RU2619750C1 - Method of treating patients with lung gangrenous abscess - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: thoracic abscessotomy and cavity drainage are carried out. In postoperative period on the third day, a sterile porous sponge corresponding to the size of the lesion cavity and pre-covered with a non-adhesive dressing material is placed in the abscess cavity. Control video-abscessoscopy is carried out, the wound is sealed and the drainage system is adjusted for active vacuum aspiration. The negative pressure is maintained for three minutes first at the level of 40 mmHg, then at the level of 70 mmHg, constantly alternating these levels. Bandaging with dressing change is carried out every 3-5 days and is followed by momentary video-abscessoscopy and material collection for microbiological study.

EFFECT: method enables to reduce treatment length and improve the sanation quality of the lesion site, provides conditions for dynamic observation of the treatment process.

1 ex

Description

The invention relates to medicine, in particular to thoracic surgery, and relates to a method for the treatment of acute gangrenous lung abscess.

A known method of endoscopic treatment of lung abscess, the essence of which is that when performing computed tomography, the localization of the lung abscess is determined. With fibrobronchoscopy, the draining bronchus is determined and postural drainage is established (1).

The disadvantage of this method is that in patients with gangrenous lung abscesses, traditional methods of achieving postural drainage, as well as therapeutic methods of endobronchial drainage, are ineffective due to the sequestration of large sections of lung tissue, which, due to their size, are not able to evacuate into the lumen of the bronchi.

There is a method of surgical treatment of lung abscess, the essence of which is that external transthoracic drainage of the abscess according to Monaldi is performed with tubular drainage fixed to the skin by ligatures (2).

The disadvantage of this method is that this method is applicable provided that there is a predominantly liquid component in the cavity of the destruction of the lung tissue. Using this method does not allow to remove sequestered and necrotic lung tissue.

A known method for the surgical treatment of gangrenous lung abscess by performing thoracoabscessostomy, the essence of which is that by resection of the rib, an anastomosis is created between the destruction site and the external environment, which allows sanitizing the abscess cavity in the lung (3).

The disadvantages of this method is the presence of an open wound with constant exudation, which requires multiple daily dressings. The period of lung sequestration against the background of such passive drainage averages 2 weeks, which affects the long periods of formation of delimited sequestration and cleansing the abscess cavity. Thoracoabscessostomy is considered as the first stage of treatment of patients with gangrenous lung abscesses, aimed at stopping the systemic inflammatory reaction and cleansing the destruction cavity. The second stage involves a resection of the lung with a focus of infection. The presence of a passive thoracoabscessostomy, although it allows to reduce the time of preparation of the patient for radical surgery compared with transthoracic drainage, but remains quite long. This method is taken by us as a prototype.

The aim of the present invention is to optimize the treatment of patients with gangrenous lung abscess, reducing the time and quality of rehabilitation of the destruction site, providing conditions for dynamic monitoring of the treatment process.

This goal is achieved by the fact that in the postoperative period on the third day a sterile porous sponge or 3D gauze is installed in the abscess cavity, corresponding to the size of the destruction cavity and pre-coated with non-adhesive dressing material; control video abscessoscopy is performed, the wound is sealed and the drainage system is set up for active vacuum aspiration, while negative pressure is maintained for three minutes, first at 40 mm Hg, then 70 mm Hg, constantly alternating between its levels; Bandaging with dressing changes is carried out once every 3-5 days and is accompanied by simultaneous video abscessoscopy and sampling for microbiological examination.

The alternation of levels of negative pressure provides not only continuous evacuation of exudate, quick cleansing of the destruction cavity and complete removal of lung sequestration, but also stimulation of proliferation of granulation tissue. Active vacuum drainage of the destruction cavity allows you to control the amount of exudate by collecting it in a measuring container, helps to reduce the number of dressings, reduce the time for cleaning the abscess cavity. Performing video abscessoscopy simultaneously with ligation allows you to control the effectiveness of treatment.

The method is implemented as follows.

After the standard surgical aid, which consists in layer-by-layer dissection of soft tissues, subperiosteal resection of a fragment of a rib 6-8 cm long, a wide excision of the underlying abscess wall is performed in order to open the destruction cavity and subsequent creation of the anastomosis - they form a thoracoabscessostoma. In the postoperative period, on the third day, a sterile porous sponge or 3D gauze is installed in the abscess cavity, corresponding to the size of the destruction cavity and pre-coated with non-adhesive dressing. Perform control video abscessoscopy. Next, the wound is sealed and the drainage system is set up for active vacuum aspiration connected to a portable vacuum aspirator. At the same time, negative pressure is maintained for three minutes, first at a level of 40 mm Hg, then 70 mm Hg, constantly alternating between its levels due to the risk of bleeding. Dressing with dressing replacement is carried out with a frequency of 1 time in 3-5 days and is accompanied by simultaneous video abscessoscopy and sampling of material for microbiological examination. This allows you to evaluate the dynamics of the disease, to make a necrectomy of the delimited zones of tissue necrosis, to identify the appearance or obliteration of bronchial fistula.

The proposed method with a positive effect was performed in 10 patients. In 8 patients, the combination of thoracoabscessostomy and vacuum drainage with dynamic video abscessoscopy allowed the formation of a zone of limited fibrosis and spontaneous closure of the thoracoabscessostomy. In 2 patients, the proposed method made it possible to prepare the patient for radical lung surgery in a short time.

Clinical example

Patient I., 49 years old, was admitted September 2, 2014 to the Department of Thoracic Surgery, GBUZ "SOKB im. V.D. Seredavina ”with complaints of pain in the right half of the chest, dry cough, shortness of breath and fever up to 38 ° C. During the examination, an acute gangrenous abscess of the lower lobe of the right lung was diagnosed. After short-term preoperative preparation, the patient performed a thoracoabscessostomy on the right with a subperiosteal resection of the 7th rib, necrosecestrectomy on 05.09.2014. Vacuum drainage started on the third day after surgery and preliminary video abscessoscopy with an assessment of the risk of developing arrosive bleeding. There was an inactive leakage of air through the lung parenchyma in the area of the thoracoabscessostomy, which did not interfere with the vacuum drainage. The negative pressure mode was maintained at 40 and 70 mm Hg. for three minutes, alternating. Dressings were carried out every 3-5 days as the container was filled, simultaneously performing video abscessoscopy and sampling for microbiological examination.

The duration of vacuum drainage was only 14 days. On the CT of the right lung already on the 19th day after the operation, sections of linear fibrosis were determined in the basal sections; the presence of a dry clean residual cavity up to 10 mm wide was determined from the posterior-lateral surface. The patient was discharged from the hospital on the 23rd day with a chest wound on ointment dressings. Examined 1 month after discharge. The chest wound healed by secondary intention, radiographically lungs without infiltrative changes.

A method of surgical treatment of patients with gangrenous lung abscess can be recommended for use in the practice of a thoracic surgeon.

INFORMATION SOURCES

1. Blashentseva S.A. The technique of endoscopic drainage of acute lung abscesses // Thoracic and cardiovascular surgery. - 2001. - No. 1. - S. 36-40.

2. Surgery of the lungs and pleura. Guide for Doctors / Under. Ed. I.S. Kolesnikova and M.I. Lytkina. - L., "Medicine", 1988. - S. 141-185.

3. Gostishchev V.K., Smolyar V.A., Kharitonov Yu.K. and other Thoracoabscessostomy in the complex treatment of patients with pulmonary gangrene // Surgery. - 2001. - No. 1. - S. 54-57.

Claims (1)

A method of treating patients with gangrenous lung abscess, including performing thoracoabscessostomy and drainage of the cavity, characterized in that in the postoperative period on the third day a sterile porous sponge is installed in the abscess cavity, corresponding to the size of the destruction cavity and pre-coated with non-adhesive dressing material; control video abscessoscopy is performed, the wound is sealed and the drainage system is set up for active vacuum aspiration, while negative pressure is maintained for three minutes, first at 40 mm Hg, then 70 mm Hg, constantly alternating between these levels; Bandaging with dressing changes is carried out once every 3-5 days and is accompanied by simultaneous video abscessoscopy and sampling for microbiological examination.