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1 All authors: Department of Radiology, Massachusetts General Hospital, White 270, 55 Fruit St., Boston, MA 02114.
Received September 25, 2000;
accepted after revision March 5, 2001.
Address correspondence to M. J. O'Neill.
Abstract
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SUBJECTS AND METHODS. Of the 40 consecutive patients who presented with at least four therapeutic paracenteses in a 4-week period, 24 patients underwent the percutaneous tunneled procedure. All had malignant ascites.
RESULTS. All 24 patients had successful insertion of a permanent tunneled peritoneal drainage catheter. Eighteen were outpatients and six were inpatients. All patients were relieved of their clinical symptoms, including abdominal distention and dyspnea, and were relieved of lower extremity discomfort. The mean life span after catheter placement was 7.2 weeks. Twenty (83%) of the 24 patients were treated at home with their catheters in place. Three patients experienced minor complications from bacterial peritonitis, which responded to antibiotics. One patient had to have his catheter removed.
CONCLUSION. Percutaneous placement of specialized tunneled catheters appears to be a viable and safe technique in patients who have symptomatic ascites that require frequent therapeutic paracentesis for relief of symptoms.
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In the past, permanent peritoneal drainage catheters have not been considered viable treatment options for malignant ascites because of the concerns about complications related to infection, catheter malposition, and catheter occlusion [1, 2]. However, cuffed, silastic, tunneled, and peritoneal catheters have been used for many years, with acceptable complication rates, for dialysis in patients who have end-stage renal disease [3,4,5].
Generally, peritoneal catheters are placed in the operating room under sterile conditions. We report the results of a prospective study of 24 patients with end-stage, large-volume, malignant ascites in whom we percutaneously placed tunneled peritoneal dialysis catheters. Catheters were placed under sonographic and fluoroscopic guidance. We report the technical success rate, complication rate, and long-term results in this group of patients.
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Twenty-four (60%) of the 40 eligible patients elected to have the tunneled peritoneal catheter placement, and 16 patients (40%) decided to continue with repetitive therapeutic paracenteses. The latter group of patients had an average of one therapeutic paracentesis a week until they died. Fourteen of the patients undergoing tunneled catheter placement had ovarian cancer; six, pancreatic; two, lung; and one patient each, malignant thymoma and renal cell carcinoma. All 24 patients who chose to have tunneled catheters inserted had significant discomfort, fatigue, and diminished appetite related to their ascites. Eighteen patients also had significant lower extremity edema.
Patient Preparation
All 24 catheters were placed in patients in a radiology procedure room
containing both sonographic and fluoroscopic capabilities (Diagnost 76 Plus;
Phillips Medical Systems, Hamburg, Germany). All procedures were performed
using a general surgical sterile technique. Initially, each patient's hair was
shaved from the abdominal wall in the surgical field. The surgical field was
prepared initially with povidone iodine solution, followed by an alcohol
scrub. The operators, technologists, and patient were required to wear head,
face, and shoe coverings. Access to the room was restricted to the team
performing the procedure. The patients were prohibited from eating or drinking
6 hr before the procedure and received conscious sedation with midazolam and
fentanyl. Prophylactic preprocedure antibiotic coverage for skin flora with IV
cefazolin was also administered.
Radiologic Technique
Sonography was performed before the surgical scrub to localize an area in
the lower abdomen in which there was a large pocket of ascites. A lateral
location for initial access was preferred to facilitate a medially directed
subcutaneous tunnel (Fig. 1). This type of tunnel allows the exit site of the catheter to be close to
midline, a convenient place for access.
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After a site was selected and the patient was prepped, an 18-gauge sheathed needle (Longdwell; Baxter, Irvine, CA) was used to obtain access into the peritoneal cavity under sonographic guidance. After access was confirmed with aspiration of a small amount of ascites, a 0.038-Amplatz guidewire (Davis; Cook, Bloomington, IN) was placed through the sheath and coiled into the peritoneal cavity. Generally, the guidewire falls into the most dependent portion of the cavity, but this is not necessary to ensure adequate drainage. Under fluoroscopic guidance, serial dilatation was performed to allow passage of a 16-French peel-away sheath over the Amplatz guidewire into the peritoneal cavity.
Placement of the Catheter
The peritoneal catheter is made of polymeric silicone material and needs to
be prepared for passage through the peel-away sheath over the Amplatz
guidewire. Because the material is soft and has a high friction coefficient,
the catheter is difficult to slide over a guidewire and through a sheath. We
used a coaxial placement system. First, the peritoneal catheter was preloaded
onto a 120-cm, 5-French catheter (Davis; Cook). This was accomplished by first
feeding an Amplatz guidewire through the Davis catheter
(Fig. 2). Second, this assembly
was lubricated with a small amount of sterile gel and fed through the lumen of
the peritoneal catheter until the tip of the Davis catheter protruded out the
end of the dialysis catheter (Fig.
2). Third, the Amplatz guidewire was removed from this assemblage.
The outside of the peritoneal catheter was also lubricated with the sterile
gel and the entire assembly was introduced into the peritoneal cavity over the
original Amplatz guidewire that was coiled in the peritoneal cavity through
the 16-French sheath (Fig.
2).
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Once the peritoneal catheter was positioned in the peritoneal cavity, the sheath, guidewire, and Davis catheters were removed. The proximal portion of the catheter was attached to pressurized IV tubing and suction bottles, and the ascites drained while the subcutaneous tunnel was fashioned.
Subcutaneous Tunnel
The subcutaneous tunnel was formed in a lateral-to-medial direction.
Approximately 12 cm of subcutaneous tissue and skin along the tunnel path was
infiltrated with 2% lidocaine mixed with sodium bicarbonate.
Next, a plastic tunneling device similar to those used for Hickman catheters (Bard, Salt Lake City, UT) was passed from the initial catheter access point along the subcutaneous tissues into the anesthetized abdominal wall (Fig. 3). A small exit skin incision was made at the 12-cm mark so that the tunneling device could be delivered out of the tunnel. The catheter was then attached to the backside of the tunneling device (Fig. 3) and pulled through the subcutaneous tunnel to ensure that no kinking occurred in the tunnel. The portion of the peritoneal dialysis catheter that rests in the tunnel had two cuffs to secure the catheter and to protect the patient against tunnel infections. Care had to be taken to ensure that each of the cuffs was buried in the tunnel, approximately 1-2 cm from each skin incision site (Fig. 3).
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Securing the Catheter
The catheter was secured to the skin with a single purse-string nylon 3.0
suture at the exit site, and the insertion site was closed with a single
inverted subcutaneous absorbable 3.0 chromic suture and a steri strip
(Ethicon, Sommerville, NJ). Sterile dressing was applied to both sites with
instructions not to remove for 72 hr.
Outpatient Catheter Care
At discharge, all patients were provided with hospice care through the
Visiting Nursing Services. Both the patients and the nurses were given
specific instructions on wound care, catheter flushing, and fluid
drainage.
Continuous drainage was accomplished by attaching the catheters to a large drainage bag by connecting the tubing with a three-way stopcock for irrigation access.
Intermittent drainage was established by clamping the catheter. The nurses with the Visiting Nursing Services were instructed to access the catheter under sterile conditions, with the connecting tubing and vacuum bottles emptying 2-3 L of fluid at a time to maintain the patient's comfort. In both drainage scenarios, access to the catheters was performed under sterile conditions. The intermittent drainage approach involved more steps in connecting and disconnecting the catheter from the drainage bag. Because we believed that home care would be easier if the intermittent drainage approach were used, all patients were instructed to use this method of drainage.
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No immediate complications from the intermittent drainage treatment were noted. No patients died from hemorrhage or infection. None of the initial aspirates of ascites obtained during the procedure showed infection, nor did any patients have a fever during the first week of the procedure. Four (17%) of the 24 patients developed complications—three minor and one major. Four patients developed symptomatic bacterial peritonitis with positive ascites cultures at 22, 25, 28, and 33 days postplacement. All of these patients presented with abdominal pain and fever. Two of the four patients were treated at home with IV antibiotics, and two patients required hospitalization. Three of the four patients responded to IV antibiotics, with resolution of their fever and abdominal pain within 72 hr of therapy; the catheters remained in place and were functioning at the time of the patients' deaths. The fourth patient presented with both bacterial peritonitis and a tunnel infection at 33 days postplacement, and the catheter was removed. This patient was treated for 1 week with IV antibiotics, and his symptoms were resolved.
All four patients who developed bacterial peritonitis were discharged home with the intermittent drainage method. The three patients who were successfully treated for peritonitis had their ascites drained by the continuous drainage method, after resolution of their symptoms.
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Current long-term treatment options include a peritoneal-atrial valve [6] and peritoneovenous shunting [3, 7,8,9,10]. These treatments are effective but require invasive surgical procedures in a patient population in which palliation is the primary concern.
The use of percutaneously placed tunneled peritoneal catheters for the treatment of malignant ascites, to our knowledge, has not been previously reported. Several authors have described the percutaneous placement of tunneled peritoneal catheters for dialysis [11, 12], using a similar method of catheter delivery. Lorentzen et al. [13] described percutaneous placement of peritoneogastric shunts in five patients with malignant ascites. However, none of the shunts functioned more than a week after placement.
The technical success rates reported in our patient population are higher than those with other percutaneous treatments, such as repetitive paracentesis and peritoneogastric shunts [1, 3]; the technical success rates are also significantly higher than those reported for surgically placed peritoneal dialysis catheters [3]. The complication rate in our series was comparable with those rates reported for catheters placed surgically for the purpose of peritoneal dialysis [3, 7,8,9,10]. The rate of catheter removal was lower than for catheters placed surgically.
Statistically, it is difficult to say whether patients will have a lower infection rate if they were treated with the "continuous drainage" method as opposed to the "intermittent drainage" method. However, one can postulate that the bacterial peritonitis our patients exhibited was caused by the constant manipulation required to carry out the intermittent technique.
By adapting the surgical procedure of placing tunneled peritoneal catheters, we have shown a safe, effective, and minimally invasive way of treating malignant ascites in patients who have end-stage malignancies. With a permanent catheter, a visiting nurse can carry out the drainage of the peritoneal cavity, eliminating the need for multiple hospital visits. In patients with copious production of ascites, constant gravity drainage may be the simplest method of catheter care with intermittent flushing used to maintain catheter patency. In patients with slightly lower outputs or with relatively higher residual functional capacity, intermittent drainage is possible, but slightly more cumbersome.
In conclusion, tunneled peritoneal dialysis placement is a safe, effective, and minimally invasive option for palliative treatment of large-volume malignant ascites in patients with end-stage malignancies.
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