A. Know the culprit of the disease
Mycobacterium tuberculosis is referred to as Mycobacterium tuberculosis. As early as 1882, German bacteriologists proved that Mycobacterium tuberculosis is the causative agent of tuberculosis. The bacterium can attack all tissues and organs of the body. Currently, there are about 8 million new cases of tuberculosis worldwide each year, and it causes about 3 million deaths. In China, about 250,000 people die from tuberculosis each year, which is more than twice the total number of deaths from various infectious diseases.
II. Etiology
Tuberculous abscess chest is mostly caused by the rupture of tuberculosis cavity or subpleural caseous lesion, which infects the pleura, or can be caused by the direct spread of paravertebral abscess of spinal tuberculosis. Surgical procedures for tuberculosis complicated by bronchopleural fistula or pleural cavity infection can also cause pneumothorax. In addition, exudative pleuritis effusion is not absorbed for a long time, and some of them can gradually develop into pneumothorax.
Third, pathological changes
At the initial stage of tuberculosis infection of the chest cavity, acute inflammation, congestion and exudation occur, forming scattered nodules of tuberculous pneumothorax, and the pleural effusion is plasmacy, containing white blood cells and fibrin, which gradually becomes chronic tuberculous pneumothorax after a long period of time, with thick and hard fiber plates and often calcification. The contraction of the fibrous plate narrows the rib space, deforms the ribs into a triangular cross-section, atrophies the intercostal muscles, and convexes the spine to the healthy side. The pustulothorax can be limited or total. Sometimes the abscess chest breaks into the intercostal space and even invades the ribs, forming a cold abscess or breaking out of the skin to form a skin sinus tract, with long-term pus flowing more than once and persisting.
IV. Clinical manifestations and signs
Acute onset has obvious toxicity symptoms, such as chills, high fever, excessive sweating, dry cough, chest pain and so on. When there is a lot of pus in the chest, there may be chest tightness and shortness of breath. If there is bronchopleural fistula, a large amount of pus sputum (i.e. abscess chest fluid) is coughed up, sometimes it is bloody. In chronic cases, there is no fever, but anemia and wasting are more obvious. When combined with infection, high fever and leukocytosis, the symptoms are similar to those of acute abscess chest, and there are even symptoms of toxic shock.
The signs of tuberculous pustulosis are generally similar to those of exudative pleurisy. The chest wall may have localized pressure pain and even mild swelling. In chronic cases, there is collapse of the thorax, narrowing of the rib space, weakened respiratory movement, solid sounds on percussion, reduced breath sounds on auscultation, shifting of the trachea to the affected side, and often accompanied by pestle-like fingers (toes).
In case of massive pus accumulation in the chest cavity, the affected side of the chest is full, the respiratory movement is weakened, the rib space is flattened, the percussion is turbid, the mediastinum is shifted to the opposite side, the trachea and heart edge turbid sounds are biased to the healthy side, the auscultatory breath sounds are weakened or disappeared, and the fibrillation is weakened. In the late stage of tuberculous septic chest, the mediastinum is shifted to the affected side by the contraction of the scar. The chest wall is invaginated by the contraction of the pleural scar, the ribs are clustered, the rib space is narrowed, and the spine is curved to the opposite side.
V. Diagnosis
Based on the symptoms, signs, leukocytosis, X-ray examination and thoracentesis aspiration laboratory test, the diagnosis can be confirmed if the pus is yellowish, thin and contains cheese-like material, no pathogenic bacteria growth in the smear and culture, and tuberculosis bacteria are found in the pus. Pathological examination of the pus cavity wall with typical features of tuberculosis can make a clear diagnosis. The pus is examined by smear and culture of tuberculosis bacilli and common bacteria, which helps to make the diagnosis.
VI. Treatment methods
The principle of surgery is to eliminate the dead cavity and infection foci, improve the immunity of the patient’s body, enhance the function of lung ventilation and air exchange, and ensure the supply of blood and oxygen to tissues and organs. Chronic tuberculous abscess chest is a disease that is difficult to be cured by conservative medical treatment, and surgical treatment is a more ideal and effective treatment method. Surgical treatment should be carried out with adequate preoperative preparation, and surgery should be performed when the tuberculosis infection foci are well controlled in order to ensure the safety of the surgery and postoperative period. In order to ensure that the tuberculosis foci will not cause wide spread after surgery, it is generally recommended to go through at least 3 months of anti-tuberculosis drug treatment.
1.Pleural fibrous plate stripping: It is the preferred method and the best procedure for the surgical treatment of chronic abscess chest, and can also be the first procedure for all chronic abscess chest surgeries. For simple abscess chest without lesions in the lung, total pleurodesis should be performed as far as possible, not only to remove the thickened fiber plate constituting the abscess cavity but also to fully loosen the lung and diaphragm, so that the pleural cavity can be reconstructed. This procedure not only completely releases the fibrous plate from the lung, but also restores the movement of the thorax and the diaphragm, which facilitates the elevation of the diaphragm and the displacement of the mediastinum to eliminate the residual cavity. It also has an important role in the improvement of lung function.
Those with stable lesions after treatment of simple tuberculous pleurisy with residual cavities. As the disease progresses. Thick fibrous plates form on the pleural surface. Even calcification occurs, which restricts both the expansion of the lung. The pulmonary function is more severely impaired, and the ventilation/blood flow ratio decreases due to the compression of the lung tissue in the corresponding part of the lesion, which can lead to different degrees of hypoxemia. Elimination of the residual cavity and improvement of lung function are the main focus of treatment in this group of patients. Patients with bilateral lesions, in particular, can die from respiratory failure due to restrictive ventilation impairment due to severe pleural calcification and thoracic collapse.
Surgical method: Using intravenous compound anesthesia, the pus cavity is entered through the posterior lateral part of the thoracic pus cavity by incising the wall fiber plate, repeatedly cleaning the pus cavity, removing the accumulated pus in the pus cavity, scraping away the cheese necrotic tissue and granulation tissue, repeatedly disinfecting the pus cavity with iodine and alcohol, and then repeatedly wiping the pus cavity with dry gauze several times until the gauze is free of purulent material.
From the anterior mediastinum or where the adhesions are mild, the gap between the dirty fibrous plate and the lung tissue is identified and the dirty fibrous plate is carefully peeled off. The degree of fibrous adhesions varies from site to site, and those with loose adhesions can be easily peeled off completely. In some patients, the gap cannot be found because of the close and fused adhesions between the fibrous plate and the dirty pleura, so a detour can be made to keep the sheet, and “+” and “#” can be drawn for larger sheets to loosen the adhesions in the thoracic cavity to facilitate lung expansion.
2, thoracoplasty: thoracoplasty is suitable for cases with short history, combined with severe irreversible tuberculosis lesions in the lung or complex bronchopleural fistula, uncomfortable with pleural exfoliation or pleuropneumonectomy, only with thoracoplasty can these patients collapse the chest wall and adhere to the dirty pleura, so as to eliminate the abscess cavity and cure the abscess chest.
Anti-tuberculosis drug treatment is started 1 week before surgery, all laboratory tests and imaging examinations are improved, and the size and location of the abscess cavity are determined by X-ray film. Pay attention to increasing nutrition, correcting anemia and hypoproteinemia, improving general condition, encouraging bed activity, paying attention to respiratory function exercise, and improving respiratory and circulatory function before surgery. Prior to surgery, repeated thoracentesis should be performed and penicillin should be injected into the thoracic cavity to control secondary infection.
Surgical method: intravenous compound anesthesia is used, and the height of the upper and lower ends of the incision depends on the site of the abscess cavity. If there is a chest wall fistula or drainage opening, the scar tissue around the opening should be removed together. The abscess cavity is incised, a section of the rib bone in the lower part of the abscess cavity is amputated, the thickened pleura is incised, the pus is aspirated, the granulation tissue in the wall and dirty layers of the abscess cavity is scraped away, and all the ribs covering the abscess cavity are amputated under the periosteum about 2-3 cm away from the edge of the abscess cavity, so that the chest wall muscle collapses and is closely connected to the bottom of the abscess cavity, and then the thickened wall layer of the pleura, the edge and the outer slope are removed. If the intercostal muscle cannot reach the bottom of the cavity, the anterior or posterior end of the intercostal muscle bundle can be cut off alternately one by one so that the muscle bundle collapses and fills the bottom of the abscess cavity. After surgery, 2 rubber tubes are placed outside the muscle for drainage to keep the drainage tube unobstructed.
3.Pleuropneumonectomy: If chronic tuberculous pus chest is combined with extensive lung tissue lesions, such as combined with large cheese cavity, repeated hemoptysis before surgery, combined with bronchial dilatation on the affected side, other surgeries are not suitable for radical treatment and pleuropneumonectomy should be performed. However, pleuropneumonectomy is highly invasive, bleeding and complications, and some studies have shown that the surgical mortality rate is as high as 25%, thus limiting its use in the surgical treatment of tuberculous septic chest.
However, in cases of drug-resistant Mycobacterium tuberculosis infection, which is difficult to control with drugs, this procedure should also be performed to avoid further postoperative expansion of the lesion. To avoid severe intraoperative bleeding, the mural fibrous plate should be preserved as much as possible; a chest drain should be placed after surgery to keep the drain open; and postoperative nutrition and anti-infection treatment should be strengthened.