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.

The Palliative Management of Refractory Cirrhotic Ascites Using the PleurX (©) Catheter

Background. Treatment options are limited for patients with refractory cirrhotic ascites (RCA). As such, we assessed the safety and effectiveness of the PleurX catheter for RCA. Methods. A retrospective analysis was performed on all patients with RCA who have undergone insertion of the PleurX catheter between 2007 and 2014 at our clinic. Results. Thirty-three patients with RCA were included in the study; 4 patients were lost to follow-up. All patients were still symptomatic despite bimonthly large volume paracentesis and were not candidates for TIPS or PV shunt. Technical success was achieved in 100% of patients. The median duration the catheter remained in situ was 117.5 days, with 95% CI of 48-182 days. Drain patency was maintained in 90% of patients. Microorganisms consistent with spontaneous bacterial peritonitis (SBP) from a catheter source were isolated in 38% of patients. The median time to infection was 105 days, with 95% CI of 34-233 days. All patients were treated for SBP successfully with antibiotics. Conclusion. Use of the PleurX catheter for the management of RCA carries a high risk for infection when the catheter remains in situ for more than 3 months but has an excellent patency rate and did not result in significant renal injury.