Peritoneovenous shunt for pancreatic ascites

Pancreatic ascites: study of therapeutic options by analysis of case reports and case series between the years 1975 and 2000

OBJECTIVE

Because of the low incidence of pancreatic ascites, only case reports and case series have been published, and no randomized controlled trials have been performed to find out which is the best therapeutic approach. The aim of this study was to evaluate the utility of the different treatments for pancreatic ascites by a thorough review of all case reports described in the literature in which an independent analysis of the efficacy of the treatment administered to each patient is possible.

METHODS

We conducted an analysis of all case reports and case series of pancreatic ascites published between 1975 and 2000 in which clinical data of every patient could be identified individually. A total of 139 cases were studied. Clinical characteristics, treatments administered, and response to therapy of every patient were registered. Conservative therapy included drainage of ascitic fluid, total parenteral nutrition and diet, and somatostatin analogues. Interventional therapy was either endoscopic or surgical.

RESULTS

After multivariate analysis, the only treatments related to success were surgery (adjusted OR = 8.2, 95% CI = 3.0-22.9) and transpapillary stent (adjusted OR = 7.3, 95% CI = 0.8-62.9). No significant relationship was found between failure or death and the use of other treatments, age, sex, year of publication, underlying disease, site of leakage, or serum amylase levels. The apparent lack of effect of somatostatin analogues could be attributed to the small number of cases and the heterogeneity of the dosages.

CONCLUSIONS

Conservative therapy is not advisable for pancreatic ascites because of the high proportion of failures. Interventional therapy with surgery or transpapillary stent has a positive effect in the clinical outcome.

Endoscopic treatment of pancreatic ascites

Pancreatic ascites, etiologically related to a leaking pseudocyst or ductal disruption, has been treated medically with hyperalimentation, somatostatin analog, and large-volume paracentesis. Surgery is ultimately required in more than 50% of such patients. Mortality figures in patients with pancreatic ascites approximate 15% to 25% with either treatment modality. We describe 4 patients who were found to have ductal disruptions in conjunction with pancreatic ascites who responded to transpapillary pancreatic duct endoprosthesis placement. There has been no recurrence of ascites in these patients at a mean follow-up of 12 months following stent-retrieval. Further evaluation of endoscopic therapy for pancreatic ascites appears warranted.

Role of endoscopic retrograde pancreatography in pancreatic ascites

We present a case of pancreatic ascites. The diagnosis was strongly suspected on the basis of ascitic fluid analysis and was confirmed by observation of pancreatic duct contrast leakage at endoscopic retrograde pancreatography (ERP). Computed tomography was not helpful in this case. For localization and final confirmation of the lesion, ERP is the most valuable investigative method.