00:17:271 Management for Hydrothorax in Peritoneal Dialysis R1 吳悌暉

00:17:272 Management Options for Hydrothorax Complicating Peritoneal Dialysis-Review Articles Seminars in Dialysis—Vol 16, No 5 (September– October) 2003 pp. 389–394 Department of Medicine and Therapeutics, Chinese University of Hong Kong, Shatin, Hong Kong SAR, China

00:17:273  Hydrothorax secondary to pleuroperitoneal communication as a complication of peritoneal dialysis (PD) was first described in 1967  Incidence ranged from 1.0% to 5.1% (1.9% on average); 62% of the cases were female  Patients often develop symptomatic sterile transudative pleural effusion (mostly right-sided)

00:17:274 Diagnostic clues  Chemical analysis (glucose, protein, lactate dehydrogenase) of pleural fluid  Methylene blue discoloration of the dialysate followed by thoracocentesis  Peritoneal scintigraphy  Contrast computed tomographic peritoneography

00:17:275 Mechanisms  Congenital diaphragmatic defects - autopsy and operative observation of diaphragmatic fluid-filled blebs overlying tendinous diaphragm discontinuities due to collagen fiber loss （ left-sided defects are covered by the heart and pericardium ）  Pleuroperitoneal pressure gradient  Lymph drainage disorder - operative finding of diaphragmatic lymphatic swelling

00:17:276  Ten major series were included in the period 1978–2002,identifying 104 consecutive cases of hydrothorax complicating PD

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8 Interruption of PD  First and foremost, management of hydrothorax complicating CAPD should begin with interruption of PD  Under normal circumstances, interruption of CAPD for a period of 2–6 weeks is recommended  Spontaneous closure of the diaphragmatic defects is facilitated by the performance of small volumes of peritoneal exchanges  Success rate = 53%

00:17:279 Conventional Pleurodesis  Administration of a chemical agent via chest tube, followed by designated positioning of the patient every 10–15 minutes  As a rule of thumb, a 10-day wait is recommended after performing pleurodesis before resuming CAPD  Contraindication to thoracoscopy  Success rate = 48%

00:17:2710 Thoracotomy  A limited thoracotomy incision, with direct inspection defects or blebs overlying the tendinous part  Sites of fluid leakage can then be repaired by direct suturing, with or without reinforcement with Teflon felt patches  Limited eligibility of dialysis patients for open thoracotomy  Success rate = 100%

00:17:2711 Video-Assisted Thoracoscopic Approach  Allows direct application of talc (chemical pleurodesis) and abrasion of the parietal pleura (mechanical pleurodesis)  In the former situation, thoracoscopy is thought to offer reliable distribution of talc to effect uniform pleurodesis  Chest drains were removed after a median of 5 days (range 2–15 days) postoperatively, whereas CAPD was reinstituted after 3–4 weeks  Encouraging results have been reported with thoracoscopic closing of these diaphragmatic breaches by direct repair with endoscopic suturing  Success rate = 88%

00:17:2712 Pathogenesis and management of hydrothorax complicating peritoneal dialysis- Review Articles Current Opinion in Pulmonary Medicine 2004, 10:315–319 Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China

00:17:2713 Summary  Once hydrothorax secondary to pleuro- peritoneal communication is confirmed in CAPD patients, temporary cessation of peritoneal dialysis remains the first-line treatment. Current evidence shows that video-assisted thoracoscopic pleurodesis or repair should be the treatment of choice in patients who failed conservative management

00:17:2714 Acute hydrothorax in CAPD: Early Thoracoscopic (VATS) intervention allows return to peritoneal dialysis Nephron 2002;92: Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK

00:17:2715 Materials and Methods  Between 1995 and 2000 we studied 6 patients (3 male, 3 female, mean age 62, range years) receiving CAPD for chronic renal failure

00:17:2716 Operative Technique  Under general anaesthesia and utilizing single lung ventilation, the thoracoscope is introduced into the right hemithorax. The abdomen is palpated and often fluid can be seen to enter the chest. This site of communication is then closed with a single clip. Following this a full parietal pleurectomy is performed to obliterate the pleural space and prevent further hydrothoraces

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00:17:2718 Results  Diaphragmatic defects (fistula) were clearly identified in 3 of the 6 patients.  In the other three patients, small pleural blebs were seen on the surface of the diaphragm  Directly closed with an endoclip  Parietal pleurectomy was performed in all cases  No perioperative morbidity and all patients had returned uneventfully to CAPD 1 month following hospital discharge  At follow up with a median of 40 months there was no recurrence of hydrothorax

00:17:2719 Discussion  This is the largest series of patients yet reported  We recommend early thoracoscopic surgery and pleurectomy as the first choice modality in treating pleuro-peritoneal fistula  We have not found it necessary to perform preoperative contrast peritoneoscintigraphy to identify fistulae  As the mainstay of therapy, parietal pleurectomy, will prevent recurrence even if small defects have failed to be identified

00:17:2720 Video-assisted thoracoscopic surgery for hydrothorax in peritoneal dialysis patients — check-air-leakage method European Journal of Cardio-thoracic Surgery 28 (2005) 648–649 Kaohsiung Chang Gung Memorial Hospital

00:17:2721 Technique  Under general anaesthesia, the patient was ventilated through a dual-lumen endotracheal tube, with their ipsilateral lung deflated. The patient was then placed in the decubitus position with their right side facing up. Three entry portals were created.

00:17:2722 Technique  The pleural cavity was filled with sterile water  Inflated the CO2 to the peritoneal cavity via the peritoneal catheter. The pressure in the peritoneal cavity was maintained at 12 mmHg  Via thoracoscopy, continuous air bubbles leaking from the diaphragmatic defect were located in the pleural cavity  The video-assisted thoracoscopic surgery (VATS) procedure was then performed to repair the pleuroperitoneal communication with direct suturing. Talc pleurodesis was also performed.

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00:17:2725 Comment  Compared with methylene blue infusion, checking air leakage was easier and allowed for clearer identification of the defect  Even when small defect was not detected by methylene blue infusion, it was easily identified by this method  This method is now the first procedure chosen at Kaohsiung Chang Gung Memorial Hospital and the methylene blue infusion test is no longer used

00:17:2726 Finally

00:17:2727 Conclusion  Diagnosis - Pleural fluid to serum glucose gradient of more than 50 mg/dL - Pleural and peritoneal fluid protein content uniformly ＜ 4 g/L

00:17:2728 Conclusion  Treatment - First-line treatment - temporary cessation of peritoneal dialysis with small volume exchanges - Video-assisted thoracoscopic repair with pleurodesis should be the treatment of choice in patients who failed conservative management

00:17:2729 THANKS