A Case of Successful Surgical Decortication for Empyema With Trapped Lung in a Patient With Decompensated Cirrhosis

Abstract

Introduction: Hepatic hydrothorax (HH) is a difficult-to-control complication of cirrhosis. Chest tube (CT) drainage is an option for management of HH, but is associated with a high rate of secondary infection and other complications. Case Report: A 35-year-old male with hepatitis C cirrhosis was transferred to our hospital for management of HH. Prior to transfer, a pleurex catheter was placed because he required serial thoracenteses. At our hospital, a trial of aggressive diuresis was unsuccessful, so he underwent transjugular intrahepatic portosystemic shunt (TIPS). However, drainage from the catheter continued at 1-1.5 liters daily, and further diuresis was limited by hyponatremia. With a MELD score of 24 and refractory HH, liver transplant (OLT) was clearly indicated. However, shortly after TIPS, pleural fluid culture grew methicillin-resistant S. aureus. He was treated with antibiotics and his pleurex catheter was removed, but chest computed tomography showed multifocal pneumonia, persistent multiloculated effusion, and trapped lung. He was treated with tissue plasminogen activator infusion via new CTs, but his trapped lung did not resolve. Bacterial culture of further pleural fluid samples remained without growth, and he was discharged with a plan to complete a 6-week course of vancomycin with his CTs in place. Less than 2 weeks later, the patient was re-admitted with encephalopathy. Repeat diagnostic thoracentesis yielded a new culture growing E. coli. Consensus after extensive multidisciplinary discussion was that resolution of his infection and trapped lung was no longer realistic, and OLT impossible, without surgical intervention. Therefore, he underwent open thoracotomy and decortication. Persistently high post-operative CT output combined with hyponatremia made it very difficult to remove his 4 CTs, the final CT being removed on post-op day 56. He was discharged with a plan to complete an outpatient OLT evaluation. Unfortunately, he resumed using illicit drugs, precluding further consideration for OLT. He was later readmitted with renal failure, and died approximately 6 months after his initial presentation. However, his empyema was ultimately not what limited his survival. Discussion: There is little literature regarding the safety of surgical decortication of patients with cirrhosis, although 1 small case series reported a mortality of 50%. This case highlights the risk of managing HH with drainage catheters. Additionally, the case demonstrates that successful surgical decortication of empyema is possible in a decompensated cirrhotic, which may be the factor limiting OLT candidacy and long-term survival.