Tunnelled peritoneal drainage catheter insertion for refractory ascites in cirrhosis

2.1 Refractory ascites is a common complication of cirrhosis of the liver. Build-up of fluid causes difficulty in breathing, fatigue, nausea, poor appetite, acid reflux, abdominal pain and infection. Mortality at 2 years in people with refractory ascites is 50% or more, and 5‑year survival is normally less than 20%.

2.2 Treatment options for symptomatic relief include dietary sodium and fluid restriction, diuretics, large-volume paracentesis (a temporary drain inserted into the abdomen to drain the ascitic fluid) with albumin infusion, or insertion of a transjugular intrahepatic portosystemic stent shunt (TIPSS). If the cause of liver failure and ascites cannot be treated or treatment fails, liver transplantation may be used in some people. If TIPSS or liver transplantation is not suitable, long-term ascitic drainage peritoneal catheters are a palliative treatment option.

2.3 The procedure is usually done as a day case with local anaesthesia, with or without sedation. Ultrasound, fluoroscopy or both are used to guide catheter insertion and placement. A guidewire introducer needle is inserted percutaneously into the peritoneal cavity and ascitic fluid is aspirated. A guidewire is then inserted through the introducer and into the peritoneal cavity. A fenestrated drainage catheter is tunnelled subcutaneously from a second incision away from the guidewire insertion site. It is then inserted over the guidewire into the peritoneal cavity using a dilator and peel-away sheath. A polystyrene cuff on the catheter is positioned inside the subcutaneous tunnel. The dilator and guidewire are removed and the catheter insertion site and exit sites are sutured. Antibiotics may be offered during and after the procedure.

2.4 A lockable drainage line is connected to a valve at the outer end of the catheter to allow the ascitic fluid to be drained into a vacuum bottle or a drainage bag. Before hospital discharge, the ascites is normally drained to dryness and albumin replacement is given. After this procedure, ascites drainage is done in the community or at home without giving replacement albumin. This is typically supervised by district nurses.

2.5 People can drain small amounts of ascitic fluid repeatedly from their peritoneal cavity into vacuum bottles. The volume of fluid drained and how often it is done can be adjusted according to their needs.