Cause: 因為已經被問到兩次了,而且有人說可以把Diaphragm補起來...所以來查查！！
Definition: recurrent pleural effusion in patients with end-stage liver disease and portal hypertension in the absence of comorbid cardiac or pulmonary disease
Theories:
1955: hydrothorax develop frequently have defects in the diaphragm that permit egress of ascites into the negative-pressure space of the pleural cavity
=> Intra-abdominal pressure elevated -> Diaphragm herniation -> rupture to pleural space
=> Can be seen under following the passage of various tracers—air, dyes, and radiolabeled substances—from the peritoneal to pleural compartments and by direct thorascopic visualization of the defects （1992～2005）
2007: Development of hydrothorax include transdiaphragmatic leakage of fluid from lymphatic channels and azygos vein hypertension
Icidence: 5~12%
More right side(85%), 仍有Left side(13%) or bilateral side(2%)!!
Diagnosis:
Thoracocentesis: transudative by traditional criteria of Light and colleagues
(From Aliment Pharmacol Ther 2004; 20: 271–279.)
Treatment:
For relieve dyspnea
=> Therapeutic thoracentesis ,
=> No need of chest tube:
induced infection, acute renal failure, and reflecting large volume loss , even poor outcomes
Medical Management: Similar to ascites
=> diet salt restriction(low sodium diet of 70–90 mmol/day) and
diuretics(BEST: furosemide 40 mg/day and spironolactone 100 mg/day.)
=> Doubling dose 3-5 days,
=> up to spironolactone up to 400 mg/day and furosemide up to 160 mg/day.
=> Early TIPS -> But not so sure as ascites-> 79% and 75 % response at POM1 and POM6
(Dhanasekaran et al, 2009).
但如果不能作TIPS, 那就不好處理了～～～
(From Aliment Pharmacol Ther 2004; 20: 271–279.)
Surgical treatment:
Definite: Liver transplantation!!
Other surgical tx:
# Timing: TIPS or VATS repair of the diaphragmatic defects (with or without pleurodesis) are effective strategies in those who are not transplant candidates or those awaiting organ availability.
=> Surgical repair of the diaphragmatic defects => 問題還是Child C 的Morbidity and Mortality!
=> Traditional thoracoscope + talc
Chest 2000; 118: 13–7.
thoracentesis followed by talc poudrage under thoracoscopy and repair of diaphragmatic defects if seen
18 patients with 21 procedures
=> Diaphragm defect was only in 5 pts. (27.8%)
=> High morbidity (57.1%) and mortality (38.9%)
=> Only 10/21 (47.6%) effective
=> 43.7% recurred and with complication
=> VATS + talc Pleurodesis + repair
Chest. 1996 Apr;109(4):1093-6.
8 patients underwent VATS to localize and close of diaphragmatic defects!
2 no defects, Drainage placed for 15 and 18 days, Volume: 3 and 4L
6 with defects(75%), Drainage placement for 7.6 +/- 1.75 days, Volume: 0.408 +/- 0.157 mL
No of these 6 pts got recurrence....
Am J Gastroenterol 2002; 97: 3172–5.
15 pts with VATS + talc pleurodesis
11/15 (73%) resolution at 1st month,
8/11: asymptomatic after median 5.5 m/o f/u
3/11:recurr between 45~60 days after VATS
Complications: Pain, Low grade fever, fistula and empyema!
=> VATS + talc Pleurodesis , no repair
Ann Thorac Surg. 2003 Mar;75(3):986-9.
=> Conclusion: Even with tunnel, Talc pleurodesis still effect!
-> In poor clinical status, repeat injection may be useful!
VATS+pleurodesis: a choice!
13 pts underwent VATS + Pleuraodesis,
=> 2 of them with defects(15.4%), 1 of them with fluid leakage
=> 10 of them no recurrence, 2 of them got late recurr before dying from cirrhosis
1 of them ear;y recurrence -> following Talc pleurodesis
8 pt cannot tolerate GA-> Chest tube insertion
=> 3: Septic shock-> die!
=> 3: early recurrence -> Cured after Talc pleurodesis
1: mid-term
1: early recurr -> Tx with TIPS -> Partial improvement!!
=> VATSsurgery with talc is safe and successful in about 3/4 of patients,
but repeat talc slurry through the chest tube or repeat VATS is often needed.
=> An alternative effective Tx to TIPS
41 pts underwent VATS + talc pleurodesis, followed 6 m/o
=> Only 2 patient with defect (<5 font="">
=> 1/40 (2.5%) Mortality -> Intra-operative, Due to coagulopathy!
=> 7/41 (17%) need repeat beside talc injection
=> Overall success rate: 80% (33 / 41)
=> 4 experienced symptomatic fluid collection, and Tx by repeat VATS -> 2/4 success!!
=> VATS + other pleurodesis
9 pts with VATS ->argon plasma -> bioabsorbable prostheses
-> 3ml fibrin glue and sprinkled 5 KE of OK-432 + 100mg minocyclin
All clinical improvement, 7/9 successful (77.8%),
2 recur at POM1 and POM4, 1/2: success after repet pleurodesis!!
=> Tunnel pleral catheters!!
=> Catheter placement -> as useful in palliative care...
Take home message:
1. 遇到Hepatic Hydrothorax 的病人, 重點還是在Ascites control!!
2. Definite Defect 其實不常見( <5 b="">
3. 治療, 能換肝就換肝, 不能換肝或等換肝太嚴重的, TIPS可以是選擇
VATS +/- pleurodesis +/- defect repair 也是有效的 (recently可到70~80% 成功率！)
=> This is CS field
4. 重點還是在這種病人能不能忍受General anethesia, 千萬不要輕易開進去！！！
Reference:
Blumgart’s Surgery of the Liver, Biliary Tract, and Pancreas, 5th edition
Chest. 1996 Apr;109(4):1093-6.
