Diagnosis and Management of Hepatic Hydrothorax.

Hepatic hydrothorax is a pleural effusion (typically ≥500 mL) that develops in patients with cirrhosis and/or portal hypertension in the absence of other causes. In most cases, hepatic hydrothorax is seen in patients with ascites. However, ascites is not always found at diagnosis and is not clinically detected in 20% of patients with hepatic hydrothorax. Some patients have no symptoms and incidental findings on radiologic examination lead to the diagnosis of the condition. In the majority of cases, the patients present with symptoms such as dyspnea at rest, cough, nausea, and pleuritic chest pain. The diagnosis of hepatic hydrothorax is based on clinical manifestations, radiological features, and thoracocentesis to exclude other etiologies such as infection (parapneumonic effusion, tuberculosis), malignancy (lymphoma, adenocarcinoma) and chylothorax. The management strategy involves a stepwise approach of one or more of the following: Reducing ascitic fluid production, preventing fluid transfer to the pleural space, fluid drainage from the pleural cavity, pleurodesis (obliteration of the pleural cavity), and liver transplantation. The complications of hepatic hydrothorax are associated with significant morbidity and mortality. The complication that causes the highest morbidity and mortality is spontaneous bacterial empyema (also called spontaneous bacterial pleuritis).

Hydrothorax and air fluid levels in the right chest - a diagnostic dilemma.

SUMMARY: A diaphragmatic defect that permits abdominal contents to herniate into the right side of the chest is rare. In adults with right-sided diaphragmatic hernias, few occur without a history of trauma, and even fewer are symptomatic. This case report illustrates such a case and the rare entity of an anterolaterally located hernia. Although uncommon and easily missed, consequences of diaphragmatic hernias can be disastrous. The importance of a combination of high clinical suspicion and the use of computed tomography (CT) to aid diagnosis, and the dangers of a surgical condition being incorrectly assessed and admitted to a non-surgical specialty are highlighted in this case.

Minimally invasive surgery for pleuroperitoneal communication complicating peritoneal dialysis.

OBJECTIVE: Pleuroperitoneal communication (PPC) is an uncommon but serious complication of continuous ambulatory peritoneal dialysis (CAPD). At present, there are many kinds of treatment options, with different effects. We describe our single-institutional experiences in the minimally invasive surgery of pleuroperitoneal communication complicating continuous ambulatory peritoneal dialysis in detail. METHODS: Our study consecutively enrolled 12 pleuroperitoneal communication patients complicating CAPD. All patients underwent direct closure of the defective diaphragm and mechanical rub pleurodesis under video-assisted thoracoscopy. What is more, pseudomonas aeruginosa injection was infused into the thoracic cavity postoperatively to further promote pleural adhesion, which was the innovation of our study. RESULTS: After 1.0-8.3 months of CAPD, all 12 patients presented hydrothorax in the right side. All these patients received surgery 7-179 days (18.0 ± 49.5 days) after onset. Bleb-like lesions situated on the diaphragm were discovered in all patients and three patients also had obvious hole on the surface of diaphragm. Pseudomonas aeruginosa injection was infused into the thoracic cavity postoperatively, and three cases showed fever with remission after 2-3 days of symptomatic treatment. The time from surgery to restarting CAPD ranged from 14 to 47 days, with a median of 20 days. There was no recurrence of hydrothorax and transformation to hemodialysis during the follow-up period (median: 7.5 months). CONCLUSIONS: Video-assisted thoracoscopic direct closure of the defective diaphragm and mechanical rub pleurodesis plus chemical pleurodesis using pseudomonas aeruginosa injection postoperatively is a safe and effective option for the treatment of pleuroperitoneal communication complicating continuous ambulatory peritoneal dialysis with 100% success rate.

Effect of pleural adhesions on short- and long-term outcomes after minimally invasive esophagectomy: a propensity score matching analysis.

BACKGROUND: The extent to which the presence of pleural adhesions affects the surgical and oncological outcomes of patients undergoing McKeown minimally invasive esophagectomy (MIE) for esophageal cancer (EC) has not previously been studied. METHODS: Data of consecutive EC patients undergoing McKeown MIE by a single surgeon in the Department of Thoracic Surgery at Daping Hospital from November 2015 to December 2020 were collected. Patients were grouped according to the presence or absence of pleural adhesions when entering the chest cavity. Propensity score matching (PSM) was used to reduce selection bias from confounding factors. Kaplan-Meier was used to assess the survival differences. RESULTS: A total of 617 consecutive EC patients underwent McKeown MIE were enrolled. There were 116 patients with pleural adhesions (Group A) and 501 patients without pleural adhesions (Group B). Patients in Group A were more likely to be older than those of patients in Group B: (66.26 vs. 63.27, P = 0.001). In addition, Group A had more patients with chronic obstructive pulmonary disease (COPD) (24.1% vs. 16.8%, P = 0.04). After propensity score matching (102 matched patients in Group A and 185 matched patients in Group B), these findings were no longer statistically significant. Postoperative pulmonary infection occurred in 57 patients in Group A and in 15 patients in Group B (53.9% vs. 13.0%, P < 0.001). In addition, the presence of pleural adhesions was significantly associated with the prolonged operation time (232 min vs. 210 min, P < .001), length of stay (12 days vs. 10 days, P = 0.001), and hydrothorax requiring drainage (12.7% vs. 5.4%, P = 0.04). However, the disease-specific survival and disease-free survival rates were comparable between the two groups (P = 0.40 and 0.13, respectively). CONCLUSIONS: The presence of pleural adhesions predicted an increased operation time, length of stay, postoperative pneumonia, and hydrothorax requiring drainage of EC patients undergoing McKeown MIE, but did not exert unfavourable effect on long-term survival.

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.

[Early Resuming of Continuous Ambulatory Peritoneal Dialysis on the Following Day After Surgery for Pleuroperitoneal Communication:Report of a Case].

A 72-year-old man was introduced continuous ambulatory peritoneal dialysis (CAPD) for chronic renal failure. Five months later, he was pointed out a massive right pleural effusion. Being diagnosed with pleuroperitoneal communication, he was referred to our department for surgery. Dialysis fluid and indocyanine green were injected through a peritoneal catheter for CAPD 30 minutes before surgery. A small fistula was detected by pressing the abdomen and using infrared thoracoscopy. The fistula was sutured and covered with polyglycolic acid sheet and fibrin glue. A day after surgery, CAPD was resumed. He was discharged on the post operative sixth day without any complications.

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.

Thoracoscopic mesh implantation as a definitive treatment approach for peritoneal dialysis-associated hydrothorax.

Pleuroperitoneal leakage with the formation of hydrothorax is a rare complication of peritoneal dialysis, usually necessitating termination of peritoneal dialysis. We hypothesized that implantation of a polypropylene mesh on the diaphragm using video-assisted thoracoscopic surgery might induce permanent closure of pleuroperitoneal leakage. We report a case series of n = 12 peritoneal dialysis patients with pleuroperitoneal leakage and right-sided hydrothorax who underwent video-assisted thoracoscopy with mesh implantation from 2011 to 2020. Pleuroperitoneal leakage had been confirmed before surgery by intraperitoneal administration of toluidine blue, contrast-enhanced computer tomography or glucose determination from the pleural effusion. Median time from the start of peritoneal dialysis to manifestation of pleuroperitoneal leakage was 52 days. Video-assisted thoracoscopic surgery revealed multiple penetration points in the tendinous part of the diaphragm in all patients, which appeared as blebs. These were closed by covering the whole diaphragm with a polypropylene mesh. In all patients, peritoneal dialysis was paused for three months and bridged by hemodialysis. After restarting peritoneal dialysis and a median follow-up time of 1.9 years, none of the patients experienced a recurrence of pleuroperitoneal leakage. This case series demonstrates that pleuroperitoneal leakage in peritoneal dialysis patients can be permanently closed using thoracoscopic mesh implantation and allows peritoneal dialysis to be continued as renal replacement therapy.

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.

Intrauterine Ultrasound-Guided Laser Coagulation as a First Step for Treatment of Prenatally Complicated Bronchopulmonary Sequestration: Our Experience and Literature Review.

INTRODUCTION: Prenatal ultrasound-guided laser coagulation (USLC) for complicated bronchopulmonary sequestrations has been described but a consensus on the procedure and on the following management is still lacking. We present our experience and provide a literature review. METHODS: Retrospective review of patients treated in our center. Literature review and combined analysis of perinatal data were performed. RESULTS: Five cases were treated at our center, all presenting with severe hydrothorax. Four met the criteria for fetal hydrops. Four cases underwent postnatal computed tomography (CT) scan: in one case, there was no evidence of persistent bronchopulmonary sequestration. The other three underwent thoracoscopic resection, in two, a viable sequestration was found. Including our series, 57 cases have been reported, with no mortality and a success rate of 94.7%. Mean gestational age (GA) at the procedure was 28 ± 3.4 weeks and mean GA at birth and birth weight (BW) were 38.6 ± 2.3 weeks and 3,276 ± 519.8 g, respectively. In 80.6% of the cases investigated postnatally, a residual mass was found, 50% of cases who showed prenatal arterial flow cessation had a persistent sequestration postnatally, and 26.3% of cases underwent postnatal sequestrectomy. Both patients in our series had pathology examination confirming a viable bronchopulmonary sequestration. CONCLUSION: Prenatal USLC seems to be a valid option for bronchopulmonary sequestration complicated by severe hydrothorax and/or fetal hydrops. Authors believe that this procedure should aim to reverse fetal distress and allow pregnancy continuation, and it should not be considered a definitive treatment. The currently available data do not support changes of the common postnatal management.

Respiratory distress associated with acute hydrothorax during transurethral electrocoagulation: a case report.

BACKGROUND: In patients undergoing abdominal radiotherapy or transurethral surgery, bladder perforations are a possible complication. Likewise, pleural effusions due to a pleuroperitoneal leak caused by either a congenital or acquired diaphragmatic defect can also occur. We report a case in which a saline solution, which migrated into the abdominal cavity from a bladder perforation during transurethral electrocoagulation, further formed bilateral pleural effusions and caused rapid ventilation failure. CASE PRESENTATION: A patient undergoing radiation therapy and hormone therapy for prostate cancer underwent emergency surgery for electrocoagulation due to hematuria and a rapid drop in hemoglobin. The surgery began under general anesthesia, and we first noticed an increase in airway pressure and a decrease in dynamic lung compliance, followed by abdominal distension. Based on readouts from the respiratory mechanics monitor, we suspected lung abnormalities and performed a pulmonary ultrasound, leading to a diagnosis of bilateral pleural effusions, which we then drained. CONCLUSIONS: Respiratory mechanics monitoring is simple and can be performed at all times during anesthesia, and when combined with pulmonary ultrasound, diagnoses can be made quickly and prevent deaths.

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.

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.

Sterile cerebrospinal fluid ascites, hydrothorax and hydrocele as a complication of ventriculoperitoneal shunting in an elderly patient.

An 89-year-old man with a history of multiple abdominal surgeries and ventriculoperitoneal (VP) shunt placement for normal pressure hydrocephalus presented for intractable abdominal bloating and scrotal swelling, for which imaging revealed massive ascites, bilateral hydrocele and small bilateral pleural effusions. Cardiac, hepatic and renal workup were insignificant. Culture and cytology of ascitic fluid were negative for infection or malignancy. Aetiology of the ascites as secondary to Cerebrospinal fluid (CSF) from the VP shunt was confirmed via ligation of the shunt. Sterile CSF ascites, hydrothorax and hydrocele are rare complications of VP shunt for hydrocephalus and are mostly presented in paediatric patients. We report the first known case of concurrent CSF ascites, hydrothorax and hydrocele in an elderly patient. We examine the difficulty of shunt replacement as a diagnostic and treatment modality in this age group and propose the use of reversible shunt ligation as a diagnostic modality.

Surgical correction of hydrothorax complicating pediatric peritoneal dialysis.

Hydrothorax complicating continuous cycling peritoneal dialysis (CCPD) is an uncommon event. Its presentation may occur shortly after or years after initiation of dialysis. Surgical intervention offers the advantage of direct visualization and repair of the diaphragmatic defect. Video assisted thoracoscopy surgery (VATS) has been increasingly used in identifying these defects to facilitate this repair. We present 2 pediatric cases who underwent successful direct surgical repair of diaphragmatic defects using VATS with return to CCPD. Initial approach with VATS should be strongly considered in patients in whom a lifetime change in modality has significant repercussions.

A rare coincidence of a chylothorax and a hydrothorax caused by gastric adenocarcinoma - a case report.

We present a case report of a 74-years old patient with a finding of bilateral pleural effusion due to a different fluid composition caused by gastric adenocarcinoma. The finding of a bilateral effusion, where the exudate fluid is of a different chemical composition, is a rare phenomenon. While the right-sided exudate had the characteristics of hydrothorax, the left-sided exudate had those of chylothorax. The initial suspicion of a lung tumor was not confirmed, and further examination surprisingly revealed gastric adenocarcinoma. The patient did not benefit from targeted oncological treatment for a long time and the chemotherapy was terminated after 3 cycles. The cause of right-sided hydrothorax is therefore attributed to hypalbuminemia and secondary pneumonia, left-sided chylothorax was a primo-manifestation of gastric adenocarcinoma. There is only a small number of similar case reports of patients with gastric tumor and chylothorax in the literature. While the recorded cases were mostly Asian ethnic patients, the course of their illness - including survival - was almost strikingly similar (and unfavorable).

Non-Infectious, Necrotizing and Granulomatous Aortitis in a Female Gorilla.

A 41-year-old female captive gorilla with progressive weight loss and hydrothorax of unknown origin was euthanized and submitted for necropsy. The ascending aorta showed intimal aortic thickenings, consistent with so called 'tree bark' changes. Microscopic examination revealed a non-infectious, necrotizing and granulomatous aortitis with no evidence of systemic vasculitis or infectious disease elsewhere in the body. While rare, large vessel vasculitides should be considered as a differential diagnosis in gorillas presenting with progressive non-specific signs and vascular intimal changes.

The effectiveness and safety of computed tomographic peritoneography and video-assisted thoracic surgery for hydrothorax in peritoneal dialysis patients: A retrospective cohort study in Japan.

INTRODUCTION: Albeit uncommon, hydrothorax is an important complication of peritoneal dialysis (PD). Due to paucity of evidence for optimal treatment, this study aimed to evaluate the effectiveness and safety of computed tomographic (CT) peritoneography and surgical intervention involving video-assisted thoracic surgery (VATS) for hydrothorax in a retrospective cohort of patients who underwent PD in Japan. METHODS: Of the 982 patients who underwent PD from six centers in Japan between 2007 and 2019, 25 (2.5%) with diagnosed hydrothorax were enrolled in this study. PD withdrawal rates were compared between patients who underwent VATS for diaphragm repair (surgical group) and those who did not (non-surgical group) using the Kaplan-Meier method and log-rank test. RESULTS: The surgical and non-surgical groups comprised a total of 11 (44%) and 14 (56%) patients, respectively. Following hydrothorax diagnosis by thoracentesis and detection of penetrated sites on the diaphragm using CT peritoneography, VATS was performed at a median time of 31 days (interquartile range [IQR], 20-96 days). During follow-up (median, 26 months; IQR, 10-51 months), 9 (64.3%) and 2 (18.2%) patients in the non-surgical and surgical groups, respectively, withdrew from PD (P = 0.021). There were no surgery-related complications or hydrothorax relapse in the surgical group. CONCLUSIONS: This study demonstrated the effectiveness and safety of CT peritoneography and VATS for hydrothorax. This approach may be useful in hydrothorax cases to avoid early drop out of PD and continue PD in the long term. Further studies are warranted to confirm these results.