Indwelling peritoneal and pleural catheters in the management of malignant and non-malignant ascites and pleural effusion: experiences from a Danish tertiary center

ABSTRACT

Recurrent pleural effusions and ascites significantly impair quality of life, particularly in patients with advanced malignant and non-malignant disease. Traditional management often relies on repeated hospital-based procedures, which provide temporary symptom relief but place a considerable burden on patients and healthcare systems. This retrospective cohort study evaluates the safety, effectiveness, and clinical outcomes of indwelling pleural and peritoneal catheters (IPCs and IPeCs) in 63 patients treated at Lillebaelt Hospital Vejle between October 2019 and October 2024. A total of 30 patients received IPCs and 33 received IPeCs. Most had malignant effusions or ascites, but a notable proportion had non-malignant causes such as heart failure, liver cirrhosis, or renal disease. Following catheter placement, median survival was 45 days for IPC patients and 34 days for IPeC patients. Infection rates were low: 17% of IPC patients developed superficial skin infections, all treated successfully with oral antibiotics, and 6% of IPeC patients developed peritonitis, with one case potentially unrelated to the catheter. Importantly, 70% of IPC and 76% of IPeC patients had no hospital visits due to catheter-related complications, supporting the safety and outpatient feasibility of these devices. Additionally, a substantial proportion of patients—23% (IPC) and 30% (IPeC) – were able to remain in their own homes, potentially with support from home care services, rather than requiring institutionalization. These findings underline the benefit of early catheter placement in supporting patient autonomy and symptom control. Our results confirm that IPCs and IPeCs are safe and effective for managing both malignant and non-malignant effusions, with low complication rates and high patient benefit. Our findings support broader use of these catheters in palliative care. Earlier consideration of catheter placement may further improve outcomes and quality of life.

Introduction

Pleural effusion, the abnormal accumulation of fluid in the pleural space, is a common clinical condition, with approximately 20,000 cases per year in Denmark [1]. It is associated with various underlying diseases, including congestive heart failure, malignancy, pneumonia, and pulmonary embolism [2]. The clinical significance of pleural effusion varies widely, ranging from benign incidental findings to life-threatening complications such as empyema or undiagnosed malignant effusions.

Malignant pleural effusion (MPE) occurs in approximately 20% of all malignancies and is a marker of advanced or metastatic disease [3]. Due to its high prevalence, MPE poses a significant healthcare burden [4]. It causes debilitating symptoms, including dyspnea, chest pain, and reduced physical function, leading to a profound decline in quality of life. The prognosis remains poor, with a median survival ranging from 4 to 9 months, depending on tumor type and patient factors [5].

The management of MPE is primarily palliative, aiming to alleviate symptoms and improve quality of life. Repeated thoracentesis provides temporary relief but often requires frequent hospital visits. More definitive interventions include talc pleurodesis and indwelling pleural catheters (IPCs) [6]. IPCs have transformed the management of recurrent pleural effusions by offering a minimally invasive, patient-centered approach that enables long-term outpatient fluid drainage. Studies have demonstrated that IPCs not only provide sustained symptom relief but also reduce hospital admissions and the need for repeated procedures [7].

Similar to MPE, malignancy-related ascites (MRA) is a common complication of advanced cancers, particularly gastrointestinal, ovarian, and breast malignancies. It represents a significant cause of palliative care needs due to its substantial symptom burden, which includes abdominal distension, dyspnea, early satiety, nausea, vomiting, and general discomfort – all of which severely impair quality of life [8]. The prognosis for MRA is poor, with a median survival ranging from 4 to 16 weeks, depending on cancer type and patient factors [9]. Traditional management strategies include diuretics, salt restriction, and repeated large-volume paracentesis. However, these measures often provide only temporary relief, requiring frequent hospital visits and carrying risks such as infection, bleeding, and rapid fluid re-accumulation [10].

The use of indwelling peritoneal catheters (IPeCs) has changed the management of recurrent ascites. These devices enable continuous home-based drainage, reducing the need for repeated hospital interventions while enhancing patient autonomy and quality of life [11]. In this retrospective cohort study, we evaluated the clinical characteristics and outcomes of patients who underwent indwelling pleural and peritoneal catheter implantation at our department between October 2019 and October 2024.

Materials and methods

This retrospective study included all patients identified with the International Classification of Diseases, 10^th Edition (ICD-10) procedure codes for implantation of either an indwelling peritoneal catheter or an indwelling pleural catheter at Lillebaelt Hospital Vejle between October 2019 and October 2024. Patients with both benign and malignant causes of ascites or pleural effusion were included.

Patients were retrospectively identified from hospital records using procedure codes for indwelling pleural catheter implantation (KGAA10A) and indwelling peritoneal catheter implantation (KTJA11). Relevant data were systematically extracted from each patient’s medical records, including: Demographics (sex, smoking status, living situation), underlying condition (malignant or non-malignant, with specific diagnoses), survival duration (days from catheter implantation to death), catheter-related complications (number of infections and hospital visits), and comorbidities.

The IPC and IPeCs used were Pleurx™ catheter (Becton, Dickinson and Company, NJ, US) or Rocket (Rocket Medical PLC, UK). The type of indwelled catheter was not possible to obtain in medical records. The procedures were performed as an out-patient procedure without the use of sedation.

The retrospective study was approved by the hospital administration.

Descriptive statistics were applied, with continuous variables presented as means and medians, and categorical variables reported as frequencies or percentages.

Results

Indwelling pleural catheter

The characteristics of 30 patients with an IPC are presented in Table 1. The median age at the time of catheter placement was 77 years (range: 28–99 years), with a majority being male. A significant proportion (73%) were either current or former smokers. Comorbidities were frequent, present in 80% of patients, primarily chronic obstructive pulmonary disease (30%), atrial fibrillation (20%), and type II diabetes (20%). Twenty-three percent of patients lived alone, while 63% were co-residing, and 13% either lived in a care facility or were transferred to hospice care.

Table 1.

Characteristics of patients with indwelling pleural catheter.

Characteristic	Value
N	30
Age, median (range)	77 (28–99)
Female sex	37%
Smoking status
Current smoker	10%
Previous smoker	63%
Never smoker	27%
Comorbidity
None	20%
One or more than one	80%
Living situation
Alone	23%
Co-residing	63%
Institutional care	13%

In total, 73% had an IPC placed due to malignant pleural effusion, with the underlying malignancies detailed in Figure 1. Among the remaining patients with benign pleural effusions, the underlying causes were heart failure (5 of 9), liver cirrhosis (2 of 9), renal failure (1 of 9), and a combination of heart and renal failure (1 of 9).

Figure 1.

Distribution of malignancies leading to indwelling pleural catheter placement.

No procedure-related complications were observed. Following pleural catheter implantation, the median survival was 45 days (range: 3–263 days). Catheter-related infections occurred in 17% of patients; however, all were superficial skin infections that were successfully managed with oral antibiotics. Regarding healthcare utilization, 70% of patients required no hospital visits due to pleural catheter-related complications, 10% had one hospital visit, and 20% had two visits. No patients had more than two visits. These visits were related to the management of the aforementioned infections and issues with fluid leakage.

While more pleural catheters were implanted in the later years, we found no differences in outcomes between the early and more recent periods.

Indwelling peritoneal catheter

The characteristics of 33 patients with an indwelling peritoneal catheter are presented in Table 2. The median age in this group was 72 years (range: 47–87 years), with a female majority. A smaller proportion (54%) were current or former smokers compared to the pleural catheter group. Comorbidities were common, with 88% of patients having at least one, most frequently atrial fibrillation (18%) and hypertension (18%). Despite their health status, 30% of patients lived alone, 64% were co-residing, and 6% lived in a care facility.

Table 2.

Characteristics of patients with indwelling peritoneal catheter.

Characteristic	Value
N	33
Age, median (range)	72 (47–87)
Female sex	61%
Smoking status
Current smoker	9%
Previous smoker	45%
Never smoker	42%
Unknown	3%
Comorbidity
None	12%
One or more than one	88%
Living situation
Alone	30%
Co-residing	64%
Institutional care	6%

The majority (85%) had peritoneal catheters placed for malignant ascites, with malignancy types shown in Figure 2. The remaining patients with benign ascites all had underlying liver cirrhosis.

Figure 2.

Distribution of malignancies leading to indwelling peritoneal catheter.

Following peritoneal catheter implantation, the median survival was 34 days (range: 3–710 days). Catheter-related infections occurred in 6% of patients, all of whom developed peritonitis. However, of these two patients, one had liver cirrhosis as the underlying condition, making the association with the catheter less certain. Regarding hospital visits, 76% of patients had no catheter-related admissions, 18% had two visits, and 6% had three or more visits. These hospital contacts were primarily for the management of infections and fluid leakage complications

Discussion

Our findings demonstrate that indwelling pleural and peritoneal catheters are a safe and effective option for managing recurrent pleural effusions and ascites, with low infection rates, minimal hospital visits, and a substantial proportion of patients maintaining independent living. These results support the growing evidence that catheter-based management is a well-tolerated alternative to repeated thoracentesis or paracentesis, particularly in palliative care settings.

One primary concern with long-term indwelling catheters is the risk of infection. However, our study found low catheter-related infection rates, with 17% of pleural catheter patients experiencing only superficial skin infections, all successfully treated with oral antibiotics, comparable to previous findings [12]. Similarly, only 6% of peritoneal catheter patients developed peritonitis. These findings align with previous studies reporting low infection rates when proper catheter care protocols are followed [11,13].

A key advantage of indwelling catheters is that they enable patients to remain in their own homes, potentially with support from home care services, rather than requiring institutionalization. Despite advanced disease, 23% of IPC patients and 30% of IPeC patients lived alone, while most others co-resided with a spouse. Only a minority were in hospice or a care facility. This is particularly important in palliative care, as maintaining autonomy significantly improves quality of life [14,15]. By enabling home-based fluid drainage, catheters help reduce symptom burden without requiring frequent hospital visits, supporting both patient independence and caregiver well-being while also reducing hospital expenditures [16].

Frequent hospital admissions increase the risk of hospital-acquired infections. In our study, 70% of pleural catheter patients and 76% of peritoneal catheter patients had no hospital visits due to catheter-related issues. Only a small proportion required one or two visits, reinforcing the efficacy and safety of these devices in an outpatient setting [17]. While we cannot assess patients’ subjective experiences or preferences for follow-up in this study, these findings suggest that indwelling catheters may reduce hospital dependency. This aligns with a patient-centered approach and the goals of modern palliative care. Potential effects on perceived quality of life warrant further investigation in future studies.

A notable concern identified in our study, is that some patients had catheters implanted very late in their disease course, with survival as short as three days post-procedure. This suggests that in certain cases, catheter placement was delayed until the patient was already in an advanced terminal stage, limiting its potential benefit and exposing patients to invasive procedures with little or no therapeutic gain. While the median survival was 34 and 45 days, respectively, earlier implantation could provide greater symptom relief and improved quality of life for a longer duration, as other studies have reported longer median survival after implantation [18]. Current clinical recommendations suggest that the insertion of indwelling pleural or peritoneal catheters should be considered in patients with an estimated life expectancy of 3–12 months [19]. This indicates that, in many cases within our study, implantation occurred later than optimal. It is also possible that the relatively low infection rates observed in our study were influenced by the short duration many patients had the catheter in place before death, limiting the time for complications to occur. At our institution, a conservative approach was initially adopted during the program’s early phase, where patients were primarily considered for IPC or IPeC when fluid drainage was required on a weekly basis. Moving forward, efforts should be directed toward refining patient selection and optimizing the timing of catheter insertion in accordance with current recommendations [19]. This would help maximize symptom control, reduce unnecessary procedural risks, and improve overall quality of life for patients during the final months of life.

Our study confirms that indwelling catheters can be safely used for both malignant and non-malignant conditions. While most patients had malignancy-related effusions or ascites, a significant number presented with non-malignant causes such as medically intractable heart failure, liver cirrhosis, or renal disease. Infection rates were not higher in non-malignant cases compared to malignant ones. Given the low complication rates and high symptom relief, these findings support exploring the possibilities to expand the use of IPCs and IPeCs beyond oncology to patients with non-malignant recurrent effusions that are refractory to standard treatments, as previously suggested [20,21].

Limitations

This study has several important limitations that must be acknowledged. First, it was conducted at a single center in Denmark, which may limit the generalizability of the findings to other healthcare settings, regions, or countries with different patient populations, healthcare infrastructure, and clinical practices. The single-center design introduces potential institutional bias, as practices surrounding catheter placement, timing, and follow-up may differ significantly elsewhere.

Second, the retrospective nature of the study imposes inherent limitations. Data were collected from existing medical records, which may be incomplete or inconsistently documented. This design restricts our ability to control for confounding variables and to capture patient-reported outcomes such as symptom relief, quality of life, and preferences for care – factors that are highly relevant in palliative settings.

Conclusions

Indwelling pleural and peritoneal catheters provide a safe, effective, and minimally invasive solution for managing recurrent pleural effusions and ascites, particularly in palliative care settings. Our study highlights their role in minimizing the need for hospital, maintaining patient autonomy, and minimizing complications. However, the timing of implantation should be optimized to maximize benefits. Additionally, our findings support the use of IPCs and IPeCs for treatment-refractory benign effusions.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Ethical approval

The study was approved by the hospital administration.

Data availability statement

Anonymized data can be provided on request after approval from the Danish Data Protection Agency.