Denver Peritoneovenous Shunt Performed Under Local Anaesthesia for Intractable Ascites Following Esophagogastrectomy

Case Report

Austin J Surg. 2014;1(5): 1025.

Denver Peritoneovenous Shunt Performed Under Local Anaesthesia for Intractable Ascites Following Esophagogastrectomy

Yoshito Nako1, Atsushi Shiozaki1*, Hitoshi Fujiwara1, Hirotaka Konishi1, Ryo Morimura1, Yasutoshi Murayama1, Shuhei Komatsu1, Hisashi Ikoma1, Yoshiaki Kuriu1, Takeshi Kubota1, Masayoshi Nakanishi1, Daisuke Ichikawa1, Kazuma Okamoto1, Toshiya Ochiai2, Chouhei Sakakura1 and Eigo Otsuji1

1Department of Surgery, Division of Digestive Surgery, Kyoto Prefectural University of Medicine, Japan

2Department of Surgery, Division of Digestive Surgery, North Medical Center, Kyoto Prefectural University of Medicine, Japan

*Corresponding author: Atsushi Shiozaki, Department of Surgery, Division of Digestive Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto 602-8566, Japan

Received: May 20, 2014; Accepted: August 18, 2014; Published: August 21, 2014

Abstract

We herein described a 70-year-old male patient with lower thoracic esophageal cancer (T1aN2M0, Stage II) and gastric cancer in the upper body (T1bN0M0, Stage IA), who underwent subtotal esophagectomy and proximal gastrectomy with reconstruction using colon interposition in January, 2011. He exhibited abdominal distension in April, 2011. Ultrasonography revealed massive ascites, the cytology of which was class II, and mediastinal lymph node recurrence was detected using PET/CT. Although the patient received DCF chemotherapy (2 courses of 5-FU 600 mg/m2 days 1-5, docetaxel 60 mg/ m2 day1, and cisplatin 50 mg/m2 day 4) and achieved a complete response in the mediastinal lymph nodes, no improvements were noted in massive ascites. Lymphorrhea was not detected by lymphangiography. Although a definite diagnosis had not been obtained, a Denver peritoneovenous shunt (DPVS) was placed in August, 2011. A marked amelioration in ascites was observed following surgery, and the patient was subsequently discharged without complications. DPVS is a simple procedure that can be successfully applied to the treatment of intractable ascites.

Keywords: Denver peritoneovenous shunt; Intractable ascites; Esophagectomy

Introduction

Ascites following surgery for digestive cancer is frequently attributed to postoperative lymphorrhea, peritoneal metastasis, cirrhosis, and under nutrition. However, difficulties are associated with the treatment and management of ascites after surgery because it may be intractable and the cause may be unclear. Conventional medical treatments, such as the restriction of dietary sodium and administration of diuretics, are typically used as the first line of therapy for ascites. Repeated Paracentesis is also frequently performed to ameliorate abdominal distention because of its simplicity, but has been linked to complications such as cardiac failure by massive fluids shift, infection, intestinal damage, and, most importantly, the loss of nutrients, which eventually result in cachexia. Concentrated ascites reinfusion therapy (CART) or a peritoneovenous shunt (PVS) may be chosen for cases that have not shown improvements by either medication or repeated paracentesis [1].

We here in described a case of intractable ascites after surgery for esophageal and gastric cancer that was successfully treated by the placement of a Denver peritoneovenous shunt (DPVS).

Case Presentation

The patient was a 70-year-old male with lower thoracic esophageal cancer (T1aN2M0, Stage II) [2,3] and gastric cancer in the upper body (T1bN0M0, Stage IA) [4,5], who underwent subtotal esophagectomy and proximal gastrectomy with reconstruction using colon interposition in January, 2011. His postoperative recovery was uneventful, and he was discharged 48 days after surgery. However, he exhibited abdominal distension in April, 2011, and was admitted to the hospital for examinations and treatments.

He had an operation scar on his upper abdomen, and marked abdominal distension. A laboratory examination on admission revealed that total protein and albumin were slightly decreased at 5.4 g/dl and3.5 g/dl, respectively. Carcinoembryonic antigen; CEA, squamous cell carcinoma antigen; SCC-Ag, and cytokeratin 19 fragment; CYFRA, which are tumor markers were all within normal limits. A serological study for hepatitis B and C was negative. A cytological examination showed that ascites was class II. Computed tomography; CT of the abdomen revealed massive ascites (Figure 1A). No recurrence was detected in the remnant stomach or ileocolic reconstruction by gastrointestinal endoscopy. Loop diuretics and paracentesis were administered and improved ascites, therefore, the patient was discharged. Two weeks later, he presented with abdominal distention. PET/CT revealed massive ascites and mediastinal lymph node recurrence on the right side of Th4 (SUV4.7) and Th6 (SUV9.2) (Figure 1B). The patient received two courses of DCF chemotherapy (5-FU 600mg/m2: days 1-5, docetaxel 60mg/m2: day1, and cisplatin 50mg/m2: day 4) to treat mediastinal lymph node recurrence, and resulted in a complete response. However, no improvements were noted in massive ascites. Therefore, the patient was re-examined to establish the cause of massive ascites.