Peritoneovenous Shunt Research Articles

Proximal splenic artery embolization for treatment of refractory ascites, a single-center experience.

Refractory ascites from portal hypertension can be managed with regular large-volume paracentesis (LVP) or transjugular intrahepatic portosystemic shunt (TIPS). Large-volume paracentesis is clinically unsatisfactory and many patients are ineligible or relatively contraindicated for TIPS or Denver shunt. Proximal splenic artery embolization (PSAE) using coils or plugs reduces but does not completely stop splenic arterial inflow, differing from distal splenic artery embolization techniques. By reducing splenic arterial inflow, splenic vein outflow is also decreased, lowering portal pressure and thus treating refractory ascites. In this institutional review board-approved single-center retrospective study, electronic medical records were reviewed to obtain demographics and baseline clinical and laboratory data, paracentesis data before and after PSAE, PSAE procedural details, and follow-up imaging up to 12months post-PSAE. Mixed-effects models were used for statistical analysis. Ten patients with LVP-dependent ascites meeting inclusion criteria underwent PSAE for refractory ascites from 2017 to 2024. Prior to PSAE, four patients had TIPS, three had liver transplants, and the remaining three were neither TIPS nor transplant candidates. In the month before PSAE, patients averaged 3.8±1.7 paracentesis sessions, draining a total of 20.84±10.39L of fluid monthly. Post-PSAE, the number of paracentesis sessions decreased to 2.1±2.7, 1.0±1.7, 0.4±1.1, and 0.0±0.0 at 1, 3, 6, and 12months, respectively (p=0.03). Corresponding ascitic volume drained decreased to 8.7±10.3, 2.7±6.4, 2.0±5.4, and 0.0±0.0L (p=0.01). Over the 12-month follow-up period, 6 of 10 patients became LVP-independent. Proximal splenic artery embolization can improve refractory ascites in certain patients with portal hypertension, thus providing safe and effective treatment as an alternative to TIPS.

Drainage of ascites in cirrhosis.

For cirrhotic refractory ascites, diuretics combined with albumin and vasoactive drugs are the first-line choice for ascites management. However, their therapeutic effects are limited, and most refractory ascites do not respond to medication treatment, necessitating consideration of drainage or surgical interventions. Consequently, numerous drainage methods for cirrhotic ascites have emerged, including large-volume paracentesis, transjugular intrahepatic portosystemic shunt, peritoneovenous shunt, automated low-flow ascites pump, cell-free and concentrated ascites reinfusion therapy, and peritoneal catheter drainage. This review introduces the advantages and disadvantages of these methods in different aspects, as well as indications and contraindications for this disease.

Narrative review of malignant ascites: epidemiology, pathophysiology, assessment, and treatment.

Malignant ascites (MA) is common in patients with advanced cancer, and about 60% of patients with MA experience distressing symptoms. In addition, MA has been identified as a poor prognostic factor, therefore, making the management of MA an important issue. We aimed to review literature describing MA provide a narrative synthesis of relevant studies. A literature search of articles published between 1971 and May 2023 was performed in PubMed, and Cochrane library using the words "ascites/malignant ascites" and the theme of each section. Authors independently selected the articles used and summarized. Finally, this manuscript was obtained consensus through discussed among all authors. The pathophysiological mechanism of ascites formation involves increased vascular permeability and impaired fluid drainage through the lymphatic system, which explain the occurrence of peritoneal carcinomatosis, portal hypertension due to liver tumors, liver cirrhosis in the background of hepatocellular carcinoma, and Budd-Chiari syndrome caused by tumor occlusion of the hepatic vein. The efficacy and safety of various treatments and procedures have been investigated previously; however, no treatment guidelines have been established yet. Diuretics and paracentesis are often selected as the first lines of treatment. Intraperitoneal drug administration (catumaxomab, bevacizumab, aflibercept, hyperthermic intraperitoneal chemotherapy, triamcinolone), indwelling peritoneal catheters, peritoneovenous shunting, and cell-free and concentrated ascites reinfusion therapy are commonly used to manage refractory ascites. A new device for this purpose is alfapump, which transfers ascites fluid from the peritoneum into the urinary bladder. In addition, thoracic epidural analgesia may be effective for managing ascites-related symptoms. Despite these options, no standard treatment for MA has been established yet because few trials have been conducted in this area. There are many issues to be investigated, and future research and treatment development are expected.

Chronological Course and Clinical Features after Denver Peritoneovenous Shunt Placement in Decompensated Liver Cirrhosis.

Refractory ascites affects the prognosis and quality of life in patients with liver cirrhosis. Peritoneovenous shunt (PVS) is a treatment procedure of palliative interventional radiology for refractory ascites. Although it is reportedly associated with serious complications (e.g., heart failure, thrombotic disease), the clinical course of PVS has not been thoroughly evaluated. To evaluate the relationship between chronological course and complications after PVS for refractory ascites in liver cirrhosis patients. This was a retrospective study of 14 patients with refractory ascites associated with decompensated cirrhosis who underwent PVS placement between June 2011 and June 2023. The clinical characteristics, changes in cardiothoracic ratio (CTR), and laboratory data (i.e., brain natriuretic peptide (BNP), D-dimer, platelet) were evaluated. Follow-up CT images in eight patients were also evaluated for ascites and complications. No serious complication associated with the procedure occurred in any case. Transient increases in BNP and D-dimer levels, decreased platelet counts, and the worsening of CTR were observed in the 2 days after PVS; however, they were improved in 7 days in all cases except one. In the follow-up CT, the amount of ascites decreased in all patients, but one patient with a continuous increase in D-dimer 2 and 7 days after PVS had thrombotic disease (renal and splenic infarction). The mean PVS patency was 345.4 days, and the median survival after PVS placement was 474.4 days. PVS placement for refractory ascites is a technically feasible palliative therapy. The combined evaluation of chronological changes in BNP, D-dimer, platelet count and CTR, and follow-up CT images may be useful for the early prediction of the efficacy and complications of PVS.

Massive neoplastic ascites

Peritoneal metastases frequently occur in primary or recurrent abdominal malignancy and are often associated with massive ascites, which determines severe abdominal bloating, respiratory distress, and poor quality of life in patients with few months of life. After the failure of traditional medical therapies, simple drainage is effective in providing temporary symptom relief but does not provide a durable solution. Several treatment options are available, but no standard treatment strategy has been established, and none of the treatments consistently showed the ability to extend life expectancy. This review focuses on outcomes and adverse events of simple drainage, catheter placement, intraperitoneal therapy, peritoneovenous shunting, hyperthermic intraperitoneal chemotherapy, early postoperative intraperitoneal chemotherapy, pressurized intraperitoneal aerosol chemotherapy, and cell-free and concentrated ascites reinfusion therapy. The choice between the available options for durable symptom management requires both care and caution in weighing risks and benefits according to the patient’s life expectancy.

Management of cirrhotic ascites: Seven-step treatment protocol based on the Japanese evidence-based clinical practice guidelines for liver cirrhosis 2020.

Liver cirrhosis is a severe illness, associated with multiple complications, which can lead to liver failure. One of the major complications of cirrhosis is ascites. This review describes a stepped treatment approach for the management of ascites in Japanese patients with cirrhosis. It is broadly based on the 2020 update of the Japanese clinical practice guidelines for liver cirrhosis, which is briefly compared with guidelines from Europe and the United States. Step 1 is sodium restriction at a level suitable for Japanese individuals (5-7 g/day), Step 2 is albumin treatment to counteract underlying hypoalbuminemia, Step 3 is initiation of diuretic treatment with spironolactone, followed by add-on loop diuretic treatment at Step 4. Patients refractory to sodium restriction and sodium diuretics can be treated with tolvaptan (Step 5) - a vasopressin V2 receptor antagonit that is available in Japan. Patients at Steps 6 and 7 have refractory ascites and are treated with large volume paracentesis (LVP) in combination with an albumin infusion. High-dose albumin infusion (6-8 g/L) at the time of LVP has recently become possible in Japan. Cell-free and concentrated ascites reinfusion therapy (CART) is also an option at Step 6. Two of the treatment options at Step 7 are limited in Japan (transjugular intrahepatic portosystemic shunts are not approved, and access to liver donors is very limited), but patients can undergo a peritoneovenous shunt if no other options are available. While challenges remain in the treatment of ascites, adopting this stepwise treatment approach may improve patient outcomes. This article is protected by copyright. All rights reserved.

Microsurgical Peritoneovenous Bypass for the Treatment of Recalcitrant Chylous Ascites.

New treatments for recalcitrant chylous ascites are needed to avoid sequelae associated with increased intraabdominal pressures, chyle loss, and diminished quality of life. An autologous microsurgical technique was developed to treat recalcitrant chylous ascites and restore normal physiology. A retrospective case series was performed for patients with recalcitrant chylous ascites surgically treated from 2018 to 2020. The authors included all patients with recalcitrant chylous ascites refractory to current standard-of-care interventions such as diet modifications, pharmacologic therapies, and peritoneovenous mechanical shunts. All were treated with microsurgical peritoneovenous bypass with a minimum follow-up of 12 months. Six patients were included over a 2-year period. Surgery was aborted for two patients (33%) with intraoperative venous reflux of the deep inferior epigastric vein, negative on preoperative ultrasound. One patient had a successful reoperation using the contralateral greater saphenous vein; the other elected for a chronic indwelling drain for chyle drainage. Among the five successful procedures (83%), ascites drainage decreased from a median preoperative volume of 1 L/day to postoperative volume of 0.06 L/day. Median hospital length of stay was 7 days (range, 212 to 194 days). Three patients had one complication each, including vancomycin-resistant Enterococcus , spontaneous bacterial peritonitis, and pulmonary embolism. All complications resolved with additional interventions. Median follow-up was 13.5 months (range, 12 to 27 months). Microsurgical peritoneovenous bypass was a reliable and reproducible autologous surgery for the treatment of recalcitrant chylous ascites at a minimum follow-up of 12 months. Therapeutic, IV.

Ascites With Honeycombed Appearance.

A 56-year-old woman presented with alcoholic cirrhosis with complications of ascites unless treated otherwise using diuretics (on furosemide, spironolactone, and tolvaptan) and ascites puncture. She had a history of alcoholic cirrhosis, obesity, and depression. A peritoneovenous shunt temporarily improved the ascites. Shunt obstruction worsened her abdominal distention a few weeks later. During the follow-up period, she had abdominal pain with a low-grade fever. Abdominal ultrasonography revealed significant ascites with a honeycombed appearance (Figure A); however, abdominal computed tomography did not indicate the same result (Figure B). The cell count analysis of the ascitic fluid revealed bacterial peritonitis. The infected shunt was removed, assuming that it caused the honeycombed appearance. Subsequently, ascites and abdominal distension improved. Four months after the shunt removal and continuous administration of antibiotics, abdominal ultrasonography results revealed decreased ascites without a honeycombed appearance (Figure C). Peritoneovenous shunt automatically injects ascites into the jugular vein. It can help effectively reduce the number of ascites. Although it is often effective in cases where liver function is relatively well maintained, and there is no hepatic encephalopathy, it is prone to complications such as peritonitis and heart failure, and shunt obstruction can easily occur.

Mitigation of Sarcopenia after Peritoneovenous Shunt Placement in Patients with Refractory Ascites

PurposeTo evaluate the effect of peritoneonvenous shunt placement on metrics of sarcopenia in patients with refractory ascites. Materials and MethodsAn institutional review board–approved single-institution retrospective analysis of all patients who underwent peritoneovenous shunt (Denver Shunt; BD, Franklin Lakes, New Jersey) placement (N = 29) and a comparator cohort of patients with cirrhosis who underwent serial paracentesis (N = 42) from 2009 to 2019 with baseline and follow-up cross-sectional imaging of at least 3 months was performed. Axial muscle area measurements (psoas, paraspinal, and total abdominal wall) were performed using free-hand region-of-interest technique. Patient records were reviewed for demographic characteristics, referring indication, laboratory studies, and performance status. Statistical analyses were performed with Student t test, Welch unequal variances, Fisher exact test, and Wilcoxon signed rank test. ResultsThe most common indications for peritoneovenous shunt placement were metastatic disease or cirrhosis. In the shunt cohort, there were no significant differences in the aggregate psoas muscle area (13.4 vs 14.0 cm2; P = .223) or paraspinal muscle area (43.0 vs 42.2 cm2; P = .471). In the paracentesis cohort, there were significant decreases in aggregate psoas (18.1 vs 15.7 cm2; P < .0001) and erector spinae (43.4 vs 39.9 cm2; P < .0001) muscle area. In addition, there was a significant decrease in serum albumin level (3.2 vs 3.0 g/dL; P = .015) and Eastern Cooperative Oncology Group performance status score (1.0 vs 1.3; P < .0001) in the paracentesis group, compared with no significant changes in the shunt cohort. ConclusionsIn patients with refractory ascites who are not candidates for transjugular intrahepatic portosystemic shunt placement, peritoneovenous shunt mitigates loss of truncal muscle and, in some instances, promotes muscle growth.

Current treatment options of refractory ascites in liver cirrhosis - A systematic review and meta-analysis.

Refractory ascites is a severe complication of liver cirrhosis and treatment options consist in large volume paracentesis, transjugular intrahepatic portosystemic shunt, alfapump®, peritoneovenous shunt and permanent indwelling peritoneal catheter. Our aim was to assess the efficacy, mortality and complications of each treatment. We performed a systematic review using Pubmed and Embase. Frequencies were summarized with Comprehensive Meta-Analysis Software. Seventy-seven studies were included. In patients with transjugular intrahepatic portosystemic shunt, 1-year mortality was 33% (95% CI 0.29-0.39, I2=82.1; τ2=0.37; p<0.001) with lower mortality in newer studies (26% vs. 44%). At 6 months, mortality in patients with alfapump® was 24% (95% CI 0.16-0.33, I2=0.00; τ2=0.00; p=0.83), 31% developed acute kidney injury (95% CI 0.18-0.48, I2=44.0; τ2=0.22; p=0.15). Mortality at 12 months was 44% (95% CI 32%-58%, I2=76.7, τ2=0.44, p<0.001) in peritoneovenous shunts and 45% (95% CI 38%-53%, I2=61.4, τ2=0.18, p=0.003) in large volume paracentesis, respectively. Overall mortality in patients with permanent indwelling catheters was 66% (95% CI 33%-89%, I2=82.5, τ2=1.57, p=0.001). Mortality in patients with transjugular intrahepatic portosystemic shunt was lower in newer studies, probably due to a better patient selection. Acute kidney injury was frequent in patients with alfapump®. Permanent indwelling catheters seemed to be a good option in a palliative setting.

Pleurovenous Shunt Placement for the Management of Nonmalignant Pleural Effusion.

Therapeutic thoracentesis is a first-line therapy in the management of patients with medically refractory, nonmalignant pleural effusion. However, when required in short intervals, serial thoracenteses can lead to increased procedure-related complications and negatively impact quality of life. Alternative treatment options vary depending on the etiology of fluid accumulation. Hepatic hydrothorax secondary to cirrhosis is a common cause of medically refractory pleural effusion encountered by interventional radiologists. In select patients in whom surgical pleurodesis, transjugular intrahepatic portosystemic shunt placement, and/or tunneled pleural catheter placement cannot be performed or provide inadequate relief, implantation of a pleurovenous (Denver) shunt may assist in palliation. The Denver shunt system allows decompression of pleural fluid into the central venous circulation by utilizing unidirectional valves and a manually operated subcutaneous pump. Though limited reports have described favorable technical and clinical success, more research is required to determine the safety and efficacy of this procedure. This article discusses pleurovenous shunt placement, postprocedure shunt evaluation, and potential associated complications.

Abstract No. 597 Rate of referral for durable therapy for refractory ascites: an unmet need

Transjugular intrahepatic portosystemic shunts (TIPS), peritoneovenous shunts (PVS), and peritoneal drains (PD) provide durable ascites control compared with large-volume paracentesis (LVP), with improved nutritional status, quality of life, and survival. Nonetheless, LVP remains the principal treatment for ascites with guidelines recommending durable therapies in limited populations or not at all. Purpose: Determine the prevalence of patients undergoing LVP for refractory ascites eligible for durable therapy (TIPS, PVS, PD), rate of referral for durable therapy, and barriers to referral.

Postoperative chylous ascites after total gastrectomy successfully treated using peritoneovenous (Denver) shunt: a case report

BackgroundChylous ascites (CA) is a rare complication of gastrectomy for gastric cancer. While most cases of postoperative CA improve with medication or nutritional support, some are refractory to conservative treatment. A peritoneovenous shunt (PVS) may help patients who are poor candidates for surgery. However, PVS placement for postoperative CA after gastroenterological surgery has been rarely reported. Herein, we present a case of postoperative CA following total gastrectomy with para-aortic lymphadenectomy, treated successfully by PVS placement.Case presentationA 74-year-old man who underwent total gastrectomy with para-aortic lymph node dissection was hospitalised because of insufficient oral intake and dehydration. His abdomen was markedly distended with severe bilateral lower extremity oedema. On admission, abdominal computed tomography (CT) showed a high volume of ascites and no signs of cancer recurrence. Accordingly, postoperative CA resulting from drainage of fluid on paracentesis was diagnosed. Despite nutritional support, diuretics, and octreotide administration, his abdominal distension and nutritional status did not improve. We could not identify the sites of lymphatic leakage in the three intranodal lymphangiographies followed by CT. Although we considered a surgical treatment in our patient, we decided against it. Because we could not identify lymphatic leakage site during lymphangiography, surgical treatment might have a potential failure of detection and closure of leakage site. Furthermore, the patient’s general condition was poor because of malnutrition resulting from the loss of lymphatic fluid. Consequently, we decided to place PVS. After PVS placement, his abdominal distension improved rapidly, and he was discharged without serious complications. Thirteen months after PVS, patient has no relapse of abdominal distention and nutrition status has improved.ConclusionPVS might be a good option to manage refractory postoperative CA, as the leakage point cannot be detected on lymphangiography.

Postoperative Adjuvant Chemotherapy Using a Denver Shunt for Refractory Ascites after Pancreatic Cancer Surgery: A Report of Two Cases

Postoperative Adjuvant Chemotherapy Using a Denver Shunt for Refractory Ascites after Pancreatic Cancer Surgery: A Report of Two Cases

An embolic stroke of undetermined cause that changed to a high‒flow patent foramen ovale after peritoneovenous shunting and was suspected to be due to catheter‒related thrombosis

An embolic stroke of undetermined cause that changed to a high‒flow patent foramen ovale after peritoneovenous shunting and was suspected to be due to catheter‒related thrombosis

Clinical practice guideline for the treatment of malignant ascites: section summary in Clinical Practice Guideline for peritoneal dissemination (2021)

Patients with peritoneal dissemination (PD) caused by abdominal malignancies are often associated with massive ascites, which shows extremely dismal prognosis because of the discontinuation of systemic chemotherapy mostly due to poor performance status. Many treatment methods, such as simple drainage, peritoneovenous shunting (PVS) and cell-free and concentrated reinfusion therapy (CART), have been used for symptom relief. However, the clinical efficacies of these methods have not been fully investigated yet. Recently, we developed the Clinical Practice Guideline for PD caused by various malignancies according to "Minds Clinical Practice Guideline Development Guide 2017". In this guideline, we systematically reviewed information on clinical diagnosis and treatments for PD using PubMed databases (2000 – 2020), and clarified the degree of recommendation for clinical questions (CQ). The evidence level was divided into groups by study design and quality. The literature level and a body of evidence were evaluated in reference to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Based on the results of systematic review, the strength of the recommendations was evaluated at a consensus meeting of the Guideline Committee. This is the English synopsis of the part of treatment of malignant ascites in Clinical Practice Guideline for PD, 2021 in Japanese. The guidelines summarize the general aspect of the treatment of malignant ascites and statements with recommendation strengths, evidence levels, agreement rates and future perspective for four raised clinical questions.

Peritoneovenous shunt as a palliative option in generalized lymphatic anomaly.

Peritoneovenous shunt as a palliative option in generalized lymphatic anomaly.

Radiologically Placed Peritoneovenous Shunt is an Acceptable Treatment Alternative for Refractory Ascites Due to End-Stage Liver Disease

PurposeTo compare patients treated with large-volume paracentesis (LVP), transjugular intrahepatic portosystemic shunt (TIPS), and peritoneovenous shunt (PVS) for ascites. Materials and MethodsA retrospective study of 192 patients treated with LVP (94), TIPS (75), or PVS (23) was performed. Records were reviewed for patient characteristics and outcomes. The patients’ age differed (LVP, 59.5 years; TIPS, 58.8 years; and PVS, 65.6 years; P = .003). Nonalcoholic steatohepatitis was the most common etiology in the PVS cohort (11/23, 47%), and hepatitis C in the TIPS (27/75, 36%), and LVP cohorts (43/94, 46%) (P = .032). The model for end-stage liver disease score was significantly different (LVP, 14; TIPS, 13; and PVS, 8; P = .035). Hepatocellular carcinoma was higher in the PVS cohort (6/23 patients, 25%) than in the TIPS (4/75, 5%), and LVP (12/94, 12%) cohorts (P = .03). ResultsEmergency department visits and hospital readmissions were the highest in the LVP cohort (40%, ≥2 readmissions, P < .001). Patients required fewer LVPs after TIPS (1.5 to 0.14, P < .001) or PVS (2.1 to 0.5, P = .019). In an unadjusted Cox model, patients in the TIPS cohort were found to have a 58% reduction in the risk of death compared with patients in the LVP cohort (P = .003). Transplant-free survival (PVS, 44 days; TIPS, 155 days; and LVP, 213 days) differed (log rank = 0.001). ConclusionsThe survival in the PVS and TIPS cohorts was similar, with less healthcare utilization than the LVP cohort. PVS is a satisfactory alternative to LVP.

Cocoon abdomen: bowels in a web

Cocoon abdomen is a rare, idiopathic condition characterised by fibrous encapsulation of the bowel segments giving an appearance of a cocoon. The patient may present with variable and non-specific symptoms like abdominal pain, tenderness, vomiting and it sometimes even leads to intestinal obstruction. We hereby report a case of 54-year-old male who presented with symptoms of intestinal obstruction. Apart from the sparing of 60 mm of the resection margin at either ends, most of the segment was encased by the peritoneum giving a ‘spider-web’ appearance. On opening the intestinal segment, there were multiple areas of kinking of the wall with narrowing of the lumen in the areas of the ‘cocooning’. No obvious mass lesion was identified either on the mucosal aspect or in the mesentery. Microscopic examination revealed that multiple loops of small bowel were tethered together by a loose, oedematous fibrovascular membrane. Sclerosing encapsulating peritonitis (SEP) is an extremely rare clinical entity and was first described by Foo et al. in 1978,1 in an adolescent girl, which is reported to be the most common age group. Our case was found in a middle-aged male, which differs in both age group and sex of the common incidence of this entity. The aetiology of this condition remains unknown; however there have been cases where the patients have had a prior abdominal surgery, abdominal tuberculosis, liver transplant or recurrent peritonitis.2 1.Foo KT, Ng KC, Rauff A, et al. Unusual small intestinal obstruction in adolescent girls: The abdominal cocoon. Br J Surg 1978; 65: 427–30.2.Stanley MM, Reyes CV, Greenlee HB, et al. Peritoneal fibrosis in cirrhotics treated with peritoneovenous shunting for ascites. Digest Dis Sci 1996; 41: 571–7.

Abstract No. 113 Mitigation of sarcopenia after Denver shunt placement in patients with refractory ascites due to cirrhosis

In patients with ascites due to portal hypertension, TIPS placement results in muscle gain and decreased overall mortality. When TIPS is contraindicated, peritoneovenous shunt (Denver shunt) is a viable alternative. We evaluated the effect of Denver shunts compared to large-volume paracentesis on sarcopenia in patients with refractory ascites secondary to cirrhosis.