1. Indwelling peritoneal pleurX® catheters for the palliation of malignant ascites: A case Series
Dr Clare Turner
Dr Ian O’Sullivan
Dr Fiona Rawlinson
Dr Pola Grezybowska
Dr Rhian Owen
Anne Brennan
Theresa Pace
Y Bwythn Newydd, SPCU, Bridgend

2. Background
Reaccumulation of ascites is a common problem in palliative care
Causes significant symptoms
Large volume paracentesis (LVP) remains the commonest treatment modality in the UK1
May require repeated hospital/hospice visits or inpatient admissions for paracentesis

3. PleurX® drains
Used for the palliation of recurrent malignant pleural effusions2
Several US case reports3,4 have described their use for the effective palliation of malignant ascites
Potentially reduce the pain and anxiety associated with repeated procedures and allows drainage at home, thus avoiding hospital visits

4. The PleurX® Catheter

5. Rosenburg et al 20045
A retrospective study of 107 patients comparing repeated LVP with PleurX® drains
April 1999-Sept 2002
40 PleurX® and 67 LVP (392 procedures)
Demonstrated similar efficacy & complication rates between both techniques

6. Our experience…Case 1 79 ♀ pancreatic cancer with ascites
Required 2 LVP within 3 weeks
D/W radiology – pleurX catheter inserted
Aimed to drain 2L twice weekly
Symptoms uncontrolled as variable quantities of fluid draining often <1L
Therefore drained more frequently – often daily
Decision to drain governed by patient

7. Case 1: Outcome
Patient satisfied with catheter and level of symptom control & relieved didn’t have to undergone further paracentesis
Discharge planning started + DNs trained in use of drains
Other circumstances meant she remained in the SPCU until she died 6 weeks later
Extensive leak of ascitic fluid after death on removal of catheter – distressing for staff

8. Case 2 38 ♀ metastatic cholangiocarcinoma
Admitted with recurrent ascites and deteriorating LFTs - ascites had reaccumulated despite 2 LVP in 6/52
Pt very anxious at thought of further paracentesis so pleurX catheter inserted
Wanted to go home but lived in a rural area in a different region – some issues with funding of equipment and training of DNs which were resolved prior to insertion

9. Case 2: Outcome
Initial subumbilical puncture site deemed unsuitable for use due to interference with clothing continued to leak fluid. Colostomy bag used with good effect
Symptoms governed frequency of drainage
Seemed pleased with decision to have drain
Discharged having further drainages in the community (by DNs) with good effect
Died 10/7 post discharge. Catheter removed with no apparent complications

10. Case 3 81♀ metastatic ovarian cancer 7 previous LVP on a monthly basis
During an informal psychiatric admission she was transferred to a medical ward for further LVP
Described the week before LVP as “awful” due to distressing abdominal distension
HPCT suggested PleurX catheter based on frequent drainage & detrimental effect this was having on her mental state

11. Case 3: Outcome
Reported immediate symptomatic benefit & was grateful this would keep her out of hospital
Drained several times on ward with good symptomatic effect & discharged home
Symptoms determined frequency of drainage, but limited to max of 2L twice weekly due to concerns over protein loss and dehydration
Died peacefully at home 8 days later

12. Conclusions The PleurX® drain :-
Can prevent escalation of symptoms due to reaccumulation of large fluid volumes
Allows palliation at home avoiding hospital visits
Reduces anxiety associated with repeated invasive procedures
Appears to provide patient satisfaction

13. Learning points
Choice of puncture site should be carefully considered to ensure maximal comfort and tolerability
Optimal frequency and volume of drainage is difficult to determine, but ultimately is best dictated by the patient’s symptoms
Training and supply issues are to be expected, but can be resolved by liaising with the manufacturer

14. Possible complications
Hypotension, infection, dehydration and hypoalbuminaemia
common to all drainage techniques
evidence suggests complication rates similar to that of LVP5
Risk of subcutaneous metastatic seeding6
… but must balance risks against symptomatic benefits!

15. Important future considerations
Drainage time is unpredictable - can be up to an hour, must consider the impact on nursing resources
Potential for patients or carers to be educated in catheter management with nursing support5,7
Need to determine the best procedure for removal of the catheter after death to ensure patient dignity

16. In Summary… All three patients perceived benefit from the catheter
Many issues/problems encountered would be expected to resolve with further experience
All three patients had poor expected prognoses & we do not believe that death was in any way related to the intervention
The PleurX® catheter could be considered earlier & more frequently for the palliation of malignant ascites

17. References
1. Macdonald R, Kirwan J, Roberts S et al. Ovarian Cancer and Ascites: A Questionnaire on Current Management in the United Kingdom. Journal of Palliative Care 2006;9(6):
2. van dern Torn LM, Schaap E, Surmont VF et al. Management of recurrent malignant pleural effusions with chronic indwelling pleural catheter. Lung Cancer 2005;50:(1)123-7
3. Iyengar TD, Herzog TJ. Management of symptomatic ascites in recurrent ovarian cancer patients using an intra-abdominal semi-permanent catheter. American Journal of hospice and palliative Care 2002;19:1:35:38
4. Richard HM, Coldwell DM, Boyd-Kranis RL et al. Pleurx tunneled catheter in the management of malignant Ascites. Journal of Vascular Interventional Radiology 2001;12:
5. Rosenberg S, Courtney A, Nemcek AA et al. Comparison of percutaneous management techniques for recurrent malignant ascites. Journal of Vascular Interventional Radiology 2004;15:
6. Reichner CA, Read CA. Subcutaneous metastatic seeding after removal of a pleurx catheter. Chest 2005; 128(4):457S
7. Brubacher S, Holmes Gobel, B. Use of the Pleurx Pleural Catheter for the Management of Malignant Pleural Effusions. Clinical Journal of Oncology Nursing 2003;7(1):35-38