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Management of malignant ascites with a vascular port
Management
of Malignant
Ascites
With a Vascular
Port
By James A. Borger, Paul Pitel, and Ginger Crump Jacksonville, Florida 0 A 15 year old with severe malignant ascites, refractory to medical management, was treated with a venous port. This proved to be an effective way to control the ascites and was easily placed under local anesthesia, with little risk or discomfort to the patient. Copyright o 1993 by W.B. Saunders Company INDEX WORDS: Ascites, malignant.
I
N PATIENTS with intraperitoneal malignant disease, unrelenting ascites develops occasionally, which is refractory to all medical treatment. In such a case it was decided, in view of the terminal status, to relieve the overwhelming ascites in an effective but low-risk fashion to palliate the patient. The options normally available are repeated needle aspirations of the peritoneal cavity, placement of an indwelling external catheter, or placement of a peritoneo-venous shunt.Q These methods have significant drawbacks so we decided on a compromise approach-vascular port implantation. CASE REPORT A 15-year-old boy presented to his local physician with a history of constipation, lower abdominal pain, and back pain. The initial physical examination showed hepatomegaly, a large rectal mass, and moderate ascites. Computed tomography (CT) showed a large pelvic mass with lesions also in the right kidney, spleen, liver, lungs, and mediastinum. Results of head CT and bone marrow aspiration were negative. Tumor markers (o-fetoprotein and human chorionic gonadotropin) were negative. A needle biopsy of the liver showed hepatocellular carcinoma. Initially he was treated with cisplatin, vincristine, and 5-fluorouracil and radiation to his pelvis. The response was good initially, but within 3 months, follow-up CT showed hepatic and splenic mass enlargement. Chemotherapy was then changed to ifosfamidei Mesna (Asta Medica, Frankfurt, Germany) and etoposide. Follow-up 3 months later showed all masses enlarging. At this point, a conference was held with the family, which resulted in a change of therapeutic goals from cure to supportive and palliative care. The patient’s condition continued to deteriorate, with increasing pain and ascites. This resulted in nausea, vomiting, and respiratory embarrassment. To relieve this, paracentesis was undertaken, but within 3 weeks the ascites had reaccumulated. At this time the decision was made to implant a venous port subcutaneously, placing the catheter in the peritoneal space. This was accomplished with local anesthesia and mild sedation. The port was placed over the anterior lower chest, and the catheter was tunneled subcutaneously to the left upper quadrant and placed under direct vision into the abdominal cavity. Fluid was removed via the port at a rate of 1,000 mL per aspiration, and aspirated up to five times a week. The patient tolerated this with no problems and remained relatively symptomfree until his death 10 weeks later.
Journa/off’ediatric Surgery, Vol28, No 12 (December), 1993: pp 1605.1606
During this period, the port was accessed 21 times, with removal of over 21,000 mL of fluid. There were no problems related to fluid removal, possible catheter obstruction, or infection. This patient’s condition was significantly palliated with this procedure.
DISCUSSION
Beyond palliation, there is little to offer an endstage cancer patient, as exemplified by this case. With the onset of unrelenting malignant ascites, such patients face not only a limited life span but also a fairly miserable time until they die. Relieving the fluid excess in a safe, painless, and effective way, appears to be quite significant. As mentioned, there are not a lot of options in such cases, so using this previously unreported method was gratifying. Multiple paracentesis carry increased risk of infection, discomfort of repeated needle sticks into the abdominal cavity, and an increased chance of puncturing a hollow viscous as the number of aspirations rises. In this case, the malignant ascites began to reaccumulate within days of removal and required constant reaspiration. An approach similar to ours was described in South Africa.3 Essentially a silastic drain (similar to a short-term renal dialysis catheter) is implanted in the peritoneal cavity and exits onto the abdominal wall. This approach has two problems we avoid: (1) there is direct access of bacteria into the abdominal cavity in an already compromised patient, and (2) daily wound care is necessary because the silastic catheter protrudes from the skin. The indwelling port requires no such wound care and when not in use it is completely sealed from the outside environment by a skin barrier, therefore reducing any chance of contamination of the peritoneal cavity. The final accepted method of removing ascites requires a peritoneo-venous shunt. Placement requires a greater operative procedure, catheterization of a major venous channel, and probable general anesthesia; this carries the risk of disseminated intravascular coagulopathy because of the large infusion of protein intravenously. Again, the patient was a very
From Nemours Children k Clinic, Jacksonville, FL. Address reprint requests to James A. Borger, MD, Nemours Children’s Clinic, 807 Nira St, Jacksonvdle, FL 32207. Copyright o 1993 by W.B. Saunders Compan_v 0022-3468/9312812-0029$03.00/O
1606
poor anesthetic risk, and we wanted to perform the least-painful procedure that was effective. With that in mind we decided to insert a venous port subcutaneously and tunnel the catheter subcutaneously to the abdominal wall, and then insert it into the peritoneal cavity. With only mild sedation and local anesthesia, this was accomplished with minimal difficulty. The only problem we foresaw with the port was possible protein deposition in the catheter and subsequent obstruction. This did not occur. We were able to remove significant amounts of ascitic fluid in a timely fashion by simply accessing the port. This
BORGER. PITEL, AND CRUMP
proved to be effective, with little risk, and resulted in excellent palliation for the patient. REFERENCES 1. Millard FC, Powis SJ: Management of intractable malignant ascites using the Denver peritoneo-venous shunt. J R Colt Surg Edinb 33:8-9,1988 2. Edney JA, Hill A, Armstrong D: Peritoneo-venous palliate malignant ascites. Am J Surg 158598-601, 1989
shunts
3. Belfort MA, Stevens PJ d’E, DeHaek K, et al: A new approach to the management of malignant ascites; a permanently implanted abdominal drain. Eur J Surg Oncol16:47-53, 1990
of Malignant
Ascites
With a Vascular
Port
By James A. Borger, Paul Pitel, and Ginger Crump Jacksonville, Florida 0 A 15 year old with severe malignant ascites, refractory to medical management, was treated with a venous port. This proved to be an effective way to control the ascites and was easily placed under local anesthesia, with little risk or discomfort to the patient. Copyright o 1993 by W.B. Saunders Company INDEX WORDS: Ascites, malignant.
I
N PATIENTS with intraperitoneal malignant disease, unrelenting ascites develops occasionally, which is refractory to all medical treatment. In such a case it was decided, in view of the terminal status, to relieve the overwhelming ascites in an effective but low-risk fashion to palliate the patient. The options normally available are repeated needle aspirations of the peritoneal cavity, placement of an indwelling external catheter, or placement of a peritoneo-venous shunt.Q These methods have significant drawbacks so we decided on a compromise approach-vascular port implantation. CASE REPORT A 15-year-old boy presented to his local physician with a history of constipation, lower abdominal pain, and back pain. The initial physical examination showed hepatomegaly, a large rectal mass, and moderate ascites. Computed tomography (CT) showed a large pelvic mass with lesions also in the right kidney, spleen, liver, lungs, and mediastinum. Results of head CT and bone marrow aspiration were negative. Tumor markers (o-fetoprotein and human chorionic gonadotropin) were negative. A needle biopsy of the liver showed hepatocellular carcinoma. Initially he was treated with cisplatin, vincristine, and 5-fluorouracil and radiation to his pelvis. The response was good initially, but within 3 months, follow-up CT showed hepatic and splenic mass enlargement. Chemotherapy was then changed to ifosfamidei Mesna (Asta Medica, Frankfurt, Germany) and etoposide. Follow-up 3 months later showed all masses enlarging. At this point, a conference was held with the family, which resulted in a change of therapeutic goals from cure to supportive and palliative care. The patient’s condition continued to deteriorate, with increasing pain and ascites. This resulted in nausea, vomiting, and respiratory embarrassment. To relieve this, paracentesis was undertaken, but within 3 weeks the ascites had reaccumulated. At this time the decision was made to implant a venous port subcutaneously, placing the catheter in the peritoneal space. This was accomplished with local anesthesia and mild sedation. The port was placed over the anterior lower chest, and the catheter was tunneled subcutaneously to the left upper quadrant and placed under direct vision into the abdominal cavity. Fluid was removed via the port at a rate of 1,000 mL per aspiration, and aspirated up to five times a week. The patient tolerated this with no problems and remained relatively symptomfree until his death 10 weeks later.
Journa/off’ediatric Surgery, Vol28, No 12 (December), 1993: pp 1605.1606
During this period, the port was accessed 21 times, with removal of over 21,000 mL of fluid. There were no problems related to fluid removal, possible catheter obstruction, or infection. This patient’s condition was significantly palliated with this procedure.
DISCUSSION
Beyond palliation, there is little to offer an endstage cancer patient, as exemplified by this case. With the onset of unrelenting malignant ascites, such patients face not only a limited life span but also a fairly miserable time until they die. Relieving the fluid excess in a safe, painless, and effective way, appears to be quite significant. As mentioned, there are not a lot of options in such cases, so using this previously unreported method was gratifying. Multiple paracentesis carry increased risk of infection, discomfort of repeated needle sticks into the abdominal cavity, and an increased chance of puncturing a hollow viscous as the number of aspirations rises. In this case, the malignant ascites began to reaccumulate within days of removal and required constant reaspiration. An approach similar to ours was described in South Africa.3 Essentially a silastic drain (similar to a short-term renal dialysis catheter) is implanted in the peritoneal cavity and exits onto the abdominal wall. This approach has two problems we avoid: (1) there is direct access of bacteria into the abdominal cavity in an already compromised patient, and (2) daily wound care is necessary because the silastic catheter protrudes from the skin. The indwelling port requires no such wound care and when not in use it is completely sealed from the outside environment by a skin barrier, therefore reducing any chance of contamination of the peritoneal cavity. The final accepted method of removing ascites requires a peritoneo-venous shunt. Placement requires a greater operative procedure, catheterization of a major venous channel, and probable general anesthesia; this carries the risk of disseminated intravascular coagulopathy because of the large infusion of protein intravenously. Again, the patient was a very
From Nemours Children k Clinic, Jacksonville, FL. Address reprint requests to James A. Borger, MD, Nemours Children’s Clinic, 807 Nira St, Jacksonvdle, FL 32207. Copyright o 1993 by W.B. Saunders Compan_v 0022-3468/9312812-0029$03.00/O
1606
poor anesthetic risk, and we wanted to perform the least-painful procedure that was effective. With that in mind we decided to insert a venous port subcutaneously and tunnel the catheter subcutaneously to the abdominal wall, and then insert it into the peritoneal cavity. With only mild sedation and local anesthesia, this was accomplished with minimal difficulty. The only problem we foresaw with the port was possible protein deposition in the catheter and subsequent obstruction. This did not occur. We were able to remove significant amounts of ascitic fluid in a timely fashion by simply accessing the port. This
BORGER. PITEL, AND CRUMP
proved to be effective, with little risk, and resulted in excellent palliation for the patient. REFERENCES 1. Millard FC, Powis SJ: Management of intractable malignant ascites using the Denver peritoneo-venous shunt. J R Colt Surg Edinb 33:8-9,1988 2. Edney JA, Hill A, Armstrong D: Peritoneo-venous palliate malignant ascites. Am J Surg 158598-601, 1989
shunts
3. Belfort MA, Stevens PJ d’E, DeHaek K, et al: A new approach to the management of malignant ascites; a permanently implanted abdominal drain. Eur J Surg Oncol16:47-53, 1990