Plevral Efüzyonlarda Tanısal Yaklaşım ve Cerrahi Tedavi
Özet
Plevra, akciğerleri ve göğüs duvarını örten, aralarında negatif basınçlı sıvı barındıran mezotelyal seröz bir yapıdır. Plevral boşlukta sıvı birikmesi olan plevral efüzyonlar; hidrostatik/onkotik basınç değişiklikleri, plevral basınç azalması veya geçirgenlik artışı gibi mekanizmalarla gelişir. Işık (Light) kriterlerine göre transüda ve eksüda olarak iki ana gruba ayrılırlar. Transüdalar çoğunlukla konjestif kalp yetmezliği ve siroz gibi sistemik hastalıklardan kaynaklanırken; eksüdalar maligniteler, tüberküloz ve parapnömonik enfeksiyonlar gibi lokal patolojilere sekonder gelişir. Tanısal süreçte anamnez ve fizik muayenenin ardından akciğer grafisi, ultrasonografi, bilgisayarlı tomografi ve torasentez gibi yöntemler etkin şekilde kullanılır. Kesin tanı konulamayan durumlarda veya loküle sıvıların yönetiminde video yardımlı torakoskopi (VATS) yüksek tanısal başarı sunar. Tedavi yaklaşımı transüdalarda öncelikle altta yatan primer hastalığın medikal kontrolüne dayanırken; komplike eksüdalarda, ampiyemde ve malign plevral efüzyonlarda tüp torakostomisi, fibrinolitik tedavi, kimyasal plöredezis (özellikle steril talk ile) ve dekortikasyon gibi minimal invaziv veya cerrahi müdahaleler multidisipliner bir şekilde uygulanır.
The pleura is a mesothelial serous structure covering the lungs and chest wall, maintaining a negative pressure fluid space. Pleural effusions, characterized by fluid accumulation in this space, develop due to hydrostatic/oncotic pressure alterations, decreased pleural pressure, or increased permeability. Based on Light's criteria, effusions are categorized into transudates and exudates. Transudates primarily stem from systemic diseases like congestive heart failure and cirrhosis, whereas exudates are secondary to local pathologies such as malignancies, tuberculosis, and parapneumonic infections. Following history and physical examination, imaging modalities like chest radiography, ultrasonography, computed tomography, and thoracentesis are effectively utilized for diagnosis. In undiagnosed cases or for managing loculated fluids, video-assisted thoracoscopic surgery (VATS) provides high diagnostic yields. The therapeutic approach for transudates focuses on the medical management of the primary underlying disease. Conversely, complicated exudates, empyema, and malignant pleural effusions require a multidisciplinary approach involving minimal invasive or surgical interventions, including tube thoracostomy, fibrinolytic therapy, chemical pleurodesis (predominantly with sterile talc), and decortication.
Referanslar
Soysal Ö, Ziyade S. 2013. İlker Özden, Hasan Şevket Kavukçu (Ed.), Göğüs Cerrahisi (1585-1601). İstanbul: İstanbul Tıp Kitapevi
Saenz NC, Schnitzer JJ, Eraklis AE, et al. Posterior mediastinal masses. J Pediatr Surg 1993;28(2):172–176.
Reynolds M. Benign and malignant mediastinal neurogenic tumors in infants and children. In: Shields TW, ed. Mediastinal Surgery. Philadelphia, PA: Lea & Febiger; 1991, 4348-4367
Ribet ME, Cardot GR. Neurogenic tumors of the thorax. Ann Thorac Surg 1994;58(4):1091–1095.
Albertino K. Structure, blood supply and lymphatic vessels of the sheep’s visceral pleura. Am J Anat 1982;165-227
Agostoni E, Zocchi L. Pleural liquid and its exchanges. Respiratory Physiology & Neurobiology 2007;159:311–323.
Weinberger SE. Pulmonary anatomy and physiology. In: Weinberger SE (Ed). Principles of Pulmonary Medicine. 3rd. Ed. Philadelphia: W.B Saunders Company, 1998: Chapter 1: 1-20.
Menzies R, Fraser R. Round atelectasis. Pathologic and pathogenic features. Am J Surg Pathol 1987;11:674–81.
Wang PM, Lai-Fook SJ. Upward flow of pleural liquid near lobar margins due to cardiogenic motion. J Appl Physiol 1992; 73: 2314.
Wang PM, Lai-Fook SJ. Upward flow of pleural liquid near lobar margins due to cardiogenic motion. J Appl Physiol 1992; 73: 2314.
Lai J, Gouldstone A, Butler JP, et al. Relative motion of the lung and chest wallpromotes uniform pleural space thickness. Respir. Physiol. Neurobiol. 2002;131:233–243.
Zocchi L. Physiology and pathophysiology of pleural fluid turnover. Eur Respir J 2002; 20:1545–1558.
Curry FE. Mechanics and thermodynamics of capillary exchange. In: Handbook of Physiology. Renkin Eugene M, Christopher Charles Michel (Eds). The Cardiovascular System. Microcirculation. Bethesda, MD: Am. Physiol. Soc., 1984, sect. 2, vol. IV, chapt. 8,p.309–374.
Light RW, Roger JT, Moyer JP, et al. Prevalence and clinical course of pleural effusions at 30 days after coronary artery and cardiac surgery. Am J Respir Crit Care Med 2002;166(12 Pt 1): 1567-71.
Marel M. Epidemiology of pleural effusion. Eur Respir Mon 2002;22:146-56.
http://www.cdc.gov. National vital statistics. Mortality. Ageadjusted death rates 358 selected causes by race and sex
Şenyiğit A, Işık B, Coşkunsel N, Anık H, Özbay B, Topçu F. 305 plevral effüzyonlu vakanın incelenmesi. Solunum Hastalıkları 1996;7(3):395-404.
Metintaş, M. 2016. Plevral Hastalıklar Tanı ve Tedavi Rehberi. Bilimsel Tıp Yayınevi, Ankara
Light RW. Pleural effusion. NEJM 2002;346:1971–1977.
Kalomenidis I, Light RW. Eosinophilic pleural effusions. Curr Opin 2003;9;254-260
Sahn AS, Heffner JE. Pleural fluid analysis. In Textbook of Pleural Diseases. Ed. Light RW, Lee YCG. Arnold 2003:191-209
Chang SC, Perng RP. The Role of Fiberoptic Bronchoscopy in Evaluating the Causes of Pleural Effusions. Arch Intern Med.1989;149:855-857
Quinn T, Alam N, Aminazad A, et al. Decision making and algorithm forthe management of pleural effusions. Thorac Surg Clin. 2013;23(1) 11-6
Ali Özdülger, Bahar Ulubaş. Plevral efüzyonlar ve tedavisi ve Plevra Tüberkülozu. Göğüs Cerrahisi, Ed.Mustafa Yüksel, Akın Eraslan Balcı. Nobel Tıp, 2015; 529-539
Soni NJ, Franco R, Velez MI, et al. Ultrasound in the diagnosis and management of pleural effusions. J Hosp Med. 2015 Dec;10(12):811-6
Grimberg A, Shiueoka DC, Atallah AN et al. Diagnostic accuracy of sonography for pleural effusion: systematic review. Sao Paulo Med J 2010;128(2):90-5.
Alrajab S, Youssef AM, Akkus N et al. Pleural ultrasonography versus chest radiography for the diagnosis of pneumothorax: review of the literature and meta-analysis. Crit Care 2013;17(5):R208.
Blaivas M, Lyon M, Duggal S. A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. Acad Emerg Med 2005;12(9):844-9.
Mercaldi CJ, Lanes SF. Ultrasound guidance decreases complications and improves the cost of care among patients undergoing thoracentesis and paracentesis. Chest 2013;143(2):532-8.
Stigt JA, Groen HJ. Percutaneous ultrasonography as imaging modality and sampling guide for pulmonologists. Respiration 2014;87(6):441-51.
Koegelenberg CF, Irusen EM, Von Grote et al. The utility of ultrasound-guided thoracentesis and pleural biopsy in undiagnosed pleural exudates. Thorax 2015;70(10):995-7.
Grogan DR, Irwin RS, Channick R et al. Complications associated with thoracentesis. A prospective, randomized study comparing three different methods. Arch Intern Med 1990;150(4):873-7.
Barnes TW, Morgenthaler TI, Olson EJ et al. Sonographically guided thoracentesis and rate of pneumothorax. J Clin Ultrasound 2005;33(9):442-6.
Hooper C, Lee YC, Maskell N. Investigation of a unilateral pleural effusion in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010;65(Suppl 2):ii4-17.
Qureshi NR, Rahman NM, Gleeson FV. Thoracic ultrasound in the diagnosis of malignant pleural effusion. Thorax 2009;64(2):139-43.
Na MJ. Diagnostic tools of pleural effusion. Tuberc Respir Dis (Seoul). 2014 May;76(5):199-210.
Leung AN, Muller NL, Miller RR. CT in differential diagnosis of diffuse pleural disease. AJR Am J Roentgenol 1990;154(3):487-92.
Metintas M, Üçgün I, Elbek O, et al. Computed tomography features in malignant pleural mesothelioma and other commonly seen pleural diseases. Eur J Radiol 2002;41(1):1-9.
Maasilta P, KivisaariL, Holsti LR, et al. Radiographic chest assessment of lung injury following hemithorax irradiation for pleural mesothelioma. Eur Respir J 1991;4(1):76-83.
Sahin AA, Cöplü L, Selçuk ZT, et al. Malignant pleural mesothelioma caused by environmental exposure to asbestos or erionite in rural Turkey: CT findings in 84 patients. AJR Am J Roentgenol 1993;161(3):533-7.
Porcel JM, Hernandez P, Martinez-Alanso M, et al. Accuracy of fluorodeoxyglucose-PET imaging for differentiating benign from malignant pleural effusions: a metaanalysis. Chest 2015;147(2):502-12.
Abrams LD. A pleural-biopsy punch. Lancet 1958;1(7010):30-1.
Pereyra MF, San-Jose E, Ferreiro L, et al. Role of blind closed pleural biopsy in the managment of pleural exudates. Can Respir J 2013;20(5):362-6.
Chakrabarti B, Ryland I, Sheard J, et al. The role of Abrams percutaneous pleural biopsy in the investigation of exudative pleural effusions. Chest 2006;129(6):1549-55.
Proakash URS, Reiman HM. Comparison of Needle Biopsy with Cytologic Analysis fort the Evaluation of Pleural Effusion: Analysis of 414 Cases. Mayo Clinic Proc 1985:60;158-64
Maskell NA, Gleeson FV, Davies RJ. Standard pleural biopsy versus CT-guided cutting-needle biopsy for diagnosis of malignant disease in pleural effusions: a randomised controlled trial. Lancet 2003;361(9366):1326-30.
Loddenkenper R. Thoracoscopy- State of the Art. Eur Respir J 1998: 11;213-221
Rahman NM, Ali NJ, Brown G, et al. Local anaesthetic thoracoscopy: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010;65(Suppl 2):ii54-60.
Rodriguez-Panadero F, Janssen JP, Astoul P. Thoracoscopy:general overview and place in the diagnosis and management of pleural effusion. Eur Respir J 2006;28(2):409-22.
Rayn CJ, Rodgers RF, Unni KK, Hepper NG. The Outcome of Patients with Pleural Effusion of Undeterminate Cause at Thoracotomy. Mayo Clin Proc 1981:56; 145-149
Cardenas A, Arroya V. Manegment of ascites and hepatic hyrothorax. Best Pract Res Clin Gasteroenterol 2007;21:55-77
Runyon BA,Greenblatt M, Ming RCH, et al. Hepatic Hydrothorax is a Relative Contraindication to Chest Tube Insertion. Am J Gastroenterol 1986;81:566-567
Ray S, Mukherjee S, Ganguly J, et al. A cross-sectional prospective study of pleural effusion among cases of chronic kidney disease. Indian J Chest Dis Allied Sci 2013;55(4):209-13.
Ziyade S, Uğurlucan M, Soysal Ö. Urinothorax: urine Discharge from thorax. Ann Thorac Surg 2008;85:2141
Porsel JM, Light RW. Plerual effusions due to pulmonary emboli. Curr Opin Pulm Med. 2012; 18. 355-358
Coche EE, Muller NL, Kim KI, et al. Acute pulmonary Embolism: Ancillary Findings at Spiral CT. Radiology 1998;207: 753-758
Kalomenidis I, Stathopoulos GT, Barnette R, et al. Vascular endothelial growth factor levels in post-CABG pleural effusions are associated with pleural inflammation and permeability. Respir Med 2007;101(2):223-9.
Edling JE, Bacon BR. Pleuropulmonary complications of endoscopic variceal scerotherapy. Chest 1991;99:1252-7
Güler M. Tüberküloz Plörezi. In: Özkara Ş, Kılıçaslan Z (eds). Tüberküloz. İstanbul: Toraks Kitapları. 2010;275-290.
Ulubaş BB, Mutlu AG, Ökten F, ve ark. 164 Tüberküloz Plörezili Olgunun Retrospektif İncelenmesi. Solunum Hastalıkları 2000;11:401-405.
Yurdakul AS, Çalışır HC, Taci N ve ark. Tüberküloz Plörezi Olgularının Özellikleri. Solunum Hastalıkları 2002;13:30-36.
Mihmanlı A, Özşeker F, Baran A, ve ark. Tüberküloz plörezili 105 olgunun değerlendirilmesi. Tüberküloz ve Toraks Dergisi 2004;52(2):137-144.
Dalar L, Karasulu L, Özkan, ve ark. Tüberküloz Plörezi Tanısında Kanser Antijen 125 (CA 125)’in Tanı Değeri. Toraks Dergisi 2008;9(1):27-33.
Görgün D, Bayraktaroğlu M, Seçik F, ve ark. Tüberküloz Plörezinin Özellikleri ve Tanı Yöntemlerinin Değerlendirilmesi. Solunum 2009;11(2):54-60.
Lazarus AA, McKay S, Gilbert R. Pleural tuberculosis. Dis Mon 2007;53(1):16-21.
Kerti CA, Micron I, Cozma GV, et al. The role of surgery in the management of pleuropulmonary tuberculosis - seven years’ experience at a single institution. Interact Cardiovasc Thorac Surg 2009;8(3):334-7
Tong BC, Hanna J, Toloza EM, et al. Outcomes of video-assisted thoracoscopic decortication. Ann Thorac Surg 2010;89(1):220-5.
Günlüoğlu Z, Gürses A. In: Turna A, Eroğlu A, Kayı Cangır A eds. Göğüs Cerrahisi 2. Baskı İstanbul, İstanbul Tıp Kitapevi.2013;1519-35
Rahman NM, Maskell NA, Davies CW, et al. The relationship between chest tube size and clinical outcome in pleural infection. Chest 2010; 137:536.
Tokuda Y, Matsushima D, Stein GH, Miyagi S. Intrapleural fibrinolytic agents for empyema and complicated parapneumonic effusions: a meta-analysis. Chest 2006;129:873.
Medford AR, Awan YM, Marchbank A, et al. Diagnostic and therapeutic performance of video-assisted thoracoscopic surgery (VATS) in investigation and management of pleural exudates. Ann R Coll Surg Engl 2008;90(7):597-600.
Johnston WW. The malignant pleural effusion: A review of cytopathlogical diagnoses of 584 specimens from 472 consecutive patients. Cancer. 1985;56:905-909.
Psallidas I, Kalomenidis I, Porcel JM, et al. Malignanth pleural effusion: from bench to bedside. European Respiratory Review: an Official Journal of the European Respiratory Society, 01 Jun 2016, 25 (140):189-198.
Light RW, Hamm H. Malignant pleural effusion: Would the real cause please stand up? The European Respiratory Journal. 2007; 10:1701-1702.
Wei Y, Shen K, Tanfeng Lv, et al. Comparison between closed pleural biopsy and medical thoracoscopy for the diagnosis of undiagnosed exudative pleural effusions: a systematic review and meta-analysis. Transl Lung Cancer Res 2020;9 (3):446-458.
Garrido W, Viedma EC, Villar AF, et al. Recommendations of diagnosis and treatment of pleural effusion. update. Archivos de Bronconeumologia (English Edition). 2014;50 (6):235-49.
Murthy SC, Rice TW. Surgical management of malignant pleural effusions. Thorac Surg Clin. 2013;23 (1):43-9.
Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: the TIME2 randomized controlled trial. JAMA 2012;307 (22):2383-9.
Işık AF, Şanlı M, Yılmaz M, et al. Intraplural hyperthermic perfusion chemotherapy in subjectswih metastatic plural malignancies. Respiratory medicine 2013;107 (5):762-7.
Van Leeuwen Bl, Graf W, Phalman L, Mahteme H. Swedish experience with peritonectomy and HIPEC. HIPEC in peritoneal carcinomatosis. Ann Surg Oncol 2008;15 (3):745-53.
Bibby AC, Dorn P, Psallidas I, et al. ERS/EACTS statement on the management of malignant pleural effusions. Eur Respir J. 2018; 52 (1):1800349. Published 2018 Jul 27.
Heffner, John E (Au), Maldonado, Fabien (SectionEd), Finlay, Geraldine (DeputyEd). Chemical pleurodesis. Jan 2020. Up to date. WoltersKluwer
Baiu I, Yevudza E, Shrager JB. Talc Pleurodesis: A Medical, Medicolegal, and Socioeconomic Review. Ann Thorac Surg. 2020; 109 (4):1294-1301.
Tan C, Sedrakyan A, Browne J, et al. The evidence on the effectiveness of management for malignant pleural effusion: a systematic review. Eur J Cardiothorac Surg 2006; 29:829.
Undiganosed pleural effusion. In: Light RW, Gary Lee YC (eds). Textbook of Pleural Diseases. 2nd ed. London: Hodder Arnold, 2008:491-7.
Davies HE, Nicholson JE, Rahman NM, et al. Outcome of patients with nonspecific pleuritis/ fibrosis on thoracoscopic pleural biopsies. Eur J Cardiothorac Surg 2010;38(4):472-7.
Venekamp LN, Velkeniers B, Noppen M. Does ‘idiopathic pleuritis’ exist? Natural history of non-specific pleuritis diagnosed after thoracoscopy. Respiration 2005;72(1):74-8.
Metintas M, Ak G, Cadırcı Ö, et al. Outcome of patients diagnosed with fibrinous pleuritis after medical thoracoscopy. Respir Med 2012;106(8):1177-83.
