Pleuroperitoneal Shunt Research Articles

Pleuroperitoneal shunt for persistent pleural drainage after Fontan procedure

Persistent effusions of chylous fluid may prolong the hospitalization period of many patients who have had a Fontan procedure. Herein we report the case histories of two patients in whom use of a pleuroperitoneal shunt to control the effusion shortened the hospital stay by several weeks.

Ascites after pleuroperitoneal shunting

If conventional therapy fails in patients with intractable malignant pleural effusion, the pleuroperitoneal shunt is a valuable alternative. In a 59-year-old man with disabling malignant pleural effusion, massive ascites developed shortly after insertion of a pleuroperitoneal shunt. This shunt was replaced by a pleurovenous shunt. The ascites disappeared, and pleural effusion did not recur. The patient died 6 months later.

Pleuroperitoneal shunt for recurrent malignant pleural effusions.

The therapeutic options available for the management of malignant pleural effusions associated with a restricting malignant cortex remain unsatisfactory. The efficacy of pleuroperitoneal shunts was evaluated in 16 patients with recurrent malignant effusions. There were no operative deaths; one patient died on the third postoperative day as a result of lymphangitis carcinomatosa. The median hospital stay was five (range 3-21) days. Palliation was obtained in all but one of the other 15 patients. There was no appreciable reaccumulation of pleural fluid as judged by radiography. Two patients developed occlusion of the shunt. In one case this was due to blood clots in the pleural catheter and necessitated insertion of a new shunt. The other shunt was removed because of obstructing infected fibrin debris, and a rib resection was performed. There were eight deaths related to the underlying malignancy after a mean interval of 7.3 (range 1.5-23) months. The other six patients are still alive, with a mean survival of 11.0 (range 5-20) months, and have achieved good symptomatic relief. The insertion of a pleuroperitoneal shunt can offer effective palliation for patients with recurrent malignant pleural effusions.

Yellow Nails, Lymphedema and Pleural Effusion: Treatment of Chronic Pleural Effusion with Pleuroperitoneal Shunting

Pleural effusion secondary to lymphedema may be chronic, symptomatic and refractory to treatment, occasionally requiring invasive and painful procedures such as chemical pleurodesis, open pleural abrasion or pleurectomy to achieve control of the effusion and gain symptomatic relief. We report a patient with <i>yellow nail syndrome</i> and chronic pleural effusion successfully treated with pleuroperitoneal shunting.

Pleuroperitoneal Shunt for Pneumonectomy Cavity Malignant Effusion

Delayed mediastinal shift toward the remaining lung is an unusual cause of postpneumonectomy dyspnea. We report a patient who developed severe dyspnea when a malignant effusion occurred in the pneumonectomy cavity and caused a contralateral mediastinal shift. Repeated thoracentesis was needed until insertion of a pleuroperitoneal shunt effected palliation.

Pleuroperitoneal shunts in the management of persistent chylothorax

Between Jane 1981 and June 1988, we placed pleuroperitoneal shunts in 16 patients for the management of refractory chylothorax on the Pediatric Surgical Service, University of Virginia. The cause of the chylothorax was caval thrombosis from central venous catheters in 5 patients, idiopathic in 3, and mediastinal lymphangioma in 2, and in 6, it developed after a cardiac procedure. Chylothorax in each patient was unresponsive to thoracentesis, tube thoracostomy, and dietary manipulations. A Denver double-valved shunt system is currently employed and is implanted using general anesthesia. Manual pumping is required postoperatively for several months. Twelve (75%) of the 16 patients had excellent results with complete elimination of the chylothorax and resolution of symptoms. In 10 of these 12, the shunt has been removed. Four had an unsatisfactory result: 3 had inferior vena cava hypertension, and 3 were low-birth-weight premature infants. Four patients seen early in this series required revision of the position of the pleural catheter, with successful drainage in each instance. Pleuroperitoneal shunting is a safe, simple, and effective treatment of chylothorax in infants and children. In view of our success in treating chylothorax with these shunts, we recommend early shunting before the development of nutritional immunological depletion.

Pleuro-peritoneal shunting. Alternative therapy for pleural effusions.

Pleural effusions are resistant to standard therapy, which causes discomfort and can require prolonged hospitalization. As an alternative, pleuroperitoneal shunting for pleural effusions of various etiologies was evaluated. We implanted 36 shunts in 29 patients. Two patients had bilateral shunts and five had shunt revisions. The effusion was related to a malignancy in 22 patients, postoperative chylothorax in two patients, and other causes in five patients. Therapeutic thoracentesis had been attempted in 28 patients, and eight had had chest tube placement previously with attempted sclerosis. Seven patients had a trapped lung syndrome. There was no operative mortality. All patients were deemed ready for discharge from the hospital if they had recovered from the operation within 48 hours. Five patients had poor results, either because of a moribund status or their refusal or inability to pump the shunt. Of the remaining 24 patients, four had good results with temporary improvement, and excellent results were achieved in 20 patients (83.3%), who experienced symptomatic relief and stabilization or regression of pleural effusion until the time of their death. Patients with chylothorax experienced complete resolution. The 14 patients with malignant effusions had a median survival of 4 months, and there were no instances of peritoneal tumor seeding. In conclusion, pleuroperitoneal shunting is an alternative therapy for pleural effusions that requires a limited hospitalization only, is associated with minimal and short-term discomfort, achieves excellent results in properly selected patients, and is the only viable therapy when lung expansion cannot be achieved.

Chylothorax with chylous ascites, successfully controlled by pleuro-peritoneal and peritoneo-venous shunts

A 29-year-old male patient was referred to our hospital because of bilateral chylothorax. He was first treated with bilateral closed pleural drainage and intravenous hyperalimentation. He lost 2000-2500 cc of chyle every day. One month later, when the right pleural effusion had decreased in volume, a left pleuroperitoneal shunt was placed, which controlled the effusion on the left thereafter. As serous effusion accumulated in the right pleural space again, transthoracic supradiaphragmatic thoracic duct ligation was performed, but the chylous leak continued undiminished. Two months later, the right pleural effusion decreased spontaneously, and ascites appeared. A peritoneo-venous shunt was interposed to control the ascites without loss of fluid. It was appropriate to use a double-valved shunt tube to prevent occlusion. Chyle was returned to the vein, and the normal physiological route was restored. His nutritional state returned to normal. He was discharged on a low fat diet and is doing well.

Pleuroperitoneal shunting for malignant pleural effusions.

Traditional therapy for malignant pleural effusions includes thoracentesis or tube drainage with instillation of irritants to achieve pleurodesis. This can require a lengthy hospitalization, causes pain and discomfort, and has an appreciable failure rate. Because of these drawbacks, the authors used a shunting device to transfer fluid to the peritoneal cavity in 17 patients with malignant pleural effusions. Eleven patients had undergone previous therapeutic thoracenteses and three had chest tube placement with failed sclerosis. The shunt was a subcutaneous valved pump chamber with attached pleural and peritoneal catheters, which used manual compression to transfer fluid against the normal abdominal/pleural pressure gradient. Operative placement under local or general anesthesia was performed without complication. Five patients achieved minimal benefit, either because of moribund status or their inability to compress the pump effectively. In the other 12 patients, there was radiographic evidence of diminished or stabilized pleural effusion; respiratory symptoms were effectively palliated, and no further treatment for their effusion was required. Peritoneal dissemination of malignant cells has not been clinically detected. We feel that pleuroperitoneal shunting is a valid new method for treatment of malignant pleural effusions which can effectively palliate respiratory symptoms with low morbidity. Advantages include the absence of external tubing and the possibility for only a short hospitalization or even outpatient placement. Shunting is applicable for patients who are able to perform the requisite pumping and is particularly suitable for those with trapped lungs or who have failed attempted pleural sclerosis.

Pleuroperitoneal shunting for recalcitrant pleural effusions

From March 1, 1984, to Nov. 1, 1985, six patients underwent pleuroperitoneal shunting for either malignant (n = 5) or benign (n = 1) effusions intractable to the usual therapy. A modified double-valve Denver peritoneovenous shunt was inserted under local anesthesia in each case, and fluid from the right or left pleural space was shunted to the subhepatic space or pelvic area. No early complication was recognized in the perioperative period. Each shunt is working in the patients who are alive, and both functioned up to the time of death in the two who have died. Intraoperative pressures simultaneously recorded from both the chest and abdomen indicated that spontaneous flow would not occur without active pumping. All pleural effusions, including the solitary bilateral one, were alleviated by pumping the shunt 20 times four times a day. Two of the patients with cancer died after 1 and 2 months of unrelated events, with their symptomatic pleural effusions relieved. Two are alive at 20 and 10 months, respectively. The long-term follow-up revealed no erosions, shunt failures, infections, or symptomatic pleural effusions.

Malignant pleural effusions.

Pleural effusions are common in cancer patients, developing either from the malignant condition or from unrelated causes, such as congestive heart failure, pulmonary infarction, or infection. Diagnosis of malignant pleural effusion rests on demonstration of the presence of malignant cells in the pleural fluid or pleural biopsy specimen. Treatment is usually aimed at relief of symptoms rather than at the underlying malignancy. Specific therapeutic measures include thoracentesis, chest tube drainage, pleurodesis with chemicals or biologic agents, radiation and systemic chemotherapy, surgical pleurodesis, and pleuroperitoneal shunt. These should be supplemented by ancillary measures to maintain fluid and nutritional balance and prevent complications.

Pleuroperitoneal Shunt in Recurrent Pleural Effusions

Intractable recurrent pleural effusions remain a therapeutic problem. In most instances, instillation of a sclerosing agent into the pleural cavity does obviate the problem. However, in certain circumstances, the more drastic approach of performing a radical parietal pleurectomy must be used. The Denver peritoneovenous shunt was used in 3 patients to shunt the pleural fluids into the peritoneal cavity. In 2 patients, a complementary peritoneovenous shunt was also done. Control of intractable pleural effusion was achieved in all patients. The concept of the pleuroperitoneal shunt takes into consideration the ease of shunting the pleural fluid into the peritoneal cavity from where the fluid is readily reabsorbed by the large peritoneal surface. The shunt can be placed with the patient under local or general anesthesia.

Chylothorax: An assessment of current surgical management

The development of chylothorax is a serious and often life-threatening clinical entity. Optimal management of this problem has not been well defined to date. We reviewed our experience with chylothorax in patients of all ages during the past 10 years. Ages ranged from 2 days to 69 years. The etiologies were traumatic in 17 and congenital or idiopathic in three. Six patients (five infants) were treated nonoperatively with either repeated thoracenteses or chest tube drainage. Fourteen patients (11 infants) underwent operative treatment: transthoracic thoracic duct ligation (five patients), pleuroperitoneal shunting (seven), pleuroperitoneal shunting combined with reoperation on a patient with congenital heart disease (one), and reoperation alone on a patient with congenital heart disease (one). Duration of preoperative therapy ranged from 9 days to 2 months (average 3.3 weeks). Five of six (83.3%) patients treated nonoperatively died. Of the surgically treated group, only two of 14 (14.3%) died, and 11 of the 12 survivors had resolution of the chylothorax and immediate clinical improvement. Our experience suggests that both pediatric and adult patients respond poorly to nonoperative treatment of chylothorax and that this treatment has a high mortality rate. Post-traumatic and congenital chylothorax should be treated operatively after a limited trial (1 to 2 weeks) of nonoperative therapy. Pleuroperitoneal shunting may offer a reasonable and effective alternative to thoracotomy and thoracic duct ligation.

Pleuroperitoneal shunts in the management of neonatal chylothorax

Pleuroperitoneal shunts have been placed in five ventilator-dependent newborns with persistent chylothorax. The etiology of the chylothorax appeared to be secondary to superior vena caval obstruction in three patients and was idiopathic in the remaining two. Despite traditional therapies these infants were on a progressively deteriorating clinical course. Hakim-Cordis low-pressure ventricular-peritoneal shunt catheter systems were used in each infant. Ultrasonography was used to follow the regression of pleural effusions and to determine the need for shunt compression. Shunt patency was confirmed with radionuclide studies. Four of five infants had a complete resolution of their chylothorax and pulmonary insufficiency. Three of these infants were extubated within 28 days following the placement of the shunt. Nutritional and metabolic stability was rapidly achieved. The shunts were removed several weeks later without recurrence of the chylothorax. A fifth infant failed to improve after the placement of the pleuroperitoneal shunt and died of progressive pulmonary insufficiency. The placement of pleuroperitoneal shunts in infants with refractory chylothorax is safe, technically easy to perform, and is associated with few complications.