PROLONGED AIR LEAK AFTER LUNG RESECTION

Objectives - to analyze the causes of postoperative air leak and to propose a therapeutic and diagnostic algorithm for this complication. Material and methods. The study includes the analysis of the prolonged air leak causes after various lung resections, the classification of the causes according to their affiliation, the designed definitions of basic concepts. Results. The most common causes of prolonged air leakage are the incompetence of the lung resection line, the undetected (unresolved) cause of pneumothorax, the inadequate drainage system function. Various tactical approaches to this problem were described. Depending on the effectiveness of the auxiliary techniques, the indications for repeated operations were determined. Conclusion. Knowledge of the causes of postoperative prolonged pathological air leak is the basis for the optimal management of patients after lung resection

MODERN ALGORITHMS OF THORACIC CAGE STABILIZATION IN PATIENTS WITH MULTIPLE RIB FRACTURES AND FLAIL CHEST

Objectives - to improve the treatment results in patients with multiple rib fractures and flail chest via the development and implementation of modern therapeutic and tactical algorithms. Material and methods. A non-randomized prospective study has been carried out to evaluate the results of treatment in 198 patients with multiple rib fractures and flail chest in the period of 2011-2017. Three clinical types were identified: 1) patients with multiple rib fractures with disordered thoracic cage structure - 77 (38.9%); 2) patients with flail chest - 71 (35.9%); 3) patients with multiple rib fractures without disordered thoracic cage structure - 50 (25.2%). There were developed and applied the diagnostic and treatment algorithms depending on the severity of injures of sternocostal frame and intrapleural organs, the presence and severity of associated injuries and background diseases, the conditions of medical aid. Results. The treatment tactics of all patients was based on the differentiated, staged and combined use of various methods of stabilizing the thoracic cage including the advanced types of medical care. Surgical stabilization methods were used in 162 patients, in 26 of them a combination of surgical techniques was applied, in 20 - the internal pneumatic stabilization, in 42 - the conservative treatment was performed. The retrospective analysis and the obtained results compared to the results of the equivalent historical group allowed us to state the decrease of mechanical ventilation time from 11.0 ± 3.9 to 5.1 ± 3.2 days (t = 1.17; p> 0.05), the length of stay in the ICU from 11.5 ± 5.4 to 6.8 ± 3.7 days (t = 0.72; p> 0.05), the complications frequency from 36.5% to 15.9% and mortality rate from 22.3% to 8.7%. Conclusion. Modern diagnostic and treatment algorithms in patients with multiple rib fractures and flail chest are based on stage-by-stage application, succession and combination of various methods of the thoracic cage stabilization throughout the medical assistance process. The algorithms, allowing to stabilize the thorax and to improve the condition of the patients in general, make it possible to realize the full potential of modern thoracic surgery

ENTERAL INSUFFICIENCY TREATMENT IN PATIENTS WITH GENERALIZED PERITONITIS

Objectives - to improve the treatment results in patients with generalized peritonitis complicated by the enteral insufficiency syndrome. Material and methods. In the period of 2016 -2018 there were 45 patients with a widespread peritonitis admitted to Samara regional clinical hospital named after V.D. Seredavin for treatment. The patients were divided into a control and a main group. The patients of the main group received the intestinal intubation with a specially designed catheter, the intestinal lavage during surgery and in the early postoperative period, the enterosorption, enteral nutrition and bowel decontamination; and in the absence of contraindications - the enteral oxygen therapy. Dynamics of the enteral insufficiency syndrome (EIS) development in both groups were evaluated according to the defined criteria, including laboratory and clinical indicators. Each criterion could weight from 1 to 3 points, their amount reflected the degree of enteral insufficiency. Results. In the main group of patients the small intestinal function was notably restored till the beginning of the third day, what coincided with the transition of the third degree of enteral insufficiency in the second. In patients of the control group the restoration of intestinal function was starting in period of fifth and sixth day after the operation, but the 3d degree of enteral insufficiency remained for 12 hours. Conclusion. The intestinal treatment in combination with the standard therapy allowed to reduce the degree of EIS in the beginning of treatment. This helped to improve the treatment results in general

Синдром желтых ногтей в практике торакального хирурга

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СТРАТЕГИЯ И ТАКТИКА ХИРУРГИЧЕСКОГО ЛЕЧЕНИЯ ИНФЕКЦИОННЫХ ОСЛОЖНЕНИЙ ПОСЛЕ СТЕРНОТОМИИ

Background. Postoperative sternal and mediastinal complications are relatively rare and constitute about 0.3–6.9 %. However, taking into account a larger number of heart surgeries, the incidence of sternal osteomyelitis and mediastinitis is inevitably on the rise. It is the practice to identify 2 types of complications in relation to the depth of tissue damage: superficial sternal wound infection (suture sinuses, subcutaneous abscesses, sternal osteomyelitis with the formation of sequestra) and deep sternal infection with the development of mediastinitis. The treatment of patients with post-sternotomy complications is long-term and expensive.Materials and methods. The results of treatment were studied in 95 patients with post-sternotomy infectious complications, including 46 (48.4 %) patients with superficial sternal infection and 49 (51.6 %) patients with deep sternal infection and development of mediastinitis. The role of vacuum therapy in treating infectious complications after sternotomy was assessed. The causes of poor treatment outcomes were analyzed.Results and discussion. Step 1 is aimed at abolishing an infectious process and involves necrectomy, lancing a phlegmon, removal of metallic ligatures, excision of sinus tracts, resection of the osteomyelitically changed sternum and ribs. At this step, current technologies were used to treat purulent wounds, by regularly carrying out bacteriological tests. Vacuum therapy was performed in 41 (43.2 %) patients to abolish a purulent sternal process in guidance. The mean time to plasty was 12–28 days. All the patients received etiotropic antibacterial therapy. The optimal variant of Step 2 was omentoplasty and the use of a strand of the greater omentum in combination with mesh prosthesis. The necessary conditions for achieving a successful result in patients with deep sternal infection are to observe the continuity of treatment and to timely propose indicators by the second step, which is achieved by the treatment of patients at a specialized health care institution where a whole package of therapeutic measures can be implemented.Conclusion. Attention should be concentrated on the treatment of patients with post-sternotomy infectious complications at a specialized department that deals with this problem and that can provide a comprehensive approach using up-to-date technologies both to manage purulent wounds and to accomplish the reconstructive and plastic stage. Vacuum therapy is the best way to prepare purulent sternal and mediastinal wounds for plastic surgery. The use of the greater omentum is not only a good procedure to treat anterior mediastinitis, but also a method to reinforce relatively satisfactorily the anterior chest wall. Введение. Послеоперационные осложнения в области грудины и средостения относительно редки и составляют около 0,3–6,9 %. Однако, учитывая рост количества операций на сердце, неизбежно увеличивается и частота возникновения остеомиелита грудины и стерномедиастинита. Принято выделять 2 типа осложнений в зависимости от глубины поражения тканей: поверхностную инфекцию в области грудины (лигатурные свищи, подкожные абсцессы, остеомиелит грудины с формированием секвестров) и глубокую стернальную инфекцию с развитием стерномедиастинита. Лечение пациентов с постстернотомическими осложнениями длительное и дорогостоящее.Материалы и методы. Изучены результаты лечения 95 больных с инфекционными осложнениями после стернотомии. Пациентов с поверхностной инфекцией в области грудины было 46 (48,4 %), с глубокой стернальной инфекцией и развитием стерномедиастинита – 49 (51,6 %). Дана оценка роли вакуум-терапии в лечении инфекционных постстернотомических осложнений. Проведен анализ причин неблагоприятных исходов лечения.Результаты и обсуждение. Первый этап был направлен на купирование инфекционного процесса и заключался в некрэктомии, вскрытии флегмоны, удалении металлических лигатур, иссечении свищевых ходов, резекции остеомиелитически измененной грудины и ребер. На этом этапе применяли современные технологии лечения гнойных ран с регулярным бактериологическим контролем. Для купирования гнойного процесса в средостении у 41 (43,2 %) пациента проводили вакуум-терапию. Средние сроки до пластического этапа составляли 12–28 дней. Все больные получали этиотропную антибактериальную терапию. Оптимальным вариантом второго этапа была оментопластика, а также использование пряди большого сальника в сочетании с сетчатым протезом. У пациентов с глубокой стернальной инфекцией необходимыми условиями достижения успешного результата являются соблюдение преемственности лечения и своевременное выставление показаний ко второму этапу, что достигается нахождением больных в одном специализированном лечебном учреждении, где возможно выполнение всего комплекса лечебных мероприятий.Выводы. Лечение пациентов с инфекционными осложнениями после стернотомии должно быть сосредоточено в специализированном отделении, которое занимается данной проблемой, способно обеспечить комплексный подход с применением современных технологий как в лечении гнойных ран, так и при осуществлении реконструктивно-пластического этапа. Наилучшим способом подготовки гнойной раны грудины и средостения к пластической операции является вакуум-терапия. Использование большого сальника – не только хороший способ лечения переднего медиастинита, но также метод относительно удовлетворительного укрепления передней грудной стенки.

Трудности диагностики и лечения при пневмотораксе и гигантских буллах

Spontaneous pneumothorax is the most common acute chest disease. Often, giant bullae give the impression of the presence of air in the pleural cavity. Inadequate differential diagnosis leads to vain drainage of the pleural cavity, damage to the lung with its collapse and pneumothorax.The aim. Analyze diagnostic and tactical mistakes in patients with pulmonary emphysema, which manifests with giant bullae, and outline the ways to prevent complications.Methods. The analysis of the treatment of 1,636 patients with pulmonary emphysema and its complications undergoing treatment in the thoracic surgical department of the Samara Regional Clinical Hospital named after V.D.Seredavin in the period from 2001 to 2018 is presented.Results. Giant bulla were diagnosed in 35 (2.1%) patients, 16 of them were hospitalized ungently. In 6 patients, the diagnosis of a giant bulla of the lung was correct, and the patients were referred to the thoracic surgical department. In 10 patients, a giant bulla of the lung was regarded as pneumothorax, and pleural drainage was performed before referral to the thoracic surgical department.Conclusion. The correct interpretation of the radiological data and comparison with the clinical picture allows avoiding diagnostic errors and the associated danger and complications.Спонтанный пневмоторакс является самым частым острым заболеванием органов грудной клетки. Нередко гигантские буллы создают впечатление о наличии воздуха в плевральной полости. Неадекватная дифференциальная диагностика приводит к напрасному дренированию плевральной полости, повреждению легкого с его спадением и возникновением пневмоторакса.Целью исследования явился анализ диагностических и тактических ошибок у пациентов с буллезной эмфиземой легких, представленной гигантскими буллами, и обозначение путей профилактики осложнений.Материалы и методы. Проведен анализ лечения пациентов (n = 1 636) с эмфиземой легких и ее осложнениями, госпитализированных в хирургическое торакальное отделение Государственного бюджетного учреждения здравоохранения «Самарская областная клиническая больница имени В.Д.Середавина» Министерства здравоохранения Самарской области (2001–2018).Результаты. Гигантские буллы диагностированы у 35 (2,1%) пациентов, 16 из которых госпитализированы в экстренном порядке. Верный диагноз гигантская булла легкого установлен в 6 случаях, больные направлены в хирургическое торакальное отделение. В 10 случаях гигантская булла легкого расценена как пневмоторакс и до поступления в хирургическое торакальное отделение больным проведено дренирование плевральной полости.Заключение. Верная интерпретация рентгенологических данных и сопоставление с клинической картиной позволяет избежать диагностических ошибок и связанных с этим дальнейших опасностей и осложнений

Who, how and where should treat a patient with surgical complications of lung cancer (organizational, diagnostic, therapeutic, socio-ethical aspects)?

The Objectivewas to discuss various aspects (organizational, diagnostic, therapeutic and socio-ethical) of care for patients with surgical complications of lung cancer and the role of thoracic surgeon in the management of these patients. Different problematic issues of the management of patients with surgical complications of lung cancer (pneumothorax, pulmonary hemorrhage, paracancrotic abscess, pleural empyema) directed to the department of general thoracic surgery are presented. Various aspects of the management of patients with surgical complications of lung cancer are considered: organizational, diagnostic, therapeutic, social and ethical. The implementation of the presented aspects requires the training of specialists: thoracic surgeons in oncology and the technique of interventions, taking into account the principles of oncological radicalism, oncologists in the features of infectious postoperative complications. Improving the treatment and diagnostic approach in this category of patients will extend the life of those of them in whom radical surgical, chemotherapeutic and radiation treatment is impossible. Recognition of patients as palliative does not mean the cessation of emergency measures to save them from life-threatening complications. The problem can be solved with the participation of thoracic surgeons, oncologists, healthcare organizers

A clinical case of stepwise correction of the chest wall complications after combined treatment for breast cancer

Radiation-induced sternal osteomyelitis as a complication of combined therapy for breast cancer is quite rare. As a rule, these patients are treated not by oncologists, but by thoracic and general surgeons. We present a clinical case report of successful treatment of chronic radiation-induced sternal osteomyelitis in a 52-yearold woman, who developed it at 2 years after radical mastectomy for breast cancer. The patient recovered after long-term, stepwise treatment including surgical procedures. The infectious process was stopped by wound debridement and vacuum-assisted dressings. The reconstruction stage included the use of a flap from m. pectoralis major. Treatment of radiation-induced sternal osteomyelitis fits to a widely accepted algorithm of surgical care for patients with anterior thoracic wall infections; however, at each step of care the surgeon can come across difficulties related to the pathological effects of the ionizing radiation

Отдаленные результаты клинической эффективности разных схем вакцинации против пневмококковой инфекции и возможный механизм действия вакцинации у больных бронхиальной астмой

The aim of this study was to assess long-term effects of pneumococcal vaccination with 23-valent polysaccharide vaccine (PPV23) and 13-valent conjugate vaccine (PCV13) in patients with bronchial asthma. Methods. One hundred and three patients with mild to severe asthma were involved. They were randomly assigned to vaccination with PCV13, or PPV23, or PPV23 followed by PCV13, or vice versa. Clinical efficacy of vaccination was evaluated using number of asthma exacerbation a year before and 1 and 4 years after the vaccination; need in antibiotics a year before and 1 and 4 years after the vaccination; and number of hospitalizations due to asthma exacerbation a year before and 1 and 4 years after the vaccination. Results. In a year after vaccination, number of patients who had not experienced asthma exacerbation increased significantly in PPV23, PPV23/PCV13, and PCV13/PPV23 groups (р < 0.01 to p < 0.001). In 4 years after vaccination, number of patients without exacerbations increased significantly in PCV13/PPV23 group only (48.1%; р < 0.01). Number of patients who did not require hospitalization due to asthma exacerbation increased significantly in PCV13 group only (81.8%; р < 0.05). Conclusion. The authors proposed a hypothesis of impact of pneumococcal vaccines on immunopathogenesis of bronchial asthma. The authors consider vaccination against pneumococcus using PCV13 followed by PPV23 should be a part of the basic therapy of asthma.Целью исследования явилась оценка отдаленных клинических результатов вакцинации 23-валентной полисахаридной (ППВ-23) и 13-валентной конъюгированной полисахаридной (ПКВ-13) пневмококковыми вакцинами при раздельном и последовательном применении с определением оптимальной схемы вакцинации у взрослых больных бронхиальной астмой (БА). Предложена гипотетическая схема влияния противопневмококковой вакцинации на иммунопатогенез БА. Материалы и методы. Проведена оценка клинических эффектов вакцинации у больных БА в течение 1-го и 4-го годов после вакцинации против пневмококковой инфекции с использованием различных схем. Результаты. Через 1 год после вакцинации отмечалось значимое увеличение числа пациентов без обострений БА в группах ППВ-23, ППВ-23 / ПКВ-13 и ПКВ-13 / ППВ-23 (р < 0,01–0,001), а через 4 года после вакцинации – значительное увеличение числа пациентов без обострений только в группе ПКВ-13 / ППВ-23 (48,1 %; р < 0,01); при этом значимое увеличение числа пациентов без госпитализаций наблюдалось только в группе ПКВ-13 (81,8 %; р < 0,05). Предложена гипотетическая схема влияния вакцинации против пневмококковой инфекции на иммунопатогенез БА. Заключение. Пациентам с БА показано введение в комплекс базисной терапии вакцинации ПКВ-13 с последующим введением ППВ-23