What is the preferred treatment between Transjugular Intrahepatic Portosystemic Shunt (TIPS) and intercostal drainage tube placement for patients with hepatic hydrothorax who have failed first-line management?

Management of Hepatic Hydrothorax: TIPS vs. Intercostal Drainage Tube

Transjugular Intrahepatic Portosystemic Shunt (TIPS) is strongly recommended over intercostal drainage tube placement for patients with refractory hepatic hydrothorax who have failed first-line management. 1

Understanding Hepatic Hydrothorax

• Hepatic hydrothorax is defined as the accumulation of transudative fluid in the pleural space in patients with cirrhosis and portal hypertension, affecting approximately 10% of individuals with advanced liver disease 1
• It forms due to small diaphragmatic defects (more often on the right side) through which ascites moves into the pleural space due to negative intrathoracic pressure during inspiration 1
• Associated with poor prognosis, with median survival ranging from 8-12 months without liver transplantation 1, 2

First-Line Management

• Initial treatment focuses on controlling ascites with sodium restriction and diuretics 1
• Therapeutic thoracentesis is indicated for symptomatic relief in patients with dyspnea but provides only temporary benefit 1

Management of Refractory Hepatic Hydrothorax

TIPS (Recommended Approach)

• Strong recommendation with moderate-quality evidence for TIPS in selected patients with refractory hepatic hydrothorax 1
• Clinical response rates range from 42-79% with complete resolution of hydrothorax 1
• Meta-analysis of six studies (208 participants) showed an overall response rate of 56% 1
• Can improve liver function in some patients, with potential increases in serum albumin 3
• May serve as a bridge to liver transplantation 1, 4

Intercostal Drainage Tube (Not Recommended)

• Chronic pleural drainage should not be performed due to frequent complications 1
• Complications include:
  • Pneumothorax, pleural infection (empyema), and bleeding 1, 5
  • Protein depletion and renal dysfunction from excessive fluid loss 1
  • Bacterial infections, particularly with indwelling catheters 5

Patient Selection for TIPS

• Careful patient selection is critical for successful outcomes 1
• Contraindications for TIPS include:
  • Bilirubin >50 μmol/L and platelets <75×10⁹/L 1
  • Pre-existing hepatic encephalopathy 1
  • Active infection, severe cardiac failure, or severe pulmonary hypertension 1
• Early mortality risk is related to progressive liver disease, particularly in patients >65 years 6, 7

Alternative Options

• Liver transplantation is the definitive treatment when indicated 1
• Pleurodesis may be considered for patients not eligible for TIPS or transplantation, but has high complication rates (up to 82%) 1
• Thoracoscopic repair with mesh for well-defined diaphragmatic defects in selected patients 1

Clinical Pitfalls and Caveats

• Most studies on TIPS for hepatic hydrothorax were conducted over a decade ago, with only one including PTFE-covered TIPS 1
• No direct comparative studies between TIPS and standard treatment exist, limiting data on comparative survival 1
• Risk of post-TIPS hepatic encephalopathy is significant (reported in up to 66.6% of cases) 7
• 30-day mortality after TIPS ranges from 18-25%, primarily related to severity of underlying liver disease 4, 7
• Improvements in patient selection criteria may have reduced early post-TIPS mortality, but published data confirming this are lacking 1

In conclusion, while both options have risks, TIPS offers superior outcomes for managing refractory hepatic hydrothorax compared to intercostal drainage tubes, which should be avoided due to their high complication rates and limited efficacy.