LAUSR

Introduction In those patients who are not a candidate for liver transplantation or TIPSS, managing refractory ascites is challenging. Repeated large volume paracentesis (LVP) is effective but requires hospitalization. Long term abdominal drains (LTAD) have been considered as an alternative to minimize the need for admission and improve quality of life. Methods A retrospective review of all patients treated with LTAD(Rocket ®) between 2009 and 2019 in Royal Derby Hospital was undertaken and included the indication, frequency of hospital admission for LVP prior to and after LTAD insertion, MELD score, SBP prior to insertion, complications encountered following insertion, the need for re-insertion and duration of the drain. Results 24(7 female) patients had LTAD inserted under ultrasound guidance by experienced interventional radiologists. Ascites was secondary to liver cirrhosis in 22 patients (NASH 10; ALD 7; HCV 3; HFE 1; PBC 1) and heart failure/cardiac cirrhosis in 2 patients. The median MELD score was 14(6–32). Median number of LVP in 6 months prior to LTAD insertion was 5 (0–15), with median interval of 2 weeks. Following LTAD insertion, median LVP in 6 months fell to 0(0–5). SBP was diagnosed and treated in 7 patients before LTAD,6 of whom remained on prophylaxis. No immediate complications were reported. Following LTAD, 15 patients (5/15 had pre-LTAD diagnosis) developed SBP at median 60(20–425) days. Post-LTAD SBP was treated with antibiotics but 5 died. In 10 patients LTAD was removed after median 10 days of antibiotics and only 4 were replaced. For those who had replacement, 2 of 3 patients given prophylaxis suffered recurrent SBP. Other indications for removal were (leak 2; blockage 2). Patients needed hospitalization for median 19 (2–40) days in the 6 months prior to LTAD, and 12(0–34) days in the following 6 months. In 11 of 20 patients with MELD score less than 21 (figure 1), the drain remained for 90 or more days while the median lifespan of LTAD in the whole cohort was 67(6–465). Conclusions In some patients, LTAD achieved long term palliation without hospital admission but many developed SBP post-insertion. Nevertheless, there was still a reduction in hospital stay. It was not possible to identify factors which might predict a successful outcome from this small cohort. Further research should focus on the impact of LTAD on quality of life measures, the role of antibiotic prophylaxis and better defining when LTAD is best employed in the natural history of patient’s with ascites.