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Table of Contents 
ORIGINAL ARTICLE
Year : 2019  |  Volume : 25  |  Issue : 1  |  Page : 57-60

Central venous catheter as peritoneal indwelling catheter for the management of recurrent malignant ascites: A case series


Department of Oncoanaesthesia and Palliative Medicine, Dr. B.R. Ambedkar IRCH, AIIMS, New Delhi, India

Date of Web Publication31-Jan-2019

Correspondence Address:
Dr. Sachidanand Jee Bharti
Room No: 139, Department of Oncoanaesthesia and Palliative Medicine, Dr. B.R. Ambedkar IRCH, AIIMS, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPC.IJPC_145_18

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 » Abstract 

Background: Malignant ascites is an accumulation of fluid in the peritoneal cavity due to the manifestation of terminal metastatic malignancies. Accumulation of ascitic fluid could cause abdominal distention, early satiety, and shortness of breath. The onset and progression of these symptoms are not only distressing but also cause deterioration of the quality of life. Malignant ascites is associated with poor prognosis with anticipated life expectancy ranging from 1 to 4 months. Therapeutic paracentesis is the mainstay of palliation for malignant ascites. It only provides a temporary relief of symptoms, ascites re-accumulates, and paracentesis has to be repeated. Objectives: The aim of this case series was to evaluate our experiences when treating malignant ascites with placement of central venous catheter in the peritoneal cavity, with special emphasis on patient satisfaction, comfort of caregiver, technical success, and adverse events. Methods: Five patients with advanced disease and recurrent malignant ascites who required multiple paracentesis were selected for placement of 7-FG triple-port Central venous catheter in the peritoneal cavity. Maximum fluids that can be tapped were removed in ward. Patients and their relatives were assessed for satisfaction with the procedure. Results: Out of 5 patients, 3 were female and 2 male (age between 46 and 62 years). Two patients had carcinoma gallbladder and one each of carcinoma ovary, breast, and prostate. All patients were followed up till 1 month from catheter placement. Patients and their relatives were well satisfied in terms of frequent hospital visit for paracentesis. Conclusion: In summary, we suggest that central venous catheter may be used as indwelling peritoneal catheter for the symptom management of recurrent malignant ascites. It provides a relatively safe and cost-effective alternative to serial large-volume paracentesis that requires multiple hospital admissions.


Keywords: Ascites, central venous catheters, paracentesis, quality of life, satisfaction scale


How to cite this article:
Ratre BK, Suvvari P, Hoda W, Roychoudhury P, Bharti SJ, Bhatnagar S. Central venous catheter as peritoneal indwelling catheter for the management of recurrent malignant ascites: A case series. Indian J Palliat Care 2019;25:57-60

How to cite this URL:
Ratre BK, Suvvari P, Hoda W, Roychoudhury P, Bharti SJ, Bhatnagar S. Central venous catheter as peritoneal indwelling catheter for the management of recurrent malignant ascites: A case series. Indian J Palliat Care [serial online] 2019 [cited 2019 Apr 20];25:57-60. Available from: http://www.jpalliativecare.com/text.asp?2019/25/1/57/251075



 » Introduction Top


Malignant ascites is an accumulation of fluid in the peritoneal cavity caused by peritoneal infiltration (50%), liver metastases (15%) causing secondary portal hypertension, lymphangitic carcinomatosis, lymphatic obstruction (20%), or a combination of these factors (15%).[1] Malignancies most commonly associated with ascites are gynecologic malignancies, especially ovarian cancer, gastrointestinal malignancies, breast cancer, and carcinoma of unknown primary.[2]

The recurrent accumulation of fluid can cause symptoms of abdominal distention, early satiety, and nausea. Patients often complain of shortness of breath, limited mobility, and lower extremity edema. In extreme cases, painful abdominal distension, vomiting, or intestinal obstruction due to bowel compression may occur. The onset and progression of these symptoms are not only distressing but also cause deterioration of the quality of life.[3] Malignant ascites is associated with poor prognosis with anticipated life expectancy ranging from 1 to 4 months.[4]

Treatment options available for malignant ascites include paracentesis, implantable peritoneal catheters, and peritoneovenous shunting. Drugs such as diuretics may be effective in some patients, particularly those with massive liver metastasis that causes portal hypertension. Therapeutic paracentesis is the mainstay of palliation for malignant ascites,[5] but it only provides a temporary relief of symptoms.

The aim of this case series was to evaluate our experience when treating malignant ascites with placement of central venous catheter in the peritoneal cavity, with special emphasis on patient satisfaction, comfort of caregiver, technical success, and adverse events.


 » Methods Top


Patients with terminal disease and recurrent malignant ascites who required multiple paracentesis were selected for placement of 7-FG triple-port central venous catheter in peritoneal cavity. After taking consent from patient and relative, the puncture site was located by ultrasound (curvilinear probe with frequency of 2–5 MHz). About 5–10 ml of 2% lignocaine was used for local anesthesia. Central venous catheter was placed in peritoneal cavity using Seldinger technique under ultrasound guidance [Figure 1]. All ports were checked by syringe aspiration; a collecting bag was connected with distal port, and details of using all ports and all kinds of connection were demonstrated and taught to patients' relative [Figure 2]. Maximum fluids that can be tapped were removed in ward. After complete satisfaction of patients and their relatives, a patient was discharged from the ward with exchange of contact details for future telephonic conversation. The primary caregiver was instructed to remove fluid when a patient had some symptoms due to fluid accumulation. It was also instructed not to remove more than 1 l of fluid in two consecutive days because fluid removal was done at home by a caregiver without supervision of any medical health-care professional.
Figure 1: Placement of guide wire using Seldinger technique

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Figure 2: Central venous catheter placed in peritoneal cavity

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Observation

Out of 5 patients, 3 were female and 2 were male (age between 46 and 62 years). Two patients were of carcinoma gallbladder and one each of carcinoma ovary, breast, and prostate. All patients were followed up till 1 month from catheter placement [Table 1]. There were no procedure-related complications during catheter insertion, and there were no major complications during follow-up. There was puncture site leak in one patient of carcinoma ovary on the 20th day of catheter insertion for which then the patient was called in the hospital and central venous catheter was removed. Catheter was functioning in all patients up to day 30 of placement. The patient and their relatives were well satisfied in terms of frequent hospital visit for paracentesis.
Table 1: Details of cases

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 » Discussion Top


There are multiple management options available such as diuretics, paracentesis, and implantable peritoneovenous shunting, but paracentesis is the mainstay for the symptom management of recurrent malignant ascites.[5] Case series suggest that approximately 90% of patients will respond symptomatically to paracentesis, with as little as a few liters of fluid removed.[6],[7] However, the effect of paracentesis is short lived and has to be repeated.[8] Repeated abdominal paracentesis requires frequent hospital trip; frequency should be guided by the patient's symptoms (distension of abdomen, pain, shortness of breath, and early satiety). Furthermore, repeated large volume paracentesis associated with multiple complications such as pain due to multiple needle puncture, hypotension, infection, intestinal perforation, hypoproteinemia, secondary peritonitis, fatigue, dizziness, and nausea contributes to the patient's dissatisfaction.[9] Patients often delay their hospital visit due to discomfort caused by procedure and wait till they experience a high level of pain and abdominal distension before scheduling their next visit.[10] Frequent hospital visits not only affect the quality of life of the patient but also it increases the burden on their caregivers. To overcome the drawback of multiple paracentesis, indwelling peritoneal drainage catheter was considered to be the first choice. Few studies reported the successful use of many different catheters for refractory ascites.[11],[12],[13]

In this case series, central venous catheter set for Seldinger technique was used for abdominal paracentesis. Few studies testified its safety, feasibility, and effectiveness in malignant ascites.[14],[15],[16] The central venous catheter has lots of advantages over other indwelling catheter such as simple technique of placement, whereas other methods are more invasive and may require operating room for placement.[17] Immediate complication, such as perforation and bleeding, was less. Catheter-induced peritonitis can also be reduced by placement of short length of catheter into the peritoneal cavity.[18],[19] Because of reduced flow rate with central venous catheter, the chances of paracentesis-induced circulatory dysfunction were also reduced.[20] Further flow rate can also be controlled by the interposition of three-way stopcock and governor between catheter hub and tube of collection bag. This was found to be simple and easy to manage by family members at home. The most commonly reported adverse event was catheter blockage which was resolved by simple flushing of the device. Other complications included pain and leakage around the catheter insertion site, which usually resolved spontaneously and did not require any intervention.[21],[22] One of our patients had catheter insertion site leak on the 20th days of placement, the patient called to attend the outpatient department, and the catheter was removed. Peritonitis rarely occurred in malignant ascites patient. Rosenberg et al. and Courtney et al. reported one case of peritonitis, respectively, in their study.[10],[21] Many other authors reported no case of peritonitis in their studies.[8],[15],[16],[22]


 » Conclusion Top


We suggest that central venous catheter may be used as indwelling peritoneal catheter for the symptom management of recurrent malignant ascites in advance cancer cases. It provides a relatively safe and cost-effective alternative to serial large-volume paracentesis that requires multiple hospital visits. Central venous catheter has high rates of patency and low rates of infection. In addition, the operation of central venous catheter is simple and easy to drain ascites fluid at home and obviates the need for patients and caregivers to make frequent hospital visit for repeated procedure.

Patient selection remains the mainstay for successful management, and in patients with malignant ascites and short expected survival, this technique seems to be effective.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 » References Top

1.
Enck RE. Malignant ascites. Am J Hosp Palliat Care 2002;19:7-8.  Back to cited text no. 1
    
2.
Muir JC. Ascites. In: Von Roenn J, Smith TJ, Loprinzi CL, von Guten CF, editors. Optimizing Cancer Care-The Importance of Symptom Management: ASCO Curriculum. Vol. 1. Dubuque (IA): Kendall/Hunt; 2001. p. 1-31.  Back to cited text no. 2
    
3.
Rosenberg SM. Palliation of malignant ascites. Gastroenterol Clin North Am 2006;35:189-99, xi.  Back to cited text no. 3
    
4.
Lacy JH, Wieman TJ, Shively EH. Management of malignant ascites. Surg Gynecol Obstet 1984;159:397-412.  Back to cited text no. 4
    
5.
Lee CW, Bociek G, Faught W. A survey of practice in management of malignant ascites. J Pain Symptom Manage 1998;16:96-101.  Back to cited text no. 5
    
6.
Becker G, Galandi D, Blum HE. Malignant ascites: Systematic review and guideline for treatment. Eur J Cancer 2006;42:589-97.  Back to cited text no. 6
    
7.
Saif MW, Siddiqui IA, Sohail MA. Management of ascites due to gastrointestinal malignancy. Ann Saudi Med 2009;29:369-77.  Back to cited text no. 7
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8.
Mercadante S, Intravaia G, Ferrera P, Villari P, David F. Peritoneal catheter for continuous drainage of ascites in advanced cancer patients. Support Care Cancer 2008;16:975-8.  Back to cited text no. 8
    
9.
Sudulagunta SR, Sodalagunta MB, Bangalore Raja SK, Khorram H, Sepehrar M, Noroozpour Z, et al. Clinical profile and complications of paracentesis in refractory ascites patients with cirrhosis. Gastroenterology Res 2015;8:228-33.  Back to cited text no. 9
    
10.
Rosenberg S, Courtney A, Nemcek AA Jr., Omary RA. Comparison of percutaneous management techniques for recurrent malignant ascites. J Vasc Interv Radiol 2004;15:1129-31.  Back to cited text no. 10
    
11.
Agah S, Tavakoli S, Nikbakht H, Najafi M, Al-Agha A. Central venous pressure catheter for large-volume paracentesis in refractory ascites. Indian J Gastroenterol 2014;33:310-5.  Back to cited text no. 11
    
12.
White J, Carolan-Rees G. PleurX peritoneal catheter drainage system for vacuum-assisted drainage of treatment-resistant, recurrent malignant ascites: A NICE medical technology guidance. Appl Health Econ Health Policy 2012;10:299-308.  Back to cited text no. 12
    
13.
Po CL, Bloom E, Mischler L, Raja RM. Home ascites drainage using a permanent tenckhoff catheter. Adv Perit Dial 1996;12:235-6.  Back to cited text no. 13
    
14.
Ye M, Pan HM, Wang HY, Lou F, Jin W, Zheng Y, et al. Catheterization-associated complications of intraperitoneal chemotherapy in advanced gastric cancer. World J Gastroenterol 2004;10:1372-4.  Back to cited text no. 14
    
15.
Gu X, Zhang Y, Cheng M, Liu M, Zhang Z, Cheng W, et al. Management of non-ovarian cancer malignant ascites through indwelling catheter drainage. BMC Palliat Care 2016;15:44.  Back to cited text no. 15
    
16.
Stukan M, Leśniewski-Kmak K, Wróblewska M, Dudziak M. Management of symptomatic ascites and post-operative lymphocysts with an easy-to-use, patient-controlled, vascular catheter. Gynecol Oncol 2015;136:466-71.  Back to cited text no. 16
    
17.
Rozenblit GN, Del Guercio LR, Rundback JH, Poplausky MR, Lebovics E. Peritoneal-urinary drainage for treatment of refractory ascites: A pilot study. J Vasc Interv Radiol 1998;9:998-1005.  Back to cited text no. 17
    
18.
O'Neill MJ, Weissleder R, Gervais DA, Hahn PF, Mueller PR. Tunneled peritoneal catheter placement under sonographic and fluoroscopic guidance in the palliative treatment of malignant ascites. AJR Am J Roentgenol 2001;177:615-8.  Back to cited text no. 18
    
19.
Lee A, Lau TN, Yeong KY. Indwelling catheters for the management of malignant ascites. Support Care Cancer 2000;8:493-9.  Back to cited text no. 19
    
20.
Coll S, Vila MC, Molina L, Gimenez MD, Guarner C, Solà R, et al. Mechanisms of early decrease in systemic vascular resistance after total paracentesis: Influence of flow rate of ascites extraction. Eur J Gastroenterol Hepatol 2004;16:347-53.  Back to cited text no. 20
    
21.
Courtney A, Nemcek AA Jr., Rosenberg S, Tutton S, Darcy M, Gordon G, et al. Prospective evaluation of the Pleur X catheter when used to treat recurrent ascites associated with malignancy. J Vasc Interv Radiol 2008;19:1723-31.  Back to cited text no. 21
    
22.
Meier M, Mortensen FV, Madsen HH. Malignant ascites in patients with terminal cancer is effectively treated with permanent peritoneal catheter. Acta Radiol Open 2015;4:1-7.  Back to cited text no. 22
    


    Figures

  [Figure 1], [Figure 2]
 
 
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