Hydrothorax due to PPC is a rare but a well-known complication of CAPD . When hydrothorax is found in CAPD patients, the cause is suspected to be PPC. Hydrothorax is usually found in a right-sided cavity and involves cough, dyspnea, and chest pain, but some patients have no symptoms .
As the onset cause of PPC, several studies speculate that PPC is speculated to be induced by (1) the defects of diaphragm due to abnormal intraperitoneal pressure, (2) congenital or traumatic diaphragm defects, (3) defects or laceration of blebs in the fragile region of the diaphragm, and (4) migration through lymphatic vessels [3,4,5,6]. In this report, the pathogenesis in the patient was suspected to be an abnormal intraperitoneal pressure caused by injecting a CAPD solution, leading to the defect of the diaphragm.
PPC is diagnosed by pleural fluid examination and the transition of 99mTc-MAA radioscintigraphy from peritoneal cavity to pleural cavity. In this case, the preoperative diagnosis of PPC was obtained by using 99mTc-MAA radioscintigraphy.
Although approximately 50% of the patients need to convert to hemodialysis, most of the patients still need to continue CAPD for social reasons . Either a nonsurgical or surgical method is taken for treating PPC. As the nonsurgical method, pleurodesis and the temporary cessation of CAPD are performed. For pleurodesis, OK-432, talc powder, fibrin glue, and minomycin are used. Temporary cessation of CAPD may lead to the spontaneous healing of diaphragmatic defects. However, the nonsurgical method is estimated to be effective for only 50% of all cases . Most of the patients still need to continue CAPD for social reasons, and they require surgical treatment. As the surgical procedure to treat PPC, the resection, direct suturing, and reinforcement of the responsible lesion of the diaphragm are performed, and these techniques are used either singly or in combination. In 1996, Di Bisceglie et al. reported the first case of VATS for PPC . Observing the thoracic cavity more precisely, VATS can be a highly useful approach than thoracotomy. Saito et al. reviewed 29 cases of PPC and found that the overall treatment success rate for PPC is 72%. According to the previous report, the success rate is 89% in 21 fistula-confirmed cases, but only 38% in 8 cases in which fistulae are unconfirmed. In this case, by carefully inspecting the diaphragm with a thoracoscope, a hole was detected at the right central tendon of the diaphragm, and direct suturing was performed successfully.
In previous reports, PGA sheets, fibrin glue, and pericardial fat pad tissues are used to reinforce the diaphragm for treating PPC [8, 9]. However, the recurrence of PPC is still reported. In this case, reinforcement was strengthened for reducing the recurrence of hydrothorax more. As additional reinforcement materials, the latissimus dorsi and intercostal muscles can be considered. There is no report on the reinforcement of the diaphragm with pedicled muscle flaps. In this case, we selected a harvested pedicled LDM flap by minimal invasive technique, because it has a sufficient volume and blood flow for reinforcing the closed fistulae and its surroundings. Furthermore, for preventing the recurrence of hydrothorax from other parts of the central tendon center, we have used PGA sheet and fibrin glue.