Refractory pancreatic ascites due to chronic pancreatitis: a real-world tertiary referral centre cohort analysis

Abstract

Introduction: Pancreatic ascites (PA) is a rare complication of chronic pancreatitis (CP) and evidence regarding optimal management strategies remains limited. This study reports the experience of managing refractory PA in patients with complicated CP at Groote Schuur Hospital, Cape Town, South Africa in comparison to contemporary series.

Methods: Patients identified through an ethics-approved CP registry who presented with PA between 1 January 2012 and 30 March 2025 were included. Patients with PA due to malignancy, acute pancreatitis, iatrogenic causes, or trauma were excluded. Data collected included demographics, clinical characteristics, imaging findings, management strategies, and outcomes.

Results: Nine patients (median age 40, range 30–51 years) of whom six were male were included. The most common aetiology was alcohol, and the most common presentation was ascites and weight loss. Eight out of nine patients had evidence of nutritional deterioration, and the median serum albumin was 25 g/L (range 19–38). The most common imaging finding was pseudocysts, while pancreatic duct strictures and stones were demonstrated in 1 patient each. ERCP was attempted in all patients and an endoscopic cyst gastrostomy performed in one. Five patients had successful stent placement, of whom three had complete resolution of ascites, and one underwent surgery. Of the four patients in whom stent drainage could not be performed three went on to surgery. Of the four patients who were operated three underwent a longitudinal pancreatico-jejunostomy and one a left pancreatectomy and splenectomy. Two patients developed major complications, one with bleeding following an endoscopic cyst-gastrostomy and another developed infected ascites. Two patients died of hospital-acquired resistant Klebsiella infections.

Conclusion: The management of PA remains challenging with substantial mortality rates in this high-risk patient group. Endoscopic intervention achieved resolution in select cases, while surgical intervention provided definitive management. Further studies are necessary to refine treatment strategies and individualised approaches to optimise patient outcomes.