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Osman KT, Naritsin A, Amuchi B, Qamar AA. Liver transplantation for refractory hepatic hydrothorax is associated with a greater survival benefit compared to other complications of cirrhosis. Liver Transpl 2024; 30:142-150. [PMID: 37450656 DOI: 10.1097/lvt.0000000000000218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 06/28/2023] [Indexed: 07/18/2023]
Abstract
Hepatic hydrothorax (HH) is a significant complication of cirrhosis associated with increased mortality. Liver transplantation (LT) remains the best treatment modality. We aim to assess predictors of mortality and the survival benefit of LT in patients with HH. A prospectively maintained cohort of adult patients with cirrhosis, being evaluated for LT at our institution, was retrospectively reviewed from 2015 to 2020. The primary outcome was death or LT. Cox proportional hazard regression identified associations between covariates and death. We calculated the years saved due to LT by comparing patients who were on the waiting list with patients who received an LT. This was done by calculating the area under the Kaplan-Meier curve. Censoring occurred at the time of the last follow-up or death. Patients with refractory HH had the lowest median survival of only 0.26 years. Within the HH group, having a refractory HH group was significantly associated with an increased risk of mortality (HR 1.73; 95% CI 1.06-2.81; p -value 0.03). Refractory HH was also significantly associated with mortality when evaluated in the entire cohort and after adjusting for other covariates (HR 1.48, 95% CI 1.03-2.11; p -value 0.03). Patients with refractory HH had the highest 1-year survival benefit with LT (0.48 y), followed by patients with non-refractory HH (0.28 y), then patients with other complications of cirrhosis (0.19 y). In this large study evaluating the prognostic impact of HH on patients with cirrhosis, refractory HH was an independent predictor of mortality. LT provides an additional survival benefit to patients with HH compared with those without HH.
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Affiliation(s)
- Karim T Osman
- Division of Gastroenterology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Anastasia Naritsin
- Department of Internal Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Brenda Amuchi
- Department of Internal Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Amir A Qamar
- Division of Gastroenterology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
- Division of Transplant and Hepatobiliary Diseases, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
- Tufts University School of Medicine, Boston, Massachusetts, USA
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2
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Bellamy CO, Burt AD. Liver in Systemic Disease. MACSWEEN'S PATHOLOGY OF THE LIVER 2024:1039-1095. [DOI: 10.1016/b978-0-7020-8228-3.00015-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
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Cadranel JFD, Ollivier-Hourmand I, Cadranel J, Thevenot T, Zougmore H, Nguyen-Khac E, Bureau C, Allaire M, Nousbaum JB, Loustaud-Ratti V, Causse X, Sogni P, Hanslik B, Bourliere M, Peron JM, Ganne-Carrie N, Dao T, Thabut D, Maitre B, Debzi N, Smadhi R, Sombie R, Kpossou R, Nouel O, Bissonnette J, Ruiz I, Medmoun M, Dastis SN, Deltenre P, Artru F, Raherison C, Elkrief L, Lemagoarou T. International survey among hepatologists and pulmonologists on the hepatic hydrothorax: plea for recommendations. BMC Gastroenterol 2023; 23:305. [PMID: 37697230 PMCID: PMC10496231 DOI: 10.1186/s12876-023-02931-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 08/23/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND The Hepatic hydrothorax is a pleural effusion related to portal hypertension; its diagnosis and therapeutic management may be difficult. The aims of this article are which follows: To gather the practices of hepatogastroenterologists or pulmonologists practitioners regarding the diagnosis and management of the hepatic hydrothorax. METHODS Practitioners from 13 French- speaking countries were invited to answer an online questionnaire on the hepatic hydrothorax diagnosis and its management. RESULTS Five hundred twenty-eight practitioners (80% from France) responded to this survey. 75% were hepatogastroenterologists, 20% pulmonologists and the remaining 5% belonged to other specialities. The Hepatic hydrothorax can be located on the left lung for 64% of the responders (66% hepatogastroenterologists vs 57% pulmonologists; p = 0.25); The Hepatic hydrothorax can exist in the absence of clinical ascites for 91% of the responders (93% hepatogastroenterologists vs 88% pulmonologists; p = 0.27). An Ultrasound pleural scanning was systematically performed before a puncture for 43% of the responders (36% hepatogastroenterologists vs 70% pulmonologists; p < 0.001). A chest X-ray was performed before a puncture for 73% of the respondeurs (79% hepatogastroenterologists vs 54% pulmonologists; p < 0.001). In case of a spontaneous bacterial empyema, an albumin infusion was used by 73% hepatogastroenterologists and 20% pulmonologists (p < 0.001). A drain was used by 37% of the responders (37% hepatogastroenterologists vs 31% pulmonologists; p = 0.26).An Indwelling pleural catheter was used by 50% pulmonologists and 22% hepatogastroenterologists (p < 0.01). TIPS was recommended by 78% of the responders (85% hepatogastroenterologists vs 52% pulmonologists; p < 0.001) and a liver transplantation, by 76% of the responders (86% hepatogastroenterologists vs 44% pulmonologists; p < 0.001). CONCLUSIONS The results of this large study provide important data on practices of French speaking hepatogastroenterologists and pulmonologists; it appears that recommendations are warranted.
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Affiliation(s)
| | | | | | | | - Honoré Zougmore
- Hepatogastroenterology and Nutrition Department GHPSO Boulevard Laennec, 60100, Creil, France
| | | | | | - Manon Allaire
- Hepatogastroenterology Department, La Pitié Salpétrière, Paris, France
| | | | | | | | | | | | - Marc Bourliere
- Hepatogastroenterology department, Saint-Joseph, Marseille, France
| | | | | | - Thong Dao
- Hepatogastroenterology department, CHU Caen, Caen, France
| | - Dominique Thabut
- Hepatogastroenterology Department, La Pitié Salpétrière, Paris, France
| | | | - Nabil Debzi
- Hepatology Department CHU Mustapha, Alger, Algérie, Algeria
| | - Ryad Smadhi
- Hepatogastroenterology and Nutrition Department GHPSO Boulevard Laennec, 60100, Creil, France
- Hepatology Department CHU Mustapha, Alger, Algérie, Algeria
| | - Roger Sombie
- Gastroenterology Department, CHU Yalgado Ouedraogo Ouagadougou, Ouagadougou, Burkina Faso
| | - Raimi Kpossou
- Hepatogastroenterology Deparment, National Hospital and University Center Hubert Koutoukou Maga, Cotonou, Benin
| | - Olivier Nouel
- Hepatogastroenterology Department, St Brieuc, France
| | - Julien Bissonnette
- Department of Hepatology and Liver Transplantation, University of Montreal Hospital, Montreal, Canada
| | - Isaac Ruiz
- Department of Hepatology and Liver Transplantation, University of Montreal Hospital, Montreal, Canada
| | - Mourad Medmoun
- Hepatogastroenterology and Nutrition Department GHPSO Boulevard Laennec, 60100, Creil, France
| | | | | | - Florent Artru
- Hepatogastroenterology Department, Lausanne, Suisse, Switzerland
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Singh V, De A, Mehtani R, Angeli P, Maiwall R, Satapathy S, Singal AK, Saraya A, Sharma BC, Eapen CE, Rao PN, Shukla A, Shalimar, Choudhary NS, Alcantara-Payawal D, Arora V, Aithal G, Kulkarni A, Roy A, Shrestha A, Mamun Al Mahtab, Niriella MA, Siam TS, Zhang CQ, Huei LG, Yu ML, Roberts SK, Peng CY, Chen T, George J, Wong V, Yilmaz Y, Treeprasertsuk S, Kurniawan J, Kim SU, Younossi ZM, Sarin SK. Asia-Pacific association for study of liver guidelines on management of ascites in liver disease. Hepatol Int 2023; 17:792-826. [PMID: 37237088 DOI: 10.1007/s12072-023-10536-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 04/08/2023] [Indexed: 05/28/2023]
Affiliation(s)
- Virendra Singh
- Punjab Institute of Liver and Biliary Sciences, Mohali, Punjab, India.
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Arka De
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rohit Mehtani
- Department of Hepatology, Amrita Institute of Medical Sciences and Research, Faridabad, India
| | - Paolo Angeli
- Department of Internal Medicine and Hepatology, University of Padova, Padua, Italy
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Sanjaya Satapathy
- Division of Hepatology, Sandra Atlas Bass Center for Liver Diseases and Transplantation, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, NY, USA
| | - Ashwini K Singal
- University of South Dakota Sanford School of Medicine, Sioux Falls, USA
| | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - B C Sharma
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, Delhi, India
| | - C E Eapen
- Department of Hepatology, Christian Medical College, Vellore, India
| | - P N Rao
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | - Akash Shukla
- Department of Gastroenterology, Lokmanya Tilak Municipal General Hospital and Lokmanya Tilak Municipal Medical College, Sion, Mumbai, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | | | | | - Vinod Arora
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Guru Aithal
- Biomedical Research Unit, NIHR Nottingham Digestive Diseases, Nottingham, UK
| | - Anand Kulkarni
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | - Akash Roy
- Institute of Gastrosciences and Liver Transplantation, Apollo Multispeciality Hospitals, Kolkata, India
| | - Ananta Shrestha
- Department of Hepatology, The Liver Clinic, Liver Foundation, Kathmandu, Nepal
| | - Mamun Al Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Madunil A Niriella
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Tan Soek Siam
- Department of Hepatology, Hospital Selayang, Selangor Darul Ehsan, Malaysia
| | - Chun-Qing Zhang
- Department of Gastroenterology, Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Lee Guan Huei
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Ming-Lung Yu
- School of Medicine, College of Medicine and Center of Excellence for Metabolic Associated Fatty Liver Disease, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | | | - Cheng-Yuan Peng
- Centre for Digestive Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Tao Chen
- Department of Infectious Diseases, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jacob George
- University of Sydney School of Medicine, Sydney, Australia
| | - Vincent Wong
- Mok Hing Yiu Professor of Medicine, Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
| | - Yusuf Yilmaz
- Liver Research Unit, Institute of Gastroenterology, Marmara University, Istanbul, Turkey
- Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
| | | | - Juferdy Kurniawan
- Hepatobiliary Division, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital Jakarta, Jakarta, Indonesia
| | - Seung Up Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | | | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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5
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Osman KT, Cappuccio JM, Batarseh CI, Qamar AA. Hepatic hydrothorax is not associated with increased complications or poor survival after liver transplantation. Expert Rev Gastroenterol Hepatol 2023; 17:199-204. [PMID: 36620933 DOI: 10.1080/17474124.2023.2166929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Hepatic hydrothorax (HH) is associated with a poor prognosis. Liver transplant (LT) is the best treatment modality. We aim to assess post-LT morbidity and mortality in patients with cirrhosis and HH. RESEARCH DESIGN AND METHODS Adult patients with cirrhosis, who underwent LT at our institution from 2015 to 2020, were retrospectively reviewed. Baseline data was obtained at the time of LT. Patients were followed from baseline until the last follow-up or death. Censoring occurred at the time of the last follow-up or death, whichever occurred earlier. Cumulative incidence of outcomes was determined by the Kaplan-Meier method. Short-term post-operative complications were compared between both groups as well. RESULTS 428 patients had a LT, of which 72 (16.8%) had HH. Most of the baseline characteristics were similar between patients with and without HH; however, patients in the HH group had a higher proportion of pre-operative history of ascites and hepatic encephalopathy. Pre-operative HH was not significantly associated with post-LT mortality (Hazard ratio 1.12, 95% confidence interval 0.54-2.32; P-value 0.76). Patients had similar short-term post-operative complications between both groups. CONCLUSIONS LT is an excellent therapeutic option for patients with cirrhosis and HH, with excellent long-term survival without increased morbidity.
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Affiliation(s)
- Karim T Osman
- Department of Internal Medicine, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Joseph M Cappuccio
- Department of Internal Medicine, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Cristina I Batarseh
- Department of Internal Medicine, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Amir A Qamar
- Department of Gastroenterology, Lahey Hospital and Medical Center, Burlington, MA, USA.,Department of Transplantation and Hepatobiliary Diseases, Lahey Hospital and Medical Center, Burlington, MA, USA.,Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
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Pippard B, Bhatnagar M, McNeill L, Donnelly M, Frew K, Aujayeb A. Hepatic Hydrothorax: A Narrative Review. Pulm Ther 2022; 8:241-254. [PMID: 35751800 PMCID: PMC9458779 DOI: 10.1007/s41030-022-00195-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 06/01/2022] [Indexed: 12/10/2022] Open
Abstract
Hepatic hydrothorax (HH) represents a distinct clinical entity within the broader classification of pleural effusion that is associated with significant morbidity and mortality. The median survival of patients with cirrhosis who develop HH is 8-12 months. The diagnosis is typically made in the context of advanced liver disease and ascites, in the absence of underlying cardio-pulmonary pathology. A multi-disciplinary approach to management, involving respiratory physicians, hepatologists, and palliative care specialists is crucial to ensuring optimal patient-centered care. However, the majority of accepted therapeutic options are based on expert opinion rather than large, adequately powered randomized controlled trials. In this narrative review, we discuss the epidemiology, pathophysiology, clinical characteristics, and management of HH, highlighting the use of salt restriction and diuretic therapy, porto-systemic shunts, and liver transplantation. We include specific sections focusing on the role of pleural interventions and palliative care, respectively.
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Affiliation(s)
- Benjamin Pippard
- Department of Respiratory Medicine, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - Malvika Bhatnagar
- Department of Respiratory Medicine, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - Lisa McNeill
- Department of Hepatology, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Mhairi Donnelly
- Department of Hepatology, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Katie Frew
- Department of Palliative Medicine, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Avinash Aujayeb
- Department of Respiratory Medicine, Northumbria Healthcare NHS Foundation Trust, North Shields, Northumbria Way, Northumberland, Cramlington, NE23 6NZ, UK.
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7
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Abstract
Although the potential causes of nonmalignant pleural effusions are many, the management of a few, including complicated pleural infections and refractory heart failure and hepatic hydrothoraces, can be challenging and requires the assistance of interventional pulmonologists. A pragmatic approach to complicated parapneumonic effusions or empyemas is the insertion of a small-bore chest tube (e.g., 14-16 Fr) through which fibrinolytics (e.g., urokinase and alteplase) and DNase are administered in combination. Therapeutic thoracenteses are usually reserved for small to moderate effusions that are expected to be completely aspirated at a single time, whereas video-assisted thoracic surgery should be considered after failure of intrapleural enzyme therapy. Refractory cardiac and liver-induced pleural effusions portend a poor prognosis. In cases of heart failure-related effusions, therapeutic thoracentesis is the first-line palliative therapy. However, if it is frequently needed, an indwelling pleural catheter (IPC) is recommended. In patients with hepatic hydrothorax, repeated therapeutic thoracenteses are commonly performed while a multidisciplinary decision on the most appropriate definitive management is taken. The percutaneous creation of a portosystemic shunt may be used as a bridge to liver transplantation or as a potential definitive therapy in nontransplant candidates. In general, an IPC should be avoided because of the high risk of complications, particularly infections, that may jeopardize candidacy for liver transplantation. Even so, in noncandidates for liver transplant or surgical correction of diaphragmatic defects, IPC is a therapeutic option as valid as serial thoracenteses.
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Affiliation(s)
- José M Porcel
- Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, IRBLleida, University of Lleida, Lleida, Spain
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Craciun R, Mocan T, Procopet B, Nemes A, Tefas C, Sparchez M, Mocan LP, Sparchez Z. Pulmonary complications of portal hypertension: The overlooked decompensation. World J Clin Cases 2022; 10:5531-5540. [PMID: 35979136 PMCID: PMC9258359 DOI: 10.12998/wjcc.v10.i17.5531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 02/22/2022] [Accepted: 04/09/2022] [Indexed: 02/06/2023] Open
Abstract
The systemic nature of cirrhosis and portal hypertension has long been recognized, and the amount of data characterizing the interplay between each system is becoming ever so complex. Lung involvement was among the first described associated entities in cirrhosis, with reports dating back to the late nineteenth century. However, it appears that throughout the years, interest in the pulmonary complications of portal hypertension has generally faded, especially in contrast to other decompensating events, as expertise in this field has primarily been concentrated in highly experienced tertiary care facilities and liver transplantation centers. Despite affecting up to 10%-15% of patients with advanced liver disease and having a proven prognostic impact, hepato-pulmonary syndrome, porto-pulmonary hypertension, and hepatic hydrothorax are frequently misdiagnosed, mistreated, or misinterpreted. This lack of precision might adversely impact patient care, referral to expert centers, and, ultimately, liver disease-related mortality and successful transplantation odds. The present minireview aims to increase awareness of the pulmonary complications of chronic liver disease by providing a brief overview of each of the three entities. The paper focuses on the essential theoretical aspects, addressing the most critical knowledge gaps on the one hand and, on the other hand, critically discussing one key issue for each complication.
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Affiliation(s)
- Rares Craciun
- 3rd Medical Clinic, Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Gastroenterology Clinic, "Prof. Dr. O. Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Tudor Mocan
- 3rd Medical Clinic, Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Gastroenterology Clinic, "Prof. Dr. O. Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Bogdan Procopet
- 3rd Medical Clinic, Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Gastroenterology Clinic, "Prof. Dr. O. Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Andrada Nemes
- Intensiv Care Unit I, Cluj County Emergency Hosptial, Cluj-Napoca 400006, Romania
| | - Cristian Tefas
- 3rd Medical Clinic, Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Gastroenterology Clinic, "Prof. Dr. O. Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Mihaela Sparchez
- 2nd Paediatric Clinic, ”Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca 400126, Please enter the state or province, Romania
| | - Lavinia-Patricia Mocan
- Department of Histology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400349, Romania
| | - Zeno Sparchez
- 3rd Medical Clinic, Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Gastroenterology Clinic, "Prof. Dr. O. Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
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9
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Raevens S, Boret M, De Pauw M, Fallon MB, Van Vlierberghe H. Pulmonary Abnormalities in Liver Disease: Relevance to Transplantation and Outcome. Hepatology 2021; 74:1674-1686. [PMID: 33636019 DOI: 10.1002/hep.31770] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/17/2021] [Accepted: 02/08/2021] [Indexed: 12/14/2022]
Abstract
Pulmonary disease in liver cirrhosis and portal hypertension (PH) constitutes a challenging clinical scenario and may have important implications with regard to prognosis, liver transplantation (LT) candidacy, and post-LT outcome. Pre-LT evaluation should include adequate screening for pulmonary diseases that may occur concomitantly with liver disease as well as for those that may arise as a complication of end-stage liver disease and PH, given that either may jeopardize safe LT and successful outcome. It is key to discriminate those patients who would benefit from LT, especially pulmonary disorders that have been reported to resolve post-LT and are considered "pulmonary indications" for transplant, from those who are at increased mortality risk and in whom LT is contraindicated. In conclusion, in this article, we review the impact of several pulmonary disorders, including cystic fibrosis, alpha 1-antitrypsin deficiency, hereditary hemorrhagic telangiectasia, sarcoidosis, coronavirus disease 2019, asthma, chronic obstructive pulmonary disease, pulmonary nodules, interstitial lung disease, hepatic hydrothorax, hepatopulmonary syndrome, and portopulmonary hypertension, on post-LT survival, as well as the reciprocal impact of LT on the evolution of lung function.
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Affiliation(s)
- Sarah Raevens
- Department of Gastroenterology and Hepatology, Ghent University-Ghent University Hospital, Ghent, Belgium
| | - Maxine Boret
- Department of Gastroenterology and Hepatology, Ghent University-Ghent University Hospital, Ghent, Belgium
| | - Michel De Pauw
- Department of Cardiology, Ghent University-Ghent University Hospital, Ghent, Belgium
| | - Michael B Fallon
- Department of Internal Medicine, University of Arizona College of Medicine, Phoenix, AZ
| | - Hans Van Vlierberghe
- Department of Gastroenterology and Hepatology, Ghent University-Ghent University Hospital, Ghent, Belgium
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Matei D, Craciun R, Crisan D, Procopet B, Mocan T, Pasca S, Zaharie R, Popovici B, Sparchez Z. Hepatic Hydrothorax-An Independent Decompensating Event Associated with Long-Term Mortality in Patients with Cirrhosis. J Clin Med 2021; 10:3688. [PMID: 34441984 PMCID: PMC8396982 DOI: 10.3390/jcm10163688] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 02/08/2023] Open
Abstract
Background: Hepatic hydrothorax (HH) is an understudied complication of decompensated cirrhosis. We aimed to evaluate the long-term prognosis of patients with HH by comparing them with a matched non-HH group. Methods: This retrospective study included 763 consecutive patients hospitalized for decompensated cirrhosis and ascites. Ninety-seven patients with HH were matched for survival analysis with non-HH patients based on liver disease severity. Results: The prevalence of HH was 13.1%. Patients with HH had significantly worse overall liver function. Upon matching, patients with HH had a lower long-term survival (15.4% vs. 30.9% at 5 years) with a mean overall survival of 22.2 ± 2.2 months for the HH group vs. 27.1 ± 2.6 months for the non-HH group (Log Rank-0.05). On multivariate survival analysis using Cox regression, the MELD-Na score, ALBI grade, hepato-renal syndrome, and grade III ascites had a significant impact on mortality in patients with HH. In patients with HH, a MELD-Na score ≥ 16, ALBI grade III, hepato-renal syndrome, or severe ascites delineated high-mortality risk groups. Conclusions: HH is consistently associated with more advanced liver disease. Patients with HH have worse long-term survival, their prognosis being closely intertwined with overlapping decompensating events.
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Affiliation(s)
- Daniela Matei
- Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (D.M.); (R.C.); (B.P.); (T.M.); (S.P.); (R.Z.); (Z.S.)
- Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania
| | - Rares Craciun
- Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (D.M.); (R.C.); (B.P.); (T.M.); (S.P.); (R.Z.); (Z.S.)
- Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania
| | - Dana Crisan
- Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (D.M.); (R.C.); (B.P.); (T.M.); (S.P.); (R.Z.); (Z.S.)
- Department of Gastroenterology, Cluj-Napoca Municipal Hospital, 400139 Cluj-Napoca, Romania
| | - Bogdan Procopet
- Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (D.M.); (R.C.); (B.P.); (T.M.); (S.P.); (R.Z.); (Z.S.)
- Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania
| | - Tudor Mocan
- Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (D.M.); (R.C.); (B.P.); (T.M.); (S.P.); (R.Z.); (Z.S.)
- Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania
| | - Sergiu Pasca
- Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (D.M.); (R.C.); (B.P.); (T.M.); (S.P.); (R.Z.); (Z.S.)
| | - Roxana Zaharie
- Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (D.M.); (R.C.); (B.P.); (T.M.); (S.P.); (R.Z.); (Z.S.)
- Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania
| | - Bogdan Popovici
- Department of Thoracic Surgery, “Leon Daniello” Pulmonology Hospital, 400371 Cluj-Napoca, Romania;
| | - Zeno Sparchez
- Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (D.M.); (R.C.); (B.P.); (T.M.); (S.P.); (R.Z.); (Z.S.)
- Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania
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Biggins SW, Angeli P, Garcia-Tsao G, Ginès P, Ling SC, Nadim MK, Wong F, Kim WR. Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 2021; 74:1014-1048. [PMID: 33942342 DOI: 10.1002/hep.31884] [Citation(s) in RCA: 437] [Impact Index Per Article: 109.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Scott W Biggins
- Division of Gastroenterology and Hepatology, and Center for Liver Investigation Fostering discovEryUniversity of WashingtonSeattleWA
| | - Paulo Angeli
- Unit of Hepatic Emergencies and Liver TransplantationDepartment of MedicineDIMEDUniversity of PadovaPaduaItaly
| | - Guadalupe Garcia-Tsao
- Department of Internal MedicineSection of Digestive DiseasesYale UniversityNew HavenCT
- VA-CT Healthcare SystemWest HavenCT
| | - Pere Ginès
- Liver Unit, Hospital Clinic, and Institut d'Investigacions Biomèdiques August Pi i SunyerUniversity of BarcelonaBarcelonaSpain
- Centro de Investigación Biomèdica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)MadridSpain
| | - Simon C Ling
- The Hospital for Sick Children, Division of Gastroenterology, Hepatology and Nutrition, and Department of PaediatricsUniversity of TorontoTorontoOntarioCanada
| | - Mitra K Nadim
- Division of NephrologyUniversity of Southern CaliforniaLos AngelesCA
| | - Florence Wong
- Division of Gastroenterology and HepatologyUniversity Health NetworkUniversity of TorontoTorontoOntarioCanada
| | - W Ray Kim
- Division of Gastroenterology and HepatologyStanford UniversityPalo AltoCA
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12
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Banini BA, Alwatari Y, Stovall M, Ogden N, Gershman E, Shah RD, Strife BJ, Shojaee S, Sterling RK. Multidisciplinary Management of Hepatic Hydrothorax in 2020: An Evidence-Based Review and Guidance. Hepatology 2020; 72:1851-1863. [PMID: 32585037 DOI: 10.1002/hep.31434] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/08/2020] [Accepted: 06/04/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Bubu A Banini
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Yahya Alwatari
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA
| | - Madeline Stovall
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA
| | - Nathan Ogden
- Division of Interventional Radiology, Department of Radiology, Virginia Commonwealth University, Richmond, VA
| | - Evgeni Gershman
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Rachit D Shah
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA
| | - Brian J Strife
- Division of Interventional Radiology, Department of Radiology, Virginia Commonwealth University, Richmond, VA
| | - Samira Shojaee
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Richard K Sterling
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
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Schultheiß M, Bettinger D, Thimme R, Rössle M. 30 Jahre transjugulärer intrahepatischer portosystemischer Shunt (TIPS) – Rückblick und Perspektive. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2020; 58:877-889. [PMID: 32947633 DOI: 10.1055/a-1217-7866] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
ZusammenfassungDer transjuguläre intrahepatische portosystemische Shunt (TIPS) wird seit 30 Jahren in der Therapie der portalen Hypertonie erfolgreich eingesetzt. In nationalen und internationalen Leitlinien ist die Indikation zur TIPS-Anlage bei Varizenblutung und refraktärem Aszites wissenschaftlich gut belegt und klar definiert. Bei seltenen Indikationen wie dem hepatorenalen Syndrom, der Pfortaderthrombose oder dem neoadjuvanten Einsatz fehlt derzeit noch eine eindeutige Studienlage. Eine wichtige Kontraindikation und klinisch bedeutendste Komplikation nach TIPS ist die hepatische Enzephalopathie (HE). Es wird versucht, die Post-TIPS HE mit technischen Weiterentwicklungen der Stents zu reduzieren.
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Affiliation(s)
- Michael Schultheiß
- Department Innere Medizin, Klinik für Innere Medizin II, Gastroenterologie, Hepatologie, Endokrinologie und Infektiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg
| | - Dominik Bettinger
- Department Innere Medizin, Klinik für Innere Medizin II, Gastroenterologie, Hepatologie, Endokrinologie und Infektiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg
| | - Robert Thimme
- Department Innere Medizin, Klinik für Innere Medizin II, Gastroenterologie, Hepatologie, Endokrinologie und Infektiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg
| | - Martin Rössle
- Department Innere Medizin, Klinik für Innere Medizin II, Gastroenterologie, Hepatologie, Endokrinologie und Infektiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg
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Abstract
Hepatic hydrothorax (HH) is a pleural effusion that develops in a patient with cirrhosis and portal hypertension in the absence of cardiopulmonary disease. Although the development of HH remains incompletely understood, the most acceptable explanation is that the pleural effusion is a result of a direct passage of ascitic fluid into the pleural cavity through a defect in the diaphragm due to the raised abdominal pressure and the negative pressure within the pleural space. Patients with HH can be asymptomatic or present with pulmonary symptoms such as shortness of breath, cough, hypoxemia, or respiratory failure associated with large pleural effusions. The diagnosis is established clinically by finding a serous transudate after exclusion of cardiopulmonary disease and is confirmed by radionuclide imaging demonstrating communication between the peritoneal and pleural spaces when necessary. Spontaneous bacterial empyema is serious complication of HH, which manifest by increased pleural fluid neutrophils or a positive bacterial culture and will require antibiotic therapy. The mainstay of therapy of HH is sodium restriction and administration of diuretics. When medical therapy fails, the only definitive treatment is liver transplantation. Therapeutic thoracentesis, indwelling tunneled pleural catheters, transjugular intrahepatic portosystemic shunt and thoracoscopic repair of diaphragmatic defects with pleural sclerosis can provide symptomatic relief, but the morbidity and mortality is high in these extremely ill patients.
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Affiliation(s)
- Yong Lv
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
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Angeli P, Bernardi M, Villanueva C, Francoz C, Mookerjee RP, Trebicka J, Krag A, Laleman W, Gines P. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018; 69:406-460. [PMID: 29653741 DOI: 10.1016/j.jhep.2018.03.024] [Citation(s) in RCA: 1773] [Impact Index Per Article: 253.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 03/28/2018] [Indexed: 02/06/2023]
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Cardoso FS, Karvellas CJ. Respiratory Complications Before and After Liver Transplant. J Intensive Care Med 2018; 34:355-363. [PMID: 29886790 DOI: 10.1177/0885066618781526] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Respiratory complications before and after liver transplant are common, diverse, and potentially have a negative impact on patient outcomes. In this review, we discuss the most frequent respiratory conditions that patients may develop in the perioperative period. Their prevention and/or treatment may help to maximize the benefit these patients may derive from liver transplant. This review examines diagnostic and therapeutic approaches to these complications for hepatologists, surgeons, and critical care physicians.
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Affiliation(s)
- Filipe S Cardoso
- 1 Gastroenterology and Intensive Care Divisions, Hospital Curry Cabral, Central Lisbon Hospital Center, Nova Medical School, Nova University, Lisbon, Portugal
| | - Constantine J Karvellas
- 2 Division of Gastroenterology (Liver Unit) and Department of Critical Care Medicine, University of Alberta, Edmonton, Canada
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Kara S, Sen N, Akcay S, Moray G, Kus M, Haberal M. Liver Transplant and Reexpansion Pulmonary Edema: A Case Report. EXP CLIN TRANSPLANT 2018. [PMID: 29528016 DOI: 10.6002/ect.tond-tdtd2017.p43] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Hydrothorax occurs frequently in patients with endstage liver disease and usually requires drainage of pulmonary effusion during the hepatectomy phase of liver transplant. Reexpansion pulmonary edema is a rare but potentially fatal complication seen after rapid reexpansion of the collapsed lung following thoracentesis of pleural fluid or tube drainage of pneumothorax. This condition, which manifests with various degrees of clinical severity, is rarely reported following liver transplantation. Herein, we present a 62-year-old male patient who developed reexpansion pulmonary edema after drainage of massive pleural effusion, which caused a total collapse in the right hemithorax during liver transplant. Six hours after pleural fluid drainage, the patient developed a nonproductive cough, mild tachypnea, shortness of breath, and low oxygen saturation (88%). His chest radiograph showed diffuse heterogeneous opacities in the right hemithorax. Computed tomography of the thorax revealed consolidations containing air bronchograms and ground glass opacities in the parenchyma of the right lung; these findings did not extend to the periphery and were observed less frequently in the inferoposterior left lung. These symptoms and radiologic findings were diagnosed as reexpansion pulmonary edema. Complete clinical and radiologic improvements were achieved within 72 hours of mechanical ventilatory support.
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Affiliation(s)
- Sibel Kara
- From the Department of Chest Diseases Baskent University Adana Dr. Turgut Noyan Teaching and Medical Research Center, Adana, Turkey
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19
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Garbuzenko DV, Arefyev NO. Hepatic hydrothorax: An update and review of the literature. World J Hepatol 2017; 9:1197-1204. [PMID: 29152039 PMCID: PMC5680207 DOI: 10.4254/wjh.v9.i31.1197] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Revised: 09/17/2017] [Accepted: 10/15/2017] [Indexed: 02/06/2023] Open
Abstract
This review considers the modern concepts of pathogenesis, diagnostic methods, and treatment principles of hepatic hydrothorax (HH). HH is the excessive (> 500 mL) accumulation of transudate in the pleural cavity in patients with decompensated liver cirrhosis but without cardiopulmonary and pleural diseases. It causes respiratory failure which aggravates the clinical course of liver cirrhosis, and the emergence of spontaneous bacterial pleural empyema may be the cause of death. The information was collected from the PubMed database, the Google Scholar retrieval system, the Cochrane reviews, and the reference lists from relevant publications for 1994-2016 using the keywords: "liver cirrhosis", "portal hypertension", "hepatic hydrothorax", "pathogenesis", "diagnostics", and "treatment". To limit the scope of this review, only articles dealing with uncomplicated hydrothorax in patients with liver cirrhosis were included. The analysis of the data showed that despite the progress of modern hepatology, the presence of HH is associated with poor prognosis and high mortality. Most patients suffering from it are candidates for orthotopic liver transplantation. In routine clinical practice, stratification of the risk for an adverse outcome and the subsequent determination of individual therapeutic strategies may be the keys to the successful management of the patient's condition. The development of pathogenetic pharmacotherapy and optimization of minimally invasive treatment will improve the quality of life and increase the survival rate among patients with HH.
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20
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Hung TH, Tseng CW, Tsai CC, Hsieh YH, Tseng KC, Tsai CC. Mortality Following Catheter Drainage Versus Thoracentesis in Cirrhotic Patients with Pleural Effusion. Dig Dis Sci 2017; 62:1080-1085. [PMID: 28130709 DOI: 10.1007/s10620-017-4463-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 01/16/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pleural effusion is an abnormal collection of body fluids that may cause related morbidity or mortality in cirrhotic patients. There are insufficient data to determine the optimal method of drainage, for symptomatic relief in cirrhotic patients with pleural effusion. AIMS In this study, we compare the mortality outcomes of catheter drainage versus thoracentesis in cirrhotic patients. METHODS The National Health Insurance Database, derived from the Taiwan National Health Insurance Program, was used to identify cirrhotic patients with pleural effusion requiring drainage between January 1, 2007, and December 31, 2010. In all, 2556 cirrhotic patients with pleural effusion were selected for the study and divided into the two groups (n = 1278/group) after propensity score matching. RESULTS The mean age was 61.0 ± 14.3 years, and 68.9% (1761/2556) were men. The overall 30-day mortality was 21.0% (538/2556) and was higher in patients treated with catheter drainage than those treated with thoracentesis (23.5 vs. 18.6%, respectively, P < 0.001 by log-rank test). After Cox proportional hazard regression analysis adjusted by patient sex, age, and comorbid disorders, the risk of 30-day mortality was significantly higher in cirrhotic patients who accepted catheter drainage compared to thoracentesis (hazard ratio 1.30, 95% confidence interval 1.10-1.54, P = 0.003). Old age, hepatic encephalopathy, bleeding esophageal varices, hepatocellular carcinoma, ascites, and pneumonia were associated with higher risks for 30-day mortality. CONCLUSION In cirrhotic patients with pleural effusion requiring drainage, catheter drainage is associated with higher mortality compared to thoracentesis.
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Affiliation(s)
- Tsung-Hsing Hung
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 2, Minsheng Rd., Dalin Township, Chiayi County, 62247, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chih-Wei Tseng
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 2, Minsheng Rd., Dalin Township, Chiayi County, 62247, Taiwan. .,School of Medicine, Tzu Chi University, Hualien, Taiwan.
| | - Chen-Chi Tsai
- School of Medicine, Tzu Chi University, Hualien, Taiwan.,Division of Infectious Disease, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi County, Taiwan
| | - Yu-Hsi Hsieh
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 2, Minsheng Rd., Dalin Township, Chiayi County, 62247, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Kuo-Chih Tseng
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 2, Minsheng Rd., Dalin Township, Chiayi County, 62247, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chih-Chun Tsai
- Department of Mathematics, Tamkang University, Tamsui, Taiwan
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Huang PM, Kuo SW, Chen JS, Lee JM. Thoracoscopic Mesh Repair of Diaphragmatic Defects in Hepatic Hydrothorax: A 10-Year Experience. Ann Thorac Surg 2016; 101:1921-7. [PMID: 26897323 DOI: 10.1016/j.athoracsur.2015.11.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Revised: 10/05/2015] [Accepted: 11/09/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND The objective was to analyze the outcomes of thoracoscopic mesh repair for hepatic hydrothorax (HH) at our institution during the past 10 years. METHODS A total of 63 patients with refractory HH who underwent thoracoscopic mesh onlay reinforcement to repair diaphragmatic defects from January 2005 to December 2014 were included in the study. Mesh covering alone was used in 47 patients and mesh with suturing was used in 16 patients. Patient demographics, Child-Pugh class, and model for end-stage liver disease (MELD) score were evaluated to predict morbidity and mortality. RESULTS Of the patients (mean age, 60.4 ± 15 years; 31 men and 32 women), 14.3% had concomitant underlying diseases of renal insufficiency, 34.9% had diabetes mellitus, and 4.8% had pneumonia. Diaphragmatic blebs were the most common diaphragmatic defects (29 of 63 [46%]). After a median 20.5 months of follow-up examinations, 4 patients experienced recurrence. The 1-month mortality rate was 9.5% (6 of 63 patients). On multivariable analysis, underlying impaired renal function (p = 0.039) and MELD scores (p = 0.048) were associated with increased 3-month mortality in 16 patients. Contrary to the rising Child-Pugh score (p = 0.058), rising MELD scores represented an increase in kidney or liver failure and mortality. The main causes of 3-month mortality were septic shock (n = 6), acute renal insufficiency (n = 4), gastrointestinal bleeding (n = 4), hepatic encephalopathy (n = 1), and ischemic bowel (n = 1). CONCLUSIONS Thoracoscopic mesh repair for refractory HH improves symptoms and lowers the recurrence rate.
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Affiliation(s)
- Pei-Ming Huang
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Shuenn-Wen Kuo
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jin-Shing Chen
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jang-Ming Lee
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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Abstract
PURPOSE OF REVIEW Treatment of hepatic hydrothorax is challenging because of its rapid symptomatic recurrence. This review will focus on potential therapeutic approaches to hepatic hydrothorax. RECENT FINDINGS Hepatic hydrothorax is refractory to salt restriction and diuretics in approximately 25% of cases. Primary management options for these patients include serial thoracenteses, transjugular intrahepatic portosystemic shunt (TIPS) placement, and insertion of an indwelling pleural catheter (IPC). Response rate to TIPS, being the first choice whenever possible, is about 80%. IPC is emerging as a feasible alternative in patients who require frequent therapeutic thoracenteses, particularly if TIPS is contraindicated. Pleurodesis is not advocated because of the low likelihood of a pleural symphysis owing to the rapid re-accumulation of pleural fluid. The only cure for hepatic hydrothorax, a defined complication of end-stage liver disease, is liver transplantation. SUMMARY No single treatment option for refractory hepatic hydrothorax is ideal. However, in patients with contraindications to or who are awaiting liver transplantation, TIPS seems the most beneficial therapy, whereas IPC promises to be an alternative second-line consideration.
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24
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Abstract
Hepatic hydrothorax is defined as a pleural effusion in patients with liver cirrhosis in the absence of cardiopulmonary disease. The estimated prevalence among patients with liver cirrhosis is approximately 5-6%. The pathophysiology involves the passage of ascitic fluid from the peritoneal cavity to the pleural space through diaphragmatic defects. The diagnosis is made from clinical presentation and confirmed by diagnostic thoracentesis with pleural fluid analysis. The initial medical management is sodium restriction and diuretics, but liver transplantation provides the only definitive therapy. For patients who are not transplant candidates and those who await organ availability, other therapeutic modalities that are to be considered include transjugular intrahepatic portosystemic shunt placement, videoassisted thoracoscopic surgery repair, pleurodesis, and vasoconstrictors (eg, octreotide and terlipressin). The primary therapeutic goals are to reduce ascitic fluid production and improve symptoms to bridge the time for liver transplantation.
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25
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Endo K, Iida T, Yagi S, Yoshizawa A, Fujimoto Y, Ogawa K, Ogura Y, Mori A, Kaido T, Uemoto S. Impact of preoperative uncontrollable hepatic hydrothorax and massive ascites in adult liver transplantation. Surg Today 2014; 44:2293-9. [PMID: 24509883 DOI: 10.1007/s00595-014-0839-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 12/16/2013] [Indexed: 12/28/2022]
Abstract
PURPOSE Uncontrollable hepatic hydrothorax and massive ascites (H&MA) requiring preoperative drainage are sometimes encountered in liver transplantation (LT). We retrospectively analyzed the characteristics of such patients and the impact of H&MA on the postoperative course. METHODS We evaluated 237 adult patients who underwent LT in our institute between April 2006 and October 2010. RESULTS Recipients with uncontrollable H&MA (group HA: n = 36) had more intraoperative bleeding, higher Child-Pugh scores, lower serum albumin concentrations and higher blood urea nitrogen concentrations than those without uncontrollable H&MA (group C: n = 201). They were also more likely to have preoperative hepatorenal syndrome and infections. The incidence of postoperative bacteremia was higher (55.6 vs. 46.7%, P = 0.008) and the 1- and 3-year survival rates were lower (1 year: 58.9 vs. 82.9%; 3 years: 58.9 vs. 77.7%; P = 0.003) in group HA than in group C. The multivariate proportional regression analyses revealed that uncontrollable H&MA and the Child-Pugh score were independent risk factors for the postoperative prognosis. CONCLUSIONS Postoperative infection control may be an important means of improving the outcome for patients with uncontrollable H&MA undergoing LT, and clinicians should strive to perform surgery before H&MA becomes uncontrollable.
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Affiliation(s)
- Kosuke Endo
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan,
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Lee S, Jung HS, Choi JH, Lee J, Hong SH, Lee SH, Park CS. Perioperative risk factors for prolonged mechanical ventilation after liver transplantation due to acute liver failure. Korean J Anesthesiol 2013; 65:228-36. [PMID: 24101957 PMCID: PMC3790034 DOI: 10.4097/kjae.2013.65.3.228] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 03/26/2013] [Accepted: 04/02/2013] [Indexed: 12/28/2022] Open
Abstract
Background Acute liver failure (ALF) is a rapidly progressing and fatal disease for which liver transplantation (LT) is the only treatment. Posttransplant mechanical ventilation tends to be more prolonged in patients with ALF than in other LT patients. The present study examined the clinical effects of prolonged posttransplant mechanical ventilation (PMV), and identified risk factors for PMV following LT for ALF. Methods We reviewed data of patients undergoing LT for ALF between January 2005 and June 2011. After grouping patients according to administration of PMV (≥ 24 h), donor and recipient perioperative variables were compared between the groups with and without PMV. Potentially significant factors (P < 0.1) from the univariate intergroup comparison were entered into a multivariate logistic regression to establish a predictive model for PMV. Results Twenty-four (25.3%) of 95 patients with ALF who received PMV had a higher mortality rate (29.2% vs 11.3%, P = 0.038) and longer intensive care unit stay (12.9 ± 10.4 vs 7.1 ± 2.7 days, P = 0.012) than patients without PMV. The intergroup comparisons revealed worse preoperative hepatic conditions, more supportive therapy, and more intraoperative fluctuations in vital signs and less urine output in the with- compared with the without-PMV group. The multivariate analysis revealed that preoperative hepatic encephalopathy (≥ grade III), intraoperative blood pressure fluctuation, and oliguria (< 0.5 ml/kg/h) were independent risk factors for PMV. Conclusions PMV was associated with deleterious outcomes. Besides care for known risk factors including hepatic encephalopathy, meticulous attention to managing intraoperative hemodynamic circulatory status is required to avoid PMV and improve the posttransplant prognosis in ALF patients.
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Affiliation(s)
- Serin Lee
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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27
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Abstract
Improved outcomes in liver transplant recipients reflect advances in surgical technique, post-operative care, immunosuppression as well as better selection of potential candidates. The pre-transplant evaluation is a multidisciplinary process intended to recognize and treat important comorbid conditions that may impair outcomes during the peri- and post-transplant periods. Important psychosocial issues should also be ascertained and tackled early during the pre-transplant evaluation with an overarching intention to improve the success of liver transplantation.
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Affiliation(s)
- Andres F Carrion
- Division of Gastroenterology, University of Miami Miller School of Medicine, 1120 NW 14th Street, suite 310E, Miami, FL 33136, USA.
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28
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Pulmonary contraindications, indications and MELD exceptions for liver transplantation: a contemporary view and look forward. J Hepatol 2013; 59:367-74. [PMID: 23557870 DOI: 10.1016/j.jhep.2013.03.026] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 03/21/2013] [Accepted: 03/22/2013] [Indexed: 12/11/2022]
Abstract
Pulmonary concerns in liver transplant candidates have intraoperative and outcome implications. Evolving MELD exception policies address transplant priority for problems such as hepatopulmonary syndrome, portopulmonary hypertension, and hemorrhagic hereditary telangiectasia. Other pulmonary issues such as refractory hepatic hydrothorax, advanced chronic obstructive lung disease (including alpha-1 antitrypsin deficiency) and indeterminate pulmonary nodules may affect liver transplant consideration. Herein, we discuss current pulmonary-related contraindications, indications and MELD exception policies for liver transplantation, suggesting future considerations.
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Singh A, Bajwa A, Shujaat A. Evidence-based review of the management of hepatic hydrothorax. ACTA ACUST UNITED AC 2013; 86:155-73. [PMID: 23571767 DOI: 10.1159/000346996] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 01/08/2013] [Indexed: 12/19/2022]
Abstract
Hepatic hydrothorax (HH) is an example of a porous diaphragm syndrome. Portal hypertension results in the formation of ascitic fluid which moves across defects in the diaphragm and accumulates in the pleural space. Consequently, the treatment approach to HH consists of measures to reduce the formation of ascitic fluid, prevent the movement of ascitic fluid across the diaphragm, and drain or obliterate the pleural space. Approximately 21-26% of cases of HH are refractory to salt and fluid restriction and diuretics and warrant consideration of additional treatment measures. Ideally, liver transplantation is the best treatment option; however, most of the patients are not candidates and most of those who are eligible die while waiting for a transplant. Treatment measures other than liver transplantation may not only provide relief from dyspnea but also improve patient survival and serve as a bridge to liver transplantation.
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Affiliation(s)
- Amita Singh
- Department of Pulmonary and Critical Care, UF College of Medicine at Jacksonville, Jacksonville, FL 32209, USA.
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Quaglia A, Burt AD, Ferrell LD, Portmann BC. Systemic disease. MACSWEEN'S PATHOLOGY OF THE LIVER 2012:935-986. [DOI: 10.1016/b978-0-7020-3398-8.00016-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
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