Reinfusion of Malignant Ascites through an Extracorporeal Peritoneal Venous Shunt to Avoid Complications and Assess the Safety of a Denver Shunt: A Case Report.

Abstract

Introduction: Malignant ascites due to peritoneal metastasis of gastric cancer is challenging to manage, especially in frail and elderly patients. Traditional treatments like diuretics and paracentesis offer limited relief and can lead to complications such as malnutrition and dehydration. The Denver shunt, a type of peritoneal venous shunt (PVS), can alleviate symptoms but carries risks of severe complications like acute heart failure and disseminated intravascular coagulation (DIC). Assessing patient tolerance before Denver shunt insertion is crucial to prevent life-threatening events.

Case presentation: An 82-year-old woman with advanced gastric cancer developed refractory malignant ascites unresponsive to diuretics and cell-free and concentrated ascites reinfusion therapy (CART). Given her age and frailty, along with the small amount of blood in the ascites, there were concerns about the risks associated with a Denver shunt. An extracorporeal PVS was employed to reinfuse ascites at a controlled rate using an infusion pump. The infusion started at 40 mL/h and was carefully monitored. When the patient experienced paroxysmal supraventricular tachycardia at 60 mL/h, the rate was reduced, and β-blocker therapy was initiated. No signs of heart failure, infusion reactions, or DIC were observed during the 8-day extracorporeal reinfusion. After confirming stable laboratory tests including D-dimer levels which elevated slightly on day 3 and decreased on day 7 without intervention, a Denver shunt was safely inserted without severe complications. Thereafter, patient's ascites was effectively managed, not deteriorating her quality of life, until her passing away 2 months later.

Conclusion: This case suggests that extracorporeal PVS, in which controlled reinfusion of ascites for several days can prevent acute complication and monitor potential adverse events, can be a valuable prior treatment before Denver shunt insertion in patients with malignant ascites, especially for frail and elderly patients.