710 GASTROINTESTINAL ENDOSCOPY VOLUME 49, NO. 6, 1999 Pancreatic ascites is an uncommon but well- recognized complication of both acute and chronic pancreatitis that is associated with significant mor- bidity and mortality. Pancreatic ascites is defined as a massive fluid accumulation with high protein and amylase content resulting from benign pancreatic disease. 1 The etiology in approximately 80% of cases is leakage or rupture of a pancreatic pseudocyst communicating with a ductal disruption. 2,3 The remainder of cases are due to ductal disruption in the absence of a pseudocyst. 2,3 Conservative medical management—withholding of oral feedings, total parenteral nutrition, 4,5 treatment with somato- statin analogs 2,6,7 and large volume paracentesis, 8 for up to 4 weeks—has led to successful resolution of pancreatic ascites in only approximately 50% of cases. Surgical management consisting of partial pancreatic resection, cystogastrostomy, or cystoje- junostomy has met with limited success in cases of intractable pancreatic ascites. 5,9,10 Postsurgical recurrence rates up to 50% have been reported in cases where the ductal disruption was not visual- ized preoperatively by endoscopic retrograde pan- creatography (ERP). 11,12 Despite the improved suc- cess rate of surgical therapy in cases in which duct disruption is visualized by ERP, the mortality rates for operative and nonoperative management simi- larly range from 1% to 25%. 9 An alternative strategy for the treatment of patients with pancreatic ascites and ERP evidence of ductal disruption is endoscopic transpapillary pancreatic duct stent placement. Theoretically, placement of a pancreatic duct stent could facilitate healing of ductal disruptions by partially occluding the leaking duct or bypassing the pancreatic sphinc- ter, converting the normally high-pressure pancre- Endoscopic pancreatic duct stenting to treat pancreatic ascites G. Alan Bracher, MD, Anuj Paul Manocha, MD, John R. DeBanto, MD, Lawrence K. Gates, Jr., MD, Adam Slivka, MD, PhD, David C.Whitcomb, MD, PhD, Brian L. Bleau, MD, Charles D. Ulrich II, MD, Stephen P. Martin, MD Cincinnati, Ohio, Lexington, Kentucky, and Pittsburgh, Pennsylvania Background: Management of pancreatic ascites with conservative medical therapy or surgery has met with limited success. Decompression of the pancreatic ductal system through transpapillary stent placement, an alternative strategy, has been reported in only a handful of cases of pancreatic ascites. Methods: We reviewed all cases from 1994 to 1997 in which patients with pancreat- ic ascites underwent an endoscopic retrograde pancreatogram documenting pan- creatic duct disruption with subsequent placement of a transpapillary pancreatic duct stent. Clinical end points were resolution of ascites and need for surgery. Results: There were 8 cases of pancreatic ascites in which a 5F or 7F transpapillary pancreatic duct stent was placed as the initial drainage procedure. Pancreatic ascites resolved in 7 of 8 patients (88%) within 6 weeks. Ascites resolved in the eighth patient, a poor candidate for surgery, following placement of a 5 mm expand- able metallic pancreatic stent. No infections, alterations in ductal morphology, or other complications related to stent placement were noted. There was no recurrence of pancreatic ascites or duct disruption at a mean follow-up of 14 months. Conclusions: Our experience doubles the number of reported cases in which transpapillary pancreatic stent placement safely obviated the need for surgical inter- vention in the setting of pancreatic ascites. This therapeutic endoscopic interven- tion should be seriously considered in the initial management of patients with pan- creatic ascites. (Gastrointest Endosc 1999;49:710-5.) Received February 17, 1998. For revision July 27, 1998. Accepted November 11, 1998. From the Division of Digestive Diseases, Department of Medicine, University of Cincinnati, Cincinnati, Ohio; Division of Digestive Diseases and Nutrition, Department of Medicine, University of Kentucky, Lexington, Kentucky; Division of Gastroenterology and Hepatology, Department of Medicine, University of Pittsburgh, and the VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania—The Midwest Multicenter Pancreatic Study Group. Reprint requests: Stephen P. Martin, MD, Division of Digestive Diseases, University of Cincinnati Medical Center, Box 670595, 231 Bethesda Ave., Cincinnati, OH 45267-0595. 37/1/95738