Palliative Treatment of Malignant Refractory Ascites by Positioning of Denver Peritoneovenous Shunt

Abstract

Malignant ascites is relatively common in patients with certain types of end-stage cancer. Traditional treatments based on fluid and salt restriction and diuretic therapy often are not able to contain neoplastic ascites. These patients consequently undergo repeated abdominal paracentesis, with further plasma protein loss and risk of injury to abdominal viscera. The aim of this study was to evaluate our experience with Denver peritoneovenous shunt and the outcome of patients with malignant ascites and suggest some modifications to improve device patency. From February 1997 to December 1999, 44 Denver peritoneovenous shunts were placed in 42 patients, 17 women and 25 men, aged between 38 and 77 years (mean, 62.3), affected with malignant ascites due to advanced abdominal cancer. At the time of admission, 72% of patients had pain, 88% dysphagia, 66% nausea and/or vomiting, and 83% dyspnea. Eleven patients underwent local anesthesia with lidocaine and 33 general anesthesia with rapidly metabolized drugs. In 27 cases we used the peritoneal-internal jugular right vein surgical approach and in 3 cases the peritoneal-femoral vein surgical access, joining the saphena vein to the cross. In 10 cases, a radiological positioning of the Denver peritoneovenous shunt was effected by a trans-subclavian access. Relief of ascites symptoms was obtained in 87.5% of cases, with reduction of dyspnea, an increased appetite and improved ambulation. Denver peritoneovenous shunt is a good device to relieve malignant ascites, thereby reducing the risk of complications and the number of hospital admissions due to repeated paracentesis and consequently improving the quality of life. A careful patient selection, an accurate follow-up and some device modifications could improve the shunt performance, allowing a wider application of the Denver peritoneovenous shunt.

Drainage of malignant ascites: patient selection and perspectives

“…Fluid is maintained within the body, minimizing protein and electrolyte loss, and reducing patient discomfort associated with repeated PC 35. This technique permits home management, but requires careful patient selection and post- procedure management to avoid serious complications from fluid overload 6,36.…”

Safety and Efficacy of the PleurX Catheter for the Treatment of Malignant Ascites

“…8 Peritoneovenous shunting is another option for patients with malignant ascites, although many patients with advanced cancer may not be eligible for this procedure. 9 The PleurX catheter system was approved in 2005 for the intermittent drainage of symptomatic, recurrent, malignant ascites that does not respond to medical management of the underlying disease; and for palliation of symptoms related to recurrent malignant ascites. The PleurX catheter is not approved for nonmalignant ascites, and it is contraindicated when the peritoneal cavity is multiloculated and the drainage of a single loculation would not be expected to provide relief of dyspnea or other symptoms, in the setting of coagulopathy, or when the peritoneal cavity is infected.…”

“…7 Peritoneovenous shunts (e.g., a Denver shunt) transfer fluid from the peritoneal cavity to the systemic circulation through a one-way compressible valve system. 9 Fluid is maintained within the body, minimizing protein and electrolyte loss and reducing patient discomfort associated with repeated paracentesis. 9 This technique permits home management, but requires careful patient selection and postprocedure management to avoid serious complications from fluid overload (e.g., cardiac congestion and disseminated intravascular coagulopathy).…”

Traitement palliatif de la carcinose péritonéale

“…La dérivation péritonéoveineuse par valve de Le Veen ou de Denver a été proposée [6]. La plupart s'accordent pour limiter sa place à de rares indications en cas d'échec des autres traitements chez des patients dont l'ascite est invalidante et dont l'espérance de vie est supérieure à trois mois.…”