Ann Thorac Surg 2002;74:218-221
© 2002 The Society of Thoracic Surgeons
Original article: general thoracic
Long-term follow-up of thoracoscopic pleurodesis for hydrothorax complicating peritoneal dialysis
Siu-ka Mak, FRCP (Edin)*a,
Kyaw Nyunt, FRCS (Edin)b,
Ping-nam Wong, MRCP (UK)a,
Kin-yee Lo, MRCP (UK)a,
Gensy M.W. Tong, MRCP (UK)a,
Yuk-ping Tai, FRCS (Edin)c,
Andrew K.M. Wong, FRCP (Lond)a
a Department of Medicine and Geriatrics, Renal Unit, Kwong Wah Hospital, Hong Kong, China
b Department of Surgery, Kwong Wah Hospital, Hong Kong, China
c Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China
Accepted for publication March 28, 2002.
* Address reprint requests to Dr Mak, Renal Unit, Department of Medicine and Geriatrics, Kwong Wah Hospital, Waterloo Rd, Kowloon, Hong Kong, China
e-mail: maksk{at}ha.org.hk
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Abstract
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Background. Massive hydrothorax is a significant complication of continuous ambulatory peritoneal dialysis (CAPD) and its ideal management remains undefined. Conservative management in the form of intermittent peritoneal dialysis had limited success. The use of conventional pleurodesis and open thoracotomy were associated with morbidities and limitations. We retrospectively reviewed the long-term outcome of 8 patients with massive hydrothorax complicating CAPD, 6 of whom received thoracoscopic pleurodesis.
Methods. Among 397 patients undergoing continuous ambulatory peritoneal dialysis during the period from 1994 to 1998, hydrothorax developed in 8 patients. Four patients were first treated with temporary intermittent peritoneal dialysis using 1-L exchange cycles. Three of them had a recurrence of the hydrothorax whereas only one could resume continuous ambulatory peritoneal dialysis successfully. Two patients then underwent conventional pleurodesis but failed. One of them was switched to hemodialysis. Thoracoscopic pleurodesis was performed for the remaining 2 patients together with 4 other patients with hydrothorax once this complication developed. There were no gross abnormalities including pleuroperitoneal communication sites identified. Talc poudrage was performed in 2 patients and mechanical rub pleurodesis in the other 4 patients. All had uncomplicated procedure and uneventful recovery.
Results. One patient after thoracoscopic pleurodesis was soon switched to hemodialysis for an unrelated reason. The other 5 patients resumed continuous ambulatory peritoneal dialysis with no recurrence of hydrothorax for a mean period of 50 months (range 19 to 84).
Conclusions. With thoracoscopic pleurodesis, patients resumed continuous ambulatory peritoneal dialysis without recurrence of hydrothorax on long-term follow-up.
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Introduction
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Massive hydrothorax is a well-known complication of continuous ambulatory peritoneal dialysis (CAPD) affecting 1.6% to 2% of these patients [1, 2]. It has been suggested that this complication may require permanent discontinuation of peritoneal dialysis [3]. Conservative management in the form of cessation of CAPD, aspiration, or drainage of the hydrothorax and temporary hemodialysis or intermittent peritoneal dialysis using low-volume exchange cycles has been associated with a success rates of 41% to 54% [1, 4]. The use of conventional pleurodesis and open thoracotomy with surgical closure of pleuroperitoneal communication has been found useful [1, 4]. However, both the failure rate and the associated morbidities are of concern. Thoracoscopic pleurodesis with and without direct surgical obliteration of visualized communicating sites have been performed with success in a number of reported cases [5–8]. Although the ideal management of this condition remains undefined we believe that simple thoracoscopic pleurodesis without direct surgical obliteration of communicating sites is a reasonable approach to offer the best chance of maintaining peritoneal dialysis. This retrospective study looked at the long-term outcome of 8 patients with massive hydrothorax complicating CAPD, 6 of whom received thoracoscopic pleurodesis.
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Patients and methods
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Among 397 patients undergoing CAPD during the period from 1994 to 1998 at our center, there were 8 patients in whom hydrothorax developed. Locally in Hong Kong, as a result of smaller body size of patients in general, three daily 2-L exchanges have been the standard starting therapy for CAPD in most centers. All 8 patients had massive right-sided hydrothorax with typical biochemical characteristics of crystal clear pleural fluid: low white blood cell count, low protein and lactate dehydrogenase levels, and raised glucose level. Except for 1 patient (no. 8) who developed this complication almost 6 years after starting CAPD, the majority had their onset within the first 6 months.
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Results
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Previous treatment for the hydrothorax
Upon diagnosis of the hydrothorax, 4 patients (nos. 1 to 4) were first treated with intermittent peritoneal dialysis using 1-L exchange cycles for 4 to 6 weeks (Table 1).
Apart from 1 patient (no. 2) who then resumed CAPD successfully for 64 months up to the last follow-up, 3 patients had recurrence of their hydrothorax at 6 to 8 weeks after CAPD was restarted. Two of them then received conventional pleurodesis with oxytetracycline (no. 4) or talc (no. 1) through a chest drain. They were both put on temporary hemodialysis. CAPD was restarted 4 weeks later and both had the hydrothorax recur. One patient decided to switch to hemodialysis and the other received thoracoscopic pleurodesis. The third patient who failed to respond to intermittent peritoneal dialysis had also received thoracoscopic pleurodesis.
Thoracoscopic pleurodesis
Thoracoscopy (10 mm 0-degree and 30-degree laparoscopes; Stryker, Santa Clara, CA) was performed in 6 patients (nos. 3 to 8) under local or general anesthesia. Two portals of entry were made in the midaxillary zone at the sixth and seventh right intercostal spaces. All pleural fluid was aspirated under direct visualization and the diaphragm and pleural surfaces were inspected. Apart from an adhesion band at the apex of the upper lobe in 1 patient (no. 4) and a small bullous sac at the diaphragmatic dome in another (no. 8), no other abnormalities including pleuroperitoneal communication sites were identified. In 2 patients (nos. 4 and 6), 5 g medical grade talc powder was put inside a mucus extractor (Uno, Denmark). There were two tubings attached to the bottle. One was connected to a Tissomat machine (Immuno AG, Vienna, Austria), which was normally used for spraying tissue glue to stop surface bleeding. With the Tissomat machine turned on, nitrogen gas was ejected into the bottle and mixed with the powder and a jet of talc powder was generated and came out through the outlet catheter (Fig 1).
Alternatively, oxygen from a jet ventilator could be used for the same purpose. The talc powder was then sprayed evenly onto the pleural surfaces under thoracoscopic guidance. For the other 4 patients the parietal pleura were rubbed with a piece of Marlex mesh (Band Implants, Billerica, MA) mounted on a grasper. Upon completion a chest drain was inserted under direct vision through the trocar site. All patients were put on temporary hemodialysis for 4 weeks before CAPD was resumed.
Outcome
Patient no. 5 was restarted on CAPD at the fifth week but soon had a severe episode of peritonitis requiring removal of the Tenckhoff catheter. She then decided for long-term hemodialysis. The other 5 patients resumed CAPD successfully with no recurrence of hydrothorax or evidence of altered peritoneal membrane properties for a mean period of 50 months (range 19 to 84). Two patients (nos. 3 and 8) died 19 and 31 months, respectively, after thoracoscopic pleurodesis with normal functioning peritoneum. Radiologically, 2 of the 5 patients with CAPD resumed long-term had a persistently blunted costophrenic angle.
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Comment
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Continuous ambulatory peritoneal dialysis is an increasingly utilized treatment modality for end-stage renal disease (ESRD) worldwide. Massive hydrothorax is an uncommon but well-recognized complication. It has been suggested that the development of this complication might require permanent discontinuation of peritoneal dialysis (patient no. 1 in this series) [3]. Locally, Hong Kong provides government reimbursement for ESRD treatment for most citizens and it is our policy to use CAPD as a first-line renal replacement therapy as it is much more cost effective than in-center hemodialysis. That prompted us to look into ways to actively persevere with peritoneal dialysis when such a complication develops and particularly so when the patient opts against hemodialysis, as for cases in this series. A conservative approach consists of drainage of pleural effusion together with temporary hemodialysis or intermittent peritoneal dialysis using low-volume exchange cycles. This resulted in limited success (41 to 54%) [1, 4]. Three of our 4 patients treated with intermittent peritoneal dialysis using 1-L exchange cycles had recurrence of the hydrothorax after a short period of apparent success. Thus this approach has not been successful in our experience and we have not used this in half of the cases in the present study.
Chemical pleurodesis has been performed with tetracycline, talc, fibrin glue, autoblood, N-CWS (Nocardia rubra cell wall skeleton), and OK-432 [1, 9–11]. The reported success rate in hydrothorax was 52% to 53% [1, 4]. The conventional chemical pleurodesis performed in 2 of our patients both failed.
The similarity of the biochemistry of the pleural fluid in hydrothorax and the peritoneal dialysate suggests the presence of a mechanical pleuroperitoneal communication. Surgical closure during open thoracotomy of such communications including gross diaphragmatic defects [12] and eventration of diaphragm [13] has resulted in resolution of the hydrothorax and CAPD could be resumed [4, 13]. However, that these communications may be too small to be demonstrated even with imaging techniques or postmortem studies suggests that most communicating sites are indeed small and difficult to localize intraoperatively [4].
Thoracoscopic pleurodesis has increasingly been used in the treatment of malignant pleural effusion with a success rate of 95% to 100% [14]. The procedure permits an excellent view of the entire parietal pleura and lung surface and compared with open thoracotomy is ideal for patients with mild coagulopathy as incisions are kept to a minimum [15]. Obviously, open thoracotomy might still be required when gross diaphragmatic defects are suspected [12, 13]. Pleurodesis can be in the form of pleurectomy, mechanical pleural abrasion, and talc poudrage [14]. When talc was used thoracoscopic pleurodesis could be performed under local anesthesia and has not been associated with clinically significant pain [8, 14] as in our patients and there was no problem of clumping of the talc in loculated spaces as had been described in conventional talc pleurodesis [16]. This is possibly related to the much smaller amount (5 g) of talc used during thoracoscopy as compared with thoracotomy [8]. Radiologically only 5% of these patients had a fine border around the apex and another 5% had blunted costo-pleural angle [17]. There remains much controversy as to whether talc should be used for pleurodesis in conditions other than malignant pleural effusions [18, 19] when talc has been found in bronchoalveolar lavage fluid and in multiple organs after intrapleural administration in both humans and experimental animals [18]. Also, the development of acute respiratory distress syndrome after talc pleurodesis, though rare, is a concern [19]. In contrast, mechanical pleurodesis using either Marlex or Prolene (Ethicon, Somerville, NJ) mesh for abrasion of the parietal pleura would eliminate the potential problems of backflow into the peritoneal cavity and formation of talc granuloma when chemical sclerosing agents are used. It has been shown that mechanical pleurodesis was as effective as talc poudrage [20]. However, general anesthesia is required for the procedure.
When compared with pleurodesis for patients with malignant pleural effusion where removal of chest drain was mostly possible within 48 hours after the procedure [14], chest drainage was more prolonged in the present series with a mean of 6.7 ± 4.9 days. This may be explained by the acquired platelet dysfunction commonly encountered in uremic patients [21].
Altogether we have performed thoracoscopic pleurodesis for 6 patients. Apart from the patient who was switched to long-term hemodialysis soon after the procedure for another reason, all 5 patients could resume CAPD successfully without recurrence of the hydrothorax on long-term follow-up. Okada and associates [6] reported their findings of demonstrable pleuroperitoneal communication sites during thoracoscopic pleurodesis by infusing colored dialysis fluid into the peritoneal cavity during surgery. Either flaws or small blebs on the diaphragm were then transmurally sutured before pleurodesis using biological glue with or without irradiation with Ar-laser was performed. Tsunezuka and associates [7] reported their case in which resection of the identified weak portion of the diaphragm together with pleurodesis was performed. All our 6 patients had their entire pleural surface and diaphragm fully inspected during thoracoscopic pleurodesis and apart from an adhesion band at the apex of the upper lobe in 1 patient and a small bullous sac at the diaphragmatic dome in another, no other abnormalities including pleuroperitoneal communication sites were identified. We have not infused colored peritoneal dialysis fluid as in the Okada series [6]. However, the demonstrated efficacy of simple thoracoscopic pleurodesis in our patients, as well as in the Jagasia series [8], without direct surgical obliteration of pleuroperitoneal communications is convincing.
The adhesion band encountered during thoracoscopic pleurodesis in 1 of our patients was likely related to her previous chemical pleurodesis through a chest drain. This might potentially prevent the successful application of the sclerosing agent to the entire pleural surface during subsequent thoracoscopic pleurodesis if the conventional pleurodesis should fail. This drawback for using thoracoscopic pleurodesis as a rescue therapy for failed conventional pleurodesis should be considered. In contrast to the reported 41% to 54% success rates with the use of intermittent peritoneal dialysis using low-volume exchange cycles [1, 4], we have found this method largely unsuccessful (25%). Therefore for patients who are reluctant to discontinue peritoneal dialysis and be maintained on hemodialysis we propose the treatment algorithm to be a limited trial of low-volume intermittent peritoneal dialysis followed by thoracoscopic pleurodesis.
With thoracoscopic pleurodesis, patients with massive hydrothorax had successful resumption of CAPD without recurrence on long-term follow-up. The procedure was simple and safe and we witnessed no ill effects on their subsequent peritoneal membrane function. The choice between talc poudrage and mechanical rub pleurodesis has to be defined. Thoracoscopic talc poudrage can be performed under local anesthesia but any long-term sequelae of its use cannot be excluded. Thoracoscopic pleurodesis permits visualization of any pleuroperitoneal communications and direct surgical obliteration if appropriate but our series suggests that this is not commonly required.
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Abstract
Introduction
