Abstract
Dear Editor:
We are writing in response to the article published in the Journal of Palliative Medicine titled “Therapeutic Procedures for Malignant Ascites in a Palliative Care Outpatient Clinic” (Korpi et al., 2018). 1 A total of 118 paracenteses and 48 tunneled drainage catheter insertions were performed in 104 patients in an outpatient palliative care clinic. The volume of fluid removed had a median of 3700 mL, with observed complications of post-procedural hypotension, leakage at the puncture site, and pain. Ultimately, the study concluded that outpatient drainage of malignant ascites in a palliative care setting is feasible. However, despite these findings, there has been a lack of further research into palliative care providers performing outpatient paracenteses for those with malignant ascites.
As the global population ages, the incidence of malignancies continues to rise. With this increase, malignancy-associated complications, such as malignant ascites, will become more prevalent. Following a diagnosis of malignant ascites, the average survival is only three to six months, during which patients experience debilitating symptoms, including pain, bloating, nausea, vomiting, and constipation. While palliative care providers manage these symptoms with medications, such treatments do not address the underlying cause—fluid accumulation due to malignant ascites.
The current standard of care for malignant ascites includes repeated large-volume paracenteses or the placement of an indwelling abdominal catheter. Large-volume paracentesis is a bedside procedure that provides temporary symptom relief and can be performed in both inpatient and outpatient settings. However, symptom relief typically lasts only seven days on average, with a range of 4 to 45 days 2 . Though no formal guidelines exist, standard practice suggests placing an indwelling catheter in patients requiring two or more paracenteses. However, the optimal timing and frequency of these procedures remain unclear. In cases where an indwelling catheter is contraindicated—such as in patients with loculated ascites, peritonitis, or non-correctable coagulopathy—repeated paracenteses are often the only option for symptom relief.
Given that symptom relief is a primary goal of palliative care, outpatient bedside paracenteses should fall within the scope of palliative care providers. To evaluate current practices, we conducted a PubMed search for “outpatient paracentesis,” yielding 231 articles dating back to 1971. Narrowing the search to include “malignant ascites” produced 18 articles, of which we focused on five—three specifically addressing paracenteses in malignant ascites. Results are shown in Table 1. We analyzed each study based on patient population, diagnoses, volume of ascitic fluid removed, complications, and cost-effectiveness. These studies, with a total of 160 patients with malignant ascites, reported complications in 7 patients (4.3%).
Our analysis suggests that outpatient paracenteses offer significant benefits for patients with malignant ascites, including symptom relief, low complication rates, and reduced hospitalizations. Furthermore, these findings raise broader questions about the role of palliative care providers in performing other bedside procedures, such as thoracenteses and joint injections, to enhance symptom management. Moving forward, further research and quality improvement initiatives are essential to better define the risks, benefits, and long-term impact of outpatient paracenteses in palliative care settings.