Thoracoscopic mesh implantation as a definitive treatment approach for peritoneal dialysis-associated hydrothorax

Abstract

Pleuroperitoneal leakage with the formation of hydrothorax is a rare complication of peritoneal dialysis, usually necessitating termination of peritoneal dialysis. We hypothesized that implantation of a polypropylene mesh on the diaphragm using video-assisted thoracoscopic surgery might induce permanent closure of pleuroperitoneal leakage. We report a case series of n = 12 peritoneal dialysis patients with pleuroperitoneal leakage and right-sided hydrothorax who underwent video-assisted thoracoscopy with mesh implantation from 2011 to 2020. Pleuroperitoneal leakage had been confirmed before surgery by intraperitoneal administration of toluidine blue, contrast-enhanced computer tomography or glucose determination from the pleural effusion. Median time from the start of peritoneal dialysis to manifestation of pleuroperitoneal leakage was 52 days. Video-assisted thoracoscopic surgery revealed multiple penetration points in the tendinous part of the diaphragm in all patients, which appeared as blebs. These were closed by covering the whole diaphragm with a polypropylene mesh. In all patients, peritoneal dialysis was paused for three months and bridged by hemodialysis. After restarting peritoneal dialysis and a median follow-up time of 1.9 years, none of the patients experienced a recurrence of pleuroperitoneal leakage. This case series demonstrates that pleuroperitoneal leakage in peritoneal dialysis patients can be permanently closed using thoracoscopic mesh implantation and allows peritoneal dialysis to be continued as renal replacement therapy.

Keywords: Diaphragm; Hydrothorax; Mesh; Peritoneal dialysis; Pleuroperitoneal leakage; VATS.

Fig. 1

Right-sided pleuroperitoneal leakage in a 74-year-old male peritoneal dialysis patient. A Chest x-ray showing a right-sided pleural effusion. B Pleuroperitoneal leakage site demonstrated during video-assisted thoracoscopic surgery

Fig. 2

Thoracoscopic closure of pleuroperitoneal leakage site using mesh implantation. A Port placement for the biportal VATS technique. B Polypropylene mesh with sutures covering the diaphragm

Fig. 3

Radiologic appearance after mesh implantation in a 74-year old male peritoneal dialysis patient. A Chest x-ray 3 months after mesh implantation on the right diaphragm. B Computed tomography of the thorax 12 months after mesh implantation on the right diaphragm