The clinical treatment of chronic tuberculous septic chest is complex, and the choice of surgical approach is extremely critical in surgical treatment, which is directly related to the success or failure of the operation and the survival quality of the patient, and therefore should be paid attention to. We have treated the more complicated chronic tuberculous septic chest patients with a combination of surgical methods and achieved more satisfactory results.
Pleural fibrous plate debridement is the first choice and the best procedure for the surgical treatment of chronic tuberculous septic chest, and it can also be the first procedure for all chronic septic chest surgeries, which can not only remove the whole septic cavity, but also re-expand the compressed lung tissue and not cause deformity of chest wall due to surgery, so it is the most ideal surgical method for the treatment of chronic septic chest. However, if the residual cavity is still left after the denudation of the dirty fiber plate and the release of the lung and diaphragm, additional local thoracoplasty can be chosen in the first stage, or the time of closed drainage of the chest cavity can be extended, and whether additional local thoracoplasty can be decided according to the review. Wang Cheng, Department of Thoracic Surgery, Shandong Provincial Chest Hospital
For patients with reversible intrapulmonary lesions combined with bronchopleural fistulas who are to undergo thoracoplasty, drainage should be performed first to improve the patient’s systemic symptoms, followed by lesion removal-fistula repair-dissection of the dirty fiberboard, then adequate effective drainage, and the decision of whether and when to perform additional local thoracoplasty should be made based on the review. This cleanses the abscess cavity, controls the infection, and serves to regulate intrathoracic pressure through the chest drainage tube. On the one hand, under the long-term chronic stress of respiratory motion, the lung slowly re-expands and the residual cavity slowly decreases; on the other hand, the slow re-expansion of the lung prevents the spread of tuberculosis foci due to rapid expansion of the lung tissue. On the other hand, the slow re-expansion of the lung can avoid the spread of tuberculosis foci due to rapid expansion of lung tissue. The purpose of controlling infection and reducing the residual cavity can be achieved, and the lung function can be preserved to the maximum extent, and the postoperative deformity brought by thoracoplasty can be avoided or reduced.
Pleurodesis + lobectomy or partial pulmonary resection can be used in the case of abscess combined with tuberculosis cavity or large caseous lesions, bronchiectasis, lung abscess, destroyed lung, bronchopleural fistula and other irreversible intrapulmonary lesions, which can completely remove the lesions, but with large surgical trauma, bleeding and high incidence of postoperative complications. If the residual cavity is left, further thoracic revision, transplantation of tied greater omentum or transfer of chest wall flap may be required to fill the abscess cavity. The key to successful surgery is to fully free and release the remaining lung tissue, release the diaphragm, and appropriately prolong the drainage time to reduce and thus eliminate the postoperative residual cavity.
When the chest wall is externally penetrated by tuberculous septic chest, additional incisions are sometimes required in addition to the open chest incision because of the variable extent of chest wall abscess injection, and the selection of additional incisions should be based on the convenience of removing the externally penetrated sinus tract with the internal and external meeting of the open chest incision, and the convenience of removing the chest wall lesion at the same time. The difference with simple chest wall tuberculosis lesion removal lies in the removal of the ribs. In chest wall tuberculosis lesion removal, not only the rib segments involved in the lesion are removed, but also the rib segments covering the sinus tracts or lesions are removed. In addition to the placement of closed chest drains, negative pressure drains should be placed in the chest wall, which should be submerged in healthy muscle tissue as much as possible and drawn out from the opposite direction of fluid gravity when the patient is lying down or standing, with negative pressure drainage, and the placement time of the drainage tube should be extended appropriately. Placement of negative pressure drainage tubes in the direction of gravity can reduce or avoid the formation of sinus tracts after extubation.
Pleural dissection failure or post-pneumonectomy abscess and lack of more effective treatment can be treated by muscle flap tamponade + limited thoracoplasty, which has the advantages of less trauma, less bleeding and can significantly reduce deformity than traditional thoracoplasty.
From the paper “The role of compound surgery in the surgical treatment of chronic tuberculous abscess chest” by Wang Cheng, et al.