Thoracoscopic Diaphragmatic Defect Closure For Refractory Hepatic Hydrothorax Complicated By Pleural Fluid Infection
Yochun Jung1, Sang Yun Song2, Kook Joo Na2.
1Chonnam National University Hospital, Gwangju, Korea, Republic of, 2Chonnam National University Hwasun Hospital, Hwasun, Korea, Republic of.
ObjectiveHepatic hydrothorax (HH) refractory to medical treatment is a difficult clinical condition in patients with liver cirrhosis. Particularly, in cases that pleural fluid infection due to indwelling pleural catheter also occurs, there are few treatment options. We report a case that thoracoscopic surgery for direct closure of diaphragmatic defect (DD) successfully treated refractory HH with pleural fluid infection. MethodsA 53-year-old man with cirrhosis was admitted because of a refractory right pleural effusion for 4 months. He had a pleural catheter, which was inserted 2 months ago for symptom control. The laboratory examination revealed that he was in Child class C with a model for end-stage liver disease score 25, and the inflammatory markers were elevated. The methicillin-resistant coagulase-negative Staphylococcus (MRCNS) and Klebsiella pneumoniae have grown in the pleural fluid culture. K. pneumoniae was also identified in the blood cultures, so antibiotic therapy was started. No bacteria were found in the following blood cultures, however, MRCNS was consistently identified in pleural fluid cultures. Surgery was performed on the 12th day of antibiotic administration. Initially, a peritoneal drain was laparoscopically placed and one laparoscopic port was left for creating pneumoperitoneum. When the peritoneal cavity was inflated, one site of air leakage in the diaphragm could be detected. Suture closure of the DD was performed, followed by thoracoscopic pleurodesis. Postoperatively, however, incomplete DD closure was suspected. Therefore, we performed reoperation on postoperative day (POD) 4 and reinforced the previous suture site by coverage with Prolene mesh. ResultsPostoperatively, the amount of chest tube drainage was dramatically reduced. The peritoneal drain was clamped on POD 5, and the amount of chest tube drainage was monitored for 3 more days, after which the peritoneal drain was removed. Confirming that no bacteria were identified in the postoperative pleural fluid cultures three times, chest tube was removed on POD 11. The patient was transferred to hepatologist for ascites control and discharged on POD 35. On 5-months follow-up visit, recurrence of pleural effusion was not noticed. ConclusionThoracoscopic diaphgragmatic defect closure can be an effective treatment option for refractory hepatic hydrothorax, even in cases complicated by pleural fluid infection.
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