Hydrothorax after robotic-assisted surgical staging of endometrial cancer

Hydrothorax after robotic-assisted surgical staging of endometrial cancer

Gynecologic Oncology Reports 3 (2013) 14–15 Contents lists available at SciVerse ScienceDirect Gynecologic Oncology Reports journal homepage: www.el...

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Gynecologic Oncology Reports 3 (2013) 14–15

Contents lists available at SciVerse ScienceDirect

Gynecologic Oncology Reports journal homepage: www.elsevier.com/locate/gynor

Hydrothorax after robotic-assisted surgical staging of endometrial cancer Holly R. Sato ⁎, Howard G. Muntz Women's Cancer Care of Seattle, Northwest Hospital & Medical Center, University of Washington Medicine, USA

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Article history: Received 30 August 2012 Accepted 13 October 2012 Available online 23 October 2012 Keywords: Robotic surgery Hydrothorax Laparoscopy Hysterectomy Endometrial cancer

Introduction Endometrial cancer is the most common gynecologic malignancy in the United States with an estimated 47,130 new cases in 2012 (Siegel et al., 2012). The International Federation of Gynecology and Obstetrics recommended surgical staging for endometrial cancer in 1988 based on findings that 20% of women with clinical stage I disease have evidence of extra-uterine disease at the time of surgery (Mikuta, 1993). Surgical staging entails total hysterectomy and bilateral salpingo-oophorectomy with pelvic and para-aortic lymphadenectomy routinely performed for patients who are at intermediate to high risk for lymph node spread. The recent introduction of the da Vinci Surgical System™ (Intuitive Surgical, Inc, Sunnyvale, CA) has advanced the field of gynecologic oncology by allowing more widespread use of a minimally invasive approach for the surgical management of endometrial cancer. There are currently 1615 da Vinci Surgical Systems™ installed in the United States (Intuitive Surgical). Use of the da Vinci Surgical System™ in gynecologic surgery requires steep Trendelenburg patient positioning in order to retract the bowel into the upper abdomen for visualization of the pelvic organs. A rare, yet serious, complication of pelvic laparoscopic surgery is hydrothorax from extravasation of irrigation fluid into the pleural space caused by a pleuroperitoneal leak. We present the first reported case of a hydrothorax due to a pleuroperitoneal leak in robotic-assisted surgery.

Case report The patient is a 61 year-old female with a history of Stage II left-sided breast cancer diagnosed 2 years prior treated with lumpectomy, lymph node sampling, radiation therapy, and chemotherapy. She did not receive adjuvant tamoxifen. She presented to her primary gynecologist for postmenopausal bleeding with endometrial biopsy revealing serous adenocarcinoma of the endometrium. Computed tomography scan was negative for findings concerning for metastatic disease. The patient underwent a robotic-assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, pelvic lymphadenectomy, and para-aortic lymphadenectomy to the level of the inferior mesenteric artery. She had a history of two prior cesarean sections and the uterus was densely adhered to the anterior abdominal wall requiring extensive adhesiolysis. There was also an incidentally found perforated diverticular abscess in the sigmoid colon that required repair. The remainder of the surgery was uncomplicated with a total robotic operative time of 207 min during which the patient was in steep Trendelenburg and 3000 ml of normal saline irrigation fluid was used. There was no indication of respiratory compromise during the surgery. The patient was extubated in the recovery room. She had a brief period of new onset atrial fibrillation shortly afterwards that resolved spontaneously. The episode of atrial fibrillation was attributed to acidemia as her arterial blood gas showed a pH of 7.27 and subsequent evaluation showed normal electrolytes, thyroid stimulating hormone, and echocardiogram. A chest radiograph in the post anesthesia care unit also revealed a new, large right pleural effusion (Fig. 1). The pleural effusion was attributed to a pleuroperitoneal leak of irrigation fluid into the pleural space during surgery as she did not have any other etiology for a sudden onset pleural effusion. She underwent thoracentesis on post-operative day one for 550 ml of fluid. Broad spectrum antibiotics were administered due to possible superimposed infection of the pleural fluid based on 32,681 nucleated cells per millimeter3 in the fluid. She continued to be symptomatically short of breath with increased oxygen requirements and underwent another thoracentesis for 200 ml of fluid on post-operative day two. Subsequent radiographs showed improvement in the size of the right pleural effusion. Cytology of the fluid revealed no malignant cells with no organisms growing from the final fluid culture. The patient subsequently improved and was discharged home on post-operative day six.

Discussion ⁎ Corresponding author at: Women's Cancer Care of Seattle, 1560 N. 115th St., Medical Office Building, Suite 101, Seattle, WA 98133, USA. Fax: +1 206 368 6808. E-mail addresses: [email protected], [email protected] (H.R. Sato). 2211-338X/$ – see front matter © 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.gynor.2012.10.004

Hydrothorax complicating laparoscopic surgery is a rare, yet known, complication and occurs when fluid from the intraabdominal

H.R. Sato, H.G. Muntz / Gynecologic Oncology Reports 3 (2013) 14–15

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hypothesis is supported by electron microscopy images showing 4–12 μm diameter pores between mesothelial cells and diaphragmatic lymphatics. Additionally, lymphatics are more numerous in the right diaphragm perhaps explaining the more common finding of a right hydrothorax (Verreault et al., 1986). Laparoscopic surgery may promote the passage of intraabdominal fluid into the pleural space in those patients at risk for this complication. Increased intraabdominal pressure due to insufflation of the abdomen during laparoscopy may force open defects in the diaphragm causing migration of fluid into the pleural space. The patient is also placed into Trendelenburg during pelviscopy, and even steeper Trendelenburg in robotic surgery, with fluid naturally pooling under the diaphragm then moving into the pleural space. This is the first reported case of hydrothorax due to a pleuroperitoneal leak in robotic-assisted surgery although it has been described in other varieties of surgery. Kanno et al. reported a hydrothorax occurring in a healthy woman who underwent a laparoscopic myomectomy (Kanno et al., 2001). A total of 6000 ml of irrigation was used with 5300 ml being recovered during the 4.5 hour procedure. The patient was hypoxic after extubation with chest radiograph revealing a large right pleural effusion. A chest tube was placed and 850 ml of fluid was drained. Ronghe et al. described three cases of hydrothorax after laparoscopic surgery for endometriosis during which 1 to 1.5 l of ADEPT™ (4% icodextrin), an anti-adhesion fluid, was left in the abdomen (Ronghe et al., 2009). Gallagher and Roberts-Fox reported a patient who developed a hydrothorax after operative hysteroscopy during which there was a perforation of theleft cornua resulting in 2 l of 1.5% glycine draining into the peritoneal cavity (Gallagher and Roberts-Fox, 1993). Hydrothorax has also complicated non-gynecologic surgery with Verma and Sekiya reporting a hydrothorax after hip arthroscopy (Verma and Sekiya, 2010). Extravasation of irrigation fluid into the abdominal cavity during hip arthroscopy is well documented in the orthopedic literature. However, in this particular patient, the fluid, normal saline with epinephrine, then passed into the pleural space leading to a symptomatic hydrothorax. Surgeons and anesthesiologists should be mindful of the amount of irrigation fluid used and recovered during robotic-assisted surgery. Hydrothorax should be considered in the differential diagnosis in patients undergoing any laparoscopic surgery with new onset respiratory compromise. Fig. 1. Post-operative anterior–posterior (A) and lateral (B) chest radiograph demonstrating large right hydrothorax.

Conflicts of interest

cavity passes into the pleural space through a pleuroperitoneal leak. This phenomenon has been commonly described in peritoneal dialysis patients and patients with cirrhosis. Acute pleural effusion in patients undergoing peritoneal dialysis occurs in 1.6 to 10% of patients with women more commonly experiencing this complication (Lew, 2010; Garcia and Carrasco, 1998). Right-sided pleural effusions are more common occurring in 88% of patients with this complication (Lew, 2010). Similarly, pleural effusions are seen in 5 to 10% of patients with cirrhosis, with right-sided effusions being more common, and are thought to be caused by leakage of ascites into the pleural space (Verreault et al., 1986). This leak has been demonstrated in studies in which radioisotope tagged fluid was injected into the peritoneal cavity with subsequent imaging revealing presence of the fluid in the pleural space (Verreault et al., 1986). Several mechanisms have been proposed to explain the etiology of the pleuroperitoneal leak. Many propose the presence of a congenital diaphragmatic defect connecting the peritoneal cavity to the pleural space (Lew, 2010). Another hypothesized mechanism is that peritoneal fluid passes into the pleural space through diaphragmatic lymphatics (Verreault et al., 1986). This

References

There are no conflicts of interest to disclose.

Gallagher, M.L., Roberts-Fox, M., 1993. Respiratory and circulatory compromise associated with acute hydrothorax during operative hysteroscopy. Anesthesiology 79, 1129–1131. Garcia, R.R., Carrasco, A.M., 1998. Hydrothorax in peritoneal dialysis. Perit. Dial. Int. 18, 5. Intuitive Surgical, a. Second quarter earnings 2012http://phx.corporate-ir.net/phoenix. zhtml?c=122359&p=irol-IRHome Accessed July 26, 2012. Kanno, T., Yoshikawa, D., Tomioko, A., Kamijyo, T., Yamada, K., Goto, F., 2001. Hydrothorax: an unexpected complication after laparoscopic myomectomy. Br. J. Anaesth. 87, 507–509. Lew, S.Q., 2010. Hydrothorax: pleural effusions associated with peritoneal dialysis. Perit. Dial. Int. 20, 13–18. Mikuta, J.J., 1993. International Federation of Gynecology and Obstetrics staging of endometrial cancer 1988. Cancer 71, 1460–1463. Ronghe, R., Bjornsson, S., Hannah, P., 2009. Pleural effusion following use of saline and fluid anti-adhesion agents at laparoscopic surgery — a case series of three patients. BJOG 116, 1524–1526. Siegel, R., Naishadham, J., Jemal, A., 2012. Cancer statistics 2012. CA Cancer J. Clin. 62, 10–29. Verma, M., Sekiya, J.K., 2010. Intrathoracic fluid extravasation after hip arthroscopy. Arthroscopy 26, S90–S94. Verreault, J., Lepage, S., Bisson, G., Plante, A., 1986. Ascites and right pleural effusion: demonstration of a peritoneo-pleural communication. J. Nucl. Med. 27, 1706–1709.