Long term ascites drains (ltads) for refractory ascites - safe in clinical practice or not? a real world clinical experience update

Background/Aim

Concerns exist regarding increasing use of long term ascitic drains (LTADs) in patients with refractory ascites complicating cirrhosis. Current UK consensus guidelines¹ recommend LTAD consideration in non-transplant candidates who are diuretic refractory/intolerant and entering a palliative phase of their illness.¹ The REDUCe feasibility study² demonstrated an increased risk of cellulitis and leakage in those with long term ascitic drains compared to standard paracentesis. Data from our own centre has revealed previously a 50% complication rate.³ Pending the ongoing REDUCe 2 trial results, the aim of this update was to evaluate our LTAD service assessing safety/efficacy of LTADs comparing to previously published data.

Methods

A retrospective case note review was conducted with local QEHB audit approval. Previously published data pertained to 25 LTADs inserted January 2012 to May 2018. 62 further LTAD data was reviewed (May 2018 to December 2022).

Results

62 drains were done in 60 patients (70% M), 29 (47%) had ArLD, 23 (37%) NAFLD. 17 (27%) had concurrent HCC. 13 (21%) had previously documented SBP. 40 (62%) of drains were planned insertions compared to 14 (56%) in our last review. Use prophylactic antibiotics increased from 4 (14%) to 34 (53%). 57 (92%) were referred to palliative care at the time of LTAD compared to 21 (84%) in our previous review. 18 (30%) of patients were alive at 6 months compared to 13 (50%) in our previous review. Please see table 1 for a review of the complications When data amalgamated over a 10-year period (LTADs=91), the overall complication rate for LTADs was 37 (41%). 17 (19%) major and 20 (22%) minor.

Conclusions

Our latest data demonstrates reduced rates of infections compared to our previous data and similar other complications such as leakage. Over a decade experience overall complication rate was 41% (n=37) – the majority minor. In experienced centres, insertion of LTADs remain a good palliative option however patient selection remains key and the patients need to be aware of the complication rates which will be informed by REDUCe2.

References

Macken L, Corrigan M, Prentice W on behalf of the British Association for the Study of the Liver/British Society of Gastroenterology (BASL/BSG) End of Life Special Interest Group, et al. Palliative long-term abdominal drains for the management of refractory ascites due to cirrhosis: a consensus document Frontline Gastroenterology 2022;13:e116-e125. Macken L, Mason L, Evans C, et al. PTU-020 REDUCe study: multi-centre feasibility RCT in cirrhosis-related palliative refractory ascites. participant reported outcomes. Gut 2019;68:A121. Corrigan M, Thomas R, McDonagh J, Speakman J, Abbas N, Bardell S, Thompson F, Holt A, Jones R, Willis A, Karkhanis S. Tunnelled peritoneal drainage catheter placement for the palliative management of refractory ascites in patients with liver cirrhosis. Frontline gastroenterology. 2021 Mar 1;12(2):108–12.