Long-Term Abdominal Drains as a Therapeutic Option in Refractory Ascites - A Systematic Review

Refractory ascites (RA) is the most common complication of end-stage liver disease (ESLD) with a significant burden in terms of symptoms and overall quality of life (QoL). There are limited therapeutic options available for this population and most ultimately undergo serial large-volume paracentesis (LVP). Long-term abdominal drains (LTAD) are commonly used for malignant ascites drainage but not for ascites related to ESLD, due to concerns about kidney injury and infection.

This review aims to describe the safety, effectiveness, and impact on the QoL of LTAD in ESLD-related ascites.

Using systematic review methodology, PubMed-MEDLINE, Embase, and Google Scholar databases were searched for studies published between January 1, 2001, to June 1, 2024, combining medical subject headings (MeSH) ([cirrhosis OR chronic liver disease] AND refractory ascites AND [permanent-tunneled peritoneal catheter OR tunneled catheter OR indwelling catheter OR long-term abdominal drains]). Inclusion and exclusion criteria were applied to the results.

One hundred thirty-nine studies were identified, with 16 deemed eligible for final analysis, including three randomized clinical trials. The studies varied in design, included different types of LTAD, and were generally of low quality, with many lacking statistical power due to small sample sizes. In terms of effectiveness, technical success was 100%, and as long as LTAD remains in situ, no need for additional LVP is required. Overall, the catheters remained in situ for periods ranging from 3 to 436 days. In terms of safety, kidney injury occurred in 17-50% of patients, but only if >1.5 L/day were drained. Infections, including cellulitis and peritonitis, occurred in 7-58% of patients and were generally resolved with antibiotic therapy and/or device removal. LTAD do not appear to have a negative impact on mortality. Regarding QoL, the data are contradictory with most studies reporting an overall neutral effect.

LTAD should be considered as an option in RA from ESLD in the future but more quality studies are needed to confirm their safety and benefits in controlling symptoms. This could be an important step in terms of improving the palliative needs of this population.