The procedure for maintaining the pleural cavity in these patients was as follows: 1) early, on the 2nd day, the onset of fibrinolytic therapy, against the background of which daily puncture rehabilitation of the pleural cavity and local antibacterial therapy were carried out, with constant bacteriological and cytological control of pleural exudate; 2) creation in a pleural cavity of a small, about 20 – cm waters. Art., positive pressure, leveling dangerous by the occurrence of the failure of the bronchus stump air pressure gradient between the tracheobronchial tree and the residual pleural cavity. To this end, at the end of the pleural puncture, the puncture needle was removed at the height of the patient’s deep breath; 3) maintaining a “semi-dry” pleural cavity, when the level of exudate in the upright position of the patient is located below the level of the bronchus stump,the orientation is lower than the projection of the 5th rib.

The applied method of maintaining a residual pleural cavity allows to achieve favorable conditions for healing the bronchus stump due to the elimination of the pressure gradient, which is dangerous for the tightness of the bronchus stump (tracheal suture), preventing the progression of the inflammatory process in the wall of the bronchus or trachea when there is insufficient pleurisy when in contact with pleural exudate — so called “maceration” (I. Kolesnikov, 1960). The loss of protein and electrolytes with aspirated pleural fluid is significantly reduced, which happens in the case of “semi-dry” management of the pleural cavity. The use of fibrinolytic enzymes can prevent the early formation of fibrinothorax and createthe necessary concentration of antibiotics is uniform throughout the entire volume of pleural exudate, and when the pleural empyema is threatened, it is free to sanitize the pleural cavity.

The use of this technique in 84 patients made it possible to achieve an uncomplicated postoperative course, despite the severity and large volume of surgical intervention and the real risk of insolvency of the stitches of the bronchus or trachea stump.

In the diagnosis of primary failure of the bronchus stump, if the patient’s condition permits, as a rule, a retracotomy is performed and the defect is sutured. After the implementation of the new method of treatment of the bronchus stump — the modified Overholt method — no longer were cases of complete divergence of the bronchus stump over its entire width. In patients with small sizes of bronchus stump defects (up to 3 — mm in diameter) with its primary insolvency, in cases of a serious condition of patients and a significant risk of reoperation, as well as in

cases when bronchial fistula was diagnosed against the background of developing pleural empyema (secondary failure), conservative treatment was performed.

Conservative methods of treatment of insolvency stump bronchus, tracheal sutures include rehabilitation of the pleural cavity and local endobronchial treatment aimed at stimulating the growth of granulations in the area of ​​the bronchial (tracheal) defect.

The applied methods of endoscopic treatment of bronchial fistulas after pneumonectomy, such as chemical cautery, removal of ligatures, use of medical adhesives, temporary endobronchial occlusion of defects, as a rule, are ineffective as they allow to achieve success not more than in 15–20% of patients and fail to telnosti, not exceeding 1 – mm. The use of these methods does not provide for the creation of a “functional rest” for the walls of the fistula, as for draining the pleural cavity in order to prevent aspiration of the pleural cavity. exudate requires the use of closed or open drainage (thoracostomy) of the pleural cavity. As a result of its depressurization, a significant air pressure gradient arises between the tracheobronchial tree and the operated hemithorax, and the air flow generated during the various respiratory phases, especially from the tracheobronchial tree into the pleural cavity, prevents the bronchial fistula from healing and even increases its size.

The basis of the method of treatment of bronchial fistula developed in the clinic was the idea to create such a method for closed drainage of the pleural cavity, in which, along with the possibility of complete removal of exudate through the drainage tube, a slight (measured) positive pressure can be maintained in the pleural cavity, reducing the dangerous pressure gradient, ensuring better contact between the walls fistula, however, does not cause displacement of the mediastinum.

For this purpose, a device consisting of a drainage tube has been developed and created for inhaling and exhaling lapans . The creation of positive pressure in the pleural cavity is provided by a breath valve, which contributes to the flow of air into the drainage system. The magnitude of the positive pressure in the cavity depends on the height of the liquid column in the bank in which the expiratory valve is placed (underwater drainage according to Petrov-Bulau). When a pressure in the pleural cavity is created above the liquid column, a spontaneous discharge of its excess through the exhalation valve occurs. The level of positive pressure is selected individually using a pressure gauge, and then the level of the liquid in the canister is set to correspond to the minimum pressure during the various phases of respiration. It, as a rule, should be about 20 cm of water. Art. General view of the inhalation and exhalation valves is shown in Figure 60.

The developed treatment method was applied in 34 patients with failure of the bronchus stump after pneumonectomy. Combined with local endoscopic therapy (chemical cauterization of the bronchial mucosa in the area of ​​the defect), it allowed for the closure of bronchial fistula in 28 patients (82.4%). As a rule, the size of the insolvency of the bronchus stump in them did not exceed 3 mm. It is important to note that in 2 patients the size of bronchial fistulas was significant and exceeded half the width of the bronchus stump. To assess the effectiveness of the method used, one can indicate that in the control group of 100 patients (operated from 1960 to 1986) by conservative measures, it was not possible to achieve the healing of bronchial fistulas of such size in any of the patients.

The problems of local treatment of patients after extended and expanded combined resections of the lung in most cases are associated with the choice of a rational tactics of management of the pleural cavity after pneumonectomy.