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Chapter30:CT-guided neurolysis for cancer-related abdominal and pelvic pain
A B
C D
Figure 30.5 (A) Celiac plexus neurolysis, retrocrural technique. The tip of the needle (arrowhead) is in the right retrocrural space with ipsilateral-only contrast
spread (arrow). (B) Technique was repeated on the contralateral side with needle placement (arrowhead) and contrast spread (arrow) in the left retrocrural space.
(C) Postprocedure computed tomography demonstrates ethanol spread (arrows) extending cranially in the right and left retrocrural space. The greatest, greater,
and lesser splanchnic nerves course through this space. (D) Transdiscal trajectory of needle (long arrow) with tip in the contralateral retrocural space (arrowhead).
Contrast in the ipsilateral retrocural space (short arrow) was deposited from previous (not shown) paravertebral needle placement.
inadvertent spinal artery injection with neurolytic. During the
procedure, it is important to aspirate prior to every injection to
help assess vascular intrusion.
Some patients may not have signicant pain relief aer
CPN. If a procedure is unsuccessful, repeat CPN may be considered. First, images from a prior procedure are reviewed to
ascertain previous needle placement, spread of contrast, and
volume of neurolytic injected; the procedure may be repeated
using the same technique if one or more of these variables is
found to be suboptimal. However, modication of approach
Figure 30.6 Celiac plexus neurolysis, retroaortic retrocrural technique. A 22G
Chiba needle (arrowhead) is advanced through a retroaortic plane (long arrow)
to the contralateral retrocural space (short arrow). Unilateral contrast spread is
seen. After ethanol deposition and needle flush, the needle is retracted to the
ipsilateral retrocrural space and injection repeated (not shown).
may be considered, i.e., opting for a retrocrural neurolysis if
prior antecrural neurolysis was unsuccessful.
Superior hypogastric neurolysis
Over 50% of patients with lower abdominal/pelvic primary
or secondary malignancy may suer from pelvic pain.
Opioid anlagesics are again the mainstay of therapy. Because
nociceptive information from the bladder, prostate, gonads,
30,31,32,33
uterus, upper vagina, and bowel from the descending colon to
the upper rectum travel with sympathetic aerents via the superior hypogastric plexus, superior hypogastric neurolysis can be
319
Section X:Specialized interventional techniques in cancercare
Figure 30.7 Superior hypogastric
neurolysis, transdiscal approach. Needle
is advanced through the L5–S1 disc.
Neurolytic is instilled anterior to the disc.
an important adjunctive tool in the treatment of cancer-related
pelvicpain.
Anatomy
Nociceptive stimuli from pelvic organs travel along sympathetic aerents to the lumbar sympathetic chain. ese bers
form a network that lies anterior to the L5–S1 vertebral levels
and is an extension of the aortic plexus over the aortic bifurca-
30,34
tion.
transdiscal approach (Figure30.7).
It is generally accessed by needle via a paravertebral or
35
Technique
Although many reports in the literature describe uoroscopic
guidance for superior hypogastric neurolysis, CT guidance may
be performed eectively. As with CPN, CT guidance oers the
advantage of excellent anatomic delineation and helps guide
needle placement in a retroperitoneal location anterior to the
L5–S1 levels, while avoiding aorta, common iliac vessels, and
exiting spinal nerves.
Positioning and approach
e superior hypogastric plexus is typically accessed using a
posterior approach. In general, a paravertebral or a transdiscal approach may be used. If a transdiscal approach is selected,
prophylactic antibiotics (e.g., 1gram cefazolin intravenously)
are administered. e patient is placed in the prone position
with pillow placed underneath the abdomen to facilitate rightand/or le-sided access to the superior hypogastric nerve;
however, a lateral decubitus position may be considered if the
patient is unable to lieprone.
Preliminary CT images are obtained for access planning.
e CT gantry is angulated such that CT images are parallel to
the L5–S1 disc. Aneedle path is planned which ideally terminates near midline and anterior to the L5–S1 disc (Figure30.8).
Exiting spinal nerve roots may be visualized on CT; a needle
trajectory is chosen that avoids traversal of these roots so as
Figure 30.8 Superior hypogastric neurolysis. Needle (arrowhead) is advanced
via transdiscal trajectory with tip advanced just anterior to the L5–S1 disc.
Contrast spread (arrow) is seen anterior to the disc.
to reduce the risk of intraprocedural pain. However, a paravertebral approach may be hampered by iliac crest, lumbar
transverse process, or other intervening structures. If a purely
paravertebral route is unavailable on either side, a transdiscal
approach is chosen. e use of a transdiscal approach may also
shorten procedure time.
35
A 20–22G needle (e.g., Chiba) is advanced using CT, CT
uoroscopy, or cone-beam CT guidance just past the anterior margin of the disc, where there is typically a sense of loss
of resistance, but no more than 1cm anterior to the disc.35
Aspiration is performed to ensure no return of blood products;
this is performed prior to every needle injection. Subsequently,
2mL dilute contrast is administered (Figure30.8) in similar
fashion to CPN. Ideally, contrast spread is observed anteriorly
on both sides of the L5–S1 disc, and may be seen over the upper
sacrum as well as along the common iliac vessels. In this scenario, 2mL local anesthetic (e.g., 1% lidocaine) is administered
followed by 20mL 95–100% ethanol. e needle is ushed with
320
Chapter30:CT-guided neurolysis for cancer-related abdominal and pelvic pain
saline or local anesthetic and removed. However, if contrast
spread is seen only unilaterally, the volume of ethanol injected
is halved and indwelling needle tip adjustment toward the contralateral side or new needle placement on the contralateral
side may be performed.
Outcomes
A number of reports have described reduction in pain scores
as well as opioid requirements aer superior hypogastric neu-
19,30,36
rolysis.
Plancarte etal., for example, reported a reduction
in pain score of 50% in 51% of patients undergoing the procedure.36 Erdek etal. also found a strong correlation between
positive outcome and CT guidance.
19,30
Complications
As with other CT-guided procedures, bleeding is a possible
complication. Some authors using uoroscopic technique
suggest the risk of injury to the ureter as well as lumbosacral
nerves.30 However, the use of CT guidance may help reduce this
risk, as intervening structures are better delineated. If a transdiscal approach is used, there may be a small risk of discitis or
disc herniation/rupture.
30,35,37
Figure 30.9 Ganglion impar neurolysis. Needle is advanced through the
sacrococcygeal junction (arrow). Contrast spread (arrowhead) is noted in the
precoccygeal space.
and caudad within the precoccygeal space. Ideally, contrast
encompasses the ganglion if visible on CT.
39,40
is is followed
with 2mL local anesthetic (e.g., 1% lidocaine) and 5–10mL
95–100% ethanol. e needle is ushed with local anesthetic or
normal saline and removed.
Ganglion impar neurolysis
Although superior hypogastric neurolysis may be a useful
adjunct in the treatment of cancer-related pelvic pain, it may
be less eective for low pelvic/perineal pain. e termination
of the paravertebral sympathetic chains known as the ganglion
impar or ganglion of Walther is another target for neurolysis.38
It may be performed in conjunction with superior hypogastric
Outcomes
Only a few reports exist in the literature summarizing the
experience with ganglion impar blockade/neurolysis in
cancer-related pain. In a series of 16 patients with cancer-related
rectal, vaginal, and/or perineal pain, 50% had complete relief,
whereas the remaining patients had 60–90% pain relief, with
follow-up ranging from 4months to death.
38,41
neurolysis.
Anatomy
e ganglion impar lies anterior to the sacrum/coccyx, at
approximately the level of the sacrococcygeal ligament.38 It is
involved in mediating sympathetic and nociceptive information from the lower rectum/anus, distal vagina and urethra,
vulva, and perineum.38 It can sometimes be visible on CT as
an oval-shaped structure measuring about 2–3mm in longest
dimension anterior to the sacrococcygeal joint or coccyx.
39,40
Technique
Various techniques using uoroscopic, CT, and ultrasound guidance have been described.
suggested as enabling more accurate needle placement with
lower risk of complication, such as traversal of pelvic viscera
or vessels.
38,39
Typically, the patient is placed in prone position
with pillow placed below the abdomen and lower extremities
internally rotated.39 CT gantry angulation may be performed to
38,39,41,42,43,44,45
CTguidance has been
obtain images parallel to the sacrococcygeal junction; sagittal
reformations may be helpful to identify the junction.
A single 22G needle is advanced through the sacrococcygeal joint, with tip advanced just anterior to the junction.
Approximately 2mL dilute contrast as with CPN is injected
(Figure 30.9); contrast spread is typically seen cephalad
Complications
Although signicant complications have not been reported in
the literature, potential complications include perforation of
pelvic viscera or bleeding.39 In addition, traversal or injection
of the sciatic nerve is a possibility.39 Use of CT guidance, emptying the bladder prior to the procedure, and use of contrast
injection through the needle to predict neurolytic spread may
help minimize these complications.
39
References
1. Kambadakone A, abet A, Gervais DA, Mueller PR, Arellano
RS. CT-guided celiac plexus neurolysis:a review of anatomy,
indications, technique, and tips for successful treatment.
Radiographics 2011; 31:1599–1621.
2. de Oliveira R, dos Reis MP, Prado WA. e eects of early or
late neurolytic sympathetic plexus block on the management of
abdominal or pelvic cancer pain. Pain 2004:110:400–408.
3. Staats PS, Hekmat H, Sauter P, Lillemoe K. e eects of
alcohol celiac plexus block, pain, and mood on longevity in
patients with unresectable pancreatic cancer:a double-blind,
randomized, placebo-controlled study. Pain Med 2001; 2:28–34.
4. Wong GY, Schroeder DR, Carns PE, etal. Eect of neurolytic
celiac plexus block on pain relief, quality of life, and survival
in patients with unresectable pancreatic cancer:a randomized
controlled trial. JAMA 2004; 291:1092–1099.
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5. Wyse JM, Chen Y-I, Sahai AV. Celiac plexus neurolysis in the
management of unresectable pancreatic cancer:when and how?
World J Gastroenterol 2014; 20:2186–2192.
6. Yan BM, Myers RP. Neurolytic celiac plexus block for pain
control in unresectable pancreatic cancer. Am J Gastroenterol
2007; 102:430–438.
7. Miguel R. Interventional treatment of cancer pain:the fourth
step in the World Health Organization analgesic ladder? Cancer
Control 2000; 7:1490156.
8. Shulman M, Harris JE, Lubenow TR, Nath HA, Ivankovich AD.
Comparison of epidural butamben to celiac plexus neurolytic
block for the treatment of pain of pancreatic cancer. Clin J Pain
2000; 16:304–309.
9. Arcidiacono PG, Calori G, Carrara S, McNicol ED, Testoni
PA. Celiac plexus block for pancreatic cancer pain in adults.
Cochrane Database Syst Rev 2011; 16:CD007519.
10. Tam A, Ahrar K. Palliative interventions for pain in cancer
patients. Semin Intervent Radiol 2007; 24:419–429.
11. Rathmell JP. Atlas of Image-Guided Intervention in Regional
Anesthesia and Pain Medicine. 2nd edn. Philadelphia,
PA:Lippincott Williams and Wilkins,2012.
12. Eisenberg E, Carr DB, Chalmers TC. Neurolytic celiac plexus
block for treatment of cancer pain:a meta-analysis. Anesth
Analg 1995; 80:290–295.
13. Penman D. Celiac plexus neurolysis. Best Pract Res Clin
Gastroenterol 2009; 23:761–766.
14. Noble M, Gress FG. Techniques and results of neurolysis for
chronic pancreatitis and pancreatic cancer. Curr Gastroenterol
Rep 2006; 8:99–103.
15. Soweid AM, Azar C. Endoscopic ultrasound-guided celiac plexus
neurolysis. World J Gastroenterol Endosc 2010; 2:228–231.
16. Mercadante S,Nicosia F. Celiac plexus block:a reappraisal. Reg
Anesth Pain Med 1998; 23:37–48.
17. Wang PJ, Shang MY, Qian Z, etal. CT-guided percutaneous
neurolytic celiac plexus block technique. Abdom Imaging 2006;
31:710–718.
18. Titton RL, Lucey BC, Gervais DA, Boland GW, Mueller
PR. Celiac plexus block:a palliative tool underutilized by
radiologists. Am J Roentgenol 2002; 179:633–636.
19. Erdek MA, Halpert DE, Gonzalez-Fernandez M, Cohen SP.
Assessment of celiac plexus block and neurolysis outcomes and
technique in the management of refractory visceral cancer pain.
Pain Med 2010; 11:92–100.
20. Loukas M, Klaassen Z, Merbs W, etal. A review of the thoracic
splanchnic nerves and celiac ganglia. Clin Anat 2010; 23:512–522.
21. Bonica JJ. e role of the anaesthetist in the management of
intractable pain. Proc R Soc Med 1954; 47:1029–1032.
22. Erdine S. Celiac ganglion block. Agri 2005; 17:14–22.
23. de Cicco M, Matovic M, Fracasso A, etal. Single-needle
celiac plexus block:is needle tip position critical in patients
with no regional anatomic distortions? Anesthesiology 1997;
87:1301–1308.
24. Zhang XM, Zhao QH, Zeng NL, etal. e celiac
ganglia:anatomic study using MRI in cadavers. Am J Roentgenol
2006; 186:1520–1523.
25. de Cicco M, Matovic M, Bortolussi R, etal. Celiac plexus
block:injectate spread and pain relief in patients with regional
anatomic distortions. Anesthesiology 2001; 94:561–565.
26. Penman ID, Gilbert D. Basic technique for celiac plexus block/
neurolysis. Gastroenterol Endosc 2009; 69:S163–S165.
27. Wang ZJ, Webb EM, Westphalen AC, Coakley FV, Yeh BM.
Multi-detector row computed tomography appearance of celiac
ganglia. J Comput Assist Tomogr 2010; 34:343–347.
28. Rykowski JJ, Higler M. Ecacy of neurolytic celiac plexus block
in varying locations of pancreatic cancer. Anesthesiology 2000;
92:347–354.
29. Ina H, Kitoh T, Kobayashi M, etal. New technique for the
celiac plexus block:the transintervertebral disc approach.
Anesthesiology 1996; 85:212–217.
30. Kroll CE, Schartz B, Gonzalez-Fernandez M, etal. Factors
associated with outcome aer superior hypogastric plexus
neurolysis in cancer patients. Clin J Pain 2014; 30:55–62.
31. van der Beuken-van Everdingen MH, de Rijke JM, Kessels AG,
etal. Prevalence of pain in patients with cancer:a systematic
review of the past 40years. Ann Oncol 2007; 18:1437–1449.
32. van der Beuken-van Everdingen MH, de Rijke JM, Kessels
AG, etal. High prevalence of pain in patients with cancer in a
large population-based study in e Netherlands. Pain 2007;
132:312–320.
33. Breivik H, Cherney N, Collett B, etal. Cancer-related pain:a
pan-European survey of prevalence, treatment, and patient
attitudes. Ann Oncol 2009; 20:1420–1433.
34. Bosscher H. Blockade of the superior hypogastric plexus block
for visceral pelvic pain. Pain Pract 2001; 2:162–170.
35. Gamal G, Helaly M, Labib YM. Superior hypogastric
block:transdiscal versus classic posterior approach in pelvic
cancer pain. Clin J Pain 2006; 22:544–547.
36. Plancarte R, de Leon-Casasola OA, El-Helaly M, Allende S,
Lema MJ. Neurolytic superior hypogastric plexus block for
chronic pelvic pain associated with cancer. Reg Anesth 1997;
22:562–568.
37. Erdine S, Yucel A, Celik M, Talu GK. Transdiscal approach
for hypogastric plexus block. Reg Anesth Pain Med 2003;
28:304–308.
38. Scott-Warren JT, Hill V, Rajasekaran A. Ganglion impar
blockade:a review. Curr Pain Headache Rep 2013; 17:306.
39. Datir A, Connell D. CT-guided injection for ganglion impar
blockade:a radiologic approach to the management of
coccydynia. Clin Radiol 2010; 65:21–25.
40. Chang-Seok O, In-Hyuk C, Hyun-Ju J, etal. Clinical
implications of topographic anatomy on the ganglion impar.
Anesthesiology 2004; 101:249–250.
41. Plancarte R, Amescua C, Patt RB, etal. Presacral blockade of
the ganglion of Walther (ganglion impar). Anesthesiology 1990;
73:A751.
42. Foye PM. New approaches to ganglion impar blocks via
coccygeal joints. Reg Anesth Pain Med 2007; 32:269.
43. Ho KY, Nagi PA, Gray L, etal. An alternative approach to
ganglion impar neurolysis under computed tomography
guidance for recurrent vulvar cancer. Anesthesiology 2006;
105:861–862.
44. Foye PM. Ganglion impar injection techniques for coccydynia
(coccyx pain) and pelvic pain. Anesthesiology 2007;
106:1062–1063.
45. Lin CS, Cheng JK, Hsu YW, etal. Ultrasound-guided ganglion
impar block:a technical report. Pain Med 2010; 11:390–394.
322
Chapter
Palliative procedures for ascites and eusion
31
Hooman Yarmohammadi and George I. Getrajdman
Introduction
e denition of ascites is the pathological accumulation of
uid in the peritoneal cavity. Malignant ascites is accumulation
of uid in the peritoneal cavity as a consequence of cancer.1
Refractory ascites is when ascites fail to respond to:(1) bed
rest; (2)uid restriction to 1500mL/day and salt restriction
to 80 mmol/day; (3) 400 mg/day spironolactone or 300mg/
day triamterene plus 120mg/day furosemide for 4 weeks; or
(4) when patients are intolerant to medical therapy because of
azotemia.
2,3
e most common cause of benign and malignant ascites,
accounting for nearly 80% of cases, is liver cirrhosis.4 Malignant
ascites is present in approximately 10% of all patients with
ascites.5 e cancers most commonly associated with ascites
can be divided into two groups of intra-abdominal (i.e., ovary,
stomach, pancreas, and colon) and extra-abdominal (i.e.,
breast, lung, and lymphoma) malignancies.6 In approximately
20% of all patients with malignant ascites the primary origin of
the tumor is unknown.
7
e pathophysiology of malignant ascites is multifactorial and not completely clear.8 e cause of ascites in cancer
patients diers from that in patients with cirrhosis. e most
common recognized pathophysiology is alteration in vascular
permeability of the parietal peritoneum and metastatic spread
to the peritoneum or peritoneal carcinomatosis (50%).
Vascular endothelial growth factor (VEGF) increases vascular permeability. Multiple reviews have demonstrated high
levels of VEGF in patients with malignant ascites, particularly in patients with ovarian, gastric, and colorectal cancers.10
Other mentioned causes are obstruction of draining lymphatics due to lymphatic invasion (20%; most commonly seen in
lymphoma and breast cancer), liver metastasis, resulting in
portal vein hypertension (15%), and hormonal mechanisms.11
Depleted or reduced circulatory blood volume activates the
renin–angiotensin–aldosterone system, leading to sodium
retention in patients with ascites, including patients with
malignant ascites.
12
Diagnostictests
A basic metabolic panel, including serum electrolytes, blood
urea nitrogen and creatinine, hepatic function panel, including
serum albumin, and urinary sodium levels, provides measures
of liver function, volume, and nutritional depletion, and helps
to guide initial therapy. A diagnostic paracentesis should be
performed for cell count with dierential, Gram stain with culture, albumin level, and cytology. Cytology is 97% sensitive for
carcinomatosis. Aserum-ascites albumin gradient >1.1gram/
dL is 97% accurate for the diagnosis of portal hypertension.
Management of ascites
Ascites causes discomfort and signicant reduction in the
patient’s quality of life. Except for breast, lymphoma, and ovarian cancer, once cancer patients develop ascites, the 1-year survival is less than 10% and the median survival time ranges from
1 to 4months. erefore, palliative therapies play a vital role in
the management of these patients. Treatment options include
dietary restriction, diuretics, repeated large-volume paracentesis, permanent indwelling catheters, implantable abdominal
ports/drains, peritoneovenous shunts, and transjugular intrahepatic portosystemic shunt (TIPS).
Diuretics and sodium restriction
Reduction in sodium intake to 1–2grams of salt per day, uid
restriction to 1–2L/day, and diuretics are oen used as the rst
line of therapy. However, there are no controlled trials assessing
6,9
their ecacy in malignant ascites.13 Nevertheless, diuretic therapy seems to be successful in 40–44% of patients with malignant ascites.
with malignant ascites secondary to liver metastases and portal
hypertension with low serum albumin levels,14 and usually do
not work in the setting of carcinomatosis. ese are the patients
who have high plasma renin activity and serum-ascites albumin gradient >1.1g/dL and negative uid cytology.14 Even in
this group of patients, diuretics and sodium restriction appear
to be eective at the beginning of the disease and the ecacy
decreases with progression of the disease.
Spironolactone is the most commonly used diuretic in
malignant ascites and the dose ranges from 100 to 450mg/day.
Other drugs, such as furosemide, may be added to this regimen, particularly if urine sodium is <30mEq/L or the patient
develops hyperkalemia on spironolactone. In general, the
maximum ascitic reabsorption expected from ecient diuretic
5,8,12
Diuretics are more eective in treating patients
Interventional Oncology, Second Edition, ed. Jean-François H. Geschwind and Michael C. Soulen. Published by Cambridge University Press.
©Cambridge University Press2016
323
Section X:Specialized interventional techniques in cancercare
therapy is about 800mL, a weight loss of <1kg/day.15 Typical
starting doses are 100mg spironolactone taken in the morning, with or without 40mg furosemide. Daily weights should
be recorded for 1week and basic metabolic panel rechecked.
If the initial dose is not eective and the basic metabolic panel
remains acceptable, the dose(s) can be doubled. is is continued weekly until ascites becomes controlled or the patient
reaches an intolerable dose, with a maximum dose of 160mg
furosemide and 400mg spironolactone.
Medical therapy has the advantage of being non-invasive.
e disadvantages are limited eectiveness in malignant ascites
and the risks associated with medical treatment and diuretics,
such as hyponatremia, hyperkalemia, dehydration, cramping, renal insuciency (20%), and hepatorenal syndrome.
erefore, these patients need continuous check of clinical
parameters and electrolytes.
Large-volume paracentesis
Large-volume paracentesis is the most common method of
managing malignant refractory ascites.12 Large-volume paracentesis provides temporary symptomatic relief in approximately 90% of patients.
5,8,16
e drainage volume should be
Figure 31.1 Pigtail or Cope-type loop catheter (Cook Medical Inc.,
Bloomington, IN, USA).
adjusted depending on the patient’s condition and severity of
ascites. Up to 4–6liters per session has been generally accepted
to be safe, but patients with larger volumes can be tapped dry to
maximize duration of benet.
17,18
Although there is no consensus on the speed of uid drainage, reports show that 30–90minutes is generally well tolerated.19 Drainage can be accomplished
with no image guidance. However, ultrasound guidance is fast,
simple, and decreases the risks. Ultrasoundguidance is also
important in patients with loculated ascites.
Some authors recommend simultaneous infusion of 5%
dextrose during paracentesis to prevent hypotension.20 If the
patient is hypotensive, dehydrated, or known to have severe
renal impairment, simultaneous intravenous hydration should
be considered. Concurrent albumin infusion has been shown
to be beneciary in patients with cirrhotic-related ascites; however, there is no evidence that its infusion is helpful in patients
with malignant ascites.
21,22
e main advantage of large-volume
paracentesis is that it provides rapid temporary symptomatic
relief in approximately 90% of patients.
8,16
However, palliation
is brief, with symptoms returning aer a few days, and repeated
treatment is required at a mean interval of 10.4days.8 ere
is risk of visceral injury, uid leak, peritonitis/sepsis, bowel
perforation, hypotension, renal failure, or uid loculation.
Chronic depletion of uid, electrolytes, and proteins leads to
rapid deterioration in quality of life over 1–2months.
23
Permanent indwelling catheters
A permanent catheter should be oered to patients requiring
frequent large-volume paracentesis. e patient will be able to
easily drain ascites from home, eliminating the need for hospital visits. Options include non-tunneled pigtail or Cope-type
loop catheters (Figure 31.1), tunneled catheters such as
Tenckho (Figure31.2), PleurX (Denver Biomedical, Denver,
CO) (Figure31.3), and the Asept Peritoneal Drainage System
Figure 31.2 Tenckhoff peritoneal dialysis catheters; straight and coiled (Cook
Medical Inc. Bloomington, IN, USA).
(pfmmedical, Cologne, Germany), and peritoneal Port-ACaths (Smiths Medical, St. Paul, MN) (Figure31.4).
28,29,30,31,32
12,24,25,26,27,
ese catheters are placed with ultrasound or uoroscopy
as guidance using intravenous conscious sedation. ey are
usually placed as an outpatient procedure or during hospital
admission. Asingle dose of prophylactic antibiotic is recommended prior to placement.
5,24
Risk of infection is multifactorial and depends on type of
catheter, tunneling, operator’s experience, and sterility of the
324
Chapter31:Palliative procedures for ascites and eusion
AB
procedure.24 Tunneled catheters are associated with lower rate
of infection and greater stability compared to non-tunneled
catheters.
27,33
ey have a long-term success rate of 96%.34
Potential complications are leakage from the insertion site,
catheter occlusion, catheter dislodgment, and cellulitis.34
Catheters may remain in place for many months. However, it
has been recommended to remove them once daily drainage is
less than 100mL in order to prevent infection.
35
Pigtail or Cope-type loop catheter
ese catheters are typically placed using ultrasound or uoroscopy as guidance. Ascites is drained intermittently or con-
Figure 31.3 PleurX catheter (Denver Biomedical, Golden, CO, USA).
tinuously through gravity and capped. Complications occur in
24–35% of patients and include peritonitis, leakage, occlusion,
and dislodgment.
26,29,36
Infection rates in these types of catheters are most likely related to the duration of catheter placement. erefore, non-tunneled catheters should be used only
when the life expectancy is only a fewweeks.
Tenckho catheter
ese catheters have one or two Dacron cus that reside in
the subcutaneous tissue. e tip may be straight or coiled
(Figure 31.2). Scar tissue forms around the cu and lowers
infection rate and dislodgment. ese catheters are placed
under ultrasound and uoroscopy guidance to minimize complications, i.e., bowel perforation or bleeding.
5,29,33
e catheter
is inserted either midline or in the lower quadrants (le or right,
lateral to the course of inferior epigastric vessels) depending
on where the largest area of ascites is observed on ultrasound
(Figure31.5). e catheter is tunneled in the subcutaneous tissue. e tunnel is created in a lateral and inferior or lateral and
superior direction. e cu should lie at least 2cm distal to the
incision in the subcutaneous tissue. e tube should exit in a
way that the site is visible to the patient for daily care and the
tube is easily accessible to the patient for drainage. e procedure is performed as an outpatient procedure. In patients with
Figure 31.4 Peritoneal Port-A-Cath (Bard Medical, C. R. Bard Inc., Covington,
GA, USA).
dicult anatomy, CT guidance may beused.
Complications are catheter occlusion, leakage, cellulitis,
and peritonitis. Barnett and Rubins performed a literature
Figure 31.5 (A) Tenckhoff catheter
(white dotted lines) placed in midline and
tunneled lateral and superior. (B) Tenckhoff
catheter placed in the right lower
quadrant; the subcutaneous tunnel is
directed lateral and superior.
325
Section X:Specialized interventional techniques in cancercare
Peritoneal Port-A-Catheters
ese ports are placed using the same technique that is used
for placing venous or chest ports (i.e., mediport) and the port
is placed in the subcutaneous pocket.
Two dierent types of abdominal ports have been reported
in the literature for management of malignant ascites.
31,32,37
e
rst group used 6F or 8F vascular access ports.37 Ahigh complication rate was reported with this group, including occlusion, wound dehiscence, and high rate of bacterial peritonitis.37
e second group used 16F ports specially designed for peritoneal access.
31,32
e larger catheter size allowed faster drainage
of ascites.
ese ports can be accessed only using special non-coring
needles, i.e., Huber needle. erefore, the main disadvantages
of these ports are that health care professionals are required
Figure 31.6 PleurX catheter (white arrows) placed in the most dependent
area of the pelvis; the tunnel is directed superior and medial, forming a C loop.
for each drainage attempt. Additionally, drainage speed is very
slow compared to other catheters.
Peritoneovenousshunts
Peritoneovenous shunt was introduced by Harry H. Leveen
in 1974.38 Lund and Newkirk modied it in 1979 by adding
a unidirectional pump that could be manually compressed.
is variant was associated with a lower rate of occlusion. e
most recent shunt is a modication known as the Denver shunt
(CareFusion Corporation, San Diego, CA) (Figure31.7).
review and stated that peritonitis occurred in 4.4% of cancer
patients who received a Tenckho catheter.33 In order to minimize leakage, the ascites should be well drained. erefore, it
is recommended to drain the ascites, at the time of procedure,
as much as can be safely achieved. Additionally, applying topical surgical glue to the access incision may further minimize
leakage.
Depending on the rate of ascites reaccumulation, each
patient is instructed to drain the ascites frequently enough to
avoid developing tense ascites. is usually results in draining
every other day. Catheters are drained using intermittent-gravity
drainage.
e shunt transmits the ascites uid from the peritoneal
cavity back into the central venous circulation. e Denver
shunt is made of two Silastic limbs connected by a pump chamber. is pump chamber contains either one or two one-way
valves that open at a pressure of 1cm H2O. ese unidirectional valves prevent the reux of blood into the venous limb of
the shunt. e two-valve model is more commonly used and is
more eective in preventing reux.39 e one-valve type is used
when the ascites uid is very viscous or the amount of daily
production of ascites is very high.
39
e Denver shunt is available with two venous limb sizes of
11.5F and 15.5F. e smaller sizes should be used when accessing the saphenous vein or subclavian vein. Most authors prefer
PleurX and Asept catheters
ese catheters are 15.5F Silastic, single-cu, tunneled catheters. ey are Food and Drug Administration-approved for
draining both malignant pleural eusion and ascites. ese
catheters have a one-way valve, making it a closed system,
therefore the catheter will not drain unless connected to customized vacuum bottles. e PleurX catheter is placed using
similar technique for Tenckho catheter placement, with
minor dierences. e access site is superior and lateral to the
umbilicus and the subcutaneous tunnel is made medially and
superior. is method creates a C-shape tunnel and helps prevent uid leakage (Figure31.6).
Patients are instructed to drain their ascites every day for
2 weeks to allow the tunnel tract to heal. Aerwards, they
are instructed to perform drainage as needed to prevent tight
ascites.
Complications are similar to Tenckho catheter and include
infection, occlusion, leakage, and peritonitis.
23,26,27
internal jugular vein for access. Both 11.5F and 15F calibers
can be used in the internal jugular vein. e larger-size shunt
occludes less commonly compared to the smaller-caliber
catheter.
Since there is no external drainage catheter, there is no
lifestyle limitation. Furthermore, there is no loss of uid or
protein-rich ascites. erefore, this shunt is especially benecial in patients with chylous ascites.
e procedure is relatively simple and can be performed
with moderate sedation, although some anesthesiologists will
use deep sedation or general anesthesia. Some authors perform
it as an outpatient procedure and some admit the patient for
overnight observation.
40,41,42,43
Patients receiving Denver shunts
are oen cachectic, and vulnerable to hypothermia due to the
large exposed area of prepped surgical eld, so a warming
device is recommended. e pump chamber should be placed
over the lower ribs to permit manual compression of the pump.
e distance from the pump chamber to the rst peritoneal
326
Chapter31:Palliative procedures for ascites and eusion
A BC
Figure 31.7 Denver shunt. (A) The internal jugular vein limb with the tip of the shunt at the level of the cavoatrial junction (arrows). (B) The Denver shunt pump
along the lower right chest wall (arrows). (C) The peritoneal limb of the shunt ending in the pelvis (arrows).
side hole is shorter than on tunneled catheters, so the distance
from the planned pump pocket to the peritoneal entry site
must be measured carefully to assure that the side holes will be
well within the peritoneal cavity.
Since the longest part of the procedure is draining the
patient’s ascites, the rst step is to place a large-bore drainage
catheter at the planned peritoneal entry site. All ascites should
be drained in order to minimize the risk of disseminated intravascular coagulopathy (DIC).44 While the ascites is draining,
lidocaine with epinephrine is inltrated generously in the
pump pocket. A2-cm incision is made cephalad to the planned
location of the pocket, so that it is well away from the location
that the patient will be pumping. e peritoneal end and pump
are then tunneled down to the peritoneal entry site, taking care
not to torque the tubing.
Once the peritoneal end of the device is in place, access to
the internal jugular vein is obtained, and the long tunnel from
the pump pocket incision to the jugular access site is anesthetized. Along malleable metal tunneler comes with the kit.
Using surgical glue to attach the venous limb to the tunneler is
a useful trick to prevent dislodgment of the catheter while pulling through the long tunnel, especially in cachectic patients.
Once all the ascites is drained, high-ow tubing is used
to instill 1liter of warm saline into the peritoneal cavity. e
large-bore drain is then exchanged for the peritoneal end of the
shunt via an included peel-away sheath, and the pump used to
prime saline through the venous limb of tubing. e venous
limb is then placed, and the incisions sutured andglued.
All patients should receive a prophylactic intravenous antibiotic (rst-generation cephalosporin). Some authors continue the antibiotic for 7–10 days postprocedure.39 Patients
are instructed to pump the shunt 20 times twice a day, while
recumbent in the morning and evening. e manual pumping
should be performed while the patient is in the supine position,
because the maximum ow occurs when the patient is supine.
e overall complication rate of peritoneovenous shunts is
25–40%.
16,41,45
Complications of peritoneovenous shunting are
occlusion (most common at 24–31%), infection (4.5%), transient fever (5%), thrombosis of central veins, pulmonary edema
(10–16%), pulmonary embolism (6.7%), leak, congestive heart
failure, dissemination of tumor, variceal bleeding, and DIC
(2.4–9.3%).
6,46,47,48
Most patients develop a dilutional coagulopathy, and some authors use the term “subclinical” DIC.
e maximum change in coagulation factors occurs immediately postprocedure. ese changes gradually normalize from
day 3 to 2weeks aer the shunt placement.
49,50
Transient fever
happens in 5% of patients and should be dierentiated from
infection.
e shunt drains ascites uid that may contain malignant
cells into the central venous system, particularly the pulmonary vasculature. is complication has been described in multiple case reports.
51,52,53
However, there is no clear evidence of
clinically important hematogenous dissemination of tumor
cells. Tarin etal. evaluated 14 patients with inoperable cancer who were treated with peritoneovenous shunts for malignant ascites.54 ey concluded that clinical observations and
ndings at necropsy indicated that peritoneovenous shunting
does not result in the establishment of clinically important
hematogenous metastases and that metastases do not necessarily develop even when large numbers of viable tumor cells
regularly enter the blood.54 High protein content in the ascitic
uid (>4.5g/L) was considered a contraindication to shunting
because of higher risk of shunt occlusion; however, this can be
prevented by using the 15.5F Denvershunt.
Patient selection is the most important step in treating
patients with shunt. In general, complications are more frequent
in patients with highly cellular ascites uid. Contraindications
for placing Denver shunt include:congestive heart failure, history of variceal bleeding, grossly bloody ascites, coagulation
disorder (high international normalized ratio of > 2.0, low
327
Section X:Specialized interventional techniques in cancercare
platelet counts <50×109), peritonitis, loculated ascites, liver
failure (total bilirubin level >6mg/dL), and renal failure (if the
patient is not on dialysis).
6,8,55
Massive pleural eusion, varices
with no history of bleeding, and portal hypertension are relative contraindications.
56,57
e shunt is eective in symptomatic relief in 70% of
patients.6 e best response rate is seen in patients with ovarian
or breast cancer (≥50%) and the worst response rate has been
reported in patients with gastrointestinal cancers (10–15%).6
erefore, some authors classify gastrointestinal cancer as a
contraindication for shunt placement.
6,16
e Denver shunt has the advantage of no external drain
and no loss of uid or nutrients, therefore it provides excellent palliation and higher quality of life. As a result, the shunt
should be used in patients with no contraindication and in
whom life expectancy is long enough to derive benet. ere
is no consensus on the time span; some authors advocate an
expected survival of more than 1month and others more than
3months.
6,58,59,60
Overall, the mean functional survival time for
peritoneovenous shunt is 12weeks, with 75% of patients eectively palliated until death.
8,50
beta-interferon was eective in 40% of patients with malignant ascites.72 e mechanism by which OK-432, a penicillin
heat-treated powder of Su-strain Streptococcus pyogenes A3,
acts is by activation of the cytotoxic T cell.
69,73
Intraperitoneal
OK-432, alone or in combination with interleukin-2, demonstrated 60% response rate in 77 patients with gastrointestinal
malignant ascites and 82% in 22 gastric cancer patients.
73,74
Side eects of immunotherapy include fever, chills, nausea, and
bowel distension.
Intraperitoneal radioisotopes, like AU-198 or 32P chromic phosphate, have been used in the treatment of malignant
ascites. However, they have been gradually abandoned because
of the complex logistics involved.
75,76
An increased level of activity of VEGF has been reported
in dierent cancers, including ovarian, gastric, pancreatic,
colorectal, and sarcoma.77 erefore, a new concept of targeted
therapy with the goal of reducing the production of ascites by
inhibition of neovascularization of the tumor via inhibition of
VEGF has been reported.77 Anti-VEGF drugs that have been
investigated include anti-VEGF antibodies, anti-VEGF receptor antibodies, and metalloproteinase inhibitors. Bevacizumab,
an anti-VEGF molecule, has been injected intraperitoneally in
Transjugular intrahepatic portosystemicshunts
TIPS creation is an eective treatment for refractory ascites.61
However, TIPS in regard to malignant ascites is only useful in
cancer patients who have portal hypertension as the underlying mechanism of ascites formation.62 TIPS is contraindicated
in patients with extensive liver metastasis, congestive heart failure, liver failure, and hepatic encephalopathy. Complications of
TIPS are hepatic encephalopathy, occlusion, and liver failure.
patients with malignant ascites of gastrointestinal, gynecological, and breast cancer origin, and was successful in decreasing
ascites.77 Matrix metalloproteinases (MMP) increases vascular permeability similarly to VEGF. MMPs are utilized by
cancer cells in the process of metastasis.78 MMP inhibitors
were given intraperitoneally in mice with ovarian and colon
cancer-induced ascites and the eusion resolved.
79
Intraperitoneal chemotherapy, immunotherapy, and targeted
therapy all are promising medical options for the treatment of
Other suggested methods for treatment of
malignant ascites; however, their clinical application is not yet
completely elucidated and further investigations are needed.
malignant ascites
Intraperitoneal chemotherapy has been studied with different drugs and in various cancers. Most common drugs
used are cisplatin, mitomycin, Adriamycin, bleomycin, and
5-uorouracil.
63,64,65
e outcomes are not encouraging, particularly when used in patients with gastrointestinal malignancies. Ovarian cancer seems to be the most sensitive cancer to
intraperitoneal chemotherapy.15 Since the chemotherapy drug
needs to be evenly distributed in the peritoneal cavity, presence
of loculated ascites is a contraindication for this technique.
Overall, a temporary partial response is detected in less than
half of the patients (<47%), and these results are based on
isolated experiences with small numbers of patients. e complications include fever, abdominal pain, and adhesions in the
longterm.
Immunotherapy with intraperitoneal injection has been
reported with dierent success rates and dates back to the
1980s. ese include intraperitoneal injection of alpha- or
beta-interferon,66 tumor necrosis factor(TNF),67 non-pathogenic
forms of infectious agents like Corynebacterium parvum,68 and
OK-432.
69,70
TNF inhibits the interaction between VEGF and
its receptor, F1k-1. However, the ecacy of intraperitoneal
TNF treatment has not been well documented in humans with
malignant ascites.71 Gebbia etal. reported that intraperitoneal
Management of malignant eusions
Malignant pleural eusions are more commonly seen with
breast and lung cancer, as well as lymphoma. Similarly to
malignant ascites, the presence of malignant eusions indicates
poor prognosis, with expected survival of a few months.
Malignant eusions may cause dyspnea, shortness of
breath, cough and pleuritic chest pain, impairing the quality of
life of cancer patients. e treatment options are thoracentesis
or drainage catheter insertion.
Computed tomography (CT) of the chest within 1 week
(or more recently if there has been an intervention) should be
performed prior to performing the procedure.17 is CT scan
provides important procedure-planning information and may
also detect any loculations.
Thoracentesis
e initial thoracentesis is used for diagnostic purposes. e
aspirate is sent for culture, cell count, cytology, pH level,
and lactate dehydrogenase. It may also be useful to identify
non-malignant eusions in patients with known malignancy.
Malignant eusions in patient with lymphoma or small cell
lung cancer may resolve aer chemotherapy. In these patients
328