Surgical management of pancreatic ascites

Background:  Pancreatic ascites is a challenging problem faced by clinicians. The management requires a multidisciplinary approach. Timely surgical intervention is the key especially in patients with chronic pancreatitis and pancreatic ascites where conservative and endoscopic treatments were not successful. Methods: The data was retrieved from a prospectively maintained database for a period of 4 years. A total of 14 patients were included. They were initially optimized with ascitic fluid drainage, nutritional supplementation either enteral or parenteral. Endoscopic retrograde cholangio pancreatography (ERCP) was done in patients with failed conservative treatment after 2 weeks. Endoscopic pancreatic stenting was attempted in proximal ductal disruptions. Nonresponders were taken up for surgery. The type of surgery was based on the site of leak and associated pancreatic pathology like pseudocyst. Results:  Initially three patients were responded to conservative management. ERCP was done in 9/14 patients. ERCP demonstrated leak of contrast into peritoneal cavity in 3 (3/9), leaking pancreatic pseudocyst in 3 (3/9) and non-visualisation of distal duct in 2 (2/9). ERCP and stenting of pancreatic duct was attempted in three patients and was successful in resolution of symptoms in one. Nine out of fourteen needed surgical intervention. Surgery was based on site of leak and presence of pseudocyst. Conclusions:  Majority of the patients in our study were ethanolics and a change in life style early in the course can prevent this morbid disease. Nasojejunal tube feeding with blendarized home feeds will improve the nutritional status. CECT abdomen and ERCP will give a road map in deciding the type of intervention. For proximal ductal disruption endoscopic stenting should be tried before going for a major surgical intervention. Surgery provides definitive cure.