RU2801808C1 - Method of surgical treatment of large subpleural location tuberculosis lung cavities not drained by bronchomas - Google Patents

Abstract

FIELD: medicine; thoracic surgery; phthisiosurgery.

SUBSTANCE: musculoskeletal incision is made, at least 10 cm long. Resection of two or three ribs located next to the cavity is performed. The cavity is opened and a cavernostomy is formed. After the surgery, local sanitation of the cavity is performed with the help of loose tamponade with gauze swabs from 1 to 3 weeks. Then a vacuum aspiration system is installed. The replacement of the components of the vacuum aspiration system, namely the absorbent polyurethane sponge and the sealing film, is carried out once every 6–10 days. To perform tamponade of the cavity, the volume of the polyurethane sponge should be less than the volume of the cavity by 20–30%.

EFFECT: method allows to perform surgical treatment by single-stage operation of a subpleurally located tuberculous cavity larger than 5 cm with no bronchial drainage, maintain functioning lung tissue in the operated lung, reduce the severity of a cosmetic defect of the chest wall, and reduce the treatment time.

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Description

Technical field

SUBSTANCE: invention relates to medicine, namely to thoracic surgery and phthisiosurgery, and can be used for local surgical treatment of patients with large subpleurally located tuberculous caverns of the lungs of non-draining bronchi.

State of the art

Large subpleural cavities are formed during the progression of fibrous-cavernous pulmonary tuberculosis, which is one of the most dangerous clinical forms of pulmonary tuberculosis and is characterized by a high epidemic danger to others. In case of complications of such caverns with tuberculous lesions of the bronchi with the formation of their complete stenosis, the cavities block and increase in size. The healing of such cavities under the influence of anti-tuberculosis chemotherapy alone is impossible.

The literature describes the use of resection operations for the treatment of lung cavities, but the possibilities of using resection operations for large subpleural cavities are limited, as a rule, by the high prevalence of the tuberculous process - the presence of foci of dropouts in surrounding and distant areas of the lung tissue, severe functional disorders and severe comorbid conditions in a patient . Collapse surgery (thoracoplasty, extrapleural pneumolysis) for large and giant caverns is not always effective, since it is not possible to simultaneously create the necessary amount of collapse [M.I. Perelman, V.N. Naumov, V.G. Dobkin, V.P. Streltsov, A.V. Dubrovsky Indications for surgical treatment of patients with pulmonary tuberculosis. Problems of Tuberculosis, 2001, Volume: 79, No. 2, pp. 51-55; Yablonsky P.K., Sokolovich E.G., Avetisyan A.O., Vasiliev I.V. The role of thoracic surgery in the treatment of pulmonary tuberculosis (literature review and own observations). Medical Alliance. 2014;(3):4-10; Chudnykh S.M., Ivanov A.V., Malov A.A. Video-assisted extrapleural pneumolysis in the treatment of patients with destructive forms of tuberculosis. Moscow surgical journal. 2009, No. 1(5), p. 19-23. ISSN: 2072-3180; Orlova I.V. An organ-preserving method of surgical treatment (interpleural excision of the outer wall of the cavity and suturing of the draining bronchi) in patients with chronic cavitary pulmonary lesions of various etiologies. Medical news. - 2021. - №6. - S. 62-65]. Also, due to the subpleural location of the cavity, collapse surgery can be complicated by the opening of the cavity and the formation of a long-term non-healing thoracic fistula.

A number of techniques are known, when, after performing a cavernotomy, various additional operations are used for correction. Thus, in giant caverns, 1–2 months after cavernotomy, additional posterior superior thoracoplasty was performed to reduce the volume of the cavity cavity. The duration of treatment of patients undergoing cavernotomy and additional operations for complete closure of incompletely healed (residual) cavity reached 4-6 months [Surgical treatment of pulmonary tuberculosis./ Ed. OK. Bogush. M: Medicine, 1979, 296 s, ill. 97, bibliography -234 titles; G.G. Gorovenko Surgical treatment of cavities in pulmonary tuberculosis by opening them. Kyiv, 1954, 106 p.].

In one of the latest publications, data are given that 68 patients after cavernotomy underwent one or more additional interventions: thoracoplasty, thoracomyoplasty, or plastic surgery of the “residual cavity cavity” with a muscle or musculoskeletal pedicled flap. The process of clinical cure in 80±4.9% of patients took from 5 to 17 years, and mortality from tuberculosis in the long term reached 15±4.3% [Omelchuk D.E. Narkevich A.A., Narkevich A.N. Results of the method of open treatment of caverns (cavernotomy) in fibrous-cavernous tuberculosis of the respiratory organs. Siberian Medical Review. 2020; (4): 56-62. DOI: 10.20333/2500136-2020-4-56-62 UDC 616-089].

Also known is a method of surgical treatment of the cavity by single-stage cavernotomy with myoplasty. Soft tissues were dissected in layers up to the rib cage and part of the ribs closest to the cavity were resected, intercostal muscle flaps were separated and the cavity was dissected with a wide resection of its outer wall, the cavity was scraped and sanitized, and then the cavity was closed with a muscle flap. But this method - single-stage muscle flap cavernoplasty in active pulmonary tuberculosis is not used because of the high probability of recurrence and complications [SU1273071A1, 1986].

A known method of treatment, which consists in the fact that after cavernotomy, gauze swabs moistened with 2-3 ml of immozymase are introduced into the cavity. Through the microirrigator, the installed tampons are daily irrigated with physiological saline, the tampons are changed 2-4 times with an interval of 3 days. The use of immozymase has improved and accelerated the preparation for the next surgical intervention - muscle plasty [SU 1688882 A1; 1991]. However, this method has not found wide application.

Closest to the claimed method is the surgical implementation of cavernotomy, which consists in the fact that after the musculocutaneous incision, the ribs are resected and the intercostal muscles are mobilized to gain access to the outer wall of the cavity, then this wall is excised, widely opening the cavity, the inner surface of the cavity wall treated with an 80% solution of trichloroacetic acid, the cavity is plugged with gauze swabs with an oil-balsamic mixture. In the future, dressings are carried out every 2-3 days already without cauterization with acid. With a favorable course, the walls of the cavity are covered with granulation tissue, the cavity decreases in size and gradually heals [Bogush L.K. Cavernotomy in pulmonary tuberculosis, - In the book: Cavernotomy and other methods of local treatment of cavities. M., 1972, p.] This traditional method of cavernotomy has a serious drawback - it requires long-term (up to one and a half years) inpatient treatment with dressings and replacement of gauze swabs every 2-3 days, the use of long-term local antibacterial drugs. However, with large cavities (more than 5 cm), traditional cavernotomy is practically not used due to the risk of the formation of the so-called "lattice lung", the elimination of which often requires one-stage or staged pleuropneumonectomy (organ-removal operation).

Thus, with all existing methods of cavernotomy at the stage of open sanitation of the cavity, it is assumed that the cavity is filled with gauze swabs with various drugs applied to them - antibiotics, antiseptics or ointments, such swabs put pressure on the walls of the cavity and on the underlying lung tissue, which contributes to the formation of a stable residual cavity of the cavity. Therefore, when sanitation of the cavity walls is achieved, after cavernotomy, another operation is always followed to close the residual cavity of the cavity due to resection of the ribs and the use of a muscle flap (pectoralis major, serratus or latissimus dorsi muscle).

Disclosure of invention

The technical problem solved by the claimed invention is to increase the effectiveness of surgical treatment of large, subpleurally located, tuberculous caverns that are not drained by the bronchus.

The technical result of the claimed invention is to reduce the duration of treatment, the cure occurs as a result of one operation, and not multiple, and also large cavities from 5 cm in size are healed by the claimed method.

The technical result is achieved by a method that includes performing a cavernotomy with the formation of a cavernostomy, after local sanitation of the cavity walls, the residual cavity is loosely plugged with gauze swabs for a period of 1 to 3 weeks after the operation, subsequently sanitation is performed using a low-vacuum drainage system until the residual cavity is eliminated and a skin scar is formed. .

The method of surgical treatment of large subpleurally located tuberculous cavities of the lungs not drained by the bronchus consists in a skin-muscular incision not less than 10 cm long, resection of part of the 2-3 ribs located close to the cavity in order to open maximum access to the outer wall of the cavity; then the outer wall of the cavity is opened, the cavity is freed from the liquid content, if any, and a cavernostomy is formed, at which point the operation is completed; then there comes a period of conservative treatment of the cavity cavity, which is first carried out with the help of gauze tampons, but when a scar is formed along the perimeter of the cavernostomy, and the inner surface of the cavity is cleared of necrotic tissues - which takes from 1 to 3 weeks, tampons are no longer used, and they are installed through the cavernostomy low-vacuum drainage system (vacuum aspiration system (VAC-system). In this case, vacuum aspiration modes are used in the range from -65 to -90 mm Hg.

The frequency of replacement of the components of the vacuum aspiration system was 1 time in 6-10 days (each time the frequency was determined by the condition of the polyurethane sponge and the sealing film - the components of the vacuum aspiration system that needed to be replaced as they lost their working qualities during operation. During this period, the ongoing 1.5-2 months, inflammation stops in the wall of the cavity, healing processes are intensive - granulation tissue develops well, the volume of the cavity decreases in a vacuum until it is completely scarred. tuberculosis and drug tolerance of the patient, according to federal guidelines for the treatment of pulmonary tuberculosis.

The advantages of the proposed method are:

- after cavernotomy, long-term tamponade with gauze swabs is not used for local sanitation,

- solutions of antiseptics and antibacterial drugs are not used for a long time,

- no additional operations are applied, but a vacuum aspiration system (VAC-system) is installed, after which the cavity begins to quickly decrease in size and heals completely, without requiring additional operations, only a small retracted scar remains on the skin, the stellate cavity heals in the lung tissue scar due to the convergence of its walls and a slight displacement of the lung structures surrounding the cavity,

- The healing period from the moment of the cavernotomy operation is from 1.5 to 3 months.

Brief description of the drawings

The implementation of the method is illustrated by the following drawings.

In FIG. 1 shows a CT scan of the chest in three projections before surgery. A - a giant cavern in the upper lobe of the right lung, in the left lung - foci of screening and an area of tuberculous infiltration. B - the lower border of the cavity in the upper lobe of the right lung along the posterior segment of the IV rib, in the underlying sections, there are foci of dropouts with perifocal infiltration and small cavities of destruction, bronchiectasis. B - cavity in the upper lobe of the right lung, on the left in C1-2 - a cavity of destruction with thin walls up to 2 cm in diameter, in the underlying sections there are foci of dropouts.

Fig. 2. Appearance of the patient: A - view of the area of cavernotomy with a sealing film and microdrainage of the vacuum aspiration system (VAC-system), B - appearance of the patient during the healing of the cavity, 3 months after cavernotomy, before discharge from the surgical department.

Fig. 3 - control CT scan of the chest in three projections 6 months after surgery: A - panoramic direct projection - displacement of the mediastinum and trachea to the right, pronounced pleural folds in the area of the healed cavity of the upper lobe of the right lung; B - tomogram in the right sagittal projection - there are no cavity formations on the right; B - in the right and left lungs - there are no cavity formations, resorption of focal and infiltrative changes.

Implementation of the invention

At the first stage, a cavernotomy operation is performed: over the cavity area (axillary or paravertebral access), an incision of the skin and soft tissues is made, at least 10 cm long, to the depth of the ribs, parts of 2-3 ribs are resected subperiosteally in order to maximally open the outer wall of the cavity, the and intercostal bundles are excised, the outer wall of the cavity is maximally excised, purulent-necrotic tissues are aspirated from the cavity cavity and the walls are treated with antiseptic preparations (iodonate), invaginating sutures are applied to the skin along the perimeter of the stoma with the capture of soft tissues and the formation of a cavernostomy, at the end of the operation, into the formed the cavity is loosely installed with gauze swabs.

At the second stage, local sanitation of the cavity cavity is performed, first with loose tamponade with gauze swabs from 1 to 3 weeks after the operation, while the following parameters should be achieved: the absence of pain during dressings, a scar is formed along the perimeter of the cavernostoma, inflammation in the cavity wall is reduced and the production of purulent necrotic discharge into the lumen of the cavity. This allows you to switch to the use of a vacuum aspiration system (VAC system) and its use continues until the complete elimination of the cavity cavity and the formation of a skin scar at the site of the cavernostomy. The frequency of dressings once every 6-10 days is associated with the need to replace the components of the vacuum aspiration system (absorbent polyurethane sponge and sealing film) as they lose their working qualities during operation. When tamponade of the cavity cavity, the volume of the polyurethane sponge should be less than the volume of the cavity by 20-30%.

This method was tested in the treatment of 3 patients.

RESULTS: Total operation time - from 35-45 minutes, total blood loss from 30 - 70 ml. All patients achieved complete healing of the cavity. During the long-term follow-up period from 1 to 2 years, there were no recurrences of tuberculosis.

The patient is 38 years old. Tuberculosis history since 1998, successfully treated, cure achieved. Late recurrence of tuberculosis in 2008, since then she has been constantly treated, but gradually formed fibro-cavernous pulmonary tuberculosis with multidrug resistance.

The patient was admitted to the Federal State Budgetary Institution "NMIC FPI" in the direction from the region of Russia after additional examination diagnosed with fibrous-cavernous pulmonary tuberculosis in the phase of infiltration and seeding. (progression against the background of ongoing anti-tuberculosis therapy), MBT (+). XDR (H R E Z S Km Eto Ofx Lfx Mfx). Complications: complete post-tuberculous cicatricial stenosis of the upper lobe bronchus on the right. Cachexia. BMI 14.8. DN 2.

According to CT scan of the chest, there was a giant cavity in the upper lobe of the right lung - a tuberculous cavity with a maximum size of 11 cm, with a small level of fluid in it. In fact, the entire upper lobe of the right lung was represented by this cavity. Massive focal seeding and the formation of large infiltrative foci were in the surrounding lung tissue. On the left in C1-2, a thin-walled cavity up to 2 cm in size was determined, with a moderately pronounced pericavitar infiltration (Fig. 1).

Microbiological examination of sputum by fluorescent microscopy revealed AFB 2+, molecular genetic method - MBT DNA was detected, drug resistance of the causative agent of tuberculosis was clarified

Treatment was prescribed according to the 5th chemotherapy regimen (RCT), intensive phase, with the inclusion of 7 drugs with anti-tuberculosis activity: Bq 0.2g., Lzd 0.6g., Lfx 1.0g., Cs 0.5g., Z 1.0g., Cm 0.7g. ., meropenem 1.0 x 2 r / d i.v. + amoxiclav.

The decision of the surgical council - given the presence of an active widespread tuberculous process, cachexia, for the treatment of a giant cavity in the upper lobe of the right lung, complicated by complete cicatricial stenosis of the right upper lobe bronchus, cavernostomy is indicated, followed by the installation of a vacuum aspiration system (VAC system).

A cavernostomy was performed on the right: a paravertebral incision of the skin, soft tissues 10 cm long, in depth - to the surface of the ribs, the posterior segments of three ribs (3, 4 and 5 ribs on the right) were resected periosteally for 5, 6 and 7 cm, intercostal muscle bundles were excised, the cavern was opened, the outer wall of the cavern was excised, the liquid purulent contents of the cavern were aspirated, the walls of the cavern cavity were treated with antiseptics, suggestive sutures were placed on the skin with the formation of a cavernostomy, tamponade of the cavity with gauze swabs. Pseudomonas aeruginosa growth was obtained by sowing the contents of the cavity for nonspecific microflora, drug resistance was determined, the information was used when choosing drugs for plugging the cavity cavity.

Loose tamponade of the cavity cavity with gauze swabs was carried out for 3 weeks until the pain syndrome ceased during dressings, the formation of the edges of the cavernostoma and the reduction of inflammation and purulent-necrotic discharge.

Then a vacuum aspiration system was installed in the cavity of the cavernostomy.

Before installing the vacuum aspiration system, the volume of the residual cavity of the cavity was 450 cm3. A constant mode of vacuum aspiration was maintained in the range from -65 to -90 mm Hg. [Birke-Sorensen H. et.al, Evidence-based recommendations for negative pressure wound therapy: treatment variables (pressure levels, wound filler and contact layer)-steps towards an international consensus. Journal of Plastic, Reconstructive & Aesthetic Surgery, 2011, vol. 64, pp. S1-16.]

The replacement of the components of the vacuum aspiration system was performed 1 time in 6 - 10 days (on average, after 6.8 days). each time according to the condition of the sealing film (rolling and seal failure) and the condition of the absorbent polyurethane sponge (mucus). A total of 11 dressings were performed during the treatment.

Against the background of the treatment, a positive trend was noted in the form of a cessation of inflammation in the walls of the cavity, the development of granulations and a gradual decrease in its volume. At the same time, a general positive dynamics of the patient's condition was noted: normalization of temperature and laboratory blood parameters, an increase in body weight by 7 kg, resorption of focal and infiltrative changes in both lungs, a decrease and then cessation of the excretion of the causative agent of tuberculosis with sputum.

The cavity of the cavernostomy after the installation of a vacuum aspiration system healed with the formation of an indented scar on the skin after 2.5 months (Fig. 2). The control CT scan of the chest, performed at the same time, showed that a giant cavern in the lung tissue of the upper lobe of the left lung had healed with a scar, and a cavern 2 cm in diameter had healed in the upper lobe of the left lung.

After 3 months after cavernotomy, the patient was discharged from the surgical department and continued chemotherapy for tuberculosis, taking into account the terms prescribed by the Federal Clinical Guidelines for the Treatment of Pulmonary Tuberculosis.

Six months after the cavernotomy, the control CT scan of the chest showed no cavity in the upper lobe of the right and C1-2 of the left lung, and significant resorption of infiltrative and focal changes was noted (Fig. 3).

At the control CT of the OGK in a year there is no negative dynamics. Continues treatment at the place of residence.

Thus, the positive characteristics of the method are:

1. do not use local antiseptic and antibacterial drugs, tampons for the entire period of cavity treatment, but only 1-3 weeks immediately after cavernotomy;

2. the period of treatment in the surgical department is reduced to 1.5-3 months;

3. there are no pronounced cosmetic defects of the chest wall, only an inverted scar is formed, which may only need a cosmetic aid;

4. no additional thoracomyoplastic operations are required to complete the treatment, which is often used with other methods to eliminate the residual cavity of the cavity;

5. the skeleton of the chest is preserved, which positively affects the function of breathing;

6. is characterized by minimal trauma and allows maximum preservation of the functioning lung parenchyma on the side of the giant cavity, unlike other resection and collapse surgical interventions;

7. Positive dynamics of the tuberculous process is observed both on the side of using the vacuum aspiration system and in the opposite lung in the form of resorption of infiltrative and focal formations, healing of small decay cavities.

Thus, an effective method for the surgical treatment of large subpleural tuberculous caverns has been proposed, which implies the maximum preservation of functioning lung tissue in the operated lung, the healing of the cavity after cavernotomy without the use of additional surgical operations, the absence of a pronounced cosmetic defect of the chest wall, and a relatively short period of inpatient treatment.

Claims (3)

1. A method of surgical treatment of a subpleurally located tuberculous cavity larger than 5 cm with no bronchial drainage by a one-stage operation, including a musculoskeletal incision of at least 10 cm in length, resection of two or three ribs located next to the cavity, opening of the cavity and formation of a cavernostomy, which differs the fact that after the operation, local sanitation of the cavity cavity is performed first with loose tamponade with gauze swabs from 1 to 3 weeks, and then a vacuum aspiration system is installed for sanitation. 2. The method according to claim 1, characterized in that the replacement of the components of the vacuum aspiration system, namely the absorbent polyurethane sponge and the sealing film, is carried out 1 time in 6-10 days. 3. The method according to claim 1, characterized in that during tamponade of the cavity of the cavity, the volume of the polyurethane sponge should be less than the volume of the cavity by 20-30%.