Various Treatment Modalities in Hepatic Hydrothorax: What Is Safe and Effective?

Abstract

PurposeHepatic hydrothorax is a complication of decompensated liver cirrhosis that is difficult and complex to manage. Data concerning the optimal treatment method, other than liver transplantation, are limited. This study aimed to compare the clinical features and outcomes of patients treated with various modalities, while focusing on surgical management and pigtail drainage.Materials and MethodsForty-one patients diagnosed with refractory hepatic hydrothorax between January 2013 and December 2017 were enrolled.ResultsThe mean Child-Turcotte-Pugh and model for end stage liver disease scores of the enrolled patients were 10.1 and 19.7, respectively. The patients underwent four modalities: serial thoracentesis (n=11, 26.8%), pigtail drainage (n=16, 39.0%), surgery (n=10, 24.4%), and liver transplantation (n=4, 9.8%); 12-month mortality rate/median survival duration was 18.2%/868 days, 87.5%/79 days, 70%/179 days, and 0%/601.5 days, respectively. Regarding the management of refractory hepatic hydrothorax, surgery group required less frequent needle puncture (23.5 times in pigtail group vs. 9.3 times in surgery group), had a lower occurrence of hepatorenal syndrome (50% vs. 30%), and had a non-inferior cumulative overall survival (402.1 days vs. 221.7 days) compared to pigtail group. On multivariate analysis for poor survival, body mass index <19 kg/m2, refractory hepatic hydrothorax not managed with liver transplantation, Child-Turcotte-Pugh score >10, and history of severe encephalopathy (grade >2) were associated with poor survival.ConclusionSerial thoracentesis may be recommended for management of hepatic hydrothorax and surgical management can be a useful option in patients with refractory hepatic hydrothorax, alternative to pigtail drainage.

Multidisciplinary Management of Hepatic Hydrothorax in 2020: An Evidence‐Based Review and Guidance

“…( 2 ) In another study of 41 patients with cirrhosis and HH undergoing serial thoracentesis (n = 11), pigtail drainage (n = 16), surgery (n = 10), or liver transplantation (n = 4), the 12‐month mortality rate was 18.2%, 87.5%, 70%, and 0%, respectively, for each modality. ( 86 ) One obvious limitation of this study is the small number of patients in each arm; however, the considerably lower mortality of patients in the transplant arm compared to the other groups is nonetheless striking and underscores the potentially curative role of transplant in this disease entity.…”

Preoperative Trapped Lung Is Associated With Increased Mortality After Orthotopic Liver Transplantation

“…The presence of indwelling catheters in the pleural space in this population of patients is associated with significant morbidity and generally low rates of pleurodesis. 1 –3,5,9,10,12,13 In addition, chronic and ongoing drainage can lead to malnutrition and decreased serum albumin. 11,13…”

“…1 –4 Hepatic hydrothorax occurs in up to 15% of patients with end-stage liver disease, 4 is most often right-sided and is usually characterized by transudative effusions. 1,3,5 –7 It commonly leads to minimal clinical symptoms, 1 –6 but in some it can cause significant pulmonary disease including respiratory failure. 1…”

“…1,8 More definitive pleural drainage, such as tube thoracostomy, video-assisted thoracoscopic surgery (VATS) decortication, or indwelling pleural catheters, have variable success and are associated with significant morbidity. 1 –3,5, 9 –13…”

Hepatic Hydrothorax: A Narrative Review

“…Importantly, several studies have also commented on the poor outcomes observed in patients with HH requiring intercostal chest drain insertion. Specifically, Yoon et al studied patients with refractory HH and found that the 12-month mortality of those undergoing thoracocentesis (11 patients) was 18.2%, but in those requiring pig tail drainage (16 patients), this increased to nearly 90% [47]. Further retrospective studies conducted by Orman and Lok (27 patients with HH) [48] and Liu et al (24 patients with HH) [49] reported 3-month mortality rates of approximately 40 and 27%, respectively, for those patients undergoing chest drain insertion.…”