Peritoneovenous Shunt Research Articles

More on the Management of Ascites

Malignant disease accounts for approximately 10% of all cases of ascites, which is defined as an abnormal accumulation of fluid in the peritoneal cavity. It most commonly occurs in advanced ovarian carcinoma as well as in breast, lung, and gastrointestinal cancers, although 1 in 5 patients with malignant ascites may have cancers of unknown origin. Troublesome symptoms include abdominal distension, early satiety, dyspnea, nausea, and reduced mobility. The pathophysiology of malignant ascites is complex and multifactorial. Ascites may result from the mechanical obstruction of lymphatic drainage by tumor cells leading to incomplete absorption of intraperitoneal fluid and protein, especially in patients with breast cancer and lymphoma. Due to the high protein content of the fluid, increased vascular permeability has been implicated in the etiology. The accumulation of ascites from obstructed lymphatics can lead to a reduction in the circulating blood volume which, in turn, activates the rennin–angiotensin–aldosterone system causing sodium retention. It is for this reason that sodium restriction and diuretics are most often used to manage ascites. There is no generally accepted gold standard for the management of malignant ascites. Paracentesis and diuretics are most commonly employed followed by peritoneovenous (PV) shunting or permanent drainage, dietary measures, and systemic or intraperitoneal chemotherapy. In 2006, Becker et al published an article trying to make sense of the treatment of malignant ascites as well as offering some management guidelines. They undertook a literature search for articles published between 1966 and August 2005, utilizing strict inclusion criteria including the use of abdominal paracentesis, diuretics, and PV shunting in the treatment of symptomatic ascites. Thirty-two studies were identified and none were randomized clinical trials. Abdominal paracentesis provides symptomatic relief in 90% of the patients. Complications of this procedure include secondary peritonitis, pulmonary embolism, and hypotension. It is this last complication that is most concerning to clinicians especially with regard to infusion fluids or albumin during the procedure. Becker et al note that studies in the setting of liver disease report that up to 5 L of ascitic fluid can be removed quickly without the risk of significantly affecting the plasma volume or kidney function. Also, symptomatic improvement occurs with the removal of a few liters, ranging from 0.8 to 15 L, with a mean of 5.3 L and median of 4.9 L. In this issue, Zama and Edgar report a case series of homebased paracentesis in 6 hospice patients. Of 6 patients, 4 had chronic liver disease and the remaining 2 patients had breast cancer and soft tissue sarcoma, respectively. All had failed diuretics and prior paracentesis. The median survival from last paracentesis to death was 38.4 days with a range of 6 to 57 days. The procedure was done without ultrasound guidance and any untoward complications. In this first of a kind report, the authors conclude that home-based therapeutic paracentesis in symptomatic patients is both safe and effective, providing less burden to the patient and family. The use of diuretics in the management of malignant ascites is inconsistent. As noted by Becker et al, a survey of physicians on the use of diuretics showed that 61% prescribed them, however, only 45% felt them to be effective. Overall, slightly less than half (43%) of the patients respond no matter what the underlying tumor be. Spironolactone is a commonly used diuretic and raises the plasma rennin level which, as noted previously, can be lowered causing sodium retention. Furthermore, there is a suggestion that ascites due to extensive liver metastases responds better to diuretics than ascites caused by peritoneal carcinomatosis or chylous ascites. After failing paracentesis and diuretics, PV shunting becomes a consideration. The PV shunts were first developed to control the ascites associated with cirrhosis and later used in patients with malignant ascites. The concept of the PV shunt is quite simple and involves draining the fluid in the abdominal cavity back into the systemic circulation. There are 2 types of shunts, that is, the LeVeen and the Denver shunts. The LeVeen shunt drains the fluid into the superior vena cava via a 1-way valve opening at a pressure of 3 cm H2O. Although the Denver shunt was developed to prevent occlusion by proteinaceous material, the valve opens at a positive pressure gradient of 1 cm H2O preventing detectable reflux. Contraindications include hemorrhagic ascites, high ascitic fluid protein content (greater than 4.5 g/L), loculated ascites, portal hypertension, bleeding disorders, and cardiac and renal failures. About 6% of the patients will sustain a major complication such as pulmonary edema, pulmonary emboli, clinically relevant disseminated intravascular coagulation (DIC), and infection. When PV shunting was initially reported, there was great concern that

Complete Remission of Refractory Hepatic Hydrothorax in Patient with Advanced Liver Cirrhosis and Hepatocellular Carcinoma Using Transjugular Intrahepatic Portosystemic Shunt

Hepatic hydrothorax is defi ned as the presence of pleural fl uid (> 500 mL) in the absence of primary cardiac or pulmonary disease. It occurs in approximately 5% to 10% of patients with advanced cirrhosis. In most cases, it is associated with ascites. However, there have been some cases those are not related to ascites. The possible causes include hypoalbuminemia, hypertension of the azygous vein, defects in the tendinous portion of the diaphragm, and lymphatic leakage through the thoracic duct. It is mostly rightsided (85%), but may also be left sided (13%) or bilateral (2%). Initial treatments consist of a low salt diet, diuretics, and thoracentesis. If these are not eff ective, other modalities should be considered. For example, pleurodesis, surgical repair of the diaphragmatic leakage, insertion of a peritoneovenous shunt, and liver transplantation has been tried. Th e transjugular intrahepatic portosystemic shunt (TIPS) placement is one of the modalities for treatment of hepatic hydrothorax. However, the eff ect of TIPS was contradictory. We report here a case of hepatic hydrothorax that was treated with TIPS.

Peritoneovenous Shunt for Chylous Ascites after Lung Transplantation for Lymphangioleiomyomatosis

A 37-year-old woman with lymphangioleiomyomatosis (LAM) who underwent right single-lung transplantation from a cadaveric donor developed persistent chylous ascites. Despite use of diuretics and sirolimus to reduce ascites-associated symptoms and to prevent gastroesophageal reflex triggered by increased abdominal pressure, the ascites were refractory, and periodic paracenteses were required. With placement of a peritoneovenous shunt (Denver shunt), the patient's abdominal circumference decreased, and her symptoms abated. Thus, placement of a peritoneovenous shunt can be an effective management strategy for refractory chylous ascites in patients with LAM, even after lung transplantation.

Percutaneous Placement and Management of Peritoneovenous Shunts

Peritoneovenous shunts are used in the treatment of recurrent ascites or recurrent pleural effusions. Generally speaking, the shunts allow passage of ascites or pleural effusions (by either passive or active means) back into the central venous system. The most recent development in peritoneovenous shunts, known as the Denver Shunt, is a modification of a shunt developed for the treatment of hydrocephalus. In recent years, the Denver shunt has been placed by interventional radiologists. It is used to treat both cirrhotic and malignant effusions in the peritoneal and pleural cavities. Reported complications of the shunt are shunt occlusion, infection, post-shunt coagulopathy, deep vein thrombosis, catheter breakage, and leaks. This article discusses the technical aspects related to the percutaneous placement and maintenance of the Denver Shunt.

Malignant ascites – current treatment and novel therapeutic options

Malignant ascites is a common problem in patients with advanced malignancies and peritoneal spread of tumour. Treatment strategies include paracentesis, diuretics and peritoneovenous shunts; however, there are no established evidence-based guidelines for optimal therapy. This review is intended to add clarity to the current procedures for the management of malignant ascites, and furthermore discusses new promising approaches.

Chylous ascites complicating pediatric renal transplantation

Chylous ascites (CA) is an unusual complication of pediatric abdominal surgery which can be difficult to manage. Little data are available to guide therapy. We describe the presentation, clinical course and management of two patients, a 7-year-old boy and 2.5-year-old girl, who experienced CA following intraperitoneal renal transplantation. Both cases failed medical management, and the patients required surgical intervention. One required a peritoneovenous shunt while the other required an external abdominal drain. Both patients eventually experienced resolution of the CA and excellent long-term renal function. These case descriptions highlight the challenges of optimizing nutrition while controlling chylous output. We also review some of the risk factors associated with CA and draw attention to the consideration of this diagnosis in any renal transplant recipient with post-operative abdominal distention and ascites.

Sclerosing encapsulating peritonitis

Sclerosing encapsulating peritonitis (SEP) is a rare cause of intestinal obstruction. This entity has been reported as either primary idiopathic or secondary to other diseases. We report SEP in 2 cirrhotic patients and review the literature. Both patients had decompensated cirrhosis and episodes of spontaneous bacterial peritonitis. One patient underwent a Denver shunt placement before developing SEP. This patient remains alive and is managed conservatively. The other patient deceased from multi-organ failure after the resection of gangrened small bowel. The manifestations of SEP are often nonspecific that leads to misdiagnosis and/or delayed diagnosis. Early diagnosis of SEP is difficult but not impossible. Surgical treatment is often required when intestinal obstruction is present. Nevertheless, patients with this problem can be treated conservatively with immunosuppressive therapy with or without total parenteral nutrition (TPN) before going for surgery.

The management of malignant ascites in Palliative care: An audit of clinical practice and development of standards and guidelines

BackgroundMalignancy is the underlying cause in approximately 10% of all cases of ascites. About 15–50% of patients with malignancy will develop ascites. Cancers commonly associated with the development of ascites...

Management of Refractory Ascites

Ascites that does not respond or recurs after high-dose diuresis and sodium restriction should be considered refractory ascites. As cirrhosis advances, the escaping fluid overwhelms the lymphatic return. Decrease in renal plasma flow leads to increased sodium reabsorption at the proximal tubule leading to decreased responsiveness to loop diuretics and mineralocorticoid antagonists, which work distally. These complex hemodynamic alterations lead to refractory ascites. In refractory ascites, high-dose diuresis (400 mg of spironolactone and 160 mg of furosemide) and sodium restriction (<90 mmol/d) result in inadequate weight loss and sub optimal sodium excretion (<78 mmol/d). Further use of diuretics is limited by complications such as encephalopathy, azotemia, renal insufficiency, hyponatremia, and hyperkalemia. Therapy for refractory ascites is limited. The available therapies are repeated large volume paracentesis (LVP), transjugular intrahepatic portosystemic shunts, peritoneovenous shunts, investigational medical therapies, and liver transplantation. LVP with concomitant volume expanders is the initial treatment of choice. Transjugular intrahepatic portosystemic seems to be superior to LVP in reducing the need for repeated paracentesis and improves the quality of life. Several treatments that act at different steps in the pathogenesis of ascites are investigational, and some show promising results. Splanchnic and peripheral vasoconstrictors (Octreotide, Midodrine, and Terlipressin) increase effective arterial volume and decrease activation of the renin-angiotensin system with resultant increase in renal sodium excretion. Clonidine when given with spironolactone has been shown to cause rapid mobilization of ascites by significantly decreasing the sympathetic activity and renin-aldosterone levels. Natural aquaretics and synthetic V2 receptor antagonists (satavaptan) are being evaluated for mobilization of ascites by increasing the excretion of solute-free water. Liver transplantation remains the only definitive therapy for refractory ascites. Because refractory ascites is a poor prognostic sign, liver transplantation should be considered and incorporated early in the treatment plan.

肝切除後難治性腹水に対して腹腔静脈シャントが有効であった１例

肝切除後難治性腹水に対して腹腔静脈シャントが有効であった１例

Concept and Indication of Peritoneovenous Shunt (PVS)

Concept and Indication of Peritoneovenous Shunt (PVS)

乳がん転移再発患者の難治性腹水に対して腹腔静脈シャント造設が有効であった1例

乳がん転移再発患者の難治性腹水に対して腹腔静脈シャント造設が有効であった1例

Malignant ascites: A review of prognostic factors, pathophysiology and therapeutic measures

Malignant ascites indicates the presence of malignant cells in the peritoneal cavity and is a grave prognostic sign. While survival in this patient population is poor, averaging about 20 wk from time of diagnosis, quality of life can be improved through palliative procedures. Selecting the appropriate treatment modality remains a careful process, which should take into account potential risks and benefits and the life expectancy of the patient. Traditional therapies, including paracentesis, peritoneovenous shunt placement and diuretics, are successful and effective in varying degrees. After careful review of the patient's primary tumor origin, tumor biology, tumor stage, patient performance status and comorbidities, surgical debulking and intraperitoneal chemotherapy should be considered if the benefit of therapy outweighs the risk of operation because survival curves can be extended and palliation of symptomatic malignant ascites can be achieved in select patients. In patients with peritoneal carcinomatosis who do not qualify for surgical cytoreduction but suffer from the effects of malignant ascites, intraperitoneal chemotherapy can be safely and effectively administered via laparoscopic techniques. Short operative times, short hospital stays, low complication rates and ultimately symptomatic relief are the advantages of laparoscopically administering heated intraperitoneal chemotherapy, making it not only a valuable treatment modality but also the most successful treatment modality for achieving palliative cure of malignant ascites.

Repositioning of Surgically Placed Peritoneovenous Shunt Catheter by Forming “In Situ” Loop Snare

We describe a technique that allows repositioning of malfunctioning peritoneovenous shunt (PVS) catheters. We report a 67-year-old female with refractory ascites, who presented with malfunctioning PVS. The catheter tip was outside the superior vena cava (SVC), possibly in a small mediastinal vein, which makes its tip inaccessible to regular snares and retrieval devices. We used "in situ" loop snare technique to reposition the tip of the catheter into the inferior vena cava (IVC). In situ loop snare technique can be used to reposition malfunctioning PVS catheters caused by a kink or by malposition of its tip. The technique avoids surgical or interventional replacement of these catheters. This technique can be also used for retrieval of foreign body fragments that have no free ends and, therefore, cannot be captured by a snare or other retrieval devices.

Early implantation of Denver shunt.

The Denver peritoneovenous shunt is useful in the resolution of refractory ascites, because it alleviates symptoms and allows effective palliation. However, this shunt did not prolong the life expectancy of patients with decompensated liver cirrhosis. Therefore, when deciding whether or not to implant a Denver shunt, it is important to determine the condition of the patient with refractory ascites. Here, we determined the appropriate time for Denver shunt implantation. We retrospectively studied 21 patients who underwent Denver shunt implantation for hepatic failure-related ascites. The patients were divided into PC and WPC groups depending on whether or not paracentesis was performed before implantation of the Denver shunt, respectively. The mean interval from hospital admission to Denver shunt implantation was significantly shorter in the WPC group (9.0±2.2 days) than in the PC group (25.9±5.9 days) (p<0.0001). The mean survival time was significantly longer in the WPC group (8.4±2.5 months) (p<0.0071) than in the PC group (5.6±1.7 months). Early implantation of a Denver shunt should be considered for the treatment of ascites that is resistant to conservative medical therapy.

Cardiomyopathie cirrhotique : une entité spécifique

Cirrhosis is a frequent and severe condition, which is the late stage of numerous chronic liver diseases. It is associated with major hemodynamic alterations characteristic of hyperdynamic circulation and with a series of structural, functional, electrophysiological and biological heart abnormalities termed cirrhotic cardiomyopathy. The pathogenesis of this syndrome is multifactorial. It is usually clinically latent or mild, likely because the peripheral vasodilatation significantly reduces the left ventricle afterload. However, sudden changes of hemodynamic state (vascular filling, surgical or transjugular intrahepatic porto-systemic shunts, peritoneo-venous shunts and orthotopic liver transplantation) or myocardial contractility (introduction of beta-blocker therapy) can unmask its presence, and sometimes convert latent to overt heart failure. Cirrhotic cardiomyopathy may also contribute to the pathogenesis of hepatorenal syndrome. This entity has been described recently, and its diagnostic criteria are still under debate. To date, current management recommendations are empirical, nonspecific measures. Recognition of cirrhotic cardiomyopathy depends on a high level of awareness for the presence of this syndrome, particularly in patients with advanced cirrhosis who undergo significant surgical, pharmacological or physiological stresses.

The conservative treatment of postoperative chylous ascites in gynecologic cancers: four case reports

Chylous ascites is a rare complication following radical surgery in gynecologic cancers. Its treatment is difficult due to nutritional and immunological problems caused by protein and lymphocyte loss. Its conservative treatment includes the use of a low-fat diet, medium chain triglyceride intake, paracentesis, total parenteral nutrition, and somatostatins. Other treatment options for resistant cases include surgical exploration and peritoneovenous shunt. We present four gynecologic cancer cases with development of chylous ascites following pelvic-para-aortic lymph dissection. Two of these cases were endometrial cancer, one was cervical cancer, and the last one was ovarian cancer. In three of these cases, chylous ascites developed immediately after surgery. In the cervical cancer case, it developed following surgery and radiotherapy. All subjects responded to conservative treatment. Chylous ascites should be considered in the differential diagnosis of abdominal distension following retroperitoneal surgery. Cases generally respond well to conservative treatment. However, treatment options should be personalized, and the right treatment should be chosen for each patient. The best measure is to pay utmost attention to the ligation of large lymph vessels during lymph dissection.

Denver Peritoneovenous Shunts for the Management of Malignant Ascites: A Review of the Literature in the Post LeVeen Era

Most case series describing peritoneovenous (PV) shunts for malignant ascites include both LeVeen and Denver shunts. Conclusions based on these studies are no longer clinically relevant since the LeVeen shunt has been discontinued. The purpose of this study was to identify outcomes specific to Denver shunts to establish expected results in the modern era. Case series describing PV shunts for malignant ascites between 1980 and 2008 were identified through a keyword PUBMED search. Whenever possible, results attributable to Denver shunts were abstracted and analyzed. Nineteen series describing 341 patients undergoing 353 Denver PV shunts for malignant ascites were identified. The primary indications for PV shunts were unspecified or cancers of unknown origin (40%), ovarian cancer (16%), and pancreatic cancer (8%). Primary patency averaged 87 ± 57 days. Seventy-four per cent of patients died with functioning shunts. Complications occurred in 38% of patients including occlusion (24%) and disseminated intravascular coagulation (9%). Average survival of all patients was 3.0 ± 1.7 months and shunts provided effective palliation in 75.3%. One and a half per cent of 133 patients who had autopsies were reported to have hematologic dissemination. These results are not statistically different than overall results reported for both shunts combined or LeVeen shunts alone. Studies that report combined outcomes with Denver and LeVeen shunts for malignant ascites are neither negatively, nor positively influenced by one specific shunt. Expectations following PV shunting for malignant ascites do not have to be revised because LeVeen shunts are no longer available.

The use of peritoneal venous shunting for intractable neonatal ascites: a short case series

Introduction Intractable ascites in neonates has a varied etiology; and often, the cause is idiopathic. The management usually consists of observation, diuretics, paracentesis, albumin replacements, and self correction. However, in some cases, the above treatment remains unsuccessful. Results We present 2 cases of intractable ascites causing metabolic abnormalities, severe protein and immunoglobulin loss, and respiratory compromise. Although the use of peritoneovenous shunts for intractable ascites has been reported previously, our cases differ in both technique and patient size. Our first patient is an ex–28-week premature, 1.4-kg infant with intractable ascites for which a peritoneal drain was initially placed. After 3 weeks and putting out nearly 300 mL of ascitic fluid daily, we placed a peritoneal venous shunt attached to a Medtronic pump. A 6.6F Broviac was placed through the Internal Jugular. The Medtronic pump was placed subcutaneously on the right chest. The pump was compressed 5 to 10 times every 8 hours, keeping fluid actively being infused from the belly to the vascular system. The second patient was 5 months old, 2.8 kg, with a course complicated by necrotizing enterocolitis, prolonged total parenteral nutrition, and progressive liver failure and underwent the same procedure. Both patients had dramatic responses to the shunting postoperatively, with clinical, radiographic, and laboratory evidence of resolution of the ascites. The first patient had the shunt removed at 6 months of age and continues to do well, whereas our second patient had no recurrence of the ascites, but died about 1 year later from cardiopulmonary complications. Conclusion These 2 cases demonstrate that peritoneovenous shunting, with the assistance of a Medtronic pump, is an effective treatment of intractable neonatal ascites and should be considered early in the course before complications develop.

Feasibility of externalized peritoneovenous shunt (EPVS) for malignant ascites

PurposeTo evaluate a new modified peritoneovenous shunt therapy, the externalized peritoneovenous shunt (EPVS) system placement, used to treat patients with malignant ascites.MethodsWe retrospectively reviewed 10 patients, who were not suited for conventional peritoneovenous shunts (PVS), with malignant ascites, which was refractory to medical therapies. Patient characteristics, technical success, efficacy, duration of EPVS placement, adverse events, and outcome were evaluated. Clinical efficacy of the EPVS was evaluated by the change in subjective symptoms.ResultsThe primary reasons for applying EPVS were severe anasarca in 4 patients, potential PVS dysfunction in 3 patients, poor performance status in 2 patients, and a history of PVS occlusion in 1 patient. EPVS was successfully placed in all patients, and it provided clinical efficacy in 8 patients (80%). Early death occurred within 7 days after EPVS placement in 2 patients because of renal failure. The median duration of EPVS placement was 10.4 days (range, 2-28 days). In 6 patients (60%), the EPVS was exchanged to conventional PVS sequentially, since the initial EPVS placement resulted in an improvement of the subjective symptoms of the patients, without serious complications.ConclusionEPVS placement may be an option for patients with malignant ascites who may not be appropriate for conventional PVS placement.