Eleven years' experience with pericardial-peritoneal window in the management of malignant and benign pericardial effusions

Incarcerated Small-Bowel Pericardial Diaphragmatic Hernia After Pericardio-Peritoneal Window Creation: Report of a Rare Case

Patient: Female, 84-year-old

Final Diagnosis: Diaphragmatic hernia • small bowel obstruction

Symptoms: Abdominal pain

Medication: —

Clinical Procedure: Laparoscopic surgery

Specialty: Surgery

Neoplastic Pericardial Disease

Pericardial tumors are rare lesions that include a range of neoplastic conditions that may arise within the pericardium or metastasize to involve it secondarily. Understanding the spectrum of lesions that are included in the differential diagnosis of a pericardial mass-lesion is critical to making timely, accurate diagnoses and getting the appropriate therapy should one be necessary. This review summarizes the radiologic and pathologic findings of the most commonly encountered of these entities.

Good outcome following liver transplantation using pericardial-peritoneum window for hepato-atrial anastomosis to overcome advanced hepatic alveolar echinococcosis and secondary Budd-Chiari Syndrome - a case report

BACKGROUND

This report presents a case of a 57- year old female with advanced Hepatic Alveolar Echinococcosis causing a secondary Budd-Chiari Syndrome due to infiltration of the suprahepatic inferior vena cava treated successfully by liver transplantation.

CASE PRESENTATION

A temporary veno-venous bypass was introduced, but a typical end to end cavo-caval anastomosis wasn't possible in this case. In order to access a disease free part of the inferior vena cava, an oval window of the diaphragm was excised, providing communication between the peritoneum and pericardium. A vascular clamp was placed onto the right atrium which allowed for an atrial-caval anastomosis. The remainder of hepatectomy was performed in a conventional manner. In the post-operative period and during the 18 month follow-up there were no complications. The patient remains in good general condition with optimal graft function.

CONCLUSIONS

A hepato-atrial anastomosis with a pericardial-peritoneum window during liver transplantation is feasible and extends the curability potential for patients with advanced Hepatic Alveolar Echinococcosis considered for liver transplantation.

Laparoscopic repair of an iatrogenic intrapericardial diaphragmatic hernia using the falciform ligament flap

Iatrogenic intrapericardial diaphragmatic hernia after creation of a pericardial-peritoneal window is a very rare entity. We present the clinical case of an acute intestinal bowel obstruction due to herniation of small bowel into the pericardial sac. After laparoscopic reduction of the herniated small bowel, the diaphragmatic defect was successfully repaired using the hepatic falciform ligament.

Diagnosis and Management of Pericardial Disease

The pericardium serves many important functions but is not essential for life. Pericardial heart disease comprises only pericarditis and its complications, tamponade and constriction, and congenital lesions. However, the pericardium is affected by virtually every category of disease. Thus the critical care physician is likely to encounter the patient with pericardial disease in a variety of settings, either as an isolated phenomenon or as a complication of a variety of systemic disorders, trauma, or certain drugs. Despite exhaustive etiological lists, the cause of pericardial heart disease is often never identified. This article reviews the diagnosis and management of acute and chronic pericarditis with an emphasis on those areas of greatest interest to the intensivist.

Subxiphoid video-pericardioscopy

Pericardial effusion may be associated with many diseases, but sometimes its aetiology is not easy to elucidate. Subxiphoid video-pericardioscopy is useful for the study of the pericardial cavity. Through a subxiphoid approach, the pericardium is incised and a rigid (usually a video-mediastinoscope) or a flexible endoscope (flexible bronchoscope or flexible choledoscope) is inserted into the pericardial cavity. The inner surface of the parietal pericardium and the epicardium can be explored and biopsies can be taken under visual control. In addition, a subxiphoid pericardial window can be developed, and sclerosing agents instilled for pericardiodesis, if a malignant aetiology is confirmed. In case of pericardial effusion associated with lung cancer, video-pericardioscopy helps to confirm the absence or presence of pericardial tumour implant or infiltration, and to establish the resectability of the tumour. Other than transient arrhythmias during the procedure, video-pericardioscopy has no major complications. When compared with surgical pericardial drainage, video-pericardioscopy has higher sensitivity without specific risks. Rigid endoscopes are the best devices to explore the posterior and lateral pericardial surfaces, the pulmonary veins being the posterior limit of the exploration. Big anterior mediastinal masses and pericardial symphysis may render the exploration impossible.

Pericardial-peritoneal window: a novel palliative treatment for malignant and recurrent cardiac tamponade

Transdiaphragmatic approach to the pericardium through a subxiphoid incision is a safe, rapid, and effective way to obtain drainage of the pericardium fluid in patient of disseminated malignancy with recurrent cardiac tamponade. No drainage tubes are needed; pericardial fluid is absorbed by the peritoneum; there is no need for double lumen tubes for single lung ventilation and the subxiphoid incisions are small and almost painless.

Transabdominal ligation of the thoracic duct with pericardial-peritoneal shunting in a case of primary idiopathic chylous pericardial effusion

Primary chylous pericardial effusion is a rare entity with few cases reported so far. We report a case of idiopathic etiology in a previously healthy 16-year-old boy. The patient presented with intermittent chest pain and dizziness caused by a chronic pericardial effusion. An echocardiogram revealing a pericardial effusion and open pericardiocentesis with a drainage of approximately of 500 ml of chylous fluid established the diagnosis. Patient had no history of trauma, cardiac surgery, central insertion of subclavian catheters or blunt injury. Computed tomography ruled out malignancies in the abdomen and chest. Clinical, laboratory and radiological investigations for the possible underlying cause of the condition were not determined. Management with a dietary regimen consisting of a medium-chain triglyceride-rich diet, octreotide pharmacological treatment and initial subxiphoid resection with pericardial tube drainage was unsuccessful. Surgical approach was required consisting of pericardio-peritoneal window with trans-abdominal ligation (clipping) of the thoracic duct above the diaphragm. Postoperative outcome was uneventful and there was a rapid recovery after surgical management.

Neoplastic pericardial effusion

Neoplastic pericardial effusion is a serious and common clinical disorder encountered by cardiologists, cardiothoracic surgeons, oncologists, and radiation oncologists. It may develop from direct extension or metastatic spread of the underlying malignancy, from an opportunistic infection, or from a complication of radiation therapy or chemotherapeutic toxicity. The clinical presentation varies, and the patient may be hemodynamically unstable in the setting of constrictive pericarditis and cardiac tamponade. The management depends on the patient's prognosis and varies from pericardiocentesis, sclerotherapy, and balloon pericardiotomy to cardiothoracic surgery. Patients with neoplastic pericardial effusion face a grave prognosis, as their malignancy is usually more advanced. This review article discusses the epidemiology and etiology, pathophysiology, clinical presentation, diagnosis, management, and prognosis of neoplastic pericardial effusion.

Survival post surgery for malignant pericardial effusion

The study reviews the survival of patients with malignant pericardial effusion treated with a subxiphoid pericardial window. The medical records of 60 consecutive patients diagnosed with a malignant pericardial effusion and treated with a subxiphoid pericardial window between 1994 and 2008 were reviewed. 72% had lung cancer. Overall 30-day mortality was 31%. Survival rates at 3 months, 6 months, 1 year, and 2 years were 45%, 28%, 17%, and 9%, respectively. Overall median survival was 2.6 months. Patients with malignant pericardial effusion, especially those with primary lung cancer have poor survival rates. In advanced malignancy, the subxiphoid pericardial window procedure provides only short-term palliation of symptoms, and has no effect on long-term survival. The use of any surgical procedure in patients with malignant advanced pericardial effusion should be considered along with non-surgical options on a case-by-case basis depending on symptoms, general status, and expected survival.

Constrictive pericarditis secondary to infection with Mycoplasma pneumoniae

Pericardial effusions can be insidious, variable in presentation, and may result from a wide variety of causes. We report here a rare case of pericardial effusion in a pediatric patient secondary to infection with Mycoplasma pneumoniae that progressed to cardiac tamponade and constrictive pericarditis. The differential diagnosis of pericardial effusion is reviewed as well as current treatments for pericardial effusions and constrictive pericarditis.

The intraoperative management of patients with pericardial tamponade

The anesthetic management of patients with pericardial tamponade is challenging, as they present with not only the cardiovascular compromise that defines pericardial tamponade, but often have comorbid conditions that increase the complexity of their management. This review describes the pathophysiology, etiology, clinical presentation, and anesthetic management of patients with pericardial tamponade, with an emphasis on the intraoperative period and the management of pericardial window procedures, the most common clinical scenario where anesthesiologists will encounter pericardial tamponade.

Successful Repair of a Diaphragmatic Hernia Through a Pericardial Window with Acellular Dermal Matrix

A successful placement of a transabdominal pericardial window is associated with diaphragmatic hernia. In this paper, we present the case of a 5-month-old ex-31-weeks-premature baby who developed a symptomatic diaphragmatic hernia following a chronic pericardial effusion who was treated successfully with a laparoscopic transabdominal pericardial window. Laparoscopy and a pericardial window were used to manage the symptomatic effusion that developed following a bilateral thoracotomy and median sternotomy for the patient's massive hygroma. The patient was followed before and after pericardial drainage with a serial examination, chest radiography, and echocardiography. In addition, computerized tomography was also used for long-term follow-up following the repair of the hernia. An acellular dermal matrix was utilized for patching the hernia with a laparotomy. The abdominal approach in both operations offered direct access to the pericardial space and hernia, thereby avoiding previously operated thoraces. A subsequent follow-up at 9 months following the creation of the window suggested a recurrent tamponade physiology. Plain radiographs and an echocardiogram showed herniation into the pericardial sac. The hernia was operatively reduced and repaired with an acellular dermal matrix. Recovery and subsequent followup at 1 year revealed no hernia, full symptom resolution, and no recurrence of the pericardial effusion. A pericardial window is an effective approach for the management of chronic pericardial effusion. Diaphragmatic herniation through a pericardial window can be successfully repaired with an acellular dermal matrix.

[Pericardioperitoneal shunt in the treatment of pericardial effusions in neoplasic patients]

Neoplasia-related pericardial effusions are a frequent finding and pose diagnostic and therapeutic challenges. Although they appear in the context of an underlying neoplastic disease, 50% of these effusions have a benign etiology; they are indirectly caused by the tumor. The remaining cases (neoplastic pericardial effusions - NPE) derive from extension of tu- moral disease to the epi and/or pericardium and have, therefore, a worst prognosis. Despite several treatment options, the lack of appropriate guidelines difficults the evaluation of their efficacy and safety. Pericardioperitoneal shunt (PPS) is a surgical pericardial drainage method, which has demonstrated its usefulness in the management of NPE. At the CHC, this procedure is performed under videoassisted toracoscopic guidance (VATS). During the last 8 years, 18 patients have been submitted to this therapeutic option, which proved to be safe, efficacious and with low morbimortality rates.

Lateral position prevents respiratory occlusion during surgical procedure under general anesthesia in the patient of huge anterior mediastinal lymphoblastic lymphoma

Lymphoblastic lymphoma, an aggressive mediastinal mass, is recognized as serious threat to the patient in developing cardiac tamponade or airway obstruction. Surgical procedure is often required to relieve clinical emergency and to establish prompt pathological diagnosis. However, in such a patient, acute respiratory occlusion in the spine position can be a life-threatening complication during general anesthesia. We describe a 17-year-old man whose cardiac tamponade was treated by pericardial-pleural window through a left anterior thoracotomy in the lateral position. The patient recovered from hemodynamic compromise without showing respiratory occlusion during general anesthesia and remained in the lateral position until extubation. Pathological diagnosis was precursor T-lymphoblastic lymphoma. There were no complications attributable to the operative procedure. Further chemotherapy reduced the mediastinal mass in size after two weeks when the patient developed sepsis and died. Lateral position prevents respiratory occlusion during surgical procedure under general anesthesia in the patient of huge anterior mediastinal tumor with airway obstruction.

Pericardioperitoneal shunt: further development of the procedure using VATS technique

We report a modification of the previously described VATS (video-assisted thoracic surgical) method of pericardioperitoneal shunt. Our method was used in 5 patients with pericardial tamponade requiring permanent drainage.

Critical care of patients with cancer. Surgical considerations

Surgical evaluation of and therapy for the critically ill cancer patient continue to present significant challenges despite, or perhaps in part because of, an ongoing technologic refinement of therapeutic modalities within a modern ICU.

Percutaneous echocardiographically guided pericardiocentesis in pediatric patients: evaluation of safety and efficacy

The purpose of this study was to evaluate the safety and efficacy of echocardiographically (echo) guided pericardiocentesis in pediatric patients. Echo-guided pericardiocenteses performed in pediatric patients (age >/=16 years) at the Mayo Clinic between 1980 and 1997 were identified. Presentation, cause and characteristics of the effusion, details of the pericardiocentesis procedure, and outcome were determined by comprehensive chart review supplemented by telephone interviews when necessary. Seventy-three pediatric patients, median age 6.7 years (range 1 day to 16 years), underwent 94 consecutive echo-guided pericardiocenteses for effusions of various causes. Twenty-one (22%) procedures were performed in children younger than 2 years. All but 1 procedure were successful (99%). A mean fluid volume of 237 mL (range 4 to 970 mL) was withdrawn. Only a single attempt was needed for entry into the pericardial space in 87 (93%) procedures. No deaths were associated with the pericardiocentesis procedure. Only 1 major complication occurred (1%), a pneumothorax requiring chest tube reexpansion. Three (3%) minor complications-2 instances of right ventricular puncture and a small pneumothorax-did not require treatment. Extended catheter drainage for a mean of 5.2 +/- 4.5 days (range 1 to 19 days) was used with 30 (32%) of the 94 procedures. For the 52 patients who underwent pericardiocentesis without catheter drainage as the initial management strategy, 18 required 21 repeat pericardiocenteses for recurrence of effusion. In contrast, for the 21 patients who had pericardial catheterization as the initial management strategy, none had recurrences necessitating a repeat procedure (P <.001). Increased utilization of a pericardial catheter was associated with a concomitant decrease in the number of surgical pericardial procedures over the study period. Echo-guided pericardiocentesis was the only therapeutic modality for the management of effusion in 73% of all patients. Echo-guided pericardiocentesis is safe and effective in pediatric patients, including children younger than 2 years. The increasing use of pericardial catheterization in conjunction with this technique was associated with significant reduction of recurrence and decreased frequency of surgical interventions for treatment of pericardial effusion. Echo-guided pericardiocentesis with extended catheter drainage should be considered as primary management strategy for clinically significant pericardial effusions in pediatric patients.

Malignant effusive disease of the pleura and pericardium

Malignant pleural and pericardial effusions are a common problem in the treatment of patients with lung cancer, breast cancer, or lymphoma and may occur with any malignancy. These effusions are frequently symptomatic and, in the case of the pleural space, may be the presenting sign of cancer. In other patients, they represent markers of recurrent, disseminated, or advanced disease. Given the poor prognosis of most patients presenting with these effusions, reducing symptoms and improving quality of life are the primary goals of treatment. Permanent drainage and/or obliteration of the pleural or pericardial space are crucial to the effective management of the effusion and will provide long-term palliation. Immediate relief can be accomplished via external drainage, but definitive therapy may often also require interventional radiology, cardiology, and thoracic surgery, as well as medical and radiation oncology. The pathophysiology, diagnosis, and treatment of malignant pleural and pericardial effusions are discussed in this article.

Pericardial tamponade as the first manifestation of adenocarcinoma

We hereby report on 13 cases of pericardial tamponade as the first manifestation of an adenocarcinoma. The primary tumor was detected in 10 cases: 7 lung, 1 stomach, 1 breast and 1 thyroid. A first cytologic examination of the pericardial fluid yielded the diagnosis of adenocarcinoma in 10 cases, whereas a second cytology was needed in another two cases. The pericardial biopsy was positive in 7 out of 7 patients. The therapeutic procedures included pericardiocentesis in 9 patients (6 of whom had recurrent tamponade), a pericardial window in 4 and pericardiotomy in 4 (without recurrences). The mean survival was 4 months.