Chemical pleurodesis for hepatic hydrothorax

Success of Using Iodopovidone as a Sclerosing Agent for Chemical Pleurodesis in a Tertiary Care Center: A Descriptive Cross-Sectional Study

Introduction:

Pleurodesis is a procedure to achieve symphysis between the two layers of pleura aimed at preventing the accumulation of either air or fluid in the pleural space. In Nepal, intrapleural instillation of the chemical sclerosing agent is more commonly done as a Thoracoscopy facility is not easily available. However, iodopovidone is rarely used for this purpose in Nepal. The study aims to find the prevalence of success using iodopovidone as the chemical sclerosing agent.

Methods:

The study included cases undergoing pleurodesis over a two-year period. The clinic-odemographic data, diagnosis, treatment effect and treatment response were analyzed. The treatment response was graded as Treatment Success (Complete Response or Partial Response) and Treatment Failure.

Results:

Pleurodesis was done in a total of 54 cases. Of those, 39 cases were Secondary Spontaneous Pneumothorax, 11 were Malignant Pleural Effusion, 3 were Primary Spontaneous Pneumothorax, and 1 was a case of Hepatic Hydrothorax. Among Secondary Spontaneous Pneumothorax, Pleurodesis was successful in 37 (95%) out of 39 cases, with 35 (90%) having a Complete Response and 2 (5%) having a Partial Response while 2 (5%) had Treatment failure. Among Malignant Pleural Effusion, treatment success was achieved in 6 (55%) out of 11, whereas 5 (45%) failed the treatment. The commonest complication was burning sensation, and the commonest pain scale was “distressing.”

Conclusions:

This study highlights the safety and the ease of use of iodopovidone as an agent for chemical pleurodesis. It confirms the high rate of success of pleurodesis in cases of pneumothorax as found in other studies. In contrast, the success rate is understandably lower in cases of Malignant Pleural effusion.

Circumferential dural resection technique and reconstruction for the removal of giant calcified transdural herniated thoracic discs

OBJECTIVE

The authors report a novel paradigm for resection of the disc or dural complex to treat giant calcified transdural herniated thoracic discs, and they describe a technique for the repair of dural defects. These herniated thoracic discs are uncommon, complicated lesions that often require a multidisciplinary team for effective treatment. The intradural component must be removed to effectively decompress the spinal cord. The opening of the friable dura mater, which frequently adheres to the extradural component of the disc, can result in large defects and difficult-to-manage CSF leaks.

METHODS

The authors performed a retrospective study of the technique and outcomes in patients with a transdural herniated disc treated at St. Joseph’s Hospital and Medical Center within a 4-year period between 2012 and 2015.

RESULTS

During the study period, 7 patients (mean age 56.1 years) presented to the department of neurosurgery with clinical symptoms consistent with myeloradiculopathy. In all cases, 2-level corpectomies of the involved levels were combined with circumferential resection of the dura and complete decompression of the spinal cord. The dural defect was repaired with an onlay dural patch, and a large piece of AlloDerm (LifeCell Corp) graft was sewn to close the pleural defect. Every patient had a perioperative lumbar drain placed for CSF diversion. No patient suffered neurological decline related to the surgery, and 3 patients experienced clinically significant improvement in function. Two patients developed an early postoperative CSF leak that required operative revision to oversew the defects.

CONCLUSIONS

This novel technique for decompression of the spinal cord by dural resection for the removal of giant calcified transdural herniated thoracic discs is safe and results in excellent decompression of the spinal cord. The technique becomes necessary when primary repair of the dura is not possible, and it can be used in cases in which the resection of pathology includes the dura.

Effectiveness and Safety of Pleurodesis for Hepatic Hydrothorax: A Systematic Review and Meta-Analysis

BACKGROUND

Hepatic hydrothorax (HH) is a serious complication of end-stage liver diseases, which is associated with poor survival. There is no consensus regarding the treatment of HH.

AIM

To evaluate the effectiveness and safety of pleurodesis for HH in a systematic review with meta-analysis.

METHODS

All relevant papers were searched on the EMBASE and PubMed databases. As for the data from the eligible case reports, the continuous data were expressed as the median (range) and the categorical data were expressed as the frequency (percentage). As for the data from the eligible case series, the rates of complete response and complications were pooled. The proportions with 95 % confidence intervals (CIs) were calculated by using random-effect model.

RESULTS

Twenty case reports including 26 patients and 13 case series including 180 patients were eligible. As for the case reports, the median age was 55 years (range 7-78) and 15 patients were male. The prevalence of ascites was 76 % (19/25). Seventeen (65.38 %) patients responded favorably to pleurodesis. As for the case series, the mean age was 51.5-63.0 years and 83 patients were male. The pooled prevalence of ascites was 90 % (95 % CI 81-97 %) in 7 studies including 71 patients. The complete response rate after pleurodesis was reported in all studies, and the pooled rate was 72 % (95 % CI 65-79 %). Complications related to pleurodesis were reported in 6 studies including 63 patients, and the pooled rate was 82 % (95 % CI 66-94 %).

CONCLUSION

Pleurodesis may be a promising treatment for HH, but carries a high rate of complications.

Role of the peritoneopleural pressure gradient in the genesis of hepatic hydrothorax. An isotopic study

SUMMARY

Hepatic hydrothorax is defined as the development of significant pleural effusion in a patient with cirrhosis without primary pulmonary or cardiac disease. This complication is seen in 4-10% of patients with cirrhosis. The pleural effusion is a result of a direct passage of ascitic fluid into the pleural cavity through a defect in the diaphragm. We report two patients with posthepatitis cirrhosis presenting with a significant pleural effusion. The peritoneopleural communication was demonstrated by peritoneal scintigraphy. The role of the peritoneopleural pressure gradient is discussed.