Tubeless supra-costal percutaneous nephrolithotomy is associated with significantly less hydrothorax: a prospective randomized clinical study.

OBJECTIVES: To evaluate prospectively whether a tubeless (JJ stent-only) percutaneous nephrolithotomy (PCNL) might reduce the risk of hydrothorax, compared to an approach where a nephrostomy tube is left. MATERIALS AND METHODS: We conducted a two-arm open-label prospective randomized study (NCT02036398) comparing tubeless supra-costal PCNL (with a JJ stent only) to standard PCNL (with nephrostomy tube and JJ stent) using intention-to-treat (ITT) and per-protocol (PP) analyses. All patients underwent a standard single-stage prone supra-costal procedure with single-tract access. Complication data were collected according to the Clavien-Dindo grading system. The primary endpoint was the rate of hydrothorax, and secondary endpoints included stone-free rate (SFR) and complication rate. Multivariable logistic regression analysis identified factors associated with hydrothorax formation. RESULTS: Out of 101 patients approached, 75 were finally analysed. No differences were observed between the two arms with regard to baseline demographic and stone characteristics. The mean largest stone size ranged between 23 and 24.2 mm. No significant difference was seen in the mean operating time and length of hospital stay. The incidence of hydrothorax was significantly higher in the nephrostomy group in comparison to the tubeless group (37.8% vs 15.8%, P = 0.031, and 38.4% vs 13.8%, P = 0.016, in the ITT and PP analyses, respectively). The SFR and complication rate were similar in both groups using the ITT and PP analyses. Multivariable logistic regression analysis showed that nephrostomy tube placement was the only covariate associated in a statistically significant manner to hydrothorax (odds ratio 3.628, 95% confidence interval 1.073-12.265; P = 0.038). CONCLUSION: The rate of hydrothorax in supra-costal PCNL is associated with the type of postoperative drainage left. When possible, a tubeless approach should be applied as it may confer a lower risk of hydrothorax.

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.

Improved accuracy of screw implantation could decrease the incidence of post-operative hydrothorax? O-arm navigation vs. free-hand in thoracic spinal deformity correction surgery.

PURPOSE: The purpose of this study was to analyze the occurrence of PE after intra-operative O-arm navigation-assisted surgery and determine whether the post-operative PE incidence could be decreased by using O-arm navigation as compared to conventional free-hand technique. METHODS: A cohort of 27 patients with spinal deformity who were operated upon with an O-arm navigated system (group A) between 2013 and 2016 were enrolled in the study. A total of 27 curve-matched patients treated by conventional free-hand technique were included as the control group (group B). Whole spine posterior-anterior and lateral radiographs, and CT scans were taken pre and post-operation. Radiologic parameters and volume of PE were measured and compared between the two groups. RESULTS: There were no significant differences in age, Cobb angle, and sagittal contour between the two groups pre-operatively. The mean total volume of post-operative PE was significantly larger in the free-hand group (p < 0.001). In the O-arm group, 59 malpositioned screws were identified in 22 patients. In the free-hand group, 88 malpositioned screws were found among 26 patients. The screw perforation rate was higher in the free-hand group than in the O-arm group (p = 0.007). In the O-arm group, the mean volume of PE was significantly larger among patients with malpositioned screws than those without malpositioned screws (p < 0.001), as well as in the free-hand group. CONCLUSION: The volume of PE after correction surgery can be significantly decreased by application of O-arm navigation system as compared to conventional free-hand technique. We ascribed the improvement to the accuracy of screw implantation navigated by O-arm.

Frequency of Hepatic Hydrothorax and its Association with Child Pugh Class in Liver Cirrhosis Patients.

OBJECTIVE: To determine the frequency of hepatic hydrothorax and its association with Child Pugh Class in patients with liver cirrhosis. STUDY DESIGN: Descriptive, analytical study. PLACE AND DURATION OF STUDY: Jinnah Postgraduate Medical Centre, Karachi, Medical Unit-III, (Ward- 7), from June 2012 to May 2013. METHODOLOGY: All patients with established diagnosis of decompensated chronic liver disease were included. Detailed history, thorough physical examination, routine laboratory investigations, chest X-ray and abdominal ultrasound were carried out in all patients to find out the presence of pleural effusion and ascites, respectively. Fifty milliliters of pleural fluid was aspirated in all patients with pleural effusion using the transthoracic approach, taking ultrasound guidance, wherever required. Fluid was sent for microscopic, biochemical, and microbial analysis. SBEM defined if pleural fluid with polymorphonuclear (PMN) cell count > 500 cells/mm3 or positive culture with PMN cell count > 250 cells/mm3 with exclusion of a parapneumonic effusion. RESULTS: Two hundred and six patients met the inclusion criteria, with mean age of 41.25 ±13.59 years. Among them, 149 (72.3%) were males and 57 (27.7%) females. Twenty-three (11.2%) had hydrothorax; right sided involvement was in 18 (78.3%) subjects, 3 (13%) had left sided while bilateral pleural effusion was found in 2 (8.7%) cases. SBEM was found in 07 (30.43%) cases. Mean serum albumin 3.125 ±0.71 gram/dl. There was association between serum albumin levels and hydrothorax. Asignificant association of hydrothorax with Child Pugh scoring system (p=0.018), but not with serum albumin (p=0.15). CONCLUSION: The frequency of hepatic hydrothorax has a significant association with hepatic function as assessed by Child Pugh scoring system, but not with serum albumin.

Hepatic hydrothorax: About a hospital serie of 63 cases.

BACKGROUND: Hepatic hydrothorax is a less common complication of cirrhosis with an estimated prevalence of 10- 15%. In the vast majority of cases, ascites are also present but significant pleural effusion may develop in patients without ascites. Hepatic hydrothorax is associated with cirrhosis whatever its etiology. The prognosis of hepatic hydrothorax remains unclear and is closely related to available therapeutic options. The aim of our study is to determine the prevalence of hydrothorax in cirrhotic patients, detail its clinical and therapeutic characteristics, and study the evolutive profile of cirrhotic patients with hydrothorax by comparing it to those without hydrothorax. We also search predictive factors of development of this complication in cirrhotic patients. METHODS: We conduct a retrospective and case-control study including 63 cirrhotic patients with hepatic hydrothorax hospitalized in gastroenterology department of Charles Nicolle hospital of Tunis, during a period of fiveteen years, from January 2000 to January 2015. RESULTS: The prevalence of hydrothorax was 14.5%. The mean age was 62 ± 14 years (range, 22- 86 years). The sex ratio H/F was 1.52. Hepatic hydrothorax was symptomatic in 35 patients. It was right-sided in 60%, left-sided in 24% and bilateral in 16% of cases. Hydrothorax was on average size abundance in 54% of cases. It was transsudatif in 52.5% of cases. Hepatitis C was the most frequent cause of cirrhosis (54%). Our results show that hepatic hydrothorax was present with important ascites in 35 patients. Hydrothorax was significantly related to Child-Pugh C severity of cirrhosis (p=0.0001). Hydrothorax occurence was significantly associated with a low level of albumin (p=0.001), an important hyponatremia (p=0.001) and a low prothrombin rate (p=0.02). A therapeutic thoracentesis was performed in 57% of cases. Diuretics based on spironolactone and furosemide were indicated in 30 patients. Evolution was favorable in 19 patients. Refractory hepatic hydrothorax was present in 31 patients. Death, in the days which follow the hospitalisation, was in 13 patients. The 5-years survival rate was 60%. The mean survival time of patients with hepatic hydrothorax was 8.41 years against 10.75 years at patients without hepatic hydrothorax. CONCLUSION: Hepatic hydrothorax is a common complication in our study. The improvement of the prognosis of our patients would require a better therapeutic management and especially the possibility of orthotopic liver transplantation which is the optimal therapeutic option for patients with hepatic hydrothorax.

Clinical effects and complications of TIPS for portal hypertension due to cirrhosis: a single center.

AIM: To determine the clinical effects and complications of transjugular intrahepatic portosystemic shunt (TIPS) for portal hypertension due to cirrhosis. METHODS: Two hundred and eighty patients with portal hypertension due to cirrhosis who underwent TIPS were retrospectively evaluated. Portal trunk pressure was measured before and after surgery. The changes in hemodynamics and the condition of the stent were assessed by ultrasound and the esophageal and fundic veins observed endoscopically. RESULTS: The success rate of TIPS was 99.3%. The portal trunk pressure was 26.8 ± 3.6 cmH2O after surgery and 46.5 ± 3.4 cmH2O before surgery (P < 0.01). The velocity of blood flow in the portal vein increased. The internal diameters of the portal and splenic veins were reduced. The short-term hemostasis rate was 100%. Esophageal varices disappeared completely in 68% of patients and were obviously reduced in 32%. Varices of the stomach fundus disappeared completely in 80% and were obviously reduced in 20% of patients. Ascites disappeared in 62%, were markedly reduced in 24%, but were still apparent in 14% of patients. The total effective rate of ascites reduction was 86%. Hydrothorax completely disappeared in 100% of patients. The incidence of post-operative stent stenosis was 24% at 12 mo and 34% at 24 mo. The incidence of post-operative hepatic encephalopathy was 12% at 3 mo, 17% at 6 mo and 19% at 12 mo. The incidence of post-operative recurrent hemorrhage was 9% at 12 mo, 19% at 24 mo and 35% at 36 mo. The cumulative survival rate was 86% at 12 mo, 81% at 24 mo, 75% at 36 mo, 57% at 48 mo and 45% at 60 mo. CONCLUSION: TIPS can effectively lower portal hypertension due to cirrhosis. It is significantly effective for hemorrhage of the digestive tract due to rupture of esophageal and fundic veins and for ascites and hydrothorax caused by portal hypertension.

Outcome predictors of cirrhotic patients with spontaneous bacterial empyema.

BACKGROUND: Spontaneous bacterial empyema (SBE) is a complication of cirrhotic patients in which a pre-existing pleural effusion becomes infected. This retrospective study was designed to investigate the bacteriology and outcome predictors of SBE in cirrhotic patients. METHODS: Medical records of cirrhotic patients treated in a tertiary care university hospital from December 2004 to December 2008 were retrospectively reviewed. RESULTS: Of 3390 cirrhotic patients seen during the study period, 81 cases of SBE were diagnosed. The incidence of SBE was 2.4% (81/3390) in cirrhotic patients and 16% (81/508) in patients with cirrhosis with hydrothorax. There were 46 monomicrobial infections found in 46 SBE patients. Aerobic Gram-negative organisms were the predominant pathogens (n=29, 63%), and Escherichia coli (n=9, 20%) was the most frequently isolated sole pathogen. The mortality rate of SBE was 38% (31/81). Univariate analysis showed that Child-Pugh score, model for end-stage liver disease (MELD)-Na score, concomitant bacteraemia, concomitant spontaneous bacterial peritonitis, initial intensive care unit (ICU) admission and initial antibiotic treatment failure were predictors of poor outcomes. Multivariate regression analysis demonstrated that the independent factors related to a poor outcome were initial ICU admission [odds ratio (OR): 4.318; 95% confidence interval 1CI) 1.09-17.03; P=0.037], MELD-Na score (OR: 1.267; 95% CI 1.08-1.49; P=0.004) and initial antibiotic treatment failure (OR: 13.10; 95% CI 2.60-66.03). CONCLUSION: Spontaneous bacterial empyema in cirrhotic patients is a high mortality complication. The independent factors related to poor outcome are high MELD-Na score, initial ICU admission and initial antibiotic treatment failure. High MELD-Na score may be a useful mortality predictor of SBE in cirrhotic patients.

[Modern aspects of the clinicomorphological picture of acute and subacute infective endocarditis].

The purpose of the study was to determine peculiarities of the clinico-morphological picture of modern infective endocarditis (IE). The authors generalize the results of 100 morphological studies of acute and subacute IE (AIE and SAIE) within the last 20 years (1985--2005). AIE and SAIE had developed in 52% and 35% of cases, respectively, after operations, medical manipulations and examinations. The development of secondary AIE was favored by congenital heart defects and mitral valvular (MV) prolapse, while secondary SAIE developed in patients with congenital heart defects as well as atherosclerotic and rheumatic heart defects. The feature of contemporary IE is the prevalence of primary clinico-morphological form with isolated aortal valvular (A V) lesion. Morphological changes in organs formed as a result of multiple septic embolism, immunocomplex lesion, panarteritis, and cardiac insufficiency. The occurrence and progress of the latter was caused by prominent AV and MV insufficiency (during several weeks in patients with AIE and several months in SAIE), myocarditis, pericarditis, myocardial dystrophy, and cardiosclerosis.

Noninfectious complications of peritoneal dialysis.

Peritoneal dialysis is an established form of renal replacement therapy. With its increasing popularity, we are now encountering a variety of complications. Noninfectious complications are usually less common as compared with infectious complications. In this review, we discuss some of the common noninfectious complications of peritoneal dialysis such as hernias, hydrothorax, hemoperitoneum, pancreatitis, ischemic colitis and necrotizing enterocolitis, pneumoperitoneum, GERD, subcapsular steatosis and hypokalemia. The awareness of these complications will help in early diagnosis and treatment.

Management of massive and persistent ascites and/or hydrothorax after liver transplantation.

PURPOSE: To describe the results of the treatment of eight liver transplantation (LT) patients subsequently developing large volumes of long-lasting ascites. PATIENTS AND METHODS: Between August 1996 and February 2003, 405 LTs were performed in 375 patients, eight (1.97%) of whom (six men and two women of mean age of 55.4 +/- 5.2 years) subsequently developed massive (> 500 mL/d) and persistent ascites and/or hydrothorax. All patients were HCV positive. The mean age of the liver donors was 66.8 +/- 21.9 years. All LTs were performed by replacement of the recipient retrohepatic vena cava. RESULTS: The eight patients displayed sinusoidal portal hypertension related to biopsy-proven recurrence of HCV infection. Mean wedged hepatic venous pressure was 14.9 +/- 5.1 mm Hg and mean portal vein/right atrial pressure gradient (PAPG) was 17.3 +/- 4.8 mm Hg. In two patients, the ascites appeared the day after LT; in the remaining six, ascites and/or hydrothorax appeared after 342.3 +/- 167.7 days. Seven patients with a mean PAPG of 18.4 +/- 3.9 mm Hg and a mean plasma/ascites albumin concentration gradient of 2.8 +/- 0.3 g/L were treated by means of a trans-jugular intrahepatic portosystemic shunt TIPS, and one (with a PAPG of 9 mm Hg and a plasma/ascites albumin concentration gradient of 1.38 g/L) by means of spleen arterial embolisation. After a mean follow-up of 558 +/- 147.2 days, the ascites and/or hydrothorax have resolved in five patients (62.5%), one (12.5%) has stable ascites not requiring paracentesis, and two (25%) have died of multiorgan failure. CONCLUSIONS: These data suggest the efficacy of the aggressive treatment of massive and persistent ascites and/or hydrothorax.

[X-ray study in the diagnosis of traumatic mediastinitis and its complications]. / Rentgenologicheskoe issledovanie pri diagnostike travmaticheskogo mediastinita i ego oslozhnenii.

The study was based on the clinical and X-ray analysis of 68 patients treated at the Thoracoabdominal Surgery, N.V. Sklifosovsky Research Institute of Emergency Care, in 1992-1997. The paper gives pre- and postoperative X-ray findings of patients with mediastinitis. It shows it possible to define the precise location of a mediastinal inflammatory process, its severity and possible complications. The X-ray symptomatology of mediastinitis is presented according to the location and developmental stage of a mediastinal process. Jointly with surgeons, the authors have developed a procedure for X-ray examination of patients in the postoperative period, which involves the study of the course of the disease and the evaluation of the adequacy of performed treatment. The paper analyzes the most specific and severe complications of traumatic mediastinitis. Special emphasis is laid on the fact that during control X-ray studies it is important to keep the procedure that permits timely diagnosis of complications at different developmental stages of mediastinitis.

The role of midtrimester targeted fetal organ screening combined with the "triple test" and maternal age in the diagnosis of trisomy 21: a retrospective study.

OBJECTIVE: Our purpose was to evaluate the role of fetal ultrasonography in prenatal detection of trisomy 21. STUDY DESIGN: A retrospective study was performed on all cases of trisomy 21 diagnosed prenatally or postnatally between January 1990 and December 1993 in the Jerusalem metropolitan area. Our program of prenatal detection of trisomy 21 is a three-tiered, chronologically progressive screening that includes maternal age, biochemical serum markers, and targeted fetal organ survey. Sixty-seven thousand ninety-two babies were born during the study period; 17,084 maternal biochemistry analyses (triple test) were performed; and 6315 fetuses were karyotyped. RESULTS: One hundred eight cases of trisomy 21 were diagnosed prenatally and postnatally. The overall rate of detection of trisomy 21 was 92.2% when our recommendations were followed. Among those cases diagnosed prenatally, 66.6% of trisomy 21 cases had been referred for fetal karyotyping because of maternal age > or = 35 years, 18.5% because of abnormal triple test results, and 11.1% because of fetal ultrasonographic findings associated with trisomy 21. Among women < 35 years old, 80% of trisomy 21 cases were detected prenatally. Of these, 50% had been referred for karyotyping because of triple test results and 30% because of abnormal ultrasonographic findings. CONCLUSION: Midtrimester ultrasonographic targeted fetal organ screening plays a critical role in prenatal diagnosis of trisomy 21 among women under the age of 35 years.

Vascular erosion by central venous catheters. Clinical features and outcome.

We evaluated the clinical characteristics of eight patients who presented with vascular erosion from central venous catheters and reviewed the available literature. Patients typically presented with dyspnea or chest pain, unilateral or bilateral pleural effusions, and mediastinal widening one to seven days after catheter insertion. Pleural fluid appeared transudative with variable glucose concentrations (range, 174 to 588 mg/dl) that were always greater than concurrent serum values. Diagnosis was delayed 3.0 +/- 1.5 days (range, 0 to 11 days) after vascular erosion. One patient died and four patients received chest tubes. Seven of eight patients had left-sided line placement; six of these seven left-sided catheters abutted the superior vena cava wall within approximately 45 degrees of perpendicular. Results of a literature search confirm the hazards of delayed diagnosis and the importance of left-sided catheter placement as a risk factor for vascular erosion.

[Iatrogenic hydrothorax after catheterization of the left internal jugular vein]. / Hidrotórax yatrógeno tras la cateterización de la vena yugular interna izquierda.

We report a case of hydrothorax after cannulation of left internal jugular vein that was not detected early. This complication could be due to various factors: first, venous approach from the left side, given its special anatomic arrangement; second, cardiorespiratory dynamics, and head and neck motion on postural changes during the intervention, and third, incorrect fixation of the catheter to the skin. We discuss preventive measures to avoid such complication. Finally, we advise right approach wherever possible as well as routine control of correct placement of the catheter tip by radiographic film with contrast medium.

Acute hydrothorax in continuous ambulatory peritoneal dialysis--a collaborative study of 161 centers.

Follow-up studies on 3,195 patients from 161 centers in Japan undergoing continuous ambulatory peritoneal dialysis (CAPD) were performed for 1-104 months to clarify the incidence as well as the clinical features of acute hydrothorax. In these studies, 50 patients (1.6%) developed this complication. Twenty-seven (54%) were men, and 23 (46%) were women, ranging in age from 6 to 79 (average 49) years. The interval between onset of CAPD and hydrothorax ranged from 1 day to 8 years. Four had left-sided, and 2 had bilateral hydrothorax, but the majority (88%) were right-sided. Dyspnea was experienced by 37 of these 50 patients, but the remaining 13 (26%) patients were asymptomatic. Hydrothorax was fully resolved in 27 of them following a brief interruption of CAPD or the combined use of small exchange volumes in a semi-sitting position and pleurodesis with tetracycline or other agents. The remaining 23 patients (46%) were switched to hemodialysis permanently. Despite recurrence, 1 patient continued successfully on CAPD. It was concluded that acute hydrothorax is one important possible complication, although the risk may be low. Constant surveillance is necessary to detect pleural effusions in patients during CAPD.