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Clinical Investigations: SURGERY |

Outcome Analysis of Cirrhotic Patients Undergoing Chest Tube Placement* FREE TO VIEW

Lawrence U. Liu, MD; Hassan A. Haddadin, MD; Carol A. Bodian, DrPH; Samuel H. Sigal, MD; Jessica D. Korman, BA; Henry C. Bodenheimer, Jr, MD; Thomas D. Schiano, MD
Author and Funding Information

*From the Division of Liver Diseases (Drs. Liu, Haddadin, Sigal, Bodenheimer, and Schiano, and Ms. Korman) and the Department of Biomathematical Sciences (Dr. Bodian), The Mount Sinai Medical Center, New York, NY.

Correspondence to: Thomas D. Schiano, MD, Division of Liver Diseases, Box 1104, The Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029; e-mail: Thomas.Schiano@msnyuhealth.org



Chest. 2004;126(1):142-148. doi:10.1378/chest.126.1.142
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Published online

Objectives: Patients with cirrhosis can acquire pulmonary conditions that may or may not be related to their illness. Although posing a greater risk for complications, chest tubes are sometimes placed as treatment for hepatic hydrothorax and other pulmonary conditions. The aim of this study was to analyze the outcomes of chest tube placement in cirrhotic patients.

Methods: A retrospective analysis was performed of 59 adults with cirrhosis undergoing chest tube placement. Variables that were investigated included reason for chest tube placement, complications developing while having the tube in place, and outcome.

Results: The 59 subjects were classified as having Child-Turcotte-Pugh (CTP) class A cirrhosis (n = 3), CTP class B cirrhosis (n = 31), and CTP class C cirrhosis (n = 25). Indications for having a chest tube placed were hepatic hydrothorax (n = 24), pneumothorax (n = 9), empyema (n = 8), video-assisted thoracoscopy (VAT) [n = 7], non-VAT (n = 5), and hemothorax (n = 3). The CTP class A subjects had their chest tubes removed without further complications early in the course, and were excluded from further statistical analysis. Twenty-five subjects (42%) had significant pleural effusions requiring chest tube placement. Among the CTP class B and class C subjects, the median duration with chest tube in place was 5.0 days (range, 1 to 53 days). Serum total bilirubin levels, presence of portosystemic encephalopathy, and CTP C classification were predictors of mortality. Mortalities were seen in 5 of 31 CTP class B subjects (16%), and 10 of 25 CTP class C subjects (40%). The tubes were successfully removed in a total of 39 subjects (66%) with no further procedure. Forty-seven subjects (80%) acquired one or more of the following complications: renal dysfunction, electrolyte imbalances, and infection.

Conclusions: When placed for all indications, chest tubes may be successfully removed in the majority of cirrhotic patients. However, a third of all patients still die with the chest tube still in place. Failure to remove the chest tube increases mortality in patients with increasing severity of liver disease.

Patients with cirrhosis can acquire several pulmonary conditions related to portal hypertension, including hepatopulmonary syndrome, portopulmonary hypertension, spontaneous bacterial empyema, and hepatic hydrothorax.12 Hepatic hydrothorax is usually a right-sided transudative pleural effusion that is often problematic to treat. Sodium restriction, diuretics, and repeated thoracentesis have all been shown to have limited success in the treatment of hepatic hydrothorax3; video-assisted thoracoscopy (VAT) with talc pleurodesis4and transjugular intrahepatic portosystemic shunts have resulted in better control, although these procedures are a temporizing measure prior to liver transplantation.5

Chest tubes are sometimes used as treatment for hepatic hydrothorax, although patients with cirrhosis may have increased morbidity with chest tube placement, with difficulty in removing the tube without correction of the underlying liver disease or portal hypertension.3,56 Patients with liver disease also can acquire other pulmonary conditions, eg, pneumothorax or hemothorax, that may necessitate chest tube placement as well as the need to undergo VAT for diagnostic purposes. Patients with cirrhosis may be at greater risk for acquiring complications while having a chest tube in place. These complications include increased bleeding due to coagulopathy, infection due to poor wound healing, renal failure, and electrolyte disturbances from external fluid losses with prolonged duration of tube placement.

A comprehensive review of the medical literature has identified only two small series67 detailing the results of cirrhotic patients undergoing chest tube placement. In an effort to more fully analyze the outcomes of chest tube placement in patients with cirrhosis, we examined all cirrhotic patients undergoing chest tube placement over the last 16 years at a tertiary referral center for patients with liver disease.

A retrospective analysis was performed of adult patients with cirrhosis undergoing chest tube placement at The Mount Sinai Medical Center from 1986 to 2001. Patients were identified through their admission database and medical records by matching International Classification of Diseases, Ninth Revision codes for hepatitis (general 573.3, chronic 571.40, recurrent 571.49, viral 070.9, chronic hepatitis B 070.32, chronic hepatitis C 070.54), cirrhosis and its complications (general 571.5, alcoholic 571.2, nonalcoholic/cryptogenic 571.5, peritonitis 567.8, portal hypertension 572.3, ascites 789.5), and surgical complications to the respiratory system 997.3, general hemothorax 511.8, pleural effusion 511.9, spontaneous pneumothorax 512.0, iatrogenic pneumothorax 512.1, other pneumothoraces 512.8, empyema 510.9, hemorrhagic complication of procedure 998.1, and/or thoracic surgical procedures (insertion of chest tube 34.04, open chest drainage 34.09, thoracoscopy 34.21, and thoracentesis 34.91). The study was approved by The Mount Sinai Medical Center Institutional Review Board.

One hundred one subjects were initially identified; 42 of them were excluded for the following reasons: pediatric age (n = 3), chest tubes inserted after liver transplantation (n = 26), absence of chest tube insertion at all, ie, subject underwent thoracentesis only (n = 6), absence of cirrhosis (n = 3), coding error, ie, pulmonary artery catheter insertion (n = 1), pacemaker placement (n = 1), mediastinoscopy (n = 1), subject with abnormal liver chemistries and no chest tube inserted (n = 1) Three Child-Turcotte-Pugh (CTP) class A subjects had their chest tubes removed without further complications; they were excluded from further statistical analyses. This left a total of 56 subjects. Among these subjects, seven subjects had chest tubes inserted twice, with two of them undergoing three chest tube insertions; chest tube re-insertion events were excluded from our study.

Variables obtained from chart review included age, gender, etiology of liver disease, reason for chest tube placement, duration of chest tube placement (in days), complications occurring with the chest tube in place, and outcome. Outcomes were defined as follows: removal of chest tube without further intervention, removal of chest tube on undergoing transjugular intrahepatic portosystemic shunt placement or liver transplantation, or death with chest tube in place. Serum levels of total bilirubin, albumin, and prothrombin time, and the degree of hepatic encephalopathy and ascites were recorded; these five components were then used for determination of each subject’s CTP score (CTP class A, 5 to 6 points; CTP class B, 7 to 9 points; CTP class C, 10 to 15 points). Whether the individual required TIPS placement or went on to liver transplantation with the chest tube in place was also recorded. Chest radiograph findings 1 day after chest tube removal were also evaluated in patients with effusions to ascertain if appreciable effusions recurred.

The incidence of renal dysfunction (serum creatinine level > 1.5 mg/dL), electrolyte imbalances (serum sodium level < 130 mEq/L, serum potassium level < 3.0 mEq/L, and/or serum bicarbonate level < 20 mEq/L), and infection (serum WBC count > 10.0 × 103/μL, and/or a temperature > 38.2°C) occurring after having the chest tube inserted were recorded, along with their timing after chest tube placement. All subjects who had signs of infection were treated with antibiotics.

Statistical Analysis

Each subject’s outcome was classified as a “failure” if the subject died while the chest tube was still in place. “Successes” include chest tube removal with TIPS placement or with liver transplantation, as well as removal without further intervention. χ2 tests were used to look for associations between demographic and disease variables and failure to remove the chest tube. Logistic regression analysis was used to test for the significance of such variables after accounting for CTP score. In order to study whether the risk of failure changed with duration of the tube being in place, subjects were stratified into four groups according to increasing numbers of days until chest tube removal. A χ2 test of trend was used to compare the proportions for which chest tube removal was associated with a successful outcome. It should be noted that standard life table methods are not applicable with these data because the tubes could be removed for a positive reason (“success”) as well as for death. Standard failure-time methods are suitable when the subjects start in one condition and are followed until they move to a specified other condition (typically from being alive to being dead), or are censored for reasons unrelated to the single outcome of interest. Similarly, analyses of associations between complications and chances of a successful outcome were stratified for time until the occurrence of the complication.

Table 1 outlines the clinical characteristics of the study patients. Among the 59 subjects (31 men and 28 women), there were 3 subjects who were classified as having CTP class A cirrhosis, 31 subjects as having CTP class B, and 25 subjects as having CTP class C. The three CTP A subjects, two men and one woman, had their chest tubes removed with no further complications after 3 days, 5 days, and 6 days, respectively. Indications for their tube placement were pleural effusion (n = 1) and pneumothorax (n = 2). They were excluded from further statistical analysis.

Among the remaining 29 male subjects, 12 subjects were CTP class B and 17 subjects were CTP class C; the remaining 27 female subjects included 19 subjects with CTP class B and 8 subjects with CTP class C. The average age for the CTP class B subjects was 57.5 ± 10.5 years (range, 38 to 77 years), and 48.7 ± 9.7 years (range, 20 to 64 years) for CTP class C subjects.

Etiologies of liver disease in the subjects were hepatitis C (n = 21), alcohol (n = 20), cryptogenic (n = 7), primary biliary cirrhosis (n = 3), hepatitis B (n = 2), tumors (n = 2), and autoimmune hepatitis (n = 1). Indications for having a chest tube placed were hepatic hydrothorax (n = 24), pneumothorax (n = 9), empyema (n = 8), VAT (n = 7), non-VAT (n = 5), and hemothorax (n = 3). Twelve subjects underwent thoracoscopy (VAT, n = 7; non-VAT, n = 5). The indication for all VAT procedures was biopsy of lung mass. The five subjects who underwent non-VAT had the procedure performed for biopsy of lung mass (n = 4) and for decortication (n = 1).

Among the 56 CTP class B and class C cases, the median days with chest tube in place were 5.0 (range, 1 to 53 days). With chest tube still in place, 1 subject underwent a TIPS procedure, 4 subjects underwent liver transplantation, 36 subjects had their tubes removed with no further intervention, and 15 subjects died. Five of 31 CTP class B subjects died (16%), and 10 of 25 CTP class C subjects died (40%).

Among the demographic variables and disease characteristics assessed, serum levels of total bilirubin ≥ 3.0 (p = 0.08), presence of hepatic encephalopathy (p = 0.04), and CTP class C (p = 0.05) each were predictors of chest tube failure (ie, death with tube in place). Neither encephalopathy nor bilirubin was statistically significant once CTP class was accounted for. There was no significant association with gender, etiology, degree of ascites, albumin, prothrombin time, or reason for placing the chest tube.

The median days with chest tube in place were 5.0 (range, 1 to 53 days) for CTP class B subjects, and 4.0 (range, 1 to 39 days) for CTP class C subjects (Table 2 ). With chest tube in place, 30 subjects (14 subjects with CTP class B [47%] and 16 subjects with CTP class C [53%]) acquired renal failure. Thirty-two subjects (15 subjects with CTP class B [47%] and 17 subjects with CTP class C [53%]) acquired electrolyte imbalances: 25 subjects (78%) had a serum sodium level < 130 mEq/L, 5 subjects (16%) had a serum potassium level < 3.0 mEq/L, and 18 subjects (56%) had a serum bicarbonate level < 20 mEq/L; 14 subjects (44%) had more than one type of electrolyte imbalance.

Twenty-seven subjects (14 subjects with CTP class B [52%] and 13 subjects with CTP class C [48%]) acquired infections: 10 subjects (37%) had at least one documented temperature > 38.2°C, and 25 subjects (93%) had a serum WBC count > 10.0 × 103/μL; all subjects with fever also had leukocytosis during this event. Documented causes for the infections were bacteremia (n = 5), empyema (n = 4), pneumonia (n = 3), spontaneous bacterial peritonitis (n = 3), and secondary peritonitis (n = 1). Organisms were identified in only five subjects (19%): Staphylococcus aureus (n = 2), Enterococcus faecalis (n = 2), and Clostridium perfringens (n = 1).

The complications noted while having the chest tube in place were not limited to one type, eg, renal dysfunction, electrolyte imbalances, or infection. Nine subjects experienced both renal dysfunction and electrolyte imbalances, 3 subjects had both renal dysfunction and infection, 4 subjects had both electrolyte imbalances and infection, and 14 subjects had all three types of complications. Altogether, 47 of the 59 subjects (80%) had complications with the chest tube in place. In addition to the previously mentioned events, isolated complications included bleeding (n = 1), reaccumulation of pleural effusion after removal necessitating another chest tube to be placed (n = 1), and persistent drainage of pleural effusion after removal (n = 2).

Among the 24 subjects with pleural effusions, chest radiographs obtained 1 day after chest tube removal (not to be confused for the radiographs obtained immediately after tube removal) revealed total resolution of effusion in 16 subjects (67%); 1 subject required chest tube reinsertion due to reaccumulation of the hydrothorax. Three of these subjects died within 3 days of having the chest tube in place. On further investigation, these subjects had documented sepsis just before undergoing chest tube placement. Outcomes of chest tube placement are summarized in Tables 2, 3 .

Six of our subjects had chest tubes placed after undergoing thoracoscopy (diagnostic and/or therapeutic), with the median duration of 2 days (range, 2 to 20 days) for two subjects with CTP class B, and 14 days (range, 1 to 39 days) for four CTP class C subjects. We did not find any association between length of time the chest tubes remained in place and successful removal. Among the 56 cases, 41 cases (73%) were successes. In the subset of 27 subjects who still had their tubes in place after 5 days, 17 cases (63%) were successes. The success rate was 71% for the subset of 17 subjects with tubes still in place after 10 days, and 75% of the 8 subjects with tubes still in place after 15 days. An alternative way to describe these data are shown in Table 4 , separated by CTP score. In Table 4, subjects are grouped as to increasing intervals of times to when chest tubes were removed, and the numbers of subjects with successful outcomes are compared. There is no evidence of a trend between time until chest tube removal and overall outcome (p = 0.29). Among the 15 subjects who died with the tube in place, 10 subjects died on or before 10 days after insertion (ie, subjects with increased morbidity died earlier). In total, 73% of the subjects survived the chest tube procedure. However, if the four subjects who underwent liver transplant and the one subject who underwent TIPS with the chest tubes in place are not considered successes, the success rate drops to 64%. Characteristics of the subjects who died are described in Table 5 .

Twelve subjects had no renal failure, electrolyte imbalances, or infections while chest tubes were in place. Their tubes were removed after 1 to 13 days (median, 2 days) with no further intervention. Twenty-four subjects had at least one of these complications on the day their chest tube was placed; 33% of the subjects died with their chest tube in place. The chance of dying was similar for subjects who had their first complication on days 1 to 2 (n = 9; 33% died), days 3 to 5 (n = 8; 25% died), or after day 5 (n = 4; 50% died).

Cirrhotic patients may acquire pulmonary or pleural complications that can arise unrelated (ie, tumors, pneumothorax, hemothorax) or directly related to portal hypertension (ie, hepatic hydrothorax, spontaneous bacterial empyema, hepatopulmonary syndrome).12 Hepatic hydrothorax, which was the most common indication for chest tube placement in our subjects, is encountered in 5 to 10% of cirrhotic patients with ascites.89 Our study confirms what has been found in previous studies, which is that difficult-to-manage hepatic hydrothorax is typically found in advanced stages of cirrhosis, ie, CTP class B and CTP class C. All of our subjects with hydrothorax also had appreciable ascites. There are numerous proposed pathophysiologic mechanisms for hepatic hydrothorax, but the most plausible one is that there is passage of ascites through rents or leaks in the diaphragm.10 Cirrhotics with ascites are at risk for spontaneous bacterial peritonitis; likewise, cirrhotics with hepatic hydrothorax may acquire spontaneous bacterial empyema.2,11Several treatment modalities have been proposed and described for hepatic hydrothorax, such as thoracentesis,12 pleurodesis,4,7,13 surgical repair of diaphragmatic leaks,7,14and peritoneovenous shunting.1516 In two small series of patients, Runyon et al6and De Campos et al,7 described the disadvantages of placing a chest tube in cirrhotic patients; high morbidity and mortality were noted due to associated fluid and protein losses. Conklin et al17 noted that hepatic hydrothorax tended to be recalcitrant to repeated thoracenteses and prolonged chest tube drainage due to a rapid recurrence of the effusion. Sixty-seven percent of our subjects had total resolution of their pleural effusions, as documented by chest radiographs obtained 1 day after chest tube removal, with no further treatment. TIPS has also been used1719 and, at present, is the most favored therapy for refractory hepatic hydrothorax.20 Despite the success of TIPS, however, the mortality rate after placement for this indication is 25 to 40%.20

Thoracoscopy is performed for a variety of reasons, and it can be divided into two indications: diagnostic and therapeutic. Published studies have examined performance of this procedure in subjects not having chronic liver disease. Risks are 2% for procedure-related complications and 0.8% for missed injury rate21; the mean duration for having a chest tube in place for these patients is 3 to 4 days.22 Symptomatic hepatic hydrothorax has been controlled using VAT surgery with talc pleurodesis in 73% of patients, with no procedure-related mortality noted.4 Six of our subjects underwent chest tube placement after thoracoscopy; none were performed for symptomatic hepatic hydrothorax. Although none of the two CTP class B subjects died with a chest tube in place, one subject acquired hyponatremia, and infection (S aureus and E faecalis empyema). Two deaths were noted among the four CTP class C subjects due to the development of hepatorenal syndrome and sepsis, respectively. Though the small number of patients undergoing VAT in this study limits statistical analysis, it appears that the complication rate of VAT in cirrhotic patients may be significant.

Most commonly, chest tubes are used to treat pleural effusions, empyemas, hemothoraces,23and pneumothoraces. Sosa et al24investigated the outcome of noncirrhotic patients who had chest tubes placed for thoracic trauma; the procedures were successfully performed up to 30 days after injury, with tube removal after an average of 7 days. Current literature, however, is limited regarding the use of chest tubes for these indications in the cirrhotic population. Although only three of our subjects underwent chest tube placement for correction of complications from trauma, their mean duration of having the tube in place was 12.3 ± 0.9 days (range, 11 to 13 days). Thus again, the duration of chest tube placement in cirrhotic patients appears much longer. Klemperer et al25reported a threefold duration of placement in cirrhotic subjects who had required chest tube placement after having undergone cardiac surgery. No deaths were reported in cirrhotics who were CTP class A; however, 80% of those who were CTP class B died, not because of poor cardiac performance, but rather from postoperative infection and bleeding that were attributed to liver disease. Our subjects’ mortality rates were less striking although still significant, with 5 deaths noted among our 31 CTP class B subjects (16%), and 10 deaths among our 25 CTP class C subjects (40%). The mortality rate in the latter group is similar to the high perioperative mortality rates of CTP class C patients undergoing surgery.26Thus, chest tube placement in a patient with CTP class C cirrhosis should be thought of as carrying the same mortality risk as that of undergoing TIPS27 or general surgical procedures.

Overall, the subjects requiring chest tube placement were those with advanced liver disease, ie, CTP class B and class C. Our subjects had a similar clinical spectrum requiring chest tube placement as those reported in the noncirrhotic population. The duration of chest tube insertion was longer than those reported in noncirrhotics, both for diagnostic and for therapeutic purposes. Deaths while having a chest tube in place were deemed by the authors to be secondary to complications from having it in place, rather than to adverse effects from the tube placement procedure.

A limitation of our study is that in being a retrospective study covering a period of 16 years, a number of eligible subjects may have been missed. Some coding errors were noted during the identification of subjects; it is possible that cirrhotic patients who underwent chest tube placement may have had the procedure assigned an erroneous code. However, multiple International Classification of Diseases, Ninth Revision codes were utilized and combined in an effort to identify as many subjects as possible, and extensive chart reviews were carried out. Thus, we believe it is unlikely that a significant number of subjects were overlooked. Serial chest radiographs could have been obtained in order to confirm the resolution of the pleural effusions; however, in light of the lack of recurrent symptomatic hydrothorax in these subjects, we can only speculate on the frequency of long-term resolution.

In summary, this is by far the largest group of cirrhotic patients undergoing chest tube placement that has been reported. It appears that chest tubes, when placed for all indications, can indeed be successfully removed in a majority of cirrhotic patients and that symptomatic pleural effusions may resolve, at least in the short term. However, almost a third of all patients die with the chest tube still in place. In addition, chest tubes remain in place in many patients for extended periods of time. Mortality rate is high in these patients and, as expected, increases in the setting of more advanced liver dysfunction. Complications of prolonged chest tube placement contribute significantly to mortality; hence, this procedure should be avoided whenever possible, especially in patients with advanced degrees of liver dysfunction.

Abbreviations: CTP = Child-Turcotte-Pugh; TIPS = transjugular intrahepatic portosystemic shunt; VAT = video-assisted thoracoscopy

This study was performed at The Mount Sinai Medical Center, New York, NY.

Table Graphic Jump Location
Table 1. Characteristics of Cirrhotic Patients Undergoing Chest Tube Placement*
* 

Data are presented as No., mean ± SD, or No. (%).

Table Graphic Jump Location
Table 2. Outcome of Chest Tube Placement in CTP Class B and CTP Class C Cirrhotic Patients*
* 

Data are presented as No. or No. (%) unless otherwise indicated.

OLT = open lung transplantation.

Table Graphic Jump Location
Table 3. Comparison of Outcome in Patients with CTP Class B and CTP Class C Cirrhosis
Table Graphic Jump Location
Table 4. Days to Chest Tube Removal by Outcome
Table Graphic Jump Location
Table 5. Characteristics of Patients Who Died With Chest Tube in Place
Fallon, MB, Abrams, GA (2000) Pulmonary dysfunction in chronic liver disease.Hepatology32,859-865. [PubMed]
 
Xiol, X, Castellote, J, Baliellas, C, et al Spontaneous bacterial empyema in cirrhotic patients: analysis of eleven cases.Hepatology1990;11,365-370. [CrossRef] [PubMed]
 
Xiol, X, Guardiola, J Hepatic hydrothorax.Curr Opin Pulm Med1998;4,239-242. [CrossRef] [PubMed]
 
Ferrante, D, Arguedas, MR, Cerfolio, CJ, et al Video-assisted thoracoscopic surgery with talc pleurodesis in the management of symptomatic hepatic hydrothorax.Am J Gastroenterol2002;97,3172-3175. [CrossRef] [PubMed]
 
Strauss, RM, Boyer, TD Hepatic hydrothorax.Semin Liver Dis1997;17,227-232. [CrossRef] [PubMed]
 
Runyon, BA, Greenblatt, M, Ming, RH Hepatic hydrothorax is a relative contraindication to chest tube insertion.Am J Gastroenterol1986;81,566-567. [PubMed]
 
De Campos, JRM, Filho, LOA, Werebe, EC, et al Thoracoscopy and talc poudrage in the management of hepatic hydrothorax.Chest2000;118,13-17. [CrossRef] [PubMed]
 
Kirsch, CM, Chui, DW, Yenokida, GG, et al Case report: hepatic hydrothorax without ascites.Am J Med Sci1991;302,103-106. [CrossRef] [PubMed]
 
Rubinstein, D, McInnes, IE, Dudley, FJ Hepatic hydrothorax in the absence of clinical ascites: diagnosis and management.Gastroenterology1985;88,188-191. [PubMed]
 
Kirschner, PA Porous diaphragm syndromes.Chest Surg Clin N Am1998;8,449-472. [PubMed]
 
Xiol, X, Castellvi, JM, Guardiola, J, et al Spontaneous bacterial empyema in cirrhotic patients: a prospective study.Hepatology1996;23,719-723. [CrossRef] [PubMed]
 
Xiol, X, Castellote, J, Cortes-Beut, R, et al Usefulness and complications of thoracentesis in cirrhotic patients.Am J Med2001;111,67-69. [CrossRef] [PubMed]
 
Falchuk, KR, Jacoby, I, Colucci, WS, et al Tetracycline-induced pleural symphysis for recurrent hydrothorax complicating cirrhosis: a new approach to treatment.Gastroenterology1977;72,319-321. [PubMed]
 
Mouroux, J, Christophe, P, Venissac, N, et al Management of pleural effusion of cirrhotic origin.Chest1996;109,1093-1096. [CrossRef] [PubMed]
 
Bories, P, Garcia Compean, D, Michel, H, et al The treatment of refractory ascites by the LeVeen shunt: a multi-centre controlled trial (57 patients).J Hepatol1986;3,212-218. [CrossRef] [PubMed]
 
Stanley, MM, Ochi, S, Lee, KK, et al Peritoneovenous shunting as compared with medical treatment in patients with alcoholic cirrhosis and massive ascites.N Engl J Med1989;321,1632-1638. [CrossRef] [PubMed]
 
Conklin, LD, Estrera, AL, Weiner, MA, et al Transjugular intrahepatic portosystemic shunt for recurrent hepatic hydrothorax.Ann Thorac Surg2000;69,609-611. [CrossRef] [PubMed]
 
Siegerstetter, V, Deibert, P, Ochs, A, et al Treatment of refractory hepatic hydrothorax with transjugular intrahepatic portosystemic shunt: long-term results in 40 patients.Eur J Gastroenterol Hepatol2001;13,529-534. [CrossRef] [PubMed]
 
Jeffries, MA, Kazanjian, S, Wilson, M, et al Transjugular intrahepatic portosystemic shunts and liver transplantation in patients with refractory hepatic hydrothorax.Liver Transpl Surg1998;4,416-423. [CrossRef] [PubMed]
 
Kirsch, CM Cirrhotic hydrothorax and the “law of unintended consequences.”Chest2000;118,2-4. [CrossRef] [PubMed]
 
Villavicencio, RT, Aucar, JA, Wall, MJ, Jr Analysis of thoracoscopy in trauma.Surg Endosc1999;13,3-9. [CrossRef] [PubMed]
 
Landreneau, RJ, Keenan, RJ, Hazelrigg, SR, et al Thoracoscopy for empyema and hemothorax.Chest1996;109,18-24. [CrossRef] [PubMed]
 
Yeam, I, Sassoon, C Hemothorax and chylothorax.Curr Opin Pulm Med1997;3,310-314. [CrossRef] [PubMed]
 
Sosa, JL, Pombo, H, Puente, I, et al Thoracoscopy in the evaluation and management of thoracic trauma.Int Surg1998;83,187-189. [PubMed]
 
Klemperer, JD, Ko, W, Krieger, KH, et al Cardiac operations in patients with cirrhosis.Ann Thorac Surg1998;65,85-87. [CrossRef] [PubMed]
 
Friedman, LS The risk of surgery in patients with liver disease.Hepatology1999;29,1617-1623. [CrossRef] [PubMed]
 
Chalasani, N, Clark, WS, Martin, LG, et al Determinants of mortality in patients with advanced cirrhosis after transjugular intrahepatic portosystemic shunting.Gastroenterology2000;118,138-144. [CrossRef] [PubMed]
 

Figures

Tables

Table Graphic Jump Location
Table 1. Characteristics of Cirrhotic Patients Undergoing Chest Tube Placement*
* 

Data are presented as No., mean ± SD, or No. (%).

Table Graphic Jump Location
Table 2. Outcome of Chest Tube Placement in CTP Class B and CTP Class C Cirrhotic Patients*
* 

Data are presented as No. or No. (%) unless otherwise indicated.

OLT = open lung transplantation.

Table Graphic Jump Location
Table 3. Comparison of Outcome in Patients with CTP Class B and CTP Class C Cirrhosis
Table Graphic Jump Location
Table 4. Days to Chest Tube Removal by Outcome
Table Graphic Jump Location
Table 5. Characteristics of Patients Who Died With Chest Tube in Place

References

Fallon, MB, Abrams, GA (2000) Pulmonary dysfunction in chronic liver disease.Hepatology32,859-865. [PubMed]
 
Xiol, X, Castellote, J, Baliellas, C, et al Spontaneous bacterial empyema in cirrhotic patients: analysis of eleven cases.Hepatology1990;11,365-370. [CrossRef] [PubMed]
 
Xiol, X, Guardiola, J Hepatic hydrothorax.Curr Opin Pulm Med1998;4,239-242. [CrossRef] [PubMed]
 
Ferrante, D, Arguedas, MR, Cerfolio, CJ, et al Video-assisted thoracoscopic surgery with talc pleurodesis in the management of symptomatic hepatic hydrothorax.Am J Gastroenterol2002;97,3172-3175. [CrossRef] [PubMed]
 
Strauss, RM, Boyer, TD Hepatic hydrothorax.Semin Liver Dis1997;17,227-232. [CrossRef] [PubMed]
 
Runyon, BA, Greenblatt, M, Ming, RH Hepatic hydrothorax is a relative contraindication to chest tube insertion.Am J Gastroenterol1986;81,566-567. [PubMed]
 
De Campos, JRM, Filho, LOA, Werebe, EC, et al Thoracoscopy and talc poudrage in the management of hepatic hydrothorax.Chest2000;118,13-17. [CrossRef] [PubMed]
 
Kirsch, CM, Chui, DW, Yenokida, GG, et al Case report: hepatic hydrothorax without ascites.Am J Med Sci1991;302,103-106. [CrossRef] [PubMed]
 
Rubinstein, D, McInnes, IE, Dudley, FJ Hepatic hydrothorax in the absence of clinical ascites: diagnosis and management.Gastroenterology1985;88,188-191. [PubMed]
 
Kirschner, PA Porous diaphragm syndromes.Chest Surg Clin N Am1998;8,449-472. [PubMed]
 
Xiol, X, Castellvi, JM, Guardiola, J, et al Spontaneous bacterial empyema in cirrhotic patients: a prospective study.Hepatology1996;23,719-723. [CrossRef] [PubMed]
 
Xiol, X, Castellote, J, Cortes-Beut, R, et al Usefulness and complications of thoracentesis in cirrhotic patients.Am J Med2001;111,67-69. [CrossRef] [PubMed]
 
Falchuk, KR, Jacoby, I, Colucci, WS, et al Tetracycline-induced pleural symphysis for recurrent hydrothorax complicating cirrhosis: a new approach to treatment.Gastroenterology1977;72,319-321. [PubMed]
 
Mouroux, J, Christophe, P, Venissac, N, et al Management of pleural effusion of cirrhotic origin.Chest1996;109,1093-1096. [CrossRef] [PubMed]
 
Bories, P, Garcia Compean, D, Michel, H, et al The treatment of refractory ascites by the LeVeen shunt: a multi-centre controlled trial (57 patients).J Hepatol1986;3,212-218. [CrossRef] [PubMed]
 
Stanley, MM, Ochi, S, Lee, KK, et al Peritoneovenous shunting as compared with medical treatment in patients with alcoholic cirrhosis and massive ascites.N Engl J Med1989;321,1632-1638. [CrossRef] [PubMed]
 
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    Print ISSN: 0012-3692
    Online ISSN: 1931-3543