Thoracoscopic Diaphragmatic Defect Closure And Pleurodesis In A Hepatic Hydrothorax Patient
Yochun Jung1, Sang Yun Song2, Kook Joo Na2, In Seok Jeong1, Chung Hwan Jun1, Sung Kyu Choi1.
1Chonnam National University Hospital, Gwangju, Korea, Republic of, 2Chonnam National University Hwasun Hospital, Hwasun, Korea, Republic of.
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Hepatic hydrothorax – a portal hypertension-associated transudative pleural effusion lacking cardiac or pulmonary diseases – is caused by ascites migration into the pleural cavity through diaphragmatic defects. Hepatic hydrothorax refractory to medical treatment is a quite difficult clinical condition in patients with liver cirrhosis. Since 2013, we have been performing thoracoscopic surgeries for primary closure of diaphragmatic defects, in which 1) pneumoperitoneum is created to localize diaphragmatic defects and 2) chemical pleurodesis is performed. This study presents one of our surgery cases to introduce its procedure.
A 63-year-old man was admitted for a refractory right pleural effusion diagnosed one year ago. He was previously diagnosed with liver cirrhosis 5 years ago. He was classified as Child class B with a model for end-stage liver disease score 10. Preoperative echocardiography and chest computed tomography showed no other abnormal findings. We decided to perform surgery for refractory hepatic hydrothorax. With the patient in the left lateral decubitus position, three 5-mm laparoscopic ports were placed. A Jackson-Pratt drain was placed in the subphrenic area for postoperative ascites drainage. One laparoscopic port was left to allow cardon dioxide insufflation for creating pneumoperitoneum. When the peritoneal cavity was inflated, one site of air leakage in the diaphragm could be detected through a 2-cm thoracic working port. Primary closure of the diaphragmatic defect was performed through an additional 2.5-cm working port, and then talc powder was applied to the entire diaphragm.
Postoperatively, positive airway pressure was given until extubation on postoperative day 1. The abdominal drain was kept open for ascites drainage. The abdominal drain was clamped on postoperative day 5, and the chest tube drainage was monitored for 2 more days, after which both the chest and abdominal drains were removed. The patient was transferred to hepatologist for ascites control on postoperative day 9 with no postoperative morbidity. On his 12-months-follow-up visit, recurrence of pleural effusion was not noticed.
Thoracoscopic primary closure of diaphgragmatic defects and pleurodesis can be a safe and effective treatment option in patients with refractory hepatic hydrothorax.
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