RU2547612C2 - Method of surgical treatment of chronic pleural empyema without bronchopleural fistula after pneumoectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to thoracic surgery. Subperiosteal resection of posterior and lateral parts of the ribs within the empyema cavity boundaries is realised. The residual pleural cavity is eliminated by means of a scar-muscular flap from the paracostal commissure and tissues of intercostal spaces. Before submergence into the residual pleural cavity the flap is given plasticity by the dissection of the commissure with three vertical cuts. The flap is submerged into the cavity. The peripheral edge of the paracostal commissure of the anterior thoracic wall is sewn with the subscapular and anterior serratus muscles.

EFFECT: method ensures the reduction of trauma, prevention of the chest deformation due to carrying out combined plasty of the pleural cavity with the flap from the pleural commissure and intercostal tissues, as well as makes it possible to form the plastic commissure flap due to performing vertical cuts in it, prevent terminal osteomyelitis of the resected ribs due to their isolation from the infected pleural cavity.

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Description

The invention relates to medicine, namely to surgery. The aim of the invention is to improve the results of surgical treatment of chronic pleural empyema without bronchopleural fistula after pneumonectomy by combined plasty - thoracoplasty and scar-muscle plasty of the residual pleural cavity with a flap from the pleural mooring and intercostal tissues.

Total pleural empyema is a frequent complication of pneumonectomy performed for cancer, gangrene, abscesses, common tuberculosis and other lung diseases. The main cause of postoperative empyema is the failure of the sutures and fistula of the stump of the main bronchus. The complication rate ranges from 6.1 to 24.5%, postoperative mortality - from 7.5 to 12.5% (Kobak M.E. et al., 2012; Pikin O.V. et al., 2012; Sinev E. N. et al., 2012). By closed drainage, pleurostomy and tamponade of the pleural cavity, it is possible to transfer acute pleural empyema into chronic and stabilize the patient's condition. Medical manipulations on the bronchus stump succeed in healing the bronchopleural fistula in a number of patients.

The treatment of chronic pleural empyema after pneumonectomy is achieved by resection of the ribs, thoracoplasty in order to reduce the volume of the pleural cavity. Thoracoplasty is usually supplemented with muscle plasty of the residual pleural cavity (Muromsky Yu.A. et al., 1985; Protsenko A.V., 2009). The resection of the lower angle of the scapula to the level of the scapular spine is performed. A paracostal mooring with intercostal muscles is excised. To a considerable extent they mobilize the latissimus dorsi muscle, scapula muscles, and sometimes the pectoralis major muscle. Mobilized muscle layers are immersed in the residual pleural cavity and fixed with sutures to its walls (Muromsky Yu.A. et al., 1985; Protsenko A.V., 2009). Negative features and consequences of the described operation are its trauma, the loss of viable tissues - parts of the scapula and intercostal muscles, significant deformation of the chest in the area of surgical intervention, impaired function of the corresponding half of the shoulder girdle.

We have developed a method of scar-muscle plasty of the residual pleural cavity. Unlike the analogue, we do not mobilize the latissimus dorsi and scapula muscles, we do not skeletonize and do not resect the lower part of the scapula, we do not excise the paracostal mooring with intercostal muscles, but we use these tissues as plastic material. After subperiosteal resection of the posterior and lateral parts of the ribs, a scar-muscle flap is formed within the empyema cavity from the tissues of the intercostal spaces and the paracostal mooring. The flap becomes plastic after performing vertical sections of the scar mooring on it. It is immersed in the residual pleural cavity. To prevent terminal osteomyelitis of the resected ribs, they are isolated from the infected residual pleural cavity by stitching the edges of the crossed paracostal mooring at the ends of the ribs along the anterior axillary line with the subscapularis and anterior dentate muscles.

Description of the technique for developing the plastic method developed by us. Thoracoplasty is performed in the patient’s position on the abdomen through a posterior vertical incision of tissues along the paravertebral line enveloping the lower edge of the scapula. A pleurodermal fistula is excised at the lower angle of the scapula. Ribs from the head to the front axillary line within the boundaries of the empyema cavity are secreted and subperiostally. As a rule, the back of the first rib is removed. By horizontal cuts through the bed of the second rib and the bed of the lowest resected rib, the empyema cavity is opened, its contents are aspirated. The vertical incision connecting the ends of the horizontal incisions in the projection of the anterior axillary line intersects the intercostal spaces and the paracostal mooring. As a result, a scar-muscle flap is formed from the pleural mooring and intercostal tissues with the base at the spinal column. The curette scrapes the granulation layer from all the walls of the empyema cavity, erupted ligatures after previous operations are removed. The residual pleural cavity is washed with an antiseptic solution. Three vertical parallel sections dissect the paracostal mooring to the tissues of the intercostal spaces. The first section of the mooring is performed along the spine in the area of the base of the flap. The spaces between the vertical sections of the mooring should be the same width. Due to the incisions, the mooring scar-muscle flap becomes plastic and performs well in the “dead” paravertebral space. The viability of the flap is provided by the preserved blood flow through the intercostal vessels. The scar-muscle flap is immersed in the residual pleural cavity, with single sutures it is fixed to the mediastinum and the anterior chest wall.

In order to prevent osteomyelitis of the resected ribs and fill the residual pleural cavity, the ends of the ribs are isolated from this cavity by suturing with the help of single absorbable sutures the edges of the crossed paracostal mooring on the anterior chest wall in the projection of the anterior axillary line with the subscapularis and anterior serratus muscles at the outer edge of the scapula. Tubular drainages under the scar-muscle flap and under the scapula are brought. The wound of the chest wall is sutured in layers. Drainage from under the scapula is removed after 3-4 days, from under the scar-muscle flap - not earlier than 10 days after surgery.

We give a clinical observation. A., 49 years old. Case history 13381. He was hospitalized in the clinic on September 5, 2007 for chronic pleural empyema after left-sided pneumonectomy for fibro-cavernous tuberculosis. Pneumonectomy performed in 2005. The postoperative period was complicated by a fistula of the main bronchus stump and pleural empyema. 5 weeks after pneumonectomy, pleurostomy was performed: resection of the VII and VIII left ribs between the paravertebral and scapular lines, tamponade of the empyema cavity. In the future, dressings were performed. The fistula of the stump of the main bronchus healed after 4 months. The thoracic fistula closed after 6 months, but subsequently repeatedly recurred, the last time it opened 2 months ago. A purulent effusion was released from the pleural cavity.

In adolescence, he received a blind shot wound of the left shoulder joint with destruction of the humeral head, so the range of motion in the joint is limited.

09/25/2007, 7-rib thoracoplasty and scar-muscle plasty of the residual pleural cavity were performed according to the method described above. After dissection of the soft tissues along the paravertebral line, around the lower corner of the scapula, a subperiostal resection of the II-VIII ribs was performed. Two horizontal sections through the bed II and VIII and a vertical section in the projection of the anterior axillary line formed a scar-muscle flap of paracostal mooring and intercostal tissue with a base at the spine.

The empyema cavity contained 20 ml of clear yellow exudate. Fistula of the stump of the main bronchus was absent. After curettage of the granulation layer (Fig. 1), linear parallel sections of the mooring (Fig. 2) were made on the scar-muscle flap and the flap was immersed in the residual pleural cavity (Fig. 3). The subscapular and anterior dentate muscles are hemmed with single sutures to the edge of the pleural mooring in the projection of the anterior axillary line in order to delimit the ends of the resected ribs from the residual pleural cavity. Two tubular drainages were established in the operative intervention zone, the wound was stitched in layers. The duration of the operation is 3 hours 10 minutes. Surgical blood loss was 500 ml. The postoperative period was uneventful. Chronic pleural empyema eliminated (figure 5). Discharged from the hospital in satisfactory condition 23 days after the operation.

Brief description of photos

Figure 1. A., 49 years old. Scar-muscle flap and residual pleural cavity after curettage of the granulation layer. The number 1 indicates the scar-muscle flap, which is removed beyond the residual pleural cavity, is turned to the spine and is held using hemostatic clamps superimposed on its vertical edge, number 2 is the edge of the pleural mooring on the anterior chest wall.

Figure 2. The same patient. Continuation of the operation: dissection of the pleural mooring on a scar-muscle flap. The number 1 denotes a scar-muscle flap, removed beyond the residual pleural cavity, the number 3 - vertical sections of the pleural mooring on the scar-muscle flap.

Figure 3. The same patient. The scar-muscle flap is immersed in the residual pleural cavity. The number 1 indicates the scar-muscle flap, namely its muscular surface, the number 2 - the edge of the pleural mooring on the anterior chest wall, the number 4 - the ends of the resected ribs along the front axillary line, the number 5 - the extensor of the back in the fascial case.

Figure 4. Panoramic chest x-ray of patient A. before thoracoplasty and cicatricial muscle repair. The number 6 indicates the cavity of chronic left-sided empyema after pneumonectomy, the number 7 - numerous grains in the left shoulder joint.

Figure 5. Survey radiograph of the chest of patient A. after plastic surgery. The cavity of chronic empyema of the pleura is not determined. The number 8 indicates the left dome of the diaphragm.

6. Type of patient A. after plastic surgery before discharge from the clinic. In the projection of the V intercostal space under the left nipple, there is a scar after pneumonectomy. 7. View of patient A. with raised hands after plastic surgery before discharge from the clinic.

Fig. 8. Type of patient A. after plastic surgery before discharge from the clinic. A dark stripe on the skin of the back indicates a scar after thoracoplasty. In the area of the left shoulder joint, a scar is visible after a gunshot shot wound in adolescence.

BIBLIOGRAPHIC LIST

1. Kobak M.E., Elnik A.V., Basek T.S., Kirillov Yu.V. The results of pneumonectomies for pulmonary tuberculosis / Materials of the II international congress "Actual directions of modern cardio-thoracic surgery." - SPb. May 24-26, 2012. - S.163-165.

2. Muromsky Yu.A., Binetskiy E.S., Zubkova L.F. and other Muscular thoracoplasty with pleural empyema // Thoracic surgery. - 1985. - No. 4. - S.15-18.

3. Pikin O. V., Glushko V. A., Kolbanov K. I., Sobolev A. V. Comparative evaluation of various methods of covering the stump of the main bronchus after radical surgery in patients with NSCLC with a high risk of developing purulent-inflammatory complications / Materials of the II international congress “Actual directions of modern cardio-thoracic surgery”. - SPb. May 24-26, 2012. - S. 224.

4. Protsenko A.V. The choice of the method of thoracoplasty with bronchial fistula and pleural empyema after pneumonectomy // Annals of surgery. - 2009. - No. 2. - S. 40-42.

5. Sinev E.N., Chichevatov D.A., Gorshenev A.N. Prevention of bronchopleural fistulas using a diaphragm flap: analysis of 10 years of experience / Materials of the II international congress "Actual directions of modern cardio-thoracic surgery." - SPb. May 24-26, 2012. - S.365-367.

Claims (1)

A method for the surgical treatment of chronic pleural empyema without bronchopleural fistula after pneumonectomy, including subperiosteal resection of the posterior and lateral parts of the ribs within the boundaries of the empyema cavity, elimination of the residual pleural cavity by a scar-muscle flap from the paracostal mooring and intercostal spaces, characterized in that the pleural cavity is attached to the flap with plasticity by dissecting the moorings with three vertical sections, after its immersion, the peripheral Kray parakostalnoy Mooring anterior chest wall with the chuck and the serratus anterior muscle.

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