MTG9: PleurX and ascites
A discussion on PleurX and ascites with Dr Hans-Ulrich Laasch, a Consultant Radiologist and one of the clinical expert advisers for the guidance.
This podcast was added on 22 Mar 2012
“Hello and welcome to this podcast from NICE on the PleurX medical technology guidance. I’m at the Christie NHS Foundation Trust in Manchester. Joining me is Dr Hans-Ulrich Laasch, a Consultant Radiologist who is one of the clinical expert advisers for the guidance.”
“Dr Laasch, what is ascites and what are its associated symptoms?”
“Ascites is a collection of fluid within the abdominal cavity around the organs in the abdomen, which if it reaches certain levels will include symptoms which include breathlessness, the inability to take large meals, or even to fasten the clothes. There is normally a small amount of fluid, within the abdomen which allows the organs to move against each other with breathing, laughing, hiccupping, but if the balance of production and reabsorption is disturbed, the fluid can build up and reach very large volumes which can 10 litres or more.”
“And what are the causes of ascites?”
"There are a number of causes. One of the commonest causes is liver failure and hepatic cirrhosis. Other causes might include inflammation in the abdomen, appendicitis for example, or a rupture of the bowel. The patients we exclusively deal with are patients who have cancer who now have ascites as a consequence of their cancer."
“Are there any particular guidelines, or are there any particular stages, when ascites should be drained?”
“There aren’t really any guidelines for malignant ascites, which means in the context of cancer it is usually a decision between the patient and the treating oncologist at which point the symptoms are so limiting that treatment is suggested. Treatment in the context of cancer really depends very much on what other treatments are still available. If the patient is still undergoing chemotherapy or has not even started chemo, one might remove some of the fluid in order to make the patient feel better, to reduce the breathlessness. However, there might come a point where all treatment has been tried and the ascites is still coming back and really requires removing.”
“Right, and what is the conventional treatment for ascites?”
“The conventional treatment of ascites is to drain it off, that is called paracentesis, and it is performed usually under local anaesthesia and ultrasound guidance, where a small catheter/a small tube is inserted through the abdominal wall into the fluid and it is drained out into a bag over the space of several hours, usually over several days. At the Christie, until three or four years ago, this would require the patient to be admitted, an ultrasound scan to be performed for localisation of the fluid, and then the patient would be transferred for a ward and admitted, and after checking of the appropriate blood factors that it was safe to insert a drain.
“Subsequently, it then depends on how well the patient tolerates the paracentesis and how quickly the fluid can be drained off. Symptoms that may occur are dizziness, light-headedness, a drop in blood pressure and feeling weak or fatigued from it.
“We are in the very lucky position at the Christie in that we have a dedicated procedure team that has started to offer paracentesis as a day case procedure where the patients is admitted in the morning and the fluid is drained off quite rapidly during the day and the patient discharged in the evening after the drain has been removed.
“This has only just become established practice and not all patients are suitable for this as the removal of large volumes of fluid can leave the patients very washed out and tired.
“Furthermore, every time a drainage is performed, this carries a small but definite risk of causing haemorrhage, of causing injuries to the organs on the inside of the abdomen and one is particularly concerned about punctures of the bowel of the liver or any other organs that might be on the inside.”
“Thank you, and so what is the PleurX peritoneal catheter drainage system?”
“The PleurX system takes the drainage to a different level insofar as the tube that is used for the drainage remains in the abdomen and the patient goes home with the tube. The tube itself is larger than the conventional catheter, it measures 15 French which is the circumference in mm, it has approx. 5mm diameter, it is made out of soft silicon, and about 20-25 cm extend from the skin of the patient to the outside.
“A longer portion of the drain remains on the inside of the abdominal cavity and if and when the patient requires the fluid draining, it can be done at home at the patient’s convenience. The risks of the insertion procedure are very much the same as of normal paracentesis, however the plan would be for this to be the last and definitive procedure so there is no risk of repeated injuries by repeated procedures.”
“Thank you, so how is the procedure performed?”
“The procedure itself is very straightforward. By definition patients tend to have a large amount of fluid in the abdomen which makes the procedure very safe because there is a large space to site the drain. It is done under ultrasound control, where the most suitable site on the abdomen is identified and marked.
“Following this, local anaesthesia is applied to the skin the tissues under the skin and the very sensitive lining of the abdomen called the peritoneum. If the local anaesthetic is applied properly, the procedure is essentially painfree.
“Similar to tunnel central lines, also called Hickman type lines which are used for long-term administration of chemotherapy, the PleurX catheter runs under the skin for about 5-6 cm before it takes a turn and then it actually enters the abdomen. This track under the skin – the skin tunnel –has the advantage of reducing the risk of infection.
“The PleurX catheter has a little cuff on the outside which allows the tissues of the skin tunnel to grow into it and fix it to the abdominal wall. This takes about three weeks and for that period of time an extra suture is attached around the drain to prevent it falling by accident.
“In our institution the PleurX is only sited by specially trained staff which are two interventional radiologists, which has the advantage that the procedure is done by people who are really very familiar with these kind devices and these type of procedures. It takes about 15-20 minutes and that includes an initial drainage of ascites which usually reaches two litres by the time the procedure is concluded. As I said, if done properly the procedure is essentially painfree. We have never required sedation or general anaesthesia for any of these, although sedation would be available at our institution if that was required.”
“Thanks. So Dr Laasch, how is the drainage performed once the drain is in place?”
“The drain when is not in use is contained in a waterproof dressing. It has a cap over the valved end which prevents fluid leaking out by accident or air being sucked in by accident. When the drain is used – and that is usually done by the district nurses but that could be done by the patients or the relatives if they are happy enough to do so, under sterile conditions, the drain is connected to a vacuum bottle and a litre at a time is evacuated into the bottle. This may be done several times a week. The beauty of this system however is that it does not need to be done according to a rigorous schedule. It can be done 1 or two bottles at a time, it can be done over the weekend, it can be done spaced at irregular intervals if this suits better with the district nurse support. However, it may also be used more flexibly if patients want to travel away for a weekend or for a few days and they can take some bottles with them.”
“So how do patients look after the drain once it’s been inserted?”
“At the time of insertion the drain is fixed with one suture and there’s an additional suture that covers a small incision for the insertion. These sutures are removed after three weeks. When the drain is not in use it is covered by a waterproof dressing which allows the patients to have a shower and to have a bath. Once the first three weeks have passed, the tissues tend to have grown into the cuff under the skin very firmly, and the risk of displacing it by accident is very, very small.
“When the drain is not in use, it is covered by clothing, and there are no visible external stigmata. When the drain needs to be used, the waterproof dressing is removed and the important thing is that the connection and the use of the drain is performed under a-septic conditions. The pack that is supplied with the vacuum bottles contains all the necessary equipment, disinfectant swabs and sterile gloves. It is crucial that the person who performs the drainage is meticulous about working cleanly. Once the drainage has been performed, the drainage is coiled up again and covered with a waterproof dressing.”
“And would nurses help patients in looking after the drain?”
“In the first instance we expect the district nurses to perform the drainage. However, we have a number of patients who are confident and dextrous enough who look after the drains themselves. That is obviously very desirable because it increases the level of autonomy for the patient. It may also be that one of the carers, part of the family or a friend who even might be medically trained performs the drainage. It is not a difficult thing to do, as long as careful aseptic technique is observed.”
“So Dr Laasch, what patients would this PleurX system be useful for?”
“We only deal with cancer patients and it is really only designed for patients who have ascites as a consequence of their cancer. We reserve it for patients who have recurrent ascites and where they’re therapy resistant, which is not a particularly accurate phrase. But to deal with it in turn, recurrent means that it should have been drained and it has come back. So we would not put PleurX in as a primary drain.
“It would also then depend on the speed of which the ascites returns. If the patient becomes symptomatic again after two or three weeks then PleurX would naturally be a good idea. If it takes two or three months for the fluid to return, then equally the patient might decide they do not want a foreign body implanted, they might want to stick with a large volume paracentesis.
“We are in the fortunate position that we can offer this as a day case which makes patient selection a little bit more important, or if I turn this around, or we can offer a different level of service according to the patient’s wishes.
“If the patient does not favour the idea of an implantable drain, then we can say the patient can attend as a day case, have the fluid removed and return home. Once the patient understands that this system works and that the insertion that way is not that painful and they trust the procedure team, they might have a relatively lower threshold of having the procedure done. They might come sooner and therefore the experience might not be as stressful. However, if the patient requires drainage of roughly more than once a month, then PleurX would be offered.
“I would be very reluctant to offer a PleurX drain to a patient who is still undergoing chemotherapy because the treatment may stop the ascites building up or it may slow the rate of recurrence, in which case PleurX may be inappropriate.
“I would also not consider PleurX insertion for a patient who has got a benign underlying disease, so who has not got underlying cancer, because we have no experience with that to date and that would have to be considered very carefully with all the involved team.
“In patients who have had several previous large volume paracentesis, we have invariably found that they find the PleurX a great relief because they can choose when the fluid is drained, it prevents the fluid building up to a level that they become breathless and they have much more control over their own treatment.”
“So am I right in thinking this system can be used at home and outside hospital settings?”
“The great advantage of the PleurX system is it is designed to keep patients out of hospital. Before we were able to use this system we had to admit patients on an average for 5.5 days to drain an average of 4.5 litres. Now, some patients require this drainage to be performed every two or three weeks which means that within a month the patient may spend two or three weeks in hospital. That is clearly undesirable from the patient’s point of view. It is also not a very cost-effective way of performing paracentesis. Once the PleurX drain is in situ, the patient returns home, the drainage is performed at home, if and when the patient requires and at their convenience.”
“Thanks and in your knowledge and experience, what are the other advantages of the PleurX system over paracentesis?”
“The benefits to the patient are that this is hopefully the last and the definitive procedure that they receive for the drainage of their ascites. Certainly in our institution it will be performed by somebody who is an expert in these procedures. It is essentially pain free and can be done as a day case avoiding inpatient admission. Once the drain is in situ, the patient has control over when and how often the drainage is performed, and it stops the symptoms becoming so bad that the patient requires admission. It gives the patients autonomy and independence, and in a number of cases, it has also given them the confidence to start travelling from home again.
“As an anecdote, one of our first patients was a young woman with breast cancer who had two small children and her main problem was to organise childcare for the five days she would spend in hospital to have the conventional large volume paracentesis.”
“So are there any side-effects that patients might have using this system?”
“Side effects are of the procedure itself, they are rare and they are essentially identical to a conventional drain insertion. They might include some bleeding, they might include pain at the insertion or shortly afterwards as the local anaesthetic wears off. In theory there’s a small risk of injury to the organs contained within the abdominal cavity. But in practice, we have not found so far any of these to be a problem.
“PleurX insertions are done usually buy specialist practitioners who are experienced in ultrasound guidance and interventional procedures, whereas conventional paracentesis in many centres is performed by junior oncologists who may not quite have experience the in those procedures.
“Because of the logistics of this it is probably a safer procedure and so far we have had no serious complications. There may be complications occurring during the long-term use of the catheter. Again, these have been very very few. We have had maybe three or four patients who had in the first days little episodes of abdominal pain as the suction was applied in the catheter. That tended to settle down and did not require any specific treatment. We have had no patietns who developed haemorrhage or bleeding, after the procedure. It must be remembered that occasionally ascites itself may be blood-stained and that may well predate the drain insertion and is not necessarily a cause for alarm.
“The main complication we worry about is whether connection to the outside world may allow infection to get into the abdomen and cause what is called peritonitis. We have not seen any cases of this. If that were to happen it would probably require the drain removal and admission for administration of antibiotics.
“In the early days we’ve had two cases where through inappropriate use, and probably insufficient training, the wrong suture was removed too early and the drain displaced by accident. We have now trained virtually all the districts that are referred to the Christie and have not had any problems since.
“We have had a small number of patients where the ascites became loculated, which means it developed little pockets. And that may either occur as a consequence of bleeding where blood clots form or it may occur as a consequence of infection. On our first patient that necessitated the removal of the catheter but subsequently we have found that with the use of drugs designed to dissolve blood clots, we have been able to maintain catheters without requiring them to be removed.
“That can be done as a day case where a dose of the fibrinolytic – we use streptokinase – a single dose is instilled. It is left for four hours to try and break down the walls and then normal drainage is resumed. It may require four or five applications on consecutive days, but we have had excellent results with this. It is a very simple treatment, which has not been seen to have any side effects so far.”
“Could you tell me a little bit more about complication rates, if there are any, and how these compare to the paracentesis system?”
“The potential complications of the PleurX system are identical to a normal paracentesis. As we are however, not comparing like-to-like with the operator experience, the complication rates with PleurX insertion are lower than with paracentesis performed by junior staff of other specialties. What we’re also avoiding is the repeat of all the potential complications by further repeated drainages, which once the PleurX is in situ, is not required.
“Long-term complications from the PleurX drains being in situ have been extremely few and far between. We had a couple fall out, that was a training issue that has now been addressed, and we have also slightly modified our technique. We have had no patient developing peritonitis. We had one patient who developed a skin infection but the catheter did not need to be removed. We’ve had no significant pain and no significant haemorrhage. So from a practical point of view, it has been a very safe and extremely successful procedure.”
22 March 2012
This resource should be used alongside the published guidance. The information does not supersede or replace the guidance itself.
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This page was last updated: 19 September 2012