Muhammet Reha ÇELİK, Hakkı ULUTAŞ, Akın KUZUCU

Intrapleural Fibrinolytic Treatment: Management of 85 Cases

Amaç: Komplike plevral efüzyonlarda sadece tüp ve katater torakostomi ile sıvıyı drene etmek her zaman mümkün olmaz. Dreneedilemeyen kan, pıhtı, ampiyem, benign veya malign plevral sıvılarda 7-10 gün içinde akciğer üzerinden fibröz bir kabuk oluşmaya başlar. Budurum ise tuzaklanmış akciğer ve akciğer restriksiyonu, sekonder ampiyem ve dispne ile sonuçlanır. Streptokinaz yada Tissue PlazminojenActivatörü (tPA), fibrin ve diğer bazı proteinleri parçalayarak etki etmekte olup uygun zamanda yapılan fibrinolitik tedavi ile bu süreçkesintiye uğratılıp, akciğer üzerinde fibröz kabuk gelişimi önlenerek hasta daha invaziv işlemlerden kurtarılabilir.Gereç ve Yöntemler: Bu çalışmada 2003- 2013 yılları arasında tüp yada kateter torakostomisi ile intraplevral fibrinolitik tedavi (IPFT)uygulanan 85 olgu retrospektif olarak incelendi. Olgular yaş, cinsiyet, semptom, tanı ve tedaviye yanıt açısından değerlendirildi.Bulgular: Olguların 65i erkek, 20si kadın, yaş ortalaması 45.5 idi. Otuz olguya ampiyem, 13 olguya travma sonrası gelişen organizehematom, 20 olguya postoperatif, 9 olguya malign plevral efüzyon, 11 olguya benign hastalıklara bağlı drene olmayan loküle plevralefüzyon ve 2 olguya hidropnömotoraks sonrası gelişen komplikasyonlar nedeniyle intraplevral fibrinolitik tedavi uygulandı. Olguların 25sinekateter torakostomi, 60 olguya tüp torakostomi uygulandı. Olguların 7sinde IPFT başarısız oldu, 4 olguya dekortikasyon, 3 olguya VATS(video-assisted thoracoscopic surgery) ile debridman uygulandı. Oniki olguda aseptik kısmi poş kaldı. Bir olguda lokal etkiye bağlı, kantransfüzyonu ve medikal tedavi ile kontrol altına alınan intraplevral kanama saptandı.Sonuç: Loküle ampiyemlerde, pıhtılı hemotoraks ve postoperatif organize hematomlarda, yoğun fibrinli, drenajı olmayan malign plevralefüzyon ve benign plevral efüzyonlarda daha invaziv cerrahi girişimlerden önce uygulanacak IPFT güvenli, etkili, başarısı yüksek, yan etkisi azbir uygulamadır.

İntraplevral Fibrinolitik Tedavi Uygulamaları: 85 Olguluk Seri Sunumu

Objective: Fibrous cortex developes over the lung in 7-10 days if the benign or malign pleural effusion consisting of blood, coagulum orempyema could not be drained. Thus, clinical conditions like trapped lung, restrictive lung disease, or dyspnea may appear as a result offibrinous pleuritis. Both streptokinase and tissue plasminogen activator (tPA) are involved in the breakdown of proteins and fibrin. Hence,intrapleural fibrinolytic treatment (IPFT) may prevent invazive procedures by avoiding fibrous cortex develepment if it is applied at a propertime.Materials and Methods: Eighty five cases undergoing IPFT by tube or catheter thoracostomies between 2003-2013 are evaluatedretrospectively. Patients have been evaluated according to age, symptoms, diagnosis, and response to treatment.Results: The mean age of the patients was 45.5 (65 males and 20 females). IPFT was performed in 30 patients with empyema, and in 20and 13 patients due to postoperative or posttraumatic organised hematomas, respectively. Eleven patients underwent IPFT for loculatedbenign pleural effusions while 9 patients recieved the treatment for loculated malign pleural effusions. Complicated hydropneumothoraxwas the indication for IPFT in 2 patients. A total of sixty patients received tube thoracostomy while 25 patients underwent catheterthoracostomy. Tree patients had decortication and 4 underwent video assisted thoracoscopic (VATS) drainage due to failure of IPFT.Aseptic pleural space remained in 12 patients at the end of our study. One of the patients required blood transfusion and additionalmedical treatment for intrapleural hemorrhage secondary to the local absorption of the IPFT.Conclusion: IPFT is a safe, effective treatment which can be performed prior to much invasive surgical procedures in patients withloculated empyema, clotted hemothorax, or postoperative hematoma, and benign or malign pleural effusions which can not be draineddue to high fibrinous contents.

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