[Thoracoscopic diaphragmatic plication technique in a patient with refractory hepatic hydrothorax]

Refractory hepatic hydrothorax (HH) is the persistent accumulation of pleural effusion secondary to portal hypertension, in the absence of cardiopulmonary or pleural etiology. It is diagnosed in patients with cirrhosis and it is a diagnosis of exclusion. Initial management consists of diuretics and sodium restriction, with a success rate of 75-80%; the remainder progress to refractory HH. Diaphragmatic plication via thoracoscopy combined with chemical pleurodesis has emerged as a therapeutic alternative to improve quality of life and reduce hospitalizations.

A 64-year-old woman with cirrhosis due to primary biliary cholangitis, Child-Pugh B (9 points), MELD 3.0: 15 points (bilirubin 1.7 mg/dL, INR 1.0, creatinine 1.3 mg/dL, sodium 140 mEq/L, albumin 2.0 g/dL). The patient presented with pleuritic pain, dyspnea mMRC IV, and transudative pleural effusion. Diuretic therapy with propranolol, furosemide, and spironolactone was administered, along with sodium restriction (80-90 mEq/day) and fluid restriction (< 2 L/day), without improvement and with symptom progression. A diagnosis of refractory HH was made, and thoracoscopic diaphragmatic plication with chemical pleurodesis was performed, resulting in a reduction of the effusion and clinical improvement. 6 months later, there was no clinical or radiological recurrence.

Diaphragmatic plication closes defects that communicate between the abdominal and pleural cavities, reducing the pleuroperitoneal gradient. Chemical pleurodesis induces pleural adhesion and obliteration of the space. The combination of both techniques increases therapeutic effectiveness.