Several calcified foci in left pelvis, most probably phleboliths. Woman with end-stage renal disease ESRD undergoing peritoneal dialysis. Referred for ascertaining correct placement of Tenckhoff catheter. This case is not intended to be a personal endorsement or recommendation of this product. Support Radiopaedia and see fewer ads.
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To assess the technical and clinical outcome of percutaneous insertion of tunneled peritoneal catheters in the palliative treatment of refractory malignant ascites and to determine the safety and feasibility of intraperitoneal administration of cytotoxic drugs through the tunneled catheter.
Consecutive patients palliatively treated with a tunneled peritoneal catheter to drain the malignant ascites were identified. Additionally, a sub analysis of the patients with widespread ovarian cancer and refractory ascites treated with or without intraperitoneal administration of cytotoxic drugs was made.
In all 94 patients it was technically feasible to insert the peritoneal drainage catheter and to drain a median of cc range cc — cc of malignant ascitic fluid. There was no increase in catheter infection rate in patients treated with or without intraperitoneal administration of cytotoxic drugs.
Median overall survival after catheter insertion is 1. Percutaneous insertion of a tunneled Tenckhoff catheter for the palliative drainage of malignant ascites and intraperitoneal infusion of cytotoxic drugs is feasible and associated with a very low complication rate, including catheter infection.
These tunneled peritoneal lines are beneficial for symptomatic palliative treatment of refractory ascites and allow safe intraperitoneal chemotherapy. Malignant ascites is a manifestation of terminal metastatic disease with a life expectancy ranging from 1 to 4 months; the ascitic fluid production is usually associated with peritoneal tumours, lymphangitic carcinomatosis, lymphatic obstruction, encasement of the portal vein by a tumour causing prehepatic portal hypertension, or a combination of these pathophysiological mechanisms.
Medical treatment, including diuretics, have little or no effect on malignant fluid accumulation and the standard treatment for these patients was repeated paracentesis, despite the risks of infection, haemorrhage or bowel wall injury and the need for frequent trips to the hospital.
These drainage techniques include internal drainage like peritoneo-venous 5 , peritoneo-gastric 6 and peritoneo-cystic 7 shunting and external drainage techniques requiring the placement of an indwelling, tunneled peritoneal drainage or portcatheter. Most of the experience with indwelling drainage catheters has been described with the PleurX catheter; this monocuffed catheter was initially designed for drainage of malignant pleural effusions but it can also be used for drainage of malignant peritoneal fluid.
In this study we retrospectively analysed the technical feasibility and safety of the insertion of a Tenckhoff peritoneal tunnelled catheter. Additionally, the overall clinical outcomes in this patient population were analysed and finally we evaluated the feasibility and safety of intraperitoneal chemotherapy delivery through the Tenckhoff catheter in patients with widespread ovarian cancer and refractory ascites using catumaxomab.
The inclusion criteria for catheter placement were symptomatic, malignant ascites refractory to conservative and medical management in patients with widespread metastatic disease; haemostatic parameters allowing small skin incisions and subcutaneous tunnelling; absence of compartmentalization of the malignant ascitic fluid.
Active infection is considered as an exclusion criterion for catheter insertion. Refractory malignant ascites is defined as ascites in patients with widespread metastatic disease in whom the ascites cannot be mobilized by conservative or medical therapies. The patients gave informed consent before the start of the interventional procedure and institutional review board approval was obtained for this retrospective study analysis. Patients were referred to the interventional radiology department after discussion between the attending interventional radiologist and medical or surgical oncologist.
Patient preparation included a bedside ultrasound for evaluation of the amount of ascites and more specifically for evaluation of a window of ascitic fluid at the intraperitoneal puncture site. The preferred intraperitoneal puncture site was near the midline, inferior and to the right of the umbilicus; if no ascitic fluid window was identified in that area, a left-sided infra-umbilical puncture site was prepared with a tunnel area to the left flank.
Tenckhoff tunneled peritoneal drainage catheter insertion was performed under sterile conditions in the interventional radiology suite. Braun, Diegem, Belgium. No other sedation or prophylactic antibiotic medication was administered; a 2 cm skin incision was made near the midline, inferior and to the right or left of the umbilicus and ultrasound-guided puncture of the malignant ascitic fluid was carried out using an 18 gauge G sheathed needle Surflo I.
This was then exchanged for a 0. The Tenckhoff peritoneal drainage catheter Argyle peritoneal dialysis catheter, Covidien, Mansfield, MA, USA with the Cobra catheter inside was introduced over the stiff guide wire into the peritoneal cavity and positioned in a curved position in the lower pelvic region Figure 1E.
The Tenckhoff catheter is made of translucent silicone rubber tubing containing a radio-opaque stripe. The total length of the 15F catheter is 47 cm and the inner diameter is 2. The intraperitoneal part of the catheter contains small fenestrations over a length of 15 cm Figure 2. The cuffed end of the Tenckhoff catheter is tunnelled to the right or left flank using a metallic tunnelling device Argyle Faller Tunneling device, Covidien, Mansfield, MA, USA and exteriorized 7 cm lateral to the peritoneal entry site.
A Ultrasound-guided puncture of the ascitic fluid. The tip of the puncture needle white arrow is located within the fluid, far from intestinal or other abdominal structures. B Using a 4F Cobra catheter black arrow , the hydrophilic guide wire arrowheads is navigated to the lower portion of the pelvis. C The hydrophilic guide wire is exchanged for a stiff Amplatz wire arrowheads on the Cobra catheter arrow. D The 15F peel-away sheath white arrows is introduced into the peritoneal cavity over the stiff Amplatz wire arrowheads.
E The Tenckhoff catheter white arrows is introduced through the 15F peel-away sheath into the peritoneal cavity. Schematic drawing of the Tenckhoff catheter: the intraperitoneal portion contains small fenestrations over a length of 15 cm. Two cuffs with a length of 1 cm are positioned in the subcutaneous tissues. The intraperitoneal chemotherapy infusion technique was performed using a catumaxomab-based regimen as described by Baumann et al.
Patients were followed up until the end of the study March or the patient's death. Overall survival probabilities are estimated by the Kaplan-Meier method. The Wilcoxon test is used for testing survival differences between ovarian cancer patients with or without intraperitoneal chemotherapy treatment IPCT.
The prognostic value of primary pathology for survival is analysed using Cox proportional hazards models. Fisher's exact test is used for the association between intraperitoneal chemotherapy treatment and catheter infection. All tests are two-sided. All analyses have been carried out using SAS software, version 9. In 94 patients 27 men; Malignant ascites was associated with different types of metastatic cancer disease as summarized in Table 1.
The number of paracenteses prior to Tenckhoff catheter insertion is indicated in Table 2 ; overall, patients underwent a mean of 3. Once the Tenckhoff catheter was in place, a median of 3, cc range cc — 8, cc of malignant ascitic fluid was drained.
Clinical follow-up was available for 90 patients; 4 patients 4. Two patients 2. One of these two patients was also treated with intraperitoneal chemotherapy infusions.
Another patient accidentally lost the catheter 11 days after initial placement. Five out of 90 patients 5. The time interval until end of follow-up or the patient's death was a mean of 3. Further, a more detailed analysis of survival after Tenckhoff catheter insertion is made based on the underlying type of cancer.
Analysis suggests a difference in risk for early death after Tenckhoff catheter insertion according to the underlying cancer: patients with widespread gastrointestinal cancers and refractory malignant ascites have a higher risk for early death compared to the reference group of patients with widespread metastatic gynaecological cancers. Overall estimated survival for different cancer types after Tenckhoff catheter insertion.
Overall survival after clinical diagnosis of malignant ascites demonstrates a 3 and 6 month estimated survival of An analysis of the potential outcome differences between the five categories of cancer mentioned above was carried out and summarized in Table 5 and Figure 6. Overall estimated survival for different types of cancer since clinical diagnosis of malignant ascites. Analysis of overall survival since clinical diagnosis of malignant ascites for different groups of cancers.
Tunnelled Tenckhoff catheters were inserted in a total of 38 patients presenting with metastatic ovarian cancer and malignant ascites. In 23 of these patients the Tenckhoff catheter was inserted solely for repeated drainage purposes. In the remaining 15 patients the Tenckhoff catheter was inserted for the purpose of drainage of malignant ascites and for the purpose of intraperitoneal infusion of a catumaxomab-based solution.
Survival analysis in patients with metastatic ovarian cancer and malignant ascites treated with or without intraperitoneal infusion of catumaxomab after Tenckhoff catheter insertion. The technique of tunnelled catheter insertion is essentially the same for the different types of peritoneal tunnelled catheters: percutaneous access to the peritoneal cavity is gained under ultrasound guidance using Seldinger technique and insertion of the catheter through a peel-away sheath can be performed blindly or under fluoroscopic guidance.
When using these techniques, however, the position of the tip of the tunnelled catheter is not always predictable. Instead, we used a catheter-based technique Cobra catheter and hydrophilic guide wire to position the tip and the fenestrated area of the Tenckhoff catheter in the dependent portion of the peritoneal cavity lower pelvic region which might result in better drainage of the ascitic fluid later on, especially when the patient is in a sitting or supine position, although catheter tip migration after insertion is still possible especially in case of recurrent ascitic fluid accumulation associated with bowel and body movements in general.
Other post-procedural complications apart from infection are almost always minor complications and may include fluid leakage around the catheter entry point, catheter occlusion or accidental loss despite the presence of two cuffs. The life expectancy of patients with refractory malignant ascites is very poor, with a range from 1 to 4 months, which is in line with the overall results of this study, showing a median overall survival of 1.
This short life expectancy mainly depends on the natural history of the underlying widespread malignancy and subsequently patients with a longer life expectancy associated with refractory malignant ascites, such as patients with gynaecological tumours, may also benefit from the tunnelled Tenckhoff catheter for a longer period compared to patients with more aggressive tumours such as gastrointestinal malignancies.
This conclusion should be interpreted with caution, however, because this is a retrospective, single-centre, non-randomized analysis including a small number of patients.
Additionally, a multi-centre, randomized open-label phase IIa study was only able to demonstrate a slightly better therapeutic index in a high-dose catumaxomab regimen as compared to a low-dose regimen 14 and other researchers found a non-significant survival benefit days versus 81 days if intraperitoneal administration of catumaxomab took place in patients with recurrent ovarian cancer.
In conclusion, this study demonstrates that percutaneous image-guided insertion of a tunnelled Tenckhoff catheter in the peritoneal cavity is safe and effective for drainage of refractory malignant ascites, with a very low complication rate including catheter infection.
The catheter is also an efficient and safe tool for intraperitoneal administration of cytotoxic drugs with no increase in peritonitis or other infectious adverse events. Finally, owing to the natural course of the underlying malignant tumor, patients with widespread metastatic gynaecological cancers and refractory ascites may benefit for a longer period from this interventional procedure than patients with other cancers and associated malignant ascites.
National Center for Biotechnology Information , U. Journal List Radiol Oncol v. Radiol Oncol. Published online Feb 7. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Geert Maleux: eb. Geert Maleux, M. Received Oct 13; Accepted Dec This article has been cited by other articles in PMC. Abstract Background To assess the technical and clinical outcome of percutaneous insertion of tunneled peritoneal catheters in the palliative treatment of refractory malignant ascites and to determine the safety and feasibility of intraperitoneal administration of cytotoxic drugs through the tunneled catheter.
Materials and methods Consecutive patients palliatively treated with a tunneled peritoneal catheter to drain the malignant ascites were identified. Results In all 94 patients it was technically feasible to insert the peritoneal drainage catheter and to drain a median of cc range cc — cc of malignant ascitic fluid.
Conclusions Percutaneous insertion of a tunneled Tenckhoff catheter for the palliative drainage of malignant ascites and intraperitoneal infusion of cytotoxic drugs is feasible and associated with a very low complication rate, including catheter infection. Key words: peritoneal catheter, malignant ascites, palliation. Introduction Malignant ascites is a manifestation of terminal metastatic disease with a life expectancy ranging from 1 to 4 months; the ascitic fluid production is usually associated with peritoneal tumours, lymphangitic carcinomatosis, lymphatic obstruction, encasement of the portal vein by a tumour causing prehepatic portal hypertension, or a combination of these pathophysiological mechanisms.
Interventional procedure of Tenckhoff catheter placement Patients were referred to the interventional radiology department after discussion between the attending interventional radiologist and medical or surgical oncologist. Open in a separate window.
Figure 1. Figure 2. Statistical analysis Overall survival probabilities are estimated by the Kaplan-Meier method.
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