Lymphatic-venous anastomosis for the treatment of refractory lymphatic ascites following radiation therapy: A case report.

Radical treatments for intra-abdominal malignancies disturb physiological lymphatic drainage and predispose the patients to lymphatic complications such as lymphatic ascites. Despite its infrequent occurrence, lymphatic ascites is a morbid complication, and a definitive treatment protocol for refractory cases has not been established. Surgical treatments are opted depending on the etiology, symptoms, and facility equipment. Lymphatic-venous anastomosis (LVA) bypasses the proximal lymphatic blockages and provides an alternative route for lymphatic fluid recirculation into the venous system, thereby improving the lymphatic congestion. Herein, we report the utility of LVA surgery in the treatment of refractory serous lymphatic ascites that developed after radiation therapy for cervical cancer in a 77-year-old woman. The patient had massive ascites and suffered from abdominal distention and anorexia for 1 year. The ascites was unresponsive to conservative treatment. Under local anesthesia, eight incisions were made in the lower extremities just above the lymphatic channels that were identified by indocyanine green lymphography, and a total of 14 LVAs were created. The postoperative course was uneventful, and the ascites improved significantly. The patient remained free from the recurrence of ascites during 3.5 years of postoperative follow-up. LVA surgery was effective for the improvement and long-term control of lymphatic ascites. This procedure may be a viable option for the management of lymphatic ascites.

Wall suction-assisted image-guided therapeutic paracentesis: a safe and less expensive alternative to evacuated bottles.

OBJECTIVE: To assess the safety and cost savings of using wall suction and plastic canisters instead of evacuated bottles, currently in short supply, to drain, and collect large amounts of fluid during image-guided paracentesis procedures. MATERIALS AND METHODS: In a hospital-based practice, 551 image-guided paracenteses were performed in 191 consecutive patients over a 10-month period, using wall suction to facilitate drainage. Total volume of fluid removed and complications were recorded. Complications were graded using Common Terminology Criteria for Adverse Events. The pressure generated from the wall suction at our institution was measured using a manometer and compared to that of an empty evacuated bottle. Cost savings per procedure were estimated by calculating the difference in the price of supplies used to collect the average volume of fluid removed per procedure for each method. RESULTS: The mean volume of fluid removed per procedure was 3541 mL. Four (0.72%) complications occurred in 551 procedures. One grade I complication consisted of a prolonged puncture site leak of ascites. Three Grade III complications included infection, hypotension, and atrial fibrillation. All four complications appeared unrelated to the use of wall suction and were treated successfully. Maximum pressure generated from the wall suction at our institution was less than the initial pressure generated from an empty evacuated bottle. Estimated cost savings per procedure was $33.92. CONCLUSION: The use of wall suction and plastic canisters to drain and collect fluid during image-guided therapeutic paracenteses is a safe alternative to using evacuated glass bottles and reduces per-procedure costs.

Different sequential approaches of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in treating ovarian cancer with malignant ascites.

BACKGROUND AND OBJECTIVES: Treatment for malignant ascites in advanced ovarian cancer (OC) patients remains controversial. The objective of this study was to investigate the efficacy of combined continuous circulatory hyperthermic intraperitoneal chemotherapy (HIPEC) preceded or followed by cytoreductive surgery (CRS) for malignant ascites in OC patients. METHODS: Female OC patients (n = 32) with malignant ascites were divided based on stable (n = 17) or unstable (n = 15) vital signs. Stable patients were treated with CRS immediately followed by HIPEC (CRS + HIPEC). Unstable patients were treated using B-mode ultrasound-guided HIPEC followed by delayed CRS upon vital sign stability (HIPEC + dCRS). All patients were followed up until death or until December 2012. RESULTS: Median follow-up was 29 months. All patients showed ascite regression [objective remission rates (ORR) = 100 %]. Among stable patients, CRS + HIPEC was successful in 14/17 (83.4 %). Among unstable patients, HIPEC + dCRS was successful in 13/15 (86.7 %). Median survival times were 19 and 17 months in the stable and unstable groups, respectively. No significant differences in CRS rates, ascites ORR, Karnofsky performance status scores, or survival rates were observed between groups (P > 0.05). CONCLUSION: Cytoreductive surgery with immediate HIPEC and HIPEC with dCRS, determined by vital sign stability, may lead to similar outcomes in OC patients with malignant ascites.

Malignant ascites: pathophysiology and treatment.

Malignant ascites (MA) accompanies a variety of abdominal and extra-abdominal tumors. It is a primary cause of morbidity and raises several treatment challenges. MA has several symptoms, producing a significant reduction in the patient's quality of life: loss of proteins and electrolyte disorders cause diffuse oedema, while the accumulation of abdominal fluid facilitates sepsis. Treatment options include a multitude of different procedures with limited efficacy and some degree of risk. A Pubmed, Medline, Embase, and Cochrane Library review of medical, interventional and surgical treatments of MA has been performed. Medical therapy, primarily paracentesis and diuretics, are first-line treatments in managing MA. Paracentesis is widely adopted but it is associated with significant patient discomfort and several risks. Diuretic therapy is effective at the very beginning of the disease but efficacy declines with tumor progression. Intraperitoneal chemotherapy, targeted therapy, immunotherapy and radioisotopes are promising medical options but their clinical application is not yet completely elucidated, and further investigations and trials are necessary. Peritoneal-venous shunts are rarely used due to high rates of early mortality and complications. Laparoscopy and hyperthermic intraperitoneal chemotherapy (HIPEC) have been proposed as palliative therapy. Literature on the use of laparoscopic HIPEC in MA includes only reports with small numbers of patients, all showing successful control of ascites. To date, none of the different options has been subjected to evidence-based clinical trials and there are no accepted guidelines for the management of MA.

[Pleural effusions and ascites--surgical and palliative aspects]. / Pleuraerguss und Aszites--chirurgische und palliative Aspekte.

BACKGROUND: Pleural effusions and ascites are associated with distressing symptoms like dyspnoea, intestinal obstruction, vomiting, nausea and pain. In patients with underlying malignancy, the prognosis is limited to few months. After unsuccessful medical treatment, surgical and experimental palliative treatment is indicated. METHODS: This review includes a systematic analysis of surgical, experimental and palliative options. RESULTS: In patients with pleural effusions, thoracocentesis, permanent percutaneous drainage, thoracoperitoneal shunts as well as pleurodesis by tubes or thoracoscopy are available, which will be used depending on the re-expansion of the lung. In patients with ascites, paracentesis is able to control acute symptoms. For long-lasting treatment, portosystemic shunts (TIPS) are favourable for patients with liver cirrhosis. Peritoneovenous shunts can be implanted by laparotomy, but are correlated with high rates of complications and occlusions. In patients with malignancy, pleural effusions and ascites may also be controlled by complete cytoreductive surgery and hyperthermic chemoperfusion. This aggressive surgical concept is limited to single carefully selected patients. In malignant ascites, intraperitoneal immunotherapy by catumaxomab is a novel and highly effective option, which controls ascites by targeted destruction of peritoneal cancer cells. CONCLUSION: Various options for treatment of pleural effusions and ascites are available. Careful evaluation of the individual patient is necessary to improve quality of life and survival.

Drenaje permanente tunelizado de la ascitis maligna: experiencia inicial con el catéter PleurX(R) / Permanent tunneled drainage for malignant ascites: Initial experience with the PleurX(R) catheter

Objetivo. El tratamiento más utilizado en la ascitis maligna de repetición es generalmente el drenaje peritoneal temporal. Presentamos nuestra experiencia en la colocación de catéteres tunelizados permanentes en una serie de pacientes y el análisis de la seguridad y efectividad del mismo. Material y métodos. El procedimiento se llevó a cabo en una serie de 10 pacientes, con medidas de asepsia total, en la sala de ecografías dedicada a intervencionismo, únicamente con control ecográfico y bajo anestesia local. Resultados. Los catéteres se mantuvieron permeables una mediana de 52 días en los 9 pacientes que fallecieron. A uno de estos pacientes se le retiró el catéter, que permanecía permeable, por una sepsis generalizada. Un paciente permanecía con el catéter permeable a la conclusión del estudio 124 días tras la colocación. Conclusión. A pesar del escaso número de pacientes, el catéter peritoneal tunelizado parece ser un procedimiento seguro, efectivo y mínimamente invasivo para el tratamiento de la ascitis maligna en pacientes oncológicos terminales, facilitando la evacuación de la ascitis en el domicilio sin necesidad de acudir a un centro hospitalario y evitando punciones de repetición con el consiguiente riesgo para el paciente. No obstante, sería necesaria una mayor experiencia y estudios prospectivos aleatorizados (AU)

Objective. The most common treatment in recurrent malignant ascites is generally temporary peritoneal drainage. We present our experience in placing permanent tunneled catheters in a series of patients and analyze the safety and efficacy of the treatment. Material and methods. We used total aseptic measures in the interventional ultrasonography suite to place permanent tunneled catheters in 10 patients under ultrasonographic guidance and local anesthesia. Results. The catheters remained patent for a median of 52 days in the nine patients who died. In one of these, the catheter was withdrawn while still patent due to generalized sepsis. At the end of the study, one patient still had a permeable catheter 124 days after placement. Conclusion. Although the low number of patients in our series precludes generalizations, tunneled peritoneal catheters seem to be a safe and effective minimally invasive treatment for malignant ascites in terminal oncologic patients. This approach facilitates the draining of the ascites at home, obviating the need for repeated hospital visits and punctures and the risks involved therein. Nevertheless, further experience and prospective randomized trials are necessary (AU)

Reducing malignant ascites accumulation by repeated intraperitoneal administrations of a Viscum album extract.

BACKGROUND: Malignant ascites is a major problem in the management of advanced stages of certain malignancies. The possibility of reducing the accumulation of ascites by intraperitoneal injections of a Viscum album extract (Iscador M) was evaluated. PATIENTS AND METHODS: Twenty-three patients, with end-stage malignancies of varying histology, requiring repeated peritoneal punctures, were eligible for analysis. The time-interval between the first two punctures was measured and defined as the baseline. Following each subsequent puncture, Iscador M 10 mg was injected intraperitoneally. The intervals between later punctures were compared to previous intervals. RESULTS: Following the first injection, the median time-interval between injections increased from 7 to 12 days, reaching 13 days after the second injection. No toxicity was observed. CONCLUSION: This phase II study suggests that installation of Iscador M into the peritoneal cavity may reduce the need for repeated punctures. A randomized trial is needed to confirm these promising preliminary results.

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

OBJECT: 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. METHODS: 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. CONCLUSION: 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.

Malignant ascites: etiology, diagnosis, and treatment.

One of the most uncomfortable and potentially compromising symptoms of many types of cancer is ascites. Unfortunately, ascites usually occurs at a stage when cure is no longer possible and palliation is the primary treatment goal. Modern surgical advances offer the possibility of peritoneovenous shunting. This procedure can offer relief from those symptoms that may significantly alter the performance of daily living activities and for continued participation in usual life-styles.

[Surgical treatment of ascites in cirrhosis of the liver]. / Khirurgicheskoe lechenie astsita pri tsirroze pecheni.

A porto-systemic shunt can be created in patients with a stable course of cirrhosis of the liver complicated by varicosity of the esophageal veins and transitory ascites. The formation of a lympho-venous anastomosis is indicated in ascites and impaired lymph drainage from the liver. Interventions minimal in volume (peritoneo-venous shunting, reduction of arterial blood flow, etc.) are indicated in stable or progressive ascites and marked disorders of hepatic function.

Peritoneovenous shunt in treatment of ascites in patients with cirrhosis. A preliminary report with special reference to pathophysiology.

Peritoneovenous shunts (LeVeen type) were implanted in seven patients with cirrhosis complicated by ascites refractory to diuretic treatment. Three patients died of gastrointestinal bleeding and hepatic coma 1 to 7 weeks after the shunt implantation. The patients who died were those with the most severely impaired liver and kidney function. In two of the four surviving patients (observation time, 5-24 months) the shunt was patent during the observation time, and ascites disappeared. In the other two the shunt closed, in one patient repeatedly following several re-implantations. Enhanced urinary sodium excretion was observed in patients with patent shunts. After disappearance of ascites, the splanchnic venous pressures became less deranged. Long-term change in plasma volume or circulating albumin mass could not be detected. A patent shunt increases the drainage from the peritoneal cavity, but detectable increment in the overall lymph drainage was only found in a patient with a very low pre-shunt value. The findings do not support the 'overflow' theory of ascites formation but rather the 'lymph imbalance' theory. For clinical evaluation of peritoneovenous shunting in the treatment of ascites a controlled clinical trial is essential.

Peritoneo-venous shunting for ascites.

A new minor surgical procedure for ascites has been devised wherein a specially designated one way pressure activated valve is implanted to create a permanent peritoneo-venous shunt. The normally closed valves opens only when the peritoneal pressure rises 3-5 cm higher than the intrathoracic venous pressure thus preventing backflow of blood and closing the valve should the venous pressure rise from the over-infusion of ascitic fluid. The procedure has been performed on 45 patients but nine were terminal at the time of surgery. Prolonged relief of ascites occurred in 28 of 37 cases.