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Ann Thorac Surg 1996;62:1509-1510
© 1996 The Society of Thoracic Surgeons

Case Report

Videothoracoscopic Obliteration of Pleuroperitoneal Fistula in Continuous Peritoneal Dialysis

Maurizio Di Bisceglie, MD, Piero Paladini, MD, Luca Voltolini, MD, Guido Garosi, MD, Claudia Ghiribelli, MD, Nicola Di Paolo, MD, Giuseppe Gotti, MD

Institute of Thoracic and Cardiovascular Surgery and Department of Nephrology, University of Siena, Siena, Italy

Accepted for publication May 23, 1996.


   Abstract
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Hydrothorax during peritoneal dialysis is a very tedious complication. Many authors have described techniques of performing diagnosis and therapeutic procedures to take care of these complications. We describe a method to perform diagnosis and therapy by videothoracoscopy. Videothoracoscopy permits identification and closure of the tiny flaws in the diaphragm.


   Introduction
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Right hydrothorax is recurrent in some patients who are having continuous peritoneal dialysis. The tiny flaws in the diaphragm permit the passage of dialytic liquid from the peritoneum to the pleural cavity. Negative pleural pressure contributes to this leakage. Among the many methods of care, we consider operative videothoracoscopy to be the most current and the safest technique.

A 40-year-old woman suffering from chronic renal insufficiency caused by vasculitical nephritis underwent continuous peritoneal dialysis 3 times daily. One month after the start of her dialysis a large right hydrothorax developed, caused by the dialysis solution. Attempts to remedy this condition by reducing the time of daily exchanges and by increasing the number of daily exchanges were unsuccessful.

We performed videothoracoscopy with local anesthesia. After we obtained partial pulmonary collapse and the total aspiration of the residual hydrothorax, we examined the surface of the diaphragm dome while 2 L of peritoneal dialysis solution containing 2 mL of methylene blue dye was filling the abdomen. Two tiny flaws of about 1 mm were identified in the diaphragm cupola, near the tendon center. Through them we could see colored liquid passing into the pleural cavity (Fig 1Go).



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  		Fig 1. . Videothoracoscopic image of dialytic liquid passage through one of the flaws in the diaphragm.

 
We attempted to close the tiny flaws by injecting over them 2 mL of human fibrin glue (Tissucol; Immuno, Vienna, Austria) composed of freeze-dried human plasma cryoprecipitate and freeze-dried bovine thrombin. We used the following technique: through the channel of the thoracoscope we introduced a small double-lumen catheter. Through the catheter we injected separately freeze-dried cryoprecipitate human fibrin glue and freeze-dried bovine thrombin, which mixed together and solidified. Then we removed the thoracoscope and catheter together and we positioned a pleural drainage with suction of 20 cm H2O. This procedure was unsuccessful.

Some days later, the patient was submitted to videothoracoscopy under general anesthesia and double-lumen intubation. Direct suture of the diaphragm flaws with Endo Stitch (Auto Suture; United States Surgical Corp, Norwalk, CT) was accomplished. In addition, a small Teflon patch was applied to the surface of the diaphragm area around the flaws and anchored by four stitches applied with the same device. The patch was used to obtain secure adhesion of the lower face of the lung to the diaphragm, limiting the risk of infection to almost nothing.

After the operation the patient was submitted to extracorporeal dialysis for 21 days, after which she returned to peritoneal dialysis without any sign of hydrothorax. After a follow-up of 18 months the patient still has not shown any sign of hydrothorax, and she continues to receive peritoneal dialysis three times daily.


   Comment
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References
 
The origin of the diaphragm flaws is in doubt: there is a hypothesis of their congenital nature [1] with some other cofactors. Other hypotheses include the abundance of dialysate [2] and the variation between the negative pressure and the positive intraabdominal pressure [3]. A number of procedures have been used to illustrate transdiaphragmatic flaws; we have reported the use of radionuclide technetium-99m scanning [4].

During thoracoscopy the intraperitoneal instillation of methylene blue dye was used because in our opinion it permitted the exact identification of the diaphragm flaws and their subsequent correction.

We think that videothoracoscopy, recently introduced and used for many operations that in the past were done by thoracotomy, can safely be used also for the correction of minute diaphragm flaws. In the literature videothoracoscopy is preferred for patients with respiratory and cardiac defects but also for patients with chronic renal failure like in the case presented here. The surgical correction of flaws in the diaphragm by videothoracoscopy is better than traditional thoracotomy [5], particularly in a selected group of patients. It offers excellent results in comparison with the other surgical methods of pleurodesis [6–8].


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Address reprint requests to Dr Di Bisceglie, via Colleverde, 16, 53100 Siena, Italy.


   References
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 References
 

  1. Le Veen HH, Piccone VA, Hutto RB. Management of ascites with hydrothorax. Ann J Surg 1984;148:210–3.
  2. Townsend R, Fragula J. Hydrothorax in patient receiving CAPD. Arch Intern Med 1982;142:1571–2.[Abstract/Free Full Text]
  3. Green A, Logan M, Medawar W, et al. The management of hydrothorax in CAPD. Perit Dial Int 1990;10:271–4.[Abstract/Free Full Text]
  4. Kennedy JM. Procedures used to demonstrate a pleuroperitoneal communication: a review. Perit Dial Bull 1985;5:168–17.
  5. Pattison CW, Rodger RS, Adu D, Michael J, Matthews HR. Surgical treatment of hydrothorax complicating continuous ambulatory peritoneal dialysis. Clin Nephrol 1984;21:191–3.[Medline]
  6. Coltharp WH, Arnold JH, Alford WC, et al. Videothoracoscopy: improved technique and expanded indications. Ann Thorac Surg 1992;53:776–9.[Abstract/Free Full Text]
  7. Landreneau RJ, Mack MJ, Hazelrigg SR, et al. Video-assisted thoracic surgery: basic technical concepts and intercostal approach strategies. Ann Thorac Surg 1992;54:800–7.[Abstract/Free Full Text]
  8. Vlachojannis J, Boettcher I, Brandt L, Schoeppe W. A new treatment for unilateral recurrent hydrothorax during CAPD. Perit Dial Bull 1985;5:180–1.



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