Baba Keisuke, Tanie Tomoki, Matsubara Yasuo, Hirata Yoshihiro, Ikematsu Hiroaki, Boku Narikazu
Department of Oncology and General Medicine, IMSUT Hospital, Institute of Medical Science, The University of Tokyo, Tokyo, Japan.
Department of Gastroenterology, IMSUT Hospital, Institute of Medical Science, The University of Tokyo, Tokyo, Japan.
Case Rep Oncol. 2025 Feb 27;18(1):286-295. doi: 10.1159/000543892. eCollection 2025 Jan-Dec.
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.
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.
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.
胃癌腹膜转移所致恶性腹水的治疗颇具挑战性，尤其是对于体弱和老年患者。利尿剂和腹腔穿刺等传统治疗方法缓解作用有限，且可能导致营养不良和脱水等并发症。丹佛分流术是一种腹腔静脉分流术（PVS），虽可缓解症状，但存在急性心力衰竭和弥散性血管内凝血（DIC）等严重并发症的风险。在插入丹佛分流术前评估患者耐受性对于预防危及生命的事件至关重要。
一名82岁晚期胃癌女性患者出现难治性恶性腹水，对利尿剂及无细胞浓缩腹水回输治疗（CART）均无反应。鉴于其年龄和体弱状况，以及腹水中血液量少，人们担心丹佛分流术相关风险。采用体外PVS，使用输液泵以可控速率回输腹水。输液起始速度为40 mL/h，并进行仔细监测。当患者在60 mL/h时出现阵发性室上性心动过速，减慢速度，并开始使用β受体阻滞剂治疗。在8天的体外回输过程中，未观察到心力衰竭、输液反应或DIC迹象。在确认包括D - 二聚体水平在内的实验室检查稳定后（D - 二聚体水平在第3天略有升高，第7天未经干预自行下降），安全插入丹佛分流术，未出现严重并发症。此后，患者腹水得到有效控制，直至2个月后去世，生活质量未恶化。
该病例表明，体外PVS通过数天可控的腹水回输可预防急性并发症并监测潜在不良事件，对于恶性腹水患者，尤其是体弱和老年患者，可作为插入丹佛分流术前有价值的前期治疗方法。
