Palliative long-term abdominal drains in refractory ascites due to end-stage liver disease: a case series

Background: Ascites, the commonest complication of cirrhosis, leads to frequent hospitalisations. Refractory ascites (RA) confers a median survival of 6 months without liver transplantation (LT). In many the management remains palliative (large volume paracentesis, LVP). Despite calls for improvement, Palliative and End of Life (EoLC) is not yet integrated into end stage liver disease (ESLD). Long-term abdominal drains (LTAD) are a palliative strategy in malignant ascites, but not ESLD. Case presentation: A retrospective, single centre, case series review was performed of patients undergoing LTAD placement for RA secondary to ESLD at a large teaching hospital between August 2011 and March 2013. Case management: Patients with ESLD and RA, where LT was not an option, were considered for LTAD. Seven patients underwent successful LTAD insertion after multi-professional assessment. Case outcome: Following LTAD, mean hospital attendances reduced to 1 (0-4) from 9 (4-21); with none for ascites management. Median survival after LTAD insertion was 29 days (8-219). The complication rate was low and none life-threatening. Conclusions: Palliative and EoLC needs in ESLD remain under-addressed. Our data suggests LTAD may be a safe and effective palliative intervention in ESLD. Prospective randomised controlled trials comparing LVP versus LTAD in RA in ESLD are warranted.