Northup Patrick G, Harmon R Christopher, Pruett Timothy L, Schenk Worthington G, Daniel Thomas M, Berg Carl L
Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia 22908, USA.
Ann Thorac Surg. 2009 Jan;87(1):245-50. doi: 10.1016/j.athoracsur.2008.10.013.
Hepatic hydrothorax in the setting of decompensated cirrhosis is a challenging and common clinical problem. Traditional therapies such as diuretics and transjugular intrahepatic portosystemic shunts can be effective therapies in selected patients but in patients ineligible for, or intolerant of, these traditional therapies, few effective therapeutic options remain for the management of hepatic hydrothorax.
We present a series of 5 consecutive patients with refractory hepatic hydrothorax who underwent combined thorascopically guided mechanical and chemical pleurodesis aided by an intraperitoneal drain that prevented reaccumulation of the ascites while pleural inflammation and adhesion were progressing. We speculate that the prolonged contact between the parietal and visceral pleura allowed by prevention of reaccumulation of intraabdominal ascites and subsequent flux through the pleural space enhanced the efficacy of this procedure in comparison with those presented in the literature.
Despite the fact that all of our patients presented with decompensated cirrhosis, the surgical procedure and subsequent hospitalization were tolerated well by our entire cohort. Colonization of the pleural and peritoneal drainage fluid was a common complication of this procedure but was not associated with prolonged morbidity or mortality.
We present a therapy for the difficult clinical problem of refractory hepatic hydrothorax that may allow selected patients an opportunity for prolonged symptomatic control.
失代偿期肝硬化患者出现肝性胸水是一个具有挑战性的常见临床问题。利尿剂和经颈静脉肝内门体分流术等传统疗法在部分患者中可能是有效的治疗方法，但对于不符合这些传统疗法适应证或不耐受的患者，治疗肝性胸水的有效治疗选择很少。
我们报告了连续5例难治性肝性胸水患者，他们接受了胸腔镜引导下的机械性和化学性胸膜固定术，并辅以腹腔引流，在胸膜炎症和粘连进展时防止腹水再次积聚。我们推测，与文献报道的方法相比，通过防止腹腔内腹水再次积聚以及随后通过胸膜腔的液体流动，使壁层胸膜和脏层胸膜之间的接触时间延长，从而提高了该手术的疗效。
尽管我们所有的患者均表现为失代偿期肝硬化，但整个队列对手术及随后的住院治疗耐受性良好。胸膜和腹腔引流液的定植是该手术的常见并发症，但与延长的发病率或死亡率无关。
我们提出了一种治疗难治性肝性胸水这一棘手临床问题的方法，该方法可能使部分患者有机会获得长期的症状控制。
