Ann Thorac Surg 2002;74:593-595
© 2002 The Society of Thoracic Surgeons
Case report
Pericardioperitoneal shunt: further development of the procedure using vats technique
Thomas F. Molnar, MD, PhD*a,
Barbara Biki, MDb,
Örs Péter Horváth, MD, PhDa
a Department of Thoracic Surgery, University of Pécs Medical School, Pécs, Hungary
b Department of Intensive Therapy and Anesthesia, University of Pécs Medical School, Pécs, Hungary
Accepted for publication March 14, 2002.
* Address reprint requests to Dr Molnar, Surgical Clinic, University of Pécs Medical School, Department of Thoracic Surgery, H-7632 Pécs, Ifjúság u. 13, Hungary
e-mail: mft{at}iseb.pote.hu
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Abstract
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We report a modification of the previously described VATS (video-assisted thoracic surgical) method of pericardioperitoneal shunt. Our method was used in 5 patients with pericardial tamponade requiring permanent drainage.
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Introduction
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Direct pericardioperitoneal shunt, originally described 10 years ago [1], has become a widely accepted technique [2] in cases where the standard pericardiopleural window would compromise function of the lung or the patient is unwilling to accept subxiphoid external drainage [3]. We report the cases of 5 patients in the standard transdiaphragmatic approach was further developed using VATS technique to minimize the invasiveness of the method.
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Case reports
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Patient 1
A 48-year-old woman, successfully treated with chemotherapy for small cell lung cancer for 11 months, had development of the classic symptoms of pericardial effusion during the last 3 weeks of treatment. Although tapped twice, the effusion proved to be resistant to pericardiodesis by means of bleomycin sulfate instillation. Cytological study revealed the presence of malignant cells in the fluid. The main request of the patient was the shortest possible hospital stay, therefore the transdiaphragmatic approach was used. The patient was discharged the day after the uneventful operation. She is well and free from any sign of cardiac tamponade 6 months after the procedure.
Patient 2
A 51-year-old woman was receiving therapy for chronic renal failure. Recurrent pericardial fluid accumulation causing chronic pericardial tamponade developed. Three attempts at subxiphoid drainage and pericardiodesis over a 4-month period were followed by a video-assisted pericardioperitoneal shunt procedure. No evidence of malignancy was found in either the specimen taken from the pericardium or the fluid evacuated. The patient is well 5 months after the procedure and is on the waiting list for kidney transplantation.
Patient 3
A 61-year-old man was on a cytostatic regimen for small cell lung cancer (limited disease) and had responded only partially to three courses of chemotherapy during the last 8 months. Pericardial tamponade developed after ineffective tapping of a malignant pericardial effusion. A transdiaphragmatic shunt procedure was undertaken, and the patient was discharged 24 hours later. After two more courses of chemotherapy, he is well with a patent window shown on routine echocardiography at the 3-month follow-up.
Patient 4
A 47-year-old man was being treated with a cytostatic regimen for stage IV primary lung adenocarcinoma. Pericardial tamponade refractory to repeated ultrasound guided drainage and local cytostatic instillation developed. He measured 40% on the Karnofsky scale prior to the procedure. Insertion of abdominal trocars was made difficult by a caput medusae resulting from multiple liver metastases. With a meticulous port-handling technique, a transdiaphragmatic shunt procedure was carried out without major bleeding. Measurement on the Karnofsky scale rose to 70% the week after operation. The patient has lived for 2 months without tamponade or echocardiographic abnormalities.
Patient 5
A 72-year-old woman was successfully treated for pemphigus. As a complication of the treatment of the underlying disease, recurrent pericardial fluid accumulation developed and was resistant to two previous attempts at ultrasound-guided pericardial drainage. A transabdominal approach was required, as lung functions were extremely poor because of chronic obstructive pulmonary disease. The procedure was complicated by adhesions from a previous gastric resection, but standard laparoscopic techniques solved the problem, and the subdiaphragmatic space was approached without complication. The echocardiogram was normal at the 3-month follow-up. The patient had no complaints and was seeing a dermatologist regularly.
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Video-assisted technique of pericardioperitoneal shunt
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The operation is performed under standard general anesthesia, and the trachea is intubated with a single-lumen endotracheal tube. Access to the inferior aspect of the diaphragm is facilitated by tilting the table in Fowler’s position (head-up or reverse Trendelenburg’s position). The legs of the patient are abducted, and the surgeon is positioned between them. A Veress needle is inserted into the abdominal cavity 4 cm above the umbilicus. This site is then used as the camera port after intraabdominal pressure reaches 14 Hg mm. The assistant or scrub nurse operates the camera. The left-hand port is placed in the mamillary line below the inferior arch of the costal margin. This 5-mm port is for the grasper. The trocar is positioned symmetrically on the opposite side, ie, the right side (Fig 1). The 10-mm trocar receives the long-handled UltraCision Harmonic Scalpel (Ethicon Endo-Surgery, Inc). The diaphragm is grasped at the spot where the outbulging cardiac movements is the most visible in the central tendon. With the diaphragm pulled downward, the Harmonic Scalpel cuts through the diaphragm and the pericardium. A window 4 to 6 cm in diameter is created between the pericardium and the diaphragm. The camera and the manipulators are withdrawn; no drains are left behind. The three ports (2, 2, and 3 cm) are closed by a single stitch or a Steri-Strip. In our 5 patients, the procedure took 26 minutes on average (range, 8 to 49 minutes), and no procedure-related or anesthesia-related complications were encountered.
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Comment
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The operative technique is simple and straightforward, as also recognized by others [4, 5]. There were no surgical complications related to the procedure or anesthesia despite concerns that the intraabdominal pressure gradient might cause problems when the pericardial sac was opened. As a safety measure, a closed pericardial catheter was inserted preoperatively in patients 1 and 5 because tamponade was anticipated and it was thought that high abdominal pressure could lead to fatal inferior vena caval compression. There was no need to release the cocks of these safety drains during insufflation of the abdominal cavity. The only abnormality observed was a pneumopericardium on one routine postoperative chest roentgenogram (patient 3).
The immediate results were satisfactory as 3 of the 5 patients were discharged the day after the procedure. Complete and immediate resolution of symptoms and signs of tamponade, and an improved quality of life were observed in every instance. All the criteria of minimally invasive operations are fulfilled. The greatest advantage is that there is no need of external drainage, which is mandatory after either the transpleural approach (intercostal catheter and suction) or the subxiphoid route (external drain). Whether the procedure should be called (and coded as) a VATS (video-assisted thoracic surgical) procedure, the target being the pericardial sac in the thorax, remains an open question. One can argue that this is a laparoscopic procedure. Extensive intraabdominal adhesions preventing the creation of a free space represent probably the only limitation of the technique. There is a theoretical possibility of approaching the inferior aspect of the pericardium through the subxiphoid region to create a transdiaphragmatic hole from above. The exploration of this route is still under evaluation.
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Acknowledgments
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We thank Mr Kumarasingham Jeyasingham, FRCS, Bristol, UK, for the tutorial help.
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References
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- Molnar T.F., Jeyasingham K. Pericardioperitoneal shunt for persistent pericardial effusions: a new drainage procedure. Ann Thorac Surg 1992;54:569-570.[Abstract]
- Olson J.E., Ryan M.B., Blumenstock D.A. Eleven years’ experience with pericardial-peritoneal window in the management of malignant and benign pericardial effusions. Ann Surg Oncol 1995;2:165-169.[Abstract]
- Larrey D.J. Sur une blessure du pericarde suivie d’hydropericarde. Bull Sci Med 1810:6-8.
- Mayer H.J. Transdiaphragmatic pericardial window. A new approach. J Cardiovasc Surg (Torino) 1993;34:173-175.[Medline]
- Ready A., Black J., Lewis R., Roscoe B. Laparoscopic pericardial fenestration for malignant pericardial effusion. Lancet 1992;339:1609.
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Abstract
Introduction
