Chest surgery clinics of North America
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The proper management of a pleural effusion in a patient with malignancy is based on an understanding of the normal anatomy and physiology of the pleural space and the ways in which they are altered by disease. The major challenge in diagnosing and treating a cancer patient who develops a pleural effusion is determining the cause of the effusion accurately and quickly and choosing a treatment that is best suited to the individual patient. Careful selection of the treatment for pleural effusions, however, relieves symptoms in the vast majority of patients with little accompanying morbidity.
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Chest Surg. Clin. N. Am. · Aug 1994
ReviewThoracoscopy for the evaluation and treatment of pleural space disease.
Pleural disease provided the first and, for many years, the only indication for thoracoscopy. It remains the most efficient way of obtaining a diagnosis in cases of pleural effusions not diagnosed by thoracentesis and closed-needle biopsy, especially when malignancy is suspected. Thoracoscopy also can provide enough tissue to define cell type. ⋯ In early empyemas, adhesions and loculatons can be addressed, the infected material removed, and the cavity irrigated. If the lung then fully expands, the tubes may be removed when the drainage ceases, precluding the prolonged retention of empyema tubes. Thoracoscopy also has proved useful in the management of benign pleural tumors, hemothorax, and chylothorax.
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The pleural cavity is created between the 4th and 7th week of embryologic development and is lined by the splanchnopleurae and somatopleurae. These embryonic components of visceral and parietal pleurae develop different anatomic characteristics with regard to vascular, lymphatic, and nervous supply. Both pleurae have two layers: a superficial mesothelial cell layer facing the pleural space and an underlying connective tissue layer. ⋯ It flows downward along a vertical pressure gradient, presumably determined by hydrostatic pressure and resistance to viscous flow. There also may be a net movement of fluid from the costal pleura to the mediastinal and interlobar regions. In these areas, pleural fluid is resorbed primarily through lymphatic stomata on the parietal pleural surface.