Early surgical management in pancreatic ascites on a background of chronic pancreatitis

Background: Pancreatic ascites can occur as a complication of acute or chronic pancreatitis. In majority of cases, it is associated with pseudocyst or duct disruption. Management is initially conservative with paracentesis with nutritional support. Early surgery has been recently contemplated as primary management for pancreatic ascites.Methods: A prospective study was done over a duration of three years from November 2017 to October 2019 in patients of chronic pancreatitis presenting with pancreatic ascites. All patients underwent pancreatic protocol contrast enhanced computed tomography abdomen and magnetic resonance cholangiopancreatography, duct diameter and main pancreatic duct (MPD) disruption site.  pseudocyst site was identified. After optimizing patients, early surgery was planned. Surgeries included either lateral pancreatic jejunostomy, if MPD were dilated. Pancreaticogastrostomy, cystogastrostomy or cystojejunostomy, if there was pseudocyst with extraneous impression over stomach or on mesocolon, and distal pancreatectomy (and/or) splenectomy. Results: Out of 20 cases of pancreatic ascites, 6 were of acute pancreatitis and conservatively managed and 14 were subjected to early primary surgery. 8 out of 14 patients underwent LPJ. 2/14 underwent pancreaticogastrostomy. 2/14 underwent cystogastrostomy and 1/14 underwent spleen preserving distal pancreatectomy. 1/14 underwent distal pancreatectomy and splenectomy. None of the patients had postoperative recurrence of pancreatic ascites. One patient developed Postoperative intra-abdominal collection which was drained. Mortality was 2/14 (14.2%), one died immediate postoperatively and another succumb to Pulmonary embolism on post-operative day-4. Pain scores were significantly reduced post-operatively.Conclusions: Primary early surgery directed towards primary pathology, as guided by MPD status, in selected patients with chronic pancreatitis with ascites leads to faster recovery of patient.

Complications of Acute Pancreatitis Misdiagnosed as Primary Serous Papillary Carcinoma / 대한췌담도학회지

Acute pancreatitis is an inflammatory disease of pancreas which could lead to a number of complications including pancreatic ascites and pseudocysts. When these complications are severe, the secondary changes in colon, peritoneum or mesentery can make it difficult to distinguish from peritoneal carcinomas. Herein, we report a case of acute pancreatitis that was difficult to differentiate from peritoneal carcinoma. We performed a sequential procedure without peritoneal biopsy to exclude the possibility of peritoneal cancer, and we could diagnose pancreatic ascites and pseudocyst resulting from pancreatic injuries.

Pancreatic ascites and pleural effusion without pancreatic duct disruption treated with stenting / 대한내과학회지

Pancreatic ascites and pleural effusion is a rare complication of inflammatory disease of pancreas. Disruption of the pancreatic duct secondary to inflammatory pancreatic disease results in an internal pancreatic fistula into the peritoneal or pleural cavities. Thus, pancreatic secretion through the internal pancreatic fistula accumulate within the peritoneal or pleural cavities. The diagnosis is strongly suspected by paracentesis and thoracentesis, which demonstrate a markedly elevated amylase and an albumin level in pancreatic ascites and pleural effusion, and is confirmed by observation of pancreatic duct contrast leakage at endoscopic retrograde pancreatography. We report a patient with pancreatic ascites and pleural effusion who had no demonstrable pancreatic duct disruption on endoscopic retrograde pancreatography, but successfully treated by pancreatic duct stent endoscopically.

Treatment of Pancreatic Ascites with Endoscopic Pancreatic Duct Stenting and Octreotide Injection / 대한소화기내시경학회지

Pancreatic ascites is an exudative which is an amylase-rich accumulation of intraperitoneal fluid and occurs in association with rupture of a pseudocyst or disruption of the pancreatic duct. Characteristically the patient presents with increasing abdominal girth, weight loss, and varying degrees of abdominal pain. Conservative medical management, including withholding of oral feeding, total parenteral nutrition, and large volume paracentesis has led to successful resolution of pancreatic ascites in less than 50% of cases. Recently octreotide injection and endoscopic transpapillary pancreatic duct stenting have made a major impact on the conservative treatment of pancreatic ascites. We describe the case of a patient with chronic pancreatitis and pancreatic ascites who was treated by endoscopic pancreatic duct stenting and octreotide injection.

Pancreatic Pseudocysts and Ascites as Complications of Chronic Pancreatitis

A case of pancreatic pseudocysts and bloody pancreatic ascites as complications of chronic pancreatitis in eleven-year-old girl was reported. She was admitted to the pediatric ward with chief complaints of abdominal distension and bloody ascites. About nine months prior to admission, when she was stuck by a bicycle, she had sustained a blow on her abdomen. She has been apparently well until four months prior to admission, when she began to feel colidy and intermittent abdominal pain and her appetits became poor. About a week prior to admission, her mother noticed that the girl's abdomen was distended. One day prior to admission, bloody ascites was revealed by paracenteis at a local clinic. Clinical and laboratory pictures were observed for 3 months. Ascites amylase at preoperative state were 496~705 u/dl and 740~772 u/dl Protein in ascites was 2,390mg%~4,820mg%. On the fifty fifth hospital day, an exploratory laparotomy was performed. About 7,000cc of bloody ascites was drained. A 30 x 20cm sized pseudocyst with thin wall was found between stomach and transverse colon. The portion of disrupted pancreatic duct was drained with sump tube. Abdomen distension and pain was markedly relieved after operation. On the 60 th postoperative day, ultrasonography of abdomen revealed no cysts. So sump tube was removed. A brief review of the literature was done.