SESSION TITLE: Surgery Case Report Posters I
SESSION TYPE: Case Report Poster
PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM
INTRODUCTION: We report a patient in whom pleuroperitoneal communication was diagnosed following the initiation of peritoneal dialysis (PD), in whom the PD could be continued after thoracoscopic partial resection of the diaphragm.
CASE PRESENTATION: A 58-year-old woman developed proteinuria at the age of 45 years and was diagnosed as having IgA nephropathy by kidney biopsy. With worsening of the renal function, peritoneal dialysis was initiated. We placed an indwelling PD catheter and introduced PD liquid (1.5%, 1,500 ml ×3/day), however, the patient began to complain of a feeling of pressure on the chest, and a chest CT revealed retention of pleural fluid in the right thoracic cavity . The patient was diagnosed as having pleuroperitoneal communication, because the pleural effusion persisted even after PD drainage , drainage of the pleural fluid revealed a higher glucose level (395 mg/dL) of the pleural fluid than the serum glucose level (78 mg/dL). We performed thoracoscopic observation of the right thoracic cavity under general anesthesia and found several tears in the central tendon of the diaphragm that allowed passage of the dialysis fluid, therefore, we performed partial resection of the diaphragm including the tears and closed the wound with sutures. We restarted PD on the following day and could continue the PD without any problems, with no further retention of the pleural fluid or chest symptoms. At present, six years after the operation, the PD is still being continued.
DISCUSSION: Existence of congenital defects in the diaphragm and occurrence of tears in the diaphragm caused by elevation of the abdominal pressure have been considered as causes of pleuroperitoneal communication, although no pathologic findings were observed in the diaphragm in this case, and hyalinization of the tendon tissues caused by aging was assumed to be the cause of the diaphragmatic tears. Medical practices in anticipation of a spontaneous cure include discontinuation of PD and reduction of the dialysate infusion, pleurodesis, and open thoracoscopic surgery have also been performed. However, considering its reliable curative effect and low invasiveness, thoracoscopic surgery should be considered proactively for this condition, although general anesthesia would be required.
CONCLUSIONS: Because thoracoscopic diaphragm plication allows us to restart PD on the day of the operation and is low invasive, effective use of it should be considered positively.
Reference #1: Nomoto Y, Suga T, Nakajima K, Sakai H, et al. Acute hydrothorax in continuous ambulatory peritoneal dialysis--a collaborative study of 161 centers. Am J Nephrol. 1989;9(5):363-7.
Reference #2: Mak SK, Nyunt K, Wong PN, et al. Long-term follow-up of thoracoscopic pleurodesis for hydrothorax complicating peritoneal dialysis. Ann Thorac Surg. 2002 Jul;74(1):218-21.
Reference #3: Kumagai H, Watari M, Kuratsune M. Simple surgical treatment for pleuroperitoneal communication without interruption of continuous ambulatory peritoneal dialysis. Gen Thorac Cardiovasc Surg. 2007 Dec;55(12):508-11.
DISCLOSURE: The following authors have nothing to disclose: Ryo Takahashi, Yuuichirou Takahashi
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