Transjugular intrahepatic portosystemic shunts and liver transplantation in patients with refractory hepatic hydrothorax

Abstract

Hepatic hydrothorax is a relatively infrequent but potentially serious complication of cirrhosis resulting from the accumulation of ascitic fluid in the chest cavity. Medical management is initially directed at controlling ascites formation, but invasive therapeutic procedures may be required if symptoms persist. The aim of this study was to report on the long-term efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) placement to reduce portal hypertension in 12 consecutive subjects with refractory hepatic hydrothorax. Most subjects had evidence of advanced cirrhosis of varying causes (Child-Pugh class A, 1; B, 5; C, 6). Mean subject age was 54 years, and subjects were followed up for a mean of 173 days (range, 7-926 days). The portosystemic pressure gradient after TIPS was reduced to F12 mmHg in all cases. Periprocedural morbidity was noted in 2 subjects, and 30-day survival after TIPS placement was 75%. Overall, 58% of subjects experienced either a complete or partial response following TIPS placement. Subject response did not correlate with age, baseline creatinine clearance, or Child-Pugh score. Cumulative subject survival was 42%, and 4 of the 5 long-term survivors required eventual liver transplantation. Subject age G65 years was associated with early mortality after TIPS placement, but this trend was not statistically significant. All 4 subjects undergoing liver transplantation required perioperative pleural fluid drainage, but only 1 subject has experienced recurrent effusion. We conclude that TIPS may be a safe and effective temporizing treatment for carefully selected patients with refractory hepatic hydrothorax. However, patient survival is limited after TIPS and is primarily determined by availability of liver transplantation.

Outcomes of patients with chest tube insertion for hepatic hydrothorax

“…Clinical and radiographic improvement in hydrothorax has been documented in up to 68% of patients undergoing TIPS [8,[22][23][24]. Jeffries et al [9] reported one response lasting greater than 2 years. In Table 3 Reports of chest tubes placed for hepatic hydrothorax N Successful removal TIPS Complications Mortality addition, short-term mortality in the series in which therapeutic TIPS was performed is \30% [23,24].…”

“…Sodium restriction and diuresis are currently the mainstay of therapy [3,4,6,7]. In patients with refractory hydrothorax, recommended therapies include therapeutic thoracentesis, TIPS [8,9], and pleurodesis [10][11][12].…”

Transjugular intrahepatic portosystemic stent shunt for medically refractory hepatic hydrothorax: A systematic review and cumulative meta-analysis

“…TIPSS related HE was defined as new onset (i.e., never existed prior to TIPSS) or worsening (increased in frequency or severity of encephalopathy, compared to pre-TIPSS status). One study considered HE as TIPSS related if it occurred within 30 d of the procedure [24] ; and (2) Mortality After TIPSS. Death was evaluated as early (i.e., occurred within 45 d of the procedure) and overall (death irrespective of when the event occurred throughout the follow-up period).…”

“…The procedure is often used as a bridge to liver transplantation in patients with end-stage liver disease. Since RHH is an uncommon complication of cirrhosis, most of the studies on the effectiveness of TIPSS have been limited to small numbers of patients, primarily in the form of case reports [19][20][21][22] or case series [3,14,[23][24][25][26][27][28] . Findings from these studies have varied substantially.…”

Transjugular Intrahepatic Portosystemic Shunt

“…TIPS has been evaluated for refractory hepatic hydrothorax in numerous small noncontrolled trials 70,68,69,70,71,72,73 . On the whole, 198 patients underwent TIPS with a response rate (both complete and partial) ranging from 59-82%.…”