RU2423924C1 - Method of surgical treatment of disseminated fibrous-cavernous pulmonary tuberculosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to phthysiosurgery and endoscopy, and can be used in treatment of disseminated fibrous-cavernous pulmonary tuberculosis. Essence of method lies in application of valvular bronchoblocking. Preliminarily temporary occlusion of cavern-draining bronchus with valvular bronchoblocker is performed, after that - extrapleural thoracoplasty.

EFFECT: application of claimed invention makes it possible to estimate functional reserves of patient before application of surgical treatment methods, stage-by-stage surgical treatment makes it possible to reduce caverns and achieve abacillation in non-resectable patients.

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Description

The method relates to medicine, namely to phthisiosurgery and endoscopy, and can be used to treat common fibro-cavernous pulmonary tuberculosis.

Treatment of patients with advanced fibro-cavernous pulmonary tuberculosis is difficult and not effective enough, therefore there is an urgent need to develop new effective, minimally invasive, non-drug and affordable methods of treatment as a stage of surgical treatment of a heavy contingent of patients.

Under the present conditions, the role of such surgical treatment methods as artificial pneumothorax and pneumoperitoneum significantly increases (6, 7). However, fibro-cavernous pulmonary tuberculosis is one of the contraindications for their use (3).

Foam and collagen obturators are used as conservative measures for the treatment of pulmonary tuberculosis and its complications for temporary endoscopic occlusion of the bronchus (4, 8). Many clinicians note a number of complications when using such obturators: bedsores of the mucous membrane of the bronchi at their location, their displacement to other parts of the bronchial tree, exacerbation of purulent endobronchitis and destruction in the lung, and others (1, 5).

There is a method of complex treatment of patients with widespread destructive pulmonary tuberculosis using osteoplastic thoracoplasty followed by, after 22 days, valve bronchial block to create therapeutic hypoventilation of the affected segments (2 - prototype). The disadvantage of this method is that it does not provide an assessment of the patient's respiratory reserves before surgery, and this in the presence of a bilateral lesion, as well as fibrocavernous tuberculosis of a single lung, becomes crucial for the choice of treatment tactics.

The objective of the method is to increase the efficiency of surgical treatment of patients with advanced fibro-cavernous pulmonary tuberculosis.

The task is achieved by temporary occlusion of the draining bronchial cavity valve bronchial blocker followed by extrapleural thoracoplasty. Fundamentally new in the proposed method of treatment is the preliminary occlusion of the draining bronchus, which is a functional test to assess the possibility of the subsequent surgical stage of treatment. Previously, temporary occlusion of the bronchus draining the cavity was performed after using various methods of collapse therapy.

In the implementation of the proposed method for using the endobronchial non-return valve, the valve is made of a rubber mixture 52-336 / 4 (sanitary-epidemiological conclusion No. 77. ФЦ.29.251.Т.000486.12.02. Dated 16.12.2002), which is indifferent to the human body, and is a hollow cylinder. On the one hand, the internal opening of the valve has an even circular shape, and on the other, it is made in the form of a falling valve flap, which is locked by excessive external pressure and its own elastic properties of the material. Two thirds of the outer surface of the valve are thin plate radial petals for fixing it in the bronchus.

The valve allows you to freely move from the lesion to the air, sputum, bronchial contents during exhalation and coughing. It should be noted that air does not return to the affected areas of the lung - thereby gradually achieving a state of therapeutic hypoventilation and atelectasis of the lung tissue.

The effectiveness of the method lies in the fact that preliminary valve occlusion of the affected segments of the lung / lung allows you to evaluate the respiratory reserves of patients with advanced fibro-cavernous pulmonary tuberculosis, and makes it possible to adapt the respiratory system to the subsequent exclusion of lung sections from breathing.

The method is as follows: under local anesthesia during fibrobronchoscopy, the valve blocker is installed in the draining bronchus / bronchi. After a day, the patient’s condition is assessed: well-being, lung X-ray, external respiration function, blood gas composition. The next step is a 3,4,5-rib selective superior posterior extrapleural thoracoplasty on the installation side of the blocker. That allows you to achieve additional collapse of the blocked portion of the lung. Intensive chemotherapy against the background of the proposed method in some cases allows to achieve closure of destruction in the contralateral lung with bilateral destructive lesion.

With bilateral fibro-cavernous pulmonary tuberculosis, the affected segments are turned off in the same way.

Clinical example. Patient M., 34 years old, was admitted to 3 C.O. 02/27/08, with a diagnosis of bilateral fibro-cavernous pulmonary tuberculosis with total damage to the upper lobes of both lungs and C6 of the right lung, MBT (+).

Complication: Myocardial dystrophy, NK 0 DN III Art. VN III Art. MDR Office (S, R, H10, Mb, Et, E2, K, Ofl, Pas1). From the anamnesis it is known that the tube. contact - family. Changes in the lungs were detected in 2003. Initially: infiltrative pulmonary tuberculosis in the decay phase, MBT (-). Primary outpatient treatment for 14 months. The last hospitalization from 02/12/08 to 03/27/08 (1.5 months) with a diagnosis of fibro-cavernous tuberculosis of the apices of both lungs in the progression phase, MBT (+). Objective examination data: On admission shortness of breath with slight physical exertion. During auscultation in the lungs, hard breathing, a moderate amount of moist rales in the upper sections on both sides.

On examination: massive bacterial excretion of MBT (+). FVD: a significant decrease in VC to 54% against the background of extremely sharp violations of airway patency. FEV1 - 39%. IV 2106. Blood gases: p CO ₂ - 44 mmHg, pO ₂ - 68 mmHg, satO ₂ - 93%. Fibrobronchoscopy: diffuse pronounced catarrhal endobronchitis with post-tuberculous cicatricial obliteration PB6c, cicatricial stenosis of the III st. PB6a, c; left-sided limited upper lobar paraspecific endobronchitis. Lung scintigraphy: total blood flow in the right lung - 51.1%, in the left - 48.9%. X-ray examination: subtotal lesion of both lungs with the presence of large fibrous caverns in the in / lobe and C6 of the right lung and C1-3 of the left lung with focal seeding of the lower lobe on the right and C4.5 on the left.

Given the prevalence of a specific process in the lungs and low functional reserves of the patient, radical resection intervention is considered impossible. Indications for palliative surgery are established - performing sequential valve bronchial blockade of the right and left upper lobar bronchi, supplemented by a staged bilateral extrapleural thoracoplasty. On the 19th day after valvular bronchial block, right-upper-posterior 5-rib thoracoplasty was performed. In the postoperative period, respiratory failure was observed with a tendency to compensation against the background of the therapy. FVD: a significant decrease in VC to 53% against the background of extremely sharp violations of airway patency. FEV1 - 42%. IV 2226 (before operation 2106). Blood gases: pCO ₂ - 46 mmHg, pO ₂ - 62 mmHg, satO ₂ - 92%. The patient was discharged 23 days after surgery. After 1.5 months, the second stage of surgical treatment. FVD: A sharp decrease in VC to 44%, against the background of sharp violations of airway patency. FEV1 - 27%. IV 2188. Blood gases: pCO ₂ - 48 mmHg, pO ₂ - 67 mmHg, satO ₂ - 92%. FBS: Valve blockers in PVDB and LVDB. A moderate amount of viscous secretion was evacuated from the petals. Inflammatory changes in the mucosa are absent. X-ray examination: on the right there is a slight reduction in the size of the caverns in comparison with 04/18/08 to 1.2 × 2.0 cm, the second is slit-shaped. On the left, the decrease and further deformation of the cavity in C1-2 to 4.5 × 1 cm, a further decrease in the volume of the upper lobe are similar. The prevalence and nature of focal seeding is the same. The second stage of surgical treatment - the left-side upper-posterior 4-rib thoracoplasty was performed 4 months after bronchial blockade of the ICD. The patient was discharged on the 15th day after the operation. In sputum analyzes, MBT was not detected by bacterioscopy. HF: Significant decrease in VC to 47% against the background of severe airway obstruction. OFV1 - 25%, IV 1175. Both valve blockers were removed simultaneously, after 379 days.

The treatment results of the proposed method for 23 patients are presented in tables 1, 2, 3.

Table 1 Distribution of patients by forms of tuberculosis No. p / p Forms of tuberculosis Number of patients % one Fibrous cavernous pulmonary tuberculosis 13 56.5 2 Bilateral fibro-cavernous pulmonary tuberculosis 10 43.5 Total 23 one hundred

table 2 Indications for use of the valve block No. p / p Indications: Number of patients % one Before thoracoplasty (including bilateral) 17 (2) 73.9 2 Before thoracoplasty on a single lung 6 26.1 Total 23 one hundred

Table 3 The effectiveness of treatment according to x-ray dynamics and bacterial excretion depending on the volume of surgical intervention, N = 23 Surgery Cavity closure bacterial excretion before after one Extrapleural thoracoplasty (including bilateral), n = 17 fourteen 13 3 2 Extrapleural thoracoplasty on a single lung, n = 6 3 6 3 Total: 17 19 6

The proposed method of staged surgical treatment of patients with advanced fibro-cavernous pulmonary tuberculosis has several advantages in the absence of radical resection:

- an integrated approach to the collapse surgical technique of the affected areas of the lungs allows you to reduce the cavity and achieve abacillation in unresectable patients;

- allows you to evaluate the functional reserves of the patient before the use of surgical methods of treatment;

- the method is technically simple and can be widely used in specialized hospitals.

Literature

1. Kabanov A.N., Sitko L.A. Empyema of the pleura. - Irkutsk, 1985 .-- 202 p.

2. Krasnov D.V., Countless T.G., Reichrud M.V. et al. Valvular bronchial blocking in combination with collapsosurgery in the complex treatment of patients with advanced destructive pulmonary tuberculosis // XII Congress Ros. Society of Endoscopic Surgeons. - M., 2009.

3. Mishin Yu. Yu. Drug-resistant pulmonary tuberculosis // Surgical treatment of tuberculosis and other lung diseases: Mat. scientific-practical Conf. 50th anniversary of chir. services of the Chelyabinsk region counter-tube. dispensary. - Chelyabinsk, 2001. - P.38-45.

4. Molodtsova V.P. Diagnostic and therapeutic temporary occlusion of the bronchi in complicated forms of lung diseases: Abstract. dis. ... Dr. honey. sciences. - SPb., 1997.

5. Putov N.V., Levashev Yu.N., Kokhanenko V.V. Pyopneumothorax. - Chisinau, 1998 .-- 230 p.

6. Salmakhanov A.R., Huseynov G.K., Mutalimov M.A. Collapsotherapy in the complex treatment of newly diagnosed patients with destructive pulmonary tuberculosis // Probl. tuberculosis and lung diseases. - 2009. - No. 3. - S. 47-50.

7. Chukanov V.I., Mishin V.Yu., Sigaev A.T. et al. The effectiveness of artificial pneumothorax in the treatment of patients with pulmonary tuberculosis with multidrug resistance of tuberculosis mycobacteria. // Probl. tuberculosis and lung diseases. - 2004. - No. 8. - S.22-24.

8. Egamov N.E. Diagnosis and treatment of pulmonary hemorrhage: Abstract. dis. ... cand. honey. sciences. - Tashkent, 1993.

Claims (1)

A method for the surgical treatment of common fibro-cavernous pulmonary tuberculosis, including the use of valvular bronchial blocking, characterized in that it is preliminarily performed temporary occlusion of the draining bronchial cavity with valvular bronchial blocker, and then extrapleural thoracoplasty.