Journal Club By Barry Miskin MD FACS Peritoneal and Pleural Ports for Management of Refractory Ascites and Pleural Effusions Wayne L. Monsky MD PHD et al
Dec 14, 2014
Journal Club By Barry Miskin MD FACS
Peritoneal and Pleural Ports for Management of Refractory Ascites
and Pleural Effusions Wayne L. Monsky MD PHD et al
Wayne Monsky MD PhD
• Primary interest Minimally Invasive Cancer Therapies (many published ar@cles)
• Include Chemoembolizaton & Abla@on for Liver tumors
• Developed program for Port Placement in refractory ascites/effusions
• Assist Professor UC Davis • GW Med School, 1yr surgery Internship New England Deaconess Hosp. Boston, Beth Israel Deconess for Radiology Residency, Research Fellowship in Cancer Radiology, Fellowship in IR
Malignant Ascites & Pleural Effusion
• Poor Prognosis • Related Sx‐ discomfort, SOB, fa@gue, Nausea, Pain, immobility, LE swelling, decr QOL
• Pt Seek Hospice because of these Sx
Malignant Pleural Effusion
• In US over 150,000 cases per year • Accounts for 40% Chronic Pleuri@s • Recurrent, O\en resistant to systemic tx
• Difficult to stabilize with diure@cs
• Pleurodesis Used‐Only 66% successful • Surgical Pleurodesis 30 day‐75% successful
Cancer PaCents
• 50% have Malignant Ascites • 10% of all ascites is Malignant
Medical Management
• Not sufficient for sx control • Paracentesis/Thoracenteses relief in 90% • Pleurex Catheter an excellent op@on
InfecCon Rate
• Largest published series (250 Pts) of PleurX Catheter shows empyema & celluli@s rates 3.2%, 1.6%
• Poten@al for Serious Infec@on • Road block for most doctors fear of infec@on
Purpose of This Study
• Evaluate Clinical U@lity • Impact on Quality of Life (QOL)
• Evaluate Home /Hospice care with catheters for effusions
PaCent SelecCon
• Pt Referred by IR • Inclusion Criteria‐
– Adequate amount of fluid for catheter placement
– Paracentesis/Thoracentesis at least 2x/month despite ini@al medical therapy
– Acceptable coagulopathy profile & Platelet count – No evidence of current infec@on – Ability to tolerate Conscious Seda@on or GA
Study Design
• 30 Ports placed • 16 peritoneal catheters placed • 14 pleural catheters placed • Catheter approach evaluated for Clinical U@lity and quality of life (QOL)
• Standardized ques@onnaires used for Pt and Caregiver (page 813, Table 1)
Cont.
• Care was under Hospice or Home Health • Fluid aspirated 1‐3 X per week • 50ml up to 8liters each @me
• Pt followed 1 wk, 1mo, 3mo(if s@ll alive)
• Hospice Nurses Interviewed on Pt QOL at 1 to 3 months from @me of cath inser@on
12
PleurX® Peritoneal Catheter
Safety valve • Helps prevent inadvertent passage of air or fluid through the catheter.
Polyester cuff Promotes @ssue in‐growth and holds the catheter securely in place.
15.5 Fr silicone catheter So\ and flexible, conforms to the pleural space and minimizes inser@on site discomfort.
Fenestrated length, 26 cm Large smooth fenestra@ons with beveled edges promote drainage and helps avoid plugging.
Peritoneal Kit
Many Candidates
Liver Cancer
Sterile CondiCons
Proper LocaCon for Placement
Need Ultrasound
Clear Area Beware the Bowels
Percutaneous Puncture
Pull back Ascites
Wire Through Catheter
Tunneler
Catheter Placed Over Tunneler
Breakaway Sheath
Introducer In Place
Catheter In Place
Neptune
Can Collect up to 10 liters
Pleural Catheter
Home Draining
Orange Team At Work
Pleural Fluid from Cardiac Disease
Results
• Mean of 9.5 improvement in pt QOL • High degree of convenience for the approach • Sx Improvement and comfort 9.6 and 9.3
ComplicaCons
• 3 Cases Peritoneal Port Celluli@s • 1 peritoneal Port leakage of Catheter reservoir site
• 1 pleural Port removed due to Pneumo and Subcut Emphysema
• 3 peritoneal Ports & 1 pleural Port temporarily occluded (patency restored 10mg TPA)
Discussion
• Overall Improvement QOL • Pt & Caregiver reported 9.5 & 9.7 improvement
• High degree of sa@sfac@on related to Pt not needing frequent Hospital Visits for Parancentesis/thoracentesis
• 7 Pts were able to travel to see family or enjoy events for final months
$
• Cost for Port system 300$ & 450$ for PleurX • Cost for Implanta@on of Cath $18,059
• Cost of Nursing visit $300 & Supplies $15 • Cost for each Paracentesis/Thoracentesis performed in Hospital $2940
Bacterial PeritoniCs
• 8‐10% Pa@ents with Cirrho@c Asci@es get bacterial peritoni@s
• Rare in Malignant ascites
PleurX® Catheter EducaConal Offerings
40
PleurX® Catheter Drainage Kit 1L Drainage bottle with access tip
Self Adhesive Dressing
Foam Catheter Pad
Gauze Pads
Gloves
Catheter Valve Cap
Conclusion
• Placement of Peritoneal & Pleural Ports offer convenient and rela@vely safe alterna@ve to frequent paracentesis/thoracentesis in management of refractory ascites/pleural effusion
• This approach improves QOL with End Stage Disease