6.6. The collapse therapy and the surgery treatment of tuberculosis


To collapse therapeutical methods of pulmonary tuberculosis treatment refer pneumothorax and pneumoperitoneum. Normally the pleural cavity is only a potential space. The visceral pleura, covering the lung is in intimate contact with the parietal pleura lining the chest cavity. Not until the pleural space becomes filled with something, such as fluid or air, does it become an actual cavity. Since there is a negative pressure within the pleural cavity any connection with the outside atmospheric pressure will permit air to enter, allowing collapse of the lung from its natural elastic recoil.

Artificial pneumothorax (AP).

Introduction of gas in the pleural cavity between two layers of pleura – pneumothorax – results in shrinking of lungs. Pneumothorax causes reduction of elastic tension and of mechanical trauma in the pathological focuses, creates relative rest of the collapsed lung. The reduction of the lung volume and its elastic tension causes shrinking of cavities and other more or less pliable damaged focuses, that promotes them faster healing – scarring. The reduction of respiratory excursions slows down the circulation of lymph and blood in lungs and detains of toxic substances release from the pathological focuses that influence on reduction of body intoxication.

Introduction or repeated introduction of gas into pleural cavity is carried out with the help of pneumothorax device, in which there are two graduated cylinders: one – with aseptic liquid, another – with gas. The cylinders by system of tubes connected with manometer, and also among themselves. A liquid from one cylinder is pumped acts on another and supersedes gas from the last. The superseded gas gets in pleural cavity. Imposing of pneumothorax is carried out in sterile conditions. For a puncture of chest wall is produced at 3 or 1 intercostalspace on middle axillary line. The gas is soaked up visceral and parietal pleura, therefore it is necessary repeated insufflations of the gas in 7-10 days, on 300-500 ml.

The indications of treatment for pneumothorax in connection with successful antibacterial therapy are limited. Short-term pneumothorax (during one – one and a half years) is applied mainly at focus and infiltrative tuberculosis in a phase of disintegration, when the fresh cavity is formed and when long course of antibacterial treatment is not successful. The pneumothorax can be very helpful for treatment of hemoptysis.

Pneumoperitoneum (PP).

Pneumoperitoneum — is introduction of gas into the abdominal cavity, in which the reduction of lung sizes and lung elastic tension are achieved. The lungs are shrunk from the side of diaphragm dome, under which the gas, pumped to abdominal cavity accumulates. Pneumoperitoneum is imposed also with the help of pneumothorax device. The most convenient place for a puncture is the site on outside edge of musculus rectus abdominalis on 2-3 fingers from top to bottom and to the left of umbilicus. In abdominal cavity is for the first time entered 300 ml of gas, with the subsequent increase of its amount up to 800-1000 ml. The procedure with introduction of gas repeats every 7-100 days.

Pneumoperitoneum is recommended at bilateral lower lobes processes, hematogenic disseminations and presence of fresh stamped cavities. On the background of antibacterial therapy the duration of treatment with pneumoperitoneum considerably reduced (1 – 2 years) and the complications of such treatment almost is not observed. Pneumoperitoneum in case of necessity is possible to be imposed repeatedly.

Surgical methods of treatment.

The surgical methods have the big importance in combined treatment of the tuberculosis. The modernizations of methods of operative invasion, modern anesthesia, considerably expand the indications to application of the surgical help for the patient with the various forms of lung tuberculosis. Modern antibacterial therapy allows carrying out preparation of the patients for operation so that in post operation period to reduce to a minimum an opportunity of an aggravation of tubercular process. Thus it is necessary to take into account, that the tuberculosis quite often bilateral disease and in postoperative period it is possible of progressing the process in another lung. To surgical methods of treatment concern except for described above collapse therapeutical operations: extrapleural pneumothorax, oleothorax, thoracoplasty, surgery on the peripheral nerves. Widely applied lung resections are: limited cuneiform resections, segmentectomy, lobectomy and pulmonectomy – removal the whole lung, if it is completely destroyed by tubercular process.

Pneumolysis (Pneumonolysis).
Stripping of the pleura from the fascia of thoracic wall results in pneumolysis – the artificial cavity between intrathoracic fascia and parietal pleura is created. In the cavity, formed by surgical way, air is entered, the gas bubble with further repeated pumping, as is formed at intrapleural pneumothorax. It is possible to introduce in the cleared sterile the Vaseline oil, in result will be made extrapleural oleothorax. The extrapleural pneumothorax is recommended in those cases, when it is impossible to impose the intra pleural pneumothorax because of extensive multiple knits between two pleural layers. The operation is little reflected on function of external breath, but now it is applied seldom, due to successes of antibacterial therapy and development of resection surgery of lungs.

Extrapleural thoracoplasty does not have wide application. At surgery of the chest wall the resection of ribs above the tuberculous focus and with the part of thorax the lung are pressed inside of the thorax, making its collapse. Thoracoplasty causes irreversible changes: deformation and narrowing thoracic cavity, shrinking of collapsed lung, and large functional losses. Thoracoplasty is recommended at fibrotic cavernous processes with the large cavities, at hemoptysis threatening life of the patient, when the condition of the patient does not allow applying modern methods of surgical treatment of lung tuberculosis.

The operations on the peripheral nerves. carried out basically on cervical region of phrenic nerve, changing thus blood and lymph circulation of lungs. This operation provides infringement of phrenic nerve functions and rise of a diaphragm. The operation leads to collapse of the lower parts of the lungs. For achievement of the aim at operation the phrenic nerve is cut (phrenoectomy), or crashed (phrenicexision or phrenicotreption). To not ruin phrenic nerve, it is possible to use introduction in it of alcohol – phrenicoalcogolisation. In such method later function of the nerve is restored. In case of necessity alcogolisation can be repeated.

The indications for operation on the phrenic nerve are:

  1. Infiltrative processes, primary pneumonia located in lower regions of lungs and in hilum regions.
  2. Acute processes such as lobitis before imposing artificial pneumothorax.
  3. Aspiration pneumonia after thoracoplasty and pneumolysis from the same side of thorax.
  4. Infiltrative processes with a small cavity located in supra diaphragmatic part of lungs.

Now in connection with wide introduction in practice chemotherapy of tuberculosis surgery operations on the diaphragm nerve are applied seldom.

Lung resection.
Lung resections are used more often in connection with introduction into practice effective methods of chemotherapy, development of the methods of intratracheal anesthesia and improvement of methods of processing of the lung roots. Now it is one of the routine methods of lung tuberculosis treatment. Lung resections mainly perform within the limits of one – two segments, less often – lobectomy and pneumoectomy. On the basis of modern experience the following absolute indications to lung resection are established:

  1. Fibrous-cavernous lung tuberculosis with mainly unilateral localization.
  2. Stenosis of bronchi with atelectasis in lung tuberculosis.
  3. Progressing lung tuberculoma.
  4. Combination of lung tuberculosis with bronchectasis and abscessed.
  5. Empyema of pleura with pleuro-bronchial fistula, cavity on collapsed lung and MBT expectoration.
  6. Caseous pneumonia, resistant to chemotherapy.

As the relative indication to operation, mainly partial resection, serve the presence of cavernous lung tuberculosis.

Decortication and pleuroectomy. In certain cases at chronic tubercular empyema of pleura, coat condensation of visceral and parietal pleura, pleuro-pulmonic fistulas are developing. In these cases the operation is performed: decortications – removal of fibrotic stratifications on visceral pleura – and pleuroectomy – removal all pleural “bag” with both layers of pleura. These operations are considered to perform, as lung expands and in certain limits its respiratory function is restored.

A cavity resection is an opening, cleaning and drainage of a cavity through thoracic wall. The basic indications to opening a cavity are the presence of the large or huge cavity in lung, when the functional insufficiency of the respiratory and cardio-vascular systems excludes of lung resection performance. The plastic operations are applied to closing residual cavities in the lung: thoracoplasty, muscle-plasty, skin-muscle plasty.

The conclusion.

Surgical intervention – is one of stages of treatment of the patient, therefore is necessary after operation to continue treatment with antibacterial drugs, it is desirable in conditions of sanatorium. It results in reduction of number of aggravations and relapses in the post operational period. The surgery intervention requires careful selection of the patients for surgery. Besides the form of process it is necessary to take into account a functional condition of cardio-vascular system, compensatory ability of respiratory system, to determine probable functional losses from surgical intervention and, hence, to know the functional forecast. In preoperation period investigation of external breath function, up to separate broncospiromtry is carried out; lung’s blood circulation capacity is estimated with the help of angiopulmonometry.

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