Surgical methods of tuberculosis investigation

Surgical research methods in phthisiology are various invasive manipulations or “minor” operations using special surgical instruments, equipment and diagnostic equipment.

Despite the extensive clinical experience of domestic phthisiologists and the variety of diagnostic methods, in some cases there is a need to use research methods that require special conditions and skills of surgical personnel.

The purpose of surgical examination methods is to establish or clarify the diagnosis of tuberculosis, the degree of prevalence and activity of the process, the presence or absence of complications. In some cases, surgical examination methods can be used to establish concomitant or concurrent diseases.

Objectives of surgical research methods:

• obtaining pathological material for cytological, bacteriological or morphological studies;
• direct examination and palpation (including instrumental) of the lung, pleural cavity, mediastinum, lymph nodes and other organs;
• introduction of diagnostic substances or drugs into cavity formations and fistula tracts.

All surgical diagnostic methods (taking into account the degree of invasiveness of the means used and the methods of implementation) are divided into 3 main groups: needle methods, “minor” diagnostic operations and endosurgical interventions.

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Needle methods for tuberculosis testing

Needle research methods include pleural puncture and transthoracic needle biopsy.

Bringing the needle to the organ or tissue being examined requires a preliminary assessment of the topographic-anatomical relationships and establishing the exact localization of the puncture site using radiation diagnostic methods: multi-position fluoroscopy, radiography, CT and ultrasound.

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Puncture of the pleural cavity

Pleural puncture is the insertion of a needle through the soft tissues of the chest wall into the pleural cavity to obtain and remove fluid or air.

Main indications: exudative or encapsulated pleurisy, pleural empyema, intrapleural bleeding, pneumothorax, hydropneumothorax.

Every TB doctor must know the technique of performing a pleural puncture. No special preparation of the patient is required. Pleural puncture is performed with the patient in a sitting position (if the patient's condition allows). To expand the intercostal spaces, the shoulder is moved up and forward. The manipulation is performed under local infiltration anesthesia of the skin and soft tissues of the chest wall. If there is free fluid in the pleural cavity, the classic place for puncture of the chest wall is the seventh or eighth intercostal space between the middle axillary and scapular lines. Puncture of encapsulated fluid is performed taking into account the data of an X-ray examination or ultrasound. In case of pneumothorax, puncture is performed in the anterior-superior parts of the pleural cavity.

Pleural puncture is performed using standard needles of various lengths and thicknesses, connected to a syringe with a transition valve or silicone tube (to prevent air from entering the pleural cavity). The needle is inserted through the intercostal space along the upper edge of the underlying rib. During the puncture, it is desirable to completely remove all the contents of the pleural cavity to achieve tightness. For gradual displacement of the mediastinal organs, a large amount of fluid should be removed slowly. In some cases (purulent pleurisy, ongoing intrapleural bleeding, lack of tightness of the lung tissue), pleural puncture is completed with thoracocentesis with lavage of the cavity with antiseptic solutions and drainage. Samples of the fluid obtained during the puncture are taken into sterile test tubes for bacteriological examination, determination of the relative density of the fluid, cellular composition, amount of protein and glucose.

The most common complication of pleural puncture is a puncture of the lung with the development of pneumothorax or bleeding. Pneumothorax is eliminated by repeated pleural punctures, bleeding usually stops on its own or after taking hemostatic agents. Prevention of complications: careful determination of the puncture site and needle direction, strict adherence to the puncture technique.

Needle biopsy

Needle biopsy is sometimes the only method that allows establishing an accurate morphological diagnosis in cases of lung, pleural, peripheral and intrathoracic lymph node lesions. Special needles are used to obtain a biopsy. Various approaches can be used: conventional puncture of superficial lesions, transbronchial, transthoracic, endosurgical approaches.

Needle aspiration biopsy is a diagnostic procedure, a puncture of the organ or tissue being examined in order to obtain cellular material for cytological examination by aspirating it into the lumen of the needle.

Indications for needle aspiration biopsy: superficial or peripheral lymph nodes, intrathoracic and intrapulmonary formations directly adjacent to the chest wall.

Puncture of superficial formations is performed taking into account the data of examination and palpation, usually without anesthesia. Regular needles for intramuscular injections with a cannula from a disposable syringe are used.

In case of deep (intrapleural or intrapulmonary) location of the pathological formation, the examination is carried out under local anesthesia, under fluoroscopy or CT control. Thin needles 10-16 cm long are used. The puncture site is determined by the shortest distance to the tissue area being examined. The needle is inserted into the lung during a shallow breath, after which the patient is asked to breathe superficially and not to cough. To prevent obstruction of its lumen by areas of the skin epidermis or soft tissues of the chest wall, the needle is inserted with a mandrel. The position of the needle in the tissue is controlled using fluoroscopy or CT. This allows for the most accurate determination and, if necessary, change of position. The mandrel is removed, the needle is connected to the syringe and the contents are aspirated. The contents of the needle are removed onto a defatted slide and a smear is prepared for cytological examination, which is carried out immediately during the puncture (if necessary, tissue aspiration can be repeated immediately).

The efficiency of cytological verification of diagnosis using needle aspiration biopsy is highest in the diagnosis of tumor processes and reaches 97%. For non-tumor diseases, the technique is less effective, since an accurate diagnosis requires histological examination.

Complications with aspiration biopsy usually occur only with transthoracic puncture. The most common complications are bleeding and pneumothorax. To avoid such complications, do not puncture deep, root lesions. The biopsy should be performed as quickly as possible, without allowing a large amplitude of breathing during the examination.

Contraindications to transthoracic aspiration biopsy include blood clotting disorders, severe emphysema, severe concomitant cardiovascular diseases, and arterial hypertension.

Needle puncture (trepanation) biopsy is a diagnostic puncture of the pathological formation being examined in order to obtain tissue material for its histological examination using special needles.

Indications for needle puncture biopsy in phthisiology practice: round lung formations (excluding the tumor nature of the formation), superficially located intrapulmonary infiltrates or groups of foci, chronic recurrent pleurisy of unclear genesis, accompanied by a sharp thickening of the pleura.

Contraindications - similar to contraindications for aspiration biopsy. Transthoracic puncture biopsy is performed using special biopsy needles of various designs. The main requirements for needles: reliability of use, atraumatic nature and safety for the patient, the ability to obtain a tissue fragment sufficient for histological examination.

The structure of most biopsy needles is the same: they consist of the needle itself and a stylet, which is used to collect the material. During the manipulation, the stylet is removed from the needle, a section of tissue is captured and cut off, and then pulled into the lumen of the needle. The mechanism for capturing and cutting off the biopsy depends on the design of the stylet: split, hook, and fenestrated stylets are most often used. In some cases, drills, including ultrasonic ones, are used to collect the material.

Transthoracic puncture biopsy is more traumatic than aspiration biopsy. In this regard, the accuracy of the needle hitting the tissue being examined is important, this is controlled using radiological diagnostic methods. The most accurate methods are CT and polypositional ultrasound scanning using puncture adapters.

The tissue section obtained by puncture biopsy can be examined using cytological, histological, bacteriological, immunohistochemical, electron microscopic methods, which significantly increases the efficiency and reliability of diagnostics. Verification of the diagnosis using transthoracic needle biopsy is possible in 80-90% of cases. The efficiency of the method in diagnosing malignant tumors is higher than in establishing the diagnosis of inflammatory diseases.

Complications in the examination of soft tissues of the chest wall and pleura are extremely rare. Puncture biopsy of the lung is a more dangerous manipulation and in some cases can be complicated by pneumothorax, pulmonary hemorrhage, pleurisy, hemothorax, implantation metastases, air embolism.

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Open diagnostic operations

Open diagnostic operations are performed when biopsy of both superficially located and intrathoracic formations is necessary. In phthisiosurgical practice, biopsy of peripheral lymph nodes, parasternal mediastinotomy, diagnostic thoracotomy with open biopsy of the lung and pleura are performed.

Peripheral lymph node biopsy

Biopsy of peripheral lymph nodes is indicated in cases where previous manipulations have not allowed establishing a diagnosis; cervical, axillary and inguinal lymph nodes are most often examined. The operation is performed under local anesthesia or intravenous anesthesia.

Prescalene (transcervical) biopsy is a surgical removal of the tissue and lymph nodes located on the surface of the anterior scalene muscle of the neck. A 3-5 cm incision is made parallel to the collarbone above it. For histological examination, the tissue with lymph nodes is removed. Complications: damage to the subclavian or external jugular vein, opening of the pleural cavity with the development of pneumothorax.

When performing a biopsy of the axillary lymph nodes, a 3-5 cm incision is made in the axillary fossa. Enlarged lymph nodes are not always easy to isolate due to the significant amount of subcutaneous fat. They should be removed carefully so as not to damage the axillary vessels and nerves.

More accessible are the inguinal lymph nodes, which are located just under the skin and can be removed relatively easily through a small incision.

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Open lung biopsy

Open biopsy - obtaining a biopsy of the lung, pleura or lymph nodes by opening the chest cavity or mediastinum. The method is used for diffuse and disseminated lung diseases, pleurisy and intrathoracic lymphadenopathy of unknown genesis, as well as in cases where previously performed manipulations did not allow a diagnosis to be established.

The operation is performed under general anesthesia using intercostal or parasternal access. Conventional surgical instruments are used during the operation. With a small incision (mini-thoracotomy), video equipment and endosurgical instruments (video-assisted operations) are sometimes used for better examination of the pleural cavity and biopsy of deep-lying areas of the lung or hilar lymph nodes. In case of diffuse or disseminated lung lesions, marginal resection of the affected area of the lung is performed. In case of pleural lesions, forceps biopsy is performed from several sections of the pleura. In case of lymph node lesions, lymphadenectomy of one or more nodes of the pulmonary root and mediastinum is performed.

Advantages of open biopsy: high reliability, possibility of obtaining large biopsies from one or several areas of the pleura, lung or lymph nodes. The obtained material is placed in identified containers and used for various studies (morphological, bacteriological, immune). After the operation, a drainage silicone tube is left in the pleural cavity for 1-2 days. Complications of open biopsy are similar to complications of standard lung surgeries (pneumothorax, hydrothorax, hemothorax, respiratory failure, infection), but are much less common (less than 1% of cases).

Endosurgical operations

Endosurgical operations are widely used in diagnostics. They are performed using punctures or small incisions through which lighting and optical devices, a television camera, and special endosurgical instruments are introduced into the pleural cavity or mediastinum. In phthisiology, thoracoscopy (pleuroscopy) and mediastinoscopy are most widely used.

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Thoracoscopy

Thoracoscopy allows for a detailed examination of any part of the pleural cavity and (if necessary) to take biopsies from various areas of the pleura, lungs and mediastinum.

For videothoracoscopy, thoracoscopes with different viewing angles, a video camera, illuminator, monitor with color image, recording equipment, additional surgical equipment for performing various medical manipulations are used.

The absence of pleural adhesions and lung collapse by 1/2 - 1/3 of its volume are necessary conditions for performing videothoracoscopy. The operation is most often performed under general anesthesia with separate bronchial intubation and exclusion of one lung from ventilation. If there is a persistent residual cavity in the chest, the rigid lung is compressed, the examination is performed under local anesthesia. An optical thoracoscope is inserted into the pleural cavity through a trocar (thoracoport). It is connected to a video camera and the pleural cavity is examined. To perform various surgical manipulations, 2-3 additional manipulation trocars are inserted, through which a biopsy or the necessary therapeutic manipulations (separation of adhesions, cavity sanitation, removal of pathological formations) are performed using special endosurgical instruments. The thoracoscopic picture of the pleural cavity is photographed or recorded on a digital video camera.

Videothoracoscopy is widely used in the diagnosis of various exudative pleurisy and disseminated lung lesions of unclear etiology.

In case of exudative pleurisy, videothoracoscopy is performed at any time. In the initial stages of the disease (up to 2 months), it has only diagnostic value. At later stages (2-4 months), after the organization of exudate with fibrin deposition, development of adhesions and encapsulation of cavities, videothoracoscopy is used to sanitize the pleural cavity with partial pleurectomy and decortication of the lung.

In disseminated lung lesions, there is no strictly specific picture of the disease, so lung biopsy is often performed in such patients. Videothoracoscopy allows examining any "suspicious" area of the pleural cavity and lung with magnification. In case of superficial lesions, the simplest and most effective method is a forceps lung biopsy. In case of lesions located in the lungs, marginal resection is indicated. Using a videothoracoscope, a lung area is selected and resected using an endo-stapler.

Complications: bleeding, subcutaneous emphysema, prolonged absence of aerostasis. The frequency of complications when performed by a specialist with extensive experience in performing the manipulation does not exceed 1%. Contraindications to videothoracoscopy: respiratory failure and obliteration of the pleural cavity. Disadvantages of the method: the need for separate ventilation of the lungs and the impossibility of palpating the lung and other structures of the chest cavity.

Mediastinoscopy

Mediastinoscopy is a diagnostic operation involving examination of the anterior mediastinum using a mediastinoscope or a video mediastinoscope connected to a monitor.

Mediastinoscopy is performed under general anesthesia. On the anterior surface of the neck, along the edge of the manubrium of the sternum, the skin and soft tissues of the neck are cut to the anterior wall of the trachea. A tunnel is formed in the pretracheal space with a finger, into which a mediastinoscope is inserted and, under visual control, a puncture or removal of the paratracheal and bifurcation lymph nodes is performed. Advantages of video technology: image availability not only to the surgeon, but also to the assistant, the possibility of (training, optimal illumination and image clarity, the possibility of its enlargement and saving in a computer database. A perfect tool for mediastinoscopy operations helps to increase the safety of the operation.

Mediastinoscopy is used in phthisiology to clarify the cause of mediastinal lymphadenopathy of unclear etiology. It is often performed in sarcoidosis, tuberculosis and lymphogranulomatosis. The frequency of complications with mediastinoscopy does not exceed 1-2%. Bleeding, pneumothorax, damage to the nerves of the larynx are possible.