Eur J Cardiothorac Surg 2005;28:648-649
© 2005 Elsevier Science NL
Video-assisted thoracoscopic surgery for hydrothorax in peritoneal dialysis patients — check-air-leakage method
Hsu-Ting Yen
a
,
Hung-Yi Lu
a
,
Hui Ping Liu
b
,
Ming-Jang Hsieh
a
,
*
a Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Kaohsiung, 123, Ta-Pei Road, Niao Sung Hsiang, Kaohsiung Hsien, Taiwan, ROC
b Divisions of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Chang Gung University, Kweishan, Taoyuan, Taiwan, ROC
Received 10 May 2005;
received in revised form 10 June 2005;
accepted 13 June 2005.
* Corresponding author. Tel.: +886 7 7317123; fax: +886 7 7322402. (Email: octopa{at}adm.cgmh.org.tw).
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Abstract
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Hydrothorax developing from pleuroperitoneal communication as a complication of peritoneal dialysis was first described in 1967 [Edward SR, Unger AM. Acute hydrothorax—a new complication of peritoneal dialysis. JAMA 1967; 199:853–5. [1]]. The incidence of hydrothorax is approximately 1.6–2% of continuous ambulatory peritoneal dialysis (CAPD) patients. The key to successful therapy is obliteration of the transdiaphragmatic route of dialysate leakage with video-assisted thoracoscopic surgery (VATS). The method in which air leakage is checked intraoperatively is the preferred choice and better than all other procedures.
Key Words: Diaphragm • Pleural effusion • Video-assisted thoracic surgery (VATS)
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1. Introduction
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Diaphragmatic defects or blebs can be identified with intraperitoneal infusion of colored continuous ambulatory peritoneal dialysis (CAPD) fluids intraoperatively. However, as patients cannot detect diaphragmatic defects intraoperatively, the method in which air leakage is checked is typically employed at Kaohsiung Chang Gung Memorial Hospital. This method allows for direct identification of a diaphragmatic defect during surgery. 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 continuous carbon dioxide (CO2) inflation via a peritoneal catheter. When a defect exists, a continuous air bubble can be seen.
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2. Technique
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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. The first portal, for the introduction of the thoracoscope (Stryker 10mm, zero degree endoscope), was created at the 5th intercostal space along the mid-axillary line. The other two ports were created at the 8th intercostal space along the anterior and posterior axillary lines (Fig. 1
). After examination for communication between the pleural and peritoneal cavities, and for any lung and pleural pathology, the check-air-method was employed to identify intraoperatively the diaphragmatic defect. The pleural cavity was filled with sterile water; we inflated the CO2 to the peritoneal cavity via the peritoneal catheter. The pressure in the peritoneal cavity was maintained at 12mmHg. Via thoracoscopy, continuous air bubbles leaking from the diaphragmatic defect were located in the pleural cavity (Fig. 2
). 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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3. Comment
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The hydrothorax is an uncommon complication of CAPD. VATS with talc pleurodesis is a minimally invasive and effective procedure for treating this patient group [2–4]. The tools for diagnosing this condition are as follows: chemical analysis (glucose, protein, lactate dehydrogenase) of pleural fluid; methylene blue discoloration of the dialysate followed by thoracocentesis; imaging modalities which identify transfer of radio-opaque or radioactive media across the diaphragm; and, contrast computed tomographic peritoneography [4–6]. Analysis of simultaneous peritoneal and pleural aspirate protein and glucose content is the simplest and least expensive diagnostic method. These imaging studies, while sophisticated and expensive, are not suitably sensitive or indispensable in detecting pleuroperitoneal communication.
All these approaches are preoperative diagnostic methods. Intraoperative diagnostic methods are direct visualization and infusion of methylene blue colored dialysis fluid into the peritoneal cavity during surgery [7]. This report introduces the novel check-air-leakage method for identifying intraoperatively pleuroperitoneal communication. Based on the characteristics of air, continuous air bubbles leaking from the defect under the thoracoscopy can be identified. Compared with methylene blue infusion, which was commonly utilized in the past, the surgical field will be clearer under VATS. It specifies referent is a simple method for identifying a defect or bleb on the diaphragm, which can then be repaired simply with VATS. For patients with negative methylene blue infusion test results, we strongly suggest using the check-air-leakage method to identify the diaphragmatic defects during operation. In our experience, if a defect exists, the check-air-leakage method can locate it. This method is now the first procedure chosen at Kaohsiung Chang Gung Memorial Hospital and the methylene blue infusion test is no longer used.
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References
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- Edward SR, Unger AM. Acute hydrothorax—a new complication of peritoneal dialysis. JAMA 1967;199:853-855.[CrossRef][Medline]
- Chow KM, Szeto CC, Li PK-T. Management options for hydrothorax complicating peritoneal dialysis. Semin Dial 2003;16:389-394.[CrossRef][Medline]
- Tang S, Chui WH, Anthony WCT, Li FK, Chau WS, Ho YW, et al. Video-assisted thoracoscopic talc pleurodesis is effective for maintenance of peritoneal dialysis in acute hydrothorax complicating peritoneal dialysis. Nephrol Dial Transpl 2003;18:804-808.[Abstract/Free Full Text]
- Kanaan N, Pieters T, Jamar F, Goffin E. Hydrothorax complicating continuous ambulatory peritoneal dialysis: successful management with talc pleurodesis under thoracoscopy. Nephrol Dial Transpl 1999;14:1590-1592.[Abstract/Free Full Text]
- Chow KM, Szeto CC, Wong TY, Li PK. Hydrothorax complicating peritoneal dialysis: diagnostic value of glucose concentration in pleural fluid aspirate. Perit Dial Int 2002;22:525-528.[Free Full Text]
- Ortiz L, Hazley D, Seikaly MG. Thoracocentesis helps diagnose diaphragmatic defects in peritoneal dialysis patients. Pediatr Nephrol 2001;16:105-106.[CrossRef][Medline]
- Okada H, Ryuzaki M, Kotaki S, Nakamoto H, Sugahara S, Kaneko K, et al. Thoracoscopic surgery and pleurodesis for pleuroperitoneal communication in patients on continuous ambulatory peritoneal dialysis. Am J Kidney Dis 1999;34:170-172.[Medline]
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Abstract
1. Introduction
