What Is a Thoracostomy?

Thoracoplasty has been one of the most effective and safe surgical treatments for tuberculosis surgery since Alenander was introduced in 1925. With the development of pneumonectomy, thoraplasty has been reduced, but for some cases of cheese lesions, fibrous cavities or empyema, highly resistant, extensive lesions, and lung function can not tolerate cutting the lung, it is still certain Efficacy can be selected to achieve effective, permanent and selective collapse.

Li Zhengjun	(Resident)	Department of Thoracic Surgery, Shenyang Chest Hospital
Sun Wenli	(Chief physician)	Department of Thoracic Surgery, Shenyang Chest Hospital
Liu Hongxu	(Chief physician)	Department of Thoracic Surgery, the First Affiliated Hospital of China Medical University

Classification of thoracotomy

Thoracoplasty is a permanent, irreversible treatment for collapse ^[1-2] . Surgery is performed by removing part of the ribs and causing the thorax to sag. According to the different diseases to be treated, the operation is divided into extrapleural thoracoplasty and transpleural thoracoplasty according to whether the parietal pleural fiber layer is retained or removed.

Indications for thoracotomy surgery

1. Patients with severe pulmonary tuberculosis and massive hemoptysis that are not suitable for pneumonectomy (such as chronic fibrous cavitary tuberculosis, tuberculous lesions of the lung, etc.) may undergo extrapleural thoracoplasty (Figure 1) ^[2] ^[3] .

Figure 1. Cavity of left lower lobe with hemoptysis

Pulmonary tuberculosis with massive hemoptysis is fierce, and literature reports that hemoptysis is the second leading cause of death among patients who die directly from tuberculosis. There is no unified opinion on the definition of life-threatening hemoptysis. It is generally believed that a hemoptysis volume of 200ml at a time, or a hemoptysis volume of more than 600ml within 24 hours is considered hemoptysis.

Tuberculous lesions of the lung are extensive tuberculosis lesions on one side of the lung, single or multiple tuberculosis cavities, a large number of fibrous cheese lesions, combined with bronchiectasis and bronchoconstriction, mixed infections and bacterial elimination, lung collapse, pulmonary fibrosis, and lung tissue destruction Serious tuberculosis complications with severe pleural thickening, irreversible pathological changes, and loss of lung function (Figure 2).

Figure 2. Left damaged lung

2. Extensive pulmonary fibrosis, thickening of the pleura, and mediastinal displacement, while the tuberculosis lesions have not healed, there are still symptoms and sputum-positive patients can perform extrapleural thoracoplasty.

3. Chronic empyema or tuberculous empyema with intrapulmonary active tuberculosis and bronchopleural fistula may be performed with intrapleural thoracotomy (Figure 3).

Figure 3. Right chronic tuberculous encapsulated empyema

Contraindications of thoracotomy

1. Thick-walled cavity, tension cavity. Cavities below the posterior fourth rib, especially cavities in the lower lobe and hilum.

2. Those with bronchial endometrial tuberculosis.

3. Those under 18 or older. Adolescents are suffering from severe spinal deformity after surgery during the development period. The elderly with emphysema have poor respiratory function reserve and are prone to respiratory insufficiency after surgery.

Thoracoplasty

Extrapleural thoracoplasty is usually performed in two stages, with the first stage resecting the 1st to 4th ribs and the second stage resecting the 5th to 8th ribs. In chronic lesions with significant pulmonary and pleural fibrosis, it is estimated that the chest wall will not breathe abnormally after surgery. Patients who are generally in good physical condition can complete all operations in one phase. The interval between staged surgery is 2 to 3 weeks ^[2] .

1.1 Preoperative preparation:

1. X-ray chest radiograph and CT scan before operation to understand the cavity or lesion location, determine the number of ribs to be removed, including the two ribs below the lower edge of the cavity.

2. Perform liver, kidney, heart, and lung function routinely to supplement nutrition and correct anemia.

1.2 Anesthesia: intravenous anesthesia, endotracheal intubation.

1.3 General Procedures

1.3.1 Phase I surgery (Figures 4, 5)

Postoperative stage I (2 photos)

Posture and incision: take the lateral position with the lesion above, and put the upper limb flexed against the chest. A soft pillow is placed under the axilla of the healthy side to reduce the pressure on the shoulders and upper limbs and widen the intercostal space. For the posterolateral incision, the upper end of the incision needs to be flat with the scapular plane in order to fully expose and remove the first rib .

Removal of ribs: first remove the fourth rib, and then continue to remove the third, second, and first ribs. The first rib is higher and the ribs are shorter and horizontal. The first thoracic vertebra is retained to protect the brachial plexus. Care should be taken to protect the intercostal vessels and nerves from rupture of the pleura.

Dissection of the lung tip: After the first rib is removed, the tip of the lung is dissected. In this way, better collapse can be obtained.

Suture: tightly stop bleeding, generally do not drain, when there is pleural rupture, closed drainage should be used. The wound was pressure bandaged with sufficient dressing to reduce postoperative abnormal breathing movements.

1.3.2 Stage II surgery (Figures 6, 7)

Postoperative Stage II (2 photos)

A chest radiograph must be taken before the operation to understand the lung lesions. If the cavity increases, there may be bronchial endometrial tuberculosis, which is a tension cavity, and the operation should be terminated. If the disease spreads and worsens, surgery should be postponed. The last time the surgical incision was not healed and infected, the inflammation should be subsided, and effective antibiotics should be applied before surgery.

From the original incision, remove the rear end of the fifth, sixth, seventh, and eighth ribs, and at the same time remove the corresponding thoracic transverse process, retain the front rib cartilage, and increase the remaining ribs in a trapezoidal fashion from top to bottom, but the next The front of the ribs should be at the midaxillary line. If you only need to cut to the sixth rib, in order to avoid the lower angle of the scapula from sinking into the seventh rib and friction with the seventh rib, increase pain or affect the function of the upper limb, you need to remove the seventh segment of the rib or the lower angle of the scapula.

Intrapleural thoracotomy

Intrapleural thoracoplasty (Schlede) surgery was used to remove the ribs, periosteum, intercostal tissue, and pleural fiberboard at the top of the pus cavity. Modified surgery is currently used to remove only the fibrous plates on the ribs and parietal pleura to preserve the rib periosteum and intercostal tissue. 2 to 3 months after the operation, new ribs are formed to maintain the stability of the thorax, and it can significantly reduce the numbness and discomfort in the skin of the chest and abdominal wall after the operation. This is called trapezoid surgery ^[2] .

2.1 Preoperative preparation

1. Determine the chest and lung lesions. In addition to taking plain radiographs of the chest, CT scans, bronchial lipiodolography, or bronchoscopy should be performed as needed.

2. Perform heart, lung, liver, and kidney function tests.

3. Tuberculous empyema, antituberculosis treatment before surgery for 2 to 4 weeks, in addition to continuing antituberculosis treatment 1 week before surgery, add penicillin or other broad-spectrum antibiotics to control general bacterial infections.

4. If there is a bronchial pleural fistula or when the infection worsens, surgery can only be performed after the infection symptoms are controlled. Pus cavity secretions should be tested for bacterial culture and drug sensitivity.

5. Patients with anemia and low plasma protein should be given high-protein, high-calorie foods and, if necessary, blood transfusion or albumin transfusion. And encourage patients to do more activities to enhance cardiopulmonary function.

2.2 Anesthesia and intravenous anesthesia, endotracheal intubation.

2.3 General procedures

2.3.1 Position and incision take the lateral position with the diseased side up. Make a posterolateral incision.

2.3.2 Ribs The first and fifth ribs are excised, and the costal bed is cut into the pus cavity. Carefully explore the size and extent of the pus cavity to determine the number of ribs that need to be removed. Later, the 4th, 3rd, and 2nd ribs were removed from the bottom up. It is not necessary to remove the first rib beyond the top of the pus cavity, otherwise it should be removed together to avoid the formation of a stent and affecting the depression. If the condition is stable during the operation, the 7th to 10th ribs can be removed in sequence in accordance with the need. Otherwise, the operation should be terminated in time and changed to staging. The upper, lower, left, and right of the resected ribs should exceed the pus cavity, especially the posterior edge of the spinal transverse process should be removed so that there is no gap between the vertebrae. Dead space. During left thoracotomy, the anterior ribs are kept as much as possible to protect the heart and prevent excessive compression from affecting heart function.

2.3.3 Trapezoid surgery cuts the pleura and thickened fibrous layers one by one along the intercostal space, and scrapes off the cellulose, pus and cheese on the visceral pleura. If there is a bronchopleural fistula, the intercostal muscle bundle can be used to cut off the sternum, and the broken end is sutured to fill the fistula to promote healing of the fistula. The larger pus cavity can free the nearby chest wall muscle flaps to fill the pus cavity space. Finally, drainage was placed at the bottom of the pus cavity. Loose suture incisions and pressure bandaging the chest. Surgery can usually be completed at one time. If the patient is in poor condition or has an empyema, it can be completed in two stages with a gap of 2 to 4 weeks.

Postoperative management

1. Apply broad-spectrum antibiotics or select effective antibiotics for 2 to 3 weeks according to preoperative culture and drug sensitivity tests to control infection. Tuberculous empyema requires antituberculosis medication for more than 3 months.

2. Dress the chest with dressing for more than 1 month.

3. Replacement of accessories is usually performed on the 4th or 5th day after surgery. Replace it in the next 2 to 3 days. Depending on the amount of drainage secretion, gradually pull out and cut off the drainage tube. Complete extubation should be performed about two weeks after the operation.

4. Pay attention to the general condition of the patient, improve nutrition, improve immunity, and give transfusion support to the patient appropriately.

Epidemic trend and prevention of thoracoplasty tuberculosis

According to the World Health Organization report, there are currently 2 billion people infected with TB in the world. There are about 20 million active tuberculosis patients, 8 to 10 million new cases each year, and about 3 million die from TB every year.

Current status of TB epidemic in China: high prevalence, high drug resistance, high mortality, high infection rate, low decline rate, higher epidemic rate in rural areas than in cities, high proportion of tuberculosis and mortality among young adults, and increased HIV / AIDS The difficulty of tuberculosis control.

Tuberculosis is mainly transmitted by droplets. There are three main strategies for tuberculosis control today: case detection, chemotherapy and BCG vaccination.

The World Health Organization's recommended global tuberculosis control strategy, the DOTS (Directly Observed Treatment Short-course) strategy, has proven effective worldwide. The main contents of the DOTS strategy include five aspects:

1. Government's political commitment to national tuberculosis control programs.

2. The detection of infectious tuberculosis by sputum smear shows the main means of finding patients.

3. Under direct observation and supervision, patients were given free, standard short-course chemotherapy.

4. Regular and uninterrupted supply of anti-TB drugs is an important measure to ensure the smooth progress of DOTS.

5. Establish and maintain a surveillance system for TB control programmes.

Summary of Thoracoplasty

Collapse therapy was the earliest intervention in the field of surgical treatment of tuberculosis. The method is to remove the ribs or fill foreign bodies outside the pleura to collapse the diseased lung tissue and promote the absorption and fibrosis of the lesions in the lung. The collapse therapy was once widely used It plays a very important role in the surgical treatment of tuberculosis. However, there are too many complications of collapse therapy, and it is difficult to manage after surgery. Most of the surgical methods have been abandoned. Traps have been used continuously in the surgical treatment of tuberculosis. Under special circumstances, thoracotomy is still used to some extent.

Under the premise of strict supervision of tuberculosis patients and full-course management of chemotherapy, the number of patients with tuberculosis requiring surgery has been significantly reduced, and the role and status of surgery for tuberculosis have also declined significantly. However, there is a problem in the prevention and treatment of tuberculosis patients. Many problems, a large number of patients can not guarantee timely detection, reasonable chemotherapy and strict management, or delayed diagnosis and treatment for various reasons, and lost the opportunity of initial treatment, so that patients who can be cured after initial treatment are transferred to retreatment and refractory or even more As severe tuberculosis, it became a serious source of tuberculosis infection, so that more primary drug-resistant patients were generated. For these situations, surgical intervention is still needed. Tuberculosis surgery is still an effective way to solve the replication failure, various serious complications, and special types of tuberculosis in this part of tuberculosis patients. At the same time, it plays a very important role in reducing and eliminating the source of tuberculosis infection and reducing the incidence of tuberculosis.