Ann Thorac Surg 2006;82:457-459
© 2006 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Efficacy of Video-Assisted Thoracoscopic Surgery With Talc Pleurodesis for Porous Diaphragm Syndrome in Patients With Refractory Hepatic Hydrothorax
Robert J. Cerfolio, MDa,*,
Ayesha S. Bryant, MSPH, MDb
a Division of Cardio-Thoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
b Department of Epidemiology, University of Alabama at Birmingham School of Public Health, Birmingham, Alabama
Accepted for publication March 21, 2006.
* Address correspondence to Dr Cerfolio, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, 1900 University Blvd, THT 712, Birmingham, AL 35294 (Email: rcerfolio{at}uab.edu).
Presented at the Poster Session of the Fifty-second Annual Meeting of the Southern Thoracic Surgical Association, Orlando, FL, Nov 10–12, 2005.
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Abstract
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BACKGROUND: Patients with recurrent, refractory hepatic hydrothorax from porous diaphragm syndrome represent a therapeutic challenge with few options.
METHODS: A retrospective review of an electronic prospective database of patients with cirrhosis and refractory hepatic hydrothorax. Patients underwent video-assisted thoracoscopic surgery (VATS) with talc pleurodesis insufflating 2.5 g of talc. Successful therapy was defined as relief of dyspnea and control of symptomatic hydrothorax for a minimum of 6 months after the procedure.
RESULTS: There were 41 patients (21 men, median age 55 years), 25 with Child-Pugh class C and 14 with class B, and 2 liver transplant patients. The etiology of the cirrhosis was hepatitis B in 4, hepatitis C in 20, alcohol in 4, cryptogenic cirrhosis in 11, and other in 2. Definitive openings in the diaphragm were seen in only 2 patients. Seven patients (17%) required bedside talc slurry through the chest tube after the intraoperative talc. Overall success was achieved in 80% (33 of 41). Four patients experienced symptomatic fluid reaccumulation at 45, 61, 62, and 102 days and were treated with a repeat VATS, with success in 2. There was 1 operative death (coagulopathy).
CONCLUSIONS: Patients with recurrent effusions from porous diaphragm syndrome have few options. Video-assisted thoracoscopic surgery with talc is safe and successful in about three fourths of patients, but repeat talc slurry through the chest tube or repeat VATS is often needed. Video-assisted thoracoscopic surgery provides an effective alternative to transjugular intrahepatic portosystemic shunt and is a bridge toward liver transplantation in patients with few other options.
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Introduction
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The term porous diaphragm syndrome is defined as the presence of a pleural effusion, usually greater than 500 mL, in a patient who has no evidence of cardiopulmonary disease or other identifiable etiologies for the effusion. If the patient has cirrhosis, ascites, and no other explainable cause of the effusion, then a recurrent effusion is also referred to as a hepatic hydrothorax [1]. No matter the label, patients who have cirrhosis and who have recurrent pleural effusions (which are almost exclusively right-sided), or those who have a persistently high chest tube output, represent a very challenging clinical problem. The options for these patients are few. One is liver transplantation, which is a highly selective process, and the average time on the waiting list is 2.1 years [2]. The second option is transjugular intrahepatic portosystemic shunt (TIPS). This procedure has significant risks such as renal dysfunction [3] and further liver injury. The third is video-assisted thoracoscopic surgery (VATS) with talc pleurodesis. We reviewed our experience with VATS talc pleurodesis in patients with cirrhosis and refractory pleural effusion from porous diaphragm syndrome.
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Material and Methods
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This is a retrospective study using an electronic prospective database of consecutive patients with cirrhosis who underwent VATS with talc pleurodesis for recurrent or refractory pleural effusions from porous diaphragm syndrome. All patients were selected and all procedures performed in the same manner by one surgeon at the University of Alabama at Birmingham Hospital. Patients with other explainable causes of their pleural effusion besides cirrhosis, such as a malignant effusion, a chylothorax, a history of heart failure, or renal failure, were eliminated. Patients who were less than 19 years old were also excluded from the study.
Entry criteria mandated a computed tomography (CT) scan that showed no other chest pathology beside a pleural effusion, a history of at least one thoracentesis with a recurrent effusion, or a chest tube with a persistently high output (defined as greater than 500 cc a day for at least 5 days) and evidence of cirrhosis, as defined by results of liver enzyme tests and biopsy. This study and the electronic prospective database used to store the data (Excel) were approved by the Institutional Review Board at the University of Alabama at Birmingham hospital. Individual patient consent was obtained for the database.
Operative Procedure
Patients received general anesthesia and double-lumen endotracheal intubation and were placed in a standard lateral decubitus position. A 5-mm rigid thoracoscope using a 0-degree lens was used, and the right pleural effusion was drained. It was sent for cytology as well as culture. The diaphragm was very carefully observed for approximately 10 minutes looking for macroscopic openings or any fenestrations in it. Areas where fluid appeared to be weeping across it were especially targeted for talc application. If actual openings were visualized, they were closed using thoracoscopic technique with suture. In all patients, 2.5 g talc was insufflated using an atomizer. The talc was insufflated in the pleural cavity with special concentration on the hemidiaphragm. A right-angle chest tube was placed, and a second pursestring suture was placed around the chest tube site to close the opening once the tube was removed. Chest tubes were removed when the output was no greater than 400 cc a day for 2 consecutive days. If the output remained greater than this amount, the tube was removed after 14 days.
Definitions
Successful pleurodesis was defined by an asymptomatic patient who was no longer short of breath and had a chest roentgenogram that did not show an enlarging pleural effusion. A minimum of 3 months of follow-up was mandated, and chest roentgenograms were obtained for all patients between 3 months and 6 months postoperatively.
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Results
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There were 41 patients (21 men, median age 55 years). Patient characteristics are shown in Table 1. Definitive openings in the diaphragm were seen in only 5 patients. The operative outcomes are shown in Table 2. Seven patients (17%) required bedside talc slurry through the chest tube after the intraoperative talc. All 7 patients had their tubes in 14 days; the other patients had their tubes removed most commonly on postoperative day 6. Overall success was achieved in 80% (33 of 41). Four patients experienced symptomatic fluid reaccumulation at 45, 61, 62, and 102 days and were treated with a repeat VATS, with success in 2 patients. There was 1 operative death (coagulopathy and liver failure; this patient died on postoperative day 43).
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Comment
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Patients with cirrhosis who are debilitated and who present with ascites and a right hemithorax half full of ascitic fluid represent a difficult and challenging clinical scenario. Medical management is directed at sodium restriction, aggressive use of diuretics, eliminating the use of nonsteroidal agents, and careful intravascular volume maintenance. Despite maximizing these strategies, however, a refractory right hepatic hydrothorax develops in some patients from their cirrhosis.
Because of our experienced liver failure clinic and the large number of liver transplantations performed each year at the University of Alabama at Birmingham, many patients present to our institution with this relatively unusually problem. In this manuscript, we reviewed our experience with patients with recurrent right pleural effusions from porous diaphragm syndrome from cirrhosis.
Recurrent right pleural effusion can occur from other causes of porous diaphragm syndrome. It is caused by several mechanisms, including peritoneal dialysis. We have treated 14 patients who became short of breath from a right pleural effusion every time they performed peritoneal dialysis. The pathophysiology may be slightly different but the treatment is the same.
Interestingly, Moroux and colleagues [4] in 1996 reported the most common cause of hepatic hydrothorax to be from visible openings or macroscopic holes in the diaphragm. Recently, Huang and associates [5] in 2005 reported a classification of these openings. According to that report, type 1 is described as no openings, type II is small "blebs" on the diaphragm, type 3 diaphragmatic defects are small fenestrations, and type 4 is multiple gaps. In that report, which had only had 11 patients, the most common type was type 3. Despite looking very carefully for these openings use VATS with its magnification, we only found openings in 5 of the 41 patients (12%). If the cause of these effusions was only due to openings, one would have to explain why it is almost exclusively observed on the right side. Does the left hemidiaphragm lack these openings, and if so, why? There are other theories that discount openings or gaps in the diaphragm as the cause. Zocchi [6] suggests it is from the circulation of the peritoneal fluid, and Kenasewitz [7] suggests it is from the oncotic pressure of the right hemidiaphragm, which is different from the left.
Irrespective of the cause, patients with refractory hepatic hydrothorax from porous diaphragm syndrome have few treatment options. The results of TIPS for patients with Child's C are marginal. Rossle and colleagues [8] in 1996 reported on the complication of worsening hepatic failure after TIPS, and a meta-analysis by D'Amico and associates [9] included several studies that showed hepatic encephalopathy was one of the most frequent complications after TIPS. In properly selected patients, however, TIPS is very helpful. Williams and associates [10] showed an increased survival of patients, but in that report, hepatic encephalopathy did develop in 10 patients. Although liver transplantation affords definite therapy for porous diaphragm syndrome from cirrhosis, many patients do not qualify. Those patients who are fortunate enough to get on the liver transplant list face a long wait, and many succumb to their disease while waiting for a suitable replacement liver. Therefore, VATS with talc pleurodesis may offer the safest therapeutic option and is an ideal first choice. It often serves as a bridge to transplantation.
We found that although VATS talc is only 68% successfully initially, when it is combined with repeat talc slurry through the chest tube, success rises to 85%. If the effusion returns, repeat VATS and talc can be tried again safely, as the effusion ensures that the lung is not adhered to the chest wall. In an attempt to increase our success rate, in our last 25 patients, we have performed an ultrasound-guided, large-volume paracentesis on the morning of the VATS or the day before. That helps lower the amount of fluid that traverses the right hemidiaphragm and may increase the success rate of pleurodesis. Although this success rate is poor when compared with other thoracic procedures, for these patients with cirrhosis and disabling hydrothorax, almost any minor help is significant. For that reason, it has become the initial treatment we consider when patients have right pleural effusions that continue to recur despite the maximization of medical therapy for their liver failure. It is unknown if a higher dose of talc would lead to better results. We favor a dose of 2.5 mg as there may be less morbidity with this dose, and there appears to be no improvement in its pleurodesic effect at higher doses in our experience in patients with malignant effusions. We do not favor mechanical pleurodesis or pleurectomy in this subset of patients, as these procedures can be bloody and these patients have severe liver dysfunction.
These results compared favorably with the few previous reported series. Mouroux and colleagues [4] reported success using fibrin glue and talc and sewing any visible openings. Ferrante and colleagues [11], medical colleagues at the University of Alabama at Birmingham, reported our early experience in 2001 in only 15 patients and found VATS controlled hydrothorax in 73% of patients with no procedure-related mortality. The most common morbidity from VATS was pain and fever from the talc. Empyema can also occur. A dreaded complication is a persistent high-volume ascitic leak from the chest tube site. For this reason, we recommend removing the tube no later than 14 days after the procedure. We also help prevent this latter complication by placing a second U stitch around the drain site so it can be closed. Finally, if VATS talc does work, the patient's abdominal ascites usually increases, and that can lead to other problems.
In conclusion, patients with recurrent effusions from porous diaphragm syndrome represent a relatively rare but difficult therapeutic challenge. If their medical therapy has been maximized and refractory hepatic hydrothorax persists, there are few options. Video-assisted thoracoscopic surgery with talc is safe and successful in about three fourths of these patients when repeat talc slurry through the chest tube or when repeat VATS talc are implemented. Video-assisted thoracoscopic surgery is safe and relatively effective in these weak and medically compromised patients. It provides an effective alternative to transjugular intrahepatic portosystemic shunt and a safe bridge toward liver transplantation in patients with cirrhosis and severe dyspnea who have few clinical options.
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References
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- Morrow CS, Kantor M, Armen RN, et al. Hepatic hydrothorax Ann Intern Med 1958;49:193-203.[Abstract/Free Full Text]
- The Organ and Procurement and Transplantation Network. Liver Kaplan-Meier median waiting times for registrations listed 1996-2002. United States Department of Health and Human Sciences. Available at http://www.opth.org..
- Somberg KA, Lake JR, Tomlanovich SJ, et al. Transjugular intrahepatic portosystemic shunts for refractory ascitesassessment of clinical and hormonal response and renal function. Hepatology 1995;21:709-716.[Medline]
- Moroux J, Perrin C, Venissac N, et al. Management of pleural effusion of cirrhotic origin Chest 1996;109:1093-1096.[Medline]
- Huang PM, Chang YL, Yang CY, et al. The morphology of diaphragmatic defects in hepatic hydrothoraxthoracoscopic findings. J Thorac Cardiovasc Surg 2005;130:141-145.[Abstract/Free Full Text]
- Zocchi R. The physiology and pathophysiology of pleural fluid turnover Eur Respir J 2002;20:1545-1558.[Abstract/Free Full Text]
- Kinasewitz GT, Keddissi JI. Hepatic hydrothorax Curr Opinons Pulm Med 2003;9:261-265.
- Rossle M, Haag K, Ochs A, et al. The transjugular intrahepatic portosystemic stent-shunt Hepatology 1997;25:1366-1369.[Medline]
- D'Amico G, Luca A, Morabito A, et al. Uncovered transjugular intrahepatic portosystemic shunt for refractory ascitesa meta-analysis. Gastroenterology 2005;129:1282-1293.[Medline]
- Williams DB, Waugh R, Selby W. Transjugular intrahepatic portosystemic shunt (TIPS) for the treatment of refractory ascites Aust NZ J Med 1998;28:620-626.[Medline]
- Ferrante D, Arguedas MR, Cerfolio RJ, et al. Video-assisted thoracoscopic surgery with talc pleurodesis in the management of symptomatic hepatic hydrothorax Am J Gastroenterol 2002;97:3172-3175.[Medline]
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Abstract
Introduction
