Symptomatic Ascites Research Articles

Evaluation of low-dose intraperitoneal interferon-α for palliation of ascites in patients with non-ovarian gynecologic malignancies

Objective Intraperitoneal interferon-α (IP-IFNα) has shown some benefit in the treatment of patients with ovarian cancer. Our goal was to evaluate the use of low-dose IP-IFNα for the palliative control of ascites in non-ovarian gynecologic malignancies, including primary peritoneal and uterine papillary serous carcinomas. Methods Fifteen patients with non-ovarian gynecologic malignancies received one or two doses of 10 MU (10 × 10 6 U/m 2) of IP-IFNα via single-use drum catheter for the symptomatic control of ascites. The median age for this patient group was 61 years (range 40–84). Histopathologic diagnoses were confirmed on all patients. Eleven of 15 (73%) patients had uterine cancers. Four of 15 (27%) patients had papillary serous primary peritoneal carcinomas. Thirteen of 15 (87%) patients had Stage III disease or more. All patients had been heavily pretreated with chemotherapy and all had progressive disease. Results Specific parameters used to evaluate IP-IFNα were (1) median survival; (2) number of days to recurrent ascites; (3) number of subsequent paracenteses required for symptomatic relief; and (4) symptomatology and side effects. Median overall survival was 3 months (range 0.5–13). Seven of 15 (47%) patients survived >3 months. Twelve of 15 (80%) patients had recurrent ascites within 30 days of treatment. However, 3/15 (20%) patients had a prolonged, >30-day period, without symptomatic ascites. One patient (6%) had a 270-day response with no ascites. Toxicity was minimal from IP-IFNα infusion. The most common side effect was fever in 6/15 (40%) patients. Conclusion IP-IFNα was well tolerated and may have some benefit in a subset of patients. Although 80% of patients had recurrent ascites within 30 days, 20% had a prolonged, >30-day response. Further study is warranted to determine the role of immune modulators, such as IP-IFNα, in the palliative management of patients with non-ovarian gynecologic malignancies that cause ascites.

The North American Study for the Treatment of Refractory Ascites

Background & Aims: The clinical utility of transjugular intrahepatic portosystemic shunts (TIPS) vis-à-vis total paracentesis in the management of refractory ascites is unclear. Methods: A multicenter, prospective, randomized clinical trial was performed in which 109 subjects with refractory ascites were randomized to either medical therapy (sodium restriction, diuretics, and total paracentesis) (n = 57) or medical therapy plus TIPS (n = 52). The principal end points were recurrence of tense symptomatic ascites and mortality. Results: A technically adequate shunt was created in 49 of 52 subjects. TIPS plus medical therapy was significantly superior to medical therapy alone in preventing recurrence of ascites (P < 0.001). The total number of deaths in the 2 groups was identical (TIPS vs. medical therapy alone: 21 vs. 21). There were no significant differences in the 2 arms with respect to overall and transplant-free survival. There was a higher incidence of moderate to severe encephalopathy in the TIPS group (20 of 52 vs. 12 of 57; P = 0.058). There were no significant differences in the number of subjects who developed liver failure (7 vs. 3), variceal hemorrhage (5 vs. 8), or acute renal failure (3 vs. 2). There were also no significant differences between the 2 groups in the frequency of emergency-department visits, medically indicated hospitalizations, or quality of life. Conclusions: Although TIPS plus medical therapy is superior to medical therapy alone for the control of ascites, it does not improve survival, affect hospitalization rates, or improve quality of life.GASTROENTEROLOGY 2003;124:634-641

Placement of a Permanent Tunneled Peritoneal Drainage Catheter for Palliation of Malignant Ascites: A Simplified Percutaneous Approach

To report a simple, minimally invasive method of palliative drainage of symptomatic malignant ascites, which allows patients to avoid repeated trips to the hospital for paracentesis. Since 1996, 29 patients with symptomatic, large-volume malignant ascites underwent percutaneous placement of a tunneled multiple-side-hole Tenckhoff catheter with use of a modified Seldinger technique employing curved and straight coaxial needles. Unlike previously described methods of tunneled catheter placement, this method does not require an incision. All patients were able to drain their ascites at home and all achieved significant improvement in their symptoms attributable to ascites. Twenty-three of the 29 were outpatients and were able to leave the hospital within several hours of catheter placement. Inpatients remained in the hospital for various reasons unrelated to catheter placement and most left within several days. Only one patient died in the hospital during the same admission. One patient developed cellulitis, one had persistent leakage around the catheter, one catheter had to be replaced, and one catheter was accidentally removed at home. No patient developed clinical symptoms of peritonitis or sepsis. All deaths were attributable to patients' underlying malignancies. Percutaneous placement of a permanent tunneled catheter using a modified Seldinger technique employing curved and straight coaxial needles is a safe, simple, and effective method for palliative drainage of malignant ascites that allows patients to return home quickly.

Percutaneous Peritoneovenous Shunt Creation for the Treatment of Benign and Malignant Refractory Ascites

Peritoneovenous shunt placement has been reported as a treatment of refractory ascites by general surgeons, but without a clearly established role. The authors successfully inserted shunts under ultrasonographic and fluoroscopic guidance in 12 patients who had symptomatic refractory ascites (nine men, three women; mean maintenance duration, 88.5 d). Nine patients had advanced liver cirrhosis (five with superimposed hepatoma). Other patients had stomach cancer, colon cancer, and complicated polycystic kidney disease. The mortality rate was 83%. Causes of death included bleeding from preexisting varices, sepsis, hepatic failure, rupture of hepatoma, and disseminated intravascular coagulation. The authors describe the feasibility, technical details, and short-term results of percutaneous peritoneovenous shunt placement.

Tunneled peritoneal catheter placement under sonographic and fluoroscopic guidance in the palliative treatment of malignant ascites.

We present a treatment for recurrent, symptomatic ascites in patients with malignant disease. This report summarizes our experience with percutaneous tunneled peritoneal catheters in 24 patients. Of the 40 consecutive patients who presented with at least four therapeutic paracenteses in a 4-week period, 24 patients underwent the percutaneous tunneled procedure. All had malignant ascites. All 24 patients had successful insertion of a permanent tunneled peritoneal drainage catheter. Eighteen were outpatients and six were inpatients. All patients were relieved of their clinical symptoms, including abdominal distention and dyspnea, and were relieved of lower extremity discomfort. The mean life span after catheter placement was 7.2 weeks. Twenty (83%) of the 24 patients were treated at home with their catheters in place. Three patients experienced minor complications from bacterial peritonitis, which responded to antibiotics. One patient had to have his catheter removed. Percutaneous placement of specialized tunneled catheters appears to be a viable and safe technique in patients who have symptomatic ascites that require frequent therapeutic paracentesis for relief of symptoms.

Lymphatic ascites following lymphadenectomy for gynecological malignancy.

Seven patients seen between January 1995 and December 1998 developed symptomatic lymphatic ascites following either pelvic or para-aortic lymph node dissection. The incidence of symptomatic lymphatic ascites during this 4-year period was 2.7% (7 of 263 cases). The accumulation of ascites postoperatively was associated with a prolonged postoperative ileus, abdominal pain, and extended postoperative hospitalization. Once the condition was recognized, abdominal paracentesis resulted in rapid improvement of symptoms in two patients but repeated paracenteses were required for a further two patients who had significant complications as a result of these procedures. Two patients improved following spontaneous drainage of a large amount of ascites per vagina and did not require further intervention. The final patient settled with observation only. This condition can be difficult to recognize and is a potential cause of significant postoperative morbidity.

Lymphatic ascites following lymphadenectomy for gynecological tmalignancy

Seven patients seen between January 1995 and December 1998 developed symptomatic lymphatic ascites following either pelvic or para-aortic lymph node dissection. The incidence of symptomatic lymphatic ascites during this 4-year period was 2.7% (7 of 263 cases). The accumulation of ascites postoperatively was associated with a prolonged postoperative ileus, abdominal pain, and extended postoperative hospitalization. Once the condition was recognized, abdominal paracentesis resulted in rapid improvement of symptoms in two patients but repeated paracenteses were required for a further two patients who had significant complications as a result of these procedures. Two patients improved following spontaneous drainage of a large amount of ascites per vagina and did not require further intervention. The final patient settled with observation only. This condition can be difficult to recognize and is a potential cause of significant postoperative morbidity.

Retroperitoneal drainage after complete Para-aortic lymphadenectomy for gynecologic cancer: a randomized trial

Objective: To determine the relationship between retroperitoneal drainage after complete para-aortic lymphadenectomy for gynecologic cancer and subsequent development of lymphocysts. Methods: Eighty women undergoing complete para-aortic lymphadenectomy up to the level of the left renal vein for ovarian ( n = 43) or cervical carcinoma ( n = 37) were randomly assigned to receive drainage or no drainage of the para-aortic area. Most of patients had pelvic drainage. Abdominopelvic ultrasonography was done 8 to 12 days after surgery. Postoperative complications, duration of hospital stay, and characteristics of asymptomatic lymphocysts were studied. Results: Forty-two women had para-aortic drainage and 38 did not. Complications occurred in 15 patients who had drainage and in 5 patients who did not have drainage (36% versus 13%; P < .02). Three patients (8%) in the undrained group had complications potentially related to drainage (symptomatic lymphocysts or ascites) compared with 11 (26%) in the drained group (χ 2 = 4.6; P < .05). Median duration of the hospital stay was 9 days in the undrained group and 11 days in the drained group ( P < .03). The number of asymptomatic para-aortic lymphocysts detected during the ultrasonography was 9 (24%) in the undrained and 2 (5%) in the drained group (χ 2 = 4.6; P < .05). Conclusions: The number of asymptomatic para-aortic lymphocysts was higher in patients who did not undergo drainage, but morbidity and the duration of hospitalization were increased in these patients. Routine drainage of the retroperitoneum after para-aortic lymphadenectomy should be abandoned.

Retroperitoneal Drainage After Complete Para-aortic Lymphadenectomy for Gynecologic Cancer

In Brief Objective To determine the relationship between retroperitoneal drainage after complete para-aortic lymphadenectomy for gynecologic cancer and subsequent development of lymphocysts. Methods Eighty women undergoing complete para-aortic lymphadenectomy up to the level of the left renal vein for ovarian (n = 43) or cervical carcinoma (n = 37) were randomly assigned to receive drainage or no drainage of the para-aortic area. Most of patients had pelvic drainage. Abdominopelvic ultrasonography was done 8 to 12 days after surgery. Postoperative complications, duration of hospital stay, and characteristics of asymptomatic lymphocysts were studied. Results Forty-two women had para-aortic drainage and 38 did not. Complications occurred in 15 patients who had drainage and in 5 patients who did not have drainage (36% versus 13%; P < .02). Three patients (8%) in the undrained group had complications potentially related to drainage (symptomatic lymphocysts or ascites) compared with 11 (26%) in the drained group (χ2 = 4.6; P < .05). Median duration of the hospital stay was 9 days in the undrained group and 11 days in the drained group (P < .03). The number of asymptomatic para-aortic lymphocysts detected during the ultrasonography was 9 (24%) in the undrained and 2 (5%) in the drained group (χ2 < 4.6; P < .05). Conclusions The number of asymptomatic para-aortic lymphocysts was higher in patients who did not undergo drainage, but morbidity and the duration of hospitalization were increased in these patients. Routine drainage of the retroperitoneum after para-aortic lymphadenectomy should be abandoned Drainage of the retroperitoneum following para-aortic lymphadenectomy for gynecologic malignancies provides no benefits and increases morbidity.

Ascites following ventriculoperitoneal shunting in children with chiasmatic-hypothalamic glioma.

Optic pathway gliomas in children can involve the optic nerve, chiasm, and hypothalamus. This uncommon, slowly growing tumor can cause hydrocephalus, which usually requires placement of a ventriculoperitoneal (VP) shunt. Symptomatic ascites may occasionally develop as a complication of the VP shunt procedure. The purpose of this study was to assess the risk factors associated with CSF ascites in children with optic pathway gliomas. Twenty-two children (ages 4 months to 20 years) with chiasmatic-hypothalamic optic gliomas participated in this study. Four children were diagnosed with a chiasmatic glioma, 7 with a hypothalamic glioma, and 11 with a glioma involving both the optic chiasm and hypothalamus. Twelve children (55%) developed hydrocephalus and required VP shunt placement. Of the 12 shunted children, 4 (33%) developed CSF ascites. The incidence of ascites was not associated with infection, tumor metastasis, or multiple shunt revisions. There was no correlation with the size of the tumor. All 4 children with ascites had tumor involving the optic chiasm or optic nerve. None of the 5 children with pure hypothalamic glioma who underwent VP shunt placement have developed ascites. Among the 7 children suffering from chiasmatic or optic nerve gliomas who developed hydrocephalus, the risk of developing ascites as a complication of VP shunt placement was 57% (4/7). Ventriculoatrial (VA) shunt was the treatment of choice for children with VP shunt-induced ascites. After placement of a VA shunt the ascites subsided. The children did not develop further complications. We conclude that glioma involving the optic chiasm or nerve is associated with a high risk of developing ascites following VP shunt placement. VA shunt may be the treatment of choice for children with chiasmatic or optic nerve gliomas who require a CSF diversion procedure.

Radiation therapy for symptomatic hepatomegaly in myelofibrosis with myeloid metaplasia.

To describe the experience with liver irradiation in advanced cases of myelofibrosis with myeloid metaplasia (MMM). Over a 20-yr period, 14 patients with MMM were treated with a total of 25 courses of liver, abdominal, or abdominal and pelvic irradiation for symptomatic hepatomegaly with (5 patients) or without (9 patients) ascites. All 14 patients had advanced disease and 11 (79%) had previous splenectomy. The median radiation therapy (RT) dose per course was 150 cGy (range 50-1000) administered at a median of six fractions. Four patients received two to six courses. Twelve of the 14 patients (86%) had a transient (median 3 months) subjective response from RT. However, in only 35% of these was there a transient (median 3 months) decrease in palpable liver size. Four of the five patients with ascites experienced a short-term response from RT. Eight of the 13 patients suitable for evaluation (62%) had treatment-associated cytopenia, often in the form of anemia and/or thrombocytopenia. At last follow-up, 10 patients (71%) had died after a median of 7 months (range 0.1-23) and 4 were alive at 3, 20, 33, and 57 months after RT. Low-dose abdominal RT for symptomatic hepatomegaly or ascites associated with advanced-stage MMM is myelosuppressive and provides only temporary and mainly subjective and short-lived relief.

A Phase II Trial of Triamcinolone Hexacetanide for Symptomatic Recurrent Malignant Ascites

Ascites is a common complication of advanced cancer and frequently requires paracentesis to reduce symptoms of pain, anorexia, and dyspnea. For many patients repeat paracenteses are required at short intervals. We prospectively studied 15 patients with recurrent ascites of malignancy to determine if intraperitoneal triamcinolone hexacetonide, a slowly metabolized corticosteroid, produced objective and symptomatic responses. After biochemical, radiological, and symptom assessment and the establishment of the interval between paracenteses, patients underwent large-volume paracentesis followed by intraperitoneal triamcinolone hexacetonide 10 mg/kg. Patients were followed after treatment for assessment of symptoms and physical signs of ascites. Repeat paracentesis was performed when symptomatic ascites recurred. Symptomatic ascites recurred in 13 of 15 patients, but the interval between paracenteses was extended from 9.5 ± 1.6 days to 17.5 days (P = 0.0086). Symptom questionnaire scores assessing well-being, nausea, abdominal pain, dyspnea, appetite, appearance, and change in abdominal size on a scale from 0 to 6 averaged 3.2 ± 0.3 at entry and 2.5 ± 0.2 at the 2-week assessment (P = 0.026). Self-assessed symptoms, feeling of well-being, abdominal distention, and physical appearance improved significantly. The mean serum cortisol decreased from baseline, suggesting that some systemic corticosteroid absorption occurred. Thirteen of 15 patients have died, with a median survival of 42 days. Potential adverse effects included 1 episode each of transient abdominal pain, bacterial peritonitis, and localized herpes zoster infection. In patients with ascites of malignancy, intraperitoneal triamcinolone hexacetonide appears to postpone the requirement for repeat paracentesis and improve symptoms of malignant ascites.

Intraperitoneal Pressures and Clinical Parameters of Total Paracentesis for Palliation of Symptomatic Ascites in Ovarian Cancer

Objective.The present study was designed to prospectively evaluate the intraperitoneal pressure, as well as clinical and hemodynamic effects of total paracentesis, as palliation of symptomatic ascites in ovarian cancer patients.Methods.Prospective study of 35 sequential total paracenteses was performed using a Veres cannula on patients with advanced recurrent ovarian cancer with symptomatic tense ascites. Relevant clinical symptoms and patient well-being were evaluated. Vital signs, abdominal parameters, and hydrostatic intraperitoneal pressure were recorded before, during, and after the procedure.Results.Intraperitoneal pressure dropped from 30 ± 7 cmH2O before paracentesis to 13 ± 6 cmH2O after the procedure (P< 0.0001). Marked symptomatic improvement was observed in all patients (89% complete relief, 11% partial relief), while all the patients tolerated the procedure well without any complications. The mean volume of ascitic fluid removed was 4800 ml. Mean respiratory rate and mean heart rate were both significantly decreased following the procedure (29.3 to 21.4 respirations per min and 101.5 to 93.6 beats per min, respectively). Mean systolic blood pressure mildly decreased (6.6 mmHg), while the mean diastolic blood pressure did not significantly change. None of the patients presented signs or symptoms of hypovolemia during or after the total paracentesis.Conclusions.Measurement of intraperitoneal pressures during total paracentesis for tense ascites in ovarian cancer patients indicated that the severity of symptoms correlated with the intraperitoneal pressure prior to paracentesis, but not with the volume of ascites. Intraperitoneal pressures measured following total paracentesis in patients with ovarian cancer were similar to the baseline intraperitoneal pressure measured in patients undergoing peritoneal dialysis.

Familial amyloid with a transthyretin leucine 33 mutation presenting with ascites

A 65-year-old female presented with symptomatic ascites. Light and electron microscopy examination of omental and peritoneal tissue obtained at exploratory laparotomy revealed amyloidosis. Immunochemical studies of the amyloid tissue showed positive staining with antibodies to transthyretin. Polymerase chain reaction (PCR), single strand conformation polymorphism analysis, and direct DNA sequencing demonstrated a transthyretin phenylalanine to leucine substitution at codon 33. This is only the second reported case of a transthyretin leucine 33 mutation. Moreover, this patient is unique among cases of transthyretin-associated amyloidosis with the clinical presentation of ascites. Am. J. Hematol. 59:249–251, 1998. © 1998 Wiley-Liss, Inc.

Temporary Drainage of Symptomatic Malignant Ascites by a Catheter Inserted Under Computerized Tomography

The development of malignant ascites is an unfavorable prognostic sign in patients with advanced cancer. Interventions may be justified when discomfort and overall compromise in well-being are due to diaphragmatic spinting and abdominal compression of viscera. A patient with symptomatic ascites was admitted to hospital for temporary drainage using a catheter inserted under computerized tomography. Over 12 liters of fluids were removed in 3 days, without complications. A minimal ascitic leakage occurred after removing the cannula. Dyspnea and gastrointestinal symptoms improved and the patient died with good symptom control 15 days later. This approach should be considered in advanced cancer patients with symptomatic ascites that is not responsive to diuretics. J Pain Symptom Manage 1998;15:374–378.

Symptomatic Ascites after Discontinuation of Continuous Peritoneal Dialysis

To analyze pathogenetic associations, clinical features, management, and outcome of ascites following discontinuation of continuous peritoneal dialysis (CPD). Retrospective analysis of symptomatic ascites, defined as ascites requiring at least one therapeutic paracentesis, developing in patients who discontinued CPD. Dialysis unit of one tertiary care center. Twelve patients with 13 episodes of symptomatic ascites diagnosed soon after (a few days to 2 months) discontinuation of CPD. Diagnostic tests to characterize the pathogenesis of ascites; management of ascites by hemodialysis or CPD. Evolution of clinical features and nutritional parameters, survival. Ascites was infectious in 3 episodes (non-tuberculous mycobacterial peritonitis) and noninfectious in the remaining 10 episodes. Serum-to-ascites albumin concentration gradient (AG) was 6.3 +/- 1.5 g/L in infectious ascites and 17.3 +/- 2.7 g/L ( >11 g/L in every episode) in noninfectious ascites. Infectious ascites was managed with hemodialysis, prolonged courses of antimicrobial agents, and repeated paracentesis. Paracentesis ceased after 3-9 months. The patients were alive after 52 +/- 19 months. Seven episodes of noninfectious ascites were managed by hemodialysis and repeated paracentesis. Five patients died within 6 months from cardiac causes or sepsis. The remaining 2 patients died after 14 and 16 months from cardiac causes. Three episodes of noninfectious ascites in 2 patients were treated by restarting CPD within 2-5 months. Patients were alive at 16.9 +/- 13.2 months. They were asymptomatic and achieved fluid control. On the same CPD schedule, peritoneal clearances of urea and creatinine and normalized protein nitrogen appearance were unchanged between the initial and restarted CPD. Serum albumin was 33.3 +/- 2.5 g/L at the end of the first CPD period, 23.6 +/- 2.5 g/L soon after restarting CPD, and 31.3 +/- 5.5 g/L 4 months after restarting CPD. Noninfectious ascites after discontinuation of CPD is often characterized by an AG > 11 g/L, suggesting portal hypertension. Restarting CPD in noninfectious ascites may be associated with improvement in ascites symptomatology and nutritional parameters and with satisfactory survival.

Phase I/II Study of Intraperitoneal Floxuridine and Platinums (Cisplatin and/or Carboplatin)

Previous studies have shown that intraperitoneal (ip) floxuridine (FUDR) is tolerated at a dose of 3 g × 3 days given in 1.5–2 L of normal saline (NS). In a randomized phase II trial by the Southwest Oncology Group, this treatment was selected for further study because of a favorable 1-year progression-free survival. We have now evaluated ip FUDR in full doses combined with ip cisplatin given on the third day at a dose of 60 mg/m2in 500 mL of NS. Intraperitoneal carboplatin was partially or fully substituted for ip cisplatin in patients with symptomatic neuropathies. All patients also received ip leucovorin, as previously piloted for fluoropyrimidine modulation. Seven patients with symptomatic ascites or measurable tumors were entered, as were 11 asymptomatic patients with minimal residual (≤1 cm) epithelial ovarian cancer. Six cycles of the combination of ip FUDR + cisplatin were completed in three patients; however, the combination of FUDR with both platinums was particularly well tolerated. Intraperitoneal FUDR + carboplatin (AUC of 5) was associated with some grade 3 and 4 thrombocytopenia and neutropenia. Eight of these 11 patients are alive, and 3 have been continuously with no evidence of disease exceeding 32 months. The regimen of ip FUDR + ip cisplatin (or ip FUDR with both platinums) is suitable for a phase III trial testing ip therapy either from the outset (e.g., ip up front) or after achieving clinical complete responses from initial treatment without intervening relapse (i.e., ip consolidation) in comparison to ip cisplatin.

A Randomized Study Comparing Retroperitoneal Drainage with No Drainage after Lymphadenectomy in Gynecologic Malignancies

Objective:To evaluate the clinical effectiveness of retroperitoneal drainage following lymphadenectomy in gynecologic surgery.Methods:One hundred thirty-seven consecutive patients undergoing systematic lymphadenectomy for gynecologic malignancies were randomized to receive (Group A, 68) or not (Group B, 69) retroperitoneal drainage. The pelvic peritoneum and the paracolic gutters were not sutured after node dissection. Perioperative data and complications were recorded.Results:Clinical and surgical parameters were comparable in the two groups. Postoperative hospital stay was significantly shorter in Group B (P< 0.001), whereas the complication rate was significantly higher in Group A (P= 0.01). This was mainly due to a significant increase in lymphocyst and lymphocyst-related morbidity. Sonographic monitoring for lymphocyst showed free abdominal fluid in 18% of drained and 36% of not-drained patients (P= 0.03). Symptomatic ascites developed in 2 drained (3%) and 3 not-drained (4%) patients (NS), respectively.Conclusions:Prophylactic drainage of the retroperitoneum seems to increase lymphadenectomy-related morbidity and postoperative stay. Therefore, routine drainage following lymphadenectomy seems to be no longer indicated when the retroperitoneum is left open.

A Randomized Trial of Paracentesis plus Intraperitoneal Tumor Necrosis Factor-α versus Paracentesis Alone in Patients with Symptomatic Ascites from Recurrent Ovarian Carcinoma

Purpose: Previous phase I and II studies of intraperitoneal recombinant human tumor necrosis factor-α (rhTNF-α) suggested a high degree of efficacy in reducing or eliminating ascitic fluid. To more accurately determine the efficacy of this agent, the role of paracentesis versus paracentesis plus intraperitoneal rhTNF-α was studied in a randomized trial. Patients and methods: Thirty-nine patients with symptomatic ascites with a volume of >1000 ml from recurrent epithelial ovarian carcinoma or primary peritoneal carcinoma, which was refractory to standard therapy, were randomized either to receive 0.06 mg/m2rhTNF-α (Knoll, Canada) (the dose determined optimal from phase I and II studies) intraperitoneally after drainage of fluid or to receive drainage alone. A maximum of three treatments were given at weekly intervals. Eighteen patients were randomized to receive rhTNF-α. Results: None of 18 evaluable rhTNF-α patients had either a complete response (CR) (no clinical evidence of ascites and <400 ml of fluid on ultrasound) or a partial response (PR) (asymptomatic ascites and ≤1000 ml of fluid on ultrasound). There were no CRs or PRs in the 17 evaluable patients who received drainage alone. The intraperitoneal infusion of rhTNF-α was generally well tolerated. Moderate to severe toxicity consisted of pain/discomfort in 42.1%, fever/chills in 36.9%, nausea/vomiting in 10.5%, edema in 10.5%, and hypotension in 5.3% of patients receiving rhTNF-α. Conclusion: rhTNF-α, as given in this study, was not effective in preventing recurrence of ascites in this patient population.

Ultrasonically Guided Insertion of a Peritoneo-Gastric Shunt in Patients with Malignant Ascites

A new method for internal drainage of malignant ascites is presented in 5 patients with symptomatic malignant ascites. US-guided percutaneous gastrostomy and paracentesis were performed using the Seldinger technique. A 2.5-mm Cope-loop catheter was inserted in the fluid-filled stomach. In the lower abdomen the proximal part of a Denver peritoneo-venous shunt was introduced after dilation up to 4.8 mm. The pump chamber was sutured to the skin. The distal part of the Denver shunt was cut a few cm from the pump chamber and connected to the gastrostomy catheter. When pumping, ascites is shunted to the stomach lumen. The insertion presented no complications, and all shunt systems initially functioned well. However, the shunts had to be removed within the first 2 weeks because of mechanical problems such as clotting, leakage, and peritoneal septum formation. No infections were reported. The peritoneo-gastric shunt may present a therapeutic alternative in selected patients, but the mechanical problems have first to be solved.