Minimally invasive surgical strategy for refractory hepatic hydrothorax

Video-assisted thoracoscopic surgery for pleuroperitoneal communication

Here we report the cases of five patients on continuous ambulatory peritoneal dialysis (CAPD) who developed hydrothorax because of pleuroperitoneal communication. Preoperative computed tomography (CT) peritoneography revealed penetrated sites on the diaphragm in all patients. All patients underwent video-assisted thoracoscopic surgery (VATS), and a dialysate containing indigo carmine was injected intraperitoneally through a CAPD catheter to confirm the fistula. In all patients, a thinned bleb was found at the center of the diaphragmatic tendon consistent with that noted on preoperative CT peritoneography. The bleb was resected using a surgical stapler in four patients, and the pleuroperitoneal communication did not recur. However, in one patient, the bleb was only covered with reinforcement agents and the hydrothorax recurred after CAPD. This study demonstrates that VATS treatment for pleuroperitoneal communication is safe and effective but that lesion resection would be more useful for preventing hydrothorax recurrence in patients undergoing CAPD.

Minimally Invasive Surgical Treatment of Hepatic Hydrothorax Complicated by Empyema: A Case Report

Hepatic hydrothorax complicated by empyema is difficult to manage. A 53-year-old man with liver cirrhosis was admitted for refractory right pleural effusion. He had a pleural catheter inserted 2 months prior. Pleural fluid appeared as exudate, and bacteria were identified in the pleural fluid culture. After confirming full ipsilateral lung expansion, minimally invasive surgery was performed. A diaphragmatic defect found by creating a pneumoperitoneum was closed, followed by talc pleurodesis. Postoperatively, overnight positive-pressure ventilation and 5-day peritoneal drainage were performed; chest tube drainage dramatically reduced over this time. At the 10-month follow-up, no recurrence of pleural effusion or signs of infection were observed.

Nonmalignant Pleural Effusions

Although the potential causes of nonmalignant pleural effusions are many, the management of a few, including complicated pleural infections and refractory heart failure and hepatic hydrothoraces, can be challenging and requires the assistance of interventional pulmonologists. A pragmatic approach to complicated parapneumonic effusions or empyemas is the insertion of a small-bore chest tube (e.g., 14-16 Fr) through which fibrinolytics (e.g., urokinase and alteplase) and DNase are administered in combination. Therapeutic thoracenteses are usually reserved for small to moderate effusions that are expected to be completely aspirated at a single time, whereas video-assisted thoracic surgery should be considered after failure of intrapleural enzyme therapy. Refractory cardiac and liver-induced pleural effusions portend a poor prognosis. In cases of heart failure-related effusions, therapeutic thoracentesis is the first-line palliative therapy. However, if it is frequently needed, an indwelling pleural catheter (IPC) is recommended. In patients with hepatic hydrothorax, repeated therapeutic thoracenteses are commonly performed while a multidisciplinary decision on the most appropriate definitive management is taken. The percutaneous creation of a portosystemic shunt may be used as a bridge to liver transplantation or as a potential definitive therapy in nontransplant candidates. In general, an IPC should be avoided because of the high risk of complications, particularly infections, that may jeopardize candidacy for liver transplantation. Even so, in noncandidates for liver transplant or surgical correction of diaphragmatic defects, IPC is a therapeutic option as valid as serial thoracenteses.

Hepatic Hydrothorax and Congestive Heart Failure Induced Pleural Effusion

Pleural effusions (PEs) are frequently encountered in routine clinical practice, affecting more than 3000 people per million population every year. Heart and liver failures are two of the most common causes of transudative PE. Because these effusions have nonmalignant etiologies, they are commonly referred to as benign effusions despite of the poor prognosis they foretell in their refractory stages. Like malignant effusions, symptom management is important and plays a significant role in palliation when these effusions become refractory to medical therapy.

Pleural Interventions in the Management of Hepatic Hydrothorax

Hepatic hydrothorax can be present in 5% to 15% of patients with underlying cirrhosis and portal hypertension, often reflecting advanced liver disease. Its impact can be variable, because patients may have small pleural effusions and minimal pulmonary symptoms or massive pleural effusions and respiratory failure. Management of hepatic hydrothorax can be difficult because these patients often have a number of comorbidities and potential for complications. Minimal high-quality data are available for guidance specifically related to hepatic hydrothorax, potentially resulting in pulmonary or critical care physician struggling for best management options. We therefore provide a Case-based presentation with management options based on currently available data and opinion. We discuss the role of pleural interventions, including thoracentesis, tube thoracostomy, indwelling tunneled pleural catheter, pleurodesis, and surgical interventions. In general, we recommend that management be conducted within a multidisciplinary team including pulmonology, hepatology, and transplant surgery. Patients with refractory hepatic hydrothorax that are not transplant candidates should be managed with palliative intent; we suggest indwelling tunneled pleural catheter placement unless otherwise contraindicated. For patients with unclear or incomplete hepatology treatment plans or those unable to undergo more definitive procedures, we recommend serial thoracentesis. In patients who are transplant candidates, we often consider serial thoracentesis as a standard treatment, while also evaluating the role indwelling tunneled pleural catheter placement may play within the course of disease and transplant evaluation.

[Intraoperative pleurodesis with talc and trichloroacetic acid for exudative pleuritis]

OBJECTIVE

To compare the efficacy of chemical pleurodesis with talc and trichloroacetic acid during thoracoscopy.

MATERIAL AND METHODS

Thoracoscopy with pleural biopsy was performed in 355 (83.5%) out of 424 patients with pleural effusion. Pleurodesis was ensured by intraoperative insufflation of talc powder (n=135) and application of 33% trichloroacetic acid solution to parietal and visceral pleura (n=19) in patients with malignant (125), inflammatory (6), post-traumatic (4), tuberculous (3), pancreatogenic (8) and hepatogenic (8) effusions. Drainage tubes were removed if daily drainage output volume was less than 100 ml or complete lung inflation was observed.

RESULTS

Post-pleurodesis drainage took 7.1±5.4 days. Two patients developed bumpy rashes that were initially interpreted as carcinomatosis. However, these rashes were later identified as tuberculosis. Retrospectively, these patients were not good candidates for pleurodesis. Pleurodesis with talc suppressed exudation in 89.6% of cases. Complications developed in 4 cases (3%): pneumonia (1) and pleural empyema (3). These complications were associated with a violation of technical procedure of pleurodesis, i.e. procedure in rigid lung, atelectasis (1) and bronchopleural fistula (2). Mean duration of drainage after trichloroacetic acid-induced pleurodesis was 7.9±6.7 days. This procedure was effective in 84.2% of cases, and there were no complications. There are no previous reports on the use of this pleurodesis technique in the literature. Mean duration of drainage after talc-induced pleurodesis was decreased up to 6.9±5.4 days in patients with malignant pleural effusion (p<0.05), after trichloroacetic acid-induced pleurodesis - up to 7.5±8.1 days (p>0.05) compared to patients without pleurodesis (9.1±11.2 days).

CONCLUSION

Pleurodesis with talc or trichloroacetic acid during thoracoscopy is effective for pleural effusions following malignancies, liver, kidney and cardiac diseases with decompensation. Essential requirements are adequate lung inflation, no atelectasis and bronchopleural fistula.