title: Palliative long-term abdominal drains in refractory ascites due to end-stage liver disease: A case series.
abstract: BACKGROUND
  Ascites, the commonest complication of cirrhosis, leads to frequent hospitalisations. Refractory ascites confers a median survival of 6 months without liver transplantation. In many, the management remains palliative (large-volume paracentesis). Despite calls for improvement, palliative and end-of-life care is not yet integrated into end-stage liver disease. Long-term abdominal drains are a palliative strategy in malignant ascites, but not end-stage liver disease.
  
  
  METHODS
  A retrospective, single centre, case series review was performed of patients undergoing long-term abdominal drain placement for refractory ascites secondary to end-stage liver disease at a large teaching hospital between August 2011 and March 2013. Case management: Patients with end-stage liver disease and refractory ascites, where liver transplantation was not an option, were considered for long-term abdominal drains. Seven patients underwent successful long-term abdominal drain insertion after multi-professional assessment. Case outcome: Following long-term abdominal drain insertion, mean hospital attendances reduced to 1 (0-4) from 9 (4-21), with none for ascites management. Median survival after long-term abdominal drain insertion was 29 days (8-219). The complication rate was low and none life threatening.
  
  
  CONCLUSIONS
  Palliative and end-of-life care needs in end-stage liver disease remain under-addressed. Our data suggest that long-term abdominal drains may be a safe and effective palliative intervention in end-stage liver disease. Prospective randomised controlled trials comparing large-volume paracentesis versus long-term abdominal drains in refractory ascites secondary to end-stage liver disease are warranted.
authors.affiliation: 1 Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.|2 Department of Medicine, Brighton and Sussex Medical School, Brighton, UK.
authors.forename: Lucia
authors.initials: L
authors.lastname: Macken
authors.affiliation: 3 Institute of Hepatology, King's College Hospital NHS Foundation Trust, London, UK.
authors.forename: Deepak
authors.initials: D
authors.lastname: Joshi
authors.affiliation: 4 Department of Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.
authors.forename: Jenny
authors.initials: J
authors.lastname: Messenger
authors.affiliation: 1 Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.
authors.forename: Mark
authors.initials: M
authors.lastname: Austin
authors.affiliation: 1 Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.
authors.forename: Jeremy
authors.initials: J
authors.lastname: Tibble
authors.affiliation: 5 Department of Palliative Care, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.
authors.forename: Louise
authors.initials: L
authors.lastname: Mason
authors.affiliation: 1 Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.|2 Department of Medicine, Brighton and Sussex Medical School, Brighton, UK.
authors.forename: Sumita
authors.initials: S
authors.lastname: Verma
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001201:Ascites / Q000209:etiology* / Q000628:therapy*; D005260:Female; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D010166:Palliative Care / Q000379:methods*; D019152:Paracentesis / Q000379:methods*; D011446:Prospective Studies; D012189:Retrospective Studies; D013727:Terminal Care / Q000379:methods*
keywords: End-stage liver disease; ascites; cirrhosis; end-of-life care; palliative care; paracentesis