Prognosis assessment of patients with refractory ascites treated with a peritoneovenous shunt.

BACKGROUND/AIMS: We investigated the postoperative outcome and risk factors for DIC and mortality in cases of implanted PVS. METHODOLOGY: We reviewed the cases of 65 patients implanted with PVS from 2000 to 2010. Of these patients, 32 were diagnosed with peritonitis carcinomatosa, 21 had liver cirrhosis with hepatocellular carcinoma (HCC), and 12 had liver cirrhosis without HCC. RESULTS: The postoperative morbidity rate was 18.8%, 76.2%, and 58.3% in cases of peritonitis carcinomatosa, liver cirrhosis with HCC, and liver cirrhosis without HCC, respectively. Early death (within 7 days of surgery) was 7.7% (5/65), and the cause of death in all cases was DIC. Underlying disease, low platelet count, prolongation of prothrombin time (PT), and hyperbilirubinemia were the risk factors for development of DIC, whereas underlying disease, prolongation of PT, hypoalbuminemia, and hyperbilirubinemia were risk factors for early death. Multivariate analysis showed that liver cirrhosis with HCC and prolonged PT were the risk factors for DIC. CONCLUSIONS: Patients with refractory ascites due to liver cirrhosis with HCC and those with prolonged PT should not be considered for PVS.

Therapeutic results of Denver percutaneous peritoneovenous shunt in cancer patients with malignant ascites.

BACKGROUND: Intractable ascites secondary to malignant disease deteriorates patients' quality of life. The purpose of this study was to evaluate the safety and efficacy of percutaneous peritoneovenous (Denver) shunt in treating intractable malignant ascites in cancer patients. MATERIALS AND METHODS: Thirty-five patients who had undergone Denver peritoneovenous shunt for the treatment of ascites associated with malignant tumor from October 2014 to 2017 were retrospectively analyzed. The demographic characteristics, laboratory values, and complications were recorded. Univariate and multivariate logistic regression analyses were performed. RESULTS: The sites of primary tumor were pancreatic cancer in 19 patients, bile duct cancer in 8, gallbladder cancer in 5, breast cancer in 2, and peritoneal malignant mesothelioma in 1. Palliation of abdominal distention was achieved in 29 patients (82.9%). Postoperative complications of Grade 2 or higher were seen in 11 patients (31.4%), and Grade 5 complications were observed in three patients (8.6%). Patients with a high American Society of Anesthesiologists (ASA) grade and high ascites drainage volume had a significantly higher incidence of postoperative complications than a low ASA grade and low ascites drainage volume, and a multivariate logistic analysis showed that the intraoperative ascites drainage volume was an independent risk factor for all complications. CONCLUSIONS: The Denver shunt for malignant ascites is useful for improving patients' quality of life if the indications are selected properly. Drainage of intraoperative ascites was a risk factor for postoperative complications after the Denver shunt technique in cancer patients with malignant ascites. Further experience and discussion are necessary to establish the patient selection criteria.

Percutaneous peritoneovenous shunt for treatment of refractory ascites.

PURPOSE: To evaluate the usefulness of a percutaneously placed peritoneovenous shunt (PVS) in patients with refractory ascites. MATERIALS AND METHODS: Under fluoroscopic and ultrasonographic (US) guidance, the authors placed a PVS in 55 patients (39 men and 16 women; mean age, 56 years) with refractory ascites and symptomatic abdominal distention. The cause of ascites was liver cirrhosis (n = 36), carcinomatosis (n = 17), ruptured cysts with polycystic kidney disease (n = 1), and idiopathic refractory ascites (n = 1). The authors retrospectively evaluated technical feasibility, shunt patency, complications, and clinical outcomes of each patient. RESULTS: The technical success rate was 100%, and symptomatic improvement was achieved in all but one patient. Complications occurred in 17 of the 55 patients (31%): five patients had variceal bleeding; three patients had ascites leakage; two patients each had disseminated intravascular coagulopathy, transient abdominal pain, shunt infection, and venous thrombosis; and one patient had pulmonary thromboembolism. Thirty patients (54%) died 2-690 days after the procedure (mean, 117 days), and their lifetime shunt patency was 84%. Eight patients were lost to follow-up. Seventeen patients were alive for 60-1,200 days, and their shunt patency was 71%. There was no significant difference in shunt patency between the two groups with benign and malignant ascites. CONCLUSIONS: The percutaneous placement of a PVS was a technically feasible and effective method for symptomatic relief of refractory ascites.

Predictive Factors for Treatment Failure after Peritoneovenous Shunt for Hepatic Ascites.

Peritoneovenous shunt (PVS) is used to treat refractory ascites. Here, we identify predictive factors for inhospital death after PVS placement. Thirty-five patients with refractory ascites related to liver cirrhosis and/or hepatocellular carcinoma (HCC) who underwent PVS placement between February 2005 and February 2013 were included in the study. Group A comprised 13 patients for whom the PVS placement outcome was inhospital death. Group B comprised 22 patients who were discharged after PVS placement without complications. Patient background and laboratory data were analyzed to identify risk factors for inhospital death. HCC prevalence in Groups A and B was 92 and 55 per cent, respectively (P = 0.02) and that of portal venous tumor thrombus (PVTT) was 54 and 9 per cent, respectively (P = 0.003). The mean des-γ-carboxy prothrombin (DCP) level in both groups was 15,553 ± 49,330 and 787 ± 2600 mAU/mL, respectively (P = 0.009). Multivariate analysis revealed that the presence of PVTT was the only independent predictor of inhospital death (P = 0.007). The presence of PVTT, HCC, and elevated des-γ-carboxy prothrombin levels are predictors of inhospital death after PVS placement. Therefore, PVS should not be used to treat refractory ascites in patients with these predictors, particularly with PVTT.

Peritoneovenous shunting of intractable ascites in patients with cirrhosis: improving results and predictive factors of failure.

BACKGROUND: The clinical results of peritoneovenous shunting have not been entirely satisfactory in spite of dramatic improvement of renal function and decrease of ascites. The purpose of this study is to determine whether certain modifications improved our results. METHODS: A modified LeVeen shunt was electively inserted in 56 patients who had cirrhosis with intractable ascites. In 24 patients (42.9%) the Child-Pugh's score was less than 9, and in 32 patients the score was 9 or above. Fourteen patients (25%) had previous variceal bleeding, and 15 patients (26.8%) had previous spontaneous bacterial peritonitis (SBP). LeVeen shunt was modified by the addition of a titanium venous catheter tip. Prophylactic antibiotic therapy was administered to all patients. RESULTS: No operative deaths occurred, and one patient had severe postshunt coagulopathy. Five patients (8.9%) experienced recurrent ascites resulting from blockage from the shunt. The cumulative rate of shunt blockage was 5.6% at 1 year and 12% at 2 years. Seventeen patients (30.3%) have recently had variceal bleeding. The cumulative risk of variceal bleeding was significantly higher in patients with a previous hemorrhage than in those patients without (p < 0.05). Eight patients (14.3%) had SBP after operation. The cumulative risk of SBP was higher in patients with a history of SBP than in those patients without, although the difference was not significant. Fifty-five percent of late deaths were related to variceal bleeding or to SBP. Overall cumulative 1- and 2-year survival rates were 67.2% and 55.2%, respectively. It was 82% and 71% in patients without previous variceal bleeding or SBP. CONCLUSIONS: These data suggest that peritoneovenous shunting might be beneficial only in selected patients. Previous variceal bleeding and/or SBP indicate liver transplantation in suitable patients.

Complications of Denver peritoneovenous shunting.

The records of 49 consecutive patients treated with Denver peritoneovenous shunts were reviewed to determine the incidence of complications and length of patient survival. Thirty-eight complications (16 types) were identified in 22 (45%) of the patients and, in 10 instances, contributed to subsequent death. Ten percent of shunts failed during long-term follow-up. The 54% one-year survival by life-table analysis of patients with cirrhosis treated with the Denver shunt matched results previously reported for similar patients treated with the LeVeen shunt. Patients with intra-abdominal malignant neoplasms had an 11% one-year survival overall. Although it too is associated with significant complications, the Denver peritoneovenous shunt seems to have a lower failure rate and a lower incidence of complications than the LeVeen peritoneovenous shunt. Thus, the Denver shunt offers advantages in the treatment of intractable ascites.

Peritoneal venous shunting for ascites: a 15-year perspective.

Intractable ascites is an incapacitating condition for the patient and a difficult management problem for the physician. Three different shunts have been evaluated in 26 patients over a 15-year period and, on the basis of this experience, recommendations are made to avoid some of the technical problems with peritoneal venous shunts. Nine patients had a Hyde shunt, 12 had a LeVeen shunt, and five patients had a Denver shunt. Operation was performed only after failure of medical management during a 2-24-week period of hospitalization. Four patients had malignant ascites, two nephrogenic ascites, and the remaining 24 patients had ascites secondary to alcoholic liver disease. The type of shunt used did not appear to be critical, as the results were similar in the three groups. The morbidity rate of 57% (operative deaths and need for revision) and the fact that only 27% were alive after one year emphasize that improvements are desirable. Methods to avoid technical problems influencing malfunction of the device are stressed.

Short- and long-term effectiveness, morbidity, and mortality of peritoneovenous shunt inserted to treat massive refractory ascites of nephrogenic origin analysis of 14 cases.

The experience with 14 patients with end-stage renal disease (ESRD), 13 of them maintained on chronic hemodialysis (x 20.4 months +/- 2.9 SEM) and one following successful renal transplantation, underwent placement of a peritoneovenous shunt (PVS) for refractory ascites that had been present before insertion from two to 15 months (x 5.3 +/- 0.8 SEM). A "specific" cause for the ascites could not be identified in any of the 14 patients. The ascites was an exudate in every patient (protein content greater than 3.5 gm/dl). Twelve patients (86%) obtained significant relief of the discomfort and all effects of the ascites, and objective clinical improvement persisted for at least six months. Nine patients (75%) survived one year and six (50%) survived three or more years. Three patients (21%) had recurrence of ascites because of shunt malfunction; however, two of them were successfully treated with placement of a second shunt. Eight (57%) patients have died since the onset of their ascites (x 14.1 months +/- 3.5 SEM); one death was attributable to PVS placement, while the other seven deaths were due to complications of their ESRD. Insertion of a PVS is an effective therapeutic alternative to palliate the discomfort and ill effects of massive nephrogenic ascites that is often refractory to hemodialysis with ultrafiltration.

Peritoneovenous shunts in patients with intractable ascites: palliation at what price?

Intractable ascites carries great morbidity by affecting appetite, mobility, and quality of life. Peritoneovenous shunts (PVSs) are utilized to abate intractable ascites, although long-term efficacy is unestablished. Thirty male and 18 female cirrhotics, 55 +/- 12 (standard deviation) years of age, failed multiple large-volume paracenteses and diuretic therapy before undergoing PVS. Data were collected until death or the present time. Nine patients (19%) are alive and palliated, four with working shunts [average follow-up (ave. f/u), 30 months] and five without shunts (ave. f/u, 19 months). Thirty-two (67%) patients died: 18 palliated with functional shunts (survival time, 4.4 +/- 5.7 months), 8 unpalliated with dysfunctional shunts (ave. f/u, 3.9 +/- 4.5 months), 4 unpalliated with shunts removed (ave. f/u 5.5 +/- 4.7 months), and 2 with unknown shunt function at death. Function was lost to occlusion in 26 patients, infection in 9, and ligation for disseminated intravascular coagulation in 3. Thirteen patients underwent 18 shunt replacements. At death/present time, 22 (46%) patients were palliated with functioning shunts. Seven patients were lost to follow-up. PVSs provide palliation for intractable ascites short term, but commonly occlude within 1 year. Despite palliation, complications with PVSs are high, and survival is limited.

[Peritoneovenous shunting in intractable ascites of cirrhosis. Results of a prospective study on improving prognostic factors]. / Dérivation péritonéo-veineuse dans l'ascite irréductible de la cirrhose. Résultats d'une étude prospective sur les facteurs d'amélioration du pronostic.

A peritoneovenous (LeVeen) shunt was inserted in 39 patients with cirrhosis and intractable ascites. Based on the results of previous experience, the following procedures were performed to improve outcome: 1) intraoperative drainage of most of the ascites; 2) short-term antibiotic prophylaxis by cefotetan; 3) the use of a titanium venous catheter tip. There was no operative mortality. Operative morbidity was minimal. Mean postoperative in-hospital stay was 19 +/- 5 days. Two patients had recurrence of ascites. This resulted from obstruction of the valve in one patient and of occlusion of the venous catheter in the second patient. One-year probability of shunt failure was 5.8 p. 100. Among the long-term complications, variceal bleeding was the most frequent as it occurred in 8 patients and was responsible for death in 6. One-year probability of variceal bleeding was 18.6 p. 100. Overall one-year survival was 68 p. 100, 79 p. 100 in the group of 19 patients with Pugh scores of 8 and less, 58 p. 100 in the group of 20 patients with Pugh scores greater than 8. These results suggest that technically improved peritoneovenous shunting is a low operative risk surgical procedure with high efficiency in the treatment of intractable ascites in cirrhosis.

Prognostic value of preoperative tests in the surgical treatment of ascites with the implant of Le Veen shunts in cirrhotics.

In the period of January 1978 to October 1988, 32 Le Veen shunts (LVS) were implanted in 20 patients, out of which 16 were alcoholic cirrhotics and 4 postnecrotic cirrhotics. In the present study, we correlated preoperative laboratory data of these patients with their postoperative evolution, comparing the clinical results of patients who survived more than 30 days (13 patients = 65%) with the results of those who died within the same period (7 patients = 35%). For that matter, 14 laboratory tests were performed in order to measure the serum levels of hematocrit, hemoglobin, urea, creatinine, sodium, potassium, bilirubin, albumin, AST, ALT, alkaline phosphatase, fibrinogen, gamma GT and prothrombin activity. After statistical analysis, we observed that 6 of the 14 tests performed could be considered of prognostic value in the following decreasing order of importance: fibrinogen, alkaline phosphatase, prothrombin activity, urea, gamma GT and bilirubin. We observed that all the 7 patients who died prematurely presented 3 or more of these levels altered, when compared with standard values. Based on these data, we concluded that serum levels of fibrinogen, alkaline phosphatase, urea, gamma GT, bilirubin and activity of prothrombin proved to be important factors in determining the prognosis of immediate survival in cirrhotic patients who underwent LVS implantation. We also concluded that when 3 or more of these factors are altered, the implant of LVS is contraindicated, whatever clinical criteria for indication and contraindication were taken into account.

[Use of the Leveen shunt in the treatment of clinically intractable ascites]. / Uso da válvula de Le Veen no tratamento da ascite clinicamente intratável.

From January 1978 to August 1987, 21 patients received a peritoneovenous shunt using the Le Veen valve (LVV). The indications criteria were the long-term diuretic therapy failure (mean time = 24.4 months) or resistence to medical therapy during hospital internment. The 21 patients underwent 36 surgeries, being 4 valve position review and 11 changes of LVV. The mean age was 51.6 years. Fifteen patients had alcoholic cirrhosis, 3 postnecrotic cirrhosis, one Budd-Chiari syndrome, one mansoni Schistosomiasis, and one malignant ascites. Ten were Child B and 9 Child C patients. Eight patients with history of previous esophageal varices bleeding (EVB) underwent endoscopic sclerotherapy (EE) before LVV implantation. Seven patients died in the early postoperative period (3 Child B and 4 Child C patients). Three patients died due to EVB and the others as consequence of hepatic failure (one), cardiac insufficiency (one), sepsis (one), and bronchopneumonia (one). The mean follow-up was 19.9 months (1-61). Early LVV occlusion occurred in 4 patients and late valve occlusion in others 4 patients. The LVV changes were done at ambulatorial preceeding. Ten patients (47.6%) died in late follow-up and in these cases death was related to the main disease course. It is concluded that: 1) LVV is a useful therapy in patients with intractable ascites, since it is not the terminal manifestations of disease; 2) early mortality is related to liver function and late mortality to main disease course; 3) ascitic patients with EVB should undergo endoscopic sclerotherapy before LVV implantation.

Denver peritoneovenous shunts for the management of malignant ascites: a review of the literature in the post LeVeen Era.

Most case series describing peritoneovenous (PV) shunts for malignant ascites include both LeVeen and Denver shunts. Conclusions based on these studies are no longer clinically relevant since the LeVeen shunt has been discontinued. The purpose of this study was to identify outcomes specific to Denver shunts to establish expected results in the modern era. Case series describing PV shunts for malignant ascites between 1980 and 2008 were identified through a keyword PUBMED search. Whenever possible, results attributable to Denver shunts were abstracted and analyzed. Nineteen series describing 341 patients undergoing 353 Denver PV shunts for malignant ascites were identified. The primary indications for PV shunts were unspecified or cancers of unknown origin (40%), ovarian cancer (16%), and pancreatic cancer (8%). Primary patency averaged 87 ± 57 days. Seventy-four per cent of patients died with functioning shunts. Complications occurred in 38% of patients including occlusion (24%) and disseminated intravascular coagulation (9%). Average survival of all patients was 3.0 ± 1.7 months and shunts provided effective palliation in 75.3%. One and a half per cent of 133 patients who had autopsies were reported to have hematologic dissemination. These results are not statistically different than overall results reported for both shunts combined or LeVeen shunts alone. Studies that report combined outcomes with Denver and LeVeen shunts for malignant ascites are neither negatively, nor positively influenced by one specific shunt. Expectations following PV shunting for malignant ascites do not have to be revised because LeVeen shunts are no longer available.

Morbidity and mortality after peritoneovenous shunt surgery for refractory ascites.

A prospective analysis of the morbidity and mortality after peritoneovenous shunting was carried out in 25 patients who had a total of 27 shunts for refractory ascites. Major complications were limited to the patients in whom ascites was secondary to hepatic rather than peritoneal disease. Immediate postoperative complications followed 17 out of the 23 shunts carried out in patients with liver disease and included septicaemia (two), profound hypotension (two), pulmonary oedema (one), and clinically evident disseminated intravascular coagulation (14). Long term morbidity was again limited to the patients with liver disease and included chronic shunt infection (two) and major venous thrombosis (two). Shunt associated mortality was only seen in the patients with liver disease. Despite late shunt blockage in five long term survivors with alcoholic liver disease fluid retention was easily controlled by simple medical means probably because of improved liver function associated with abstinence from alcohol. It is concluded that: (1) patients with hepatic and malignant ascites respond differently to the insertion of a peritoneovenous shunt; (2) Shunt patency should be monitored regularly in patients with liver disease and, because of the potential for septic and thrombotic complications, if blocked the shunt should be removed and; (3) because of the morbidity and mortality of peritoneovenous shunt surgery in patients with liver disease and refractory ascites, an alternative mode of therapy, such as repeated ultrafiltration and reinfusion of ascitic fluid, may be a more effective initial therapeutic approach especially in patients in whom there is a reversible element to their underlying liver disease.

[Irreducible ascites in cirrhotic patients. Results of peritoneo-jugular shunt in 16 patients (author's transl)]. / Ascite "irréductible" du cirrhotique. Résultats de la dérivation péritonéojugulaire chez 16 malades.

Peritoneo-jugular shunt with Le Veen's valve was performed in 16 cirrhotic patients with intractable ascites. The immediate effects were remarkable, with only one early death. In the long term, however, the results progressively deteriorated. Relapses occurred frequently (60%) and sometimes repeatedly, and were due to obstruction of the shunt, which had to be replaced, or in some cases to insufficient flow rate. Numerous complications were observed including, in particular, infections and digestive haemorrhages. Consumption coagulopathy was detected by laboratory tests in 5 cases, but did not produce bleeding. After 8 to 25 months, 31% of the patients are still alive.

The LeVeen shunt in the elective treatment of intractable ascites in cirrhosis. A prospective study on 140 patients.

One hundred and forty patients with an intractable ascites complicating a chronic liver disease received a peritoneovenous shunt (PVS) using the LeVeen valve. Operative mortality was ten per cent but was 25% in patients with severe liver failure. Intraoperative drainage of ascites sharply decreased postoperative complications and mortality. One-year actuarial survival rate was 81.4%, respectively 77.7%, 61.3%, and 24.7% in patients with good liver function and moderate or severe liver failure. Variceal hemorrhage occurred in 11 patients and late infection in another 11 patients. Thirty-eight patients (30.5%) had recurrence of ascites. This was mostly due to an obstruction on the venous side of the shunt. An elective portacaval shunt had to be done in 23 patients for recurrence of ascites or variceal bleeding. Among the 57 patients still alive at time of writing, 51 were free of ascites. These results suggest that PVS is an efficient operation. This procedure may be largely indicated in the selected and small group of cirrhotic patients with true intractable ascites and moderate or no liver insufficiency.

Denver peritoneovenous shunting for malignant or cirrhotic ascites. A prospective consecutive series.

A Denver peritoneovenous (PV) shunt was inserted in 54 consecutive patients for relief of malignant (24 patients) or cirrhotic (30) refractory ascites. The median age of both groups was 58 years, and the most frequent diagnoses were gastrointestinal (15) or ovarian (7) cancers and alcoholic cirrhosis (25). Median survival time was 1.7 and 3.5 months (range, 0.1-15.5 and 0.1-50.5), and the 1-month mortality 42% and 27%, respectively. Postoperative 24-h urinary output increased by 2-31, and the 1-week weight reduction was 8 and 11 kg, respectively, compared with before shunting. Complete shunt failure was encountered early in two patients, due to catheter malposition and clotting. Four more patients experienced transient failure, for an early dysfunction rate of 11%. A shunt-related operative mortality of 6% was caused by pulmonary oedema (two patients) and sepsis (one patient). Shunt malfunction intervened in almost half (6 of 14) of the cancer patients surviving 1 month but was relieved in all but 1. In 3 of 22 cirrhotic 1-month survivors, the Denver shunt had to be removed owing to clotting or sepsis (2 patients) or revised because of blockage. Seven patients with cirrhosis are alive a median of 18 months (range, 2-51) after PV shunt surgery. Side effects were detected in 22 patients (41%): thromboembolism (9 patients), sepsis (7), initially bleeding oesophageal varices (3), DIC syndrome (2), postoperative hepatic coma (2), ascitic leakage (2), and pulmonary oedema (2). Patients with gastrointestinal cancers or severe cardiac disease did not benefit from the procedure. A history of hepatic encephalopathy or a serum bilirubin level above about 100 mumol/l was a bad prognostic sign. We could confirm the reported considerable morbidity and mortality after PV shunting, but also its efficiency in certain cases. Careful patient selection and follow-up study, timing of operation, and adherence to technical details are mandatory to improve the results.

Patient selection and survival after peritoneovenous shunting for nonmalignant ascites.

Patient selection and survival after peritoneovenous shunting for nonmalignant ascites was assessed in 30 patients undergoing 44 peritoneovenous shunting procedures over a 5-year period. Indications for peritoneovenous shunting included refractory ascites alone, refractory ascites complicated by hepatorenal syndrome, and nonrefractory but recurrent ascites. Fifty-six percent of shunting procedures were complicated by shunt malfunction and an additional 13% ended in shunt removal or ligation. Serious perioperative morbidity occurred in 47% of patients. Mean duration of shunt function was significantly less (p less than 0.05) in the patients with hepatorenal syndrome (15 +/- 5 days) compared to the patients with refractory ascites alone (45 +/- 13 days), or the patients with nonrefractory ascites (64 +/- 34 days). Mean survival was 265 +/- 87 days. Survival of patients with nonrefractory ascites (767 +/- 214 days) was significantly longer (p less than 0.05) than that seen in patients with hepatorenal syndrome (28 +/- 5 days) or in patients with refractory ascites alone (256 +/- 148 days). Combined inhospital mortality was 30%. It was significantly greater (p less than 0.05) in patients with hepatorenal syndrome (70%) than in patients with refractory ascites alone (14%) or in patients with nonrefractory ascites (0%). We conclude that patient selection significantly influences survival after peritoneovenous shunting and may account for the varying results reported by other groups.

The Denver type for peritoneovenous shunting of malignant ascites.

Peritoneovenous shunts of the Denver type were inserted into 36 patients to control malignant ascites. The Denver system features a compressible pump chamber bearing a pressure sensitive valve. Initially, all the shunts functioned well. The shunt remained open until death in 21 patients, and at the beginning of the analysis, another two patients were still alive with an open shunt. Blockage of the shunt occurred in 13 patients before death. The cumulative survival time for patients after shunt insertion was 129 months and the cumulative shunt functioning time was 92 months. The over-all median survival time after shunt installation was 13 weeks, and calculated actuarially, the median shunt functioning time for long term survivors was 14 weeks. The cytologic state of the ascitic fluid did not make a statistically significant difference to the blockage-free interval (p = 0.99), neither did the type of primary tumor (p = 0.37). Complications were of a minor type. There was no laboratory or clinical evidence of disseminated intravascular coagulation. Tumor spread through the tubing was seen in one of the three autopsies performed. Denver type peritoneovenous shunting appears to provide effective palliation in the majority of patients. It should, however, only be performed as a last resort.