Reviews

Reviewed by Dr Phil Haslam Reviewed Jun 23, 2010

Consultant Interventional Radiologist, Freeman Hospital, Newcastle upon Tyne, UK - No Conflict Declared

Editor Rating

Malignant ascites is a common problem for cancer sufferers leading to repeated hospital admission for paracentesis. The ascites is usually drained with ultrasound guidance under local anaesthetic. This may be uncomfortable and at best inconvenient for the patient who may much rather be cared for at home. The Pleurx drain is essentially a means of providing more long term drainage that can be performed at home by the patient or carer.

Introduction

Malignant ascites is a common problem for cancer sufferers leading to repeated hospital admission for paracentesis. The ascites is usually drained with ultrasound guidance under local anaesthetic. This may be uncomfortable and at best inconvenient for the patient who may much rather be cared for at home. The Pleurx drain is essentially a means of providing more long term drainage that can be performed at home by the patient or carer.

Design/construction

The kits consists of a silicon catheter with multiple side holes/fenestrations and a valve at the proximal connection end. There is a polyester cuff similar to that seen for tunnelled central venous catheters and a barium stripe along the length of the catheter to aid its visibility.

Other kit contents include:

  • Drainage Line, (this connects to the catheter valve)
  • Valve Cap, (for protection)
  • 16 Fr. Peel-away Introducer
  • J-tip Guidewire
  • Tunneler (plastic)
  • 18 Ga Needle
  • 17 Ga Needle
  • Foam Catheter Pad (dressing)
  • 5-in-1 Adapter (for connecting to other drainage bags etc)
  • 8 Gauze Pads, 4 in. x 4 in (10cm x 10cm)
  • CSR Wrap
  • Syringe
  • Point-Lok Sharps Safety Device

In use

The catheter is easy to insert for any radiologist used to inserting drains and/or tunnelled central venous catheters. Ultrasound is used to locate the deepest area of ascites and to check it is not heavily loculated. Loculation is stated as a contraindication however it is still possible for some patients to benefit from a pleurx drain in this situation if the loculation is large. Other contraindications include coagulopathy and infection.

Local anaesthetic is installed into the skin and subcutaneous tissues at the peritoneal puncture site (usually more caudal) and at the catheter exit site approximately 6-8cm superior to this. The tract is also anaesthetised. Small incisions are made at each site.

The exact order of the procedure is not that important. The peritoneum is punctured under ultrasound guidance with the supplied needle and the guidewire is inserted. This should be oblique to minimise peritoneal leakage. The needle can then be removed. The catheter is attached to the tunneler and tunnelled through the subcutaneous tract and out through the puncture site similar to when inserting a Hickman line. The catheter is pulled through so that the cuff is inside the tunnel by approx 1-2cm.

The peelaway sheath can then be inserted over the guidewire. The tunneler is removed from the end of the catheter. The central dilator and wire can then be removed from the peelaway whilst pinching the peelaway or ascites will flood out. The catheter can then be pushed through the peelaway into the peritoneal cavity.

The peelaway sheath is then removed and both site sutured with the catheter firmly sutured to its exit site.

Ascites will drain freely when the connection tubing with its special end is inserted through the valve on the catheter. We tend to connect using a three way tap (connection has a male end) to a standard drainage bag for initial drainage. A vacuum bottle can be connected for subsequent drainages on the ward or at home.

Care should be taken to watch out for paracentesis hypotension (uncommon) and initially no more than six litres should be drained in 24 hours.

Drainage kits are supplied containing a connection line and vacuum bottle along with accessories for the procedure. The supplier (UK Medical in our case) undertakes training of the ward staff and carers in the use of the kit.

Results so far

To date we have performed this procedure on only 10 patients but with great success. We have had two complications, one with diaphragmatic irritation when the patient wanted us to tunnel upwards due to previous bladder irritation from temporary drainage catheters. This was rectified with placement of a Pleurx drain in the usual direction. One potentially major complication in a patient with oedema and IVC occlusion when the tunnel traversed a venous collateral that had not been apparent due to probe compression applied to the oedema. This was rectified with coils and cyanoacrylate glue to the vein. All patients have had good symptomatic relief of ascites without recurrent hospital admission for drainage.

Conclusion

A good, simple kit that does what it says. A significant improvement in patient care and no doubt also cost saving due to avoidance of repeated hospital admission.

Dr Phil Haslam
Consultant Interventional Radiologist
Freeman Hospital, Newcastle upon Tyne, UK

No conflict declared

Further information

Additional information courtesy of Dr. Hans-Ulrich Laasch, Consultant Radiologist & Interventional Lead, The Christie NHS Foundation Trust, Manchester.

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