management for hydrothorax in peritoneal dialysis

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Management for Hydrothorax in

Peritoneal DialysisR1 吳悌暉

960518

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Management Options for Hydrothorax Complicating

Peritoneal Dialysis-Review ArticlesSeminars in Dialysis—Vol 16, No 5 (September–Octob

er) 2003 pp. 389–394

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 peritoneogr

aphy

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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 dia

phragmatic lymphatic swelling

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Ten major series were included in the period 1978–2002,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 2–6 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 10–15 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 inspecti

on defects or blebs overlying the tendinous part Sites of fluid leakage can then be repaired by direc

t 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 2–15 days) postoperatively, whereas CAPD was reinstituted after 3–4 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 hydrothorax

complicating peritoneal dialysis- Review Articles

Current Opinion in Pulmonary Medicine 2004, 10:315–319

Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, C

hina

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Summary Once hydrothorax secondary to pleuro-perit

oneal 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 2002;92:725-727

Department of Cardiothoracic Surgery, Papworth Hospi

tal, 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 lun

g 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 o

f the 6 patients. In the other three patients, small pleural blebs were seen o

n 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 un

eventfully to CAPD 1 month following hospital discharge At follow up with a median of 40 months there was no recur

rence of hydrothorax

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Discussion This is the largest series of patients yet reported We recommend early thoracoscopic surgery and p

leurectomy 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 met

hodEuropean Journal of Cardio-thoracic Surgery 28 (2005) 6

48–649

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 pe

ritoneal 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 mo

re than 50 mg/dL- Pleural and peritoneal fluid protein content u

niformly ＜ 4 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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THANKS