Video-thoracoscopy in the treatment of pyofibrinothorax in children with bacterial destruction of the lungs

The research is dedicated to the development and evaluation of the effectiveness of video-thoracoscopic operations for the treatment of pyofibrinothorax in children complicated by bacterial destruction of the lungs. The relevance of the work is due to the high rate of chronicization and disability among sick children with purulent-destructive diseases of the bronchopulmonary system. The study identifies risk factors for the formation of pyofibrinothorax, develops a diagnostic and treatment algorithm, and demonstrates the high effectiveness of a minimally traumatic video-thoracoscopic approach compared to traditional thoracotomy.

Relevance of the problem

Despite the advances in the treatment of purulent-destructive diseases of the bronchopulmonary system in children, this problem remains relevant to this day. This is associated with a large number of pleuropulmonary forms of bacterial destruction, accompanied by a transition to chronic forms, which leads to subsequent disability of this category of sick children.

Chronicization of the process is often associated with the admission of children to the hospital with a long duration of the disease, prolonged and not always adequate in terms of tactics treatment in general profile hospitals at the place of residence, as well as with the development of microbial resistance during the course of treatment.

Common methods of treating pleuritis in children are puncture and drainage of the pleural cavity [4, 27, 107, 112]. However, with these methods, in 41-45% of cases, the lung in the fibrinous-purulent stage of pleuritis remains unexpanded for a long time [25, 28, 35, 150]. A complex of conservative measures in most cases does not give a pronounced positive effect.

In the presence of a negative dynamics, lack of effect from prolonged conservative treatment, worsening of respiratory failure symptoms due to chronic purulent intoxication and limited re-expansion of the lung, some surgeons [15, 114, 150] perform thoracotomy, others perform mini-thoracotomy [5, 167], sanitation of the pleural cavity, pneumolysis or decortication of the lung.

However, it should be taken into account that thoracotomy in this disease is a highly traumatic operation, the risk of complications is high, and according to data from various authors [47, 83, 96, 97, 163] postoperative mortality is about 16%.

Regarding the use of video-thoracoscopy for diagnostic and therapeutic purposes in various pathologies of the thoracic organs in children, there are only a few reports in foreign literature, and in domestic literature there are isolated mentions, and mainly concerning the mastering of techniques [24, 31, 36, 88, 149, 182, 215].

In our region, a large number of children with purulent-destructive diseases of the bronchopulmonary system are noted, which give a high percentage of chronicization and disability. The need to develop a rational treatment methodology for children with bacterial destruction of the lungs complicated by pyofibrinothorax served as the occasion for this clinical study.

Goal of the research

The goal of the research is to improve the results of treatment of purulent-destructive diseases of the lungs accompanied by pyofibrinothorax through the application of video-thoracoscopic operations.

Tasks of the work

1. To identify risk factors for the formation of pyofibrinothorax in children against the background of bacterial destruction of the lungs.

2. To develop a diagnostic and treatment algorithm for bacterial destruction of the lungs in children.

3. To determine the indications for the application of therapeutic video-thoracoscopy in children with bacterial destruction of the lungs complicated by pyofibrinothorax.

4. To study the effectiveness of various methods of treating pyofibrinothorax in children.

Scientific novelty

1. Risk factors for the formation of pyofibrinothorax in children against the background of acute bacterial destruction of the lungs have been identified for the first time.

2. New are the developed criteria for determining the indications, timing, and technique of sanitary video-thoracoscopy aimed at preventing the development of chronic bronchopulmonary and intrapleural inflammation.

3. By the methods of evidence-based medicine, the high effectiveness of video-thoracoscopic operations in children with pyofibrinothorax at various durations of the inflammatory process has been demonstrated.

4. The proposed diagnostic and treatment algorithm using ultrasonic scanning, computed tomography of the lungs and pleural cavity, and video-thoracoscopic operation in pleuropulmonary forms of bacterial destruction of the lungs in children possesses priority novelty.

Practical significance

1. The developed complex of diagnostic measures determines the indications for the most optimal treatment method for each patient and, thereby, improves the immediate and distant results of treatment of patients with pyofibrinothorax.

2. The use of sanitary video-thoracoscopic operations in children with pyofibrinothorax allows for radical sanitation of the pleural cavity with the removal of fibrinous masses and pathological formations.

3. Sanitary video-thoracoscopic operations in children with pyofibrinothorax lead to an easier postoperative period, a reduction in rehabilitation time, a decrease in disability, and a reduction in material costs for the treatment of patients with this pathology.

Basic provisions submitted for defense:

1. The risk factors for the formation of pyofibrinothorax in children are:

• a long duration of the disease and late onset of treatment of acute bacterial destruction of the lungs;

• late diagnosis of pleural complications of bacterial destruction of the lungs;

• untimely and inadequate drainage of the pleural cavity;

2. To choose a treatment tactic for pleural complications against the background of bacterial destruction of the lungs, it is necessary to use ultrasonic scanning of the pleural cavity and computed tomography of the lungs.

3. Video-thoracoscopic operations are a more effective, minimally traumatic treatment method that allows improving immediate and distant results and reducing the duration of hospitalization for patients.

4. The presence of pyofibrinothorax is an indication for performing a video-thoracoscopic operation at any duration of the disease.

Implementation into practice

The results of the conducted research are used in the daily practice of the Irkutsk State Regional Children's Clinical Hospital and the City Children's Ivano-Matreninskaya Hospital of Irkutsk. Theoretical provisions and practical recommendations outlined in the dissertation are used in the process of training interns, clinical residents, and cadets at the Department of Pediatric Surgery of the Irkutsk State Institute of Advanced Training of Physicians.

Testing of the work

The main provisions of the dissertation were reported at the Regional Scientific and Practical Conference of Pediatric Surgeons (Irkutsk, 2003), at the Interregional Scientific and Practical Conference of Young Scientists of Siberia (Irkutsk, 2003), at the exhibition "Sibzdravookhranyenie-2004" (Irkutsk, 2004).

Publications

8 printed works have been published on the topic of the dissertation.

Volume and structure of the dissertation

The dissertation consists of an introduction, a literature review, a chapter on materials and research methods, two chapters of original research, conclusion, conclusions, practical recommendations, and a list of references. The text of the dissertation is presented on 139 pages of typed text, illustrated with 15 tables and 84 figures. The bibliography includes 223 sources, of which 142 are in Russian and 81 are in foreign languages.