PURPOSE: Hepatic Hydrothorax (HH) occurs in 5-10% of cirrhotic patients and remains a significant clinical challenge. Despite medical therapy with diuretics, many patients experience intractable, debilitating dyspnea and respiratory compromise. Trans-jugular intrahepatic porto-systemic shunt (TIPS), while a valuable treatment for HH, is not always effective and liver transplantation may not be available to many patients. Indwelling tunneled pleural catheters (ITPC) have been successfully used to control dyspnea in patients with malignant pleural effusions. We present our experience with 14 cases of HH treated with ITPC either as palliation, or as a bridge to TIPS or liver transplantation.
METHODS: We identified 14 patients who received ITPC for the treatment of HH between October of 2007 and January of 2010. We used chart review and clinical assessment to determine outcomes, complications, and interventions.
RESULTS: 6 patients had ITPC placed for palliation; 3(50%) patients were discharged from the hospital before death ensued. 8 patients had ITPC placed as a bridge to TIPS or transplantation; 2(25%) underwent transplantation with successful removal of ITPC following transplantation, 3(37.5%) are listed for transplantation, 1(12.5%) is undergoing evaluation for transplantation, 1(12.5%) was ultimately not a transplant candidate, and 1(12.5%) died from a dialysis catheter infection months following spontaneous pleurodesis and ITPC removal. Of these 8 patients in which ITPC was placed as a bridge to therapy, 5(62.5%) achieved spontaneous pleurodesis with successful ITPC removal without transplant. Empyema occurred in 2 patients (25%), requiring removal of the ITPC in 1 patient.
CONCLUSION: ITPC can be used as palliation in patients with HH, allowing patients to be discharged from the hospital to comfort measures at home. ITPC may be an effective bridge to TIPS or transplantation, and in select cases, spontaneous pleurodesis occurs in the absence of any further intervention.
CLINICAL IMPLICATIONS: ITPC is a potentially valuable treatment of HH refractory to conventional medical therapy as a bridge to TIPS and transplantation, or for palliation. A larger, prospective trial would be valuable in determining the role of ITPC in these settings.
DISCLOSURE: Jeremy Kilburn, No Financial Disclosure Information; No Product/Research Disclosure Information