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！！
Ann Thorac Surg. 2003 Mar;75(3):986-9.
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
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.
(from Ann Hepatol. 2008 Oct-Dec;7(4):313-20.)
=> 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
=> 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!!
Ann Thorac Surg. 2006 Aug;82(2):457-9.
=> 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
Surg Endosc. 2004 Jan;18(1):140-3. Epub 2003 Nov 21.
9 pts with VATS ->argon plasma -> bioabsorbable prostheses
-> 3ml fibrin glue and sprinkled 5 KE of OK-432 + 100mg minocyclin
-> 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
Aliment Pharmacol Ther. 2004 Aug 1;20(3):271-9.
Ann Thorac Surg. 2006 Aug;82(2):457-9.
Ann Thorac Surg. 2003 Mar;75(3):986-9.
Chest. 1996 Apr;109(4):1093-6.
Ann Hepatol. 2008 Oct-Dec;7(4):313-20.
