Tunnelled peritoneal drainage catheter insertion for refractory ascites in cirrhosis

Evidence-based recommendations on tunnelled peritoneal drainage catheter insertion for refractory ascites in cirrhosis. This involves inserting a catheter under the skin in the abdomen to drain excess fluid when needed, at home or in community care. The aim is to reduce the need for hospital admissions and improve quality of life.

# Recommendations
Evidence on the safety of long-term tunnelled peritoneal drainage catheter insertion for refractory ascites in cirrhosis is limited but shows well-recognised complications. Evidence on the efficacy is limited in quantity and quality. Therefore, this procedure should only be used with special arrangements for clinical governance, consent, and audit or research. Find out what special arrangements mean on the NICE interventional procedures guidance page.
Clinicians wanting to do long-term tunnelled peritoneal drainage catheter insertion for refractory ascites in cirrhosis should:
Inform the clinical governance leads in their healthcare organisation.
Give people (and their families and carers as appropriate) clear information to support shared decision making, including NICE's information for the public.
Ensure that people (and their families and carers as appropriate) understand the procedure's safety and efficacy, and any uncertainties about these.
Audit and review clinical outcomes of everyone having the procedure. The main efficacy and safety outcomes identified in this guidance can be entered into NICE's interventional procedure outcomes audit tool (for use at local discretion).
Discuss the outcomes of the procedure during their annual appraisal to reflect, learn and improve.
Healthcare organisations should:
Ensure systems are in place that support clinicians to collect and report data on outcomes and safety for everyone having this procedure.
Regularly review data on outcomes and safety for this procedure.
Patient selection, continued community care support and follow up should be done by a multidisciplinary team experienced in managing the condition. The team should include a hepatologist, a specialist community nurse and specialist level palliative care.
NICE encourages further research into long-term tunnelled peritoneal drainage catheter insertion for refractory ascites in cirrhosis.# The condition, current treatments and procedure

# The condition
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 5year survival is normally less than 20%.

# Current treatments
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.

# The procedure
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.
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.
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.