Home Ascites Drainage U sing a Permanent Tenckhoff Catheter


Christopher L. Po, Eric Bloom, Lora Mischler, Rasib M. Raja

Management of refractory ascites (RA) can be accomplished in many ways. Rapid recurrence wi// be a prob/em even with repeated paracentesis. We stud ied the use of a permanent Tenckhoff catheter (PTC) for drainage of RA in 10 patients. The cause of RA was cardiomyopathy in 7 patients, ma/ignancy with /iver metastasis in 2, and end-stage /iver disease in I patient. The vo/ume of ascites drained (AD) ranged from 0.5 7.0, with a mean of2.6. Mean b/ood pressure pre-AD was 112/68 mm Hg, and post-AD was 109/66 mm Hg (p > 0.05 ). Heart rate pre and post-AD was 80 bpm and 81 bpm, respective/y (p > 0.05). The number of ADs ranged from two to 63 (mean: 16). There was nofluid rep/acement during or post AD. There were no comp/ications or infections from AD. The mean interva/ between ADs was 7.8 days. Mean duration of survival was six months. All patients eventually expired

In conc/usion, PTC can be a usefu/ and safe a/ternative for draining RA at home in terminally ill patients. Comp/ications of repeated paracentesis are minimized, and the need for hospitalization is avoided. AD with PTC may be preferred to repeated paracentesis in RA.

Key words

Ascites, Tenckhoff catheter, paracentesis

From:

Albert Einstein Medical Center, Philadelphia, Pennsylvania, U.S.A.

Introduction

Therapy for ascites can be accomplished in many ways. This includes bed rest, fluid and salt restriction, diuretics, and paracentesis (1,2). Refractory ascites (RA) can be severe and can cause severe discomfort for the patient. Diuretics are often ineffective in RA (3). Repeated, large volume paracentesis with or without albumin replacement has been used for recurrent ascites (4). Problems seen with repeated paracentesis include patient discomfort, bleeding, and ascitic fluid leak (1). We studied the use of a permanent Tenckhoff catheter for home ascites drainage.

Patients and methods

The study includes 10 patients with refractory ascites. The cause of RA was cardiomyopathy in 7 patients, malignancy with liver metastasis in 2 patients, and end-stage liver disease in 1 patient.

A Tenckhoff catheter was inserted surgically. Ascites was drained immediately after the catheter was placed. All patients were trained to drain their ascites aseptically for one week. The blood pressure and heart rate both pre and post-AD were recorded. The amount of ascites drained (AD) and the interval between drainages were also recorded.

Results

The mean age of patients was 61 years old. The volume of ascites drained ranged from 0.5 L to 7 L, with a mean of 2.6 L. The blood pressure pre-AD was 112/68 mm Hg, and post-AD was 109/66 mm Hg (p > 0.05). The heart rate pre and post-AD was 80 bpm and 81 bpm, respectively (p > 0.05). The number of ADs ranged from two to 63, with a mean of 16.

The mean interval between ADs was 7.8 days. There was no fluid replacement during or post-ADs. There were no complications or infections from ADs. One patient had renal failure and was started on peritoneal dialysis. The mean duration of survival was six months.

Discussion

Severe RA has always been a problem for patients and medical staff. Conventional treatment of ascites, such as use of diuretics, fluid and salt restriction, and bed rest (5) , in the majority of cases will become refractory to these modes of treatment.

More aggressive forms of treatment for RA are the use of a peritoneovenous shunt (6) and repeated large volume paracentesis (I). The use of a shunt has fallen out of favor because of multiple complications such as bleeding, infection, peritoneal fibrosis, disseminated intravascular coagulation, sepsis, and pulmonary embolism (7). Recently, large volume paracentesis with or without albumin replacement is on a resurgence for the treatment of ascites. Several problems are seen with repeated paracentesis ranging from patient discomfort, bleeding, and infection to leakage of ascites.

We were able to eliminate some of the complications of ascites drainage by using a permanent Tenckhoff catheter (PTC). The blood pressure and heart rate pre and post-AD were not significantly different. There were no complaints of pain or symptoms related to a decrease in blood pressure. All patients were able to drain fluid without problems. Although no infections were encountered in this study, the population studied was small, and the longest period for AD was 18 months in one patient.

There is no doubt that infection is still going to be a major problem with this procedure. Patient education and use of an aseptic technique will prevent this complication. Although all patients generally felt better after ascites drainage with PTC, the PTC did not alter prognosis and survival.

In conclusion, PTC can be a useful, cost-effective, and safe alternative for drain~g RA at home in terminally ill patients. Complications of repeated paracentesis are minimized, and the need for hospitalization is avoided. Ascites drainage with PTC may be preferred to repeated paracentesis in RA. A study with a larger population has to be performed to confmn these fmdings.

References

  1. Gines P, Tit6 L, Arroyo v:' et al. Randomized comparative study of therapeutic paracentesis with and without intravenous albumin in cirrhosis. Gastroenterology 1988; 94:1493-502.
  2. Runyon BA. Antillon MR. Montano AA. Effect of diuresis versus therapeutic paracentesis on ascitic fluid opsonic activity and serum complement. Gastroenterology 1989; 97:15~2.
  3. Lai KN, Li P, Law E, et al. Treatment of refractory ascites: is dialytic ultrafiltration better than paracentesis? Hepatology 1992; 15(2):356-7.
  4. Tit6 L, Gines P, Arroyo V, et al. Treatment of ascites with a single total paracentesis. Hepatology 1991; 13(5):1005-7.
  5. Quinterro E, Arroyo V, Bory F, et al. Paracentesis versus diuretics in the treatment of cirrhotics with tense ascites. Lancet 1985; i:611-12.
  6. Stanley MM, VenDrunen M, Greenlee HB. Peritoneovenous shunt function 2-6 years after insertion for cirrhotic ascites. ASAIO Trans 1989; 38: 170--4.
  7. Eckhauser FE, Strodel WE, Girardy JW, Turcotte JG. Bizarre complications ofperitoneovenous shunts. Ann Surg 1981; 193:180--4.
Corresponding author:
Christopher L. Po, MD, Albert Einstein Medical Center, Kraftsow Division of Nephrology, 5501 Old York Road, Philadelphia, Pennsylvania 19141 U.S.A.