00:17:271 Management for Hydrothorax in Peritoneal Dialysis R1 吳悌暉 960518.
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Transcript of 00:17:271 Management for Hydrothorax in Peritoneal Dialysis R1 吳悌暉 960518.
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Management for Hydrothorax in
Peritoneal DialysisR1 吳悌暉
960518
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Management Options for Hydrothorax Complicating
Peritoneal Dialysis-Review ArticlesSeminars in Dialysis—Vol 16, No 5 (September–Octob
er) 2003 pp. 389–394
Department of Medicine and Therapeutics, Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
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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)
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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 peritoneogr
aphy
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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 dia
phragmatic lymphatic swelling
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Ten major series were included in the period 1978–2002,identifying 104 consecutive cases of hydrothorax complicating PD
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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%
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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%
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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%
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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%
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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, C
hina
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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
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Acute hydrothorax in CAPD: Early Thoracoscopic (VATS) intervention allows
return to peritoneal dialysis
Nephron 2002;92:725-727
Department of Cardiothoracic Surgery, Papworth Hospi
tal, Cambridge, UK
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Materials and Methods
Between 1995 and 2000 we studied 6 patients (3 male, 3 female, mean age 62, range 31-72 years) receiving CAPD for chronic renal failure
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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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Results Diaphragmatic defects (fistula) were clearly identified in 3 o
f the 6 patients. In the other three patients, small pleural blebs were seen o
n 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 un
eventfully to CAPD 1 month following hospital discharge At follow up with a median of 40 months there was no recur
rence of hydrothorax
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Discussion
This is the largest series of patients yet reported We recommend early thoracoscopic surgery and p
leurectomy 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
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Video-assisted thoracoscopic surgery for hydrothorax in peritoneal
dialysispatients — check-air-leakage met
hodEuropean Journal of Cardio-thoracic Surgery 28 (2005) 6
48–649
Kaohsiung Chang Gung Memorial Hospital
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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.
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Technique The pleural cavity was filled with sterile water Inflated the CO2 to the peritoneal cavity via the pe
ritoneal 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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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
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Finally
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Conclusion
Diagnosis
- Pleural fluid to serum glucose gradient of more than 50 mg/dL
- Pleural and peritoneal fluid protein content uniformly < 4 g/L
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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
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THANKS