Ascites may be a complication of both hepatic and non-hepatic diseases (Wolf,
2008) and is formed in above of 75% in cirrhotic patients. The splanchnic
and systemic haemodynamics in cirrhotic patients have been markedly altered,
causing central hypovolaemia in addition to arterial hypotension with consequent
activation of the vasoconstrictor systems. Also, activation of sympathetic systems,
rennin-angiotensin and increased sodium re-absorption were much more evident.
Refractory ascites is the inability to be resolved by standard medical treatment
with low sodium diet and diuretics and this is the most serious complication
in cirrhotic patients with ascites; (Salerno et al.,
Other causes of ascites such as portal vein thrombosis, malignancy or infection
and non-compliance with medications and low sodium diet have been excluded the
diagnosis of refractory ascites can be made based on strict criteria (Senousy
and Draganov, 2009). The diagnosis of refractory ascites can be done based
on strict criteria by excluding other causes of ascites including portal vein
thrombosis, malignancy, infection and non-compliance with medications and low
sodium diet (Senousy and Draganov, 2009). Dietary sodium
restriction and improving sodium excretion with suitable diuretics are the corner
stone in management of ascites caused by cirrhosis (Sandhu
and Sanyal, 2005). Borie et al. (1999) stated
that the treatment of ascites itself induce complications such as water and
electrolyte disturbances, functional renal failure, encephalopathy and also
development of refractory ascites.
Also about 10% of patients with ascites do not respond to such medical treatment
and require something more invasive (Itami et al.,
2003). Other procedures can be used in treatment of these patients such
as periodic paracentesis or transjugular intra-hepatic porto-systemic shunt
(Salerno et al., 2010). The most widely accepted
therapy for patients with refractory ascites is outpatient setting of repeated
large-volume paracentesis with albumin administration every two to four weeks
intervals (Elmaadawy et al., 2010).
Many different definitions were stated for refractory ascites such as it is
ascites that cannot be clinically corrected by diuretics or ascites that recurs
rapidly with using appropriate diuretic doses or lastly when diuretics complications
overcome their continuation. In about 10% of patients with ascites refractoriness
develops with type 2 hepato-renal failure association (Zetterman,
2011). Deen et al. (2001) stated that complications
were usually associated with all peritoneal-venous shunts employed in patients
with refractory ascites. These complications included early recurrence of ascites
as frequent paracentesis does not affect the mechanisms involving in ascetic
fluid accumulation, the result reported also by Gines et
al. (2004). A simple and cheap operative method has been found in the
surgical treatment of refractory ascites to overcome the significant expenses
and high complication rates in using traditional shunt pumps like LeVeen, Denver
or Agishi shunts.
The first sapheno-peritoneal shunt was reported by Pang
et al. (1992) from Singapore, Utikal et al.
(2004) but saphenoperitoneal shunt, as performed now is a pure biological
shunt and has many potential advantages. Fishman (1982)
and Winn and Harlan (2005) were reported the significant
reduction in the risk of thrombotic occlusion caused by the intrinsic antithrombotic
activity of endothelium. Nagy et al. (2001) in
their valuable series, had performed 267 peritoneo-venous shunt operations,
by introducing a new method using an autolog-venous graft with a peritoneo-venous
anastomosis that drains the ascetic fluid into the saphenous vein, then into
the femoral vein. Their short term results proves successful use of sapheno-peritoneal
shunt in management of refractory ascetic with significant improvement in quality
of lifestyle with minimal postoperative complications, in addition to avoidance
of insertion of foreign materials in these risky patients; the results supported
by Vizsy et al. (2005).
Elmaadawy et al. (2010), in their series of
19 patients; although they used natural saphenous vein graft, reported that
synthetic shunts are devices that permit the return of ascites fluid and proteins
to the intravascular space and also, these devices are successful at relieving
ascites and reversing protein loss in some patients. Patients with refractory
ascites have very poor prognosis and therefore referral for consideration for
liver transplantation should be initiated (Senousy and Draganov,
2009) as only liver transplantation may improve the survival of such patients
(Salerno et al., 2010). Zervos
and Rosemurgy (2001) in their series proved the major role of peritoneo-venous
shunt in treatment of refractory ascites in cirrhotic patients. Positive pressure
gradient between peritoneal cavity with ascetic and the central venous pressure
is the principle factor to achieve permanent peritoneal cavity drainage with
return of accumulated ascetic fluid into the circulation. A number of drainage
systems have been developed over the course of time. Currently, the systems,
which permit active flow management (Denvers shunt) enabling us to retain long-term
cumulative function, are optimal (Utikal et al.,
The introduction of natural peritoneo-venous shunt with avoidance of insertion such foreign material has been proved to be very effective and successful in treatment of refractory ascites with minimal postoperative draw-backs and significant improve in the quality of lifestyle of these patients.
MATERIALS AND METHODS
This study was conducted in New Damietta Faculty of Medicine Al Azhar University in the period between September 2007 and December 2010 on 13 patients; 8 males and 5 females complaining of tense ascites not responding to medical treatment. Their ages ranged from 32 to 61 years with mean 36±2 years, as seen in Table 1. All patients were cirrhotic with hypoproteinaemia hypoalbuminaemia. They received frequent albumin administrations. Paracentesis had been done 2 to five times in some patients.
A full clinical history was taken and complete physical examination was performed. Laboratory investigation including complete hematologic examination, coagulation profile and an assessment of renal and liver functions tests were obtained. Serum sodium and potassium were estimated and corrected in some patients before operation.
Pelvi-abdominal ultrasonography to exclude the presence of hepatocellular carcinoma or portal vein thrombosis and bilateral great saphenous veins duplex Doppler U/S to verify the vein valves competence.
Upper gastrointestinal endoscopy was done for all patients to evaluate the esophageal and gastric varices condition. Ascetic fluid was examined physically, bacteriologically and chemically. Patients who have signs of spontaneous bacterial peritonitis (infection, abdominal pain), encephalopathy or gastrointestinal bleeding were excluded.
All patients had liver cirrhosis with hepatic cell failure and portal hypertension with Child-Pugh classification grade C, as seen in Table 1.
|| Demographic data for the patient's group
|*All patients had liver cirrhosis and portal hypertension
(Child-Pugh grade C). s: Significant
Local anaesthesia (lidocaine 5% solution) has used in all patients in this study because of the bad general health condition of this group of patients.
Through the classical incision the saphenous vein is dissected downwards from the saphenofemoral junction and the proximal 2 cm cut end is anastomosed to one end of the synthetic PTFE graft. Another incision is made above the inguinal crease through which the peritoneum is reached. A tunnel from the upper thigh to the lower abdomen is made deep to the inguinal ligament through which the synthetic graft is passed. An opening is made in the peritoneum through which the tube is entered as a nipple about 2 cm inside it. Stitches are taken between peritoneum edges which are invaginated into a tunnel and around the tube to be water tight. Non-absorbable suture materials are used. Wounds are closed drains.
Postoperatively during the follow-up period, weekly Duplex ultra-sound examination for the shunt patency, measurement of the abdominal circumference and body weight and daily urine output was done.
Statistical analysis: We used in our study two system of statistical analysis:
||Standard deviation is a widely used measurement of variability
or diversity used in statistics and probability theory. It shows how much
variation or "dispersion" there is from the average (mean, or expected value).
A low standard deviation indicates that the data points tend to be very
close to the mean, whereas high standard deviation indicates that the data
are spread out over a large range of values
||p-value in statistical significance testing, the p-value is the probability
of obtaining a test statistic at least as extreme as the one that was actually
observed, assuming that the null hypothesis is true. One often "rejects
the null hypothesis" when the p-value is less than the significance level
a (Greek alpha), which is often 0.05 or 0.01. When the null hypothesis is
rejected, the result is said to be statistically significant
Postoperatively, clinical follow up revealed, gradual decrease in body weight and abdominal girth. Also, an increase in diuresis with the unchanged diuretics doses in 12 patients representing (92.3%). There was reduction of dyspnea, an increased appetite and improved ambulation due to gradual decrease in ascites. These were evaluated weekly, as seen in Table 2.
Successful shunt formations were been found in 11 patients representing (84.6%) and were been evaluated every week by duplex ultra-sound examination.
There was a need for paracentesis in 3 patients representing (23%) and the dose of diuretic was significantly reduced in all patients and totally stopped in 4 cases representing (30.8%) after 3 months. It was noticed that frequency of patients admission to the medical department was lowered postoperatively from once/month to once/three months.
Median hospital stay was of 7 days (range 4 to 14) all these results in comparison to our previous series with autologus SP shunts are seen in Table 3.
Complications: All were minor complications that were resolved in one
week except a failure in 2 cases due to massive ascetic leakage.
|| Postoperative data
|(~: up to)
||Comparison between the synthetic SP shunt series results with
autologus SP shunt series results of the same group of researchers
|| Different presentations of preoperative tense ascites with
different types of its complications
Shunt occlusions occurred in 2 cases and occurred at the middle of the 5th
month and 8th month due to blocking with intestinal loops or omentum, as seen
in Table 4. Different presentations of preoperative tense
ascites with different types of its complications are shown in Fig.
Mortality: Two patients (15.4%) died; one at the 3rd and the other at the 6th month due to causes unrelated to the procedure. They died from hepatic failure which is considered as the etiological cause for ascites. Operative technique in details are shown in Fig. 2.
|| Operative technique in details
Ascites is a common complication in patients with chronic liver disease. Some
patients are resistant to diuretics and need therapeutic paracentesis on a regular
basis. This is inconvenient in the long term and also has resource implications
(Elmaadawy et al., 2010). Alternatively, these
patients may be treated by peritoneovenous shunts, which require insertion of
a foreign body into a central vein and are prone to occlusion (Vadeyar
et al., 1999) as they reported a success rate of (87.5%); the remaining
patient had to have the shunt removed because of ascitic leakage. In those who
underwent successful shunt formation, the need for paracentesis and the dose
of diuretic was significantly reduced over a median follow-up of 8 months. Hospital
stay in the month after discharge was significantly less than that in the month
Also, Elmaadawy et al. (2010) were reported
successful shunt formations (64.7%). The median follow-up was 11 months.
While in our study successful shunt formations were found in 84.6% nearly as
reported by Vadeyar et al. (1999) and better
than that of Elmaadawy et al. (2010). There was
in this study a failure in 2 cases due to massive ascetic leakage over a median
follow-up of 6 months.
Vizsy et al. (2005) mentioned that the traditional
pumps (LeVeen, Denver, Agishi) used in the surgical treatment of refractory
ascites have significant expenses and complication rates and in saphenoperitoneal
shunts the one-way flow is maintained by biologically given double saphenous
In this study, the used synthetic graft is not considered expensive as it is short segment of the PTFE that maintain patency and did not require much dissection, so with less complications. Also it seems that one way direction may be maintained by the increased ascitic pressure over the venous pressure.
Regarding the etiology, Vizsy et al. (2005)
ascites in their patients group have been associated with cirrhosis of
the liver (secondary to aethylism in 8, to HBV infection in 1). This correlate
to this study where all patients had hepatic cirrhosis while in study of Elmaadawy
et al. (2010), hepatic cell failure and Portal Hypertension in 14
patients (82.4%), chylous ascites in 2 patients (11.8%) and cardiac cause (Heart
failure) in one patients (5.9%)
Regarding the results, Chen et al. (2005), autologous
procedure study, the urinary output, nutritional status and Child-Pugh scores
and their quality of life had improved, but total bilirubin output had not changed
significantly. The body weight and abdominal girth tended to decrease, but not
significantly. No groin infections were noted following this procedure.
In study of Elmaadawy et al. (2010), after operation
significant reduction in abdominal girth, body weight and increase in diuresis
with diuretics in unchanged doses were observed in 76.5% of patients decreasing
their discomfort (relief of ascites symptoms, with reduction of dyspnea, an
increased appetite and improved ambulation). There was no need for paracentesis
in 52.9%, need for paracentesis in 11.8% and the dose of diuretic was significantly
reduced in all patients and totally stopped in 29.4%. Hospital stay (median)
was 11 days (range 7 to 21). Hospital re-admission after discharge was significantly
less than that in before operation.
Vizsy et al. (2004, 2005)
reported in their studies, 66.6% improvement in quality of life and reduction
in body weight and abdominal girth and increase in diuresis with standard diuretics
caused by Autologous Sapheno Peritoneal Shunts (ASPS) with minimal negative
operative effects in successful cases.
In the present study, the postoperative weekly clinical follow up revealed:
gradual decrease in ascites with increase in diuresis with even the reduced
diuretic doses and decrease in body weight and abdominal girth, in 92.3%, with
reduction of dyspnea, an increased appetite and improved ambulation. There was
a need for paracentesis in 23% and the dose of diuretic was totally stopped
in 30.8% after 3 months (Table 3). It was noticed that frequency
of patients admission to the medical department was lowered postoperatively
from once/month to once/three months. Median hospital stay was 7 days (range
4 to 14). These results agree with Elmaadawy et al.
(2010), Vizsy et al. (2004,2005)
and also with Chen et al. (2005).
Regarding the complications; in study of Vizsy et al.
(2005), there were the minor complications (33.3% for either seromas or
hematomas) and 22.2% for cellulitis] that have been self-limiting in general.
In the presence of major complications as: 11% for either peritoneal reflux
or severe hypoproteinaemia and 33.3% for shunt occlusion interventions were
needed several times. In one of the occlusions contralateral fistula was created
with PTFE prosthesis implantation, in another case desobliteration happened
with a silicone drain left in the shunt.
In the study of Elmaadawy et al. (2010), the
minor complications reported 23.5%, seromas in 11.7%, cellulitis in 5.9% and
hematoma in 5.9%; all have been self-limiting in general with the aid of antibiotics
and mild anti-inflammatory drugs. Also the major complications reported 23.5%,
shunt occlusions in 11.7%, peritoneal reflux in 5.9% needed shunt ligation and
severe hypoproteinaemia in 5.9% interventions were needed in the cases of the
occlusion and peritoneal reflux where contra-lateral shunts have been created.
The peritoneovenous shunts which require insertion of a foreign body into a
central vein are prone to occlusion (Vadeyar et al.,
1999). We encountered with major complications occurred in only 2 shunts
15.4% that were occluded at the middle of the 5th month and 8th month respectively
due to blocking with intestinal loops or omentum. The minor complications reported
(23%): One seromas, one cellulitis and a hematoma representing 7.7% for each.
This result is near to that in Elmaadawy et al. (2010)
but less than half that occurred in Vizsy et al.
(2005) study. This can be explained where less dissection was needed compared
with the autologous procedure.
Although, Gines et al. (1991), Suzuki
and Stanley (2001) and Wolf (2008) mentioned that
however, serious complications are observed in 10% of the recipients of these
synthetic devices; it is noted that similar or even higher percentage of complications
are observed in the autologous procedure.
Concerning the mortality, in the study of Elmaadawy et
al. (2010), 17.7% of patients died during follow-up from causes unrelated
to the operation; one patient (5.9%) died from hepatic failure 11 days after
the operation, two patients (11.8%) died during follow-up, one at 7 months (5.9%)
from liver failure and the other at 11 months (5.9%) from un-controllable variceal
In research of Vadeyar et al. (1999), three
patients (37.5%) died during follow-up from causes unrelated to the operation.
We have had two mortality cases (15.4%) one at the 3rd and the other at the 6th month also from causes unrelated to the procedure. They died from hepatic failure which is considered as the etiological cause for ascites. These can be considered as high percent in short periods of follow up but reflects the bad prognosis in these patients.
As regard the post-procedure Liver transplant, in the study of Vadeyar
et al. (1999) one patient underwent successful liver transplantation.
We have successful liver transplants for 2 patients (15.4%). Long-term follow
up is required to verify weather this procedure can be considered as a pre request
for liver transplant in patients with refractory ascites.
Regarding its longer duration of patency and hemodynamic effects the synthetic saphenous-peritoneal anastomosis appears a simple, safe and can be considered as cost-effective method of achieving control of refractory ascites. They improve quality of life to some extent in successful instances.
Wound complications and obstructions decreased in the short term. But, long-term follow up is required to determine if improved patients could be candidates for liver transplant.