Management for Hydrothorax in Peritoneal Dialysis

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Management for Hydrothorax inPeritoneal Dialysis

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• 960518

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Management Options for Hydrothorax
ComplicatingPeritoneal Dialysis-Review Articles

• Seminars in DialysisVol 16, No 5
  (SeptemberOctober) 2003 pp. 389394
• Department of Medicine and Therapeutics, Chinese
  University of Hong Kong, Shatin, Hong Kong SAR,
  China

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• Hydrothorax secondary to pleuroperitoneal
  communication as a complication of peritoneal
  dialysis (PD) was first described in 1967
• Incidence ranged from 1.0 to 5.1 (1.9 on
  average) 62 of the cases were female
• Patients often develop symptomatic sterile
  transudative pleural effusion (mostly
  right-sided)

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Diagnostic clues

• Chemical analysis (glucose, protein, lactate
  dehydrogenase) of pleural fluid
• Methylene blue discoloration of the dialysate
  followed by thoracocentesis
• Peritoneal scintigraphy
• Contrast computed tomographic peritoneography

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Mechanisms

• Congenital diaphragmatic defects - autopsy and
  operative observation of diaphragmatic
  fluid-filled blebs overlying tendinous diaphragm
  discontinuities due to collagen fiber loss
• ( left-sided defects are covered by the heart and
  pericardium )
• Pleuroperitoneal pressure gradient
• Lymph drainage disorder - operative finding of
  diaphragmatic lymphatic swelling

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• Ten major series were included in the period
  19782002,identifying 104 consecutive cases of
  hydrothorax complicating PD

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Interruption of PD

• First and foremost, management of hydrothorax
  complicating CAPD should begin with interruption
  of PD
• Under normal circumstances, interruption of CAPD
  for a period of 26 weeks is recommended
• Spontaneous closure of the diaphragmatic defects
  is facilitated by the performance of small
  volumes of peritoneal exchanges
• Success rate 53

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Conventional Pleurodesis

• Administration of a chemical agent via chest
  tube, followed by designated positioning of the
  patient every 1015 minutes
• As a rule of thumb, a 10-day wait is recommended
  after performing pleurodesis before resuming CAPD
• Contraindication to thoracoscopy
• Success rate 48

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Thoracotomy

• A limited thoracotomy incision, with direct
  inspection defects or blebs overlying the
  tendinous part
• Sites of fluid leakage can then be repaired by
  direct suturing, with or without reinforcement
  with Teflon felt patches
• Limited eligibility of dialysis patients for open
  thoracotomy
• Success rate 100

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Video-Assisted Thoracoscopic Approach

• Allows direct application of talc (chemical
  pleurodesis) and abrasion of the parietal pleura
  (mechanical pleurodesis)
• In the former situation, thoracoscopy is thought
  to offer reliable distribution of talc to effect
  uniform pleurodesis
• Chest drains were removed after a median of 5
  days (range 215 days) postoperatively, whereas
  CAPD was reinstituted after 34 weeks
• Encouraging results have been reported with
  thoracoscopic closing of these diaphragmatic
  breaches by direct repair with endoscopic
  suturing
• Success rate 88

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Pathogenesis and management of hydrothoraxcomplic
ating peritoneal dialysis- Review Articles

• Current Opinion in Pulmonary Medicine 2004,
  10315319
• Department of Medicine Therapeutics, Prince of
  Wales Hospital, The Chinese University of Hong
  Kong, Shatin, Hong Kong, China

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Summary

• Once hydrothorax secondary to pleuro-peritoneal
  communication is confirmed in CAPD patients,
  temporary cessation of peritoneal dialysis
  remains the first-line treatment. Current
  evidence shows that video-assisted thoracoscopic
  pleurodesis or repair should be the treatment of
  choice in patients who failed conservative
  management

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Acute hydrothorax in CAPD Early Thoracoscopic
(VATS) intervention allows return to peritoneal
dialysis

• Nephron 200292725-727
• Department of Cardiothoracic Surgery, Papworth
  Hospital, Cambridge, UK

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Materials and Methods

• Between 1995 and 2000 we studied 6 patients (3
  male, 3 female, mean age 62, range 31-72 years)
  receiving CAPD for chronic renal failure

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Operative Technique

• Under general anaesthesia and utilizing single
  lung ventilation, the thoracoscope is introduced
  into the right hemithorax. The abdomen is
  palpated and often fluid can be seen to enter the
  chest. This site of communication is then closed
  with a single clip. Following this a full
  parietal pleurectomy is performed to obliterate
  the pleural space and prevent further
  hydrothoraces

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Results

• Diaphragmatic defects (fistula) were clearly
  identified in 3 of the 6 patients.
• In the other three patients, small pleural blebs
  were seen on the surface of the diaphragm
• Directly closed with an endoclip
• Parietal pleurectomy was performed in all cases
• No perioperative morbidity and all patients had
  returned uneventfully to CAPD 1 month following
  hospital discharge
• At follow up with a median of 40 months there was
  no recurrence of hydrothorax

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Discussion

• This is the largest series of patients yet
  reported
• We recommend early thoracoscopic surgery and
  pleurectomy as the first choice modality in
  treating pleuro-peritoneal fistula
• We have not found it necessary to perform
  preoperative contrast peritoneoscintigraphy to
  identify fistulae
• As the mainstay of therapy, parietal pleurectomy,
  will prevent recurrence even if small defects
  have failed to be identified

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Video-assisted thoracoscopic surgery for
hydrothorax in peritoneal dialysispatients
check-air-leakage method

• European Journal of Cardio-thoracic Surgery 28
  (2005) 648649
• Kaohsiung Chang Gung Memorial Hospital

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Technique

• Under general anaesthesia, the patient was
  ventilated through a dual-lumen endotracheal
  tube, with their ipsilateral lung deflated. The
  patient was then placed in the decubitus position
  with their right side facing up. Three entry
  portals were created.

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Technique

• The pleural cavity was filled with sterile water
• Inflated the CO2 to the peritoneal cavity via the
  peritoneal catheter. The pressure in the
  peritoneal cavity was maintained at 12 mmHg
• Via thoracoscopy, continuous air bubbles leaking
  from the diaphragmatic defect were located in the
  pleural cavity
• The video-assisted thoracoscopic surgery (VATS)
  procedure was then performed to repair the
  pleuroperitoneal communication with direct
  suturing. Talc pleurodesis was also performed.

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Comment

• Compared with methylene blue infusion, checking
  air leakage was easier and allowed for clearer
  identification of the defect
• Even when small defect was not detected by
  methylene blue infusion, it was easily
  identified by this method
• This method is now the first procedure chosen at
  Kaohsiung Chang Gung Memorial Hospital and the
  methylene blue infusion test is no longer used

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Finally
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Conclusion

• Diagnosis
• - Pleural fluid to serum glucose gradient of more
  than 50 mg/dL
• - Pleural and peritoneal fluid protein content
  uniformlylt4 g/L

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Conclusion

• Treatment
• - First-line treatment - temporary cessation of
  peritoneal dialysis with small volume exchanges
• - Video-assisted thoracoscopic repair with
  pleurodesis should be the treatment of choice in
  patients who failed conservative management

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