RU2612601C1 - Extrapleural pneumolysis method for treatment of prevalent fibro-cavernous pulmonary tuberculosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: incision of skin and soft tissues is made along the mid-axillary line vertically, with length from 4 to 8 cm. Intercostal thoracotomy is performed transversely in the intercostal space corresponding to the cavity location area. The opening is horizontally fixed by the line retractor. Extrapleural pneumolysis is performed with videothoracoscopy supervision. A silicone seal with high cohesive parameters preliminarily sutured with a nonabsorbable monofilament thread is inserted into the prepared bed. The seal is fixed by sutured ligatures to the tissues of the chest wall. The wound is sutured in layers.

EFFECT: method provides reduced cosmetic defect, surgery trauma and risk of postoperative complications and recurrence during complex treatment of prevalent pulmonary tuberculosis due to divergent sections of tissue and preserved rib integrity.

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Description

The invention relates to medicine, namely to thoracic surgery and phthisiology and can be used in the complex treatment of advanced pulmonary tuberculosis.

A known method of treating pulmonary tuberculosis [RU 2290878, C1, A61B 17/00, 01/10/2007], including intercostal thoracotomy, extrapleural separation of the apex of the affected lung, artificial formation of extrapleural cavity with its subsequent filling with a soft tissue flap on the feeding leg, fixation of the flap to the tissues of the chest cells and suturing of the surgical wound, while after the final completion of the formation of the extrapleural cavity against the background of forced inflation of the operated lung, possible damage to the pariet is revealed pleural pleura: exclude or confirm the fact of the presence of a defect, during the establishment of which an irrigator is introduced into the pleural cavity, connect it to the active aspiration system for complete and immediate removal of air from it, and the detected defect is sutured until hermetic, after which a soft-tissue flap is formed, in which quality they use a muscle flap including the latissimus dorsi muscle, while carrying out its mobilization, the long lateral and posterior sternal nerves, muscle bundles in the area of its attachment to the humerus are maximally preserved and the axillary region, in the formed extrapleural cavity, the flap is moved through a thoracotomy, fixed to the dome and rib surfaces of the chest without tension, except for sagging and pressure on the collapsed lung.

This method has proven itself in bronchopleural fistulas, when the pleural defect is sutured, the irrigator is brought to the fistula zone, the cavity is filled with displaced muscles.

The disadvantage of this method is the insufficient collapse of the lung, the use of their own tissues in tuberculosis is fraught with infection, after the operation, a pronounced cosmetic defect remains.

The closest in technical essence to the proposed one is the method of extrapleural pneumolysis operation [RU 2448658, C1, A61B 17/00, 04/27/2012], including subperiosteal resection, artificial formation of the extrapleural cavity with its subsequent filling, fixation of the filling by suturing to the chest wall and drainage of extrapleural cavity, with preoperative anti-TB treatment with drugs depending on the sensitivity of the pathogen for 3-4 months, with localization of the cavity in the upper lobe a vertical incision is made in the axillary region 7–9 cm in size, soft tissues are dissected in layers, a subperiostal resection of the second, less often the third rib, is performed for 6–8 cm, and when the cavity is localized in other parts of the lung (middle, lower lobe), the ribs are resected located below in accordance with the projection of the cavern on the chest wall, while the extrapleural cavity is filled with a silicone seal, the size of which is calculated on a spiral computed tomograph before surgery, and the extrapleura is drained the flax cavity is carried out with a silicone tube.

The closest technical solution has proven itself positively due to the fact that due to the constant volume and weight of the filling, a stable life-long collapse of the lung tissue is achieved, which contributes to the regression of tuberculous inflammation against the background of adequate chemotherapeutic treatment. Another absolute advantage of the method is the absence of a cosmetic defect in the chest.

However, the closest technical solution has a higher invasiveness, a relatively high possibility of postoperative complications and relapses, as well as cosmetic defects.

This is due to the fact that the known method involves the need to perform subperiosteal resection of the rib to form the extrapleural bed of the silicone seal. This increases the morbidity of surgical access, the rib cage of the chest is broken, and in the case of severe fibrotization of hemitrax, a partial migration of the filling into soft tissues is possible, which reduces the effect of lung compression. Moreover, during the installation of a rigid silicone seal, there is a risk of damage to the pleura and the shell of the seal with the sharp edges of the resected ribs. Such damage can also occur in a more distant period as a result of lung resistance during the collapse process.

The objective of this invention is to create a less traumatic, as well as less likely postoperative complications and relapses and cosmetic defects, method of extrapleural pneumolysis in the treatment of common fibro-cavernous pulmonary tuberculosis with the installation of a silicone seal in the extrapleural space, eliminating its damage to the ribs during administration, which ensures its convenient placement, as well as complete preservation of the chest frame, which allows to achieve maximum compress polarization effect of the lung tissue and eliminates the possibility of unwanted migration of seals.

The technical result, which is realized when using the proposed method, is to reduce the invasiveness of the operation and the possibility of postoperative complications and relapses, as well as to reduce the possibility of a cosmetic defect.

The problem is solved, and the required technical effect is achieved by the fact that in the method of extrapleural pneumolysis in the treatment of common fibro-cavernous pulmonary tuberculosis, based on the fact that a vertical incision of the skin and soft tissues in the axillary region and intercostal thoracotomy in the transverse direction in the intercostal space corresponding to the cavern location zone, extrapleural pneumolysis is performed under the control of video thoracoscopy, forming a bed under the seal, drainage is formed of the extrapleural cavity with a single silicone tube through a contraperture, a silicone filling with high cohesive parameters and a pre-calculated volume is pre-stitched with a non-absorbable monofilament thread into the prepared bed, the seal is fixed with stitched ligatures to the tissues of the chest wall and the skin is wound in layers and cut according to the invention soft tissues in the axillary region are produced vertically along the border of the scalp, intercostal thoracotomy is performed horizontally, and about Verstov formed at an intercostal thoracotomy retractor fixed line through which the prepared bed administered silicone seal.

The graphic materials presented:

in Fig. 1, a - CT of the chest organs, a destroyed left lung;

in FIG. 1, b - CT of the chest organs, in the upper lobe - a large cavity, multiple polymorphic foci, large - with signs of decay;

in FIG. 2 - CT of the chest organs in dynamics, a cavity in the right lung is preserved, partial resorption of focal and infiltrative changes;

in Fig. 3, a is an overview radiograph of the chest organs, the cavity in the right lung is in a state of compression, abdominal, as well as infiltrative and focal changes in a single lung are not determined;

in FIG. 3, b - CT of the chest organs, a cavity in the right lung is in a state of compression, abdominal, as well as infiltrative and focal changes in a single lung are not determined.

The method of extrapleural pneumolysis in the treatment of common fibro-cavernous pulmonary tuberculosis is as follows.

A round silicone implant made of a dense cohesive with a high profile and textured shell is used as a filling. The volume of the seal is calculated based on the volume of the cavity structures to be collapsed using spiral computed tomography. Surgical access is performed in the patient's position on the healthy side. The incision is carried out vertically along the mid-axillary line with a length of 4 to 8 cm. Soft tissue to the ribs is separated vertically. Intercostal muscles are dissected in the transverse direction in 2-3 intercostal space at the upper localization of the cavity, in 4-5-6 - with the localization of the cavities in the lower parts of the lung. In this case, an incision of the skin and soft tissues in the axillary region is carried out vertically along the border of the scalp, intercostal thoracotomy is performed horizontally. This, on the one hand, makes the skin scar cosmetically invisible, and, on the other hand, horizontal intercostal thoracotomy avoids resection of the rib, in which trauma to the lung, pleura and shell of the silicone seal is possible during administration. The hole formed during intercostal thoracotomy is fixed with a linear retractor, through which a silicone seal is inserted into the prepared bed, previously sewn with a non-absorbable monofilament thread. Intercostal thoracotomy access allows using the Finochetto linear fixed retractor to dilute the wound to the width of the filling of almost any size. The formation of postoperative scars of the layers of the chest in mutually perpendicular planes prevents the development of cicatricial contractures. With this access, partial migration of the filling into the soft tissue of the chest wall is completely excluded, the skeleton of the chest is preserved, which ensures the maximum compression effect of the lung tissue. After installation, the seal is fixed with stitched ligatures to the tissues of the chest wall. The wound is sutured in layers and an aseptic sticker is applied. Drainage is attached to an active aspiration system.

The duration of the operation is 20-30 minutes with a minimum blood loss of up to 50 ml. X-ray control of the position of the seal and compression of the lung tissue containing caverns is carried out 1 day after the operation. As a rule, from the first day almost complete compression of the cavity is observed. Silicone drainage is removed on the second day after surgery. The patient can be discharged from the surgical hospital on the seventh-tenth day. Complete fibrotization of the cavity, subject to continued chemotherapy, occurs within 3-6 months.

The proposed feature of the operation, in particular, that an incision of the skin and soft tissues in the axillary region and intercostal thoracotomy is performed in mutually perpendicular planes, the hole formed during intercostal thoracotomy is fixed with a linear retractor, through which a silicone seal is inserted into the prepared bed, which allows for additional reliability of surgical access without the risk of damage to the resected segments of the ribs, lung tissue, pleura and textured shell of the seal, floor spine to maintain a rib muscle and skeleton, to create the best conditions for collapse of lung tissue, to avoid unwanted migration fillings and cosmetic defect.

In general, the proposed method has the following advantages.

1. When applying the method, the muscular and costal framework remain intact, which creates maximum aerodynamic conditions for achieving compression of pathological changes in the lung. Due to the fact that the weight, volume and shape of the filling remain unchanged, lung collapse is constant throughout the patient's life. The absence of a defect in the rib completely prevents partial migration of the seal into the soft tissues of the chest, and a cosmetic defect is completely absent.

2. A longitudinal section with a length of 4 to 8 cm allows you to freely choose the intercostal space for optimal access in accordance with the localization of pathological changes. Intercostal thoracotomy performed in a plane perpendicular to the section plane provides additional reliability of surgical access.

3. Entrance to the extrapleural space achieved by installing a linear retractor in the intercostal section provides the ability to perform extrapleural pneumolysis under the control of video thoracoscopy. In this case, a more thorough separation of the parietal pleura and hemostasis under the control of video thoracoscopy are possible than with manual exposure using the Farabef expander and the application of muscle strength. Damage to the outer shell of the seal and parietal pleura against the sharp edges of the resected ribs is completely excluded.

The proposed method of operation is indicated in the complex treatment of common fibro-cavernous tuberculosis with multidrug-resistant MBT. The advantage of such an operation is that it can be performed in the destructive phase of the process, i.e. in a situation where resection is not possible, and collapse of the lung tissue is required to achieve stabilization of the process. Tuberculosis lesion of the tracheobronchial tree is also not a contraindication to extrapleural silicone filling. The operation can be carried out in the staged surgical treatment of bilateral fibro-cavernous tuberculosis, when one lung is destroyed, and pneumonectomy is performed on the side of the largest lesion, and extrapleural pneumolysis is performed on the side of the smallest lesion. Depending on the specific clinical situation, extrapleural pneumolysis with silicone filling can be performed both at the first and second stages of surgical treatment, including the only lung.

The proposed method of operation has positively established itself as a prophylaxis and treatment of respiratory failure caused by both displacement of the mediastinum after previous operations, and caused by developed bullous changes. At the same time, aerodynamic and hemodynamic parameters are improved, the well-being of the operated patients is significantly improved. The method can be combined with other methods of collapse surgery and collapse therapy.

The operation is less traumatic, functionally and cosmetically gentle with the maximum effect of collapse of the lung tissue.

An example of successful surgical treatment using extrapleural pneumolysis with silicone filling on the only lung side according to the method described above is the following clinical observation.

Patient P. 29 years. Medical history: Infiltrative tuberculosis of the upper lobe of the left lung was detected in 2007. The course of the process is undulating. In 2011, fibro-cavernous tuberculosis of the left lung was formed. Installed by XDR Office. In 2014 she was sent to the Central Research Institute of RAMS. Diagnosed with FCT of the left lung in the phase of infiltration and seeding. Office (+). XDR Office. (H, R, E, Eto, Am, Cm, Cs, PAS). DN II-III Art.

CT of the chest is shown in FIG. 1a - a destroyed left lung; in FIG. 1, b - a large cavity in the upper lobe. There are multiple polymorphic foci, large with signs of decay.

The patient's condition was complicated by episodes of recurrent hemoptysis. When fibrobronchoscopy revealed the flow of blood from the upper lobe bronchus on the left. At the consultation, it was decided to carry out the patient two-stage treatment using pleuropneumonectomy in the first stage according to urgent indications and extrapleural pneumolysis with silicone filling in the second stage. At the 1st stage, the patient underwent pleuropneumonectomy surgery on the left. Histological examination: fibro-cavernous tuberculosis with dropout sites, pronounced activity of the tuberculosis process. The postoperative period was uneventful. In FIG. 2 - CT scan of the chest in dynamics. The cavity in the right lung is preserved. Partial resorption of focal and infiltrative changes. After 2.5 months, the patient completed the second stage of surgical treatment: extrapleural pneumolysis on the right with the installation of silicone fillings.

In Fig. 3, a - a radiograph of the chest organs, the cavity in the right lung is in a state of compression, abdominal, as well as infiltrative and focal changes in a single lung are not determined. In FIG. 3, b - CT of the chest organs, a cavity in the right lung is in a state of compression, abdominal, as well as infiltrative and focal changes in a single lung are not determined.

The patient is preparing for discharge from the hospital to continue anti-tuberculosis therapy in a sanatorium.

Thus, due to the improvement of the known method, the required technical result is achieved, consisting in reducing the invasiveness of the operation and the possibility of postoperative complications and relapses, as well as in reducing the likelihood of a cosmetic defect.

Claims (1)

The method of extrapleural pneumolysis in the treatment of common fibro-cavernous pulmonary tuberculosis, including a vertical incision of the skin in the axillary region, intercostal thoracotomy in accordance with the location of the cavity, extrapleural pneumolysis, the formation of a bed under the seal, drainage of the formed extrapleural cavity into one silicone tube through the conduit, through prepared bed of pre-stitched non-absorbable monofilament thread of silicone seal with high cohesive with parameters and in a pre-calculated volume, fixation of the filling with stitched ligatures to the tissues of the chest wall and layered suturing of the wound, characterized in that the skin incision is made vertically along the mid-axillary line from 4 to 8 cm long, the soft tissues are separated vertically to the ribs, the intercostal muscles are dissected in the transverse direction in the 2-3 intercostal space at the upper localization of the cavity and in the 4-5-6 intercostal space at the localization of the cavities and underlying parts of the lung; thoracic access to the width of the seal is diluted and fixed with a linear retractor.

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