EUS-Guided Paracentesis: Experience in 60 Consecutive Patients

Abstract

EUS-Guided Paracentesis: Experience in 60 Consecutive Patients John Dewitt, Stuart Sherman, Lee Mchenry, Kathy Mcgreevy, Julia Leblanc Background: The utility and safety of EUS-FNA sampling ascitic fluid is poorly defined. Methods: Databases were queried for all patients with successful EUSguided paracentesis from 1997 to 2005 at our hospital. Procedure reports and hospital charts were reviewed to confirm the cytologic diagnosis and clinical follow up. Results: 60 consecutive patients (33 male; mean age: 67 yrs) underwent EUSguided paracentesis. The most common indications for EUS were a known/ suspected pancreatic mass or cyst (31) or abnormal ERCP (10). Previously attempted percutaneous paracentesis was unsucessful in 3/6 patients due to inability to localize fluid for aspiration. Ascites seen by EUS was visible in only 28/54 (52%), 3/11 (27%) and 4/8 (50%) CT, US and MRI exams, respectively before EUS. Transgastric (55) or transduodenal (5) EUS-guided paracentesis (mean: 8.9 mLs; range: 1-40) revealed malignancy in 16 (27%) from primary pancreatic (9), gastric (2), urothelial (1), esophageal (1), gallbladder (1), bile duct (1) cancer or lymphoma (1). Cytology from one was suspicious for malignancy and the remaining 43 were benign. Seven with negative (6) or malignant (1) cytology from EUS-FNA underwent surgery a mean 26 days after EUS. The one with malignant ascites by EUS-FNA was confirmed intraoperatively the next day by biopsy of a peritoneal nodule. Two of the remaining six managed surgically were found to have metastatic carcinoid (1) or pancreatic adenocarcinoma (1) to the peritoneum following negative EUS-FNA cytology. Potential complications occurred in 3/60 (5%), each of whom received post-procedure antibiotics. One developed a fever 2 days after EUS, was hospitalized and discharged with negative cultures after three days. One had a fever and was treated as an outpatient for a suspected UTI. The third was asymptomatic but had air in the pancreas found on staging CT one day after EUS. This patient was managed medically and discharged with negative cultures. 45/60 (75%) received IV and/or oral antibiotics following EUS-FNA. Twelve of 16 with malignant ascites diagnosed by EUS-FNA died a mean 77 days (range: 21-167) after EUS. Four with metastatic esophageal (1), pancreatic (1) or gastric (1) cancer and lymphoma (1) remain alive 30, 110, 640 and 913 days after EUS. Conclusions: In this largest series to date, EUS frequently visualized ascites missed by other imaging studies. EUS-guided paracentesis is relatively safe, demonstrates malignancy in 27% of patients but a negative cytology does not exclude malignancy. Prognosis following detection of malignant ascites is usually poor. EUS-FNA of ascites should be performed in all patients with suspected or confirmed malignancy.