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Palliative Treatment of Malignant Ascites

Western Deep Levels Hospital Western Levels 2501, South Africa

I read with interest the article by M. J. O'Neill et al. [1] on the use of tunneled peritoneal catheters placed under sonographic and fluoroscopic guidance for the palliative treatment of malignant ascites. This practive appears to offer significant advantages over repeated paracenteses. However, both tunneled catheter drainage and repeated paracenteses have the disadvantage of removing protein and electrolytes along with the ascitic fluid. Because this unwanted result is not mentioned as a complication in the article, one assumes that it was not a problem in the relatively short periods that these terminally ill patients survived, but loss of protein would potentially be a problem in patients with a longer life expectancy.

The alternative treatment of intractable ascites is peritoneovenous shunting, which has until now been problematic because it requires invasive surgery and because blockage of the prosthetic shunt tubing frequently occurs. The recently described technique of peritoneosaphenous shunt placement [2, 3] which can be performed under local or spinal anesthesia and does not use prosthetic shunt tubing) requires relatively minor surgery and has the potential to conserve protein and avoid the risk of peritoneal infection. (The shunt placement uses more invasive surgery than tunneled peritoneal catheter placement but considerably less invasive surgery than LeVeen shunt insertion.)

I was fortunate to be involved in a peritoneosaphenous shunt program and reported preliminary experience at our institution in Doppler sonography assessment of these shunts in the initial description of this technique [3]. At this stage, our patient numbers are still too small for a more definitive report on the use of Doppler sonography in this setting. The role of Doppler sonography in the assessment of peritoneosaphenous shunts and the place of these shunts and of tunneled peritoneal catheters in the management of refractory ascites remains to be fully established. I look forward to further publications on these issues and would appreciate any comments that the authors of the article on tunneled peritoneal catheter placement [1] may have.

References

1. 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 2001;177:615 -618[Abstract/Free Full Text]
2. 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 -885[Medline]
3. Blaylock RSM, Emby D, Hopley M, Toogood JW. The peritoneosaphenous shunt for palliation of refractory ascites. S Afr J Surg 2001;39:83 -85

Reply

Massachusetts General Hospital Boston, MA 02114-2696

The procedure described by Blaylock et al. [1] is another useful and alternative means of therapy of refractory ascites, but it is more invasive than the procedure described in our article [2] and better suited for patients with longer life expectancies. The procedure we described is meant to be used only in patients with limited life expectancy, for whom palliation is the indication for therapy.

References

1. Blaylock RSM, Emby D, Hopley M, Toogood JW. The peritoneosaphenous shunt for palliation of refractory ascites. S Afr J Surg 2001;39:83 -85
2. 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 2001;177:615 -618

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Emby, D. J. Articles by O'Neill, M. J. Search for Related Content PubMed PubMed Citation Articles by Emby, D. J. Articles by O'Neill, M. J. Social Bookmarking                      What's this? Hotlight (NEW!) What's Hotlight?