Hepatic hydrothorax (HH) occurs in 5% of cirrhotic patients. Current treatment includes repeated thoracentesis, trans-jugular intrahepatic porto-systemic shunt (TIPS), pleurodesis, pleuroperitoneal or peritoneovenous shunt. Use of indwelling tunneled pleural catheter (ITPC) in symptomatic HH has not been reported. We present our experience on the effectiveness and utility of ITPC in patients with HH and poor functional status, either as palliation or as a bridge to transplant.
This is a retrospective case series. Patients had symptomatic HH from hepatic failure and were not candidates for immediate liver transplantation. Over a period of 9 months we placed ITPC (PleurX; Denver Biomedical) in 4 patients. Follow-up data was collected by clinical assessment and chart review.
The baseline characteristics are presented in table 1. ITPC remained in place from 4 to 155 days. ITPC placed in one patient for palliation to avoid repeated thoracentesis for respiratory distress died after 11 days from hepatic failure. The second patient died at 4 days from sepsis unrelated to ITPC placement. A third patient with failed TIPS is continuing to drain his symptomatic HH at home. The ITPC was removed after one month in a fourth patient as her HH improved.There were no bleeding complications. ITPC was placed in two patients while receiving mechanical ventilation. Pleural fluid cultures after two months with ITPC were negative in one patient. Another patient developed a subcutaneous swelling at the catheter site from leakage of pleural fluid. The cuff of ITPC migrated outside the skin in one patient after one month.
Baseline Characteristics at the Time of ITPC PlacementMedian (range)Age (years)59 (49-78)Platelet count (k/dL)98 (58-194)Hematocrit (percent)29.9 (29-38.5)Serum creatinine (mg/dL)0.9 (0.8-1.7)International normalized ratio (INR)1.4 (1.2-2.0)Total serum bilirubin (mg/dL)3.6 (1.0-6.5)Model of End-stage Liver Disease (MELD) score16 (8-23)Etiology of hepatic failureAlcoholic cirrhosis & hepatitis C (n=3) Cryptogenic cirrhosis (n=1)
ITPC can relieve symptomatic HH, improve quality of life and reduce the number of repeated thoracentesis without an increased risk for encepahlopathy. No serious immediate or long-term complications were experienced. A randomized controlled trial would identify benefits of ITPC in HH.
ITPC may be a safe, reversible and less invasive alternative treatment of HH, with a palliative intent in terminal patients or as a transition in patients awaiting transplantation.
Shaheen Islam, None.