1
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Chaaban T, Kanj N, Bou Akl I. Hepatic Hydrothorax: An Updated Review on a Challenging Disease. Lung 2019; 197:399-405. [PMID: 31129701 DOI: 10.1007/s00408-019-00231-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 04/27/2019] [Indexed: 12/14/2022]
Abstract
Hepatic hydrothorax is a challenging complication of cirrhosis related to portal hypertension with an incidence of 5-11% and occurs most commonly in patients with decompensated disease. Diagnosis is made through thoracentesis after excluding other causes of transudative effusions. It presents with dyspnea on exertion and it is most commonly right sided. Pathophysiology is mainly related to the direct passage of fluid from the peritoneal cavity through diaphragmatic defects. In this updated literature review, we summarize the diagnosis, clinical presentation, epidemiology and pathophysiology of hepatic hydrothorax, then we discuss a common complication of hepatic hydrothorax, spontaneous bacterial pleuritis, and how to diagnose and treat this condition. Finally, we elaborate all treatment options including chest tube drainage, pleurodesis, surgical intervention, Transjugular Intrahepatic Portosystemic Shunt and the most recent evidence on indwelling pleural catheters, discussing the available data and concluding with management recommendations.
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Affiliation(s)
- Toufic Chaaban
- Neurocritical Care Fellowship, Wexner Medical Center, Ohio State University, Columbus, OH, USA
| | - Nadim Kanj
- Pulmonary and Critical Care Division, Internal Medicine Department, American University of Beirut Medical Center, Riad El Solh, PO Box 11-0236, Beirut, Lebanon
| | - Imad Bou Akl
- Pulmonary and Critical Care Division, Internal Medicine Department, American University of Beirut Medical Center, Riad El Solh, PO Box 11-0236, Beirut, Lebanon.
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2
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Silva Cruz C, Tosatto V, Nascimento PO, Barata Moura R. Hepatic hydrothorax: indwelling catheter-related Acinetobacter radioresistens infection. BMJ Case Rep 2019; 12:12/3/e227635. [PMID: 30878955 DOI: 10.1136/bcr-2018-227635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Hepatic hydrothorax, a rare and debilitating complication of cirrhosis, carries high morbidity and mortality. First-line treatment consists of dietary sodium restriction and diuretic therapy. Some patients, mainly those who are refractory to medical management, will require invasive pleural drainage. The authors report the case of a 76-year-old man in a late cirrhotic stage of alcoholic chronic liver disease, presenting with recurrent right-sided hepatic hydrothorax, portal hypertension, hepatosplenomegaly and thrombocytopaenia. After recurrent admissions and complications, the potential for adjusting diuretic therapy was limited. After unsuccessful talc pleurodesis, an indwelling tunnelled pleural catheter was placed with effective symptomatic control. One month later, the patient was readmitted with empyema due to Acinetobacter radioresistens Despite optimised medical and surgical treatment, the patient died 4 weeks later.
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Affiliation(s)
- Cristiano Silva Cruz
- Department of Internal Medicine, Centro Hospitalar de Lisboa Central, EPE - Hospital de Santa Marta, Lisboa, Portugal
| | - Valentina Tosatto
- Department of Internal Medicine, Centro Hospitalar de Lisboa Central, EPE - Hospital de Santa Marta, Lisboa, Portugal
| | - Paula Oliveira Nascimento
- Department of Internal Medicine, Centro Hospitalar de Lisboa Central, EPE - Hospital de Santa Marta, Lisboa, Portugal
| | - Rita Barata Moura
- Department of Internal Medicine, Centro Hospitalar de Lisboa Central, EPE - Hospital de Santa Marta, Lisboa, Portugal
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Abstract
Hepatic hydrothorax (HH) is a pleural effusion that develops in a patient with cirrhosis and portal hypertension in the absence of cardiopulmonary disease. Although the development of HH remains incompletely understood, the most acceptable explanation is that the pleural effusion is a result of a direct passage of ascitic fluid into the pleural cavity through a defect in the diaphragm due to the raised abdominal pressure and the negative pressure within the pleural space. Patients with HH can be asymptomatic or present with pulmonary symptoms such as shortness of breath, cough, hypoxemia, or respiratory failure associated with large pleural effusions. The diagnosis is established clinically by finding a serous transudate after exclusion of cardiopulmonary disease and is confirmed by radionuclide imaging demonstrating communication between the peritoneal and pleural spaces when necessary. Spontaneous bacterial empyema is serious complication of HH, which manifest by increased pleural fluid neutrophils or a positive bacterial culture and will require antibiotic therapy. The mainstay of therapy of HH is sodium restriction and administration of diuretics. When medical therapy fails, the only definitive treatment is liver transplantation. Therapeutic thoracentesis, indwelling tunneled pleural catheters, transjugular intrahepatic portosystemic shunt and thoracoscopic repair of diaphragmatic defects with pleural sclerosis can provide symptomatic relief, but the morbidity and mortality is high in these extremely ill patients.
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Affiliation(s)
- Yong Lv
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
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Shojaee S, Rahman N, Haas K, Kern R, Leise M, Alnijoumi M, Lamb C, Majid A, Akulian J, Maldonado F, Lee H, Khalid M, Stravitz T, Kang L, Chen A. Indwelling Tunneled Pleural Catheters for Refractory Hepatic Hydrothorax in Patients With Cirrhosis: A Multicenter Study. Chest 2018; 155:546-553. [PMID: 30171863 DOI: 10.1016/j.chest.2018.08.1034] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 08/03/2018] [Accepted: 08/15/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The outcome of indwelling pleural catheter (IPC) use in hepatic hydrothorax (HH) is unclear. This study aimed to review the safety and feasibility of the IPC in patients with refractory HH. METHODS A retrospective multicenter study of patients with HH from January 2010 to December 2016 was performed. Inclusion criteria were refractory HH treated with an IPC and an underlying diagnosis of cirrhosis. Records were reviewed for patient demographics, operative reports, and laboratory values. The Kaplan-Meier method was used to estimate catheter time to removal. The Cox proportional hazard model was used to evaluate for independent predictors of pleurodesis and death. RESULTS Seventy-nine patients were identified from eight institutions. Indication for IPC placement was palliation in 58 patients (73%) and bridge to transplant in 21 patients (27%). The median in situ dwell time of all catheters was 156 days (range, 16-1,978 days). Eight patients (10%) were found to have pleural space infection, five of whom also had catheter-site cellulitis. Two patients (2.5%) died secondary to catheter-related sepsis. Catheter removal secondary to spontaneous pleurodesis was achieved in 22 patients (28%). Median time from catheter insertion to pleurodesis was 55 days (range, 10-370 days). Older age was an independent predictor of mortality on multivariate analysis (hazard ratio, 1.05; P = .01). CONCLUSIONS We present, to our knowledge, the first multicenter study examining outcomes related to IPC use in HH. Ten percent infection risk and 2.5% mortality were identified. IPC placement may be a reasonable clinical option for patients with refractory HH, but it is associated with significant adverse events in this morbid population.
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Affiliation(s)
- Samira Shojaee
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Medical Center, Richmond, VA.
| | - Najib Rahman
- Nuffield Department of Medicine, Oxford Center for Respiratory Medicine, University of Oxford, Oxford, England; Oxford National Institute of Health Research Biomedical Center, Oxford, England
| | - Kevin Haas
- Division of Pulmonary and Critical Care Medicine, University of Illinois, Chicago, IL
| | - Ryan Kern
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Michael Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Mohammed Alnijoumi
- Division of Pulmonary and Critical Care Medicine, University of Missouri, Columbia, MO
| | - Carla Lamb
- Division of Pulmonary and Critical Care Medicine, Lahey Hospital and Medical Center, Lynnfield, MA
| | - Adnan Majid
- Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jason Akulian
- Division of Pulmonary and Critical Care Medicine, University of North Carolina, Chapel Hill, NC
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville, TN
| | - Hans Lee
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Medical Center, Baltimore, MD
| | - Marwah Khalid
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Medical Center, Richmond, VA
| | - Todd Stravitz
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University Medical Center, Richmond, VA
| | - Le Kang
- Department of Biostatistics, Virginia Commonwealth University Medical Center, Richmond, VA
| | - Alexander Chen
- Division of Pulmonary and Critical Care Medicine, Washington University in St Louis, St Louis, MO
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Kniese C, Diab K, Ghabril M, Bosslet G. Indwelling Pleural Catheters in Hepatic Hydrothorax: A Single-Center Series of Outcomes and Complications. Chest 2018; 155:307-314. [PMID: 29990479 DOI: 10.1016/j.chest.2018.07.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 06/11/2018] [Accepted: 07/02/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Treatment of hepatic hydrothorax (HH) generally involves sodium restriction, diuretics, and serial thoracentesis. In more advanced cases, transjugular intrahepatic portosystemic shunt and liver transplantation may be required. Previously, indwelling tube drainage has been avoided due to concerns regarding high complication rates and overall poor outcomes. Recently, indwelling pleural catheters (IPCs) have been proposed as a novel treatment option for HH. METHODS This study was a retrospective review of patients who had undergone IPC placement for HH over a 10-year period at a large liver transplant referral center. We tracked outcomes, including complication rates and liver transplantation, as well as biomarkers of nutritional status. RESULTS Sixty-two patients underwent IPC placement between 2007 and 2017, with 33 IPCs (53%) placed as a bridge to liver transplantation. Complications were recorded in 22 patients (36%); empyema was the most common, diagnosed in 10 patients (16.1%). Ten patients evaluated for liver transplantation underwent successful transplantation following IPC placement. There were statistically significant decreases in both BMI and serum albumin levels following IPC placement. CONCLUSIONS IPCs represent a potential treatment for refractory HH and should be used with caution in patients eligible for liver transplantation. Ideally, IPC use for these patients would be evaluated by a multidisciplinary team. IPC use may lead to small decreases in BMI and serum albumin levels in patients over time.
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Affiliation(s)
- Christopher Kniese
- Department of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN.
| | - Khalil Diab
- Department of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Marwan Ghabril
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Gabriel Bosslet
- Department of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN
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Tunneled Indwelling Pleural Catheters for Refractory Pleural Effusions after Solid Organ Transplant. A Case-Control Study. Ann Am Thorac Soc 2018; 13:1294-8. [PMID: 27243620 DOI: 10.1513/annalsats.201601-080bc] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
RATIONALE The use of tunneled indwelling pleural catheters for management of refractory pleural effusions continues to increase. Pleural space infections are among the most common and serious complication of the procedure. The risk may be higher in patients receiving immunosuppressive medications. OBJECTIVES The aim of this study was to assess the risk of infections complicating placement of a tunneled indwelling pleural catheter in patients who have received a solid organ transplant. METHODS Electronic medical records were retrospectively reviewed to identify patients with prior solid organ transplant who subsequently underwent placement of a tunneled intrapleural catheter. We selected a matched sample of comparison patients without solid organ transplant who underwent the same procedure during the study period. Detailed chart abstraction was performed to compare baseline clinical information with procedure outcomes in both groups. MEASUREMENTS AND MAIN RESULTS Nineteen study patients underwent kidney, liver, lung, or heart transplant. Another 55 patients were included in the nontransplant comparison group. Transplant patients were taking a mean of 2.4 (range, 1-4) immunosuppressive medications. In transplant patients, the intrapleural catheter remained in place for a median of 95 days (interquartile range, 58-256 d). Two of the 19 transplant patients (16.9% 90-day Kaplan-Meier estimate) and 4 of the 55 control patients (11.0% weighted 90-day Kaplan-Meier estimate) developed a major infectious complication (not significant). There were no deaths attributed to intrapleural catheter placement in either group. CONCLUSIONS In a series of 19 patients with solid organ transplantation taking daily immunosuppressive medications who underwent placement of a tunneled intrapleural catheter, we report an 11% rate of major infectious complications over the lifetime of the catheter in the transplant group with no significant difference in 90-day estimated risk of complication between transplant and nontransplant comparison group.
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7
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Indwelling tunneled pleural catheters for the management of hepatic hydrothorax. Curr Opin Pulm Med 2017; 23:351-356. [DOI: 10.1097/mcp.0000000000000386] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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8
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Chambers DM, Abaid B, Gauhar U. Indwelling Pleural Catheters for Nonmalignant Effusions: Evidence-Based Answers to Clinical Concerns. Am J Med Sci 2017; 354:230-235. [PMID: 28918827 DOI: 10.1016/j.amjms.2017.03.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 02/07/2017] [Accepted: 03/02/2017] [Indexed: 11/30/2022]
Abstract
Pleural effusions occur in 1.5 million patients yearly and are a common cause of dyspnea. For nonmalignant effusions, initial treatment is directed at the underlying cause, but when effusions become refractory to medical therapy, palliative options are limited. Tunneled pleural catheters (TPCs) are commonly used for palliation of malignant effusions, but many clinicians are reluctant to recommend these devices for palliation of nonmalignant effusions, citing concerns of infection, renal failure, electrolyte disturbances and protein-loss malnutrition. Based on the published experience to date, TPCs relieve dyspnea and can result in spontaneous pleurodesis in patients with nonmalignant effusions. The infection rate compares favorably to that for malignant effusions with possible increased risk in patients with hepatic hydrothorax and posttransplant patients. Renal failure, electrolyte disturbance and protein-loss malnutrition have not been observed. TPCs are a reasonable option in select patients to palliate nonmalignant effusions refractory to maximal medical therapy.
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Affiliation(s)
- David Maurice Chambers
- Division of Pulmonary, Critical Care, and Sleep Disorders Medicine, University of Louisville, Louisville, Kentucky.
| | - Bilal Abaid
- Department of Infectious Disease, University of Louisville, Louisville, Kentucky
| | - Umair Gauhar
- Division of Pulmonary, Critical Care, and Sleep Disorders Medicine, University of Louisville, Louisville, Kentucky
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9
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Hung TH, Tseng CW, Tsai CC, Hsieh YH, Tseng KC, Tsai CC. Mortality Following Catheter Drainage Versus Thoracentesis in Cirrhotic Patients with Pleural Effusion. Dig Dis Sci 2017; 62:1080-1085. [PMID: 28130709 DOI: 10.1007/s10620-017-4463-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 01/16/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pleural effusion is an abnormal collection of body fluids that may cause related morbidity or mortality in cirrhotic patients. There are insufficient data to determine the optimal method of drainage, for symptomatic relief in cirrhotic patients with pleural effusion. AIMS In this study, we compare the mortality outcomes of catheter drainage versus thoracentesis in cirrhotic patients. METHODS The National Health Insurance Database, derived from the Taiwan National Health Insurance Program, was used to identify cirrhotic patients with pleural effusion requiring drainage between January 1, 2007, and December 31, 2010. In all, 2556 cirrhotic patients with pleural effusion were selected for the study and divided into the two groups (n = 1278/group) after propensity score matching. RESULTS The mean age was 61.0 ± 14.3 years, and 68.9% (1761/2556) were men. The overall 30-day mortality was 21.0% (538/2556) and was higher in patients treated with catheter drainage than those treated with thoracentesis (23.5 vs. 18.6%, respectively, P < 0.001 by log-rank test). After Cox proportional hazard regression analysis adjusted by patient sex, age, and comorbid disorders, the risk of 30-day mortality was significantly higher in cirrhotic patients who accepted catheter drainage compared to thoracentesis (hazard ratio 1.30, 95% confidence interval 1.10-1.54, P = 0.003). Old age, hepatic encephalopathy, bleeding esophageal varices, hepatocellular carcinoma, ascites, and pneumonia were associated with higher risks for 30-day mortality. CONCLUSION In cirrhotic patients with pleural effusion requiring drainage, catheter drainage is associated with higher mortality compared to thoracentesis.
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Affiliation(s)
- Tsung-Hsing Hung
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 2, Minsheng Rd., Dalin Township, Chiayi County, 62247, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chih-Wei Tseng
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 2, Minsheng Rd., Dalin Township, Chiayi County, 62247, Taiwan. .,School of Medicine, Tzu Chi University, Hualien, Taiwan.
| | - Chen-Chi Tsai
- School of Medicine, Tzu Chi University, Hualien, Taiwan.,Division of Infectious Disease, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi County, Taiwan
| | - Yu-Hsi Hsieh
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 2, Minsheng Rd., Dalin Township, Chiayi County, 62247, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Kuo-Chih Tseng
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 2, Minsheng Rd., Dalin Township, Chiayi County, 62247, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chih-Chun Tsai
- Department of Mathematics, Tamkang University, Tamsui, Taiwan
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10
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An Algorithm for Management After Transjugular Intrahepatic Portosystemic Shunt Placement According to Clinical Manifestations. Dig Dis Sci 2017; 62:305-318. [PMID: 28058594 DOI: 10.1007/s10620-016-4399-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 11/29/2016] [Indexed: 12/16/2022]
Abstract
We propose an algorithm for management after transjugular intrahepatic portosystemic shunt (TIPS) placement according to clinical manifestations. For patients with an initial good clinical response, surveillance Doppler ultrasound is recommended to detect stenosis or occlusion. A TIPS revision can be performed using basic or advanced techniques to treat stenosis or occlusion. In patients with an initial poor clinical response, a TIPS venogram with pressure measurements should be performed to assess shunt patency. The creation of a parallel TIPS may also be required if the patient is symptomatic and the portal pressure remains high after TIPS revision. Additional procedures may also be necessary, such as peritoneovenous shunt (Denver shunt) placement for refractory ascites, tunneled pleural catheter for hepatic hydrothorax, and balloon-occluded retrograde transvenous obliteration procedure for gastric variceal bleeding. A TIPS reduction procedure can also be performed in patients with uncontrolled hepatic encephalopathy or hepatic failure.
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11
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Patil M, Dhillon SS, Attwood K, Saoud M, Alraiyes AH, Harris K. Management of Benign Pleural Effusions Using Indwelling Pleural Catheters: A Systematic Review and Meta-analysis. Chest 2016; 151:626-635. [PMID: 27845052 DOI: 10.1016/j.chest.2016.10.052] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 10/15/2016] [Accepted: 10/27/2016] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The indwelling pleural catheter (IPC), which was initially introduced for the management of recurrent malignant effusions, could be a valuable management option for recurrent benign pleural effusion (BPE), replacing chemical pleurodesis. The purpose of this study is to analyze the efficacy and safety of IPC use in the management of refractory nonmalignant effusions. METHODS We conducted a systematic review and meta-analysis on the published literature. Retrospective cohort studies, case series, and reports that used IPCs for the management of pleural effusion were included in the study. RESULTS Thirteen studies were included in the analysis, with a total of 325 patients. Congestive heart failure (49.8%) was the most common cause of BPE requiring IPC placement. The estimated average rate of spontaneous pleurodesis was 51.3% (95% CI, 37.1%-65.6%). The estimated average rate of all complications was 17.2% (95% CI, 9.8%-24.5%) for the entire group. The estimated average rate of major complications included the following: empyema, 2.3% (95% CI, 0.0%-4.7%); loculation, 2.0% (95% CI, 0.0%-4.7%); dislodgement, 1.3% (95% CI, 0.0%-3.7%); leakage, 1.3% (95% CI, 0.0%-3.5%); and pneumothorax, 1.2% (95% CI, 0.0%-4.1%). The estimated average rate of minor complications included the following: skin infection, 2.7% (95% CI, 0.6%-4.9%); blockage and drainage failure, 1.1% (95% CI, 0.0%-3.5%); subcutaneous emphysema, 1.1% (95% CI, 0.0%-4.0%); and other, 2.5% (95% CI, 0.0%-5.2%). One death was directly related to IPC use. CONCLUSIONS IPCs are an effective and viable option in the management of patients with refractory BPE. The quality of evidence to support IPC use for BPE remains low, and high-quality studies such as randomized controlled trials are needed.
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Affiliation(s)
- Monali Patil
- Department of Pulmonary, Critical Care and Sleep Medicine, State University of New York (SUNY) at Buffalo, Buffalo, NY
| | - Samjot Singh Dhillon
- Department of Pulmonary, Critical Care and Sleep Medicine, State University of New York (SUNY) at Buffalo, Buffalo, NY; Department of Medicine, Pulmonary Medicine, and Interventional Pulmonary Section, Roswell Park Cancer Institute, Buffalo, NY
| | - Kristopher Attwood
- Department of Biostatistics and Bioinformatics, Roswell Park Cancer Institute, Buffalo, NY
| | - Marwan Saoud
- Department of Internal Medicine, State University of New York (SUNY) at Buffalo, Buffalo, NY
| | - Abdul Hamid Alraiyes
- Department of Pulmonary, Critical Care and Sleep Medicine, State University of New York (SUNY) at Buffalo, Buffalo, NY; Department of Medicine, Pulmonary Medicine, and Interventional Pulmonary Section, Roswell Park Cancer Institute, Buffalo, NY
| | - Kassem Harris
- Department of Pulmonary, Critical Care and Sleep Medicine, State University of New York (SUNY) at Buffalo, Buffalo, NY; Department of Medicine, Pulmonary Medicine, and Interventional Pulmonary Section, Roswell Park Cancer Institute, Buffalo, NY.
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12
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Chalhoub M, Ali Z, Sasso L, Castellano M. Experience with indwelling pleural catheters in the treatment of recurrent pleural effusions. Ther Adv Respir Dis 2016; 10:566-572. [PMID: 27655919 PMCID: PMC5933596 DOI: 10.1177/1753465816667649] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Recurrent pleural effusions are frequently encountered in clinical practice.
Whether malignant or nonmalignant, they often pose a challenge to the practicing
clinician. When they recur, despite optimum medical therapy of the underlying
condition and repeated thoracenteses, more invasive definitive approaches are
usually required. Since its introduction in 1997, the PleurX catheter became the
preferred method to treat recurrent malignant pleural effusions. Since then, a
number of publications have documented its utility in managing recurrent
nonmalignant pleural effusions. The purpose of this paper is to review the use
of the PleurX catheter in recurrent pleural effusions.
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13
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Al-Zoubi RK, Abu Ghanimeh M, Gohar A, Salzman GA, Yousef O. Hepatic hydrothorax: clinical review and update on consensus guidelines. Hosp Pract (1995) 2016; 44:213-223. [PMID: 27580053 DOI: 10.1080/21548331.2016.1227685] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hepatic Hydrothorax (HH) is defined as a pleural effusion greater than 500 ml in association with cirrhosis and portal hypertension. It is an uncommon complication of cirrhosis, most frequently seen in association with decompensated liver disease. The development of HH remains incompletely understood and involves a complex pathophysiological process with the most acceptable explanation being the passage of the ascetic fluid through small diaphragmatic defects. Given the limited capacity of the pleural space, even the modest pleural effusion can result in significant respiratory symptoms. The diagnosis of HH should be suspected in any patient with established cirrhosis and portal hypertension presenting with unilateral pleural effusion especially on the right side. Diagnostic thoracentesis should be performed in all patients with suspected HH to confirm the diagnosis and rule out infection and alternative diagnoses. Spontaneous bacterial empyema and spontaneous bacterial pleuritis can complicate HH and increase morbidity and mortality. HH can be difficult to treat and in our review below we will list the therapeutic modalities awaiting the evaluation for the only definitive therapy, which is liver transplantation.
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Affiliation(s)
- Rana Khazar Al-Zoubi
- a School of Medicine Ringgold standard institution - Pulmonary & Critical Care , University of Missouri Kansas City School of Medicine , Kansas City , MO , USA
| | - Mouhanna Abu Ghanimeh
- b School of Medicine Ringgold standard institution - Internal Medicine , University of Missouri Kansas City School of Medicine , Kansas City , MO , USA
| | - Ashraf Gohar
- c School of Medicine - Pulmonary and Critical Care Medicine , University of Missouri-Kansas City School of Medicine , Kansas City , MO , USA
| | - Gary A Salzman
- c School of Medicine - Pulmonary and Critical Care Medicine , University of Missouri-Kansas City School of Medicine , Kansas City , MO , USA
| | - Osama Yousef
- d School of Medicine - Gastroenterology Medicine , University of Missouri-Kansas City School of Medicine , Kansas City , MO , USA
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14
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Lui MMS, Thomas R, Lee YCG. Complications of indwelling pleural catheter use and their management. BMJ Open Respir Res 2016; 3:e000123. [PMID: 26870384 PMCID: PMC4746457 DOI: 10.1136/bmjresp-2015-000123] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 01/05/2016] [Indexed: 11/23/2022] Open
Abstract
The growing utilisation of indwelling pleural catheters (IPCs) has put forward a new era in the management of recurrent symptomatic pleural effusions. IPC use is safe compared to talc pleurodesis, though complications can occur. Pleural infection affects <5% of patients, and is usually responsive to antibiotic treatment without requiring catheter removal or surgery. Pleural loculations develop over time, limiting drainage in 10% of patients, which can be improved with intrapleural fibrinolytic therapy. Catheter tract metastasis can occur with most tumours but is more common in mesothelioma. The metastases usually respond to analgaesics and/or external radiotherapy. Long-term intermittent drainage of exudative effusions or chylothorax can potentially lead to loss of nutrients, though no data exist on any clinical impact. Fibrin clots within the catheter lumen can result in blockage. Chest pain following IPC insertion is often mild, and adjustments in analgaesics and drainage practice are usually all that are required. As clinical experience with the use of IPC accumulates, the profile and natural course of complications are increasingly described. We aim to summarise the available literature on IPC-related complications and the evidence to support specific strategies.
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Affiliation(s)
- Macy M S Lui
- Division of Respiratory and Critical Care Medicine, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong; Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Rajesh Thomas
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia; Pleural Medicine Unit, Institute of Respiratory Health, Perth, Western Australia, Australia; Centre for Respiratory Health, School of Medicine & Pharmacology, University of Western Australia, Perth, Western Australia, Australia
| | - Y C Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia; Pleural Medicine Unit, Institute of Respiratory Health, Perth, Western Australia, Australia; Centre for Respiratory Health, School of Medicine & Pharmacology, University of Western Australia, Perth, Western Australia, Australia
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Hu MY, Peng Y. Progress in diagnosis and treatment of hepatic hydrothorax. Shijie Huaren Xiaohua Zazhi 2014; 22:1953-1958. [DOI: 10.11569/wcjd.v22.i14.1953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Hepatic hydrothorax is defined as the presence of a significant pleural effusion that develops in a patient with cirrhosis of the liver who does not have an underlying cardiac or pulmonary disease. Hepatic hydrothorax is not rare in end-stage liver diseases. The clinical symptoms are various and many patients are misdiagnosed or never diagnosed. Approximately 21%-26% of cases of hepatic hydrothorax are refractory to salt and fluid restriction and diuretics and warrant consideration of additional treatment measures. Patients' poor conditions make treatment more difficult and unfavorable. This article aims to discuss the research progress in hepatic hydrothorax in terms of mechanisms, diagnosis and treatment.
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Singh A, Bajwa A, Shujaat A. Evidence-based review of the management of hepatic hydrothorax. ACTA ACUST UNITED AC 2013; 86:155-73. [PMID: 23571767 DOI: 10.1159/000346996] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 01/08/2013] [Indexed: 12/19/2022]
Abstract
Hepatic hydrothorax (HH) is an example of a porous diaphragm syndrome. Portal hypertension results in the formation of ascitic fluid which moves across defects in the diaphragm and accumulates in the pleural space. Consequently, the treatment approach to HH consists of measures to reduce the formation of ascitic fluid, prevent the movement of ascitic fluid across the diaphragm, and drain or obliterate the pleural space. Approximately 21-26% of cases of HH are refractory to salt and fluid restriction and diuretics and warrant consideration of additional treatment measures. Ideally, liver transplantation is the best treatment option; however, most of the patients are not candidates and most of those who are eligible die while waiting for a transplant. Treatment measures other than liver transplantation may not only provide relief from dyspnea but also improve patient survival and serve as a bridge to liver transplantation.
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Affiliation(s)
- Amita Singh
- Department of Pulmonary and Critical Care, UF College of Medicine at Jacksonville, Jacksonville, FL 32209, USA.
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The Use of a PleurX Catheter in the Management of Recurrent Benign Pleural Effusion: A Concise Review. Heart Lung Circ 2012; 21:661-5. [DOI: 10.1016/j.hlc.2012.06.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 06/26/2012] [Accepted: 06/29/2012] [Indexed: 11/21/2022]
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Abstract
PURPOSE OF REVIEW An increasing number of patients requiring surgery are presenting with chronic or end stage liver disease. The management of these patients demands anesthesiologists with in-depth knowledge of the consequences of hepatic dysfunction, the effects on other organs, the risk of surgery, and the impact of anesthesia. RECENT FINDINGS Chronic or end stage liver disease is associated with an increased risk of perioperative morbidity and mortality. It is essential to preoperatively assess possible hepatic encephalopathy, pleural effusions, hepatopulmonary syndrome, hepatopulmonary hypertension, hepatorenal syndrome, cirrhotic cardiomyopathy, and coagulation disorders. The application of two scoring systems, that is, Child-Turcotte-Pugh and model for end stage liver disease, helps to estimate the risk of surgery. The use of propofol is superior to benzodiazepines as intravenous narcotics. Although enflurane and halothane are discouraged for maintenance of anesthesia, all modern volatile anesthetics appear comparable with respect to outcome. Fentanyl, sufentanil, and remifentanil as opioids and cis-atracurium for relaxation may be the best choices in liver insufficency. Regional anesthesia is valuable for postoperative pain management. SUMMARY Current studies have employed different anesthetic approaches in the preoperative and intraoperative management in order to improve outcomes of patients with liver disease.
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Shah R, Succony L, Gareeboo S. Use of tunneled pleural catheters for the management of refractory hepatic hydrothorax. BMJ Case Rep 2011; 2011:bcr.05.2011.4213. [PMID: 22688936 DOI: 10.1136/bcr.05.2011.4213] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Hepatic hydrothorax is a complication seen in up to 10% of patients with advanced liver disease, which typically presents with recurrent pleural effusions. Current available therapeutic options are limited. We demonstrate this condition in a 52-year-old female, and discuss the diagnostic and management difficulties we encountered. Through introducing an intrapleural catheter we successfully enabled resolution of symptoms, reduced hospital admissions and significantly improved our patient's quality of life, with no recurrence of an effusion at 9-month follow-up.
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Affiliation(s)
- Raj Shah
- Department of Gastroenterology and Hepatology, NHS, Stevenage, UK.
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Current World Literature. Curr Opin Pulm Med 2011. [DOI: 10.1097/mcp.0b013e328348331c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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