RU2766521C1 - Method of treating purulent-destructive pulmonary diseases - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to thoracic surgery. Thoracoport is placed in a projection of the destruction cavity, a video thoracoscope is inserted into the destruction cavity to assess the degree of manifestation of the inflammatory process and the presence of bronchopulmonary fistulas. Destruction cavity is sanitized, followed by installation of a drainage system in the cavity through a thoracoport in the form of a fine-pored sponge with a double-lumen drainage tube passing through the entire volume of the sponge and with its distal end fixed to the base of the sponge. Thoracoport wound is closed and sealed. Pathological discharge of cavity is vacuum-aspirated at a negative pressure of 8–10 kPa until the cavity is cleaned, followed by an increase in the negative pressure to 15–18 kPa. Vacuum aspiration is performed until the cavity is closed by granulations or the destruction cavity is reduced to the size of not more than 60 mm in diameter. In the process of vacuum aspiration, an antiseptic solution is introduced drop-by-drop into the destruction cavity through the lumen of the drainage tube. On 3rd-4th day after the beginning of the vacuum aspiration, the drainage system is changed with the vacuum-assisted dressing, which is changed every 3–5 days. In the process of changing the drainage system with a vacuum-assisted dressing, a videothoracoabscessoscopy of the destruction cavity is performed. Fine-pored sponge used is a sponge whose volume exceeds the volume of the destruction cavity by 1.5 times and provides filling the entire destruction cavity with the sponge while maintaining its aspirating properties.EFFECT: method provides reducing the length of treating the patients by improving the quality of debridement of the purulent focus, reducing the number of surgical injuries while ensuring control of the inflammatory process in the lungs.6 cl, 2 ex

Description

The technical field to which the invention belongs

The invention relates to medicine, namely to thoracic surgery, and can be used for the surgical treatment of limited purulent-destructive lung diseases.

State of the art

The problem of surgical treatment of limited non-specific destructive forms of lung diseases currently remains relevant. Despite the high development of digital technologies and the widespread use of various endovideosurgical methods for the treatment of lung diseases, there is no single approach and understanding in solving this problem. Previously known methods of surgical treatment of limited lung destruction currently do not fully meet modern requirements - the simplicity of the method, its availability and economic feasibility.

The prior art method of endoscopic treatment of lung abscess [Blashentseva S.A. The technique of endoscopic drainage of acute lung abscesses // Thoracic and cardiovascular surgery. - 2001. - No. 1. - S. 36-40]. The method consists in the fact that when performing computed tomography of the chest organs, the localization of destruction in the lung is determined. Then, with fibrobronchoscopy, the draining bronchus is determined and postural drainage is established.

The disadvantage of this method is that in patients with gangrenous lung abscesses, traditional methods of achieving postural drainage, even in combination with endobronchial drainage, are ineffective due to the presence of sequestration of large areas of lung tissue, which, due to their size, are not able to evacuate into the bronchial lumen.

There is also known a method of surgical treatment of lung abscess [Surgery of the lungs and pleura. A guide for doctors / ed. I.S. Kolesnikov and M.I. Lytkin. - L., "Medicine", 1988. - S. 141-185], the essence of which is to perform external transthoracic drainage of the destruction cavity according to Monaldi with the installation of tubular drainage, which is fixed to the skin with ligatures.

The disadvantage of this method is the impossibility of controlled management of the destruction cavity in the lung, which does not allow more effective sanitation of the purulent focus, which may subsequently lead to the need to perform necrosequestrectomy.

A known method of surgical treatment of gangrenous lung abscess by forming a thoracoabscessostomy [Gostishchev VK, Smolyar VA, Kharitonov Yu.K. Thoracoabscessostomy in the complex treatment of patients with lung gangrene // Surgery. - 2001. - No. 1. - S. 54-57]. The result of the operation is achieved by resection of a section of the rib in order to artificially form a defect in the chest wall for drainage of the destruction cavity. This allows the open path to sanitize the cavity of the abscess in the lung daily.

The disadvantage of the known method for the treatment of lung abscess is the presence of an open wound, which inevitably leads to secondary infection of the focus of infection in the lung, including nosocomial strains, thereby prolonging the treatment time. The appearance of granulation tissue with this method of drainage of a purulent focus is noted on the 10-12th day. Carrying out this method of open drainage is considered as the initial stage of treatment of patients with gangrenous lung abscesses, which is aimed at stopping the systemic inflammatory reaction and cleansing the destruction cavity. The second stage involves resection of the lung with a focus of infection.

Closest to the claimed invention is a method of surgical treatment of lung abscess [RF patent No. 2619750], including layer-by-layer dissection of soft tissues, subperiosteal resection of a rib fragment up to 6-8 cm long with the formation of a thoracoabscessostomy, through which a 3D gauze or porous sponge with dimensions corresponding to the destruction cavity, control video abscessoscopy is performed. Next, the wound is sealed and the drainage system is adjusted for active vacuum aspiration, connected to a portable vacuum aspirator. At the same time, negative pressure is maintained for three minutes, first at the level of 40 mm Hg, then 70 mm Hg, constantly alternating its levels due to the risk of bleeding. Bandaging with bandage 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.

The disadvantages of this method are the invasiveness of the method of access to the destruction cavity, which creates a negative pressure only in the upper layers of 3D gauze or a porous sponge, the lack of prevention of bronchopulmonary fistulas in order to eliminate the destruction cavity. In fact, this method is reduced to the formation of a thoracoabscessostomy using active vacuum aspiration, in which the use of video abscessoscopy is leveled by resection of the rib and the size of the thoracoabscessostomy.

The technical problem to be solved by the invention is to improve the results of treatment of patients with limited cavities of intrapulmonary destruction, incl. with gangrenous lung abscesses complicated by bronchopulmonary fistulas.

Disclosure of the essence of the invention

The technical result of the invention is to reduce the time of treatment of patients by improving the quality of sanitation of the purulent focus, reducing the trauma of the operation while ensuring control of the inflammatory process in the lungs. The invention also provides methodological simplicity of the method of treatment.

The technical result is achieved by implementing a method for treating a purulent-destructive lung disease, including installing a thoracoport in the projection of the destruction cavity, introducing a video thoracoscope into the destruction cavity to assess the severity of the inflammatory process and the presence of bronchopulmonary fistulas, sanitation of the destruction cavity, followed by installation of a drainage system into the cavity through the thoracoport in the form of a finely porous sponge with a double-lumen drainage tube made of elastic material passing through the entire volume of the sponge and with the distal end fixed to the base of the sponge, suturing and sealing the thoracoportal wound, vacuum aspiration of the pathological discharge cavity (purulent-necrotic cavity contents) at a negative pressure of 8-10 kPa until the cavity is cleansed, followed by an increase in negative pressure to 15-18 kPa and vacuum aspiration until the cavity is completely closed by granulations or the destruction cavity is reduced to a size of no more than 60 mm in diameter, while in the process of vacuum aspiration, an antiseptic solution is dripped into the destruction cavity through a thin lumen of the drainage tube; 3-4 days after the start of vacuum aspiration, the drainage system is changed with a vacuum-assisted bandage, followed by their change every 3-5 days, in the process of changing the drainage system with a vacuum-assisted bandage, video thoracoabscessoscopy of the destruction cavity is performed; as a finely porous sponge, a sponge is used with a volume exceeding the volume of the destruction cavity by 1.5 times and ensuring that the sponge fills the entire destruction cavity while maintaining its aspirating properties.

In one of the private embodiments of the invention, during vacuum aspiration at a negative pressure of 8-10 kPa, an antiseptic solution is injected in a volume that ensures filling of the destruction cavity for 12 hours every day, and during vacuum aspiration at a negative pressure of 15-18 kPa antiseptic solution is administered in a volume of 500 ml for 6-8 hours every day.

In the presence of bronchopulmonary fistulas, in addition to the start of vacuum aspiration, temporary endobronchial occlusion of the zonal draining bronchus is performed with a valve occluder.

As a double-lumen drainage tube, a tube can be used, the wide channel of which is perforated in the area of contact with the sponge.

In the process of videothoracoabscessoscopy of the destruction cavity, material is taken for microbiological examination.

Trocar access to the focus of destruction is performed in the optimally accessible and shortest direction according to computed tomography of the chest organs. The use of a larger volume of finely porous polyurethane sponge allows you to fill all the hidden spaces of the cavity. The installation of a double-lumen drainage with additional drainage holes through the entire length of the sponge allows you to effectively remove exudate throughout the entire volume of the cavity, prolong the introduction of antiseptic solutions, bacteriophages, which also helps to reduce the duration of treatment. Performing VEBO of the zonal draining bronchus with a valve occluder at the initial stage of treatment allows interrupting the pathological communication of the tracheobronchial tree with the destruction cavity and additionally contributes to the elimination of the purulent focus.

Implementation of the invention

The proposed method is carried out as follows.

After hospitalization in the department of thoracic surgery, the patient undergoes computed tomography of the chest organs (CT scan of the chest), the results of which determine the size and localization of destructive changes in the lung tissue. When the cavity of lung tissue destruction is located subpleurally, the next step is surgical treatment. Under general anesthesia (usually intravenous) after dissection of soft tissues in the intercostal space in the projection of the destruction cavity, perform thoracocentesis and install a thoracoport. At the same time, access to the cavity is carried out through an incision of no more than 1.3-1.8 cm. Next, a videothoracoscope is introduced into the cavity, the degree of severity of the inflammatory process (phase of the inflammatory process), the presence of bronchopulmonary fistulas are assessed. In the monoport mode, using endoscopic instruments, the destruction cavity is sanitized (including the removal of necrotic and sequestered areas of the lung tissue), a biopsy of the lung tissue is performed, and the material is taken for microbiological and cytological examination. The drainage system is then designed using a standard fine open cell polyurethane or polyester cellular foam sponge (cellular foam), preferably with a pore size of 400-600 µm, such as Granufoam® or Foamex®. The volume of the destruction cavity is preliminarily determined by filling the latter with an antiseptic solution, and a sponge is modeled (cut out) with a shape corresponding to or close to the shape of the destruction cavity, previously visualized according to CT data, and with a volume exceeding the volume of the destruction cavity, preferably 1.5 times, which allows you to fill all the irregularities and additional small pockets in the destruction cavity, while maintaining the properties of the sponge intended for VAC therapy. A sponge of a smaller volume in the active aspiration mode does not provide filling of the entire volume of the destruction cavity, which creates the prerequisites for streaks of purulent exudate, and the use of a sponge of a larger volume leads to a violation of its aspirating properties (significant deformation of the pores), and, as a result, to the loss of the main clinical the effect of adsorption of this material and the difficulty of the outflow of pathological contents from the abscess. Through the simulated sponge, preferably in its center, a double-lumen drainage made of an elastic material is carried out through the port (for example, a medical multi-channel silicone tube (TMMK) No. 24, outer diameter 8 mm, inner diameter of the small channel 1.3 mm is used as drainage), previously perforating a wide drainage channel with additional holes with a diameter of 3-4 mm at a distance of at least 1 cm from each other along the entire length of the sponge. At the same time, the number of holes may vary depending on the length of the drainage section in contact with the sponge, and in one of the particular embodiments of the invention it can be from 5 to 9. The holes are located almost along the entire circumference of the aspiration channel, but without damaging the small diameter channel, thereby conditions are additionally created for the evacuation of pathological contents throughout the volume of the destruction cavity. Then the port is removed and the distal end of the draining tube is fixed to the base of the sponge by suturing.

The resulting drainage system is installed through the thoracoportal opening over the entire volume of the destruction cavity. Then, the thoracoportal wound is sutured and sealed, for example, with an adhesive film for VivanoMed vacuum systems, and negative pressure wound therapy (NPWT - negative pressure wound therapy) is performed. At the same time, an active vacuum aspiration system is set up, for which the draining tube is connected to a portable (or stationary) vacuum aspirator, a vacuum-assisted bandage is applied to the wound. At the initial stage of treatment, as a rule, during the first 3-4 days, negative pressure is maintained at a level of 8-10 kPa, while an antiseptic solution is dripped through a thin lumen of the drainage tube in a volume that ensures filling of the destruction cavity (preferably, in a volume of up to 1000 ml) for 12 hours every day, which allows in a more active mode to reach the next phase of the inflammatory process - the formation of active granulations.

In the presence of bronchopulmonary fistulas, before applying a vacuum-assisted bandage, VEBO (temporary endobronchial occlusion) of the zonal draining bronchus is performed with a valve occluder. For bronchoscopy, for example, a BF TE 2 bronchoscope is used. As an occluder, for example, a Medlang rubber blocker with diameters of 10 to 15 mm is used. Blocking the bronchus allows you to interrupt the pathological communication of the tracheobronchial tree with the cavity of destruction and additionally contributes to the elimination of the purulent focus.

On the 3-4th day after the installation of the vacuum dressing, dressing is performed with a change in the drainage system, followed by a change in the dressing and drainage system every 3-5 days. At the same time, video-assisted thoracoabscessoscopy is performed to assess the severity of the inflammatory process, and material is also taken for microbiological examination. When the purulent focus is cleared (as a rule, for 3-4 days), the negative pressure in the system is increased to 15-18 kPa and vacuum aspiration is continued until the cavity is completely closed by granulations or the destruction cavity is reduced to a size of no more than 60 mm in diameter (maximum size) , preferably not more than 40 mm. At the same time, in one of the private embodiments of the invention, in the process of vacuum aspiration, an antiseptic solution is continued to be injected, for example, in a volume of 500 ml for 6-8 hours every day.

The proposed method of treatment with a positive effect was performed in 6 patients. In 4 patients, it was possible to achieve the formation of local pneumopleurofibrosis at the site of the destruction cavity within 10-14 days. In 2 patients, the method made it possible to achieve sanitation of the purulent focus also in a short time, however, radical surgical treatment was not performed due to severe comorbidities.

Case Study #1

Patient F., 55 years old. Entered by transfer from a specialized hospital to the department of thoracic surgery of the State Budgetary Healthcare Institution “GKB them. I.V.Davydovsky DZM" with complaints of cough with purulent sputum, fever up to 38.8°C, weakness, shortness of breath against the background of severe concomitant pathology - parenchymal hemorrhage in the left hemisphere of the brain. Atherosclerosis of the cerebral arteries. Hypertension 3 stage III stage risk 4. CT scan of the chest revealed a gangrenous abscess of the upper lobe of the right lung: in S3 and the middle lobe of the right subpleural and paramediastinally lung, there was a large cavity formation with unevenly thick walls, 67x125x84 mm in size, drained by a suitable bronchus. After a short-term preoperative preparation, the next day from the moment of admission, under intravenous anesthesia, from the position of the patient lying on his back, at the point determined by the previously performed CT scan of the chest, thoracocentesis was performed. Received cloudy exudate, the latter was evacuated. After that, a 10 mm thoracoport was installed from a 1.6 cm incision into the destruction cavity. Videothoracoabscessoscopy was performed using an endovideosurgical complex - an endoscopic stand type 2 manufactured by Karl Storz in monoport mode. After evaluating the destruction cavity and visualizing the sequester, necrosequestrectomy was performed using endoscopic instruments (scissors, dissector). The destruction cavity was sanitized with an antiseptic solution. After that, physiological saline was poured into the destruction cavity, the volume of which was previously measured with Jeanne's syringe. Then, from the Granufoam® material with a pore size of 400 μm, a sponge was cut out with a shape that repeated the shape of the destruction cavity and a volume exceeding the measured volume of the destruction cavity by 1.5 times. Using a 10 mm trocar port, a double-lumen drainage was installed through the entire volume of the simulated sponge - a multi-channel medical tube (TMMC) No. 24 (outer diameter 8 mm, inner diameter of the small channel 1.3 mm), which was fixed to the base of the sponge. This drainage system was installed through the thoracoportal opening into the destruction cavity. Previously, on the aspiration (larger in diameter) channel in the area of contact with the sponge 6 cm long, 5 holes were made, arranged fan-shaped around the circumference of the aspiration channel without disturbing the integral channel of small diameter. The next step was VEBO with a rubber blocker "Medlang" with a diameter of 13 mm, a zonal drainage cavity for destruction of the bronchus. Next, active vacuum aspiration was established at a level of 8 kPa, while an aqueous solution of chlorhexidine 0.005% in a volume of 1000 ml was dripped through a thin drainage lumen for 12 hours every day. The change of the drainage system (tube + sponge) with a vacuum-assisted dressing was carried out after 3 days with video abscessoscopy. Further, the drainage system with a bandage was changed every 3 days (once every three days). On the sixth day, VAS visualized the cleansing of the destruction cavity, its implementation with granulations. After that, the pressure was increased to 15 kPa and aspiration was performed for 6 days until the cavity size was 35x59x54 mm. Aspiration was performed 12 days after hospitalization. The hospitalization period was 14 days. During the treatment, the destruction cavity decreased to a minimum size. Discharged for outpatient treatment with permanent drainage (Foley catheter type) and an occluder. At the control examination three weeks later, with CT of the chest cavity, the destruction cavity in the lung was completely healed. The occluder and drain have been removed. Radical surgical treatment was not performed due to the presence of severe comorbidity.

Case Study #2

Patient M., 39 years old. Entered the service of the ambulance service in the department of thoracic surgery GBUZ "GKB im. I.V.Davydovsky DZM" with complaints of pain and swelling in the projection of the left sternoclavicular joint, moderate cough with purulent sputum, fever up to 38.7°C. CT scan of the chest revealed a cavity of destruction of the upper lobe of the left lung with a breakthrough into the soft tissues of the anterior chest wall: in S3 of the left lung, a cavity of destruction of the lung was determined with the presence of a fluid level measuring 38x38 mm, which was intimately adjacent to the anterior chest wall and the anterior superior mediastinum. There is a reactive infiltration of the anterior mediastinal fat cell, invasion cannot be ruled out. The presence of a fistulous passage of the above-described formation through the sternocostal joint of the anterior rib is also noted, with spread to the soft tissues of the anterior chest wall. After a short-term preoperative preparation, the next day from the moment of admission, under intravenous anesthesia, from the position of the patient lying on his back, at the point determined by the previously performed chest CT scan, the left sternoclavicular joint was opened. A purulent discharge was obtained. A necrectomy of necrotically altered articular surfaces was performed, in which a pathological communication with the intrapulmonary destruction cavity was diagnosed. A 10 mm thoracoport was placed intraulnarly into the destruction cavity. Videothoracoabscessoscopy was performed using an endovideosurgical complex - an endoscopic stand type 2 manufactured by Karl Storz in monoport mode. After evaluating the destruction cavity and visualizing the sequestered areas of the lung tissue, necrosequestrectomy was performed using endoscopic instruments (scissors, dissector). The destruction cavity was sanitized with an antiseptic solution. After that, physiological saline was poured into the destruction cavity, the volume of which was previously measured with Jeanne's syringe. Then, from the Granufoam® material with a pore size of 400 μm, a sponge was cut out with a shape that repeated the shape of the destruction cavity and a volume exceeding the measured volume of the destruction cavity by 1.5 times. Using a 10 mm trocar port, a double-lumen drainage was installed through the entire volume of the simulated sponge - a multichannel medical tube (TMMC) No. 24 (outer diameter 8 mm, inner diameter of the small channel 1.3 mm), which was fixed to the base of the sponge. This drainage system was installed through the thoracoportal opening into the destruction cavity. Previously, on the aspiration (larger in diameter) channel in the area of contact with the sponge with a length of 4.4 cm, 4 holes were made, arranged fan-shaped around the circumference of the aspiration channel without disturbing the integral channel of small diameter. The installed VAC system filled the destruction cavity in the lung and the wound of the left sternoclavicular joint. The next step was VEBO with a rubber blocker "Medlang" with a diameter of 12 mm of a zonal drainage cavity for the destruction of the bronchus. Then we set up active vacuum aspiration at the level of 10 kPa. at the same time, an aqueous solution of chlorhexidine 0.005% in a volume of up to 1000 ml was dripped through a thin drainage lumen for 12 hours every day. The drainage system was changed after 3 days with video abscessoscopy. Thereafter, dressings were changed every 3 days. On the third day from the moment of the first operation, after the next change of the drainage system, the cleansing of the destruction cavity and the wound of the left sternoclavicular joint, their execution by granulations, was visualized in the VAC. After that, the pressure was increased to 18 kPa and aspiration was performed for 6 days until the cavity was completely closed by granulations. Aspiration was performed 9 days after hospitalization. The hospitalization period was 11 days. During treatment, the destruction cavity in the upper lobe of the left lung decreased to a minimum size and filled with granulations. The wound surface of the soft tissues of the left sternoclavicular joint was filled with granulations and healed by secondary intention. Discharged to the outpatient stage of treatment with clinical recovery in the form of the outcome of the destruction cavity in the lung tissue in the area of local pneumopleurofibrosis. The wound of the left sternoclavicular joint has decreased in size, is made by granulations, heals by secondary intention.

Claims (6)

1. A method for treating a purulent-destructive lung disease, including installing a thoracoport in the projection of the destruction cavity, introducing a videothoracoscope into the destruction cavity to assess the severity of the inflammatory process and the presence of bronchopulmonary fistulas, sanitizing the destruction cavity, followed by installing a drainage system in the form of a finely porous sponge into the cavity through the thoracoport with a double-lumen drainage tube passing through the entire volume of the sponge and the distal end fixed to the base of the sponge, suturing and sealing the thoracoportal wound, vacuum aspiration of the pathological detachable cavity at a negative pressure of 8-10 kPa until the cavity is cleaned, followed by an increase in negative pressure to 15-18 kPa and performing vacuum aspiration until the cavity is closed with granulations or the destruction cavity is reduced to a size of no more than 60 mm in diameter, while during vacuum aspiration an antiseptic solution is dripped into the destruction cavity through the lumen of the drainage tube; 3-4 days after the start of vacuum aspiration, the drainage system is changed with a vacuum-assisted bandage, followed by their change every 3-5 days, in the process of changing the drainage system with a vacuum-assisted bandage, video thoracoabscessoscopy of the destruction cavity is performed; as a finely porous sponge, a sponge is used with a volume exceeding the volume of the destruction cavity by 1.5 times and ensuring that the sponge fills the entire destruction cavity while maintaining its aspirating properties. 2. The method according to claim 1, characterized in that during vacuum aspiration at a negative pressure of 8-10 kPa, an antiseptic solution is injected in a volume that ensures filling of the destruction cavity for 12 hours every day. 3. The method according to claim 1, characterized in that in the process of vacuum aspiration at a negative pressure of 15-18 kPa, an antiseptic solution is injected in a volume of 500 ml for 6-8 hours every day. 4. The method according to claim 1, characterized in that in the presence of bronchopulmonary fistulas, in addition to the start of vacuum aspiration, temporary endobronchial occlusion of the zonal draining bronchus is performed with a valve occluder. 5. The method according to claim 1, characterized in that a tube is used as a double-lumen drainage tube, the wide channel of which is perforated in the area of contact with the sponge. 6. The method according to claim 1, characterized in that in the process of videothoracoabscessoscopy of the destruction cavity, material is taken for microbiological examination.