SESSION TYPE: Pleural Case Report Posters
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Recurrent hepatic hydrothoracies may be difficult to manage. In cases when medical therapies, usually diuretics, have failed to adequately control symptomatic effusion, thoracentesis, thoracostomy tube drainage and pleurodesis have been employed. Tunneled pleural catheters are utilized for control and long-term management of malignant recurrent pleural effusions. We report their successful use in patients with recurrent hepatic hydrothorax refractory to alternative therapies.
CASE PRESENTATION: The first patient was a 38-year-old woman with α-1 antitrypsin deficiency and end-stage liver disease (ESLD) resulting in significant abdominal ascites and symptomatic hepatic hydrothorax. Diuretics and attempted transjugular intraperitoneal shunt (TIPS) were inadequate. Both serial paracenteses and thoracenteses were needed. Ultimately, a right sided tunneled pleural catheter was placed with excellent symptomatic relief. She underwent successful orthotopic liver transplantation (OLT) eight weeks later. On post-operative day nine, the catheter was removed due to minimal output after being in place for 65 days. The second patient was a 44-year-old man with a history of previous OLT due to hepatocellular carcinoma. Transplant failure had occurred due to post-operative hepatic artery thrombosis. Diuretics were insufficient to control a hepatic hydrothorax, and serial thoracentesis was needed. A right sided tunneled pleural catheter was placed, and successfully removed 39 days later due to scant output and symptom improvement. The third patient is a 79-year-old woman with ESLD from primary sclerosing cholangitis resulting in massive splenomegaly, thrombocytopenia and recurrent hepatic hydrothorax. She required serial thoracenteses for increasing symptoms. A right sided tunneled pleural catheter was placed for palliation. She requires drainage every other day to control her symptoms, now ten weeks post-insertion.
DISCUSSION: Recurrent pleural effusion can be a potential problem in ESLD. Often, aggressive diuresis achieves symptom control, however, other potential therapies, including paracentesis, TIPS, thoracentesis, and chemical or surgical pleurodesis, can be considered. Thoracentesis carries an inherent one percent risk of pneumothorax. Tunneled pleural catheters previously have been used to manage malignant effusions, but their role has expanded to non-malignant effusions. A recent study showed pleurodesis at 110 days in patients with recurrent pleural effusion due to hepatic hydrothorax or congestive heart failure.
CONCLUSIONS: Our case series adds to the growing literature supporting the use of indwelling tunneled pleural catheters for long-term management of recurrent hepatic hydrothorax. Removal of the catheter is possible in patients who receive OLT or who achieve pleurodesis spontaneously.
1) Chalhoub M, Harris K, et al. The use of the PleurX catheter in the management on non-malignant pleural effusion. Chronic Respiratory Disease 2011; 8:185-191.
DISCLOSURE: The following authors have nothing to disclose: Daniel Casey, Charles Read, Eric Anderson
No Product/Research Disclosure InformationGeorgetown University, Washington, DC