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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Park J, Lee JJ, Lee JH, Shim YM. Treatment of Refractory Chylous Ascites with an Innovative Peritoneovenous Shunt: Temporary Usage of a Continuous Renal Replacement System: A Case Report. J Chest Surg 2022; 55:81-84. [PMID: 35115426 PMCID: PMC8824651 DOI: 10.5090/jcs.21.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/11/2021] [Accepted: 10/08/2021] [Indexed: 11/16/2022] Open
Abstract
Esophagectomy and esophageal reconstruction are commonly chosen as surgical options for esophageal cancer. However, prolonged untreated chyle leakage is associated with a poor prognosis. We report the case of a patient with refractory chylous ascites. To limit the ongoing fluid loss, we utilized the chylous ascites as an additional fluid source in a renal replacement therapy system. A continuous renal replacement therapy (CRRT) drainage system was modified to drain both the chylous ascites and venous blood. The ascites drainage rate was determined empirically and regulated by a dial-flow extension set. The CRRT mode was set to continuous venovenous hemodiafiltration and maintained for 7 days. After the patient was weaned from CRRT, ascites did not reaccumulate, and the patient's general condition improved dramatically. No infections related to the system occurred. This procedure temporarily alleviates symptoms and provides more time for alternative treatment strategies.
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Affiliation(s)
- Jiyoun Park
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Jun Lee
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Hee Lee
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Mog Shim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Abstract
Background Cerebrospinal fluid ascites is a rare complication of ventriculoperitoneal shunting and is the result of infection and subsequent peritonitis in the majority of cases. Sterile cerebrospinal fluid ascites in which no known infectious etiology is identified, is even more unusual. Case Presentation A 26-year-old female with Loeys-Dietz syndrome and congenital hydrocephalus treated with a ventriculoperitoneal shunt, was evaluated after developing new-onset ascites of unclear etiology after abdominal surgery for repair of an aortic aneurysm requiring multiple therapeutic paracenteses. Her serum ascites albumin gradient (SAAG) was greater than 1.1, suggestive of a portal hypertensive etiology. Gram stain as well as multiple cultures of her ascites fluid were both negative. Extensive investigation including hepatic venous portal gradient measurement and liver biopsy revealed no evidence of hepatic disease or portal hypertension. She was ultimately found to have sterile cerebrospinal fluid ascites which was treated successfully with a peritoneovenous shunt. Conclusion Sterile cerebrospinal fluid ascites is a rare clinical entity that has only been reported approximately 50 times in the medical literature. In this report, we also highlight it as a rare cause of high SAAG ascites. Moreover, we describe the use of a peritoneovenous shunt as a novel therapeutic option in the management of this condition.
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Affiliation(s)
- Darrick K Li
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Blake Building, 4th Floor, GI Unit, Boston, MA, 02114, USA.
| | - Jesse M Platt
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Blake Building, 4th Floor, GI Unit, Boston, MA, 02114, USA
| | - Jessica E S Shay
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Blake Building, 4th Floor, GI Unit, Boston, MA, 02114, USA
| | - Joseph C Yarze
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Blake Building, 4th Floor, GI Unit, Boston, MA, 02114, USA
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Joshi P, Thakur S, Tibballs J. Removal of Peritnoeo-venous-atrial shunt thrombus without cardiopulmonary bypass. Asian Cardiovasc Thorac Ann 2018; 26:387-389. [PMID: 29734836 DOI: 10.1177/0218492318776878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Thrombus formation is not uncommon in longstanding intracardiac catheters, but formation of a thrombus at the tip of a Peritnoeo-venous-atrial shunt, causing obstruction of the tricuspid valve, is a rare complication and frequently unrecognized. A large intracardiac thrombus causing valve obstruction requires surgical removal with the support of cardiopulmonary bypass which is associated with significant morbidity. We successfully removed a thrombus attached to the tip of peritoneovenous shunt without cardiopulmonary bypass in a 25-year-old man.
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Affiliation(s)
- Pragnesh Joshi
- 1 Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Nedlands, Australia.,2 University of Western Australia, Nedlands, Australia.,3 University of Notre Dame, Fremantle, Australia.,4 The Baird Institute, Sydney, Australia.,5 Department of Interventional Radiology, Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Sameer Thakur
- 1 Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Jonathan Tibballs
- 5 Department of Interventional Radiology, Sir Charles Gairdner Hospital, Nedlands, Australia
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Segawa T, Kato K, Kawashima K, Suzuki T, Ehara S. The influence of a peritoneovenous shunt for cirrhotic and malignant intractable ascites on renal function. Acta Radiol Open 2018; 7:2058460118764208. [PMID: 29623218 PMCID: PMC5881988 DOI: 10.1177/2058460118764208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 02/10/2018] [Indexed: 12/29/2022] Open
Abstract
Background Peritoneovenous shunts (PVS) are widely used for palliation of intractable ascites caused by peritoneal carcinomatosis (PC) or liver cirrhosis (LC). Some patients who need PVS have renal dysfunction. However, renal dysfunction is considered a relative contraindication. Therefore, it is important to assess renal function before PVS placement. Purpose To evaluate the relationship between PVS and renal function. Material and Methods Between October 2007 and July 2015, 60 patients (PC = 47; LC = 10; others = 3) underwent PVS placement for intractable ascites. Changes in estimated glomerular filtration rate (eGFR) and other adverse events (AEs) were retrospectively analyzed. Results Changes in eGFR before, one day after, and one week after PVS placement could be evaluated in 46 patients. The median eGFR before, one day after, and one week after was 56.5, 59.1, and 64.7 mL/min/1.73 m2, respectively (P < 0.05). These values were 61.6, 72, and 67.1 mL/min/1.73 m2, respectively, in PC patients (n = 34; P < 0.05) and 28.5, 27, and 37.2 mL/min/1.73 m2, respectively, in LC patients (n = 10; P < 0.05). In 17 patients with moderate to severe renal dysfunction (eGFR < 45), these values were 23.4, 23.7, and 30.5 mL/min/1.73 m2, respectively. The most frequent AE was PVS catheter obstruction, which occurred in 12 patients (20.7%). Clinical disseminated intravascular coagulation occurred in six patients (10.3%) and caused death in three patients (5.2%). Conclusion PVS placement for intractable ascites is associated with various AEs. However, PVS appeared to promote renal function, especially in patients with renal impairment.
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Affiliation(s)
- Takafumi Segawa
- Department of Radiology, Iwate Medical University, Morioka, Japan
| | - Kenichi Kato
- Department of Radiology, Iwate Medical University, Morioka, Japan
| | - Kazuya Kawashima
- Department of Radiology, Iwate Medical University, Morioka, Japan
| | - Tomohiro Suzuki
- Department of Radiology, Iwate Medical University, Morioka, Japan
| | - Shigeru Ehara
- Department of Radiology, Iwate Medical University, Morioka, Japan
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Hariharan D, Wilkes EA, Aithal GP, Travis SJ, Lobo DN. Spontaneous central venous thrombosis and shunt occlusion following peritoneovenous shunt placement for intractable ascites. Ann R Coll Surg Engl 2017; 99:e145-e147. [PMID: 28462645 DOI: 10.1308/rcsann.2017.0058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A 43-year-old man had a peritoneovenous shunt inserted for the treatment of chylous ascites secondary to myelofibrosis. Despite being on anticoagulation for superior mesenteric vein thrombosis, he developed shunt dysfunction within two weeks of insertion. Superior venacavography showed multiple filling defects in the right axillary vein, no filling of the right brachiocephalic and right subclavian vein, and thrombotic occlusion of the internal jugular veins bilaterally. The shunt was removed 11 days after insertion, and there was extensive thrombosis of the venous end of the shunt and the compressible pump chamber. Shunt thrombosis is known to occur but remains a rare complication, with 87% of such obstructions being due to a thrombus at the tip of the venous end of the shunt. Extensive thrombosis of the shunt (as in the present case) is very rare.
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Affiliation(s)
- D Hariharan
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham , UK
| | - E A Wilkes
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham , UK
| | - G P Aithal
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham , UK
| | - S J Travis
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham , UK
| | - D N Lobo
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham , UK
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Inoue Y, Hayashi M, Hirokawa F, Takeshita A, Tanigawa N. Peritoneovenous shunt for intractable ascites due to hepatic lymphorrhea after hepatectomy. World J Gastrointest Surg 2011; 3:16-20. [PMID: 21286221 PMCID: PMC3030739 DOI: 10.4240/wjgs.v3.i1.16] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Revised: 09/19/2010] [Accepted: 09/26/2010] [Indexed: 02/06/2023] Open
Abstract
A peritoneovenous shunt has become one of the most efficient procedures for intractable ascites due to liver cirrhosis. A case of intractable ascites due to hepatic lymphorrhea after hepatectomy for hepatocellular carcinoma that was successfully treated by the placement of a peritoneovenous shunt is presented. A 72-year-old Japanese man underwent partial resection of the liver for hepatocellular carcinoma associated with hepatitis C viral infection. After hepatectomy, a considerable amount of ascites ranging from 800-4600 mL per day persisted despite conservative therapy, including numerous infusions of albumin and plasma protein fraction and administration of diuretics. Since the patient’s general condition deteriorated, based on the diagnosis of intractable hepatic lymphorrhea, a subcutaneous peritoneovenous shunt was inserted. The patient’s postoperative course was uneventful and the ascites decreased rapidly, with serum total protein and albumin levels and hepatic function improving accordingly. For intractable ascites due to hepatic lymphorrhea after hepatectomy, we recommend the placement of a peritoneovenous shunt as a procedure that can provide immediate effectiveness without increased surgical risk.
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Affiliation(s)
- Yoshihiro Inoue
- Yoshihiro Inoue, Michihiro Hayashi, Fumitoshi Hirokawa, Nobuhiko Tanigawa, Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, 2-7 Daigaku-machi, Takatsuki City, Osaka 569-8686, Japan
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