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Ann Thorac Surg 1997;64:1468-1469
© 1997 The Society of Thoracic Surgeons

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Case Report

Videothoracoscopic Treatment of Hepatic Hydrothorax

Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico

Accepted for publication June 1, 1997.

	Abstract

Top Footnotes Abstract Introduction Comment References

 
Hepatic hydrothorax occurs frequently in ascites arising from communications in the diaphragm between peritoneal and pleural cavities. Numerous treatments have been described but are of limited utility due to invasiveness and poor success rate. We describe a case of hepatic hydrothorax in which the pore in the diaphragm was documented photographically and in which successful resolution was achieved with videothoracoscopic suture ligation and talc pleurodesis.

	Introduction

Top Footnotes Abstract Introduction Comment References

 
Hepatic hydrothorax is defined as the accumulation of pleural effusion in cirrhotic patients without pulmonary or cardiac disease [1]. It is usually right sided and occurs in approximately 5% of these patients [2]. The etiology of these effusions is believed to be abnormal communications between the peritoneal and pleural spaces.

Diagnostic modalities have included intraperitoneal instillation of air or contrast agents, nuclear scintigraphy, magnetic resonance imaging, and surgical exploration [3, 4]. Traditional treatments consist of fluid restriction and diuretics, chest tube drainage with chemical pleurodesis, open surgical repair of fenestrations, pleuroperitoneal or peritoneovenous shunts, transjugular intrahepatic portosystemic shunts, portacaval shunts, and most recently videothoracoscopic closure combined with pleural sclerosis [1, 5, 6].

We report a patient with cirrhosis, ascites, and hepatoma who was under evaluation for liver transplantation. He was referred with recurrent symptomatic right-sided pleural effusion. Videothoracoscopy was performed through a 12-mm port to differentiate malignant effusion from hepatic hydrothorax and to relieve symptoms. At operation a fenestration in the central tendon of the right diaphragm was identified and photographically documented (Fig 1). Suture closure of the pore using two additional 12-mm ports was performed with the Endo Stitch (U.S. Surgical, Norwalk, CT) suturing device. Five grams of talc was insufflated into the pleural space.

View larger version (78K): [in this window] [in a new window]   Fig 1. . Intraoperative view of diaphragmatic fenestration.

	Comment

Top Footnotes Abstract Introduction Comment References

 
Hepatic hydrothorax resulting from cirrhosis and ascites is common, occurring in approximately 5% of these patients. In addition, other causes of ascites such as peritoneal dialysis may also produce pleural effusions. The large number of patients affected make hepatic hydrothorax a significant clinical problem.

The etiology of these effusions is thought to be transdiaphragmatic pores, usually on the right side, creating a communication between peritoneal and pleural cavities. The decreased intrathoracic pressure relative to the abdomen causes preferential accumulation of fluid within the thorax. Subsequent respiratory compromise results.

Numerous radiographic studies such as nuclear medicine scintigraphy and magnetic resonance imaging have suggested the presence of fenestrations. However, direct demonstration of these pores using videothoracoscopy in a patient receiving peritoneal dialysis was only recently published [6]. Here we report photographic documentation of these pores in a cirrhotic patient.

Management of these patients is complex because of severe underlying disease. Noninvasive treatments such as fluid restriction, thoracostomy tubes, and chemical sclerosis are generally unsuccessful. Invasive techniques such as thoracotomy, peritoneovenous shunts, and transjugular intrahepatic portosystemic shunts are associated with high morbidity and mortality rates.

Videothoracoscopic suture closure of fenestrations with talc pleural sclerosis has had a high rate of success and a low morbidity and mortality in the few patients with hepatic hydrothorax in whom it has been performed [2, 5]. Although it has only rarely been reported in this entity, based on this report and others, it should be considered in patients with pleural effusions due to ascites.

	Footnotes

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Address reprint requests to Dr Temes, Department of Surgery, University of New Mexico, 2211 Lomas Boulevard NE, Albuquerque, NM 87131 (e-mail: ttemes{at}salud.unm.edu).

	References

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1. Morrow CS, Kantor M, Armen RN. Hepatic hydrothorax. Ann Intern Med 1958;49:193–203.[Abstract/Free Full Text]
2. Mouroux J, Perrin C, Venissac N, Blaive B, Richelme H. Management of pleural effusion of cirrhotic origin. Chest 1996;109:1093–6.[Abstract/Free Full Text]
3. Park CH, Pham CD. Hepatic hydrothorax: scintigraphic confirmation. Clin Nucl Med 1995;20:278.[Medline]
4. Urhahn R, Gunther RW. Transdiaphragmatic leakage of ascites in cirrhotic patients: evaluation with ultrafast gradient echo MR imaging and intraperitoneal contrast enhancement. Magn Reson Imaging 1993;11:1067–70.[Medline]
5. Mouroux J, Hebuterne X, Perrin C, et al. Treatment of pleural effusion of cirrhotic origin by videothoracoscopy. Br J Surg 1994;81:546–7.[Medline]
6. Di Bisceglie M, Paladini P, Voltolini L, et al. Videothoracoscopic obliteration of pleuroperitoneal fistula in continuous peritoneal dialysis. Ann Thorac Surg 1996;62:1509–10.[Abstract/Free Full Text]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Fabrizio M. Follis Jorge A. Wernly Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Temes, R. T. Articles by Wernly, J. A. Search for Related Content PubMed PubMed Citation Articles by Temes, R. T. Articles by Wernly, J. A.