Clinical implications of prompt ascitic drain removal in cirrhosis with refractory ascites

Wong, Yuk Peng; Lum, Huey-Ming; Tan, P; Teo, Eng–Kiong; Tan, Jessica; Kumar, Rahul; Thurairajah, Prem-Harichander

doi:10.11622/smedj.2021049

smedj

2021

DOI: 10.11622/smedj.2021049

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Clinical implications of prompt ascitic drain removal in cirrhosis with refractory ascites

Yuk Peng Wong¹,

Huey-Ming Lum²,

P Tan³

et al.

Abstract: Introduction: Large-volume paracentesis (LVP) is the first-line treatment for decompensated cirrhosis with refractory ascites. While ascitic drain removal (ADR) within 72 hours was once considered safe, it was uncertain if ADR within 24 hours could further reduce the risk of ascitic drain-related bacterial peritonitis (AdBP). This study aimed to investigate the association between the timing of ADR and the presence of AdBP. Methods: All cirrhotics with refractory ascites who underwent LVP in our institution f… Show more

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Cited by 3 publications

References 27 publications

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Comment on: Clinical implications of prompt ascitic drain removal in cirrhosis with refractory ascites

Thakur¹

2021

smedj

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We read Wong et al's article with great enthusiasm. (1) It highlighted the high risk of peritonitis in patients with 'non-tunnelled' ascitic drains for more than 24 hours to manage refractory ascites.Patients who undergo intermittent large-volume paracentesis (LVP) experience significant deterioration in quality of life owing to frequent procedures and hospitalisations. (2) These patients experience multiple symptoms, including shortness of breath, bloating, fatigue and poor health-related quality of life. (2) There is an unmet palliative need in patients with limited life expectancy who are not candidates for liver transplant and transjugular intrahepatic portosystemic shunt. The goals of treatment often need to focus on symptom management and comfort. Long-term abdominal drains (LTADs) are tunnelled drains inserted with radiological guidance that can serve as an alternative management option for these patients. Patients can manage the continuous drainage catheter at home, draining small amounts of ascitic fluid multiple times a week, thereby avoiding frequent hospital visits. (3) Recent studies in malignant ascites have shown that LTADs have a low complication rate and incur lower costs compared with inpatient LVP. (4) A systemic review of LTADs in non-malignant ascites showed a 100% technical insertion success rate and a 12% rate of bacterial peritonitis. (5) The REDUCe study, a feasibility randomised controlled trial, compared LVP and LTADs in refractory ascites due to cirrhosis. (6) The study demonstrated feasibility, with preliminary evidence of LTAD acceptability, safety and reduction of health resource utilisation.Hence, tunnelled LTADs seem to be a practical palliative approach for the management of refractory ascites but warrant further prospective research.

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Comment on: Clinical implications of prompt ascitic drain removal in cirrhosis with refractory ascites

Thakur¹

2021

smedj

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Authors’ reply: Comment on: Clinical implications of prompt ascitic drain removal in cirrhosis with refractory ascites

Wong¹,

Kumar²,

Tan³

et al. 2021

smedj

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We thank the author (1) for his interest in our recent work demonstrating an increased risk of ascitic drain-related peritonitis and acute kidney injury in patients with cirrhosis requiring large-volume paracentesis. (2) The author brought up the interesting concept of tunnelled long-term ascites drainage (LTAD), a cost-effective alternative to fulfil the palliative need in patients with malignant ascites. As the author rightly pointed out, the existing data for LTAD is preliminary. Current studies on LTAD are confounded by the small sample size and limited follow-up duration. While healthcare resource utilisation was reduced, the study failed to demonstrate an improvement in the quality of life of patients with LTAD, which is an important consideration when it comes to patient-centric palliative hepatology. (3) Patient selection is the key. While LTAD may be an acceptable alternative in patients with malignant ascites who have very limited survival time (median survival was only 53 days in the LTAD group), (3) we caution against extrapolating the benefit to all cirrhosis patients with refractory ascites, where the median survival is generally longer. In our current study, we demonstrated an increased risk of ascitic drain-related peritonitis and acute kidney injury in cirrhosis patients with refractory ascites when ascitic drain removal was delayed beyond 24 hours. Ascitic drain is an important risk factor for nosocomial spontaneous bacterial peritonitis, which is known to result in poorer survival among patients with decompensated cirrhosis. (4) A similar finding was demonstrated in a multicentre prospective study on the automated low-flow ascitic pump, where a high risk of bacterial infection was observed in 43.3% of patients. (5) Although the bacterial infection may be partially mitigated by administering long-term antibiotics in these patients, the potential adverse effect of long-term antibiotic prophylaxis in these patients with LTAD remained unclear.Finally, we agree with the author that more studies are required before tunnelled LTAD can be widely adopted in the management of refractory ascites. Long-term safety outcome, patient-reported outcomes and patients' preferences must be considered when selecting patients for LTAD.Yours sincerely,

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Drainage of ascites in cirrhosis

Yang,

Peng,

Zeng

et al. 2024

World J Hepatol

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For cirrhotic refractory ascites, diuretics combined with albumin and vasoactive drugs are the first-line choice for ascites management. However, their therapeutic effects are limited, and most refractory ascites do not respond to medication treatment, necessitating consideration of drainage or surgical interventions. Consequently, numerous drainage methods for cirrhotic ascites have emerged, including large-volume paracentesis, transjugular intrahepatic portosystemic shunt, peritoneovenous shunt, automated low-flow ascites pump, cell-free and concentrated ascites reinfusion therapy, and peritoneal catheter drainage. This review introduces the advantages and disadvantages of these methods in different aspects, as well as indications and contraindications for this disease.

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Clinical implications of prompt ascitic drain removal in cirrhosis with refractory ascites

Cited by 3 publications

References 27 publications

Comment on: Clinical implications of prompt ascitic drain removal in cirrhosis with refractory ascites

Comment on: Clinical implications of prompt ascitic drain removal in cirrhosis with refractory ascites

Authors’ reply: Comment on: Clinical implications of prompt ascitic drain removal in cirrhosis with refractory ascites

Drainage of ascites in cirrhosis

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