الفهرس 
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Abstract
Pleural effusion is one of the commonest disease entities seen by the pulmonologists. Pleural effusion can occur as a complication of many different diseases. The vigor with which various diagnoses are pursued depends on the likelihood that the individual has that particular disease.
Establishing an accurate diagnosis is an essential step in management of patients with pleural effusion. Thoracentesis is usually the first step in management of a patient with pleural effusion of unknown etiology. Pleural histopathology is often required to establish a diagnosis. Using pleural fluid cytological and microbiological analysis alone, the cause remain obscure in approximately 40% of malignant pleural effusions, 60% in effusions due to mesothelioma and most of cases with tuberculous pleural effusion.
Options available for pleural fluid–negative disease are limited to blind pleural biopsy (non-image guided) using Abram’s or Cope’s needle, image-guided pleural biopsy (ultrasonography or computed tomography-guided), surgical thoracotomy and finally thoracoscopy. A variety of diagnostic and therapeutic indications for medical thoracoscopy are usually adopted e.g. pleural effusion of unknown origin, suspected tuberculous pleuritis, suspected malignancy and recurrent pleural effusion requiring pleurodesis. For expert pulmonologists, advanced procedures in medical thoracoscopy are the non-routine and complex applications of the method. These applications are thoracoscopic management of the infected pleural space, thoracoscopic lung biopsy and sympathectomy.
The aim of this work was to evaluate the role of rigid medical thoracoscopy in management (diagnosis and possible treatment) of patients with undiagnosed exudative pleural effusion.
The current study enrolled 60 patients with symptomatic undiagnosed exudative pleural effusion. Medical thoracoscopy using rigid non-disposable, re-sterilizable instruments was performed in all studied patients for diagnostic and/or therapeutic purposes. The mean age was 53.9 years (SD 13.9 years). Forty-eight (80%) patients lied in the age group between 40 and 80 years. The number of male patients was 36 (60%) while 24 (40%) patients were females.
Symptoms encountered were dyspnea in 59 (98.3%) patients, cough in 17 (28.3%) patients, chest pain in 24 (40 %) patients, wheezes in 8 (13.3%) patients, fever in 3 (5%) patients and loss of weight in 28 (46.7%) patients. Dyspnea was the most common presenting symptom in the current study.
Regarding radiological findings, the pleural effusion was right-sided in 34 (56.7%), left-sided in 25 (41.6%) patients and bilateral in one (1.7%) patient. For the amount of pleural effusion, pleural collection was described as mild in 11 (18.3%) patients. Moderate effusion was detected in 31 (51.7%) patients. Large/Massive pleural effusion was detected in 18 (30%) patients. Pleural thickening was detected in 25 (41.7%) patients, pleural nodules in 10 (16.7%) patients, mediastinal lymphadenopathy in 22 (36.7%) patients, parenchymal nodules in 15 (25%) patients and parenchymal masses in 8 (13.3%) patients. Pleural thickening (41.7%) was noted to be the commonest finding in the computed tomography of the studied patients.
With respect to pleural fluid analysis, the mean pleural fluid protein and glucose contents were 4.9 gm/dl (SD 0.9 gm/dl) and 91.1 mg/dl (SD 48.5 mg/dl), respectively. The 5% trimmed mean (TrMean) pleural fluid lactate dehydrogenase (LDH) value was 556.6 IU/L (SD 645.4 IU/L). Adenosine deaminase (ADA) level was estimated in the pleural fluids of 10 studied patients. The mean pleural fluid ADA level was 23.3 U/L (SD 11.8 U/L). Pleural fluid of the studied patients was lymphocytic in 47 (78.3%) patients and neutrophilic in 13 (21.7%) patients. Malignant cells were detected in the pleural fluid of 4 (6.7%) studied patients before planning for thoracoscopy. Zheil-Nelsen stain of the pleural fluid of all studied patients was negative. All pleural fluid cultures were sterile.
The mean amount of pleural fluid drained during thoracoscopy was 2.5 L (SD 1.6 L). Lesions were present on the anterior parietal pleura in 45 (75%) patients, on the posterior parietal pleura in 56 (93.3%) patients, on the diaphragmatic parietal pleura in 49 (81.7%) patients and on the visceral pleura in 49 (81.7%) patients. Pericardial lesions were detected in 4 (6.7%) patients. Posterior parietal pleura was the most common affected location in the current study.
Pleural nodules were the commonest lesions detected as 37 (61.7%) patients had pleural nodules during thoracoscopic examination. Pleural plaques were found in 24 (40%) patients, pleural masses were found in 6 (10%) patients, focal pleural thickening was detected in 10 (16.7%) patients and finally pleural peel was found in 20 (33.3%) patients. There was significant positive correlation between the presence of pleural nodules and the occurrence of complications (X2=4.435, p=0.037). The mean thoracoscopy score was 5.9 (SD 3). Regarding adhesions encountered inside the pleural space during thoracoscopy, 24 (40%) patients were adhesion-free “grade 0”. Adhesions were grade 1 in 15 (25%) patients, grade 2 in 9 (15%) patients, grade 3 in 11 (18.3%) patients and grade 4 in a single patient. The higher the thoracoscopy score “more involvement of the pleura”, the higher the grade of adhesion “more adhesions” (r= 0.296, p=0.022). There was significant relation between the grade of adhesions and the aetiology of the pleural effusion (kwX2=9.171, p=0.01) with higher grades found in benign lesions (NSP and TB) and lowest grades found in malignant mesothelioma and malignant extrapulmonary causes of pleural effusion.
Pleural effusion was of benign nature in 21 (35%) patients (TB pleuritis in 7 (11.7%) patients and non-specific pleurisy (NSP) in 14 (23.3%) patients), while malignant pleural effusion was diagnosed in 39 (65%) patients (Bronchial carcinoma in 16 (26.7%) patients , malignant mesothelioma (MM) in 7 (11.7%) patients, metastasis from cancer ovary in 3 (5%) patients, cancer breast in 2 (3.3%) patients, adenocarcinoma of unknown primary in 8 (13.2%) patients and other malignancies in 3 (5%) patients). Malignant nature of pleural effusion was more common in higher age group (T=2.735, p=0.01).