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A Fresh Look at the Treatment of Ascites
Letters to the Editor Correction From: Scott Craig Goodwin, MD Suresh Vedantham, MD Department of Radiological Sciences UCLA Medical Center Room CHS BL-423 / 172115 10833 Le Conte Avenue Los Angeles, CA 90024-1721 Editor: We recently discovered a n error in our 1997 JVIR article documenting our preliminary experience with uterine artery embolization for fibroids (1).In the methods section, this retrospective study was incorrectly termed prospective. Please accept our apologies and this correction for a significant oversight on our part. Reference 1. Goodwin SC, Vedantham S, McLucas B, Forno AE, Perrella R. Preliminary experience with uterine artery embolization for uterine fibroids. JVIR 1997; 8:517-526.
A Fresh Look at the Treatment of Ascites From: Robert F. LeVeen, MD William C. Culp, MD Department of Radiology VA Medical Center 4101 Woolworth Avenue Omaha, NE 68105-1850 Editor: The article by Rozenblit et a1 should be commended for its innovative approach to the treatment of ascites (1).Ascites remains an imperfectly treated problem with success rates of approximately 75%, even with the recent addition of transjugular intrahepatic portosystemic shunts (TIPS) to the therapeutic armamentarium (2). There are many patients who do not respond favorably to the current therapies of paracentesis, peritoneovenous shunts, and TIPS, which may itself cause worsening hepatic function and encephalopathy. Paracentesis with albumin supplementation is a flawed solution that not only depletes the patient of protein, but also requires frequent repetition, increasing the risk of infection and other complications, such as bleeding and hepatorenal syndrome. When perfected, the author's pump will solve the problem of repetition, but it is expected to share in all the other major problems of paracentesis. The authors present strong arguments against the use of the peritoneovenous shunt. However, they dismiss the benefits of this approach, which has proved to be as good as medical therapy with paracentesis and
albumin supplementation (31, and better than medical therapy alone (4), in large prospective randomized multicenter controlled studies. One of the important advantages is the ability to conserve protein by reinfusing it into the intravascular space. This is important because these patients often have reduced liver synthetic function and become hypoalbuminemic, which reduces the oncotic pressure of the blood, resulting in exacerbated ascites. Protein loss in paracentesis and the Rozenblit concept both accentuate this process. A second salutary feature of the peritoneovenous shunt is the natural replenishment of the intravascular volume, which tends to become depleted when the ascitic fluid is drained. The hypovolemia associated with paracentesis can lead to renal compromise and the hepatorenal syndrome. For these reasons, volume replacement and albumin replacement are required. Neither feature is innate in the basic technique of Rozenblit and the problem is dismissed as equivalent to that in paracentesis. The "drainage on demand" feature will potentially lead to accelerated protein and fluid loss. This may be a much more dangerous clinical problem than that seen with less frequent intermittent paracentesis because the patients will not necessarily be followed as closely. Rozenblit's case 2 may demonstrate this problem, with the patient's presentation a t 7 weeks with severe dehydration and requirements for saline and albumin. Many of the problems cited in the references from more than 10 years ago, and historically associated with placement of the peritoneovenous shunt, have been solved. With image guidance, many of the occlusions due to inadequate placement of the venous limb can be eliminated, thus reducing the incidence of shunt failure. Shunt-related disseminated intravascular coagulopathy is avoided by draining the ascites and replacing it with saline a t the time of shunt placement. In Rozenblit's series, fastidious patient selection was practiced, excluding patients with any evidence infection of occult bacterial ~eritonitis.This is also necessarv for ~eritoneovenous shunting, in which subclinical infections often lead to catheter occlusion and may be one of the problems with some of the disappointing series. None of the large published series reflect the success and complication rates that could be currently expected with modern modifications of the technique. It is time for a fresh look a t ascites and its treatments. Development of improved devices and techniques may earn the Rozenblit concept a valid place in the armamentarium, despite the potential shortcomings listed previously. Refinement of the rather old peritoneovenous shunting technology is also anticipated and both concepts may successfully compete with the limited success now provided by the TIPS procedure. References 1. Rosenblit GN, Del Guercio LRM, Rundback JH, Poplausky MR, Lebovics E. Peritoneal-urinary drainage for treatment of refractory ascites: a pilot study. JVIR 1998; 9:9981005.
992
a
Letter to the Editor
July-August 1999 JVIR
2. Edney JA, Hill A, Armstrong D. Peritoneovenous shunts palliate malignant ascites. Am J Surg 1989; 158:598-601. 3. Gines P, Arroyo V, Vargas V, et al. Paracentesis with intravenous infusion of albumin as compared with peritoneovenous shunting in cirrhosis with refractory ascites. N Engl J Med 1991; 325:829-835. 4. Stanley MM, Ochi S, Lee KK, et al. Peritoneovenous shunting as compared with medical treatment in patients with alcoholic cirrhosis and massive ascites. N Engl J Med 1990; 321:1632-1638.
Drs. Rozenblit et a1 respond: We appreciate the complimentary assessment of our work by such authorities on the subject as Drs. LeVeen and Culp. Currently, interventional treatments to palliate refractory debilitating ascites include paracentesis, transjugular intrahepatic portosystemic shunt (TIPS), and peritoneovenous shunt (PVS; a.k.a. LeVeen shunt). We hope that peritoneal-urinary drainage (PUD) will become another treatment option. We share Drs. LeVeen's and Culp's disappointment with TIPS as a method of treatment for ascites. Actually, the concept of PUD stemmed from of our attempts to avoid TIPS in patients with cirrhotic ascites. Published data and our own experience convincingly demonstrated that in such patients, TIPS might lead to accelerated liver failure. In addition, TIPS has no utility in patients with noncirrhotic ascites due to peritoneal carcinomatosis, cardiac or renal failure. PVS is a well-recognized therapeutic option. According to the most recent randomized studies (1,2), the LeVeen shunt was more effective than periodic paracentesis in the long-term control of refractory cirrhotic ascites. PVS markedly increased the time to first readmission for ascites, decreased the total number of readmissions for ascites, and lowered diuretic requirements. Yet, vis-a-vis paracentesis the total hospitalization time was significantly longer for patients with the LeVeen shunt. This was related to the higher incidence of complications, such as severe bacterial infections, symptomatic disseminated intravascular coagulopathy, superior vena cava thrombosis, and so forth (1). The two major theoretical advantages of PVS versus paracentesis are protein preservation and "the natural replenishment of the intravascular volume," which protects against renal compromise. However, to the best of our knowledge, clinical significance of either of these two potential advantages is yet to be shown in a randomized study. In the above cited publication (I),serum albumin concentration increased significantly in patients treated by paracentesis with intravenous albumin administration, while it decreased slightly in patients with the LeVeen shunt. There was also a significant decrease of mean arterial pressure and prothrombin time in the latter group. No significant change in serum creatinine, bilirubin, and sodium concentration was found in either group. We agree with Drs. LeVeen and Culp that, with modern modifications of the PVS technique, an improvement of the success and complication rates may be expected.
Unfortunately, as they pointed out, none of the previously published large series reflected the improvement. According to one recent review (31, the use of PVS is limited by the high incidence of complications induced by the procedure. Besides, the incidence of device obstruction within the first postoperative year is approximately 40%. The review concludes that therapeutic large volume or total paracentesis associated with intravenous albumin infusion is the treatment of choice for cirrhotic patients with tense ascites. Drs. LeVeen and Culp reiterate a valid theoretical disadvantage of PUD-that being protein loss. They also warn against a possible fluid imbalance. We agree with them that the physiologic equating of PUD and large volume paracentesis is speculative. In fact, with PUD, a small volume of ascites is drained slowly and chronically in contradistinction to a periodic quick removal of a large volume by paracentesis. This distinction might lead to a completely different character of protein loss and fluid dynamics with each method. For example, PUD is probably less likely to cause an acute deterioration of the effective circulating blood volume and, consequently, might not require a plasma volume expansion by transfusion of albumin, dextran 70, or polygeline. Therefore, all pros and cons of PUD require a thorough clinical evaluation, preferably in a randomized trial. Our initial experience in no way can replace a well-organized clinical study. Nevertheless, so far, we have seen neither a dramatic protein depletion nor dehydration that resulted exclusively from PUD. A single episode of dehydration described in our report (4) was related to the synchronous inappropriate use of diuretics with PUD by a noncompliant patient. It should be noted that PUD might be used when an application of other interventional methods may be limited. In fact, our longest, 18 months to date, experience with PUD involves a patient with ascites due to cardiac failure. Thus far, the ascites and, incidentally, peripheral edema in this patient have been well controlled without significant hypoalbuminemia or dehydration. We would like to add that presently, we prefer to place the reservoir of the PUD device a t the right anterior chest wall just below the breast. This position seems to allow easier patient control due to rib cage support. In conclusion, we hope that PUD will find its place along with paracentesis, PVS, and TIPS in treating patients with intractable ascites of various etiologies. It may become especially useful when other methods have a limited application such as in severe hepatic, renal, or cardiac insufficiency, coagulopathy, or central venous thrombosis. References 1. Gines A, Planas R, Angeli P, et al. Treatment of patients
with cirrhosis and refractory ascites using LeVeen shunt with titanium tip: comparison with therapeutic paracentesis. Hepatology 1995; 22:124-131. 2. Gines P, Arroyo V, Vargas V, et al. Paracentesis with intravenous infusion of albumin as compared with peritoneovenous shunting in cirrhosis with refractory ascites. N Engl J Med 1991; 325:829-835.
A Fresh Look at the Treatment of Ascites From: Robert F. LeVeen, MD William C. Culp, MD Department of Radiology VA Medical Center 4101 Woolworth Avenue Omaha, NE 68105-1850 Editor: The article by Rozenblit et a1 should be commended for its innovative approach to the treatment of ascites (1).Ascites remains an imperfectly treated problem with success rates of approximately 75%, even with the recent addition of transjugular intrahepatic portosystemic shunts (TIPS) to the therapeutic armamentarium (2). There are many patients who do not respond favorably to the current therapies of paracentesis, peritoneovenous shunts, and TIPS, which may itself cause worsening hepatic function and encephalopathy. Paracentesis with albumin supplementation is a flawed solution that not only depletes the patient of protein, but also requires frequent repetition, increasing the risk of infection and other complications, such as bleeding and hepatorenal syndrome. When perfected, the author's pump will solve the problem of repetition, but it is expected to share in all the other major problems of paracentesis. The authors present strong arguments against the use of the peritoneovenous shunt. However, they dismiss the benefits of this approach, which has proved to be as good as medical therapy with paracentesis and
albumin supplementation (31, and better than medical therapy alone (4), in large prospective randomized multicenter controlled studies. One of the important advantages is the ability to conserve protein by reinfusing it into the intravascular space. This is important because these patients often have reduced liver synthetic function and become hypoalbuminemic, which reduces the oncotic pressure of the blood, resulting in exacerbated ascites. Protein loss in paracentesis and the Rozenblit concept both accentuate this process. A second salutary feature of the peritoneovenous shunt is the natural replenishment of the intravascular volume, which tends to become depleted when the ascitic fluid is drained. The hypovolemia associated with paracentesis can lead to renal compromise and the hepatorenal syndrome. For these reasons, volume replacement and albumin replacement are required. Neither feature is innate in the basic technique of Rozenblit and the problem is dismissed as equivalent to that in paracentesis. The "drainage on demand" feature will potentially lead to accelerated protein and fluid loss. This may be a much more dangerous clinical problem than that seen with less frequent intermittent paracentesis because the patients will not necessarily be followed as closely. Rozenblit's case 2 may demonstrate this problem, with the patient's presentation a t 7 weeks with severe dehydration and requirements for saline and albumin. Many of the problems cited in the references from more than 10 years ago, and historically associated with placement of the peritoneovenous shunt, have been solved. With image guidance, many of the occlusions due to inadequate placement of the venous limb can be eliminated, thus reducing the incidence of shunt failure. Shunt-related disseminated intravascular coagulopathy is avoided by draining the ascites and replacing it with saline a t the time of shunt placement. In Rozenblit's series, fastidious patient selection was practiced, excluding patients with any evidence infection of occult bacterial ~eritonitis.This is also necessarv for ~eritoneovenous shunting, in which subclinical infections often lead to catheter occlusion and may be one of the problems with some of the disappointing series. None of the large published series reflect the success and complication rates that could be currently expected with modern modifications of the technique. It is time for a fresh look a t ascites and its treatments. Development of improved devices and techniques may earn the Rozenblit concept a valid place in the armamentarium, despite the potential shortcomings listed previously. Refinement of the rather old peritoneovenous shunting technology is also anticipated and both concepts may successfully compete with the limited success now provided by the TIPS procedure. References 1. Rosenblit GN, Del Guercio LRM, Rundback JH, Poplausky MR, Lebovics E. Peritoneal-urinary drainage for treatment of refractory ascites: a pilot study. JVIR 1998; 9:9981005.
992
a
Letter to the Editor
July-August 1999 JVIR
2. Edney JA, Hill A, Armstrong D. Peritoneovenous shunts palliate malignant ascites. Am J Surg 1989; 158:598-601. 3. Gines P, Arroyo V, Vargas V, et al. Paracentesis with intravenous infusion of albumin as compared with peritoneovenous shunting in cirrhosis with refractory ascites. N Engl J Med 1991; 325:829-835. 4. Stanley MM, Ochi S, Lee KK, et al. Peritoneovenous shunting as compared with medical treatment in patients with alcoholic cirrhosis and massive ascites. N Engl J Med 1990; 321:1632-1638.
Drs. Rozenblit et a1 respond: We appreciate the complimentary assessment of our work by such authorities on the subject as Drs. LeVeen and Culp. Currently, interventional treatments to palliate refractory debilitating ascites include paracentesis, transjugular intrahepatic portosystemic shunt (TIPS), and peritoneovenous shunt (PVS; a.k.a. LeVeen shunt). We hope that peritoneal-urinary drainage (PUD) will become another treatment option. We share Drs. LeVeen's and Culp's disappointment with TIPS as a method of treatment for ascites. Actually, the concept of PUD stemmed from of our attempts to avoid TIPS in patients with cirrhotic ascites. Published data and our own experience convincingly demonstrated that in such patients, TIPS might lead to accelerated liver failure. In addition, TIPS has no utility in patients with noncirrhotic ascites due to peritoneal carcinomatosis, cardiac or renal failure. PVS is a well-recognized therapeutic option. According to the most recent randomized studies (1,2), the LeVeen shunt was more effective than periodic paracentesis in the long-term control of refractory cirrhotic ascites. PVS markedly increased the time to first readmission for ascites, decreased the total number of readmissions for ascites, and lowered diuretic requirements. Yet, vis-a-vis paracentesis the total hospitalization time was significantly longer for patients with the LeVeen shunt. This was related to the higher incidence of complications, such as severe bacterial infections, symptomatic disseminated intravascular coagulopathy, superior vena cava thrombosis, and so forth (1). The two major theoretical advantages of PVS versus paracentesis are protein preservation and "the natural replenishment of the intravascular volume," which protects against renal compromise. However, to the best of our knowledge, clinical significance of either of these two potential advantages is yet to be shown in a randomized study. In the above cited publication (I),serum albumin concentration increased significantly in patients treated by paracentesis with intravenous albumin administration, while it decreased slightly in patients with the LeVeen shunt. There was also a significant decrease of mean arterial pressure and prothrombin time in the latter group. No significant change in serum creatinine, bilirubin, and sodium concentration was found in either group. We agree with Drs. LeVeen and Culp that, with modern modifications of the PVS technique, an improvement of the success and complication rates may be expected.
Unfortunately, as they pointed out, none of the previously published large series reflected the improvement. According to one recent review (31, the use of PVS is limited by the high incidence of complications induced by the procedure. Besides, the incidence of device obstruction within the first postoperative year is approximately 40%. The review concludes that therapeutic large volume or total paracentesis associated with intravenous albumin infusion is the treatment of choice for cirrhotic patients with tense ascites. Drs. LeVeen and Culp reiterate a valid theoretical disadvantage of PUD-that being protein loss. They also warn against a possible fluid imbalance. We agree with them that the physiologic equating of PUD and large volume paracentesis is speculative. In fact, with PUD, a small volume of ascites is drained slowly and chronically in contradistinction to a periodic quick removal of a large volume by paracentesis. This distinction might lead to a completely different character of protein loss and fluid dynamics with each method. For example, PUD is probably less likely to cause an acute deterioration of the effective circulating blood volume and, consequently, might not require a plasma volume expansion by transfusion of albumin, dextran 70, or polygeline. Therefore, all pros and cons of PUD require a thorough clinical evaluation, preferably in a randomized trial. Our initial experience in no way can replace a well-organized clinical study. Nevertheless, so far, we have seen neither a dramatic protein depletion nor dehydration that resulted exclusively from PUD. A single episode of dehydration described in our report (4) was related to the synchronous inappropriate use of diuretics with PUD by a noncompliant patient. It should be noted that PUD might be used when an application of other interventional methods may be limited. In fact, our longest, 18 months to date, experience with PUD involves a patient with ascites due to cardiac failure. Thus far, the ascites and, incidentally, peripheral edema in this patient have been well controlled without significant hypoalbuminemia or dehydration. We would like to add that presently, we prefer to place the reservoir of the PUD device a t the right anterior chest wall just below the breast. This position seems to allow easier patient control due to rib cage support. In conclusion, we hope that PUD will find its place along with paracentesis, PVS, and TIPS in treating patients with intractable ascites of various etiologies. It may become especially useful when other methods have a limited application such as in severe hepatic, renal, or cardiac insufficiency, coagulopathy, or central venous thrombosis. References 1. Gines A, Planas R, Angeli P, et al. Treatment of patients
with cirrhosis and refractory ascites using LeVeen shunt with titanium tip: comparison with therapeutic paracentesis. Hepatology 1995; 22:124-131. 2. Gines P, Arroyo V, Vargas V, et al. Paracentesis with intravenous infusion of albumin as compared with peritoneovenous shunting in cirrhosis with refractory ascites. N Engl J Med 1991; 325:829-835.