Video-assisted thoracoscopic surgery (VATS) for the treatment of hepatic hydrothorax: report of twelve cases

Evaluation of Recurrent Right-Sided Pleural Effusion: Hepatic Hydrothorax vs. Silicone Breast Implant Rupture

We report a case of a 55-year-old woman who presented to our hospital emergency department with a recurrent right-sided pleural effusion. Her presenting symptom was shortness of breath which first began two years prior after she experienced a blunt thoracic injury. This injury resulted in the rupture of her right silicone breast implant. Since the traumatic rupture of her right breast implant, she developed asthma-like symptoms and allergies that were adequately controlled with bronchodilators, antihistamines, and glucocorticoids. Laboratory investigation was significant for elevated immunoglobulin E (IgE) levels and eosinophilia consistent with an allergic hypersensitivity reaction. She denied a history of smoking, asthma, or allergies preceding the trauma to her right breast implant. Our differential diagnosis also included the possibility of an inflammatory reaction to the silicone breast rupture as a possible etiology for the recurrent pleural effusion.

The patient underwent a right-sided diagnostic and therapeutic thoracentesis procedure on two separate occasions within a span of a month in an effort to improve her symptoms and arrive at a definitive diagnosis. Her worsening symptoms were believed to be triggered by the pleural effusion. Aspirated pleural fluid was sent to the laboratory for analysis. Both samples excluded infectious or malignant causes of the pleural effusion. Ultimately, the source of her pleural effusion was determined to be decompensated liver cirrhosis. The patient underwent a pleurodesis procedure in an effort to seal the pleural space. 

Natural history and outcomes of patients with liver cirrhosis complicated by hepatic hydrothorax

BACKGROUND

Hepatic hydrothorax (HH) is an uncommon and difficult-to-manage complication of cirrhosis with limited treatment options.

AIM

To define the clinical outcomes of patients presenting with HH managed with current standards-of-care and to identify factors associated with mortality.

METHODS

Cirrhotic patients with HH presenting to 3 tertiary centres from 2010 to 2018 were retrospectively identified. HH was defined as pleural effusion in the absence of cardiopulmonary disease. The primary outcomes were overall and transplant-free survival at 12-mo after the index admission. Cox proportional hazards analysis was used to determine factors associated with the primary outcomes.

RESULTS

Overall, 84 patients were included (mean age, 58 years) with a mean model for end-stage liver disease score of 29. Management with diuretics alone achieved long-term resolution of HH in only 12% patients. At least one thoracocentesis was performed in 73.8% patients, transjugular intrahepatic portosystemic shunt insertion in 11.9% patients and 33% patients received liver transplantation within 12-mo of index admission. Overall patient survival and transplant-free survival at 12 mo were 68% and 41% respectively. At multivariable analysis, current smoking [hazard ratio (HR) = 8.65, 95% confidence interval (CI): 3.43-21.9, P < 0.001) and acute kidney injury (AKI) (HR = 2.91, 95%CI: 1.21-6.97, P = 0.017) were associated with a significantly increased risk of mortality.

CONCLUSION

Cirrhotic patients with HH are a challenging population with a poor 12-mo survival despite current treatments. Current smoking and episodes of AKI are potential modifiable factors affecting survival. HH is often refractory of diuretic therapy and transplant assessment should be considered in all cases.

Analysis of clinical features and prognostic factors in patients with hepatic hydrothorax: a single-center study from China

Background

The clinical features and factors affecting the prognostic survival of hepatic hydrothorax (HH) are currently unknown.

Methods

We conducted a retrospective cohort study of 131 patients with HH using the Kaplan–Meier method and Cox proportional hazards regression analysis to assess factors influencing the prognosis of HH.

Results

A total of 131 patients were enrolled: the male to female ratio was 80:51 (1.59:1), and the mean age was 52.76 ± 11.88 years. Hepatitis B cirrhosis was the main cause of HH, and abdominal distention and dyspnea were the most common clinical signs. Ascites was present in varying amounts in all patients and was the most common decompensated complication, with pleural effusions mostly seen on the right side (107/131; 82%), followed by the left side (16/131; 12%) and bilateral effusions (8/131; 6%). For overall survival without transplantation, the estimated median survival time was 21 (95% confidence interval [CI]:18–25) months, and survival rates at 6 months, 1 year, and 2 years were 77.2%, 62.4%, and 29.7%, respectively. After controlling for covariates that were associated with liver-related mortality in the univariate analysis, males (hazard ratio [HR]: 1.721, 95% CI: 1.114–2.658, P = 0.005) and combined hepatic encephalopathy (HR: 2.016, 95% CI: 1.101–3.693, P = 0.001) were found to be associated with an increase in liver-related mortality.

Conclusions

In this cohort of HH patients without liver transplantation, male sex and hepatic encephalopathy were associated with a higher risk of liver-related death.

Various Treatment Modalities in Hepatic Hydrothorax: What Is Safe and Effective?

PURPOSE

Hepatic hydrothorax is a complication of decompensated liver cirrhosis that is difficult and complex to manage. Data concerning the optimal treatment method, other than liver transplantation, are limited. This study aimed to compare the clinical features and outcomes of patients treated with various modalities, while focusing on surgical management and pigtail drainage.

MATERIALS AND METHODS

Forty-one patients diagnosed with refractory hepatic hydrothorax between January 2013 and December 2017 were enrolled.

RESULTS

The mean Child-Turcotte-Pugh and model for end stage liver disease scores of the enrolled patients were 10.1 and 19.7, respectively. The patients underwent four modalities: serial thoracentesis (n=11, 26.8%), pigtail drainage (n=16, 39.0%), surgery (n=10, 24.4%), and liver transplantation (n=4, 9.8%); 12-month mortality rate/median survival duration was 18.2%/868 days, 87.5%/79 days, 70%/179 days, and 0%/601.5 days, respectively. Regarding the management of refractory hepatic hydrothorax, surgery group required less frequent needle puncture (23.5 times in pigtail group vs. 9.3 times in surgery group), had a lower occurrence of hepatorenal syndrome (50% vs. 30%), and had a non-inferior cumulative overall survival (402.1 days vs. 221.7 days) compared to pigtail group. On multivariate analysis for poor survival, body mass index <19 kg/m², refractory hepatic hydrothorax not managed with liver transplantation, Child-Turcotte-Pugh score >10, and history of severe encephalopathy (grade >2) were associated with poor survival.

CONCLUSION

Serial thoracentesis may be recommended for management of hepatic hydrothorax and surgical management can be a useful option in patients with refractory hepatic hydrothorax, alternative to pigtail drainage.

Hepatic Hydrothorax: An Updated Review on a Challenging Disease

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.

Hepatic Hydrothorax

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.

The long-term outcomes of cirrhotic patients with pleural effusion

BACKGROUND/AIM

A pleural effusion is an abnormal collection of fluid in the pleural space and may cause related morbidity or mortality in cirrhotic patients. Currently, there are insufficient data to support the long-term prognosis for cirrhotic patients with pleural effusion. In this study, we investigated the short- and long-term effects of pleural effusion on mortality in cirrhotic patients and evaluated the benefit of liver transplantation in these patients.

PATIENTS AND METHODS

The National Health Insurance Database, derived from the Taiwan National Health Insurance Program, was used to identify 3,487 cirrhotic patients with pleural effusion requiring drainage between January 1, 2007 and December 31, 2010. The proportional hazards Cox regression model was used to control for possible confounding factors.

RESULTS

The 30-day, 90-day, 1-year, and 3-year mortalities were 20.1%, 40.2%, 59.1%, and 75.9%, respectively, in the cirrhotic patients with pleural effusion. After Cox proportional hazard regression analysis adjusted by patient gender, age, complications of cirrhosis and comorbid disorders, old age, esophageal variceal bleeding, hepatocellular carcinoma, hepatic encephalopathy, pneumonia, renal function impairment, and without liver transplantation conferred higher risks for 3-year mortality in the cirrhotic patients with pleura effusion. Liver transplantation is the most important factor to determine the 3-year mortalities (HR: 0.17, 95% CI 0.11- 0.26, P < 0.001). The 30-day, 30 to 90-day, 90-day to 1-year, and 1 to 3-year mortalities were 5.7%, 13.4%, 20.4%, and 21.7% respectively, in the liver transplantation group, and 20.5%, 41.0%, 61.2%, and 77.5%, respectively, in the non-liver transplantation group.

CONCLUSION

In cirrhotic patients, the presence of pleural effusion predicts poor long-term outcomes. Liver transplantation could dramatically improve the survival and should be suggested as soon as possible.

Effectiveness and Safety of Pleurodesis for Hepatic Hydrothorax: A Systematic Review and Meta-Analysis

BACKGROUND

Hepatic hydrothorax (HH) is a serious complication of end-stage liver diseases, which is associated with poor survival. There is no consensus regarding the treatment of HH.

AIM

To evaluate the effectiveness and safety of pleurodesis for HH in a systematic review with meta-analysis.

METHODS

All relevant papers were searched on the EMBASE and PubMed databases. As for the data from the eligible case reports, the continuous data were expressed as the median (range) and the categorical data were expressed as the frequency (percentage). As for the data from the eligible case series, the rates of complete response and complications were pooled. The proportions with 95 % confidence intervals (CIs) were calculated by using random-effect model.

RESULTS

Twenty case reports including 26 patients and 13 case series including 180 patients were eligible. As for the case reports, the median age was 55 years (range 7-78) and 15 patients were male. The prevalence of ascites was 76 % (19/25). Seventeen (65.38 %) patients responded favorably to pleurodesis. As for the case series, the mean age was 51.5-63.0 years and 83 patients were male. The pooled prevalence of ascites was 90 % (95 % CI 81-97 %) in 7 studies including 71 patients. The complete response rate after pleurodesis was reported in all studies, and the pooled rate was 72 % (95 % CI 65-79 %). Complications related to pleurodesis were reported in 6 studies including 63 patients, and the pooled rate was 82 % (95 % CI 66-94 %).

CONCLUSION

Pleurodesis may be a promising treatment for HH, but carries a high rate of complications.

Hepatic hydrothorax: clinical review and update on consensus guidelines

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.

Bedside pleuroscopy in Taiwan : a great vision for critically-ill patients and intensivists

Bedside pleuroscopy can be used in daily practice by medical pulmonologists if a patient cannot tolerate either general anesthesia or being moved to an operating or endoscopy room due to their critical condition. It is a simple and safe technique that rarely has complications. The aim of this review is to summarize recent literatures about bedside pleuroscopy and share our experiences with using it in Taiwan.

Efficacy of nonsurgical tigecycline pleurodesis for the management of hepatic hydrothorax in patients with liver cirrhosis

Chemical pleurodesis is one of the therapeutic tools to control hepatic hydrothorax. Tetracycline and derivatives have been widely accepted as an effective and safe treatment for the purpose, but availability is the big concern. Tigecycline is an antibiotic derivative of tetracycline, which has demonstrated to be an effective pleurodesing agent in animal models. The aim of the study was to document two successful tigecycline pleurodesis in patients with decompensated liver cirrhosis, who were not candidates for liver transplantation. Both patients were undergoing palliative treatment for cirrhosis and developed massive pleural effusion on the right side. They underwent chemical pleurodesis in the first instance. Diagnostic thoracocentesis was done to rule out differentials and to confirm the clinical suspicion, following which, complete drainage of pleural fluids was achieved. Tigecycline of 3 mg/kg was instilled intrapleurally via the thoracic catheter, as per the protocol. The medical records and images were thoroughly reviewed. There was no recurrence of the effusion for at least 3 months, with no detected complications in the short- or long-term follow-up. In conclusion, pleurodesis with tigecycline seems to be effective and safe for the management of symptomatic hepatic hydrothorax and should therefore be promoted in the setting of liver cirrhosis at least for a short-term relief, especially in patients who do not meet the criteria for liver transplantation.

Management of refractory hepatic hydrothorax

PURPOSE OF REVIEW

Treatment of hepatic hydrothorax is challenging because of its rapid symptomatic recurrence. This review will focus on potential therapeutic approaches to hepatic hydrothorax.

RECENT FINDINGS

Hepatic hydrothorax is refractory to salt restriction and diuretics in approximately 25% of cases. Primary management options for these patients include serial thoracenteses, transjugular intrahepatic portosystemic shunt (TIPS) placement, and insertion of an indwelling pleural catheter (IPC). Response rate to TIPS, being the first choice whenever possible, is about 80%. IPC is emerging as a feasible alternative in patients who require frequent therapeutic thoracenteses, particularly if TIPS is contraindicated. Pleurodesis is not advocated because of the low likelihood of a pleural symphysis owing to the rapid re-accumulation of pleural fluid. The only cure for hepatic hydrothorax, a defined complication of end-stage liver disease, is liver transplantation.

SUMMARY

No single treatment option for refractory hepatic hydrothorax is ideal. However, in patients with contraindications to or who are awaiting liver transplantation, TIPS seems the most beneficial therapy, whereas IPC promises to be an alternative second-line consideration.

Recurrent hydrothorax and surgical diaphragmatic repair: report of 2 cases and review of the literature

BACKGROUND

Pleural effusions may result from intra-abdominal processes and sometimes present with dramatic clinical consequences. We present 2 cases of recurrent hydrothorax requiring surgical repair of diaphragmatic defects and describe when surgery may be the best treatment modality.

PATIENT 1

: A 63-year-old man with end-stage renal disease requiring peritoneal dialysis presented with dyspnea on exertion that progressed to cardiac arrest. He was found to have a tension hydrothorax that was initially stabilized with thoracentesis and tube thoracostomy. He eventually underwent surgical repair of fenestrations with complete resolution of his effusion. PATIENT 2:: A 52-year-old man with recurrent hydrothorax in the context of hepatitis C cirrhosis and hepatocellular carcinoma following radiofrequency ablation to his liver had recurrent admissions with dyspnea and a large pleural effusion. When medical therapy failed, he underwent surgical repair of a large diaphragmatic defect.

CONCLUSIONS

Hydrothorax related to peritoneal dialysis or cirrhosis may cause life-threatening scenarios in which medical management may stabilize the patient. Ultimately, surgical corrections of diaphragmatic defects may be necessary for definitive management in selected patients. Although these scenarios are rare, clinicians should be aware of these possibilities as early collaboration between medical and surgical services is essential for optimal patient care.

Hepatic hydrothorax: clinical features, management, and outcomes in 77 patients and review of the literature

Hepatic hydrothorax is an important and difficult-to-manage complication of cirrhosis and portal hypertension. Here, we aimed to study its clinical features and natural history. Complete clinical data, including outcomes, were abstracted from hospital records of patients with cirrhosis and ascites admitted to University of Texas Southwestern University teaching hospitals from January 2001 to July 2012. Hepatic hydrothorax was diagnosed based on currently accepted clinical characteristics of the disease, including a known diagnosis of cirrhosis, the presence of portal hypertension, pleural fluid analysis, and the absence of primary cardiopulmonary disease.Seventy-seven of 495 (16%) hospitalized cirrhotic patients with pleural effusion (28 female; mean age, 52 yr) met the criteria for diagnosis of hepatic hydrothorax. Resting dyspnea and cough were the most prominent presenting symptoms, occurring in 34% and 22% of patients, respectively. Pleural effusions were most often right-sided (56/77; 73%), followed by left-sided only (13/77; 17%) and bilateral effusions (8/77; 10%); 7 (9%) patients did not have detectable ascites. The mean Model for End-Stage Liver Disease (MELD) score at presentation was 16. The serum to pleural fluid albumin gradient (SPAG) was ≥1.1 in all 48 patients in whom it was measured. Most patients (64/77; 83%) were managed with diuretics and/or thoracentesis, while 8 (10%) underwent transjugular intrahepatic portosystemic shunt (TIPS) and 5 (7%) underwent liver transplant. A total of 44 of 77 (57%) patients died during a mean follow-up of 12 months. The average time from presentation to death for all patients was 368 days, while for those after TIPS it was 845 days. No deaths were reported in the liver transplant group. The data indicate that a substantial number of patients with hepatic hydrothorax had what may be considered atypical presentations, including left-sided only effusions, or pleural effusion without ascites. Here, we propose that the term "serum to pleural fluid albumin gradient (SPAG)" be used to describe the gradient between serum and pleural fluid albumin levels and suggest that not only is it consistent with the portal hypertensive pathophysiology of hepatic hydrothorax, but also it is a useful criterion for diagnosis of hepatic hydrothorax. Finally, the overall outcome of hepatic hydrothorax was extremely poor, except in those undergoing TIPS or liver transplantation.

[Hepatic hydrothorax: report of a series of 77 patients]

BACKGROUND AND OBJECTIVE

To describe the clinical characteristics, the most effective treatment and survival of cirrhotic patients with hepatic hydrothorax (HH).

PATIENTS AND METHOD

Descriptive and retrospective analysis of a cohort of consecutive patients with HH undergoing a diagnostic thoracentesis. The biochemical and radiological features of the pleural effusion, its control with different therapies and the factors affecting survival were evaluated, among other parameters.

RESULTS

Seventy-seven patients with HH were included, of whom 14% did not have ascites. HH was right-sided in 77% of the cases, and occupied half or more of the hemithorax in 68%. Pleural fluids were transudative in 81% of the cases. Diuretic-resistant HH (27%) could be managed with liver transplantation, transjugular intrahepatic portosystemic shunt (TIPS) or indwelling pleural catheters. However, pleurodesis failed in most patients. Median survival was 9.1 months, and it was only favorably affected by liver transplantation.

CONCLUSIONS

HH has a limited survival, only influenced by liver transplantation. In diuretic-resistant cases, TIPS or pleural indwelling catheters should be considered as a management option.

Evidence-based review of the management of hepatic hydrothorax

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.

Diaphragmatic repair of hepatic hydrothorax with VATS after abdominal insufflation with CO(2)

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. There have been few published case reports dealing with hepatic hydrothorax treated surgically. Recently, we treated a patient with refractory hepatic hydrothorax by directly suturing the diaphragmatic defect during VATS. During surgery, the diaphragmatic defect was identified by using abdominal insufflation with CO(2) . The defect was sutured and the diaphragm was covered by polyglycolic acid felt and fibrin glue. After surgery, the patient's pleural effusion improved, his postoperative course was uneventful and he did not require a drainage tube at discharge.

Medical thoracoscopy for the treatment of complicated hepatic hydrothorax

Hepatic hydrothorax is a complication of liver cirrhosis. Several invasive therapeutic approaches have been performed such as thoracentesis, video-assisted thoracic surgery and repair of the diaphragmatic defects with debatable results. Medical thoracoscopy is a minimally invasive and effective technique with challenging applications that has not been thoroughly used in the treatment of hepatic hydrothorax. We hereby present the case of a hepatic hydrothorax complicated by thoracic empyema in a 38-year-old patient with alcoholic cirrhosis that was treated with medical thoracoscopy and talc pleurodesis.