Peritoneovenous shunt





Definition

A peritoneovenous shunt refers to the surgical insertion of a shunting tube to achieve the continuous emptying of ascitic fluid into the venous system.


Purpose

Ascites is a serious medical disorder characterized by the pathological accumulation of fluid in the peritoneal cavity, the smooth membrane that lines the cavity of the abdomen and surrounds the organs. Ascites is usually related to acute and chronic liver disease (cirrhosis) and to a lesser degree, to malignant tumors arising in the ovary, colon, or breast. Ascites may also be associated with chronic kidney disease and congestive heart failure. The formation of ascitic fluid results from the interplay of three factors: abnormally high pressure within the liver or the veins draining into the liver (portal hypertension); abnormally low amounts of albumin in the blood (hypoalbuminemia); and changes in sodium and water excretion by the kidneys.

When medical therapy fails, peritoneovenous shunts help manage chronic ascites.


Demographics

Cirrhosis is the seventh leading cause of death by disease in the United States, killing over 25,000 people each year. Fifty percent of patients with cirrhosis will develop ascites over a period of 10 years. Cirrhosis—regardless of its cause—greatly increases the risk for liver cancer. Few studies have been conducted on the risk for liver cancer in patients with primary biliary cirrhosis; however, one study reported an incidence of 2.3%. Approximately 4% of patients with cirrhosis caused by hepatitis C develop liver cancer. In Asia, about 15% of people who have chronic hepatitis B develop liver cancer, but this high rate is not seen in other parts of the world. One Italian study that followed a group of hepatitis B patients for 11 years found no liver cancer over that period of time.


Description

A variety of shunts have been designed for peritoneovenous shunting, including the Hyde shunt (1966-1974), LaVeen shunt (1974-1980), and Denver shunt. The latter predates the LaVeen shunt, but is more popular as of 2003. All designs work about equally well.

For the peritoneovenous shunt insertion procedure, the patient only requires a local anesthetic and a sedative. A long needle is inserted into the jugular vein in the neck, and is passed down through the superior vena cava, the large vein that delivers blood from the head, neck, and upper limbs back to the heart. This serves to widen the vein. The surgeon makes an incision and inserts a tube traversing the subcutaneous tissue of the chest wall. The tube connects the peritoneal cavity to the neck, where it enters the widened jugular vein. There the surgeon attaches a pressure-sensitive one-way valve to prevent backflow.

Diagnosis/Preparation

Ascites may go unnoticed for quite some time until the patient notices a slight increase in waistline. Severe ascites with marked abdominal distension becomes very disabling, especially when associated with swelling of the legs, pleural effusions (fluid around the lungs), and shortness of breath.

Diagnosis can be established by examination of the ascitic fluid, which allows the physician to differentiate between cirrhosis and tumor-induced ascites. The fluid is taken from the peritoneal cavity in a procedure called a paracentesis . Ascitic fluid analysis includes a total polymorph count, protein and albumin concentrations, and placement of at least 10 ml of ascitic fluid each into blood culture bottles for processing. If a measurement called the serum-ascitic fluid albumin gradient is greater than 11 g/L, cirrhosis, not cancer, is suspected.


Aftercare

After surgery, the patient's vital signs are monitored in a recovery room . Pain medication and antibiotics are administered as needed. Once released from the hospital, the patient is expected to abstain from alcohol, and follow a low-salt diet and medication regime designed to control ascites.

Patients also require training in shunt maintenance. To keep the fluid moving out of the abdomen, the shunt has to be properly pumped on a daily basis. Twice a day—once at bedtime and again prior to rising in the morning—the shunt is pumped about 20 times. This is essential to limit the accumulation of fibrin and other debris within the shunt, and to avoid the formation of an occlusive fibrin sheath at the venous tip.


Risks

Complications following peritoneovenous shunt insertion are common and include infection, leakage of ascitic fluid, accumulation of abnormally large amounts of fluid in the intercellular tissue spaces of the body (edema), deregulation of the blood clotting mechanism (coagulopathy), and shunt blockage. Clogging of the shunt with debris is the most common complication. Some patients develop further complications from the ascitic fluid entering directly into their bloodstream. Often, scar tissue develops, making future liver transplants difficult.


Normal results

In spite of the complications associated with the procedure, many patients obtain useful relief from ascites following peritoneovenous shunt insertion.


Morbidity and mortality rates

The most recent guidelines from the American Association for the Study of Liver Diseases recommend peritoneovenous shunting only under these conditions:

  • Patient is diuretic-resistant, and is not a transplant candidate.
  • Patient is not a candidate for serial therapeutic paracentesis because of multiple abdominal surgical scars.
  • A physician is unavailable to perform serial paracentesis.

Cirrhosis is irreversible, but the rate of progression can be very slow depending on its cause and other factors. Five-year survival rates are about 85% in the Unites States and can be lower or higher depending on severity.


Alternatives

Alternative treatments for ascites include:

  • Diuretics . Diuretics are medications that promote the excretion of urine and help eliminate excess fluids. The treatment of ascites always involves restricting dietary salt and taking diuretic pills to increase the output of salt in the urine. This treatment is effective, at least in the short-term, in 90% of patients.
  • Repeated large-volume paracentesis. This approach, also called serial paracentesis, features repeated surgical puncture of the abdominal cavity and aspiration of the ascitic fluid.
  • Transjugular portosystemic shunt. A shunting procedure designed to relieve portal hypertension.
  • Portocaval shunt. Another shunting procedure designed to relieve portal hypertension.
  • Liver transplantation . Replacement of the patient's liver by one obtained from a donor. Liver transplantation is the only definitive treatment for ascites, and the only treatment that has been clearly shown to improve survival.

There is no satisfactory treatment for refractory ascites in patients with cirrhosis. Both peritoneovenous shunts and paracentesis have been used, but there is uncertainty about their relative merits.

See also Portal vein bypass .


Resources

BOOKS

Arroyo, V., P. Gines, J. Rodes. and R. W. Schrier, eds. Ascites and Renal Dysfunction in Liver Disease: Pathogenesis, Diagnosis, and Treatment. Oxford, UK: Blackwell Science Inc, 1999.

Moore, W. S. ed. Vascular Surgery: A Comprehensive Review. Philadelphia: W. B. Saunders Co., 2001.

PERIODICALS

Gines, P., and V. Arroyo. "Hepatorenal Syndrome." Journal of the American Society of Nephrology 10 (1999): 1833-9.

Hu, R. H. and P. H. Lee. "Salvaging Procedures for Dysfunctional Peritoneovenous Shunt." Hepatogastroenterology 48 (May-June 2001): 794-7.

Koike, T., S. Araki, H. Minakami, S. Ogawa, M. Sayama, H. Shibahara, and I. Sato. "Clinical Efficacy of Peritoneovenous Shunting for the Treatment of Severe Ovarian Hyperstimulation Syndrome." Human Reproduction 15 (2000): 113-17.

Orsi, F., R.F. Grasso, G. Bonomo, C. Monti, I. Marinucci and M. Bellomi. "Percutaneous Peritoneovenous Shunt Positioning: Technique and Preliminary Results." European Radiology 12 (May 2002): 1188-92.

Wagayama, H., T. Tanaka, M. Shimomura, K. Ogura, and K. Shiraki. "Pancreatic Cancer with Chylous Ascites Demonstrated by Lymphoscintigraphy: Successful Treatment with Peritoneovenous Shunting." Digestive Disturbance Science 10 (August 2002): 1836-8.

ORGANIZATIONS

American Gastroenterological Association. 4930 Del Ray Avenue, Bethesda, MD 20814. (301) 654-2055. http://www.gastro.org .

Society for Vascular Surgery. 900 Cummings Center, Beverly, MA 01915-1314. (978) 927-8330. http://svs.vasculaweb.org .

OTHER

"Ascites." Family Practice Notebook. http://www.fpnotebook.com/GI35.htm .


Monique Laberge, Ph.D.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?



Peritoneovenous shunt insertion is performed in a hospital by a surgeon specialized in gastroenterology or hepatology.

QUESTIONS TO ASK THE DOCTOR



  • Is there any other treatment available for ascites?
  • What are the risks associated with peritoneovenous shunting?
  • How long will it take to recover from the surgery?
  • How does the shunting mechanism work?
  • How many peritoneovenous shunt procedures does the surgeon perform each year?
  • Will further surgery be required?
  • What happens if the shunt becomes blocked?

User Contributions:

lai see
Report this comment as inappropriate
Mar 5, 2006 @ 5:05 am
hi, i am a nurse and come from malaysia. last two days, i had a patient with this denver shunt. my surgeon ask me do 2 hourly CVP monitoring and give IV lasix if urine output low. and also do pumping on the shunt for 1 time hourly. because i just read the infomation here. mention that just perform the pumping twice per day and each tome abt 20min. i just wonder is it the treatment that i mention the above only for post procedure only. thank you for ur help.
elizabeth stanziale
Report this comment as inappropriate
Apr 6, 2006 @ 7:19 pm
My mother has a Dever Shunt which has become clogged due to a fibrin clot. SHe would like to have it fixed or a new one replaced since it initially gave her great results. SHe has a chemo port on the other side. What are her options and are there any surgeons in the country that due this surgery on a frequent basis>
Gora
Report this comment as inappropriate
Jul 17, 2007 @ 11:11 am
what is difference between Laveen peritoneo-Venous shunt and ocean water seal chest drain? what is the main important options? My sister05/27/83 has sirrhosis of the liver since she was 19, it.s been 4 years!
Eddie
Report this comment as inappropriate
Oct 16, 2009 @ 2:02 am
My self I have had a shunt proceedure on my liver. After nearly 2 years of needing paracentesis taking any where from 7 to 9 liters of fluid weekly. Until my kidneys went into renal failure. Actually that was the easy part for myself. The demention and physical limitations are the worst. I have actually have Dr.s tell me while in the hospital to seek hospice. I recovered enough to go home and be simi normal. Then I went in to be tapped.I was told my kidneys are 3.0. The Dr. told me to go to another hospital (Loma Linda) in Ca. There I had the proceedure done . I was told I would be moniterd for a week after the proceedure.I was out in two days. I am still weak in my legs my stomache is gone...Its been 1 year and a half. Taking all the meds eveyrday. No booze of any kind. Even certain hand lotions have some alchol and will absorb into your skin. It takes a while to get back into shape. Hope this helps ease someones mind.
Report this comment as inappropriate
Oct 2, 2010 @ 10:22 pm
they want to put a denver shunt in my husband without it they say he only has 1 to 2 months how safe is the operation
Report this comment as inappropriate
Mar 17, 2011 @ 10:22 pm
My mother is having procedure next month and she is not asking questions .I feel she is not informed .a
Report this comment as inappropriate
Mar 19, 2011 @ 12:00 am
my mom was having the procedure today to have a shunt put in her liver, but they couldn't get the tubing that had the dye down far enough. so after two and a half hours they stopped and said they will try again on sunday. my mom has chf, diabetes, ascites, edema, cirrosis of the liver, hep c, she has had her left breast removed due to cancer, quaduple bypass surgery, and her gull bladder removed. is this still considered a safe procedure?
maninder
Report this comment as inappropriate
Jul 1, 2011 @ 7:07 am
my faher has recently diagonosed and came to know that he is suffering from cancer which has also spread in his liver also.Doctors are asking to do shunt treatment so that it may not spread in other portions also. We are worried that if his health detoroit after doing this, because now his normal life is okay. so please should we go for it or not?
Report this comment as inappropriate
Jul 23, 2011 @ 11:23 pm
My mother has cirossis too just diagnosed 5 months ago. She is also a diabetic. Has had abdomen parascentesis done 5 times-- about once a month and getting closer together. last time, they extracted 11 liter. She is just drained. none of the diuretics have worked at all- except they have drained her body of fluid and she has lost SO much weight in past 5 months.
I need to know if the Denver shunt is worth it. She has taken meds for 10 yrs for heart issues too. and has 3 metal stints in her heart. Most she has gone off of most heart meds 5 months ago and no longer takes because they are not good for the liver either.
She's also lost so much weigh. Her
Is Denver shunt worth it? Does the good outweigh the bad ?(infections, clogging risk, etc) Being a diabetic she does heal rather slowly. so Im concerned about heart he also has
Report this comment as inappropriate
Aug 6, 2011 @ 1:01 am
mom has cirrhosis of liver and pretty severe ascites (abdomen only) and once per month it is drained.(anywhere from 6-11 liter each time for past 5 months. We could continue once a month paracentesis, but surgeon says it could cause scaring and potential puncture of intestines or other problems. I am very hesitant to go with the Denver shunt and other shunts that have to be pumped daily because I'm not sure she will do it properly-- and then infection or worse problems could occur. Please give me your advice. I am her health care advocate... and need to hear from those who have experienced (for 6 months to a year minimum) and let me know what has worked best for you. Please. Mom is 75.
Rosie
Report this comment as inappropriate
Aug 23, 2014 @ 12:00 am
My husband was diagnosed with Hep C in 1993 at the age of 45. We figured that he had probably contracted the disease 20-25 years prior. He did not get any symptoms until 2002 when he got severe ascites. They put him on diuretics but they stopped working after a couple of months. He got his first Denver shunt in June 2002 and it was a life saver. That first shunt lasted until December 2006 when it permanently clogged up. In January of 2007 they put a new one in. Again a life saver. This one lasted until December 2013 and got infected this time. They decided not to replace it and tried the diuretics again. They kind of worked until about a month and a half ago (July 2014). During that time he also found out that he has liver cancer and has been put on the transplant list. They somehow don't want to replace the Denver shunt at this time. So he is getting paracentesis once a week (6 liters each time) but the ascites comes back in less than 2 days. I truly believe that those 2 shunts extended his life beyond anything any doctors ever expected. During those 12 years he lived a full complete normal life. He played golf every single week, even in the hot summer months (we live in South Florida) when the temperature reaches the high 90s. He stopped playing only about 3 weeks ago since the ascites have become intolerable. Good luck to everyone.

Comment about this article, ask questions, or add new information about this topic:

CAPTCHA


Peritoneovenous Shunt forum