Therapeutic challenges of pancreatic ascites and the role of endoscopic pancreatic stenting

Abstract

Management of pancreatic ascites poses significant therapeutic challenges. Treatment usually consists of either conservative management or interventional therapy with little consensus between the two options. Conservative therapy is the most common initial treatment option but has high failure rates hence arguing for interventional therapy as a preferred primary treatment option. Endoscopic treatment is particularly appealing due to lower failure rates and mortality than conservative therapy or surgery. We describe a patient with recurrent pancreatic ascites who was successfully managed with endoscopic transpapillary stenting. This report contributes to the limited but growing literature on the management of pancreatic ascites.

Severe, Complicated Pancreatitis With an Unclear Etiology

“…Conservative management of pancreatic ascites was initiated, including holding oral tube feeds and starting octreotide and parenteral nutrition [ 18 ]. Conservative management has a failure rate of as high as 60% and a mortality rate of 17% [ 19 ]. Endoscopic ultrasound-guided transmural drainage is adequate for most patients with pancreatic pseudocysts abutting the stomach or duodenum [ 20 ] and is likely more effective than an endoscopic approach [ 21 ].…”

Ascitis Pancreática Traumática. Manejo Conservador: Reporte De Un Caso

“…El diagnóstico requiere la demostración de líquido pancreático en la cavidad peritoneal que generalmente, se caracteriza por la elevación de la amilasa (mayor de 1.000 UI/L) y de los niveles de proteína (mayor de 3 g/dL). El manejo de la ascitis pancreática puede ser inicialmente médico; sin embargo, con una tasa de fracaso reportada en la literatura del 40%-60% y una mortalidad hasta del 17%, otro método terapéutico realizado es la terapia intervencionista como la colocación de un stent endoscópico en el conducto pancreático, la cual tiene una tasa de falla relativamente baja (14,3%) y una tasa de mortalidad del 0%; finalmente, el manejo puede ser quirúrgico con tasa de falla de 12,8% y una mortalidad reportada del 7,7% 12 . Asimismo, la ascitis secundaria a trauma con lesión del conducto y fuga secundaria requiere cirugía en más del 50% de estos pacientes, con tasas de mortalidad del 15% al 25% 13 .…”

Endoscopic Retrograde Cholangiopancreatography Induced Pancreatic Ascites

“…Pancreatic ascites describes accumulation of fluid into the peritoneum that occurs in the setting of pancreatic duct dehiscence, a ruptured pancreatic pseudocyst, or an abscess with walled off necrosis and fistula formation with leakage of pancreatic contents into the peritoneum [1][2][3][4]. Approximately 95% of reported pancreatic ascites cases have occurred in the setting of chronic pancreatitis.…”

“…Conservative management has been reported to have a failure rate of 40 to 60% with associated mortality rates of about 17% [3,5,12]. Comparatively, ERCP has been reported to have a failure rate of 14.3% and mortality rate of almost 0% [3,13]. Since ERCP has been reported to have major success for management for pancreatic ascites, it is rarely the cause of pancreatic ascites.…”

“…Pancreatic ascites typically occurs as a consequence of a pancreatic pseudocyst leakage or ductal injury leading to leakage of pancreatic secretions into the peritoneum [1,2]. While the incidence of pancreatic ascites remains unknown, it is thought to occur more frequently in males between the ages of 20 and 50 [3]. Management is usually conservative, and includes holding oral feeds, providing parenteral nutrition, octreotide, and sometimes invasive procedures including endoscopic retrograde cholangiopancreatography (ERCP) and surgery [1,2].…”