Hypertonic glucose pleurodesis and surgical diaphragmatic repair for tension hydrothorax complicating continuous ambulatory peritoneal dialysis

Abstract

We herein describe a case of tension hydrothorax that occurred on continuous ambulatory peritoneal dialysis (CAPD), highlighting the problems of diagnosis and a novel management. A 38-year-old male with end-stage renal disease (ESRD) due to diabetes mellitus developed dyspnea and poor drainage after 13 months of CAPD. Chest X-ray revealed massive right-sided hydrothorax and mediastinal shift. He underwent emergency thoracentesis and pleural fluid showed a high level of glucose. Pleuroperitoneal communication was strongly suspected, although the methylene blue test was negative. We temporarily performed hemodialysis. Two weeks later, PD was resumed but failed with recurrent right-side hydrothorax in 4 months. The pleuroperitoneal leakage was definitively confirmed by video-assisted thoracoscopic surgery (VATS). Diaphragmatic repair and pleurodesis with hypertonic glucose were performed. There was no recurrence of hydrothorax after treatment.

Effect of intrapleural injection of erythromycin on congenital refractory chylothorax in the newborn

“…In addition, there are also many pleural fixatives, such as talcum powder and hypertonic glucose. Talcum powder can increase the risk of pulmonary mesenchymoma [13], while hypertonic glucose can increase the difficulty of pleural effusion extraction [14]. Studies have also found that anhydrous alcohol injection can cause cell dehydration and solidification and cystic wall adhesion [15].…”

Diaphragmatic fenestrations seen after peritoneal dialysis catheter placement: A rare cause of hydrothorax

“…Video-assisted repair has emerged as a popular form of repair. 15–18 Mechanical and chemical pleurodesis have been shown to have efficacy as well. 19 Thus, with the efficacy of repair, hydrothorax should not detour patients or physicians from pursuing PD.…”

Mechanical Complications of Peritoneal Dialysis

“…These methods can confirm the presence of fluid in the pleural space, but do not allow for appreciation of the underlying etiology of a diaphragmatic defect, which can lead to an alternate diagnosis [71]. Additionally, the presence of increased glucose levels in the pleural fluid is suggestive of a pleuro-peritoneal communication, although this does not manifest in all patients and should not be relied upon as the sole means of diagnosis [59,70,72]. Instead, there is increasing use of peritoneal scintigraphy [68,69,[73][74][75][76], which allows not only for accurate diagnosis of fluid overload and transudative pleural effusion but also allows for the identification and localization of diaphragmatic defects without thoracoscopic intervention.…”

“…A long term study found that pleurodesis effectively reduces the risk of hydrothorax for up to 50 months after management [77]. In cases where a large defect is identified, video-assisted thoracoscopic repair [70,78,79] or less commonly, thoracotomy and repair under direct vision are performed [80]. Additionally, case studies show success at closing diaphragmatic defects with automatic endoscopic staplers [81] or endoscopic suturing devices [82] combined with overlay non-absorbable mesh [79] and fibrin glue [81].…”

“…Many of the diagnostic tools used to detect leaks elsewhere in the body are useful in diagnosing PD-associated hydrothorax. Common methods of diagnosis are chest CT [68], X-ray imaging [70], or ultrasonography [68]. These methods can confirm the presence of fluid in the pleural space, but do not allow for appreciation of the underlying etiology of a diaphragmatic defect, which can lead to an alternate diagnosis [71].…”