Thoracoscopy

1、Thoracoscopy43OChinMedJ2006;119(5):430-434ExperienceexchangeThoracoscopyfordiagnosisandmanagementoftichydrothoraxLINDian-jie,ZHANGMin,GAOGui-xin,LIBin,WANGMao-fen,ZHULingandXUELi-fuKeywords:hepatichydrothorax;thoracoscopy;pleurodesis;talcpoudrageT:三ofpleuraleffusioncausedbyrangesfr0m0.4%to30%.Somepa

2、tientswithhepatichydrothorax(HH)fa_lt0respondtoaggressivemedicalmanagementsuchasalbuminapplication,diuretics,andthoracentesis,andremainrefractorymassivepleuralfluid.TherepeatedsuctionstorelievethesymptomssuchasrespiratorydistressareassociatedwithsignificanthyponatremiaandhypoalbuminemiacausedbytheIa

3、rgevolumesoffluidIOSS.ReviewoftheIiteraturehasrevealedthat,todate,notherapyisidea1.ThisreportdescribesourexperimentsintreatingHH0fpatientswithcirrhosisandascitesbythoracoscopyandtaIcpoudrage,toofferoureffortstoapproachthepathogenesisofHHandtoexplorethenewtherapeuticstrategy.METHODSAretrospectivestud

4、ywasconducted,consistedof20menand6womenranginginagefrom32to64years【mean,(44_28.5)years,whowereadmittedtoShandongProvinciaIHospitaIfr0mMamh1992toApriI2004.Twenty-oneofthemhadpost-hepatitiscirrhosis,3patientshadalcoholiccirrhosis,1hadbiliarycirrhosis.and1hadBudd-Chiarisyndrome.Twenty-twocasesremainedr

5、efractoryright-sidedsymptomaticHHand4withbilateraIHH(1argevolumeinrightandsmallinIeft).Twenty-onecasespresentedmassiveascitesand5withmoderateandmodestascites.AllpatientshadHHhistorymorethanonemonth.Beforepleurodesis,alIpatientscalledforrepeatedthoracentesisforrapidreliefofsyndromesandaveragevolumeof

6、drainagerangedfr0m4500to24000mI【mean,(9800910)m1.ThediagnosticcriteriaofHHwasasfollows:(1)patientshadthehistoryofchronicliverdisease,albumin<30g/L,theproportionofalbumin/globinwasinverted;(2)portalveinpressurehadsteppedup,bypasscircuitwasperformedwithvaricesofesophagus,stomachfundusorabdomina1wal

7、l;(3)spleenenlargedcomplicatedwithhypersplenia;(4)patientshadmassivepleuraleffusionandmoreorlessascites.Thecharacteristicofpleuraleffusionandasciteswastransudate.Ifthesymptomofpatientsaccordedwith(1)and(4)plus(2)or(3),thediagnosiscouldbeestablished.Toestimatethepatients.tolerance,clottingtime,bloodp

8、lateletcount(BPC),IiverandrenaIfunctionandECGwereperformedbeforeoperation.Allprocedureswereprocessedonpatients.permission.TheHHwasdrained600-1000mIand300-600mIgaswasinjectedintothepleuralcavityinsteadtoestablishartificiaIpneumothoraxbeforethora-coscopy.Thentheextentofpleuralsymphysiswasobservedbyche

9、stradiography.ThepatientswerepositionedintheIateraIdecubituspositionunderIocaIanesthesia.Twenty-fourvideo-assistedthoracicsurgery(VATS)procedureswithtwoportsfoneinthefifthandoneintheeighthintercostalsspace)wereperformedusingarigidthoracoscope.Twoprocedureswithoneportwereperformedusingafiberthoracosc

10、ope.AftercompleteevacuationoftheHH,thepleuralcavitywascoveredwith3-5gofaerosolizedmedicalsteriletalcpowderanddrainedbyplacingoneortwochesttubesinthecavity.Postoperatively,medicaltherapywasmaintained,suction(20cmH20)wasDepartmentofRespiratoryDiseases.ShandongUniversityShandongProvincialHospital,Jinan

11、250002,China(LinDJ,ZhangM,GaoGX,LIB.Wl柚gMEZhuLandXueLF)Correspondenceto:DLLDian-jie.DepartmentofRespiratoryDiseases,ShandongUniversityShandongProvincialHospital,Jinan250o02.China(Tel:86-531.85186360ext236o.Email:lindianiiesohu.corn)ChineseMedicalJournal2006;119(5):43043443linseded,andthechesttubeswe

12、reremovedwhenthedrainagevolumeremained<50ml/d,oratIeast2to3daysaftersealingtheairIeaks.Thechestradiography,chestultrasoundandIiverfunctionwereperformedeveryweekafterthoracoscopyfor2or3weeks.Twentyfourcasesof26wereundergonepleurodesisviastereoplasmthoracoscopy.Completeresponse(CR)wasdefinedastheco

13、mpleteabsenceofHH;partialresponse(PR)wasdefinedastheobviousreductionofHH0rencapsulatedhydrothoraxformationwithoutresp-iratorysymptoms;ifthesymptomshadnoanychange,itwasdefinedasnonchange(NC).Thefollowupperiodrangedfr0m6monthsto3yearsandanyreaccumulationofpleuralfluidwasregaledasrecurrence.RESULTSThep

14、leuraIsurfacesof25casesweresmoothwithoutanysymphysis.TheveinsinparietaIpleuraanddiaphragmbecamevisiblein19casesandazygosveinwasobservedin6cases.Therewere16caseswithorificesIocatedonthediaphragmaticmusclearea.14caseswithvesiclesonthediaphragmtendinousarea,7casesoncostaIpart,and5caseswithorificesonthe

15、diaphragmaticpart.ThevesiclesizewasdifferentandchangedwiththerespirationandabdominaIpressure.inwhichthebiggestonewas0.6cm0.6cm0.5cm.Insomepatientswedetectedsomefiberscarsformedintherepairoftheinjureddiaphragm.OBeweekafterthoracoscopy.14casesthatperformedultrasoundandXrayexaminationswerefoundthatthep

16、leuraadheredwidelyandtheHHvanished.Therewere8casesformedencapsuIatedhydrothorax.OBeofthemwasdrainedtwiceafterthelargeencapsulatedhydrothoraxIocatedbyultrasoundandinjectedmedicaIsteriletalcpowder12gsp0ntane0usIy,andthentheHHdisappeared.Theaveragetimetoremovechesttubesrangedfr0m3t08days【mean,(4.31.5)d

17、ays.OnlytwopatientsfaUedtorespondtotalcandthedrainagevolume>600mI/d.Of24patientswhoreceivedpleurodesisviathoracoscope,14cases(58%)acquiredcompleteresponse,8cases(33%)acquiredpartialresponseand2cases(8%)hadnonchangeIntrapleuralinsuffIationoftaIcwasassociatedwithminimaImorbidity.Wedetected6caseswit

18、hmildthoracicpainforseveraIminutesand17caseswithmodestormoderatechestpainfor1-3days.Fifteencaseshadmildfeverand1casehadardentfeverfor2.3days.Only2patientssufferedfeverfor1week.OBecasepresentedintensivebellyacheaccom-paniedthetautabdominaImusclefor6hours.AsfarasIiverfulnctiontest,wefound7patientswith

19、aminopheraseslightlyelevatedand1patientwithaminopherasetwicehigherthannormaIIeve1.ThefirstIiverfulnctiontestperformedin23patientsoneweekaftertheoperation.Thesecondtestadministeredin17patientstwoweeksaftertheoperation.Weobservedthat8patients.aminopheraseslightlyincreasedand1patientsaminopheraseobviou

20、slyraisedaccompaniedbyaurigo.howeverattheendofexperiment,alIpatientsaminopherasecametopreoperationIevelsexcept3patients.Therewere2unsuccessfuIcases,onedischargedandIostthecontactandonediedofhepaticencepha10pathy1monthaftertheoperation.Theother22caseswerefoIlowedupfrOm6monthsto3years.0Bediedofhemorrh

21、ageandhepaticencepha10pathyonemonthaftertheoperation.Threediedofhemorrhagein6.12and18monthsrespectively.Onecasepresentedrecurrence18monthsafteroperation.DISCUSSIONMorrowetal.firstdescribedarapidaccumulationofmassiverightpleuraIeffusionafteradiagnosisofhepaticcirrhosisanddefineditasHHin1958.Althougha

22、wealthofIiteratureonthetreatmentofsymptomaticHHpublished,theoptimaIorstandardtherapyremainedelucidated.Morbidityofhepatichydrothoraxwasvariousbecauseofdifferentstandardstochoosepatients.Usuallyitwasfoundintherighthemoithorax(approximately70%),butcouldalsobeseenontheleftside(approximately15%),bilater

23、ally(approximately15%),andevenintheabsenceofascites.TheexactmechanismofHHremainedunknown.AnumberofdifferentmechanismshadbeenproposedtoexplainthedeveIopmentofHH,includingthefoIlowing:(1)432ChinMedJ2006;119(5):430-434HVp0aIbuminemiaandadecreaseincolloidosmoticpressure.ButthismodelcouldnotexplainwhyHHc

24、ommonlyappeamdatright-sidedhemothorax.Furthermore,somepatientswitharemarkabledecreaseinalbumindidnotproducehydrothorax,whileotherswithnormaIalbuminformedmassivehydrothorax.(2)PortaIhypertensionandbypasscirculationestablished.VaricesofesophagusandstomachfundusIeadtothehypertensionofazygos,hemi.azygos

25、vein,andthenthebodyfluidsextravasatedintopleuralcavity.However,thistheorystilIcouldnotinterpretwhyhydrothoraxwascommonlyfoundatright-sidedhemothoraxandwhysomepatientswithcollateraIcirculationdidnotproducehydrothorax.ORepatientwithBudd-ChiarisyndromehadIargeascitesaccompaniedbyhydrothorax.Afterthefir

26、stthoracoscopywefoundthatthechestwalIveinappearedandazygosveinvarixformed.AftercavaIveinbrackettreatmenttheascitesdisappeared.butthemassiveHHst川remained.Insecondthoracoscopy,wedetectedthatthepleurawascommonlynormaIandtheveinsdidnotappearordistend,whichsuggestedthehypertensionofazygosveincouldnotacco

27、untforthepathogenesisofhydrothorax.(3)TheIymphstreamofIiverincreased.andrecirculationofhepaticsinuspost-veinobstructedwhencirrhosisperformed.TheIymphIeakagecouldincreasefrom1mI,mint010mI/min.whichresultedinthepressureofIymphpassageincreasedsimilartothatofportaIvein(300mmHg),andthusthelymphvesselsinp

28、leuradistendedandruptured.(4)Ascitestransferredfr0mpentonealcavitytothepleuraIspaceviaIymphaticchannelsinthedisphragm.WhenthepleuraIlymphcirculationobstructed,thehydrothoraxappeared.Ithadeverbeenreportedthattheformationofright-sidedhydrothoraxcouldbemorecloselyrelatedtothelymphdistribution.(5)Defect

29、sofdiaphragm.Thesedefectsprobablyresultedfromanatomicthinningandseparationofthetautcollagenousflbemofthetendinousportionofthediaphragm.Congenitalfactors,highintra-abdominalpressure(cough,defecation,parturition),traumaorprolongedbedrestmightcontributetothedefects.Thetransdiaphragmaticdefectscouldbedi

30、videdintof0urtypes.Type1wasbig.GasandfluidcouldgothroughbetweenthethoraciccavityandabdominaIcavityfreely.OnepatientinthisgroupwhounderwentartiflciaIpneumothoraxtherapyandformedhydropneumothoraxwasbelongedtothistype.TypeI1wassmal1.Fluidcouldgothroughtheporebutgascouldnot.1tplayedaroleofone-waychanneI

31、topreventhydrothoraxtoflowintoabdominaIcavity.Typewassmaller.Thenegativepressureofpleuralcavityinducedascitesintopleuralcavity.WhentheascitesvolumethatabdomengeneratedwasIessthanorasmuchasthatpleuralcavityabsorbed,theHHappearedwithoutascites.TypeIVisthesmallest.Gasandfluidcouldnotgothroughtheorifice

32、intopleuraIcavity.ButHHcouldgobacktoabdominaIcavityviagravity.Sothehydrothoraxrapidlydecreasedafterdrainingtheascitesfluid.Typellandtypewerecommonlyinclinica1.DiagnosticmodalitiesofdiaphragmaticfeRestrationhadincludedinstillationofair,contrastagents,ornuclearscintigraphy(forexample.I,)intoabdomen.In

33、ourexperiment,16casespresenteddiaphragmaticvesicles,whichwereoftenmultipleanddistributedinthevariousplaceofdiaphragmaticmuscle.ItwasalsofoundoncostaIpartanddiaphragmpart.OMrobservationsweredifferentfromthepreviousviewsthatdiaphragmaticvesiclewerecommonlyseeninweakpointlikechordaandtendinousportionof

34、thediaphragm.HHwasmainlyattdbutedtohepaticcirrhosis.ThechiefcharacteristicofthecompositionofHHwastransudateandassameasthatofascites.Wheninfected,HHappearedbiphasicchanging.Somepatientscouldproducesanguineoushydrothorax.Fourcasesinthisgroupwithsanguineoushydrothoraxwerecausedbydiaphragmaticvesiclerup

35、ture.Thesanguineoushydrothoraxalsocouldbecausedbyshortcircuitofcoilateralcirculation,ruptureofcommunicatingbranchandinjuryofendotoxintobloodvesseI.Atthesametimeotherdiseasesliketuberculosis,tumor,kidneydiseaseandsoonshouldbeeliminated.Furthermore,thepositionofcontractedlungalteredwasavitaIevidenceto

36、diagnoseHHinradiology.AIlthepatientsinthisgroupunderwentthoracoscopy.Onlyonepatientwiththehistoryoftuberculouspleuritisappearedpleuralsymphysisandtheothershadsmoothpartialpleura,whichwereconsistentwiththeappearanceinradiology.TodatetheoptimalorstandardtherapyforHHremainedunclear.Usingdiureticcausedf

37、luidandelectrolyteimbalanceanddidlittlegoodtoreducehydrothorax.Dminagewasalsoineffective.ChineseMedicalJournal2006;119(5).430434433RepeatedlythoracentesiscouldJeadtosubstantiaJproteindepletion.whichinturnresultedinthedeteriorationoftheclinicaIstatus.HydrothoraxretransefusioncouldavoidtheIossofprotei

38、nandbodyfluid.butitcouldnotpreventhydrothoraxfr0mreaccumulationandincreasedthedangerofinfection.hepaticcomaanddisseminatedintrav-ascularcoagulationfDIC).MultiplemedicaImana-gementshouldbeadoptedsuchasprotectingIiverfunction,supplyingplasmaproductsandbranchedchainaminoacid,accompaniedwithwaterandsalt

39、restriction.ThiscomprehensivetreatmentcouldmakeHHandascitesdecreasedorevendisappearedinonethirdofthereportedpatients.ThepleurodesisshouldbeperformedwhentheclinicaImanagementwasineffective.TaIcumwassclerosingexperimentsmagnesiumprovedtobeoneofthemosteffectiveagentstoinducepleurodesisbyandclinicresear

40、ch.ItwasakindoftrisilicatewithchemicaIarChiteCtureMg6(SiOs)4(OH)4,whichcouldstimulatepleurafibrosisandgranulomadegeneration.Pleurodesisusingtalcpoudrageviathoracoscopewasconsi-deredtobethemostexcellentmethodtotreatmalignanthydrothoraxandrefractoryinnocenthydrothorax.ThoracoscopycouldbeoperatedunderI

41、ocaIanesthesia,andtherefore,ithaswideavailabilityandIowcost.Inthisgroup.thepleuraIeffusioncouldbedrainedcompletelyandthepleurawerecoveredbyaerosolizeddrugs.ThistherapywaseffectiveintreatingmalignantpleuraIeffusionandrefractorypneumothoraxandwasmostusefuIinpleuraladhesion.Thesuccessratewas92%.CRwas58

42、%,PRwas33%,andNCwas8%.ThismethodwasalsoprovedtobeeffectivetoHH.Thesideeffectsaboutthetreatmentofinsufflatingtalcinthepleuralcavityunderth0rac0sc0pewereslightsuchaschestpain.fever.HalfofthepatientshavechestpainandfeverbecauseoftheasepticinflammatoryreactioncausedbythetaIcstimulatingthepleuraafteroperation.Themajorityofpatientshadmodestandmoderatefeverfor2.3days.Afewpatientshadhighfeverwiththetemperatureof39.C.PatientswhohadmodestandmoderatechestpainandfeverneedednospeciaItreatmentgenerally.Inthisgroup,onlyonepatientpresentedseriousstomachachewiththeabdomenintension.Thesymptomwasnotrelie