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Drainage of malignant ascites: patient selection

and perspectives

This article was published in the following Dove Press journal:

Cancer Management and Research
12 April 2017
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Maciej Stukan Abstract: Malignant ascites (MA) is a sign of advanced cancer and poor prognosis. MA can
Department of Gynecologic
result in impairment in quality of life (QOL) and significant symptoms. As a supportive treat-
Oncology, Gdynia Oncology Center, ment, ascites can be drained by paracentesis (PC), percutaneously implanted catheters (tunneled,
Szpitale Wojewodzkie w Gdyni untunneled, central venous catheters), or peritoneal ports, or peritoneovenous shunts. The aim
Sp. z o.o., Gdynia, Poland
of this study was to evaluate the effectiveness, safety, and patient-reported outcomes (PRO) of
different drainage methods for the management of MA. A systematic review of the literature was
performed, and 32 original articles met the inclusion criteria. Patients selected for permanent
drain insertion demonstrated symptoms related to MA and had undergone repeated PC. The
primary focus of the reviewed articles was procedural safety issues. The rate of technical success
of drainage device installation was 100%. Most patients experienced improvements in symptom
control after ascites drainage. When analyzed together, 19.7% (255/1297) of patients experienced
any complication and 6.2% (81/1297) experienced serious adverse events during MA drainage.
Complications were reported for every drainage method; however, the least occurred after PC or
central venous catheter, while the most serious occurred after peritoneovenous shunts. Adverse
events were as follows: catheter obstruction: 4.4%, infection: 4.1%, leakage: 3.5%, catheter dis-
lodgment: 2.3%, hypotension: 0.6%, injuries during device insertion: 0.6%, renal impairment:
0.5%, electrolyte imbalance: 0.2%, other: 3.6%. PRO and QOL endpoints were available for
12 studies. When PRO were measured using an interview, a significant improvement in symptom
control and QOL was reported in almost all patients. Once standardized questionnaires were
used, improvements in symptomatic scores and role functioning were observed. Deterioration
was observed in cognitive and emotional subscales. MA drainage is a safe and effective method
to control symptoms associated with ascites, and should be perceived as a supportive care, that
can be applied for those who need it at any time of their cancer trajectory. Patient selection should
be performed using a thorough assessment of symptoms and QOL, and should not be delayed.
Keywords: ascites, malignant, cancer, drainage, complications, quality of life, symptoms,
palliation, support, catheter, peritoneal port, paracenetesis, shunt, effectiveness, management

Introduction
Ascites is a common sign of several diseases, both benign and malignant, and often
contributes to more symptoms than the underlying pathology itself.1 Malignant ascites
Correspondence: Maciej Stukan
Department of Gynecologic Oncology, (MA) is an abnormal accumulation of fluid in the peritoneal cavity as a result of cancer,2
Gdynia Oncology Center, Szpitale and accounts for ~10% of all cases of ascites. It occurs in many malignancies: adrenal,
Wojewodzkie w Gdyni Sp. z o.o.,
Powstania Styczniowego 1, 81-519 appendiceal, bladder, breast, cervical, colon, endometrial, esophageal, gall bladder,
Gdynia, Poland gastric, liver, lung, lymphoma, melanoma, mesothelioma, neuroendocrine, ovarian,
Tel +48 6 9211 2481
Fax +48 5 8726 0296
pancreatic, renal, testicular, and thyroid.3–11 The most common primary site is epithelial
Email [email protected] ovarian cancer (EOC), accounting for 38% of MA occurring in females.12 In many
submit your manuscript | www.dovepress.com Cancer Management and Research 2017:9 115–130 115
Dovepress © 2017 Stukan. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.
http://dx.doi.org/10.2147/CMAR.S100210
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permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php).
Stukan Dovepress

forms of malignancy, ascites is a sign of advanced disease and of tunneled catheter that can be used for ascites evacuation.
poor prognosis, with only 11% of patients surviving longer In this case, there is an intra-abdominal catheter and a port
than 6 months. EOC is an exception. The majority of women situated in the subcutaneous tissue, which can be easily
with EOC present with advanced disease (stage III or stage accessed by repeated puncture.
IV) that may include ascites. In these patients, surgical treat-
ment together with combination chemotherapy has resulted Rationale
in a median progression-free survival of 16–22 months and The management of untreatable ascites, taking into account
a 5-year survival rate of 27%, although better results are now the limited life expectancy of such patients, must be as
being reported with improvements in therapy.13 minimally invasive and as effective as possible. The ideal
There are two main factors responsible for MA formation. treatment should aim to control symptoms and improve QOL,
First, obstruction of lymphatic vessels by tumor cells has been with the least patient discomfort.1
suggested as a mechanism for impaired drainage from the Survey studies performed on a cohort of medical profes-
peritoneal cavity. Second, vascular endothelial growth factor sionals have shown variations in the management of MA.
has been identified as being instrumental in altering the per- There are no definitive data to guide clinicians.19–21 Research
meability of the peritoneal membrane, inducing angiogenesis has focused on the feasibility and complications of manage-
and permeabilizing blood vessels, and therefore causing ment procedures. To date, not much has been published
increased filtration into the peritoneal cavity.13 regarding patient-reported outcomes (PRO) in MA drainage.
The symptoms of MA are abdominal swelling (55%), The impetus for this review was to support clinical decision
abdominal pain (53%), nausea (37%), anorexia (36%), vomit- making based on the perspectives of patients, to address
ing (25%), fatigue (17%), dyspnea (11%), early satiety (6%), uncertainty or variations in practice and possible complica-
and weight change (5%).13 tions in MA drainage, and to provide a more precise estimate
First-line interventions outside the treatment of the of the effect of MA drainage on patient QOL.
primary disease include dietary restriction, diuretics, and
repeated large-volume paracentesis (PC). The relative inef- Objectives
ficiency of diuretics in specific types of MA is likely because The aim of this systematic review was to evaluate the
of different pathophysiologic mechanisms for fluid accumula- effectiveness, safety, and PRO of drainage methods for the
tion.14 A response to diuretics has been observed in patients management of individuals with MA. A secondary aim was
with ascites secondary to massive hepatic metastases who to generate a framework to better understand the perceived
have a serum:ascitic albumin gradient of >11 g/L.12,15 benefits and barriers that affect individual decision making in
Large-volume PC, where the accumulated fluid is drained offering MA drainage to patients. To this end, the proposed
intermittently for hours or even days using a fine tube inserted systematic review should answer the following questions:
into the abdomen, is widely used to provide short-term relief
from the symptoms of MA.16 PC brings immediate but tem- 1. Are there differences between various drainage methods,
porary relief in 78%–90% of cases, and implies multiple when comparing feasibility, safety, and efficacy?
hospitalizations.2,10,17 This approach is undertaken in hospital, 2. Are there any specific symptom clusters, QOL issues, or
as a day-case or inpatient procedure.18 Patients often wait until conditions that could direct clinical decision making in
fluid accumulation is substantial to avoid frequent hospital MA drainage?
stays, and to ensure the ascites is amenable to drainage,
resulting in a deterioration in their quality of life (QOL).16 Methods
To avoid repeated PC and multiple hospitalizations, a A systematic review of the literature concerning feasibility,
permanently inserted catheter in the abdominal cavity can be safety, and the clinical benefit of MA drainage was performed
considered. Fluid drained from the peritoneal cavity can be according to the preferred reporting items for systematic
directed outside the body, or to other body compartments (eg, review and meta-analysis protocols guidelines,22 without
venous shunting). In the first case, evacuation of the ascitic protocol registration or amendments.
fluid can be performed by percutaneous catheters inserted An initial literature screen, using the keywords “malignant
directly through the abdominal wall into the peritoneal cavity ascites” and “drainage” and “patient perspective” or “quality of
(eg, peritoneal, venous catheters), or with a subcutaneous life”, was performed to determine the dominant study designs.
tunnel (eg, PleurX, Tenckhoff). A peritoneal port is a type It was found that the majority are retrospective, observational,

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Dovepress Drainage of malignant ascites

single-arm cohort studies, with ~20–60 participants. Thus, The included articles were written in English as well
studies eligible for final analysis were randomized controlled as other languages if English language abstracts were pro-
trials, controlled (nonrandomized) clinical trials, all types vided, which included information that addressed the review
of original research, prospective and retrospective studies, objectives.
including case series. Review articles and case reports were A literature search was conducted using medical subject
excluded from the final analysis, but were consulted for general headings and words related to MA drainage. PubMed and
descriptions of the problem and discussion. EBSCO Discovery Service interface (from January 1980 to
Included studies were those examining patients suffering July 2016) were used to search electronic bibliographic data-
from MA and any background cancer, and included adults bases such as Medline, Cochrane Library, Web of Science,
(over 18 years old), both female and male, who underwent Academic Search Complete, ScienceDirect, Scopus, Nature
drainage of ascites. Excluded studies were those examining Publishing Group, Oxford Journals, Wiley Online Library,
patients with non-MA, or describing approaches other than and Clinical Key. To ensure literature saturation, a scan of
fluid drainage interventions (eg, pharmacology, chemotherapy, the reference list of included studies or relevant reviews
biologic agent therapy, cytoreductive surgery, hyperthermia). identified though the search was performed.
Outcomes of interest were safety, feasibility, and efficacy A Medline search included the following key words:
of ascites drainage procedures, PRO, and QOL. Comparators “malignant ascites” and “drainage” AND “patient” and
were various methods of ascites drainage. Overall survival “perspective” or “satisfaction” or “selection” or “quality of
was not considered as an outcome because, first, the popula- life” or “QOL” OR “indication” OR “complication”.
tion of patients with MA is heterogeneous with many different The author screened the titles and abstracts yielded by
primary cancers contributing to the development of ascites the search against the inclusion criteria. The full reports were
and, second, studies were performed in different settings obtained for all titles that appeared to meet the inclusion
(clinical oncology, palliative, gynecology, interventional criteria or where there was any uncertainty. The full-text
radiology, and ambulatory departments). reports were screened and it was decided whether these met
MA was defined as an abnormal accumulation of fluid in the inclusion criteria. The review author was not blinded to
the peritoneal cavity as a result of cancer.2 Ascites drainage the journal titles or the study authors or institutions.
was defined as evacuation of the accumulated fluid out of the Data that were extracted from studies included: year of
abdominal cavity. It could be performed by PC, permanently publication and clinical setting, study design, number of
inserted drains, catheters, or shunts, transferring fluid from the participants, type of cancer, type of drain/catheter, technical
abdominal cavity to outside the body or to other body com- success, complications, PRO, and the quality of the provided
partments. PC or large-volume PC was defined as a procedure data. If these data were not provided, this was recorded or
where accumulated fluid was drained intermittently using a the publication was excluded from the final analysis. Based
fine tube.23 Technical success was defined as successful place- on these data, the risk of bias was assessed and categorized
ment of the device and drainage of ascites at completion of into low, moderate, or high. The data collected are presented
the procedure. PRO were defined as measurements that came in Table 1 and incorporated into data synthesis in a descrip-
directly from the patient, both symptoms (one dimensional) tive way.
and health-related QOL (multidimensional), based on instru- Feasibility, safety, and efficacy outcomes of ascites
ments like symptom assessment scales and questionnaires.24 If drainage were defined as numbers of patients with technical
not clearly stated as quantitative data, then descriptive data are success of the catheter insertion and the quantity and quality
provided. Infectious adverse events (AEs) related to catheter of complications associated with MA drainage.
placement were graded according to Common Terminology A systematic narrative synthesis is provided with infor-
Criteria for Adverse Events (CTCAE v4.0): G2 – localized mation presented in the text and tables to summarize and
(local intervention; oral intervention indicated); G3 – intrave- explain the characteristics and findings of the included stud-
nous antibiotic, antifungal, or antiviral intervention indicated ies. Results are presented in order by key question and main
radiologic or operative intervention indicated; (no G1). Local, outcome, followed by additional outcomes. It was originally
peridrain infection was graded G2, while peritonitis and sepsis planned to first report on studies for which the risk of bias was
were graded G3. Leakage was defined as a flow of ascitic either low or moderate. However, studies with an e­ stimated
fluid from the peritoneal cavity to outside the body along the high risk of bias have been retained for certain key questions
catheter, or into subcutaneous tissue. or outcomes.

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Table 1 Risk of bias assessment and categorization of included studies
Stukan

Author Setting/department No. of Study design Type of QOL QOL assessment Risk of bias Comments
patients (P/R) cancer assessment tools (PR/AC/ST) (L/M/H/?)
(Y/N)

Dovepress
Akinci et al3 Radiology 40 R Various N NA M
Barnett and Radiology 29 R Various Y PR M
Rubins43
Belfort et al34 Gynecology 17 R Various N NA M
Bratby et al37 Radiology 24 P, observational Various N NA M Patients’ selection. MA – 24, liver cirrhosis – 2
Coupe et al4 Medical Oncology 24 P, longitudinal study Various Y ST M
Courtney et al5 Radiology 34 P, clinical trial Various Y ST L

submit your manuscript | www.dovepress.com

Easson et al10 Surgical Oncology/Palliative 61 P, comparative study Various Y ST L Testing various QLQ in a group of patients with MA
Fleming et al14 Gynecologic Oncology 19 R Various N NA M
Ghaffar et al30 Radiology 40 P, longitudinal study Various N NA L
Gough and Surgery 42 P, clinical trial Various Y AC M 17/82 patients conformed to the protocol
Balderson6
Gu et al28 Palliative 78 R Various Y PR (symptoms only) H Median time of catheter in situ – 13 days, and OS
evaluation, presents an issue of risk of bias
Harding et al18 Oncology 18 R, feasibility study Ovarian N NA M Testing safety and cost-effectiveness of paracentesis
Husain et al41 Palliative/Surgical Oncology 37 P, longitudinal study Various Y ST L Testing changes in QOL before and after paracentesis
Hussain et al36 Radiology 13 R Various N NA H Excluded patients with cardiac failure, ischemic heart
disease, creatinine >200 mmol/dL
Lee et al21 Geriatric Medicine 38 R Various N NA H Eight lost to follow-up, patients from geriatric medicine
unit only
Lungren et al7 Radiology 170 R Various N NA L
Maleux et al8 Radiology 94 R Various N NA L
Mercadante et al26 Palliative 40 P, longitudinal study Various Y AC M Symptoms rated by a patient on a linear scale from 0
to 3. No other QOL assessment. Complications data
presented not precisely
Monsky et al29 Radiology 14 P Various Y ST/AC M A questionnaire was constructed similar to the
Chronic Liver Disease Questionnaire: a ten-point scale
MA – 14, cirrhosis – 2, pleural effusions – 14
Narayanan et al54 Radiology 38 R Various N NA M
O’Neill et al55 Radiology 21 R Various N NA H
Orsi et al1 Radiology 8 R Various Y PR H Patients’ selection: eg, those with renal failure, heart
failure were excluded
Ozkan et al31 Radiology 7 R Various N NA H
Richard et al33 Radiology 10 R Various N NA H
Rosenberg et al9 Radiology 107 R, comparative study Various N NA L
Ross et al42 Radiology 43 R Various N NA M
(Continued)

Cancer Management and Research 2017:9

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 Dovepress Drainage of malignant ascites

Results

Abbreviations: AC, authors created questionnaire; MA, malignant ascites; NA, not assessed; OS, overall survival; P, prospective; PR, patient reported; PVS, peritoneovenous shunts; QOL, quality of life; QLQ, Quality of Life Questionnaire;
The literature search revealed 484 articles. Five additional

contraindication to PVS insertion. Study design not

articles were identified from other sources. After screening
titles and abstracts, 116 articles were considered relevant.

Patients’ selection – many conditions as

Duplicates (n=27), review articles (n=22), and case reports
(n=11) were removed. Full-text manuscripts were obtained
for all remaining relevant articles or where there was uncer-
tainty. Next, 18 articles were excluded because they were
not in line with the objectives of the review (surveys, cost-
effectiveness analysis, children, hepatic cirrhosis, other).
clearly specified
Risk of bias Comments

Four articles were excluded because the full texts were not
in the English language and the abstracts lacked the required
information; one was excluded because no full text or abstract
was available; another one was excluded because there was
(L/M/H/?)

no full text and the abstract did not provide sufficient data.
Finally, 32 original articles and case series were included for
M

systematic review.
L

L
L
?

There were no randomized clinical trials in the included

tools (PR/AC/ST)
QOL assessment

articles. Twelve studies were prospective and 20 were retro-

spective. The median number of included patients was 33,
ranging from 7 to 170. The risk of bias of the analyzed articles
NA
NA

NA

NA
NA

is presented in Table 1.
PR

In most of the studies, patients selected for permanent

assessment

drain insertion were symptomatic in relation to MA and

(Y/N)
QOL

had undergone repeated PC. The main indication of ascites

N
N

N
N
Y

drainage was symptomatic relief. However, the main focus

Type of

of the articles was procedural safety issues. Not many studies

cancer

Various
Various

Various

Various
Various
Various

R, retrospective; ST, standardized questionnaire; H, high; L, low; M, moderate; ?, not possible to assess.

analyzed real clinical benefits, such as degree of symptom

control or QOL. The results are summarized in Table 2 and
R, comparative study
P, longitudinal study

P, longitudinal study

Table 3.
comparative study
Study design

P, longitudinal,

General considerations
(P/R)

The rate of technical success of a drainage device installation

R

was 100%. Most of the patients experienced an improvement

patients

in symptom control after ascites drainage; however, some

No. of

authors reported the procedure to be less effective (rate of

28
69

24

43
28
33

symptom control: 64%–100%).

Complications of every drainage method were reported,
Setting/department

Gynecologic Oncology

ranging from 0% to 67%, with serious adverse events (SAEs)

Gastroenterology

Gastroenterology

ranging from 0% to 39%. The lowest level of complications

was reported in a group of 18 patients with ovarian cancer and
Radiology

Radiology

ascites managed using PC (0%), followed by PC for various

Surgery

malignancies (0%–8%, SAE 0%–5%), drainage using a cen-

Table 1 (Continued)

tral venous catheter (CVC; 9%–25%, SAE 0%), permanent

Tomiyama et al40

peritoneal port (PPP; 4%–79%, SAE 0%–4%), tunneled peri-

Tapping et al25
Stukan et al27
Seike et al11

Soderlund39
Savin et al32

toneal catheters (TPC; 8%–56%, SAE 0%–39%; for PleurX:

Author

8%–56%, SAE 0%–12%; for Tenckhoff: 9%–29%, SAE

0%), and peritoneovenous shunts (PVS; 26%–55%, SAE

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Table 2 Malignant ascites drainage – complications’ rate and quality, and patients reported outcomes as provided in included literature.
Author No. of Type of Technical Symptoms Complications Complications rate (n), by type
patients catheter success control rate, all
(%) (%) AE, SAE, Infection Infection Leakage Hypotension Injury
n (%) n (%) G2 G3

Akinci et al 40 TPC 100% NA 13(33%) 8(20%) 1 8 0 0 0

(2011)3
Barnett, 29 TPC 100% 93% 5(17%) 0 1 0 1 0 0
Rubins
(2002)43
Belfort et al 17 TPC 100% 100% 5(29%) 1(9%) 2 1 0 0 0
(1990)34

Bratby et al 24 PVS 100% NA 11(46%) 3(13%) 0 0 0 0 0

(2007)37

Coupe et al 24 PPP 100% 100% 5(21%) 3(13%) 0 1 0 1 0

(2013)4
Courtney 34 TPC 100% 83-100% 19(56%) 4(12%) 0 1 7 0 1
et al (2008)5

Easson et al 61 PC NA 78% NA NA NA NA NA NA NA

(2007)10

Fleming 19 FP 100% NA 9 (47%) 2(11%) 0 1 2 0 0

et al TPC 0 1 0 0 0
(2009)14 PPP 0 0 0 0 0
Ghaffar et al 40 PPP 100% 97.5% 2 (5%) 1(2.5%) 0 1 1 0 0
(2014)30
Gough and 42 PVS NA 64% 11(26%) 2(5%) 0 0 NA 0 0
Balderson
(1993)6
Gu et al 78 CVC 100% 100% 7(9%) 0 0 0 7 0 0
(2016)28

Harding 18 PC 100% NA 0 0 0 0 0 0 0
et al
(2012)18
Husain et al 37 PC NA NA NA NA NA NA NA NA NA
(2010)41

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Dovepress Drainage of malignant ascites

Complications, comments QOL

Renal im Electrolyte Obstruction Catheter Other QOL Results

pairment imbalance dislodgement assessment
tools
(PR/AC/ST)
0 0 1 3 0 NA NA

0 0 0 2 1 One poorly draining catheter – PR Self-control, independency.

replaced for a new one

0 0 2 0 0 PR All patients reported

satisfaction and
improvement in QOL.
0 0 8 0 3 One rapid death from NA
pulmonary edema, 2
pneumothorax; 1 seroma at the
venous insertion
1 2 1 0 0 ST (ESAS) Most important: pain and
breathlessness relief
0 0 2 0 8 One with epigastric vein injured; ST (MSAS, 1st week – 56% reported
five with dizziness and weakness, SSQ) improved overall QOL,
one with severe pain, one with 12th week – 28% reported
sudden onset of shortness of improved QOL,
breath and coughing, one anemia
with transfusion required
NA NA NA NA NA ST: ESAS:AM, Improvement in abdominal
EORTC: bloating, anorexia, dyspnea,
QLQ-C30, insomnia, fatigue, mobility,
QLQ-PAN26 role functioning, general
QOL.
Deterioration in cognitive
and emotional subscales.
0 0 5 0 0 NA NA
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0 NA NA

0 0 9 0 2 Two deaths 6 and 12 hours after AC QOL not significant

PVS insertion tendency (P=0.13) to
improve.
0 0 0 0 0 PR Alleviation in the mean
scores for abdominal
swelling, anorexia,
constipation, fatigue.
Comment: mean time of
drainage 13 days.
0 0 0 0 0 Patients with ovarian cancer NA NA
only, PC to dryness

NA NA NA NA NA ST Improvement in scores on
(ESAS:AM, symptoms of abdominal
EORTC distension, shortness of
QLQ-C30) breath, role functioning.
Global QOL did not
improve. The domain
of cognitive functioning
declined, emotional - trend
toward decline.
(Continued)

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Table 2 (Continued)
Author No. of Type of Technical Symptoms Complications Complications rate (n), by type
patients catheter success control rate, all
(%) (%) AE, SAE, Infection Infection Leakage Hypotension Injury
n (%) n (%) G2 G3

Hussain 13 PVS 100% 92% 5(38%) 1(8%) 0 0 0 0 0

et al
(2004)36
Lee et al 38 TPC 100% 100% 20(53%) 15(39%) 0 13 0 2 0
(2000)21
Lungren 170 TPC 100% NA 14(8%) 2(1%) 3 2 4 0 0
et al (2013)7
Maleux et al 97 TPC 100% NA 9(9%) 0 2 0 4 0 0
(2016)8
Mercadante 40 CVC 100% 75% 10(25%) 0 0 0 6 0 0
et al
(2008)26
Monsky 14 PPP 100% 96% 11(79%) 0 0 0 4 0 3
et al
(2009)29

Narayanan 38 TPC 100% NA 9(24%) 2(5%) 0 2 2 0 0

et al
(2014)54
O’Neill et al 24 TPC 100% 100% 4(17%) 3(12%) 0 3 0 0 0
(2001)55
Orsi et al 8 PVS 100% 100% 0 0 0 0 0 0 0
(2002)1

Ozkan et al 7 PPP 100% NA 4(57%) 0 0 0 2 0 0

(2007)31

Richard 10 TPC 100% NA 2(20%) 0 0 0 0 0 0

et al
(2001)33
Rosenberg 40 TPC 100% NA 3(8%) 1(3%) 0 1 1 0 0
et al (2004)9 67 PC 100% 5(8%) 3(3%) 0 3 0 0 0
Ross et al 43 PC 100% 87% 3(7%) 2(5%) 0 0 0 3 0
(1989)42
Savin et al 28 PPP 100% 96% 1(4%) 1(4%) 0 1 1 0 0
(2005)32

Seike et al 20 PVS 100% NA 11(55%) 3(15%) 1 0 0 0 3

(2007)11 49 PC 7(14%) 7(14%) 0 1 0 1 0

Soderlund 24 PVS NA NA 16(67%) 6(25%) 0 0 0 0 0

(1986)39

Stukan et al 43 CVC 100% 100% 5(12%) 0 1 0 0 1 0

(2015)27

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Dovepress Drainage of malignant ascites

Complications, comments QOL

Renal im Electrolyte Obstruction Catheter Other QOL Results

pairment imbalance dislodgement assessment
tools
(PR/AC/ST)
0 0 2 2 1 One procedure-related NA
mortality – pulmonary edema

0 0 5 0 0 Two with fatal hypotension; NA NA

eight were lost to follow-up;
0 0 0 5 0 NA NA

0 0 1 1 1 NA NA

0 0 0 4 0 Catheter “not working” in 17 AC Symptoms rated by a

cases – not precisely explained, patient on a linear scale
including dislodgment. from 0 to 3.
0 0 2 0 2 Three hematoma at port ST/AC On a 10-point scale, 9.5
reservoir; four leakage to by patients and 9.0 by
subcutaneous tissue / port site; the nursing staff QOL
two port site metastasis improvement. Details in
text.
0 0 0 1 4 Other: three patients reported NA
pain, one sleep disturbances.

0 0 0 1 0 NA

0 0 0 0 0 Patients’ selection: e.g. those PR Subjectively patients

renal failure, heart failure were described a great
excluded. improvement to their
QOL.
0 0 0 2 0 Long-term patency 100%, but NA
each time flushed with heparine.
None of minor complications
affected drainage.
0 0 1 1 0 NA

0 0 0 0 1 ascites loculations : PC – 2, NA
0 0 0 0 2 TPC – 1.
0 0 0 0 0 Two fatal procedure-related NA
hypotension
0 0 0 0 0 One patient experiences leakage NA
and subsequently peritonitis;
22/28 had MA
0 0 4 0 3 PVS: one DIC; one fatal NA
5 0 0 0 0 pulmonary embolism, one
pulmonary edema; three
subcutaneous bleeding; PC:
all SAE were considered
procedure-related
0 0 7 2 6 One fatal pulmonary edema NA
related to the procedure; five
thromboembolisms
1 1 3 0 0 One patient with an occult NA
primary and PS4 experienced
hypotension, renal impairment
and electrolyte imbalance
(Continued)

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Table 2 (Continued)
Author No. of Type of Technical Symptoms Complications Complications rate (n), by type
patients catheter success control rate, all
(%) (%) AE, SAE, Infection Infection Leakage Hypotension Injury
n (%) n (%) G2 G3

Tapping et al 28 TPC 100% NA 11(39%) 0 2 0 3 0 0

(2012)25
Tomiyama 33 PVS 100% NA 18(55%) 11(33%) 0 0 0 0 1
et al
(2006)40

Notes: Technical success: successful catheter placement; injury: bowel, intra-abdominal, or abdominal wall vessels injury; G1–3: grading of AEs according to CTCAE
(catheter-related infection); G2: localized; local intervention, indicated; oral intervention, indicated; G3: IV antibiotic, antifungal, or antiviral intervention indicated; radiologic
or operative intervention indicated.
Abbreviations: AC, authors created questionnaire; AE, adverse event; CTCAE, Common Terminology Criteria for Adverse Events; CVC, central venous catheter (inserted
intra-abdominally for ascites drainage); DIC, disseminated intravascular coagulation; EORTC, European Organization for the Research and Treatment of Cancer; ESAS,
Edmonton Symptom Assessment Scale; ESAS:AM , ESAS – Ascites Modification; FP, French pigtail; IV, intravenous; MA, malignant ascites; MSAS, Memorial Symptom
Assessment Survey; NA, not assessed/not applicable; PC, paracentesis; PPP, permanent peritoneal port; PR, patient reported; PVS, peritoneovenous shunts; QOL, quality
of life; QLQ-C30, Quality of Life Questionnaire Core; QLQ-PAN26, Quality of Life Questionnaire Pancreatic cancer module; SAE, serious adverse event; SSQ, subjective
significance questionnaire; ST, standardized questionnaire; TPC, tunneled peritoneal catheters (PleurX, Tenckhoff, other peritoneal)

5%–33%). The most serious procedure-related c­ omplications Based on a 28-patient study, the factors significantly
were reported for PVS (mortality from pulmonary edema associated with complications of ascites drainage were as
and thromboembolism). follows: current chemotherapy, low albumin levels, high
When analyzed together, 19.7% (255/1297) of patients white blood cell count, and renal dysfunction.25 In contrast,
experienced any complication and 6.2% (81/1297) experi- in a study of 170 patients, the authors found none of these
enced an SAE during MA drainage. Generally, the percent- factors to be significantly associated with catheter complica-
age of complications was as follows: infection, G2 – 1%; tions.7 In a prospective clinical trial, no significant changes in
infection, G3 – 3.1%; leakage – 3.5%; hypotension – 0.6%; sodium, potassium, creatinine, albumin, or total protein were
injuries during device insertion – 0.6%; renal impairment – detected when compared to levels at baseline and 12 weeks of
0.5%; electrolyte imbalance – 0.2%; catheter obstruction – drainage.5 When Tenckhoff TPC were used for MA drainage
4.4%; catheter dislodgment – 2.3%; other – 3.6%. Detailed (n=94), an analysis suggested that patients with widespread
data for various drainage methods are presented in Table 3. gastrointestinal cancers and refractory MA had a higher risk
for early death, compared with the reference group of patients
TPC with widespread metastatic gynecologic cancers. Patients
In the study with the largest number of patients, 170 TPC with pancreatic cancer (n=11) were analyzed in a separate
were inserted for the treatment of MA, with a 100% technical hepatobiliary cancer group (n=22).8
success rate for catheter insertion and no procedure-related
deaths or major placement complications. Fourteen (8%) CVC
post-placement complications were identified. Five patients CVC was used to drain ascites. The technique was not
experienced catheter malfunction. Four patients suffered painful and was easily accepted by patients. Insertion was
leakage of ascites that occurred at an average of 11.25 days technically successful in all patients, but one who required
after catheter placement at the incisional site, which required a second attempt. A mean admission time of 5.5 days
suture placement around the tunnel. Three demonstrated (range 2–14 days) was reported, and the mean drained volume
cellulitis of the tunnel tract and two developed peritonitis. during admission was 8499 mL (range 800–20700 mL), of
The annual complication event rate was 0.43 events per year which the mean was 2850 mL (300–4200 mL) in the first 24
(i.e., 0.12 events per 100 catheter-days).7 Pancreatic cancer h.26 The CVC could also be inserted, with local anesthesia,
was associated with a statistically greater catheter complica- under ultrasound guidance, with 100% technical success,
tion rate (P=0.007; odds ratio, 4.7; 95% confidence interval, without procedure-related complications, in an outpatient
1.399–15.511). These included four catheter occlusions that department.27 In the case of CVC usage, no significant
were addressed by catheter replacement and one case of cel- infection or insertion-related AEs were reported. Mechani-
lulitis treated successfully using antibiotic therapy.7 cal problems were the main issue, and included leakage,

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Dovepress Drainage of malignant ascites

Complications, comments QOL

Renal im Electrolyte Obstruction Catheter Other QOL Results

pairment imbalance dislodgement assessment
tools
(PR/AC/ST)
0 0 0 4 2 One incisional site hernia NA

0 0 4 2 11 Eight developed DIC - one died PR 60% of patients reported

from DIC; three pulmonary QOL improvement
edema - one died; one wound
hematoma

catheter dislodgment, or “not working”. These were man- MA drainage using PPP can improve the QOL for
aged using local procedures such as additional sutures, use patients with end-stage disease. On a ten-point scale, QOL
of a bag to collect the fluid if leakage occurred, and catheter improvement, compared with that prior to port placement,
replacement.26–28 CVCs are rather ineffective in patients with was rated a mean of 9.5 by the patients and 9.0 by the
mucinous ascites.27 Patients reported a­ lleviation of all the nursing staff. The 1-week QOL was lowest, with a mean
ascites-related symptoms after drainage by CVC compared of 8.7, compared with the 1- and 3-month intervals, which
with baseline, with abdominal swelling, anorexia, and con- were similar. Both patients and nurses reported a high
stipation being the most significantly changed (the severity degree of convenience (rated at 9.7 and 9.6, respectively)
of the symptoms was assessed using a linear scale).28 In and improvement of symptoms and comfort (9.6 and 9.3,
another study, it was the impression of the health care team respectively). Patients commonly stated that they were
that patients were very comfortable following CVC place- significantly more mobile and better able to perform daily
ment and reported better symptom control and an increased activities, including more strenuous activities such as
intake of food and nutritional supplements.27 gardening. Seven patients (7/14) stated that they were able
to travel for important family obligations and vacations,
PPP with minor arrangements being made for port aspiration
PPP offers a convenient and relatively safe alternative to at local hospitals by nursing staff or family.29 Thirty-nine
frequent PC in the management of refractory ascites, and (97.5%) patients were treated successfully without catheter
results in symptomatic improvement for most patients. manipulation, or antibiotic therapy, and showed complete
Ports were inserted late in the disease trajectory in patients relief of symptoms and good compliance until death.
who were heavily pretreated using chemotherapy. Infection Avoidance of repeated PC was satisfactory to patients and
occurred in 0%–4% of patients and was easily treated. Most clinicians.30 Subcutaneous tumor growth was observed
catheter-related morbidity occurred early after placement, along the tunneled catheter in two patients, 4 and 6 months
was self-limited, and did not affect ascites drainage.4,29–31 In a after placement. These patients reported associated mild
study testing PPP usage for ascites drainage, 1 of 24 patients discomfort and palpable masses. External beam irradiation
suffered from grade 3 hypotension. That patient had 9.3 L of was considered for palliation.29
ascites drained on that occasion, and therefore, the complica-
tions were likely secondary to excessive ascitic fluid removal PVS
and not directly because of the peritoneal port.4 Leakage to PVS transfer fluid from the peritoneal cavity to the systemic
subcutaneous tissue was reported in 4%–29% of patients after circulation through a one-way compressible valve system.
PPP insertion for ascites drainage.29,31,32 Hypoalbuminemia Fluid is maintained within the body, minimizing protein
was a common adverse effect, but it was assumed that it and electrolyte loss, and reducing patient discomfort asso-
was most likely influenced by disease progression, and was ciated with repeated PC.35 This technique permits home
therefore not entirely attributable to ascitic drainage.4 No management, but requires careful patient selection and
significant protein loss was observed in patients when a post-­procedure management to avoid serious complications
high-protein diet was combined with frequent, small volume from fluid overload.6,36 The most common cause of catheter
removal of ascites.9,33,34 dysfunction was fibrin sheath formation at the venous limb

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Abbreviations: AE, adverse event; CTCAE, Common Terminology Criteria for Adverse Events; CVC, central venous catheter (inserted intra-abdominally for ascites drainage); IV, intravenous; PC, paracentesis; PPP, permanent peritoneal
in a significant number of patients. Successful revision of the

Notes: Injury: bowel, intra-abdominal, or abdominal wall vessels injury; G1–3: grading of AEs according to CTCAE (catheter-related infection); G2: localized; local intervention, indicated; oral intervention, indicated; G3: IV antibiotic,
26 (15.9%)
47 (3.6%)
17 (3.0%)
2 (0.7%)

2 (1.7%)
Other
shunt could be achieved in the majority.6,37 Another reported

n (%)
complication after PVS insertion was pneumothorax, which

0
occurred more commonly with subclavian puncture com-
dislodgement
pared with other sites of venous access.37,38
Catheter

30 (2.3%)
18 (3.2%)

6 (3.7%)
4 (2.5%)
2 (1.7%)
Twenty patients underwent PVS placement and 49
n (%)

patients were subjected to PC. After PVS, abdominal girth

0 decreased significantly. The median number of procedures
Obstruction

34 (20.7%)
was less in the PVS group than in the PC group (one vs two,
57 (4.4%)
12 (2.1%)

3 (1.9%)
3 (2.6%) respectively; P<0.0001). The postoperative performance
n (%)

score (PS) was significantly improved following PVS

0

­placement (P=0.0026). Severe complications were observed

Electrolyte
imbalance

in one patient in the PVS group and in seven patients in the

3 (0.2%)

1 (0.6%)
2 (1.7%)

PC group.11
n (%)

The authors of a prospective study reported considerable

0
0
0

morbidity (41%) and mortality (6% – procedure-related

impairment

pulmonary edema and sepsis) after PVS insertion, but also

7 (0.5%)

5 (1.8%)

1 (0.6%)
1 (0.9%)
Renal

n (%)

reported its efficiency in certain cases.39 In a consecutive

0

cohort of patients who underwent PVS insertion, as many

8 (0.6%)
1 (0.2%)

4 (2.4%)

3 (2.6%)

as 55% experienced complications, 33% were serious, and

Injury
n (%)

port; PVS, peritoneovenous shunts; SAE, serious adverse event; TPC, tunneled peritoneal catheters (PleurX, Tenckhoff, other peritoneal)

two patients died (from disseminated intravascular coagu-

0

lation and pulmonary edema). No distant metastasis was

Hypotension

found.40 In another study, a 21% risk of thromboembolism

events was reported.39 However, with the use of low-dose
8 (0.6%)
2 (0.4%)
4 (1.5%)

1 (0.6%)
1 (0.9%)
n (%)

warfarin, disseminated intravascular coagulation was not

Table 3 Complications presented together and separately for different drainage methods.

seen after PVS insertion.37 Interestingly, in a series of 24

Leakage

45 (3.5%)
22 (3.9%)

13 (8.1%)
8 (7.0%)

patients with MA and 30 with ascites secondary to liver cir-

n (%)

rhosis, managed using PVS insertion, septic complications

0
0

were observed in the cirrhotic patient group only.39 Patients

Infection, G3
Complications rate, by type

with PS of 40–50 (Karnofsky score) before PVS inser-

antifungal, or antiviral intervention indicated; radiologic or operative intervention indicated.
40 (3.1%)
32 (5.7%)

tion experienced significantly less improvement after the

4 (1.5%)

3 (2.6%)
n (%)

procedure, compared with those with PS of 60 or higher.11

0
0

The importance of careful patient selection for the PVS

Infection, G2

procedure was emphasized.

13 (1.0%)
11 (1.9%)

1 (0.6%)
1 (0.6%)

PRO and QOL issues

n (%)

PRO and QOL endpoints were available in 12 of 32 evaluated

26 (15.9%)

studies. They were reported as general patient impressions,

81 (6.2%)
37 (6.5%)
12 (4.4%)

5 (4.3%)
Complications rate,

n (%)

simple linear scales for evaluation of symptoms, or standard-

SAE

ized questionnaires, sometimes modified for specific clinical

255 (19.7%)
115 (20.3%)

situations.
72 (43.9%)
22 (13.7%)
23 (20.0%)
15 (5.5%)
overall

Based on studies that provided data, symptom control was

n (%)
AE

achieved in a median of 97% of patients after MA drainage:

78%–100% for PC, 83%–100% for TPC, 75%–100% for
patients
No. of

CVC, and 96%–100% for PPP.

1297
566
275
164
161
115

When PRO were measured using an interview or a health

care impression, a significant improvement in symptom control
Total

CVC
TPC

PVS

PPP
PC

and QOL was reported in almost all patients, with the exception

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Dovepress Drainage of malignant ascites

of one study (using PVS), where only 60% of patients claimed underwent insertion of a peritoneal drain (published in 1990),
an improvement. However, once standardized questionnaires all reported satisfaction with the drain and felt that their life-
were used, before and after MA drainage, improvements in style was significantly improved by the device.34 Patients with
symptomatic scores associated with ascites (abdominal dis- permanently inserted catheters can control ascites drainage
tension, shortness of breath, anorexia, insomnia, fatigue, and by themselves, and therefore are not confined to the area of
mobility) and role functioning were observed, whereas deterio- their hospital for repeated PC.27,43
ration was seen in the emotional and cognitive subscales;5,10,41
general QOL improved10 or did not change.41 Moreover, the Discussion
symptom clusters found in patients with MA suggest that This systematic review of the literature about various
they have patterns of symptoms characteristic of patients with drainage methods for the management of individuals with
advanced disease, not just symptoms commonly associated with MA showed almost 100% feasibility of all available meth-
ascites.41 In 25% of patients admitted to a palliative care unit, ods, including PC, TPC, CVC, PPP, and PVS. There were
no relevant changes in symptom burden were observed, despite ­differences in safety issues, with the lowest rate of 5.5% of
effective removal of a large amount of abdominal fluids.26 The AE for PC and 0% of SAE for CVC. The latest had a 13.7%
patient-reported change in symptoms did neither correlate with rate of minor complications. Comparable safety profile
the amount of fluid drained nor with any baseline symptom was found for TPC and PPP with the AE rate of 20.3% and
scores. If pain scores were high at baseline, patients were not 20.0% and SAE of 6.5% and 4.3%, respectively. Special
greatly relieved after MA drainage. A worse baseline PS (50% attention and experience are crucial for selecting patients
of patients had PS 3–4 Eastern Cooperative Oncology Group for PVS because AE and SAE rates were 43.9% and 15.9%,
[ECOG] score) was predictive of a better patient-reported respectively. Efficacy defined with symptom control was
change in symptoms.10 After single PC, the duration of symp- achieved in 64%–100%, generally for all methods. Patients
tomatic relief ranged from 4 to 45 days (mean 10.4 days).42 with MA who benefit from drainage the most are those who
Two clusters of symptoms common at both pre- and post- present with symptoms associated with ascites (abdominal
PC time points were found: depression–anxiety and fatigue– distension, dyspnea, anorexia, insomnia, fatigue, and mobil-
mobility–well-being–appetite.41 When considering testing ity difficulties). Other QOL issues such as role, emotional,
the QOL of patients using questionnaires, it was noted that, and cognitive functioning should also be considered. The
clinically, those in whom “well-being” clusters with “fatigue” underlying malignancy, its symptoms, and prognosis are
and “mobility” may be more likely to benefit from PC and, important to direct clinical decision making in MA drainage.
therefore, more likely to be able to complete and return the The life expectancy of patients with refractory MA is very
post-PC questionnaires. While those in whom “well-being” poor, with an overall survival ranging from 1 to 6 months in
migrates to the anxiety–depression cluster, symptoms which nonovarian cancer and 10–24 months in ovarian cancer.8,12,44
do not improve significantly with PC, might be less likely Patients with refractory MA with a longer life expectancy,
to complete and return the post-PC questionnaires. PC does such as patients with gynecologic tumors, may also benefit
not seem to target the symptoms found to cluster but rather from the use of a tunneled catheter for a longer period,
single symptoms, without significant gains in many of the compared with patients with more aggressive tumors such
well-being and QOL domains.41 According to Husain et al, as gastrointestinal malignancies.8
symptom cluster methodology can contribute to the evidence According to survey studies, the most commonly used
for PC and other procedures in MA by identifying patients, procedure for MA management was PC. Up to 48% of phy-
grouped by their cluster profiles, who may respond differ- sicians prescribed diuretics.19,20 In Germany and Austria,
ently to a procedure. However, they acknowledged that a one-third of responders who specialized in gynecology and
study with larger sample size would be required to test the gastroenterology preferred catheter drainage over PC; very
concept. Using symptom cluster methods also allows to few medical oncologists chose the application of a catheter.20
consider alternate interventions that target the constellation In the UK, about half of responders had never used permanent
of symptoms that cluster in these patients to realize gains in indwelling catheters.19
well-being and QOL.41 Findings from multiple studies indicate that integrating
Avoidance of repeated PC and repeated admission to palliative care early in the disease trajectory can result in
hospital was satisfactory to patients and clinicians after improvements in QOL, symptom control, patient and care-
placement of PPP30 or PVS.6 In a series of 17 patients who giver satisfaction, illness understanding, quality of end-of‑life

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care, survival, and costs of care.45,46 When a patient with infusion of chemotherapy (cisplatin) or active targeted thera-
MA presents for PC, this should be a flag to signal the need peutic agents (catumaxomab) is possible.8,31
to initiate a comprehensive management plan that includes Recent studies report that free drainage of MA in a group
appropriate referral to supportive and psychosocial care.41 of patients with EOC was safe and did not cause significant
Assessment of patients with MA should include measure- hypotension.18,48,49 There is no evidence to support the use
ment of the more global symptoms of fatigue, well-being, of concomitant plasma expanders for hypotension prophy-
depression, and anxiety, in addition to shortness of breath, laxis.2,18 According to survey studies, intravenous fluids were
abdominal distension, and mobility. It has been suggested that always prescribed by 2% of physicians, and sometimes by
examining the benefits and potential side effects of PC should 38%–42%. When used, they were crystalloids (38%–61%),
be performed using a thorough assessment of symptoms and colloids (11%), or albumin (17%–40%).19,20
QOL.41 The European Organization for the Research and Intraperitoneal pressure (IAP) decreased significantly
Treatment of Cancer Quality of Life Questionnaire (EORTC after drainage of 1000–1500 mL from ascites. With all the
QLQ-C30) and the Edmonton Symptom Assessment Scale – ascites drained, IAP was maintained at 11–12 cm H2O and
Ascites Modification together, or the EORTC QLQ-C30 with at 6–8 cm H2O after 24 h. Blood pressure was stable without
the addition of the Quality of Life Questionnaire, pancreatic significant changes before and after IAP reduction (P>0.05).
cancer module (QLQ-PAN26) ascites and abdominal pain The breath rate and heart rate were improved, and 24 h
subscales could be used.10 urinary volume increased significantly after IAP reduction
Altogether, the successful management of MA using (P<0.01).50
intraperitoneal catheters is most likely multifactorial and Historically, repeated PC has been associated with signifi-
dependent on underlying malignancy, catheter type, pro- cant reduction in serum protein levels. However, the results
cedure, operator experience and setting, and the PS of the of the cited studies do not support this statement. Moreover,
patient, comorbidities, nutritional status, and the ability to there is a balance between albumin intake, metabolism, syn-
care for the device. Insertion of TPC, PPP, or PVS involves thesis, and loss, which is multifactorial.51 The concentration
many medical resources.5–7,25,30,37 For patients with EOC, a PC of visceral proteins such as serum albumin is a good indicator
to dryness can be safely performed as an outpatient, but takes of disease severity and outcome. It should not be used for
6–8 h.18 In contrast, insertion of a CVC into the abdominal either screening or diagnosis of malnutrition.52 Based on a
cavity for ascites drainage is easy, and can be performed in meta-analysis of six randomized controlled trials comparing
an outpatient department, under local anesthesia, using a the administration of albumin with that of no albumin in
short ultrasound assessment to determine the safest place to cohorts of patients with ascites and liver cirrhosis, Vincent
position the catheter.27 Moreover, the CVC provides all the et al found a 0.72 risk ratio for morbidity in patients receiving
advantages of a permanent drain. albumin vs no albumin.53 However, there was not a single
There are many benefits to permanently inserted catheters patient with MA in the evaluated trials.
(TPC, CVC, PPP) for MA management. Patients can drain
their ascites independently of health care staff or facilities, Conclusion
at home, at times that they need to control symptoms, and Selection of the most appropriate MA drainage method for
to a reasonable degree (not to dryness, as often performed at individual patients is crucial for successful management.
hospitals), so that many complications can be prevented (eg, However, this task is difficult. First, a careful interview with
hypotension, injury, leakage, rapid protein loss, or electrolyte the patient, best with the usage of QOL questionnaires, should
imbalance). All these factors contribute to better symptom provide a list and type of symptoms and QOL issues that
control and QOL. Family caregivers benefit as well. There could be targeted by ascites drainage. Second, the underly-
are some risks associated with permanent catheter usage that ing malignancy and treatment plans are important in terms
should be addressed. The most important is infection, and of expected survival and perceived benefits or harms of MA
others are fluid leakage, drain obstruction, or dislodgment. drainage (eg, EOC vs others). Some patients will benefit
Systemic chemotherapy did not increase the risk of from single PC, while others will be good candidates for
­catheter-related infection after TPC or CVC placement for TPC or PPP insertion and ascites drainage followed by
MA. Therefore, chemotherapy should not be a contraindi- chemotherapy. Drainage by CVC is an interesting method
cation to catheter placement.27,47 An additional advantage because the insertion is simple and does not involve many
of TPC or PPP for ascites drainage is that intraperitoneal health care resources, while the patient can benefit from all

128 submit your manuscript | www.dovepress.com Cancer Management and Research 2017:9
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Dovepress Drainage of malignant ascites

the advantages of TPC. Special attention and experience 12. Parsons SL, Lang MW, Steele RJ. Malignant ascites: a 2-year review
from a teaching hospital. Eur J Surg Oncol. 1996;22(3):237–239.
are crucial for selecting patients for PVS because serious 13. Kipps E, Tan DS, Kaye SB. Meeting the challenge of ascites in ovar-
complications are to be expected. The PS of patients is an ian cancer: new avenues for therapy and research. Nat Rev Cancer.
important factor. However, there are conflicting data as to 2013;13(4):273–282.
14. Fleming ND, Alvarez-Secord A, Von Gruenigen V, Miller MJ, Abernethy
whether those with poor PS will benefit from ascites drain- AP. Indwelling catheters for the management of refractory malignant
age at all. The amount of ascitic fluid should not guide the ascites: a systematic literature overview and retrospective chart review.
J Pain Symptom Manage. 2009;38(3):341–349.
decision and the goal of MA drainage is not drainage to dry- 15. Pockros PJ, Esrason KT, Nguyen C, Duque J, Woods S. Mobilization
ness, but a symptom control and QOL improvement. Ascites of malignant ascites with diuretics is dependent on ascitic fluid char-
drainage should be perceived as a supportive care that can acteristics. Gastroenterology. 1992;103(4):1302–1306.
16. Keen A, Fitzgerald D, Bryant A, Dickinson HO. Management of drain-
be applied for those who need it at any time of their cancer age for malignant ascites in gynaecological cancer. Cochrane Database
trajectory, in order to better control symptoms, QOL, and Syst Rev. 2010(1):CD007794.
17. Gamblin V, Da Silva A, Villet S, El Hajbi F. [Supportive care for malig-
treatment outcomes. nant ascites in palliative phase: place of paracentesis and diuretics]. Bull
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Author contributions 18. Harding V, Fenu E, Medani H, et al. Safety, cost-effectiveness and fea-
sibility of daycase paracentesis in the management of malignant ascites
The author conceived and designed the study, performed the with a focus on ovarian cancer. Br J Cancer. 2012;107(6):925–930.
literature search, data selection, and interpretation, drafted 19. Newman G, Pudney D. A survey of current practice in the management
of recurrent malignant ascites among oncologists and palliative-care
the manuscript, provided final approval of the version to be physicians in the UK. Clin Oncol (R Coll Radiol). 2006;18(2):154.
published and agreed to be accountable for all aspects of 20. Jehn CF, Kupferling S, Oskay-Ozcelik G, Luftner D. A survey of treat-
ment approaches of malignant ascites in Germany and Austria. Support
the work. Care Cancer. 2015;23(7):2073–2078.
21. Lee CW, Bociek G, Faught W. A survey of practice in management of
Disclosure malignant ascites. J Pain Symptom Manage. 1998;16(2):96–101.
22. Shamseer L, Moher D, Clarke M, et al. Preferred reporting items for
The author reports no conflicts of interest in this work. systematic review and meta-analysis protocols (PRISMA-P) 2015:
elaboration and explanation. BMJ. 2015;349:g7647.
23. White J, Carolan-Rees G. PleurX peritoneal catheter drainage system
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