Method for treating restricted pleural empyema at bronchopleural communication

FIELD: medicine, purulent and thoracic surgery.

SUBSTANCE: it is necessary to carry out draining and sanitation of restricted pleural empyema in a patient. Then the drainage should be substituted with a balloon catheter into the balloon of which under roentgenocontrol one should introduce isotonic NaCl solution with water-soluble contrast till complete filling the empyemic cavity and, correspondingly, occlusion of fistula-carrying bronchus. Filled up catheter should be kept for 7 d and then under roentgenocontrol gradually for 14-21 d one should remove the introduced solution. Te quantity of simultaneously removed solution should be determined according to the presence or absence of air drop out of empyemic cavity. After cavitary reduction the catheter should be removed. The innovation enables to provide reduction of pleural empyemic cavity along with occlusion of bronchopleural fistula and, also, prevent aerogenic contamination, stimulate granulation and subsequent cicatrisation of cavitary walls due to the pressure of balloon catheter upon them being filled by the cavitary volume.

EFFECT: higher efficiency of therapy.

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The present invention relates to medicine, namely to purulent and thoracic surgery, and can be used to eliminate cavity limited empyema with bronchopleural hiss.

It is known that loculated pleural, especially with bronchopleural message remains the unresolved issue of thoracic surgery, because poorly treated and subsequently formed chronic recurrent purulent process with various complications, such as hemorrhage, sepsis, amyloidosis (Gorelov F. Treatment of chronic empyema after pneumonectomy hermetic punctures. / Gorelov F., hodko E. // cardiovascular and thoracic surgery. - 1998. No. 3. P.47 - 49).

There are various ways to treat limited empyema.

So there is a method that includes the drainage of the empyema cavity of the pleura with a constant or fractional lavage antiseptics (Kolesnikov Ishimure of the lung and pleura: a Guide for physicians. / Isclassic, Myitkina. - L: M, 1988, s).

This method is directed to the drainage of purulent cavity, the formation of dry residual cavity with subsequent formation of connective tissue (favorable outcome), that provides for formation of a limited pneumosclerosis.

However, this does not exclude the possibility of development of VNU is replevying bleeding, consequently, death.

The closest in technical essence to the present invention is a method of treating acute restricted pleural empyema with bronchopleural messages (Patent No. 2161492, IPC5AV 17/00, Sianow B.C., Dambai GC, Yakimenko J.V.).

The known method is as follows. The cavity empyema sanitize antiseptic solution. After the disappearance of purulent exudate in the pleural cavity is injected powdered placenta tissue. At 4-6 days after the start of the gradual destruction of the contents of empyema cavity, which lasts for 6-10 days.

The disadvantages of this method include the fact that not instantaneous occlusion suissesse bronchus and, therefore, not excluded bronchogenic route of infection, which according to the literature data is 10-15%.

In addition, the use of alien tissue may cause reactions transplant rejection, while the biomass can be a source of reinfection.

The objective of the proposed technical solution is the development of minimally invasive way to eliminate cavity limited empyema with bronchopleural hiss.

The technical result of the invention is to decrease the morbidity method and effectiveness of treatment at the expense of preventive care is IKI pulmonary and intrapleural bleeding, exceptions blood loss and rejection of the transplant exclusions death.

The proposed method is of limited treatment of pleural empyema with bronchopleural message includes drainage, sanitation, occlusion suissesse bronchus and subsequent gradual destruction of occluder.

Differences between the proposed method is that the occlusion suissesse bronchus spend balloon catheter. To do this, under x-ray control in the balloon catheter is administered isotonic NaCl solution with vodorastvorimami contrast to full fill cavity empyema. Occlusion should be performed within 7 days, after which under x-ray control simultaneously removed from the cylinder 3-5 ml of injected solution. The amount of the solution is determined by the presence or absence of discharge of air from the cavity empyema. Phased removal of the contents of a container should be performed within 14-21 days. After complete removal of solution from the container and the reduction of cavity empyema pleural catheter is removed.

Comparative analysis of the prototype showed that the proposed method differs from known these techniques and, consequently, the estimated technical solution meets the criteria of the invention of "novelty."

Comparison of the proposed technical solution not only prototype, but the other-the mi decisions in thoracic surgery and pulmonology failed to reveal any sign, distinguishing the claimed solution to the prototype.

Distinctive techniques of the proposed method allows to completely fill the pleural cavity of the abscess and thereby occlusivity suissesse bronchus, thereby to prevent airborne contamination, to stimulate granulation and scarring of the walls of the cavity at the expense of pressures-filled balloon catheter.

The authors of the proposed solutions are not known the way of occlusion of bronchopleural messages by balloon perform oral limited empyema. In the proposed method, the filled container is occlusion suissesse bronchus. Subsequent reduction of the volume of the container creates the conditions for the complete reduction of the empyema cavity.

Distinctive techniques of the proposed method allow occlusivity suissesse bronchus and thereby prevent airborne contamination, while a pressure-filled balloon on the wall of the cavity, stimulates granulation and scarring.

Therefore, the distinctive techniques of the proposed method allow without surgical intervention and conduct of anesthesia to reduce the cavity, occlusivity suissesse bronchus, to ensure uniform pressure on the walls of the cavity with the lack of airborne recontamination, to ensure its scarring and reduction that the Veda is to full recovery of the patient. The pressure on the walls of the cavity stimulates the proliferative phase of inflammation and contributes to the formation of connective tissue.

The above allows to conclude that the technical solutions according to the criterion of "inventive step".

The method constituting the invention, intended for use in health care. The possibility of its fulfillment is confirmed as described in the application techniques and equipment. The inventive method achieves perceived by the applicant of the technical result, namely the reduction of the morbidity of the way through a minimally invasive intervention, bloodless way, the lack of development opportunities vnutriplevralnogo bleeding, rejection reactions of transplantati and therefore the exception of death.

This allows to make a conclusion on compliance of the claimed invention, the condition of patentability "industrial applicability".

The proposed method consists of the following steps.

The patient perform drainage limited parietal pleural empyema, remove pus, conduct sanitation cavity with antiseptic solutions. After reducing the level of contamination below 105SOME are replaced drainage on a balloon catheter, which is injected into the cavity empyema. Then, the balloon catheter is administered isotonic dissolve the NaCl with vodorastvorimami contrast (urographine, tracegraph). The tank is filled to full fill the cavity of the abscess, which is controlled under the electro-optical Converter (Annex to the description. 1, 2. A balloon catheter filled cavity bounded empyema). Inflated balloon is occlusion suissesse bronchus.

Then gradually, within 14-21 days from the cylinder is removed put the solution in an amount of 3-5 ml of the Created occlusion provides granulation empyema cavity through the formation of connective tissue. After complete removal of solution from the container and the reduction of the cavity to be removed (Annex to the description. Figure 3. Full reduction of the cavity limited empyema.).

The proposed method for the treatment of post-traumatic limited empyema with bronchopleural message is illustrated by a specific example.

Example. Patient b 29 l, was treated and examined in the departments of thoracic and purulent surgery with 12.10.04, 24.01.05, with a diagnosis of Concomitant injury: Open craniocerebral injury. Brain contusion severe. Closed chest trauma. Closed fragmentary fractures 2-10 ribs on the left. Multiple breaks of the upper lobe of the left lung. Intrapleural bleeding. Left hemopneumothorax. Right-sided pneumothorax. Closed abdominal trauma. Rupture of the spleen. hemoperitoneum. Closed fracture of the middle third of the left femur with displacement. Open fractures of the bones of the right foot with offset. Decompensated traumatic shock. Posttraumatic bacterial destruction of the upper lobe of the left lung, pleural empyema left with multiple bronchopleural messages. The sepsis. Septic pneumonia.

Treatment: surgery: 12.10.04 - thoracotomy left, atypical resection of the upper lobe of the left lung, the closure gaps of the upper lobe of the left lung. Laparotomy, splenectomy. Thoracocentesis, drainage of the right pleural cavity.

13.10.04 - applying skeletal traction for tuberosity b/tibia bone.

14.10.04 - bottom tracheostomy.

20.10.04 - closed reposition the bones of the right foot with X-shaped fixation spokes of Kirchner.

In the postoperative period for a long time, the situation remained extremely difficult. Conducted a comprehensive intensive therapy, blood transfusion and fresh frozen plasma, massive courses of antibiotic therapy (Tienam, Meronem + vancomycin), mechanical ventilation via tracheostomy, rehabilitation of fibrobronchoscopy, readjustment of the pleural cavity on the left.

In the postoperative period was formed loculated pleural projection of the upper lobe on the left with multiple bronchopleural message is I. Installed aspirazione-irrigation system was carried out endobronchial occlusion suissesse bronchus, however, the cavity was kept. For the elimination of bronchopleural messages and prevention of pulmonary and intrapleural bleeding was used by the proposed method. For this purpose a modified balloon catheter was installed in empyema cavity, the cylinder of which is under the control of the electro-optical Converter introduced isotonic NaCl solution with vodorastvorimami contrast - urografin. The cylinder was filled to full fill the cavity of the abscess (figure 1, 2, where 1 - a balloon catheter, which filled the cavity limited empyema). The inflated balloon was occlusion suissesse bronchus within 7 days, after which the balloon catheter under x-ray control was simultaneously removed 5 ml of injected solution. Control of the number of the removed solution was the presence/absence of discharge of air from the empyema cavity.

The phased removal of the injected solution from the container was held for 17 days. During treatment of bronchopleural message closed, and the cavity was reduced 13.01.05, After complete removal of solution from the container and the reduction of the cavity, the catheter was removed (Fig 3, where 2 is the complete reduction of the cavity limited posttraumatic empyema left). The patient was discharged udovletvoritelno state 24.01.05 on trauma treatment.

Thus, the proposed solution allows minimally invasive way to eliminate the cavity limited empyema with bronchopleural hiss by intrapleurally balloon occlusion with the formation of connective tissue in the empyema cavity.

Implementation of the proposed method does not use anesthesia benefits, enough local infiltration anesthesia at the point of drainage.

Treatment of limited empyema with bronchopleural message, including drainage, sanitation, occlusion suissesse bronchus with subsequent gradual removal of occluder, characterized in that the occlusion suissesse bronchus is carried out by drainage of empyema cavity by means of a balloon catheter with the introduction of the container under x-ray control isotonic NaCl solution with a water-soluble contrast to full fill cavity empyema, incubated for 7 days, then gradually within 14-21 days under x-ray control deletes entered the solution, the number of simultaneously removed solution is determined by the presence or absence of air vent of the empyema cavity, after the reduction of the cavity empyema pleural catheter is removed.



 

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