The success of treatment of patients undergoing advanced combined resection of the lung in the postoperative period is generally determined by rational conduct of a complex of therapeutic measures of intensive therapy aimed at maintaining and correcting the resulting impairment of function of the most important life support systems of the body, and effective local treatment. The development of common and local complications in the postoperative period are interdependent.
Intensive therapy can succeed only while maintaining the anatomical integrity of the body system where the pathology node is tied and to which the main therapeutic measures are directed. Therefore, the lack of anatomical integrity of an organ or system, for example, a leakage of a pulmonary wound, leading to collapse of the lung, unresolved bleeding with insufficient hemostasis or mechanical compression of a vital organ and other complications do not allow to achieve the final result — cure the patient at any intensity of therapeutic effects .
Local treatment is understood as a complex of therapeutic measures aimed at the prevention, early diagnosis and treatment of complications in the area of operation, directly related to surgical intervention.
The tasks of local treatment in the immediate and early postoperative periods are to create the most favorable conditions for treating the wound process and preventing infection in the pleural cavity, the possibility of early diagnosis of postoperative complications.
The question of the need for drainage of the pleural cavity after pneumonectomy continues to be controversial (Gagua RO, et al., 1988). We, without fail, after pneumonectomy, leave a drainage tube in the lower part of the pleural cavity, inserted through the 6th intercostal space along the posterior axillary line. Drainage set at the end of the operation so that its end, located in the pleural cavity, located on the back surface at the level of the dome of the diaphragm. If the drainage is low, in the rib-diaphragmatic sinus, its permeability may be impaired due to the closure of the diaphragm raised by the dome.
In the intensive care unit, drainage is connected to the Bulau-Petrov underwater system.
through a sterile vial, for accurate recording and collection of exudate from the pleural cavity. When developed pleural bleeding, blood collected from the pleural cavity is used for reinfusion. During the first five — six hours, the nature and rate of exudation is assessed. The average volume of exudate during this time is usually equal to 250 ± 150 ml. After traumatic and time-consuming operations, pleurectomy, chest wall resection, the exudation rate increases significantly. The total amount of drainage losses during this time can reach 700 ml or more.
For the differential diagnosis of overexpression and bleeding into the pleural cavity, it is necessary to further investigate hematocrit of the exudate and peripheral blood parameters, evaluate the patient’s general condition, central hemodynamic parameters, perform chest x-ray.
In an uncomplicated course of the postoperative period, the next day is usually radiographically marked accumulation of air over a single level of fluid, a slight displacement of the mediastinum in a healthy direction. Sometimes it can be observed the development of unsharply pronounced emphysema of soft tissues in the area of the thoracotomic wound, a significant accumulation of exudate in the pleural cavity, reaching the level of the 1st rib. This, as a rule, is a consequence of over-extraction and requires the evacuation of pleural exudate. A sharp decrease in the amount of exudate most often indicates hypovolemia.
In the absence of complications and special indications for the continuation of the drainage of the pleural cavity, the drainage is removed the next day after surgery. The next few days, puncture the pleural cavity is performed in order to control its tightness, administer antiseptic and antibacterial drugs, and take exudates for bacteriological and cytological studies.
Diagnosis of the threat of pleural empyema is carried out in the clinic on the basis of criteria developed. For this purpose, the total diagnostic coefficient is calculated, guided by the indicators given in the table .
With uncomplicated flow, the total diagnostic coefficient on the 4th day of the postoperative period is +4.0 ± ± 0.95, on the 8th day of the postoperative period is 11.5 ± 0.82, before discharge it is 20.0 ± 0.91. With an increasing inflammatory process and the threat of pleural empyema, the total diagnostic coefficient is: on 4–2.5 ± 2.34, on 8– day –
+19.5 ± 3.31). On the 5th day exudate in the pleural cavity is regularly delimited
fibrin films, begins the formation of fibrinothorax. Recently, in the clinic, before the development of exudate separation, it is taken for research and the introduction of antibiotics is carried out through a thin catheter introduced during the operation in the 2nd intercostal space, which saves patients from having to
holding pleural punctures. The beginning of the formation of fibrinothorax radiographically determined
the appearance of multiple levels of pleural exudate. Early differentiation of exudate (early fibrinothorax) is an unfavorable factor, which may indicate either coagulated hemothorax or the development of an infectious process. The formation of early fibrinothorax significantly complicates the rehabilitation of the pleural cavity.
With the beginning of the development of pleural exudate demarcation, control punctures of the pleural cavity are carried out from several points, which allows to obtain rather comprehensive information on the course of the wound process in the pleural cavity and to ensure greater effectiveness of local antibacterial therapy.
Clinical data and laboratory results, indicating that there are no signs of inflammation or infection of the exudate, can complete the local treatment of the pleural cavity after pneumonectomy. Usually, it is 10-11th day after surgery.
The main objectives of local treatment after partial resection of the lungs is the fastest possible unfolding of the rest of the operated lung and the elimination of residual pleural cavities (Kolesnikov IS, 1969), which is the main direction of prevention of postoperative empyema and respiratory disorders.
For the smooth and complete unfolding of the remaining part of the lung, three main conditions are necessary: free patency of the bronchi, hermetism of the wound of the lung and pleural cavity and complete evacuation of air, blood and exudate from it (Kostyuchenko AL, 1968). To these conditions it is necessary to add another equally important requirement — the correspondence between the volume and configuration of the remainder of the light capacity of the pleural cavity.
The lung rest after its partial resections is straightened by active aspiration through the drains in the pleural cavity. The success of treatment is largely determined by the adequacy of the drainage of the pleural cavity. As a rule, drainage is carried out through two drainage. The upper one, introduced in the 2nd intercostal space along the midclavicular line, is fixed in the apex of the hemithorax with a thin catgut filament. Lower drainage set the same way as after pneumonectomy. Sometimes there is a need for additional drainage of the pleural cavity. It is determined by the possibility of the formation of undrained residual cavities after the expansion of the lung, due to the nature of the operation and the resulting configuration of the lung residue.With the tightness of the pleural cavity and the slowed-down expansion of the lung residue, it is necessary to perform rehabilitation fibrobronchoscopy, thereby ensuring the free passage of the respiratory tract.
The clinic widely uses the imposition of therapeutic pneumoperitoneum, which, by raising the diaphragm dome, reduces the size of the pleural cavity and thereby creates more favorable conditions for smoothing the rest of the lung. For this purpose, air or oxygen is injected into the abdominal cavity at the rate of 20— ml per kg patient weight.
In recent years, the so-called controlled pneumoperitoneum has been used, when the gas was injected through a thin catheter left in the abdominal cavity for 2– days. The volume of injected air weighed with radiographic
data of the effectiveness of pneumoperitoneum and the general condition of the patient. The studies conducted in the clinic showed that the use of pneumoperitoneum in the early postoperative period in patients with partial lung resections allowed reducing the incidence of persistent residual pleural cavities 5 times, more than 3 times reducing the incidence of postoperative atelectasis of the operated lung, and did not result significant violations of pulmonary gas exchange and hemodynamics, despite
restrictions on the mobility of a healthy lung, due to the rise of the dome of the diaphragm. With a complete expansion of the lung and the tightness of the thoracotomy wound, in the absence of significant exudation from the pleural cavity, the drains are successively removed in 2 days. The order of their removal depends on the features of the operation and the postoperative period. The accumulation of a small amount of exudate in the pleural cavity is not considered a complication of the postoperative course, evacuate it puncture, if necessary, antibiotics are injected into the pleural cavity.