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A 71-year-old woman, who was diagnosed with carcinoma endometrium with peritoneal metastasis, who had completed several cycles of chemo-radiotherapy was referred to the pain and palliative department for best supportive care due to disease progression and poor performance status [ECOG -3] . On evaluation, the patient was drowsy and had c/o abdominal distention and discomfort with pain and generalized weakness. On evaluation patient had ascites. The patient was managed with weak opioids (Tapentadol), diuretics, and other supportive medications followed by therapeutic paracentesis in which about two liters of straw-colored ascitic fluid was drained. Following this patient had symptomatic improvement, was discharged on regular medications, and was kept under follow-up. Ten days after the discharge, the patient presented with high-grade fever (temp 101*F), and abdominal distention with discomfort with symptoms suggestive of secondary bacterial peritonitis . Blood investigations performed showed elevated total and neutrophil counts with hypoalbuminemia and dyselectrolyaemia. The patient was started on IV antibiotics (inj Meropenum) and other supportive medications. Therapeutic paracentesis was attempted but was unable to drain the fluid and fever was persisting. An ultrasound abdomen was carried out which showed a moderately defined hypoechoic collection measuring 13 mm in thickness noted along the anterior abdominal wall extending into the pelvis with multiple edematous bowel loops.
A surgical opinion was sought and suggested the possibility of incision and drainage but was deferred due to the high-risk strategy, but the patient was in severe distress due to pain (VAS7-8) and fever with a WHO Performance status of - Four. So, we decided to insert a palliative pigtail catheter to drain the collection.
After taking the consent patient was placed in the supine position, the collection was localized using ultrasound. The skin was sterilized and draped, and local anesthesia was given using 10 per cent lignocaine. A needle with an 18-gauge trocar was inserted into the peritoneal cavity collection, needle was removed leaving the trocar behind, passed a guide wire [0.035 inches] just enough to clear the trocar, removed the trocar leaving the guide wire in place, made a small incision in the skin adjacent to the guide wire and passed the dilator (7 F) over the wire and into the peritoneal space, verified whether the guide wire is moving freely in and out of the dilator throughout this process to avoid kinking of the wire. Passed the pigtail catheter (7 FR) and its trocar over the wire, and made sure that the last side hole is within the peritoneal space. Removed the trocar and guide wire leaving the pigtail catheter in place and sutured the pigtail to the abdominal wall. Placed a 3-way valve on the end of the pigtail catheter and connected it to the urobag. Obtained a confirmatory x-ray after the procedure. The entire procedure took about 10 -15 min . The patient was pain-free throughout the procedure and there were no major complications, about 1.5 lt of thick pus was collected in the bag within 24 hours of the procedure, after the procedure patient showed symptomatic improvement, pain and discomfort reduced considerably and fever subsided with an improvement in WHO performance score of two. The patient was able to sleep and appetite improved. A repeat ultrasound was performed which showed minimal fluid. The patient was discharged 3 days after the procedure and was kept on follow-up.
Peritoneal involvement is common in end-stage cancer in which ascites is a common symptom, sometimes it can lead to secondary bacterial peritonitis in which ascitic fluid gets infected changing to pus which makes it difficult to drain via normal paracentesis, and surgical options are limited greatly compromising the quality of life of the patient. Here we performed Pig-Tail catheter insertion, a palliative care procedure that is easy to perform and, in this patient helped to enhance the quality of life in the last days of her life.
DECLARATION OF PATIENT CONSENT
We have obtained all appropriate patient consent forms and Ethical clearance.
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- Miyashita H, Okamoto K, Kobayashi T, Wakabayashi Y, Kitaura S, et al. (2009) Bacterial peritonitis in a patient with malignant ascites caused by pancreatic carcinoma: Case report and review of literature. J Infect Chemother 25(6): 473-476.
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