Improving of Treatment Safety in Emergency Thoracic Surgery

Transcription

1 Improving of Treatment Safety in Emergency Thoracic Surgery Petr Habal, Jiří Šimek, Milan Štětina Charles University in Prague. Medical Faculty in Hradec Králové, Teaching Hospital in Hradec Králové Cardiac Surgery Clinic. Summary Authors point out a possibility of improving operative results in thoracic surgery with acute state. They prove it with two groups of patients, where preoperative complications are anticipated. The first group consists of the patients with thorax injury and the second group consists of the patients with relapsing pneumothorax. With a blunt thorax injury is the surgical treatment often performed on blood-soaked pulmonary tissue or on parenchyma affected by ARDS. A necessary stapler suture during an atypical reaction is accompanied by bleeding or air-leak from the resected area. To reinforce the suture, there are used various materials for staplers to utilize a padding effect. Sometimes is necessary to use tissue sealants to prevent the air-leak. Traumastem Stapler Seam Protection meets requirements on the stapler suture reinforcement and, moreover, due to its bactericidal and haemostatic effects helps the tissue healing. Key words: Traumacel Stapler Seam Protection thoracic surgery pneumothorax - COPD Introduction There is still increasing number of patients with pathological affection of pulmonary parenchyma, where air-leak or bleeding to pleural cavity occurs. A large group is created by the patients with blunt chest injury, where we are sometimes force to perform a thoracic surgical intervention (even delayed). This intervention, mostly secondary, was very rare in the past and was indicated in 10 15% of injuries. (1). There were mostly isolated injuries of thoracic wall with ribs fractures, sometimes with regional contusions of pulmonary tissue. It was possible to solve the injury complications, in most cases pneumothorax or haemothorax, by correctly ducted thoracic drainage. Surgical intervention was required only in cases of fractures with breathing insufficiency development. (2). Currently, we meet more often serious states of contused or lacerated lung lobes, as a result of high-energy traffic accidents or job related injuries. The increasing number of surgical intervention is also done by concentration of injuries to supraregional Traumacenters. At our workplace, the surgical intervention was indicated with 30% in the last five years. There are more interventions in longer time distance from the injury, mostly in hours interval. The reason is a persistent bleeding from injured lungs or prolonged air-leak with correctly ducted thoracic drainage. In interval of several days up to one week, there is necessary the intervention due to persisting haemothorax with production of organizing coagulum, or for persisting air-leak from pulmonary tissue lacerations. For many various reasons, we do not avoid even later intervention, weeks after the injury, due to incorrectly managed previous treatment. The organizing coagulum created a fibrothorax with limitation of breathing functions. 1

2 The second group is created by patients with COPD manifestations, by who, as a result of progression of a disease, relapsing pneumothorax occurs. If the pulmonary tissue collapse originates on the basis of pathologically changed tissue in pulmonary bulla, the surgical intervention is always necessary. If there is an isolated bulla, the resection is easy by way of thoracoscopy (3). If the relapsing pneumothorax of secondary type is based on bullous emphysema, the thoracoscopy is necessary very often, either by bullaectomy or even volume-reductive operation (4). There is a general effort to perform limited resectional interventions with an idea to save relatively healthy pulmonary tissue as much as possible. Tearing, air-leak and bleeding often happen during the stapler resection. There are many materials used for underlying the suture, e.g. parietal pleura or various artificial materials. Even securing of the suture by tissue sealant does not always bring an expected result. To reinforce the stapler suture during atypical resections, we recently use Traumastem Stapler Seam Protection slips and it seems that the suture is always secure without any air-leak or more significant bleeding. Structure of patients In January 2005 December 2009, we hospitalized 151 patients with chest injuries at Cardiac Surgery Clinic of Medical Faculty of Charles University and Teaching Hospital in Hradec Králové. Chart 1. shows the overview of patients with a necessity of surgical intervention. An atypical resection of damaged pulmonary tissue was necessary with some interventions. There were patients with contused and blood-soaked surrounding pulmonary tissue or with ARDS manifestation. For many reasons, the operations were not carried out under selective pulmonary ventilation. Stapler resection was performed on partly ventilated pulmonary parenchyma, which is always more difficult for placing the secure stapler suture. The second group of the patients with necessity of the surgical intervention at the same time period was created be 26 patients with relapsing pneumothorax of secondary type. The cause was a various degree of COPD, by GOLD classification in stage III. and higher. There were polymorbid patients of average age 72 years, with the second or another pneumothorax attack, which failed to be managed by the correctly ducted thoracic drainage. Air-leak was always longer than one week. Chart 2. The surgical intervention of perforated pulmonary bullae was only one alternative of the treatment. Exceptionally it was possible to choose finer thoracoscopy approach. There were more reasons for choice of limited thoracotomy. Partly it was an impossibility of selective pulmonary ventilation due to the oxygenation complications during the operation and partly multiple bullous emphysema or pleural adhesions in previous treatment. Even in these indications, there is still an effort to keep relatively healthy surrounding pulmonary tissue as much as possible. Discussion Acute interventions in thoracic surgery move towards more and more seriously affected patients. The first group of patients with blunt chest injuries mostly consists of younger patients, who suffered acute affection of more organs as a result of a high-energy traumatic process. This can be deceptive many times doctors temporize with conservative and examination procedures and they approach to surgical intervention only at the stage when other complications, as the injury consequence, occur. For example, this may be persisting bleeding from multiple lacerations in pulmonary parenchyma. The bleeding can be stopped by conservative treatment and by compression of extending 2

3 haematoma. The postponed revision is necessary to its evacuation or in case of impending transition to empyema. Another type is the prolonged collapse of pulmonary tissue with permanent air-leak from multiple ruptures of pulmonary surface. The surgeon s effort is to load the patient by his intervention as few as possible. Due to the blunt injury development, the patients can be in a serious state of breathing insufficiency, with ARDS manifestation and circulation complications. Atypical resections are complicated by untightness of a stapler suture, which is performed in a fragile, blood-soaked tissue. By using of slips it is possible to prevent this problem and to perform the resection of seriously affected pulmonary parenchyma only. The treatment of the patients from the second group is more difficult. Pathophysiology of the disease lies in the fact that a dead space (bullae) originates in pulmonary parenchyma, where is no air exchange. The bullae are either isolated or they create bullous emphysema. Additionally, bullae compress healthy surrounding parenchyma and reduce still relatively healthy pulmonary area. The COPD is a complex of three diagnoses chronic bronchitis, obstructive bronchiolitis and pulmonary obstructive empyema. As a result of the disease, it comes to flow suppression in air passages. This suppression is irreversible and hard to influence by pharmacological treatment. Male patients above 40 years are affected more often; almost 80% of them are long-time smokers. Certain small role plays also a genetic predisposition to ά 1 antitrypsin deficiency (about 0,3%). The COPD affects 6 10% of population; worldwide estimation makes around 600 millions of people. In the Czech Republic, patients die every year. Besides quite limited possibilities of pharmacological effect on the disease in the past, there was also an effort to influence the disease course by surgical way. The first operation of pulmonary bullae and volume-reductive operation was carried out by O.Brantigan in The beginnings of the treatment were connected with high mortality around 20%, caused by air-leak from resected areas of pulmonary parenchyma in postoperative period. J. Cooper in St. Luis and J.I. Miller from Atlanta contributed to rebirth of this method in The principle of the treatment is the resection of bullae and pulmonary parenchyma up to 20% of the total lung lobe volume. The pulmonary dead space is reduced and the surrounding healthy pulmonary tissue, squeezed by bullae, is released. We effectively approach to the surgical treatment when in impossible to manage pharmacologically the increasing pulmonary insufficiency. For operation are mostly indicated the patients with II. and II. degree by GOLD classification. Sometimes we are forced to operate urgently in the terminal stadium of disease, with hard to manage complications, the most often during relapsing pneumothorax. During the surgical treatment, the highest demands are placed on making a perfect air tight suture of affected pulmonary parenchyma, because the reduced volume of pulmonary tissue tends to tear during re-expansion. To reinforce very fragile pulmonary tissue, we used various padding (underlying) materials, e.g. autologous pericardium, pads from expanded polytetrafluorinethylen or material from bovine collagen. In 2009, we used Traumastem Stapler Seam Protection with all atypical resections with very good result. It was sufficient to perform a wedge-shaped resection with using of two staples and to stitch the contact surface in the place of the wedge over remaining padding material with securing atraumatic suture. (Pic.1.) Material of slips is biocompatible and resorbable, made of 100% oxidised cellulose. It has very significant antibacterial effect 3

4 against a wide range of gram-positive and gram-negative bacteria, as it is possible to prove a pathological microbial population in the lower respiratory tract with the most patients. By Ziegler, there is a pathological finding of microflora in lower respiratory tract with 48% of patients already after 3 days of mechanical ventilation (7). Thank to its ability to accelerate biochemical processes, this material significantly helps with the healing process. It also ensures quick and effective haemostasia and thereby minimizes perioperative and early post-operative bleeding. It is absorbed within 3 days, depending on volume of secretion from surrounding tissues. It is eliminated from the organism within 21 days with no side effects and does not cause any undesirable allergic reaction. The slips can be used on all types of linear staples available here. (Pic.2.) The remaining part of reticulum can be used for another haemostasia. (Pic.3) The usage is easy and both suture and haemostasia of emphysematously changed pulmonary parenchyma are always 100% what is verified by a leaktest. From our experience, it is not necessary to use tissue sealants to secure the suture, as it used to be in the past. Thereby it is possible to reduce costs on operations. Summary Even in the future, a thoracic surgeon will always face to serious injury conditions or terminal states of COPD. The surgeon, even being aware of post-operative complication and very often the last step of treatment pyramid, can t refuse these serious states. There is a possibility of influencing a timeliness of injuries treatment by early getting patients to specialized centres. Concerning the second group, there is an appeal aimed at specialized society of cooperating doctors of internal fields and pneumatology with a request to consult in time about patients with COPD complications, mainly relapsing pneumothorax, with surgical wards. Many patients, especially those with heterogeneous type of emphysema and pulmonary bullae, would definitely benefit from early surgical treatment. The new product Traumastem Stapler Seam Protection was of big help for us during operations of serious states. By its features Traumastem Stapler Seam Protection surpasses other non-resorbable materials used in the past, with economically incomparable levels. Literature: 1. Craighead C.C., Glass B.A. Management of nonpenetrating injurie of the chest. J. Amer. med. Ass. 1960; 172: Hájek M. Traumatologie hrudníku. Avicenum 1980; Achazy R, Stobernack A, Aslanian O. Spontanpneumothorax-konservative und operative therapie. Chir. Praxi. 1996;51: Baumann M.H, Strange C. Treatement of spontaneous pneumothorax a more aggressive approach Chest 1997;112(3): Bense L, Eklund G, Wiman L.G. Smoking and the increased risk of contracting spontaneous pneumothorax. Chest 1987;92(6): Fanta J, Votruba J, Neuwirth J. LVRS Surgery treatment of pulmonary emphysema Grada 2004; Ziegler D.W., Argawal N.N. The morbidity and mortality of rib fractures. J Trauma 1994;37(6):

5 Year Injury Operation Resection * Hemothorax Decortication Air- leak *- atypical resection was always performed together with another intervention Chart 1. Patients with thoracic injury and surgical intervention Year Thoracic drainage VTS LVRS* Bullaectomy *LVRS Volume-reductive type of operation Chart. 2. Patients operated for relapsing pneumothorax of secondary type, as a result of COPD 5

6 Fig. 1. Stapler with slips Traumastem Stapler Seam Protection Fig. 2. Resection of pulmonary bullae by stapler with slips Fig. 3. Resected area with using a pad. The remaining material can be use for another haemostasia Fig. 4. Preparation demonstration of air-tightening effect of suture Petr Habal, MD Teaching Hospital, Cardiac Surgery Clinic, Sokolská Hradec Králové, phabal@seznam,