Videotoracoscopy in the surgical treatment of pleural empyema

The empyema of the pleura in most cases is a complication of inflammatory and purulent-destructive lung diseases, injuries and surgical interventions on the thoracic organs and is the most complicated section in thoracic surgery. Currently, according to domestic and foreign researchers, a reduction in the frequency of acute purulent-destructive lung diseases (GDZL), complicated pleural empyema, is not observed. As is known, in 19.1% -73.0% of cases the cause of nonspecific empyema of the pleura is acute purulent-destructive pulmonary disease. At the same time the mortality rate is 7.2% - 28.3%.

Post-traumatic genesis of pleural empyema was observed in 6% -20% of observations. Mortality in posttraumatic empyema of the pleura reaches at times 30%, and the outcomes largely depend on the nature of the damage and the timing of care for victims with chest trauma.

In connection with the expansion of indications and the volume of intrathoracic interventions, the intensive growth of antibiotic resistance of microorganisms maintains a high frequency of postoperative pleural empyema and bronchopleural fistulas.

The treatment of patients with pleural empyema is still a complex problem, as evidenced by relatively high rates of mortality, process chronicization, disability of patients, most of whom are persons of working age. In addition, a change in the species composition of microflora and its tolerance to many antibacterial drugs, an increase in the proportion of anaerobic and hospital infections, and an increase in allergic population create additional difficulties in the treatment of patients with empyema of the pleura. Operative methods of treatment are often accompanied by complications, traumatic and not always feasible because of the severe condition of patients. Promising is the use of "small" surgery in the complex treatment of patients with pleural empyema, including videothoracoscopy, which, depending on the severity of pulmonary pathology, leads to a cure in 20% -90% of observations.

Among patients treated with the use of endoscopic sanation of the pleura, 8.4% were operated, whereas among the treated with punctures and drainage without examination - 47.6%.

The first thoracoscopy in the world with a massive infected left-sided pleurisy with the development of chronic fistula 11-year-old girl was Irish surgeon Dr. Cruise (1866), using the binocular endoscope developed by him.

The expediency of using thoracoscopy for pulmonary empyema was first expressed at the XVI All-Russian Congress of Surgeons G.A. Herzen (1925). At first, thoracoscopy was widely used in the treatment of pulmonary tuberculosis. However, the emergence of new effective antituberculosis drugs hampered the further development of thoracoscopy for many years. A wider application of this method in the diagnosis and treatment of inflammatory diseases of the lungs and pleura has only been received in the last two decades.

V.G. Geldt (1973), using thoracoscopy in children with pyopneumotorax, noted its decisive importance in the diagnosis of intrapleural lesions and the choice of a method of treatment. G.I. Lukomsky (1976), with widespread and total empyema, with limited empyema with destruction of lung tissue, used thoracoscopy according to Friedel's method. In the pleural cavity introduced a shortened bronchoscopic tube from the set Friedel No. 11 or No. 12, with the help of an aspirator under the control of vision removed pus and fibrin flakes from the pleural cavity. Ended thoracoscopy with the introduction into the pleural cavity of silicone drainage. Based on the experience gained, the author makes a conclusion about the expediency of using thoracoscopy in the treatment of pleural empyema.

D. Keiser (1989) reported successful treatment of acute pleural empyema with operational thoracoscopy, which used a mediastinoscope as an endoscope.

In the last two decades, the world has seen significant technical progress in the health sector, which has been realized in the creation of endovideo equipment and the emergence of new endoscopic instruments, which has expanded the scope of thoracoscopic surgery - to resection of the lungs, esophagus, removal of mediastinal tumors, treatment of spontaneous pneumothorax, hemothorax. Today, videotoracoscopic operations have become the "gold standard" in the diagnosis and treatment of many diseases of the chest, including with purulent inflammatory diseases.

P. Ridley (1991) used thoracoscopy in 12 patients with pleural empyema. In his opinion, removal of necrotic masses under the control of an endoscope and thorough washing of the empyema cavity allows achieving favorable results in the treatment of these patients.

V.A. Porkhanov et al. (1999) summarized the experience of treating 609 patients with pleural empyema using videotorakoscopic techniques. We used videotoracoscopic decortication of the lung and pleurectomy for chronic pleural empyema: 37 (78.7%) patients were cured in this way. Conversion to thoracotomy was required in 11 (1.8%) patients.

PC Cassina, M. Hauser et al. (1999) evaluated the validity and effectiveness of videothoracoscopic surgery in the treatment of non-tuberculous fibrinose-purulent pleural empyema in 45 patients after ineffective drainage. The average duration of conservative treatment was 37 days (8 to 82 days), with an effective treatment of 82%. In 8 cases, decortication was required by standard thoracotomy. In dynamic observation with the study of the function of external respiration in 86% of patients after vitro-thoracoscopic operations, normal indices were noted, in 14% - moderate obstruction and restriction. Relapses of empyema are not noted by the authors. The researchers conclude that videotoracoscopic sanation of the empyema cavity is effective in treating purulent-fibrinous empyema, when drainage and fibrinolytic therapy failed. In a later stage of the organization, pleural empyema is considered a method of choice for thoracotomy and decortication.

V.N. Egiev in 2001 described the case of successful videotoracoscopic assisted radical sanation of chronic nonspecific pleural empyema.

To increase the effectiveness of endovidoracoscopic surgery, some thoracic surgeons began using ultrasound, laser radiation, argon plasma. A.N. Kabanov, L.A. Sitko et al. (1985), a closed ultrasonic lung decortication was applied through a thoracoscope using a special waveguide-curette followed by scoring the empyema cavity in an antiseptic solution in order to enhance the rejection of pathological substrates and bactericidal properties of antiseptics. I.I. Kotov (2000) developed and introduced a method of laser thoracoscopy with evaporation of the pyogenic-necrotic layer of revealed pulmonary destruction and brewing of broncho-pleural fistulas with a laser beam of a carbon dioxide. V.N. Bodnya (2001), on the experience of treatment of 214 patients, developed the surgical technology of videothoracoscopic pleurrectomyectomy, lung decortication in the third stage of pleural empyema using an ultrasonic scalpel and treatment of lung tissue with an argon burner. The number of postoperative complications decreased 2.5 times, hospitalization time decreased by 50%, the effectiveness of the developed methodology was 91%.

V.P. Saveliev (2003) analyzed the treatment of 542 patients with pleural empyema. Thoracoscopy was performed in 152 patients with drainage of the empyemic cavity with two or more drainages for permanent flow washing. In 88.7% of them thoracoscopy was the final method of treatment.

There are different views on the timing of videotoracoscopy, some authors justify the need for more active diagnostic and therapeutic tactics, and perform a video-thoracoscopy for emergency indications on the day of admission, taking into account the general contraindications. The authors recommend performing thoracoscopy with a diagnostic and therapeutic purpose immediately after the diagnosis of empyema of the pleura. With the expansion of indications for videotorakoscopy with empyema of the pleura, it is possible to reduce the need for thoracotomy and traditional operations from 47.6% to 8.43%, to reduce postoperative mortality from 27.3% to 4.76% with a 33% reduction in hospitalization.

Other surgeons believe that thoracoscopy should be used on deferred terms after a complex of diagnostic measures and with the failure of conservative therapy by puncture and drainage. There is still a widespread opinion that it is not necessary to rush with thoracoscopy and to the listed conditions add a reliable correction of homeostatic and vollemic disorders. Probably, the last is true only at far gone pathological process in a pleura.

Indications and contraindications for the use of videothoracoscopy

Based on many years of experience using videotorakoscopy in the treatment of acute and chronic pleural empyema, the following indications were developed for its use:

• Ineffectiveness of traditional methods of treatment, including closed drainage of the pleural cavity;
• Fragmented pleural empyema (empyema of the pleura with multiple constrictions);
• Empyema of the pleura with signs of destruction of the lung tissue, including bronchopleural messages.

Contraindications to the use of videotorakoscopy are:

• The presence of general somatic diseases in the stage of decompensation;
• Intolerance to ventilation in the mode of single-pulmonary ventilation;
• Mental diseases;
• Violation of the hemostasis system;
• Bilateral lung involvement, accompanied by severe respiratory failure.

How is videotouracoscopy done?

Videotoracoscopic surgery is often performed under general anesthesia with separate intubation of the bronchi with a double-lumen tube. Such single-pulmonary ventilation is necessary to completely collimate the lung and create a free space, which allows for a thorough and complete examination of the chest cavity. But depending on the tasks that the surgeon sets for himself, videotoracoscopy can be performed under local or regional anesthesia.

The position of the patient on the operating table. The most commonly used position of the patient on a healthy side on the roller, placed in the middle of the chest, which maximizes the development of intercostal spaces. This styling, although it gives the surgeon the freedom to act, has drawbacks. Compression of a healthy lung adversely affects the ventilation when disconnected from the act of breathing a patient's lung, as well as there is a danger of leakage of purulent fluid into his bronchial tree. A more gentle laying of the patient is a semi-lateral position on a high wedge-shaped roller. In this case, the healthy lung undergoes less compression. The patient should be reliably fixed, since depending on the surgical situation, it may be necessary to change the patient's position in one direction or another.

Operative technique. The site of choice for the first thoracoport is chosen individually, depending on the shape, size and localization of the empyema cavity. Optimization of the localization of the introduction of the first port is facilitated by close examination of radiographs in 2 projections, computed tomography and ultrasound scanning of the thorax before the operation. The number of thoracoports depends on the tasks assigned to the operation. Usually 2-3 torakoportov is enough. In the case of an adhesion process in the pleural cavity, the first thoracoport is administered by the open method, penetrating the pleural cavity with a finger. In an obtuse way, an artificial pleural cavity is created, sufficient to introduce additional ports and perform the necessary surgical manipulations. In the course of videotoracoscopy, a variety of techniques are used: evacuation of purulent exudate, dissection of pleural joints to defuse the empyema cavity, removal of purulent detritus and sequestrants, resection of destructive pulmonitis zones, rinsing of the empyema cavity with solutions of antiseptics, partial or complete pleurectomy and decortication of the lung. All authors end thoracoscopy by draining the empyemic cavity. Some surgeons in the treatment of pleural empyema with bronchial fistula use passive aspiration. Most prefer active aspiration of the contents from the pleural cavity. In acute empyema without destruction of lung tissue and bronchial fistula, active aspiration is shown, which allows to eliminate the cavity and heal empyema in 87.8-93.8%. Active aspiration creates conditions for active distribution of the collapsed lung, contributes to reducing intoxication and is a measure of prophylaxis of bronchogenic dissemination of purulent infection. The degree of dilution required for lung dilatation largely depends on the duration of the existence of pyopneuromotorax, the size of bronchopleural messages, and the extent to which the lung is collapsed. Many authors propose to supplement active aspiration with flow, fractional, flow-fractional lavage of the empyema cavity, even with the use of automated control systems for this process.

Application videotorakoscopy in the treatment of pleural empyema with bronchopleural messages (BPS). The main reason for the lack of effectiveness of drainage methods is the presence of bronchopleural fistulas, which not only impede the spreading of the lung and maintain a purulent process, but also limit the possibility of washing the pleural cavity. This disadvantage is eliminated by combining videotorakoskopii with temporary occlusion of the bronchus (PBS). Despite the numerous ways to eliminate bronchopleural messages in video-thoracoscopy, such as electrocoagulation of the mouths of bronchopleural messages, the use of medical glues, staplers, brewing bronchopleural messages with high-energy laser radiation, the problem of their elimination remains relevant today. Their low efficiency is primarily due to the fact that all these manipulations are carried out in a purulent-necrotic process that contribute to the failure of the "brewed" tissues, the eruption of inflamed lung tissue and the rejection of the adhesive seal.

In the literature, reports of a combination of video thoracoscopy with temporary occlusion of the bronchus are rare. So I.I. Kotov (2000), with empyema of the pleura with bronchopleural messages of medium and large caliber with a compliant lung, recommends combining a video thoracoscopy with temporary occlusion of the bronchus. The use of temporary occlusion of the bronchus, according to VP. Bykov (1990), allowed to reduce the lethality in patients with pyopneumotorax by 3.5 times.

Early application of videotoracoscopy followed by occlusion of the fistula-supporting bronchi made it possible to achieve recovery in 98.59% of patients, and in the pleural effeminate without fistula recovery was achieved in 100%.

The mechanism of the positive effect of temporary bronchial occlusion on the course of the purulent-destructive process in the lung with pyopneumotorax consists in the following:

• A persistent vacuum is created in the pleural cavity as a result of its dissociation with the obturator with the bronchial tree.
• The residual pleural cavity is eliminated due to the expansion and increase in the volume of the healthy part of the lung, the displacement of the mediastinum, the reduction of the intercostal spaces and the rise of the diaphragm.
• Promotes the emptying and obliteration of foci of destruction in the lung tissue in conditions of temporary atelectasis of the affected parts of the lung with a constant active aspiration of the contents from the pleural cavity.
• Prevented bronchogenic dissemination of purulent infection, delimiting healthy parts of the lungs.
• Favorable conditions are created for closing bronchopleural messages as a result of the formation of adhesions between the visceral and parietal pleura, the formation of a limited fibrotorax.

The expediency of using temporary bronchial occlusion after videothoracoscopic sanation of the pleural cavity in combination with active aspiration through established drainage in the pleural cavity is recognized by all authors, as these methods complement each other and, in a complex, minimize their shortcomings. In this situation, the use of videotorakoscopy in combination with temporary occlusion of the bronchus is pathogenetically justified, expedient and promising.

Programmed videothoracoscopy

During the suppuration during acute pleural empyema after videotorakoscopy and drainage of the pleural cavity, in about half of the cases there are periods of clinical regression. Their causes are the formation of purulent-necrotic sequesters, undrained purulent deposits (fragmentation of the cavity of the empyema), the inability of the rigid lung to completely perform the pleural cavity. As a result, in 45-50% of cases in treatment can not be confined to a single primary thoracoscopy, additional manipulations, multiple sanations are necessary.

V.N. Perepelitsyn (1996) applied therapeutic thoracoscopy in 182 patients with nonspecific acute and chronic pleural empyema, 123 patients with acute para- and metapneumonic pleural empyema. Parts of the patients were performed by the rehabilitation stage thoracoscopy. On average, repeated thoracoscopy was performed four times (in 8 patients). Patients who entered the first 1-30 days from the onset of the disease managed to reduce the average length of inpatient treatment from 36 to 22 days.

VC. Gostishchev and V.P. Sazhin used dynamic torascopic sanation since 1996 in the treatment of pleural empyema. With the help of endoscopic manipulators, pulmonary-pleural joints were destroyed, fibrinous stratifications were removed from the visceral and parietal pleura, nekrektomiyu melted areas of lung tissue. After the sanation, under the control of the thoracoscope, drainage tubes were installed with the formation of a flow-aspiration system, the lung cavity of the lung abscess was drained puncture. Subsequent thoracoscopic sanations were performed at intervals of 2-3 days. In this case, the loose fusion of the lung with the pleura was shared, and stage necrectomies were performed. In the period between sanations, the pleural cavity was washed with antiseptics through the drainage system, the cavity of the lung abscess was sanitized. The presence of a normal thoracoscopic picture, the normalization of temperature served as an indication for the termination of torascopic sanations and for the transition only to the drainage sanation of the pleural cavity. The ineffectiveness of dynamic thoracoscopic sanations was usually associated with the presence of hardly removable fibrinous strata in the pleural cavity and extensive foci of destruction in the lung tissue, which served as an indication for an open sanation of the pleural cavity. For this purpose, thoracotomy was performed and under visual control, necrectomy and rinsing of the pleural cavity with antiseptics were performed. After the sanitation, the pleural cavity was loosely filled with tampons with water-soluble ointments. The operation was terminated by the formation of a guided thoracostomy with the use of a zipper-fastener for subsequent planned sanation of the pleural cavity. Dynamic torascopic sanation was used in the treatment of 36 patients with pleural empyema. The number of sanations in one patient ranged from 3 to 5. The transition to open sanation of the pleural cavity was carried out in 3 patients, which was 8.3%. Two patients died (5.6%).

A feature of the treatment of pleural empyema is the need for spreading and retaining in the expanded state of the lung. Any re-invasion can lead to collapse of the lung. Therefore, in the treatment of empyema it is important to perform not the largest, but the optimal amount of sanation of the purulent focus.

Amarantov D.G. (2009) recommends that patients with acute para- and metapneumonic pleural empyema perform emergency operative thoracoscopy in order to determine the characteristics of intrapleural changes and the degree of reversibility of the chronic component of the purulent process upon admission. Based on the characteristics of intrapleural changes revealed during the first thoracoscopy and the duration of the disease, a program of thoracoscopic treatment and tactics of antibacterial, detoxification therapy and physiotherapy are formed. After each thoracoscopy, the following is recommended to be performed only in case of signs of "clinical regression" in terms that depend on the characteristics of intrapleural changes in the first thoracoscopy. To create a stable tendency to recover or to identify irreversible signs of the formation of chronic empyema, 1-4 thoracoscopies are sufficient. The tactics of surgical procedures should depend on the thoracoscopic characteristics of the empyema cavity. Depending on the characteristics of intrapleural changes, the optimal timing for performing stage thoracoscopies in the event of signs of clinical regression in patients with a primary thoracoscopic picture of the serous-purulent stage is the 3rd, 9th, 18th day, with a picture of the purulent-fibrinous stage - 6, 12, 20 day, with a picture of the proliferative stage - 6, 12, 18th day. The proposed algorithms for performing programmed stage thoracoscopies in combination with operative methods of influencing the empyema cavity depending on the type of inflammation in primary thoracoscopy make it possible to standardize the approach to treatment of patients with acute para- and metapneumonic pleural empyema. According to the author, the use of programmed stage thoracoscopies increases the good immediate results of treatment of patients with acute para- and metapneumonic pleural empyema by 1.29 times; reduces the time of labor rehabilitation by 23%; reduces disability by 85%; increases good long-term results by 1.22 times; reduces the lethality by 2 times.

In recent years, more widely used vidoioassistirovannaya thoracic surgery, which has become an alternative to thoracotomy in many diseases, including the treatment of pleural empyema. Izmailov E.P. Et al. (2011) believe that in the treatment of acute pleural empyema the most justified is a video-assisted lateral mini-thoracotomy performed in the period from 1-1.5 months after the onset of pleural empyema development. The use of this tactic allowed 185 (91.1%) patients to achieve clinical recovery and eliminate the cavity of pleural empyema.

Yasnogorodsky OO, using the mini-access with video tracking, determines the indications for the intervention, focusing on the results of the sanation of the empyema cavity, the x-ray characterization of the pulmonary tissue state, the ability of easy to reexpansion, taking into account the somatic background, concomitant diseases, the patient's age, etc. The main advantage of this access, the author emphasizes, is the possibility of a double survey of the operated zone, sufficient lighting, the possibility of using both traditional and endoscopic instruments. Of 82 patients with pleural empyema, only 10 had the need to expand mini-access to standard thoracotomy, and most patients managed to adequately sanitize the empyema cavity.

Summarizing, we can draw the following conclusions:

1. Videotoracoscopy with empyema of the pleura has not yet received recognition and wide practical application, especially in the treatment of chronic pleural empyema. Constantly the search for the place of videotorakoscopy in the algorithm of complex treatment of pleural empyema is being carried out, the indications for its application are being worked out.
2. Videotoracoscopy with empyema of the pleura allows in most cases to cure acute empyema of the pleura, avoid its transition to the chronic.
3. The use of programmed videothoracoscopic sanations of the pleural cavity is a promising direction in the complex treatment of pleural empyema, however, the number, optimal timing and direction of each stage of thoracoscopic sanation remain to this day a completely unresolved issue and require further study.
4. The complex use of videotoracoscopy in combination with bronchial occlusion of the fistula-bearing bronchus in patients with pleural empyema with bronchopleural messages allows most patients to cure the disease, relieve the need for traumatic surgery, and otherwise prepare for traditional surgical treatment in a shorter time.
5. The place in the algorithm for the surgical treatment of the pleural empyema of video-assisted mini-thoracotomies is not clearly defined, and the advantages that it possesses give grounds to believe about the prospects of its application in the treatment of pleural empyema.

Candidate of Medical Sciences, thoracic surgeon of the Department of Thoracic Surgery Matveev Valery Yurievich. Videotoracoscopy in the surgical treatment of pleural empyema // Practical medicine. 8 (64) December 2012 / volume 1