RU2290876C1 - Method for surgical treatment of patients at destructive forms of open tuberculosis - Google Patents

Abstract

FIELD: medicine, thoracic surgery, phthisiology.

SUBSTANCE: the present innovation deals with collapsosurgical treatment of patients at destructive forms of tuberculosis of respiratory organs. It is necessary to fulfill intercostals thoracotomy, extrapleural and/or extrafascial isolation of affected respiratory department followed by developing an extrapleural cavity to introduce there the drainage and an irrigator, after that the cavity should be completely filled in with filling material as 1.5-2.5%-collagen gel. If necessary, to increase the volume of extrapleural cavity, through the irrigator one should additionally introduce 1.5-2.5%-collagen gel. The innovation provides the development of biofilling above the affected lung at achieving maximal congruence of extrapleural cavity and the gel introduced into it, exclude pulmonary compression and the development of pulmonary-pleural fistulas and, also, early or late migration of extrapleural filling due to applying specially matched gel.

EFFECT: higher efficiency of therapy.

1 cl, 1 ex

Description

The invention relates to medicine, namely to thoracic surgery and phthisiology.

Treatment of patients with respiratory tuberculosis, which is characterized by insufficient effectiveness of all known and implemented therapeutic methods of treatment, the presence of numerous contraindications to resection surgery, as the most generally accepted in the world, require and determine the search for new and improvement of known methods of surgical treatment of patients that allow to expand the delivery effective medical care. The indicated problem cannot be solved using only resection surgery.

There is a method of extrapleural pneumotorox in the surgical treatment of pulmonary tuberculosis (N. G. Stoiko. Surgical treatment of pulmonary tuberculosis. A guide for doctors. M., 1949, pp. 108-128). The method includes anterior, lateral or posterior intercostal thoracotomy with limited resection of segments of one or two ribs, digital and / or instrumental extraction of the lung in the extraleural layer with or without apicolysis in order to maximize collapse, often the upper lobe, and artificially create an extrapleural cavity with volume not less than 250-700 cm ³ , which was achieved by isolating the lung from the front to III, and from the back to YI-YII ribs, mediostinal to the root of the lung. A thorough hemostasis was performed. The wound was sutured in layers "tightly". The first insufflation of air into the extrapleural cavity was performed either at the end of the operation or in the first 6-8 hours after its completion. Then extrapleural pneumothorax was formed by performing regular gas insufflations during clinical and radiological monitoring, cavity manometry, and evacuation of exudate and / or blood accumulated in it.

However, this method is ineffective with a number of clinical and x-ray morphological variants of the course of pulmonary tuberculosis disease. The method is time-consuming, lengthy (from 1-2 years or more), accompanied by frequent complications, the main of which are:

- the development of bleeding in the extrapleural cavity,

- the presence of a syndrome of compression of the mediastinal organs with accumulated blood and / or exudate and air,

- self-detachment of the pleura in the caudal direction with the collapse of healthy segments of the lung,

- prolonged up to several months exudation into the extrapleural cavity,

- The formation of bronchial and thoracic fistulas.

A known method of surgery for extrapleural pneumolysis with intraoperative filling in the treatment of destructive forms of pulmonary tuberculosis (L.G. Bogush. Surgical treatment of pulmonary tuberculosis. M., 1979, S. 67-70). The method includes all the methodology and technique for performing the surgical operation described in the aforementioned analogue until the stage of completion of the formation of the extrapleural cavity, which was filled intraoperatively or in the early (3-7 days) postoperative period with a special material (syngenic or allogeneic adipose tissue). The wound was sutured in layers "tightly". The operation at all stages was carried out through a thoracoscope with constant illumination of the extrapleural cavity.

As the closest analogue, a method has been adopted for the surgical treatment of patients with destructive forms of pulmonary tuberculosis, including intercostal thoracotomy, extraleural and / or extrafascial excretion of the affected part of the lung, artificial formation of extrapleural cavity with its subsequent intraoperative complete filling with filling material. For sealing purposes, it was proposed to use more than 50 different materials, namely syngeneic and allogeneic adipose tissue, paraffin, petroleum jelly, cellulose, polymethylacrylate, foam rubber, iodolipol, polystan, etc. (V.D. Yampolskaya. Extrapleural pneumothorax and oleothorax for pulmonary tuberculosis. M., 1963).

The operation of extrapleural pneumolysis with filling is technically simple and low-traumatic, generally available. Despite the advantages, the method has the following disadvantages:

- all previously proposed and introduced into medical practice filling materials during operations of extrapleural pneumolysis had allogeneic and biologically determined reactions of rejection of the seal, the degree of which was due to immunological incompatibility, as well as long periods of resorption, a tendency to form sagging, pressure sores, migration of the seal, expressed inc the development of thoracic and pulmonary pleural fistulas;

- completion of the operation with achieving tightness of the wound by its layer-by-layer “deaf” suturing (without drainage) contributed to the formation of massive coagulated hemothorax, which in turn led to the formation of dense fibrous moorings with the further development of pleuropneumocirrhosis of the collapsed lung, suppuration of coagulated hemothorax with the development of acute, and then and chronic tuberculosis empyema;

- dangerous discharge of the lung, both in the dome of the chest cavity and in the mediastinum, insufficiently reliable hemostasis, leading to frequent bleeding into the formed cavity;

- air initially stored in the extrapleural cavity, rapidly forming exudate in the cavity.

The objective of the invention is to eliminate the above disadvantages, as well as the creation of a more universal, simple, affordable and effective method of collapse surgery of pulmonary tuberculosis, which can provide stabilization or cure, including the steadily progressing tuberculous inflammatory process in the lungs as a preliminary, independent and final surgical intervention, those. one-stage, primarily aimed at the final healing of the decay cavity, and a persistent cessation of bacterial excretion.

Achieving this goal is possible using the method of surgical treatment of patients with destructive forms of pulmonary tuberculosis, including intercostal thoracotomy, extrapleural and / or extrafascial excretion of the affected part of the lung, artificial formation of extrapleural cavity with its subsequent intraoperative complete filling with filling material. At the same time, drainage and irrigator are installed in the extrapleural cavity, then they are filled with filling material, which is used as 1.5-2.5% collagen gel. If necessary, it is possible after surgery to additionally introduce a collagen gel through an irrigator to increase the extrapleural cavity volume.

The formation of extrapleural cavity is carried out with continuous video support from the moment of completion of thoracotomy and the beginning of pneumolysis. Drainage is removed based on changes in the nature and rate of decrease in the daily volume of exudate by 2-5 days after surgery. The irrigator is stored for up to 7-14 days to remove exudate, dosed injection of filling material, as well as antibacterial drugs and other drugs as indicated.

The collagen gel used is produced in accordance with FSP 42-1221-01, the pH of the gel is in the neutral zone. The drug maintains a gel-like state at a temperature of 37.5-38.5 ° C, has plasticizing properties.

Using the invention will allow to obtain the following positive clinical result:

- double intraoperative drainage of the extrapleural cavity with early active and metered aspiration of air and exudate during the first days after the operation contributes to an earlier diagnosis of the development of intracavitary bleeding, will allow timely taking effective local and general measures for its final stop, prevent the formation of coagulated hemothorax, and prevent development intense extrapleural pneumo- and / or hemothorax with subcutaneous emphysema and a biliary of soft tissues with exudate and blood, and therefore, to prevent postoperative suppuration in the zone;

- filling gel-like material with pronounced mechanical plasticity, which allows to achieve maximum congruency of the extrapleural cavity and the filling mass introduced into it, excludes clinically significant compression (compression) of the lung, mediastinal organs and chest wall tissues, the formation of pressure sores, thoracic and pulmonary-pleural fistulas, also early and late migration of extrapleural fillings with its severe consequences in the chest cavity and chest wall;

- collagen gel, which is intended for intraoperative filling of the extrapleural cavity and for postoperative additional, dosed and controlled administration, creates all possible conditions for the implementation of time-controlled extrapleural pneumolysis with the final achievement of the required degree of collapse of the pulmonary tuberculosis affected by the required time in each individual patient;

- the proposed 1.5-2.5% collagen gel as a filling material with the absence of general toxicity and carcinogenicity, a sharp decrease in antigenicity already at the stage of its initial preparation, possessing the basic properties of a biopolymer, including hemostatic, easily achievable formation complexes with antibacterial substances (antiseptics, natural chemistries and semi-synthetic antibiotics), known periods of lysis and dissolution, the ability to dispose with inclusion in the general metabolism operated patients, is one of the main components of education's own loose connective tissue - bioplomby over kollalirovannym light, ie, one of the main elements of the developed method for the surgical treatment of pulmonary tuberculosis.

Thus, the proposed method for the surgical treatment of pulmonary tuberculosis, including the artificial creation of an extrapleural cavity in the area of the pathological process, its drainage with early active removal of air, blood and exudate, using a multifunctional collagen biopolymer both during and after surgery, including using antibacterial drugs, avoided a number of undesirable, including postoperative, complications and thereby increase the effectiveness of surgical treatment I have patients with pulmonary tuberculosis.

The method is used for patients with unilateral and bilateral destructive, including acutely progressive forms of pulmonary tuberculosis with bacterial excretion (except caseous pneumonia, lobitis, tuberculoma), including those with multiple multidrug resistance MBT against the background of long-term and ineffective antibacterial therapy of 3-5 and more basic and reserve anti-TB drugs in combination with the use of numerous methods and methods of pathogenetic treatment (laser, ultrasound, pharmaco-and immunotherapy, and many other), complications of tuberculosis and pulmonary heart disease.

The method is as follows. The operation is performed both in one-sided and two-sided, including simultaneous-sequential version (simultaneous) on both lungs. The operation is used both in the form of the main - final and final, and as a preliminary preparatory stage in order to stabilize tuberculosis before the final - the second, as a rule, more radical surgical intervention (resection, pulmonectomy, cavernoplasty, etc.).

The operation is performed under general anesthesia with mechanical ventilation. In the position of the patient "lying on his stomach" produce paravertebral thoracotomy (level of the spinous processes of the II-IY thoracic vertebra). Dissect the entire posterior group of back muscles, exposing the posterior segments of the IY and Y ribs, removing the scapula ipsilaterally. The posterior segment of either the III-IY or IY and Y ribs is subperitoneally resected for no more than 3-5 cm, starting from the articular joint to the ipsilateral side. The posterior bony pleura is exposed, and in the presence of powerful adhesions in the indicated zone, the intrathoracic fascia. A finger is made either with a tupfer or other instrument to detach the lung, protecting and not damaging the parietal pleura. All subsequent intrathoracic stages of the operation are performed under full visual control in the illuminated field or through a thoracoscope, and / or using a video system, while the endoscope is inserted either through the surgical wound or through the thoracoport in the adjacent intercostal space, which is then used to install drainage in extrapleural cavity.

Extrapleural pneumolysis is performed with continuous and sequential intraoperative hemostasis, as well as the refinement of the indicated volume of pneumolysis.

After the final completion of the stage of formation of the extrapleural cavity, a final thorough hemostasis is performed using electrocoagulation, completing it by filling the cavity with 5% aminocaproic acid in a volume of 0.3-0.5 L as a general and local hemostatic. At the same time, it is used to exclude or confirm the fact of damage to the mediastal and / or costal parietal pleura with the development of mixed (intra-extrapleural) pneumothorax against the background of a forced inflated operated lung. In the presence of pneumothorax, an irrigator is introduced into the pleural cavity through the adjacent intercostal space using the Seldinger technique or through a trocar, defects in the pleura from the extrapleural cavity are sutured to hermeticity. The specified irrigator is connected to an active aspiration system with immediate and complete removal of air from the pleural cavity. The irrigator is removed no earlier than 2-3 days after the operation, provided there is no air and exudate in the pleural cavity and the lung is completely expanded to the level of extrapleural filling.

The extrapleural cavity near the thoracotomy is drained through the intercostal space with silicone drainage with 2-3 lateral openings, the end of which is fixed with one suture in the dome and in addition to the chest wall from the side of the extrapleural cavity. After 2 (additional) intercostal space along the mid-scapular line, an irrigator is inserted into the extrapleural cavity, which is likewise fixed to the chest wall, and its end is placed at the bottom of the extrapleural cavity (in the presence of a pleural injury).

In the formed, drained and drained extrapleural cavity, sterile, preheated in a water bath, 1.5-2.5% collagen in the form of a gel (FS 42-2670-96) with a temperature of not more than 37.5-38 ° С is introduced. The formed cavity is filled with collagen completely, without leaving free air spaces. The wound is sutured in layers. Drainage and irrigator on the operating table are connected to an active aspiration system with a discharge of not more than 30-40 mm Hg, the general anti-tuberculosis therapy is resumed from 2-3 days.

In the early postoperative period, active aspiration of hemorrhagic exudate is continued for 2-3 days, and when its separation reaches 50-70 ml per day with transformation into serous hemorrhagic exudate, drainage is removed. At the same time, X-ray and ultrasound are monitored for the degree of collapse of the lung and cavity, the volume of the extrapleural cavity, and in case of their insufficiency, a solution of sterile 1.5-2.5% collagen is additionally injected through the irrigator, possibly in combination with 2-3 anti-TB drugs at their daily doses from the sensitivity of the office.

The necessary collapse of the lung is achieved, the irrigator is removed, intracavitary administration of anti-tuberculosis drugs is continued by the puncture method for at least 1 month after the operation against the background of conventional treatment in TB.

Clinical example.

Patient B-va, 37 years old, and / b 1981, was undergoing treatment in the thoracic department of the Bryansk regional TB dispensary from 6.11.03. on 07/15/04.

She has been ill with tuberculosis since January 17, 2003, when infiltrative tuberculosis of the upper lobe of the left lung was first detected in the phase of decay and contamination, MBT "+". Within 10 months in the hospital received the main course of anti-TB treatment. I didn’t take drugs regularly, violated the hospital regime, and abused alcohol. During treatment, multiple caseous-necrotic foci, such as tuberculoma, small thin-walled decay cavities were formed on the left in C1-C2, large thinly-encapsulated foci in C6, persistent bacterial excretion remained, with a decrease in its massive bacterioscopically.

The patient was transferred to the thoracic department for surgical treatment. At the time of admission to the thoracic department of the regional obstetric dispensary, symptoms of general intoxication are not expressed, hemogram indicators, liver, kidney, coagulogram and other laboratory parameters without features. Severe respiratory failure according to the laboratory has not been identified. After completing an additional preoperative examination on November 18, 2003, the patient underwent an operation of the upper lobectomy of the left lung. Then there was a slow expansion of the lung in the postoperative period, a persistent pleuromediastal slit-like residual cavity, a microfistula of the stump of the upper lobar bronchus, and tuberculous cultitis developed. In a remote lobe, histologically - progressive destructive tuberculosis with caseous pneumonia elements such as lobitis. Continuation of anti-tuberculosis therapy, multiple course of rehabilitation fibrobronchoscopy with rehabilitation of the bronchus stump. However, the tuberculosis process progressed - a stable cavity was formed in C6, massive bacterial excretion resumed, and therefore an organ-preserving operation was performed in the form of extrapleural pneumolysis with filling 300 ml of sterile 1.5-2.5% collagen gel. The extrapleural cavity is drained by one drainage, the drainage is connected to active aspiration on the operating table. The postoperative period was uneventful. Additional administration of collagen in the postoperative period was not required. Within 1.5 months after the operation, the cavity in C6 ceased to be determined by X-ray diffraction, bacterial excretion ceased. The patient received antibacterial anti-tuberculosis therapy with three drugs. Discharged for outpatient monitoring without signs of destructive tuberculosis and bacterial excretion.

Claims (2)

1. A method for the surgical treatment of patients with destructive forms of pulmonary tuberculosis, including intercostal thoracotomy, extraleural and / or extrafascial excretion of the affected part of the lung, the artificial formation of the extrapleural cavity with its subsequent intraoperative complete filling with filling material, characterized in that they install other extrapleural cavity and drainage , then the cavity is filled with filling material, which is used as 1.5-2.5% gel collage a. 2. The method according to claim 1, characterized in that after the operation, collagen gel is additionally introduced through the irrigator to increase the volume of the extrapleural cavity.