Clinical Study
Therapeutic Application of Percutaneous Peritoneovenous (Denver) Shunt in Treating Chylous Ascites in Cancer Patients

https://doi.org/10.1016/j.jvir.2015.12.014Get rights and content

Abstract

Purpose

To evaluate the safety and efficacy of percutaneous peritoneovenous shunt (PPVS) placement in treating intractable chylous ascites (CA) in patients with cancer.

Materials and Methods

Data from 28 patients with refractory CA treated with PPVS from April 2001 to June 2015 were reviewed. Demographic characteristics, technical success, efficacy, laboratory values, and complications were recorded. Univariate and multivariate logistic regression analysis was performed.

Results

Technical success was 100%, and ascites resolved or symptoms were relieved in 92.3% (26 of 28) of patients. In 13 (46%) patients with urologic malignancies, whose ascites had resulted from retroperitoneal lymph node dissection, the ascites resolved, resulting in shunt removal within 128 days ± 84. The shunt provided palliation of symptoms in 13 of the remaining 15 patients (87%) for a mean duration of 198 days ± 214. Serum albumin levels increased significantly (21.4%) after PPVS placement from a mean of 2.98 g/dL ± 0.64 before the procedure to 3.62 g/dL ± 0.83 (P < .001). The complication rate was 37%, including shunt malfunction/occlusion (22%), venous thrombosis (7%), and subclinical disseminated intravascular coagulopathy (DIC) (7%). Smaller venous limb size (11.5 F) and the presence of peritoneal tumor were associated with a higher rate of shunt malfunction (P < .05). No patient developed overt DIC.

Conclusions

PPVS can safely and effectively treat CA in patients with cancer, resulting in significant improvement in serum albumin in addition to palliation of symptoms.

Section snippets

Study Design

This retrospective study was conducted under an exemption from the institutional review board. Data from 28 patients with refractory CA who were treated with percutaneous peritoneovenous shunt (PPVS) placement between April 2001 and June 2015 were reviewed.

CA was defined by milky appearance of the ascites with an ascitic fluid triglyceride concentration > 110 mg/dL. The peritoneal fluid was evaluated for cytology, culture, and triglyceride level before shunt placement at the time of

Results

PPVS placement was performed in 28 patients with CA. All patients were initially treated with conservative measures for a mean duration of 71 days ± 65 (range, 9–313 d). Conservative management included diet modification (32%), total parenteral nutrition (14%), diuretic therapy (46%), octreotide injection (7%), and repeated paracentesis (86%), used alone or in combinations. Demographic characteristics are listed in Table 1. Testicular cancer (39%) was the most common primary tumor. Surgery,

Discussion

Despite satisfactory reports on shunt placement, its role in treatment of CA is controversial. In this study, intractable CA was successfully managed with Denver shunt placement in 26 of 28 (93%) patients with cancer who had failed conservative management.

A search of the literature using MEDLINE revealed 56 reported cases of CA treated with peritoneovenous shunt (LeVeen and Denver) placement (Table 3). These reports demonstrate that PPVS placement is effective in treating CA in 96.4% of

Acknowledgment

The authors thank Sahra Emamzadeh-Fard, MD, for her help with data collection.

References (39)

  • F.M. Guttman et al.

    Experience with peritoneo-venous shunting for congenital chylous ascites in infants and children

    J Pediatr Surg

    (1982)
  • T. Kanou et al.

    Peritoneovenous shunt for chylous ascites after lung transplantation for lymphangioleiomyomatosis

    Transplant Proc

    (2012)
  • I. Leibovitch et al.

    The diagnosis and management of postoperative chylous ascites

    J Urol

    (2002)
  • T.P. Manolitsas et al.

    Chylous ascites following treatment for gynecologic malignancies

    Gynecol Oncol

    (2002)
  • C. Campisi et al.

    Diagnosis and management of primary chylous ascites

    J Vasc Surg

    (2006)
  • M.A. White et al.

    Denver peritoneovenous shunts for the management of malignant ascites: a review of the literature in the post LeVeen Era

    Am Surg

    (2011)
  • W.G. Sarazin et al.

    Chylous ascites following resection of a ruptured abdominal aneurysm. Treatment with a peritoneovenous shunt

    Arch Surg

    (1986)
  • W.D. Boyd et al.

    Chylous ascites following abdominal aortic aneurysmectomy: surgical management with a peritoneovenous shunt

    J Cardiovasc Surg (Torino)

    (1989)
  • C.J. Ablan et al.

    Postoperative chylous ascites: diagnosis and treatment. A series report and literature review

    Arch Surg

    (1990)
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    G.I.G. is a member of the Medical Board of Advisors for CareFusion Corporation (San Diego, California). None of the other authors have identified a conflict of interest.

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