RU2616271C1 - Chemical pleurodesis method - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: processing of the parietal and visceral pleura during thoracoscopy is performed with peroxide solutionat a concentration of 5.5-6.5%.

EFFECT: reliable adhesions in the pleural cavity with preferential formation of fibrous adhesions with lymphohistiocytic type of infiltration without expressed inflammatory changes in the lung tissue.

4 dwg, 3 tbl, 2 ex

Description

The invention relates to medicine, namely to surgery.

A known method of obliteration of the pleural cavity using pleurectomy. Pleurectomy is performed from II to VII intercostal space. The pleura is dissected along the rib with an electrocoagulation hook or scissors, peeled from the underlying tissues and removed [“Endoscopic Surgery”. Edited by V.S. Saveliev, Moscow, 2001, p. 227]. The disadvantage of this method is its invasiveness, as well as the risk of damage to the intercostal vessels.

A known method of chemical pleurodesis using the cytostatic bleomycetin. The method consists in the fact that after thoracocentesis with active aspiration of the exudate until the pleural cavity is completely drained, 45 mg of bleomycetin in 50 ml of 0.9% NaCl solution was introduced into the pleural cavity [Belsky V.M. et al. I scientific-practical conference "Thoracic oncology", Abstracts, p. Olginka, 2003, p. 83]. The disadvantage of this method is toxicity, the high cost of bleomycetin and a low percentage of complete obliteration of the pleural cavity - according to the data cited by the authors, 46.2%.

A known method of chemical pleurodesis using talc. After thoracocentesis with active aspiration of the exudate until the pleural cavity is completely drained, pleurodesis is performed by insufflation of 5-10 ml of sterile talc. The pleural cavity is drained by 1-2 drainages for 5-10 days until the end of the exudation [D.N. Pilkevich. The second scientific-practical conference "Thoracic Oncology", Abstracts, p. Olginka, 2004, p. 50].

The disadvantage of this method is the high risk of such a complication as empyema of the pleura, which makes it quite dangerous for its use in the clinic. The use of this method of pleurodesis at a young age makes it impossible or extremely difficult and dangerous to intervene on the lung, such as transplantation, lung resection.

Close to the claimed is proposed in US Pat. RU No. 2295333, publ. 03/20/2007, a method of chemical pleurodesis in the treatment of pneumothorax.

The authors suggest introducing a solution into the pleural cavity through drainage, including chlorhexidine at a concentration of at least 0.05% and ethyl alcohol at a concentration of at least 70 volume percent. After administration, the drainage is blocked for at least 1 hour. Then connect to active aspiration with a pressure of at least 20 mm water column.

The disadvantage of this method is a pronounced inflammatory reaction that contributes to the occurrence of pneumonia in the lung tissue adjacent to the treated surface, which also occurs with all of the above methods.

The technical result is to ensure the reliability of the adhesive process in the pleural cavity without pronounced inflammatory changes in the lung tissue.

The technical result is achieved by performing thoracoscopy according to the standard technique under endobronchial anesthesia. Then, the parietal and visceral pleura are treated with a solution of hydrogen peroxide in a concentration of 5.5-6.5%. In the postoperative period, active aspiration is performed, creating a negative pressure of 20-30 mm water column.

The method was tested in an experiment on conventional laboratory rats of the WISTAR strain, weighing 180 grams. The scope of observation is 60 laboratory animals, divided into equal two groups.

The work was carried out in accordance with legislative acts regulating the principles of humane treatment of animals used for scientific research (laboratory) purposes: Law of the Russian Federation of May 14, 1993 N 4979-1; Section 3.4 of the National Standard of the Russian Federation "Principles of Good Laboratory Practice" [Order of the Russian Technical Regulation of December 2, 2009 N 544-st], the rules for the humane treatment of laboratory animals [approved. The chief state sanitary doctor of the USSR of April 6, 1973 N 1045-73].

All animals under ether anesthesia modeled spontaneous pneumothorax on one side of the chest by the method of introducing air in a volume of 2 ml through a Velish needle, an hour later they were sprayed into this cavity: in the first observation group, the known composition, including a 0.05% chlorhexidine solution in 70% ethyl alcohol; in the second group, we have proposed a solution of hydrogen peroxide in a concentration of 5.5-6.5%. All animals were removed from the pleural cavity, animals were observed and killed, in accordance with the rules of humane treatment of animals, in batches of 3-5 animals for 3, 5, 7, 10, 30 days of the experiment.

Produced tissue sampling of the lung, pleura, chest wall for histological examination. Stained with hematoxylin-eosin preparations. A comparative analysis of adhesion formation and inflammatory changes in tissues in the study groups was performed.

The best results of pleurodesis with the least inflammation in the studied tissues were obtained using 5.5-6.5% hydrogen peroxide. The effect of pleurodesis was more pronounced starting from 3 days when using this method compared to the known pleurodesis method (table 1).

Table 1. Assessment of the quality and number of adhesions using various pleurodesis methods on the 3rd day of the experiment.

Parameter Known Method -
0.05% chlorhexidine solution in 70% ethyl alcohol Suggested Method -
5.5-6.5% hydrogen peroxide Number of adhesions 0.6 ± 0.4 1 ± 0.63 The quality of adhesions Fibrinous predominate Fibrous predominate

The figure 1 presents the morphological changes, the figure 3 is an inflammatory process when using a 0.05% solution of chlorhexidine in 70% ethyl alcohol. The beginning of the organization of predominantly fibrinous adhesions (3), marked neutrophilic infiltration (5) are observed. In figure 2, morphological changes, in figure 4 - the inflammatory process when using 5.5-6.5% hydrogen peroxide. The beginning of the organization of predominantly fibrotic adhesions (4), severe lymphohistiocytic infiltration (6).

Table 2. The number of cells in the field of view when using various methods of pleurodesis on 3 days.

Cell name The known method is 0.05% chlorhexidine solution in 70% ethyl alcohol The proposed method is 6% hydrogen peroxide. Lymphocytes 19 47 Macrophages 21 12 Plasma cells eighteen one Neutrophils 32 2 Eosinophils four 0 Histiocytes 28 39 Monocytes 3 24

Data on the cellular composition shown in Table 2 regarding the group of 0.05% chlorhexidine solution in 70% ethanol indicate a high activity of the inflammatory process (neutrophilic infiltration). In the group of 5.5-6.5% hydrogen peroxide, a low activity of the inflammatory process (lymphohistiocytic infiltration) was established.

Subject to the conditions of informed consent with the conclusion of the corresponding agreement, pleurodesis was performed by the proposed method to several patients.

The use of 5.5-6.5% hydrogen peroxide in the clinic made it possible to remove the drainage earlier than with the known method, as well as reduce the number of beds (table 3).

Table 3. Comparative characteristics of the dynamics of pleurodesis in the clinic.

Parameter Known Method -
0.05% chlorhexidine solution in 70% ethyl alcohol Suggested Method -
6% hydrogen peroxide The time of removal of drainage from the pleural cavity (days) 8 3 Number of beds 23 fifteen

Example No. 1. Patient P. Diagnosis: COPD. Bullous emphysema. Spontaneous pneumothorax on the right. Operation No. 53507: Videothoracoscopic resection of the lungs with complicated emphysema. Chemical and thermal pleurodesis 08/27/2015.

In the 5th intercostal space along the anterior axillary line, in the 5th intercostal space along the midclavicular line, in the 7th intercostal space along the middle axillary line, thoracoports are installed on the right. In the pleural cavity there are adhesions that are separated by a blunt and sharp path using coagulation. During intraoperative revision in the right pleural cavity, serous hemorrhagic fluid is up to 100 ml, in the S1 of the lung there is an emphysematous changed area. The ESHELON endoscopic devices were superimposed on the upper lobe; using endoscopic cassettes - 60 mm, 45 mm, an atypical marginal resection of the upper lobe of the lung was performed. Thermal and chemical pleurodesis was carried out with an alcohol solution of chlorhexidine. Drainage of the pleural cavity in the 5th intercostal space in the midclavicular line, in the 7th intercostal space in the middle axillary line. Control of hemostasis, pneumostasis, foreign bodies. Layer closure of the postoperative wound. Aseptic sticker.

The patient was hospitalized from 08.24.2015 to 09.16.2015. Drains removed on day 8. On the control R-gram of the chest organs there are signs of obliteration of the right pleural cavity. The patient was discharged for outpatient treatment in satisfactory condition.

Example No. 2. Patient L. Diagnosis: COPD. Bullous emphysema. Recurrent bilateral spontaneous pneumothorax. Operation No. 49283: Pleurectomy. Lung decortication. Chemical pleurodesis 05.21.2015.

Under endobronchial anesthesia, lateral thoracotomy was performed in the 6th intercostal space on the left. When the pleural cavity was opened, air was released under pressure. The pleural cavity was treated with a 6% hydrogen peroxide solution. Drainages through separate cuts in the 5th intercostal space at the sternum and in the 8th intercostal space in the middle axillary line. Control of hemostasis and foreign bodies. Layered closure of the chest wound tightly. Aseptic sticker. Active suction with a vacuum of 30 mm water column.

The patient was hospitalized from 05/17/2015 to 01/06/2015. On the 3rd day, the exudation stopped, the drains were removed. On the control R-gram of the chest organs there are signs of obliteration of the right and left pleural cavities. The patient was discharged for outpatient treatment in satisfactory condition.

Thus, we have proposed a new method of pleurodesis, including treating the pleura with 5.5-6.5% hydrogen peroxide solution, which allowed us to obtain a new result not known from the prior art - the predominant formation of fibrous adhesions and the presence of lymphohistiocytic type of infiltration, whereas in the known the prior art describe fibrinous adhesions, a neutrophilic type of infiltration.

Using the proposed method is a highly effective method of chemical pleurodesis in the treatment of pneumothorax and other diseases of the chest organs due to the acceleration of the formation of adhesions in the pleural cavity with low activity of the inflammatory process in the lung tissue - the method is not associated with the likelihood of pneumonia. The proposed technique is economically advantageous, as it reduces the patient’s hospital stay.

Description to drawings

FIG. 1. The severity of the adhesive process and inflammatory infiltration in the groups of use of a 0.05% chlorhexidine solution in 70% ethanol on the 3rd day of the experiment (increase x10):

1 - lung tissue;

2 - inflammatory infiltration;

3 - fibrinous adhesions with the beginning of the organization.

FIG. 2. The severity of the adhesive process and inflammatory infiltration in the groups using 5.5-6.5% hydrogen peroxide on the 3rd day of the experiment (increase x10):

1 - lung tissue;

2 - inflammatory infiltration;

4 - fibrous adhesion.

Fig 3. The severity of inflammatory infiltration in the groups of use of 0.05% chlorhexidine solution in 70% ethanol on the 3rd day of the experiment (increase x40):

5 - neutrophilic infiltration;

6 - lymphohistiocytic infiltration.

Fig 4. The severity of inflammatory infiltration in groups using 5.5-6.5% hydrogen peroxide on the 3rd day of the experiment (increase x40):

5 - neutrophilic infiltration;

6 - lymphohistiocytic infiltration.

Claims (1)

A method of chemical pleurodesis in the treatment of pneumothorax and other diseases of the chest organs, performed using thoracoscopy, characterized in that the treatment of parietal and visceral pleura is carried out with a solution of hydrogen peroxide in a concentration of 5.5-6.5%.

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