Massive Hydrothorax Research Articles

Recurrent Massive Hydrothorax in a Patient with Decompensated Liver Cirrhosis

Aim: to demonstrate the need for a detailed differential diagnosis and selection of therapy in a patient with decompensated liver cirrhosis of combined etiology (HCV infection and primary sclerosing cholangitis). Key points. The patient came to the clinic with complaints of shortness of breath with minimal physical activity, abdominal enlargement, swelling of the legs, yellowness of the skin, and severe weakness. The complaints arose two months after suffering from left-sided focal pneumonia. Laboratory tests revealed signs of systemic inflammation, liver failure, and acute kidney injury. According to the results of instrumental studies, massive hydrothorax was noted in the right pleural cavity. The patient underwent a series of thoracentesis, and a total of about four liters of non-inflammatory pleural fluid was evacuated. Differential diagnosis was based on the presence of dyspnea and respiratory failure. The patient received effective antiviral therapy with drugs using an interferon-free regimen. Subsequently, conservative therapy was carried out, against the background of which the symptoms regressed and the patient’s condition improved. Conclusions. Hepatopleural syndrome is a serious complication in patients with decompensated liver cirrhosis, although it does not always appear secondary to massive ascites. To resolve hepatic hydrothorax, it is necessary to carry out diuretic therapy, replacement transfusion therapy with albumin preparations, and if there is a large amount of fluid in the pleural cavities, therapeutic and diagnostic thoracentesis is recommended.

Open Thoracic Drainage Followed by Proximal Splenic Artery Embolization for Massive Hydrothorax Before Living Donor Liver Transplantation

Hepatic hydrothorax is associated with postoperative infectious complications and mortality in patients undergoing living-donor liver transplantation (LDLT). Thus, preoperative management of massive hepatic hydrothorax is essential for improving the outcomes of LDLT. This study aimed to demonstrate our successful cases and strategy for treating massive hepatic hydrothorax. Our strategy for hepatic hydrothorax includes (a) mini-thoracotomy under general anesthesia for the drainage of hydrothorax, (b) preoperative hepatic inflow modulation by proximal splenic arterial embolization, and (c) nutritional and physical intervention to improve the general condition. Two patients with massive hepatic hydrothorax were treated with our strategy. Both patients had end-stage liver disease secondary to primary biliary cholangitis. Their performance status deteriorated due to massive hydrothorax. After the intervention, their performance status significantly improved. After that, LDLTs with right lobe grafts were performed. The duration of the operation was 440 and 343 minutes, with an intraoperative blood loss of 1,700 and 1,600 g, respectively. Their postoperative courses were uneventful, and they were discharged on postoperative days 16 and 14. Our pre-LDLT multimodal management strategy for massive hepatic hydrothorax, including preoperative open thoracic drainage, pre-LDLT portal inflow modulation, and nutritional intervention, improved the preoperative condition of patients undergoing LDLT, resulting in successful outcomes.

CONSIDERING PLEURAL FLUID GLUCOSE LEVELS COULD PREVENT UNNECESSARY PROCEDURES

CONSIDERING PLEURAL FLUID GLUCOSE LEVELS COULD PREVENT UNNECESSARY PROCEDURES

Bevacizumab-induced esophageal pleural fistula during maintenance therapy without radiation in lung cancer

BackgroundEsophageal pleural fistula (EPF) is a rare but fatal complication associated with bevacizumab use; however, cases reports of EPF caused by bevacizumab have not been previously published.Case presentationA 66-year-old male patient diagnosed with stage IV lung adenocarcinoma on April 24, 2020 received 6 cycles of platinum-containing dual chemotherapy combined with bevacizumab followed by three cycles of bevacizumab monotherapy. Five days before admission, he experienced chest tightness, dyspnea, and right chest pain. Bed-side X-ray examination revealed a massive right hydrothorax, and food was found in the extracted pleural effusion. EPF was further confirmed by upper gastrointestinal radiography after oral administration of iohexol. The patient underwent jejunostomy as the distal esophagus could not be identified on gastroscopy, and eventually died of septic shock on January 16, 2021.ConclusionsIt is necessary to pay attention to EPF during bevacizumab use in patients with or without risk factors.

Early outcomes of implanting larger-sized grafts in deceased donor liver transplantation.

The outcomes of large-sized graft mismatch in deceased donor liver transplantation (LT) have been rarely studied. The aim of this study was to determine whether a large-sized graft for recipient influenced the post-transplant outcomes. A total of 273 patients undergoing LT were enrolled and divided into a large and a normal-sized graft group by graft weight to recipient weight (GWRW) >2.5% (n = 76) or GWRW ≤2.5% (n = 197). Post-operative complications and outcomes were retrospectively analysed. The two groups were comparable in demographic characteristics. The rate of complications was significantly higher in the large-sized graft group including early allograft dysfunction (36.8% versus 17.8%, P = 0.001), hepatic necrosis (26.3% versus 13.7%, P = 0.01) and massive hydrothorax (25% versus 14.7%, P = 0.04). The large-sized graft group suffered higher early mortality compared with the normal-sized graft group (30 days: 14.5% versus 5.6%, P = 0.02, 90 days: 21.1% versus 9.6%, P = 0.01). The primary causes of early death were multiple organ failure (10.5% versus 2%, P = 0.002) and sepsis (2.6% versus 1.5%, P = 0.54). Four parameters including donor alanine transaminase, GWRW, estimated blood loss and model for end-stage liver disease score were significant on multivariate analysis, and indicated significant risk factors for the early mortality of recipients. In deceased donor LT, GWRW >2.5% is associated with increased liver injury, risk of early mortality and other adverse outcomes. Thus, donor livers should be allocated to recipients with GWRW ≤2.5%.

Massive hydrothorax during supracostal approach for percutaneous nephrolithotomy: A case report

Massive hydrothorax during supracostal approach for percutaneous nephrolithotomy: A case report - IJCA- Print ISSN No: - 2394-4781 Online ISSN No:- 2394-4994 Article DOI No:- 10.18231/j.ijca.2019.056, Indian Journal of Clinical Anaesthesia-Indian J Clin Anaesth

Bochdalek hernia as unusual cause of massive hydrothorax in a 50-year-old man

A 50-year-old man was urgently admitted to our department with acute dyspnoea and upper abdominal pain for 4 h. He had no history of any previous thoracoabdominal trauma or surgery....

Ovarian thecoma with massive pleural effusion in postmenopausal women: A case report.

Previous clinical reports of benign ovarian thecoma, associated with hydrothorax, are rare. The present study presents the case of a 58-year-old women exhibiting right massive pleural effusions and elevated cancer antigen (CA)125, and a pelvic ultrasound revealed a hypoechoic mass. An exploratory laparotomy was subsequently performed. During the surgery, the left ovary measured 20×15×15 cm and had a smooth surface with no excrescences or papillary projections. The patient underwent right salpingo-oophorectomy. Pathological diagnosis was determined as benign ovarian thecoma. The chest radiograph revealed no pleural effusion 6 days following the surgery. The present case demonstrated a benign ovarian thecoma, associated with massive hydrothorax and elevated CA125, which mimicked an ovarian malignancy.

Diagnosis of Peritoneal-pleural Communication by Peritoneography With 99mTc-sulfur Colloid in a 3-year-old Girl With Congenital Nephrotic Syndrome of the Finnish Type

Around 5% of patients receiving renal replacement therapy in Spain are on peritoneal dialysis. Anatomical integrity of the peritoneum is essential since increased hydrostatic pressure due to peritoneal accumulation of dialysis fluid predisposes to abdominal or pelvic hernias or chest leakage via the embryonic pneumatoenteric recess.1 We report the case of a 3-year-old girl with a history of Finnish-type congenital nephrotic syndrome, receiving postnephrectomy peritoneal dialysis since the age of 2. Fourteen months after starting peritoneal dialysis, she was admitted to our hospital due to severe dyspnea, with massive right hydrothorax on chest X-ray. To rule out pleuroperitoneal leak, a peritoneal

Pleuroperitoneal Leak Complicating Continuous Ambulatory Peritoneal Dialysis: A Case Report

Acute massive pleuroperitoneal leak-related hydrothorax is a rare, but life-threatening complication of continuous ambulatory peritoneal dialysis (CAPD). Hydrothorax develops right after the initiation of the CAPD or within a few days post-treatment. The late development of hydrothorax in patients treated with CAPD is quite rare. The interpretation of pleuroperitoneal leak-related hydrothorax as a volume overload and subsequent application of hypertonic peritoneal exchange worsen the clinical course and can lead to mortality. We here present the data from a patient who developed acute bilateral hydrothorax at the 16th month of CAPD treatment. J Med Cases. 2015;6(3):101-104 doi: http://dx.doi.org/10.14740/jmc2055w

Systemic Inflammatory Response Syndrome after Massive Extravasation into the Pleural Space of Contrast Medium during Supracostal Percutaneous Nephrolithotomy

Percutaneous nephrolithotomy is indicated for renal stones larger than 2 cm and upper ureteral stones not amenable to retrograde management. Supracostal access may enable better access to the entire collecting system and even be preferential in some cases, although having a higher risk of pleural or lung injury, resulting in hydrothorax or pneumothorax. We report a case of a patient who developed a massive hydrothorax during surgery. In this particular case the hydrothorax was mainly composed of iodixanol (visipaque®) isosmolar nonionic contrast media. We assume that this was the reason why a subsequent systemic inflammatory response syndrome (SIRS) was observed. There is no reference in the literature to a prolonged SIRS associated to a hydrothorax mainly composed of nonionic contrast media following a supracostal percutaneous nephrolitotomy.

Hydrothorax with alveolar-pleural fistula mimicking re-expansion pulmonary edema during liver transplantation: a case report.

We present a case of an alveolar-pleural fistula with hepatic hydrothorax in a patient undergoing orthotropic liver transplantation, which was detected by drainage of transudate through an endotracheal tube during operation. A standard endotracheal tube was changed to a double-lumen tube to provide differential lung ventilation. The patient was diagnosed with an alveolar-pleural fistula by direct vision of an air leak during positive-pressure ventilation through a diaphragmatic incision. There was still a concern about worsening his ventilation due to persistent aspiration of pleural effusion towards the ipsilateral lung during the remaining operation period. Surgeon repaired the defect on the exposed lung surface via diaphragmatic opening. Anesthesiologists should consider an alveolar-pleural fistula as a possible differential diagnosis with re-expansion pulmonary edema when transudate emanating from the endotracheal tube is obtained in patients with massive hydrothorax.

Massive hydrothorax following supracostal percutaneous nephrolithotomy.

Sir, Percutaneous nephrolithotomy (PCNL) is used commonly for the treatment of large renal and upper ureteric calculi. We report a 30-year-old female who developed a massive hydrothorax diagnosed postoperatively following PCNL for left renal calculus. Standard anaesthesia with controlled ventilation was administered. PCNL was performed in the prone position with a left supracostal (between 11th and 12th rib) approach. Multiple attempts were required to reach the superior calyx. Intraoperatively the patient remained haemodynamically stable. The procedure lasted 120 min; blood loss was ≈ 400 mL. Following extubation the patient was comfortable and haemodynamically stable with oxygen saturation (SpO2) 98% on 40% oxygen. After 30 min, the patient complained of breathing difficulty. She was tachypnoeic, with SpO284% (O2 5 L/min). Air entry was absent in left hemithorax, with dullness on percussion. Chest radiograph revealed left hydrothorax [Figure 1a]. An intercostal chest drain with underwater seal was inserted in the left 5th intercostal space. Haemorrhagic fluid (850 mL) was drained. Patient experienced difficulty in breathing following rapid pleural decompression. Continuous positive airway pressure was given by face mask with 100% oxygen for 20 min. Thereafter, she was asymptomatic, SpO2 was 100% and arterial blood gas analysis was normal. Repeat chest radiograph 24 h later showed lung expansion [Figure 1b]. The drain was removed on the 3rd postoperative day. The patient was discharged on the 6th postoperative day.Figure 1: Postoperative chest radiograph showing (a) opacity of left hemithorax and (b) re-expansion of the lung at 24 hAnaesthetic challenges during PCNL include the potential for fluid absorption, dilutional anaemia, hypothermia, blood loss, injury to adjacent organs and pleural space violation.[12] The renal calyceal system can be accessed via a subcostal or supracostal route. The supracostal access (above the 12th or 11th rib) is commonly used as it provides direct access to the upper, middle and lower calyx and the upper ureter.[2] However, this approach can potentially damage the lung and pleura resulting in hydrothorax, pneumothorax or hydropneumothorax.[1] Pleural injury can be avoided by supracostal puncture over the most lateral portion of the 12th rib as this portion of the diaphragm is not covered by a pleural reflection.[3] The intercostal puncture is made in the lower half of the intercostal space to avoid injury to intercostal vessels.[4] The supracostal approach requires coordination with the anaesthesiologist to control ventilation. The needle is passed through the retro-peritoneum and diaphragm during complete exhalation to prevent injury to the lung. The passage of the needle through the renal parenchyma to the collecting system is done during deep inspiration (the kidney gets displaced downwards). An Amplatz sheath is used to maintain low-pressure irrigation that can reduce the risk of pleural effusion and extravasation.[4] Reasons for development of hydrothorax are three-fold: (a) Inadvertent entry into the pleura; (b) inadequate tamponade of the nephrostomy tract combined with inadequate drainage of the kidney after the puncture; and (c) failure to seal the tract with a working sheath during stone removal.[5] Hydrothorax and pneumothorax can be difficult to identify during PCNL. Intraoperatively, a decrease in SpO2 and a significant increase of airway pressure is suggestive of hydrothorax. The diagnosis can be confirmed with a chest radiograph; with the patient in the prone position, fluid can be seen tracking along the lateral borders of the chest cavity and compressing the ipsilateral lung.[3] In the immediate postoperative period, pleural injury presents clinically with poor SpO2, dyspnoea and tachypnoea.[4] A postoperative chest X-ray is mandatory. The treatment of hydrothorax depends on patient symptoms and its extent.[4] Patients with no or mild symptoms and minimal effusion are managed conservatively; those with significant symptoms and large pleural effusion need intercostal drainage. Re-expansion pulmonary oedema, an uncommon complication following drainage of a pneumothorax or pleural effusion, presents clinically as cough, chest discomfort and hypoxemia. Risk factors include young age, long duration of lung collapse and rapid re-expansion. Treatment is largely supportive (oxygen supplementation, noninvasive and invasive ventilation). A high index of suspicion should be maintained when PCNL is performed with a prolonged operating time, multiple tracts and supracostal access. The access puncture should be performed in complete lung deflation and ventilator stand-still in coordination with the anaesthesiologist to minimise the risk of pleural injury. A chest X-ray should be performed promptly in symptomatic postoperative patients to exclude intrathoracic injury. Hydrothorax, haemothorax and/or pneumothorax sustained during PCNL may necessitate chest tube placement.

Ovarian Hyperstimulation Syndrome (OHSS) Presented as Massive Hydrothorax

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complication of controlled ovarian stimulation. Although considered uncommon, the severe form is potentially fatal. Patient can present with varied clinical presentation like pain abdomen, abdominal distension or tachypnea. Diagnosis is made by careful history, examination and investigation. Treatment is conservative and supportive care. Here, we have presented a case of severe OHSS which was missed initially, as the doctor who had first seen probably was not aware of this disease.

Massive pleural effusion in ovarian tumor patient during laparoscopic surgery.

Massive pleural effusion in ovarian tumor patient during laparoscopic surgery.

Use of Prothrombin Complex Concentrate in Patients during Heart Transplantation after Implantation of a Left Ventricular Mechanical Support System

Heart transplantation in patients after implantation of mechanical cardiac support devices entails an extremely high risk for perioperative bleeding. Recombinant activated coagulation factor VII is presently used to reduce the volume of bleeding in this patient group. There are parallel data on its administration-induced thromboembolic events in the literature. This paper describes a case of using a prothrombin complex concentrate in a patient during explantation of a left ventricular bypass system and subsequent orthotopic heart transplantation in the presence of significant hypocoagulation. At the end of a surgery, 1200 IU of the agent was used at a remaining bleeding rate of more than 1000 ml/hour. Within the first 24 hours after surgery, the rate of discharge drainage was less than 100 ml/hour. A control plain chest X-ray study revealed massive left-sided hydrothorax on day 2 postsurgery. The left pleural cavity was revised under thoracoscopic guidance and 1000 ml of blood clots were evacuated. Although the administration of prothrombin complex concentrate did not guard against re-intervention, its use seems a promising strategy in life-threatening bleedings in patients after explantation of mechanical cardiac support devices. Further multicenter investigations are required to determine the efficacy and safety of prothrom-bin complex concentration in cardiac surgery. Key words: Recombinant activated coagulation factor VII, prothrombin complex concentration, mechanical cardiac support device, orthotopic heart transplantation.

Pseudo-Meigs' Syndrome: Large Uterine Leiomyoma Associated with Elevated CA 125, Massive Right Hydrothorax and Edematous Tissues Mimicking Ovarian Carcinoma

Pseudo-Meigs' Syndrome: Large Uterine Leiomyoma Associated with Elevated CA 125, Massive Right Hydrothorax and Edematous Tissues Mimicking Ovarian Carcinoma

Congenital primary hydrothorax: effect of thoracoamniotic shunting on neonatal clinical outcome

Background. Spontaneous regression in the foetal period has been described for congenital hydrothorax. Hydrothorax may become larger and bilateral with hydrops and pulmonary hypoplasia. Prenatal thoracentesis and thoracoamniotic shunting of massive hydrothorax are indicated to decrease perinatal morbidity. In the neonatal period, persistent hydrothorax may require intensive care.Objective. To investigate neonatal outcome after thoracoamniotic shunting for congenital primary hydrothorax with hydrops/ polydramnios.Methods. Retrospective study on the postnatal management of a cohort of 28 congenital primary hydrothorax cases after thoracoamniotic shunting (January 2000–August 2005).Results. Congenital hydrotorax without major structural anomalies complicated by polidramnios and/or hydrops <34 weeks' gestation were the criteria accepted for thoracoamniotic shunting. There were neither pregnancy terminations nor utero deaths. Although 64% of cases were complicated by severe neonatal respiratory insufficiency, neonatal mortality rate was low (21.4%) if compared with literature. Univariate analysis identified ‘birth at gestational age (GA) <35 weeks’ and ‘time between prenatal shunting and birth’ as predictive factors for needing of ventilation. Multivariate analysis identified ‘birth at GA <35 weeks’ as the only independent predictor for needing ventilation. (OR = 0.08, CI 95% = 0.01–0.96, p = 0.046). No risk factors for death or adverse neurological outcomes were reported.Conclusions. Congenital hydrothorax although corrected by thoracoamniotic shunting is complicated by severe respiratory distress. The neonatal outcome may be improved limiting degree of prematurity; the presence of thoracoamniotic shunt is not per se an indication of premature birth, at least until GA >35 weeks and adequate pulmonary maturity is reached.

Massive hydrothorax following subclavian vein catheterization

Since the introduction of central venous catheterization for monitoring of the venous pressure, fluid infusion and hyperalimentation, the literature has been full of serious life-threatening complications. Of these complications is the false positioning of the central venous catheter and subsequent development of pleural effusion. In this report we are describing a case of iatrogenic massive pleural effusion following subclavian vein catheterization necessitating intercostal tube drainage and mechanical ventilation. The case highlights the importance of ensuring adequate positioning of the catheter after insertion through aspiration of venous blood, immediate post insertion X-ray and the utilization of ultrasound guidance in cases with expected difficult catheterization.

Unilateral massive hydrothorax in a gynecologic patient with pseudo-Meigs' syndrome -A case report-

Pseudo-Meigs' syndrome is characterized by the presence of a benign ovarian tumor associated with ascites and a right-sided hydrothorax. The major problem associated with pseudo-Meigs' syndrome is the respiratory distress caused by a giant mass in the peritoneal space, massive ascites and pleural effusion. Even if there are no respiratory problems prior to surgery, potential respiratory dysfunction can occur during the peri-anesthetic period, leading to hypoxia, hypercapnea and respiratory acidosis. We report a case of hypoxia during recovery from anesthesia in a gynecological patient with pseudo-Meigs' syndrome.