Efficacy and Safety of Indwelling Pleural Catheters in Management of Hepatic Hydrothorax: A Systematic Review of Literature

Abstract

Hepatic hydrothorax (HH) is an infrequent but debilitating and therapeutically challenging complication of advanced liver cirrhosis. As evidence suggests against chest tube placement in HH, many clinicians are reluctant to place indwelling pleural catheters (IPCs) for non-malignant effusions like HH. We aim to study the efficacy and safety of IPCs as an alternative treatment option in our systematic review.A literature search was conducted using the electronic database engines MEDLINE, PubMed, EMBASE, Ovid, Scopus and Cochrane Library (Cochrane Central Register of Controlled trials and Cochrane Database of Systematic Reviews) from inception to April 2018 to identify published articles and reports addressing outcomes in patients treated for HH with IPCs. The risk of bias was rated for each study using the Cochrane criteria.The search strategy retrieved 370 papers, of which four case series were selected with a total of 111 patients. After the insertion of IPCs for HH, spontaneous pleurodesis was achieved in 16 (31.4%) out of 51 patients at a mean duration of 73-222 days. As far as secondary outcomes were concerned, the frequency of pneumothorax during or after the procedure was 0 (0%) out of 92 patients, pain at insertion site 12 (20%) out of 60 patients, catheter blockage two (2.9%) out of 68 patients, pleural fluid infection five (4.5%) out of 111 patients and catheter-site cellulitis one (3.1%) out of 32 patients. Re-accumulation of pleural fluid after catheter removal was mentioned in one study, wherein 12 (20%) out of 60 patients developed recurrence of pleural effusion.We conclude IPCs as an acceptable therapeutic option for the management of refractory pleural effusion in patients with HH. Although trans-jugular intrahepatic portosystemic shunt (TIPS) and liver transplantation are the gold standards for the management of pleural effusion in these patients, cost and availability are the major concerns with these treatment modalities. IPCs are a safe and efficacious alternative with a reasonable rate of spontaneous pleurodesis.

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

“…Chest tubes in HH are associated with high morbidity, clinical deterioration resulting in death or necessitating urgent TIPS or LT (152)(153)(154), and the development of a fistula and should be avoided. More recently, lower rates of complications are reported for indwelling tunneled pleural catheters (infections, 4.5%; fluid reaccumulation, 20%; spontaneous pleurodesis, 31%), which may be considered with caution as an alternative to repeated thoracentesis (155). Patients in whom pleural fluid is frequently removed through an indwelling pleural catheter are at risk to develop protein depletion and malnutrition.…”

“…More recently, lower rates of complications are reported for indwelling tunneled pleural catheters (infections, 4.5%; fluid reaccumulation, 20%; spontaneous pleurodesis, 31%), which may be considered with caution as an alternative to repeated thoracentesis. ( 155 ) Patients in whom pleural fluid is frequently removed through an indwelling pleural catheter are at risk to develop protein depletion and malnutrition. Chemical pleurodesis often leads to loculated collections and is not recommend.…”

Medical thoracoscopy for pleural diseases

“…IPC is commonly considered in patients with recurrent, symptomatic MPE [37,38] or sometimes, nonmalignant effusions refractory to maximal diseasedirected therapy [39][40][41]. IPC placement is typically performed under local anesthesia with ultrasound guidance and does not require medical thoracoscopy [42].…”

Refractory ascites—the contemporary view on pathogenesis and therapy

“…Recently, ITPC has been proposed as an acceptable treatment alternative for HH refractory to conventional medical management. In this patient population, ITPCs provide symptomatic relief, but the morbidity and mortality still remain the major concerns with this treatment modality (Haas & Chen, 2017; Baig et al, 2018; Shojaee et al, 2019). Further studies are necessary to assess ITPC long-term safety and effectiveness in patients with HH.…”