The prevalence of decompensated liver cirrhosis (DC) is increasing worldwide [1]. Ascites-related readmissions are the predominant cause of hospitalizations in DC [1, 2]. Refractory ascites (RA), characterized by diuretic non-responsiveness or intolerance, is encountered in 10% of patients with cirrhosis and is associated with reduced survival without liver transplantation (LT) or trans-jugular intrahepatic portosystemic shunts (TIPSS) [3]. Large volume paracentesis (LVP) and albumin infusions are the only therapeutic options in those with RA who cannot undergo LT or TIPSS. LVPs are often required weekly or fortnightly, placing significant burden on hospital systems and often leading to unplanned hospitalizations. These recurrent admissions, with adverse impacts on patients' quality of life (QoL) and health expenditure, are potentially avoidable if ascites drainage can be regularly performed in patients' homes. Since ascites drainage in patients unsuitable for LT is a palliative procedure, it is best approached along principles of palliative care. Drainage using indwelling catheters is a well-accepted model of care in patients with malignant ascites and hydrothorax [4]. There is limited evidence supporting this procedure in cirrhotic patients with RA [5]. The aim of this study was therefore to explore the feasibility, effectiveness, safety, and acceptability of home drainage of ascites with long-term abdominal drains (LTAD) in an Australian health care setting as a management pathway for RA. The complete study protocol is included as Supporting Information, Section 1.
After obtaining informed consent, Rocket LTAD catheters (Rocket Medical, Watford, UK) were inserted by interventional radiologists. Participants underwent complete drainage with albumin replacement. They were discharged the next day with sufficient drainage kits for 4 weeks of drainage. The local community nurses' pathway was utilized for ongoing LTAD drains. Nurses were provided with instructions and a referral form regarding the frequency and amount of drainage to be done for each participant. Participants underwent drainage two to three times per week at home as guided by their abdominal discomfort. During each visit, one to two liters of ascites was drained, as per the previously published experience [5]. Antibiotic prophylaxis with norfloxacin or equivalent was given throughout the duration of LTAD being in situ. No albumin replacement was given. Whenever bacterial peritonitis (BP) was suspected, ascitic fluid was sampled via LTAD and from the abdominal wall. Emergency contact numbers for reporting any adverse events were provided.
Management of RA in DC patients without definitive options should be in line with the principles of palliative care by prioritizing symptomatic management and preserving QoL. This pilot study explored the option of LTAD in an Australian health care setting an
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