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Technical Innovation |
1 Department of Internal Medicine, Section of Interventional Ultrasound, St.
Anna Hospital, 44100 Ferrara, Italy.
2 Division of Oncology, Civil Hospital, 47900 Rimini, Italy.
Received April 2, 2002;
accepted after revision May 30, 2002.
Address correspondence to S. Sartori.
Introduction
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Recently, O'Neill et al. [4] proposed a useful method to place a tunneled peritoneal catheter for the palliative treatment of recurrent malignant ascites. In a pilot study evaluating the efficacy of using intraperitoneal interferon to treat malignant effusions, we used a simple method of sonographically guided placement of a peritoneal catheter to drain ascites and infuse interferon [5]. All catheters remained in situ for 4-5 weeks and, despite the frequent manipulations of the device to administer the drug (six courses of treatment per patient), only two (4.9%) of 41 patients developed bacterial peritonitis. On the basis of these results, we planned to evaluate the same method to relieve abdominal symptoms caused by rapidly recurring ascites in patients with end-stage malignancies.
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In 16 patients, placement of the peritoneal catheter was performed in the sonography suite; in five patients, this procedure was performed at the bedside because the clinical conditions of these patients made moving them not advisable. Two grams of IV cefotaxime was administered prophylactically to all patients 1 hr before the procedure; no sedation was given. Each procedure was performed by one physician and one nurse. After the patient's abdomen had been shaved as needed, the physician identified the optimal area for catheter placement in the left or right lower abdominal quadrant by performing sonography using a system with a 3- to 6-MHz convex transducer (SSA-370A; Toshiba Medical Systems, Otawara, Japan). The abdominal wall was prepared with povidone-iodine solution, a local anesthetic (5-10 mL of 2% lidocaine) was administered, and a small skin incision was made. A small-bore catheter was then placed directly into the peritoneal cavity under sonographic guidance. The device used is also commonly used to drain pleural effusions and consists of a 9-French polyurethane catheter sliding inside an 11-French introducer needle, which is firmly connected with a small cylinder-shaped collection bag (Pleurocath; Plastimed, Saint-Leu-La-Foret, France). The distal portion of the catheter (10 cm) was placed inside the needle and the proximal portion (40 cm), inside the collection bag (Fig. 1). When the tip of the needle entered the peritoneal cavity, a small quantity of fluid seeped through the thin space between the catheter and the needle and appeared inside the collection bag, confirming access into the peritoneal space. The catheter was then pushed forward into the peritoneal cavity through the introducer needle, and the needle was contemporaneously pulled out together with the collection bag.
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After the catheter had been placed, the proximal tip of the catheter was
connected with a three-way stopcock, and the tube was secured to the skin with
a string nylon suture at the exit site. To ensure sterility of the system, the
physician placed the outer portion of the catheter inside a urostomy bag that
was fixed to the skin around the exit site by an adhesive urostomy patch.
Because the urostomy bag was considered suitable to keep the peritoneal
catheter sheltered from the external environment, but inadequate to collect
large amounts of fluid because of its low capacity (
100 mL), the urostomy
bag was connected with a larger single-use drainage bag to make the collection
of ascites more comfortable (Fig.
2). Finally, the catheter was opened without touching it directly
by turning the cock on from the outside of the urostomy bag, and ascites was
drained continuously or intermittently by turning alternatively the cock on
and off, passing from the urostomy bag to the collection bag. When the
single-use collection bag was completely filled with peritoneal fluid, the
filled bag was replaced with an empty one.
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TopIntroductionSubjects and MethodsResultsDiscussionReferences |
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The mean life span of the patients after catheter placement was 6.8 weeks (range, 1-12 weeks), and no symptomatic bacterial peritonitis was observed. In two patients (9.5%), the hole through which the catheter entered the abdomen became mildly enlarged, with leakage of peritoneal fluid and periosteum skin inflammation characterized by serous oozing and a 1.5-cm area of erythema around the hole. Both patients were satisfactorily treated with topical applications of micronized sulfadiazine silver; removal of the catheter was not necessary. In four patients, the catheter became clogged, but a nurse with the visiting service unclogged the catheter by flushing 50 mL of sterile saline solution via the stopcock. These reversible clogs of the catheter were not considered complications. None of the catheters became loose or dislodged. All patients died owing to the underlying disease, and all catheters were functioning at the time of the patients' deaths.
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TopIntroductionSubjects and MethodsResultsDiscussionReferences |
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Recently, O'Neill et al. [4] proposed a method for placing a tunneled peritoneal catheter that is similar to the method used for dialysis in patients with end-stage kidney disease [6]. The method was evaluated in 24 patients with peritoneal malignancies who had a short life expectancy. This method required both sonography and fluoroscopy equipment; the surgical procedure was minimally invasive and had a mean duration of 43 min. The technical success rate was 100%: all patients were relieved of their clinical symptoms for a mean life span of 7.2 weeks. In addition, the complication rate was fairly low (17%). These good results, better than those previously reported with other percutaneous treatments, make this procedure an interesting option for the treatment of patients with recurrent malignant ascites.
Our work suggests that our method represents a valid tool for the palliation of neoplastic peritoneal effusions. As reported previously [5], we obtained a low complication rate despite the frequent manipulations of the device used to infuse six courses of interferon into the peritoneal cavity. Each administration of interferon required removal of the protective urostomy bag, connection of the three-way stopcock with an infusion pump, disconnection of the stopcock from the pump, and placement of the outer portion of the peritoneal catheter into a new urostomy bag after interferon infusion had been completed. Nevertheless, none of the catheters became displaced, and only two of 41 patients developed symptomatic peritoneal infection.
The findings from our present study confirm and reinforce the results of our previous work. We achieved a 100% technical success rate, a complication rate (9.5% minor complications) that is lower than those obtained with other techniques, and no occurrence of symptomatic peritonitis. The ability to turn the cock on and off from outside the urostomy bag without directly manipulating the catheter likely played an important role in the successful avoidance of peritoneal infections.
The device that we used is fairly inexpensive. Moreover, the procedure
requires only sonography equipment and not fluoroscopy equipment, can be
performed by two operators (one physician and one nurse), can be performed at
the bedside, is minimally invasive, and is scarcely time-consuming. Based on
these characteristics, the direct placement of a peritoneal catheter using
sonographic guidance is likely to be more cost-effective than other
percutaneous techniques currently available. In our opinion, this procedure
can be considered for the palliation of recurrent malignant ascites in
patients with a short life expectancy (
4 months), thereby reserving other
more invasive and expensive techniques for patients with a longer life
expectancy.
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TopIntroductionSubjects and MethodsResultsDiscussionReferences |
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