How is pleurodiaphragmatic adhesion managed?

Management of Pleurodiaphragmatic Adhesion

The management of pleurodiaphragmatic adhesions depends entirely on the clinical context: for symptomatic pleural effusions with adhesions preventing complete drainage, video-assisted thoracic surgery (VATS) with adhesiolysis is the preferred approach, while asymptomatic adhesions require no intervention. 1

Initial Assessment and Decision-Making

Determine if the adhesions are causing clinical problems. The presence of pleurodiaphragmatic adhesions alone is not an indication for treatment—many healthy individuals have physiological variations in the pulmonary ligament that create apparent adhesions on imaging without any pathological significance. 2

Key Clinical Scenarios Requiring Intervention:

• Symptomatic pleural effusions with loculations: When adhesions prevent complete drainage and cause persistent dyspnea despite thoracentesis 1
• Trapped lung: When adhesions prevent lung re-expansion after fluid drainage, making pleurodesis ineffective 1
• Persistent air leak in pneumothorax: When adhesions complicate management and surgical intervention is needed at 3-5 days 1
• Pleuro-peritoneal leaks in dialysis patients: When adhesions contribute to recurrent hydrothorax 1

Diagnostic Workup Before Intervention

Use transthoracic ultrasonography (TUS) rather than CT to identify septations and adhesions. TUS has 81-88% sensitivity and 83-96% specificity for detecting septations, significantly outperforming CT (71% sensitivity, 72% specificity). 1 However, CT is superior for mediastinal or fissural loculations where overlying lung prevents ultrasound visualization. 1

Assess lung expandability before planning definitive therapy:

• Perform therapeutic thoracentesis and observe for complete lung re-expansion 1
• Absence of contralateral mediastinal shift with large effusion suggests trapped lung or endobronchial obstruction 1
• Initial pleural fluid pressure <10 cm H₂O predicts trapped lung 1

Surgical Management: VATS Adhesiolysis

VATS is the preferred approach for managing symptomatic pleurodiaphragmatic adhesions in stable patients due to lower morbidity (0.14% in-hospital mortality) and shorter hospital stays compared to open thoracotomy. 3

Technique Considerations:

• Direct visualization is essential: Adhesions must be lysed under direct vision to ensure complete treatment of the entire pleural surface 1, 4
• Combination approaches yield best results: When pleurodesis is needed, combined mechanical pleurodesis (with prolene mesh) plus chemical pleurodesis (with talc) has the lowest recurrence rate at 10%, compared to 33% for single-agent approaches 1, 4
• Additional procedures may be needed: Endoscopic suturing or Teflon patch repair can prevent recurrences in complex cases 1, 4

Common Pitfalls:

Incomplete adhesiolysis is the primary cause of treatment failure. 4 Ensure complete visualization of the diaphragmatic, mediastinal, and parietal pleura. Adhesions in the lower third of the pleural cavity are particularly problematic and predict higher pleural morbidity (46.4% vs 28.6%). 5

Special Scenario: Pleuro-Peritoneal Leaks in Dialysis Patients

For dialysis patients with pleurodiaphragmatic adhesions contributing to hydrothorax, use a stepwise approach:

1. Initial management: Discontinue peritoneal dialysis temporarily (2-6 weeks) and provide alternative renal replacement therapy—this succeeds in 53% of cases 1

2. If conservative management fails: Proceed to VATS with combined mechanical and chemical pleurodesis, which has superior outcomes to tube thoracostomy-directed pleurodesis alone (48% success rate) 1, 4

3. For large diaphragmatic defects: Direct surgical repair is required, as these cannot be adequately addressed by pleurodesis alone 1, 4

4. Post-procedure: Wait 3-4 weeks after surgical repair or pleurodesis before reinitiating peritoneal dialysis 1, 4

Important prognostic factors: Female gender, polycystic kidney disease, and early leaks (within 30 days of starting dialysis) predict higher failure rates. 4 In one study, 88% of non-surgically managed patients required withdrawal from peritoneal dialysis by 26 months, compared to 0% in the VATS repair group. 1

When NOT to Intervene

Asymptomatic pleurodiaphragmatic adhesions discovered incidentally require no treatment. 2 Physiological variations in the pulmonary ligament commonly create apparent irregularities in the diaphragmatic contour on chest radiographs in healthy individuals. 2

Contraindications to VATS

Convert to open thoracotomy when:

• Patient cannot tolerate single-lung ventilation (prior contralateral pneumonectomy, abnormal airway anatomy, mechanical ventilation dependence) 1
• Extensive adhesions prevent safe thoracoscope insertion—this situation is often only appreciated intraoperatively, so surgeons must be prepared to convert 1

Postoperative Considerations

Expect increased drainage and longer chest tube duration in patients with adhesions. Compared to patients without adhesions, those with pleurodiaphragmatic adhesions have significantly higher drainage on postoperative days 1-2 (478.5 ml vs 328.6 ml on day 1), longer air leak duration (2 vs 1 day), and longer chest tube stay (4 vs 2 days). 5 Remove chest tubes by postoperative day 2 when possible, as this reduces pleural morbidity from 57.9% to 36.9%. 5