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Objectives: Treatment of refractory hepatic hydrothorax, a complication of liver cirrhosis, is complex. We aimed to investigate the usefulness of the '4-step approach', which is a minimally invasive surgical strategy combining 4 therapeutic modalities: (i) pneumoperitoneum to localize diaphragmatic defects; (ii) thoracoscopic pleurodesis; (iii) postoperative positive-pressure ventilation; and (iv) peritoneal drainage for abdominal decompression., Methods: We retrospectively analysed the medical records of 12 patients with hepatic hydrothorax who underwent surgical treatment using the 4-step approach from January 2013 to December 2017. Nine of them (75.0%) were Child C cases; the median model for end-stage liver disease score was 20.5. The diaphragmatic defects localized after forming a pneumoperitoneum were treated with primary closure followed by thoracoscopic pleurodesis, postoperative positive-pressure ventilation and peritoneal drainage., Results: Diaphragmatic defects were localized in all patients except one. The median postoperative positive-pressure ventilation duration was 20.1 h. Peritoneal drainage was performed for a median duration of 5 days; the peritoneal drains were removed at a median of 8 postoperative days. The median duration of postoperative hospital stay until discharge/transfer was 9.5 days. No operative mortalities occurred. The median duration of follow-up was 10.9 months. Eight deaths (66.7%) occurred during the follow-up period; however, no deaths were surgery-associated. Ipsilateral pleural effusion recurred in 3 patients (25%), among whom reoperation was performed in 1 without recurrence at the 13-month follow-up., Conclusions: The 4-step approach seems to be a safe and effective minimally invasive surgical strategy for treating refractory hepatic hydrothorax., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

We report the case of a 63-year-old female with hepatic cirrhosis due to chronic hepatitis C, successfully treated for refractory nonmalignant hepatic hydrothorax by using a long-term pleurovenous shunt (PVS). After failure of conventional treatment by mechanical pleurodesis, a PVS was inserted to drain the pleural fluid into the right subclavian vein. After 8 months of follow-up, the effusion is well controlled, and the shunt remains patent.

Hydrothorax developing from pleuroperitoneal communication as a complication of peritoneal dialysis was first described in 1967 [Edward SR, Unger AM. Acute hydrothorax-a new complication of peritoneal dialysis. JAMA 1967; 199:853-5. ]. The incidence of hydrothorax is approximately 1.6-2% of continuous ambulatory peritoneal dialysis (CAPD) patients. The key to successful therapy is obliteration of the transdiaphragmatic route of dialysate leakage with video-assisted thoracoscopic surgery (VATS). The method in which air leakage is checked intraoperatively is the preferred choice and better than all other procedures.

Diaphragmatic rupture due to blunt trauma is well recognised though uncommon. Most cases are diagnosed at the time of injury, but a proportion remain undiagnosed, only to present some months or even years later. This "delayed" group can present in a number of ways, including chronic abdominal and chest problems or an acute crisis. Herniation of abdominal viscera is the most common sequel, with strangulation and gangrene as the most serious complication. This paper reports a case of delayed presentation of diaphragmatic rupture and herniation presenting as tension hydropneumothorax due to small bowel perforation. A short discussion addresses the problems in diagnosis of this condition. We believe this to be the first reported case of perforated small bowel leading to tension hydropneumothorax.