Short Reports
NOVEMBER  2011 – Vol. 31, No. 6 PDI
REFERENCES
1. Piraino B, Bailie GR, Bernardini J, Boeschoten E, Gupta
A, Holmes C, et al. Peritoneal dialysis-related infections
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2. Fried LF, Bernardini J, Johnston JR, Piraino B. Peritonitis
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5. Finkelstein ES, Jekel J, Troidle L, Gorban–Brennan N,
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for distribution, contact Multimed Inc. at marketing@multi-med.com
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doi:10.3747/pdi.2010.00178
A Novel Technique to Treat Hydrothorax
in Peritoneal Dialysis: Laparoscopic ­
Hepato-diaphragmatic Adhesion
KEY WORDS: Hydrothorax; complications; laparoscopy.
One of the possible complications of continuous am-
bulatory peritoneal dialysis (CAPD), although rare, is the
development of hydrothorax, which has been reported in
2% of all patients on peritoneal dialysis (PD) (1). Typi-
cally, CAPD-related hydrothorax has an acute onset, with
respiratory distress. Chest radiography shows right-sided
pleural effusion in about 90% of cases (2).
The presence of pleuroperitoneal communication has
been identified as the most common reason (among oth-
ers) explaining hydrothorax in PD. The management of
CAPD-related hydrothorax has been extensively reviewed
(2,3). Conservative nonsurgical treatments based solely
on PD interruption or interruption combined with chemi-
cal pleurodesis [pleural instillation, through a thoracic
drain, of various sclerosing agents such as talc, tetra-
cycline, autologous blood, fibrin glue, or a hemolytic
streptococcal preparation (OK-432)] have been advo-
cated (2). Surgical approaches range from an open repair,
through a thoracotomy, of the diaphragmatic defects, to
a minimally invasive video-assisted thoracoscopic surgi-
cal technique, with or without complementary chemical
PDI november  2011 – Vol. 31, No. 6 Short Reports
or mechanical pleurodesis (2). Considering that the
cause of fluid migration to the thorax is limited to a
diaphragmatic defect, we proposed to close it using the
adhesive properties of surgical meshes placed through a
minimally invasive laparoscopic approach, which allowed
for visualization and treatment of the defect from the
abdominal side.
METHODS
Patients developing a CAPD-related hydrothorax were
identified from a prospective database created in Febru-
ary 1991 and perpetuated from that time forward at the
Nephrology department. Diagnosis was confirmed by
the typical clinical course and chest radiography. These
patients were referred to the Digestive Surgery depart-
ment [usually involved in the implantation and surgical
follow-up of the CAPD catheters (4)]. Once informed
consent was given, the patients were treated using the
laparoscopic approach.
Surgical Procedure:  Antibiotic prophylaxis was ad-
ministered at the time of the anesthetic induction (1 g
cephalosporin). Patients were placed in a Trendelenburg
position. Insufflation was performed directly through
the PD catheter. A 10-mm trocar was inserted above the
umbilicus into the abdomen. A 3CCD high-quality camera
[or, more recently, a high-definition (HD) camera (Karl
Storz Endoskope, Tüttlingen, Germany)], combined with
a 10-mm optic, was introduced to guide the positioning
of two further 5-mm trocars on the right and left sides,
5 cm below the rib arch. Exploration of the diaphragm was
then carefully performed to identify the diaphragmatic
defect. A 10×15-cm mesh of knitted polypropylene fila-
ments (Ethicon, Cornelia, GA, USA) was cut to precisely
overlap the hepato-diaphragmatic area. The mesh was
introduced through the 10-mm trocar, placed over the
defect, and fixed to the diaphragm using helical fasteners
(ProTack: Covidien, Élancourt, France).
RESULTS
Of 523 patients (315 men, 208 women) who under-
went PD for renal failure between February 1991 and
September 2010, 6 (3 men, 3 women) were referred to
the surgical unit for management of right-sided CAPD-
related hydrothorax. Mean time on PD before the onset of
hydrothorax was 20.3 ± 16.4 (standard deviation) weeks.
A diaphragmatic defect was identified in all patients. The
mean operating time was 35 ±  8.36 minutes. Postop-
erative pain was mild, with a low analgesic requirement
(paracetamol 1 g three times daily), and no patient had to
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use major analgesics or opioids. Oral feeding was resumed
the evening of the surgery. Patients restarted PD 3 weeks
after surgery. Of the 6 treated patients, 2 (33.3%) expe-
rienced a recurrence of hydrothorax and were switched
to hemodialysis. In the remaining 4 patients (66.6%),
PD was successfully resumed after 3 weeks, and the
postoperative course was uneventful.
DISCUSSION
Hemodialysis and PD for the treatment of end-stage
renal disease are equivalent in terms of long-term out-
comes and life expectancy (5), but PD carries a number
of advantages for the patient’s quality of life and implies
a substantial cost savings (5). The most frequent CAPD-
related complications, such as peritonitis or catheter
exit-site infections and abdominal hernia, can be serious
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and even life-threatening (6). Hydrothorax during PD
appears uncommon. Our reported rate of 1.14% (6/523)
over a 20-year period is comparable to rates reported
elsewhere in the literature (1). We have advocated the
use of laparoscopy to manage complications of CAPD
catheters since 1992 (4). Consequently, we considered
a laparoscopic approach from the abdominal side for the
treatment of the diaphragmatic defect causing hydrotho-
rax in these patients. That approach is less painful than
an approach using thoracoscopy or thoracotomy (7).
Thanks to the high-quality vision offered by 3CCD
cameras (and, more recently, HD cameras), identifica-
tion of the diaphragmatic defect was always possible.
In regard to the position of the gap at the reflection
line of the triangular ligament over the liver, we imag-
ined that a dense adhesion between the liver and the
diaphragm could solve the problem. Because fibrin
glue does not offer sufficient adhesive properties, we
used the adhesive effect of a surgical mesh commonly
used to treat abdominal wall hernia (8). Experimental
data show that, compared with other commercially
available prosthetic mesh grafts, polypropylene meshes
may produce more intense adhesion (9). We used this
drawback to our advantage to close the hole from
the “right” side.
Possible severe, but rare, complications related to the
placement of a surgical mesh include bacterial contami-
nation, with consequent peritonitis and hollow viscus
erosions. The management of mesh infections remains a
major challenge (10) and often requires surgical excision
if conservative antibiotic treatment fails. In our tech-
nique, the risk of infection is presumably reduced given
that the mesh is totally covered and becomes encapsu-
lated by a fibrotic reaction in approximately 3  weeks,
thus avoiding any contact with the bowel.
693
Short Reports NOVEMBER  2011 – Vol. 31, No. 6 PDI
In addition, to reduce the risk of prosthesis slippage
and possible bowel erosions, the mesh was trimmed
to fit along the peritoneal reflection on the trian-
gular ligament so as to be smaller than the liver and
was then secured to the diaphragmatic surface using
tack-like fasteners.
The problem with left-side hydrothorax (a rare occur-
rence, accounting for fewer than 10% of cases) is that the
mesh would inevitably come into contact with the stom-
ach or the colon, hampering the use of a non-absorbable
mesh. A valid option to extend our technique to a left-
side hydrothorax would be the use of an absorbable mesh.
But such considerations may be debatable because of the
small number of cases to be managed.
Two patients had early recurrence of hydrothorax after
resumption of PD. Because of their poor condition, they
were not proposed for thoracoscopic exploration and
were switched to hemodialysis treatment. These failures
might be explained by the presence of an accompanying
missed defect or by insufficient adhesion between the
mesh and the liver.
CONCLUSIONS
This new and original technique to treat CAPD
hydrothorax was successful in 66.6% of cases and al-
lowed for the reintroduction of PD after 3 weeks. It is
feasible and less invasive than a thoracic approach. It
also does not hamper the possibility of a thoracoscopic
secondary approach.
DISCLOSURES
The authors declare that they have no conflicts of
interest to disclose.
Didier Mutter1*
Cosimo Callari1
Michele Diana1
Larbi Bencheikh2
Françoise Heibel2
Jacques Marescaux1
Department of Digestive Surgery1
Department of Nephrology and Haemodialysis2
University Hospital of Strasbourg
Strasbourg, France
*email: didier.mutter@ircad.fr
REFERENCES
1. Szeto CC, Chow KM. Pathogenesis and management of
694 This single copy is for your personal, non-commercial use only.
For permission to reprint multiple copies or to order presentation-ready copies
for distribution, contact Multimed Inc. at marketing@multi-med.com
hydrothorax complicating peritoneal dialysis. Curr Opin
Pulm Med 2004; 10:315–19.
2. Lew SQ. Hydrothorax: pleural effusion associated with
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drothorax complicating peritoneal dialysis. Semin Dial
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T. Laparoscopy: an alternative to surgery in patients
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8. Tanaka K, Mutter D, Inoue H, Lindner V, Bouras G, Forgione
A, et al. In vivo evaluation of a new composite mesh (10%
polypropylene/90% poly-l-lactic acid) for hernia repair.
J Mater Sci Mater Med 2007; 18:991–9.
9. Kayaoglu HA, Ozkan N, Hazinedaroglu SM, Ersoy OF, Erkek
AB, Koseoglu RD. Comparison of adhesive properties of
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J Invest Surg 2005; 18:89–95.
10. Aguilar B, Chapital AB, Madura JA 2nd, Harold KL. Con-
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repair. J Laparoendosc Adv Surg Tech A 2010; 20:249–52.
doi:10.3747/pdi.2010.00297
Peritoneal Fixation Prevents Dislocation
of Tenckhoff Catheter
The prevalence of end-stage renal disease is now
increasing globally. Most of these patients receive di-
alysis therapies, and peritoneal dialysis is an effective
management approach, with both a low cost and a high
quality of life for the patient (1). However, peritoneal
dialysis is not free of problems, and dislocation of the
Tenckhoff catheter is one of the most frequent and ag-
gravating complications (2,3), often requiring surgical
intervention (4). Thus far, several papers have reported
a procedure to prevent dislocation in which the catheter
is fixed to the recto-uterine or rectovesical pouch under
direct vision (5–7). However, the benefits of fixation
techniques have not been adequately evaluated in terms
of catheter survival. We retrospectively analyzed our
cases to determine whether fixation of the catheter to
the visceral peritoneum may reduce dislocation.