الفهرس 
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Abstract
Introduction
Pleural diseases involve the parietal and visceral pleura and may be of either inflammatory or malignant origin, often resulting in pleural effusions. The diagnostic evaluation of pleural effusions includes chemical and microbiological studies, as well as cytological analysis, which can provide further information about the etiological disease process. However, 40% of pleural effusions remain undiagnosed after an initial thoracocentesis.
An undiagnosed exudative pleural effusion is often a difficult diagnostic dilemma that needs further histological study for a definitive etiological diagnosis. Approximately 40% of exudative pleural effusions remain without an established etiology even after simple pleural aspiration and percutaneous biopsy. Pleural biopsy is recommended for evaluation and determination of various etiologies either infectious or malignant ones.
Various biopsy techniques are available to diagnose pleural disease. These range from older techniques, such as blind or closed pleural biopsy to newer techniques including image-guided and thoracoscopic biopsy.
Presence of recurrent pleural effusion of unknown etiology or pleural mass or thickening are indication for pleural biopsy. The procedural yield of pleural biopsy using ultrasonography or CT guidance is increased owing to the ability to precisely target an abnormal area of the pleura. Ultrasonography has an advantage for assessment of loculated pleural effusions and providing a real-time approach to the biopsy without radiation. CT guidance allows better visualization of the extent of focal pleural masses, in addition to a clearer delineation of parenchymal pathology.
The advantage of thoracoscopy instrumentation has allowed for the ability to directly visualize the pleural space and has the possibility to perform a therapeutic intervention in the same session as the diagnostic biopsy of the pleura.
Aim of the work
The aim of this study is to evaluate the diagnostic yield of thoracoscopic compared to image guided pleural biopsies.
Methods
Study population: The patients were divided randomly into two groups as follows:
group I: medical thoracoscopy biopsies were taken from the suspicious pleural lesions for histopathological examination.
group II: Image guided biopsies were taken from the suspicious pleural lesions for histopathological examination. Ten of them were taken by US guidance and the other ten were taken by CT guidance.
Clinical assessment: All included patients were subjected to full history taking, full clinical examination including general and local chest examination, Routine laboratory and Radiological evaluation.
If there’s pleural effusion, Thoracentesis and pleural fluid analysis were done.
Medical thoracoscopy:Medical thoracoscopy was done in group I using a rigid thoracoscopeunder local anaesthesia with moderate sedation which is quite well tolerated by patients. In few cases, general anesthesia was applied via anesthesiologist through laryngeal mask when patients refused local anesthesia and moderate sedation. Biopsy specimens were taken from abnormal sites of parietal pleura. Biopsy specimens after being fixed in formalin were sent to the pathology department for histopathological analysis and for bacteriologic investigation.
Image guided biopsies: Image guided biopsies in group II were performed mainly in the intervention suite of the radiology department.US-guided biopsy in the current study was done under local anaesthesia for all cases. CT-guided biopsy in the current study was done under local anaesthesia with moderate sedation. An area of pleural abnormality is identified using ultrasonography or CT imaging. The Automated cutting needle devices provide better histological samples than fine-needle aspiration. Three or more samples are generally obtained to ensure adequate pleural tissue for histopathological diagnosis
Results
Diagnostic yield:
In group I the results of 19 patients (95%) were positive and only one result was negative (5%). In group II the results of 17 patients (85%) were positive and 3 results were negative (15%). According to the results of histopathological examination of pleural biopsies taken through medical thoracoscopy or image guided pleural biopsy, Metastatic adenocarcinoma and malignant mesothelioma were the most common pathological results among the studied patients. The Comparison between the different studied groups according to the pathological type of each biopsy.
Duration of the procedure
In group I the mean duration of the procedure was 27.15 min (SD 3.57) with minimum 22.0 and maximum 37.0 min. In group II
• Subgroup (1): In CT guided pleural biopsy group,the mean duration of the procedure was 50.30 min (SD 6.57) with minimum 40 and maximum 60 min
• Subgroup (2): In US guided pleural biopsygroup, the mean duration of the procedure was 10.60 (SD 4.01) with minimum 6 and maximum 18 min.
Complications:
The comparison showed a statistically significant difference that image guided biopsies has fewer complications. Trapped lung was recorded in 4 patients (20%) in group I while empyema was experienced in 2 patients (10%) and wound infection occurred in one patient (5%).On the other hand hydro pneumothorax was recorded in only 2 cases (10%) in group II which required tube drainage.
Hospital stay
The comparison between the different studied groups according to hospital stay. The comparison showed a statistically significant difference while image guided pleural biopsies needed less hospital stay. In group I, the minimum number of days needed for chest tube removal after thoracoscopy was 2 days for uncomplicated cases and the maximum was 15 days for complicated cases with a mean duration of 5.85 days (SD 4.52 days).In group II, the minimum number of days of hospital stay was 1 day so it is considered outpatient procedure and the maximum was 8 days for the complicated cases with a mean duration of 2.25 days (SD 1.86 days) and a median of 2.0 days