RU2654419C1 - Method for treatment of spontaneous pneumotorax - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to thoracic surgery. By means of thoracoscopy, the area of the supposed fusion between the parietal and visceral pleura is determined. Cut is made at the level of the third intercostal space, 2 to 5 cm in length, through which a stapling device is inserted into the pleural cavity, with help of which a modified section of the lung is resected within healthy tissues. Then cryoapplicator is injected into the pleural cavity and cryoexposure is applied to the parietal pleura in the apical sections at exposure of 6 seconds, the temperature is -196 °C to create a fusion between the parietal and visceral pleura.

EFFECT: method prevents postoperative complications.

1 cl, 2 ex, 4 dwg

Description

The invention relates to medicine, namely to the surgical treatment of spontaneous pneumothorax (SP). The morphological basis of the joint venture is pulmonary pulmonary emphysema. Most often it is necessary to deal with the so-called primary joint venture, which occurs in young people in whom the bullous process is limited to the apex of the lung. In such cases, the optimal treatment option for spontaneous pneumothorax is a resection of a portion of the lung affected by bullous emphysema, supplemented by limited pleurodesis throughout the I-III intercostal space. Pleurodesis is an indispensable step in the surgical treatment of spontaneous pneumothorax. It aims to prevent the recurrence of pneumothorax by creating adhesions between the parietal and visceral pleura. This tactic is justified by the fact that the long-term results of treatment are better after resection in combination with pleurodesis than after resection without pleurodesis. This is explained by the possibility of progression of the bullous process in the lung, which is revealed by examining patients who underwent lung resection due to SP in a long time [1, 2, 3, 4].

Several approaches to pleurodesis are known. In particular, pleurodesis by diathermocoagulation of the parietal pleura [1,5]. When using this method, deep necrosis of the parietal pleura and underlying tissues occurs with the involvement of intercostal vessels and nerves. Hemorrhages, suppuration and tissue rejection are noted. In some cases, bleeding requiring stopping is observed during coagulation and in the postoperative period.

Less traumatic is the method of treatment of pneumothorax, including coagulation-adhesive pleurodesis, carried out without destruction of the pleura [6]. According to this method, a pleural cavity is punctured for aspiration of the contents or rational choice of the site of thoracocentesis. At the site of puncture of the pleura under anesthesia, the chest wall is punctured with a trocar, the pleural contents are aspirated, then the thoracoscope optical tubes are inserted to examine the pleural cavity and identify the defect in the lung parenchyma. Having established the cause of pneumothorax, a second puncture of the chest wall with a trocar is made over the localization of the defect in the parenchyma, which passes air, in a convenient place along the intercostal space. In a state of apnea on a collapsed lung, the parenchyma is punctured with a thin needle in the area of the defect and 0.5-1 ml of MK-6 glue is injected into this place using a syringe. After 2-3 minutes, the adhesive polymerizes and firmly closes the defect in the lung.

To prevent relapse of pneumothorax, this method also involves the creation of adhesions between the parietal and visceral pleura. Under the control of vision, using a galvanocauter, several parts of the pleura are coagulated and, after 2-3 minutes, the results of gluing when inflating the lung are checked. To do this, a drainage is installed through one of the tubes of the trocar, and a gluing agent is applied through the other tube to the visceral and parietal pleura, which allows the fixation of the molten lung immediately. After removal of the last tube of the trocar through the drainage, the air is aspirated from the cavity under a pressure of 1.96-5.88 kPa. At the same time, through one of the gaps of the endotracheal tube in the calibrated lung, the same positive pressure is created that is held for 2-3 minutes until the adhesive of the expanded lung with the parietal pleura is firmly glued. The expansion of the lung under conditions of equal positive intrabronchial and negative intrapleural pressure reliably protects the pulmonary parenchyma from barotrauma, prevents the adhesive film from falling off, and does not violate pulmonary blood flow.

Thus, in the known method according to SU 1289468, the treatment of the damaged part of the lung tissue is performed by closing the defect in the lung using polymerizable glue, and the prevention of recurrence of pneumothorax is carried out by coagulation of several parts of the pleura using a galvanocauter under the control of vision. The use of a coagulation-adhesive method for treating pneumothorax has the following disadvantages. Sealing a lung defect is not a reliable treatment for a damaged part of the lung tissue, since not all patients can accurately detect the place of air leakage from the lung. Coagulation of several parts of the pleura using a galvanocauter requires verification of the results of gluing when inflating the lung. This complicates the known method and reduces the reliability of the treatment of pneumothorax.

The objective of the invention is to increase the reliability of the treatment of pneumothorax.

To solve this problem, a method for the treatment of spontaneous pneumothorax is proposed, which, like the prototype method, includes diagnostic thoracoscopy and the creation of limited adhesions between the parietal and visceral pleura through physical action on the pleural areas. The proposed method differs from the prototype in that, by thoracoscopy, the area of the alleged fusion between the parietal and visceral pleura is determined, after which an incision is made at the level of the third intercostal space with a length of 2 to 5 cm, through which a stapler is inserted into the pleural cavity, with which the changed section is resected. lung within healthy tissues, after which a cryoapplicator is introduced into the pleural cavity and cryotherapy is performed on the parietal pleura in the apical sections with an exposure of 6 sec und, a temperature of -196 ° C to create an adhesion between the parietal and visceral pleura.

For this, two thoracoports are formed, one of which introduces a telescope, and the other - a manipulator. After this, an incision is made at the level of the third intercostal space with a length of 2 to 5 cm, through which a stapler is inserted into the pleural cavity and, under endoscopic control, an atypical resection of the changed portion of the lung within healthy tissues is performed. Next, a cryoapplicator is introduced into the pleural cavity and cryotherapy is performed on the zone of the supposed fusion between the parietal and visceral pleura in the apical sections at a temperature of -196 ° C, with an exposure of 6 seconds. The pleurodesis zone is determined by video-assisted thoracoscopy and in the primary joint venture, as a rule, it is limited to I-III intercostal spaces.

Resection of the changed part of the lung within healthy tissues is a more reliable treatment of lung tissue than gluing a defect in the lung. At the same time, for resection of the lung site and for pleurodesis, the same access is used through which a stapler and a cryoapplicator are successively inserted into the pleural cavity. As a result of superficial cryotherapy on the zone of the alleged fusion between the parietal and visceral pleura in the apical sections with an exposure of 6 seconds, aseptic inflammation occurs, accompanied by stimulation of fibroplastic function, while the histological structure of the pleura is preserved. When exposure is greater than 6 seconds, necrosis of the pleura and underlying tissues is possible with the formation of a rough scar. With an exposure of less than 6 seconds, the inflammatory reaction may not develop at all. With the declared parameters of cryotherapy, the created adhesions are achieved without deep necrosis of the pleura and underlying tissues, while the vessels are not damaged, suppuration, tissue rejection and bleeding do not occur.

A new technical result achieved by the claimed invention is to reduce the morbidity of treatment of spontaneous pneumothorax and simplify its implementation.

The invention is illustrated by drawings, where in FIG. 1 shows a roentgenogram in direct projection, intense pneumothorax on the right; in FIG. 2 presents video thoracoscopy. Bullous changes in I-II segments of the upper lobe of the right lung; in FIG. 3 - video thoracoscopy, the impact of the cryoapplicator on the parietal pleura, the arrow shows the pleura, “frostbitten” immediately after application; in FIG. 4 - x-ray in direct projection the next day after surgery. In the General case, the method of treatment of pneumothorax is as follows. After processing the surgical field, diagnostic thoracoscopy is performed with video support to clarify the localization of lung tissue damage and revision of the pleural cavity. For this, two thoracoports are formed, one for introducing the telescope, and the other for introducing the manipulator, with the help of which the lung is rotated, retracted, inserted into the branches of the stapler, etc.

After repeated processing of the surgical field, an incision is made at the level of the third intercostal space with a length of 2 to 5 cm, through which a stapler is inserted into the pleural cavity and, under endoscopic control, an atypical resection of the changed portion of the lung within healthy tissues is performed using staplers UO-40, UO- 60. After that, a cryoapplicator is introduced into the pleural cavity and cryotherapy is performed on the parietal pleura in the area of the supposed fusion between the parietal and visceral pleura in the apical sections. The drainage of the pleural cavity is performed, after which the wound is sutured in layers. After the operation, clinical and radiological monitoring is performed.

Clinical example 1. A 24-year-old patient was admitted with a diagnosis of "Spontaneous pneumothorax on the right." On admission, he noted moderate shortness of breath and chest pain on the right. Radiologically determined collapse of the right lung to 0.5 volume. A thoracoscopy was performed on the right with video support. Light collapsed. In the cavity, 50 ml of serous effusion. In I-II SS, a group of emphysematous bulls of various sizes. One of the bulls was asleep. In the above manner, mini-access is formed in the III intercostal space. A UO-60 stapler was inserted into the pleural cavity, atypical resection of I-II SS within healthy tissues was performed. Then, a cryoapplicator was inserted into the pleural cavity through the same access and cryotherapy was performed on the parietal pleura in the apical sections at the level of I-III intercostal space. The postoperative course is smooth. Drainage from the pleural cavity was removed on the 3rd day. The patient was discharged on the 7th day.

Clinical example 2

The patient is 25 years old. Locksmith. Smoker The first episode of the joint venture 3 months ago, the drainage of the pleural cavity was performed, the lung straightened. Re-clinic of intense pneumothorax. Delivered to the clinic. Upon admission, a moderate condition, severe shortness of breath at rest, pain in the right half of the chest. On radiography in a direct projection, a complete collapse of the right lung is noted, a sharp displacement of the mediastinum to the left (Fig. 1). The diagnosis "Right-sided strained spontaneous pneumothorax" is confirmed. Performed temporary decompression by pleural puncture, followed by emergency video thoracoscopy. Video thoracoscopy shows that I-II segments of the upper lobe are almost entirely a cluster of small bullae (Fig. 2). A video-assisted resection of the affected segments was performed. Next, a cryoapplicator made pleurodesis over the three upper intercostal spaces (Fig. 3), the arrow shows the pleura, “frostbitten” immediately after application. The operation is completed by drainage of the pleural cavity. The next day, the full extension of the right lung was recorded (Fig. 4). Drainage was removed after 5 days with full expansion of the lung. Discharged from the department on the 7th day. A year later, he turned to the clinic with a request to receive a certificate of health for presentation at the place of work. Inspected: healthy. Radiography - the lung is straightened.

According to the claimed method, 25 patients with spontaneous pneumothorax were operated on. The observation period ranged from 1 to 12 months. Complications associated with the use of cryotherapy were not observed. Relapses of spontaneous pneumothorax were not noted.

LITERATURE

1. Chukhrienko D.P., Danilenko M.V., Bondarenko V.A., Bely I.S. Spontaneous pathological pneumothorax. Kiev, 1973, 273 p.

2. Cardillo G., Facciolo F., Giunti R., e.a. Videothoracoscopic treatment of primary spontaneous pneumothorax: a 6-year experience // Ann Thorac Surg. - 2000. - Vol. 69. - P. 357-362.

3. Chen JS, Hsu HH, Chen RJ, et al. Additional minocycline pleurodesis after thoracoscopic surgery for primary spontaneous pneumothorax // Am J Respir Crit Care Med. - 2006. - Vol. - 173. - No. 5. - P. 548-554.

4. Margolis M, Charagozloo F, Tempesta B. Video-assisted thoracic surgical treatment of initial spontaneous pneumothorax in young patients // Ann Thorac Surg. - 2003. - Vol. 76. - No. 5. - P. 1661-1663.

5. Aliev A.M., Ioffe L.Ts., Dashiev B.A. et al. Diagnostic and operative thoracoscopy. Alma-Ata, 1988, 144 p.

6. SU 1289468, publ. 02/15/1987

Claims (1)

A method for the treatment of spontaneous pneumothorax, including diagnostic thoracoscopy and the creation of limited adhesions between the parietal and visceral pleura by physically affecting the pleural regions, characterized in that by means of thoracoscopy, the zone of the alleged adhesion between the parietal and visceral pleura is determined, after which an incision is made at the level of the third intercostal space with a length of 2 to 5 cm, through which a stapler is inserted into the pleural cavity, with which a changed section of soft within healthy tissues, after which a cryoapplicator is introduced into the pleural cavity and cryotherapy is performed on the parietal pleura in the apical sections at an exposure of 6 seconds, at a temperature of -196 ° C to create an adhesion between the parietal and visceral pleura.

Images