Causes of postoperative pleural empyema are most often: its infection during surgery as a result of the opening of purulent cavities in the lung, at the intersection of the bronchus or in the postoperative period with suppuration
thoracotomy wound, or the development of bronchial fistula. Closed empyema of the pleura, according to various authors, occurs in 1.2—, 0% after surgical interventions for lung cancer.
The most dangerous and prognostically unfavorable complication is pleural empyema associated with the development of insolvency of the seams of the bronchus, trachea, and leakage of lung tissue. Among these complications a special place is occupied by the failure of the suture of the stump of the bronchus or trachea after pneumonectomy. According to a number of authors, the incidence of bronchial stump failure after extended and expanded combined pneumonectomy is 2.8–3%. Therefore, it is obvious that the problems of prevention and treatment of tracheal and bronchial fistulas after pneumonectomy are highly relevant and far from being resolved.
The prerequisites for the development of this formidable complication are traditionally considered to be the features and errors of the operative technique, circulatory disorders of the trachea and bronchus walls, infection of the pleural cavity, low reparative capabilities of the body. This is difficult to disagree. There is also at least one other factor that plays an important role in the mechanism of development of insolvency of the tracheal and bronchial sutures after pneumonectomy, which is not taken into account by most researchers.
When developing a technique for suturing the bronchus stump, in a series of experiments on animals and anatomical preparations, an employee of the clinic V.Lishenko (1986), the mechanical strength of the bronchus stump, sutured in various ways, was tested by the method of pneumopression: by definition of it magnitude at which the depressurization of the bronchial stump occurs. It turned out that on the 4th day after the operation the strength of the sutures for any methods of suturing the bronchus stump does not exceed only 40 cm of water. Art. The question naturally arose: what kind of air pressure does a trachea have in operated patients when they cough, strain it? As the conducted studies have shown, in healthy people the pressure when coughing can reach 110— cm of water, and in the operated patients on the 4th day it was equal to 65 ± 5.2 cm of water. Art., i.e. exceeded the strength of the bronchus stump. So why all the operated patients do not develop the failure of the seams?
As it turned out, at the moment of coughing, deep breathing, simultaneously with a change in pressure in the trachea, there is also a change in pressure in the pleural cavity, provided that it is tight. The resulting pressure gradient in the tracheobronchial tree and the pleural cavity does not exceed the threshold of mechanical strength of the seams. At different phases of respiration, when coughing, this gradient can be multidirectional, but as was proved in the experiment, the most dangerous is the excess pressure in the tracheobronchial tree relative to the pleural cavity. Excessive pressure in the pleural cavity is less dangerous from the point of view of the development of insolvency of the seams, since the mechanical strength threshold of the bronchus stump at any time after surgery, with this air pressure direction, always exceeds 300 cm of water. st ..
From the above, we can make an unambiguous conclusion — the creation of excess
negative pressure in the pleural cavity or its depressurization, are factors contributing to the development of insolvency of bronchial (tracheal) sutures. This is especially important to consider with advanced combined pneumonectomy, when, as a rule, it is not possible to reliably, by pleurisy, disunite the bronchial stump or tracheal suture from the operated hemithorax.
Persistent micronestability of bronchial and tracheal sutures, apparently, occurs much more often than it is diagnosed. This can probably explain the “unreasonable”, suddenly occurring changes in the nature of the pleural exudate, regarded as a threat to the development of pleural empyema.
Early diagnosis of subclinical insolvency of seams presents significant difficulties. The existing methods based on the detection of radioactive inert gas in the air bubble of the pleural cavity, which the patient breathes are complex, require special equipment and give positive results if the moment of microinterference coincides with the time study.
The clinic proposed and developed a method for the early diagnosis of subclinical proceeding insolvency of bronchial and tracheal sutures, based on the properties of camphor to escape from the body only through the lungs with the secretion of bronchial glands. Camphor, administered to the patient in a therapeutic dose subcutaneously, together with air and particles of bronchial secretions can get into the operated gemitorax only through a defect in the seam of the bronchus or trachea. Having good volatility, it accumulates in the air bubble of the residual pleural cavity and can be determined in samples from it. The air extracted from the pleural cavity during punctures was examined for the content of camphor in it using the method proposed by E.A. Peregud and E.V. Gernet (1070) for the study of industrial air. The principle of the method is based on the property of a solution of camphor in concentrated H 2 SO 4 , treated with a nitrating mixture and an excess of ammonia painted yellow. The content of camphor is determined calormetrically on a standard scale. The sensitivity of the method is 3 mg per m 2 . The method of camphor sampling is technically simple, safe for the patient and very informative.
When using the camphor test in 52 patients who had pneumonectomy, 9 of them had positive results, i.e. The presence of camphor in the air obtained by puncture from the pleural cavity on the part of the operation was detected . It is very interesting that in time this coincides with the development of early fibrinothorax, increased blood leukocytosis, cytosis and neutrophilia of the pleural exudate, low-grade fever of patients. During the study period, none of the 9 patients had reliable clinical and endoscopic signs of the presence of bronchial fistula. Conducted remedial measures prevented the development of pleural empyema, and none of these patients had any subsequent bronchial fistula obesity.
An important pattern was established when analyzing the results of the study in the postoperative period, the total diagnostic coefficient to assess the dynamics of the inflammatory process in the pleural cavity in 189 patients, after right and left-sided pneumonectomy. Thus, the condition, regarded as threatened by the development of pleural empyema, was recorded in 37.4% of patients who underwent right-side pneumonectomy and only 16.7% of patients had left pneumonectomy (p <0.001). At the same time, none of the patients, on the basis of clinical and endoscopic examination, found that the bronchus stump was inconsistent. Taking into account the difference in the incidence of insolvency of the bronchus stump on the right and on the left, it can be assumed that the resulting changes in the nature of the pleural exudate were caused by the development of subclinical undiagnosed microinsolation of the bronchus stump,self-closed during the treatment of these patients.
we far from generalizing conclusions that any secondary inconsistency of bronchus stump or tracheal sutures is in fact undiagnosed primary, but apparently the role of insolvency of bronchial (tracheal) sutures in the pathogenesis of postoperative empyema of the pleura is much more than is considered.
On Based on the studies conducted in the clinic, a method was developed for the local treatment of patients who have had pneumonectomy when they develop an insolvency of bronchial stump or tracheal sutures. This category included patients who had technical difficulties or errors during the operation during the closure of the bronchus stump, tracheal sutures, as well as a change in the postoperative total diagnostic factor, considered as a threat to the development of pleural empyema.