Annals of the Royal College of Surgeons of England (1984) vol. 66

Palliation of malignant ascites by the Denver

peritoneovenous shunt

RICHARD DOWNING BSc FRCS*Surgical Registrar

JOHN BLACK MD FRCSConsultant SurgeonCOLIN W 0 WINDSOR ChM FRCSConsultant SurgeonWorcester Royal Infirmary

Key words: CANCER, ASCITES, PERITONEOVENOUS SHUNT

SummaryFive out of 8 Denver peritoneovenous shunts placed in 7 patientsprovided excellent palliation of malignant ascites. Subclinical con-sumptive coagulopathy was detected after placement of6 shunts, but nopatient developed overt bleeding.

IntroductionThe management of malignant ascites is unsatisfactory.Traditional medical treatments comprising sodium and fluidrestriction, diuretics and intraperitoneal instillation ofcytotoxic agents are rarely effective when used alone andthese demoralised patients must usually undergo repeatedparacentesis with resultant protein and electrolyte depletion.Continuous shunting of ascitic fluid into the circulationprovides a more physiological approach by reducing asciticvolume while maintaining intravascular volume and proteinreserves. Whereas the LeVeen peritoneovenous (PV) shuntintroduced in 1974 (1) now has an established role in thetreatment of resistant cirrhotic ascites (2), the use of PVshunts in the management of malignant ascites remainscontroversial despite the recent publication of some en-couraging results (3,4). Another device the Denvershunt-is now available and we report our experience withits use in the management of 7 patients with malignantascites.

Patients and methodsEight shunts were inserted into 3 male and 4 female patients(age range 50-80 years) with ascites secondary to advancedintra-abdominal malignancy (Table I). All patients hadrequired paracentesis at frequent intervals.

DENVER SHUNT (Fig. 1)The shunt is constructed of medical grade silicone rubber.The perforated catheter (ID 2.6mm) ends in an asymmet-rical 'duck-bill' valve contained within a compressible cham-ber (6 x 1.3 cm) which is placed subcutaneously. The valve isdesigned to open at a positive pressure ofabout 1 cm ofwaterand prevents retrograde flow. Manual compression of thechamber causes the opposing flaps of the valve to rubtogether and so dislodge any contaminating material. Thedistal catheter conducts ascitic fluid into a central vein at amaximum flow rate of 30-39 ml/min at 10 cm head of water.

* Present appointment: Lecturer, Department of Surgery, QueenElizabeth Hospital, Birmingham B15 2TH.The Editor would welcome any comments on this paper by readersFellows and Members interested in submitting papers for considerationshould first write to the Editor

FIG. 1 Chamber of the Denver peritoneovenous shunt showing the'duck-bill' valve.

METHOD OF INSERTION

General anaesthesia was employed in all patients. A sub-costal incision was made and the muscle layers separated toexpose peritoneum. The shunt was primed with normalsaline, air bubbles were removed and the catheter intro-duced obliquely through the muscle layers into the peri-toneal cavity. Oblique insertion was used to prevent leakageof ascitic fluid around the catheter. The distal catheter wastunnelled subcutaneously over the anterior chest wall andinserted into the ipsilateral internal jugular vein exposed bya supraclavicular incision. The pump chamber was suturedover the eleventh and twelfth ribs.

PRE AND POSTOPERATIVE MANAGEMENT

A single dose of frusemide (40mmIV) and prophylacticantibiotics (flucloxacillin 500 mg; ampicillin 500mg IV)were givend at induction of anaesthesia. Postoperatively,patients were instructed to pump the chamber 2 or 3 timesdaily, or more frequently if spontaneous flow through thesystem was insufficient to control ascites. Haemoglobin,platelet count, haematocrit, prothrombin time (PT), partialthromboplastin time (PTT) and fibrin degradation products(FDP) were measured preoperatively and daily for 7 dayspostoperatively. Shunt patency was confirmed by placing aDoppler ultrasound probe over the distal catheter as it

ifor publication

Palliation of malignant ascites by the Denver peritoneovenous shunt

crossed the clavicle. If compression of the shunt chamberfailed to produce an audible signal, the chamber was filledwith X-ray contrast medium and X-rays taken before andafter chamber compression ('shuntogram'). The shunt wasconsidered to have failed when re-accumulation of ascitesrequired paracentesis.

ResultsSHUNT FUNCTION (Table I)Shunt failures were recorded at 1 week and 17 weeks (nos 4and 1); the patients survived a further one week and 25weeks respectively. A third shunt (No. 7) failed at 7 weeksand was replaced by a second shunt which functioned untilthe patient died 6 weeks later. A shuntogram was performedin only one patient with a negative Doppler test and thisconfirmed that the system was patent since contrast mediawas cleared from the system by pumping of the chamber(Fig. 2).

TABLE 1 Shunt function and patient survival

Patient Sex Age Primary Shunt Function- Patient Survivaltumour

1 M 68 bronchus

M 74 Pancreas

F 73 Breast

M 67 Colon

F 80 Colon

F 50 Unknown

F 61 Breast

F 61 Breast

JI

FIG. 2 Shuntogram. (A) Radiograph showing the shunt chamberand proximal catheter filled with contrast media. (B) Contrast hasbeen completely cleared from the shunt by pumping the chamber.

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The median duration of shunt function and medianpatient survival after shunt insertion were 10.8 and 12.6weeks respectively. Functioning shunts produced dramaticreductions in ascitic fluid volume with excellent palliation ofthe effects of ascites.

HAEMOTOLOGICAL CHANGES (Figs. 3 and 4)The small number of patients did not permit statisticalevaluation of results. Mean+ SD haemoglobin and haema-tocrit fell from preoperative values of 12.2 + 1.6 g/l and0.37+0.04 to minimum values of 11.1+1.0g/l and0.30 + 0.08 respectively after 24 hours. Although both indicesrose thereafter they did not return to preoperative values.Insignificant changes were recorded in PT and PTT ratios,but the mean platelet count fell from 302 + 145 x 109/1 to175 +66 x 109/1 after 3 days. Six of the 8 shunts producedrises in FDPs which were maximal within the first three days.No patient developed clinical signs of disseminated intra-vascular coagulation.

DiscussionAlthough we have only a limited experience in the use of PVshunts we believe that their use is justified in patients withmalignant ascites requiring frequent paracentesis. Shuntinsertion is a minor operative procedure and while ourpatients remained in hospital for 7 days for the purpose ofthis study, most patients would be able to return home after 2

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survival of pPV shunts, qlikely to outHowever, thmencementargued that

should be offered this form of treatment instead of paracen-tesis when ascites is first diagnosed. Unfortunately, noprospective trial has yet compared conventional manage-ment of malignant ascites with PV shunting, but this has

~t- --------------- __ _ _ __been conducted in patients with cirrhotic ascites. Shuntpatients outlived medically treated patients, experienced

--------}-tC------ ft greater weight loss and diuresis, and spent less time in

hospital (13).The Denver shunt differs from the LeVeen shunt by

having a compressible chamber which, in theory at least,may help to ensure patency of the system by clearing cellular

debris. Only three previous resports on the use of the Denvershunt in malignant ascites were found (4,11,12) and these

-- yf----g/-X -- ---t----- - -X&- provided no conclusive evidence ofits superiority over the Le-Veen shunt. The patency of both shunts can be ascertained

--/,!\ by Doppler ultrasound (14) supplemented by X-ray studiesfollowing direct injection of radio-opaque contrast media.

/////--\\Although the latter technique was used to advantage in thepresent study, puncture of the silastic tubing may introduceinfection necessitating its removal. The clearance of a radio-

-<t-------------/- nuclide (99mTc albumin) through the shunt after intraperi-toneal injection (15) is an attractive alternative.

---------------- Reluctance to insert PV shunts has arisen not only fromdoubts over long-term patency, but also concern over the

complications of the procedure. Three major complicationsmerit discussion; firstly, shunting of large volumes of asciticfluid into the circulation may produce fluid overload,

peripheral oedema and cardiac failure. The fall in haemo-globin and haematocrit in the present series was indicative of

Days post op. this fluid shift. Obviously patients with limited cardiac

es in fibrin degradation products (FDP's) during reserve must be excluded from PV shunting. Secondly,us shunting. Each line represents the values recorded disseminated intravascular coagulopathy may be heralded

by a fall in the platelet count with rising FDP's as recordedafter inserting 6 of our 8 shunts. These changes are frequentlyencountered within the first postoperative week (16,17), but

e agree with the results of previous studies which patients rarely develop a life-threatening coagulopathythat patients with functioning shunts derived (16, 19). The aetiology of DIC in these patients is unknown,enefit. Pollock (5) reported the first series of but ascitic fluid contains a number of procoagulant sub-malignant ascites treated by Holter PV shunts. stances which have been proposed as initiatives of a con-

6 patients that were assessed were relieved of sumptive coagulopathy (16). Therefore, coagulation factorstheir deaths. Ten subsequent reports have been must be monitored daily in the first week, and, if theyable II), and these show similar results to our become pregressively abnormal, removal of the shunt shouldiedian duration of shunt function approximates be considered.nedian patient survival. Indeed, the limited Finally, it may be argued that the shunting of tumour-atients with malignant ascites favours the use of containing ascitic fluid into the venous circulation willsince the patient with cirrhotic ascites is more establish pulmonary tumour metastases and speed thetlive the expected duration of shunt patency. patient's inevitable demise. However, although implants ofie average survival of patients after the com- tumour cells have been found on the intima of the superiorof PV shunting is very short and so it may be vena cava (18), and within pulmonary arterioles (19), it isin order to derive maximim benefit patients unlikely that such deposits would shorten the life span of

TABLE II Reported series of peritoneovenous shunts in malignant ascites

No.

Shunt patientsAuthor

Median shuntfunction(weeks)

Median patientsurvival(weeks)

Pollock (5)Straus et al. (3)Roaf and Stroehlein (6)Kudsk et al (7)Taylor et al. (8)Oosterlee (4)Gough (9)Qazi and Savlov (10)Lund and Newkirk (11)Oosterlee (4)Holman and Albo (12)

Holter

LeVeenLeVeenLeVeenLeVeenLeVeenLeVeenLeVeen

DenverDenverDenver

37*

113

6

t 4

10.6t (mean) 12 (mean)6 64 4

152 1523 4

12 13Effective palliation in 28 patients16 1610 125/6 shunts worked 3- 10 months

I Relates to 8 patients.* Thirty-five shunts inserted.t Relates to 31 patients only.

Palliation of malignant ascites by the Denver peritoneovenous shunt 343

patients with disseminated intra-abdominal tumour de-posits. Fatal pulmonary tumour embolisation has beenreported (20,21) but it is a rare event.

In conclusion, therefore, peritoneovenous shunting iseffective in malignant ascites. Careful postoperative monitor-ing is required to detect fluid overload and consumptivecoagulopathy but these potential complications should notdeter clinicians from advocating this useful form oftreatment.

The Denver shunt is marketed by Downs Surgical Ltd, Mitcham,Surrey.We wish to thank the Department of haematology for performingthe coagulation profiles, and Miss P Cole for typing the manuscript.

ReferencesI LeVeen HH, Christoudias G, Ip M. Peritoneo-venous shunting

for ascites. Ann Surg 1974;180:580-91.2 Greenlee HB, Stanley MM, Reinhardt GF. Intractable ascites

treated with peritoneovenous shunts (LeVeen). Arch Surg1981;1 16:518-24.

3 Straus AK, Roseman DL, Shapiro TM. Peritoneovenous shunt-ing in the management of malignant ascites. Arch Surg1979; 114:489-91.

4 Oosterlee J. Peritoneovenous shunting for ascites in cancerpatients. BrJ Surg 1980;67:663-6.

5 Pollock AV. The treatment of resistant malignant ascites byinsertion of a peritoneo-atrial Holter valve. Br J Surg 1975;62:104-7.

6 RoafJH, Stroehlein JR. Palliation of malignant ascites by theLeVeen peritoneo-venous shunt. Cancer 1980;45: 1019-24.

7 Kudsk K, Fabian TC, Minton JP. LeVeen shunts in patientswith intractable malignant ascites. J Surg Oncol 1980; 13:61-6.

8 Taylor MC, Kulatilake AE, Evans CM. Relief of malignantascites due to disseminated carcinoma of the kidney, using theLeVeen shunt. BrJ Urol 1980;52:324.

9 Gough IR. Peritoneo-venous shunts for malignant ascites. AustNZJ Surg 1982;52:47-9.

10 Qazi R, Savlov ED. Peritoneovenous shunt for palliation ofmalignant ascites. Cancer 1982, 49:600-2.

11 Lund RH, Newkirk JB. Peritoneo-venous shunting system forsurgical management of ascites. Contemp Surg 1979;14:31-45.

12 HolmanJM, Albo D. Peritoneovenous shunting in patients withmalignant ascites. Am J Surg 198 1; 142:7 74-6.

13 Wapnick S, Grosberg SJ, Evans MI. Randomised prospectivematched pair study comparing peritoneovenous shunt andconventional therapy in massive ascites. Br J Surg 1979;66:667-70.

14 Metzler M, Lichti E., Silver D. Non-invasive determination ofLeVeen shunt patency. Surgery 1980;87: 106-8.

15 Singh A, McAfeeJG, Thomas FD, Grossman ZD. Radionuclideassessment of peritoneovenous shunt patency. Clin Nucl Med1979;4:447-50.

16 Schwartz ML, Swain WR, Vogel SB. Coagulopathy followingperitoneovenous shunting. Surgery 1979;85:671-6.

17 Harmon DC, Demirzian Z, Ellman L, FischerJE. Disseminatedintravascular coagulation with the peritoneovenous shunt. AnnInt Med 1979;90:774-6.

18 LeVeen HH, Wapnick S, Grosberg S, Kinney MJ. Furtherexperience with peritoneo-venous shunt for ascites. Ann Surg1976; 184:574-81.

19 Lokich J, Reinhold R, Silverman M, Tullis J. Complications ofperitoneovenous shunt for malignant ascites. Cancer Treat Rep1980;64:305-9.

20 Smith RRL, Sternberg SS, Paglia MA, Golbey RB. Fatalpulmonary tumour embolisation following peritoneovenousshunting for malignant ascites. J Surg Oncol 1981; 16:27-35.

21 Maat B, Osterlee J, Spaas JAJ, White H, Lammes FB. Dis-semination of tumour cells via LeVeen shunt. Lancet1979; 1:988.

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