Comment on: Clinical implications of prompt ascitic drain removal in cirrhosis with refractory ascites

Dear Sir,

We read Wong et al’s article with great enthusiasm.(1) It highlighted the high risk of peritonitis in patients with ‘non-tunnelled’ ascitic drains for more than 24 hours to manage refractory ascites.

Patients who undergo intermittent large-volume paracentesis (LVP) experience significant deterioration in quality of life owing to frequent procedures and hospitalisations.(2) These patients experience multiple symptoms, including shortness of breath, bloating, fatigue and poor health-related quality of life.(2) There is an unmet palliative need in patients with limited life expectancy who are not candidates for liver transplant and transjugular intrahepatic portosystemic shunt. The goals of treatment often need to focus on symptom management and comfort. Long-term abdominal drains (LTADs) are tunnelled drains inserted with radiological guidance that can serve as an alternative management option for these patients. Patients can manage the continuous drainage catheter at home, draining small amounts of ascitic fluid multiple times a week, thereby avoiding frequent hospital visits.(3)

Recent studies in malignant ascites have shown that LTADs have a low complication rate and incur lower costs compared with inpatient LVP.(4) A systemic review of LTADs in non-malignant ascites showed a 100% technical insertion success rate and a 12% rate of bacterial peritonitis.(5) The REDUCe study, a feasibility randomised controlled trial, compared LVP and LTADs in refractory ascites due to cirrhosis.(6) The study demonstrated feasibility, with preliminary evidence of LTAD acceptability, safety and reduction of health resource utilisation.

Hence, tunnelled LTADs seem to be a practical palliative approach for the management of refractory ascites but warrant further prospective research.