CC BY
8
I. SURGERY
МРНТИ 76.29.39
A CLINICAL CASE OF POST-TRAUMATIC
^ в.,- CICATRICIAL STENOSIS OF THE RIGHT MAIN
orcid.org/0000-0002-0773-3878
Sundetov M.M -
orcid.org/0000-0002-0387-5422
AkilbekovS.D. -
orcid.org/0000-0003-4613-1658
Kurbanov D.R. -
orcid.org/0000-0002-0426-9387
Khalykov K.U. -
orcid.org/0000-0003-1266-697X
Yerimova N.Zh. -
orcid.org/0000-0002-0565-5327
Kokimbayev D.A. -
orcid.org/0000-0001-7879-3328
Alkhanov B.A. -
orcid.org/0000-0001-6543-0712
Keywords
cicatrical stenosis, resection of the bronchus
BRONCHUS
Shirtaev B.K.1, Sundetov M.M.1, Akilbekov S.D.2,Kurbanov D.R.1, Khalykov K.U.1, Yerimova N.Zh.1, Kokimbayev D.A.1, Alkhanov B.A.1
1JSC "National Scientific Center of Surgery named after A. N. Syzganov", Almaty, Kazakhstan 2Al-Farabi Kazakh National University, Almaty, Kazakhstan
Abstract
Damage to the tracheobronchial tree often occurs due to severe bruising or crushing of the chest. We describe a case of surgical treatment of a rare and complex surgical pathology-post-traumatic scar stenosis of the right main bronchus. This article presents the course of the patient's treatment and diagnosis, describes the stages of the operation and gives recommendations to surgeons.
Оц Heri3ri бронхтьщ жаракаттан кейшп тыртыкты тарылуыньщ к линикалык жагдайы
Ширтаев Б.К.1, Сундетов М.М.1, Акылбеков С.Д.2, Курбанов Д.Р.1, Халыков Еримова Н.Ж.1, Кокимбаев Д.А.1, Алханов Б.А.1
1«А.Н. Сыз?анов атында?ы Улттык ?ылыми хирургия орталь™» АК, Алматы к., Казахстан 2Эл-Фараби атында?ы Казак улттык университетi, Алматы к,., Казахстан
Туйш свздер
тыртыкты тарылу, бронхтыц резекциясы
Ацдатпа
Ке^рдек жэне бронхтардыц закымдануы квбнесе ауыр жаракат немесе кеуде куысыныц кысылуы нэтижеанде пайда болады. Бiз кYPделi жэне сирек кездеселн он жак бронхтыц жаракаттан кейiнгi тыртыкты тарылуыньщ хирургиялык емдеу жолын сипаттаймыз. Бул макалада наукасты журпзу жэне диагноз кою барысы, ота кезендерi сипатталтан жэне хирургтарга усыныстар берлген.
Клинический случай посттравматического рубцового стеноза правого главного бронха
Ширтаев Б.К.1, Сундетов М.М.1, Акильбеков С.Д.2, Курбанов Д.Р.1, Халыков К.У.1, Еримова Н.Ж.1, Кокимбаев Д.А.1, Алханов Б.А.1
1АО «Национальный научный центр хирургии им. А.Н. Сызганова», г. Алматы, Казахстан 2Казахский национальный университет им. Аль-Фараби, г. Алматы, Казахстан
_ Аннотация
Повреждения трахеобронхиального дерево часто возникает вследствие тяжелого ушиба или раздавливания Ключевые слова грудной клетки. Мы описываем случай хирургического лечения редкой и сложной хирургической патологии -рубцовый стеноз, посттравматического рубцового стеноза правого главного бронха. В данной статье представлена ход введение резекция бронха больного и диагностики, описана этапы операции и даны рекомендации хирургам.
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ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 1-2021
Introduction
The cause of post-traumatic cicatricial stenosis of the main bronchi is often ruptures of the main bronchi with a closed chest injury. The main symptoms of bronchial stenosis: paroxysmal cough, shortness of breath, hypoventilation/ emphysema of the lungs, inflammatory changes below the site of narrowing. The frequency of tracheal ruptures in closed chest trauma is from 0.5 to 0.9 %, and the main and lobar bronchi-from 2 to 5 % (Figure 1). The main methods of treatment for bronchial rupture are suturing the site of the rupture, and resection of the bronchus with end-to-end anastomosis during the formation of scar stenoses. Given the rarity of such patients, the description of individual clinical cases of the disease is useful.
Clinical case
Patient Kh., 18 years old, was admitted to the A. N. Syzganov national scientific center of surgery on 04.12.19 with complaints of severe shortness of breath, cough with difficult-to-separate sputum, pain in the chest. From the anamnesis: 02.11.19, he was injured in an accident. The scene of the accident were taken by ambulance in the hospital with polytrauma: spontaneous right pneumothorax, subcutaneous emphysema, fracture of the right scapula, fractured ribs III - X on the right, fracture of the pelvis. He was urgently hospitalized in the intensive care unit, and the pleural cavity was drained on the right side. The next day, the patient was transferred to the city hospital. Fibrobronchos-copy revealed a partial rupture of the main bronchus on the right. In dynamics, scar stenosis was formed at the site of the rupture, and therefore balloon dilation was performed twice. Given the lack of effect, the patient was transferred to our center. Chest X-ray from 05.12.19: Right (partial) segmental atelectasis of the lower lobe (S7, S9, S10) the lower lobe is reduced in volume, effusion along the main interlobar pleura. The high standing of the diaphragm. Fibrobronchoscopy from 06.12.19 (Figure 2): The mouth of the right bronchus is scarred to 0.3-0.4 cm. The length is about 0.7-0.8 cm. Cicatricial stenosis of the right bronchus. Computed tomography of the chest organs from 01.12.19 (Figure 3): CT-picture of scar stenosis of the right main bronchus.
A preoperative diagnosis was established: posttraumatic scar stenosis of the right main bronchus. It was decided to perform a circular resection of the right main bronchus with an end-to-end anastomosis. Operation was performed on 10.12.19: in the position of the patient on the
Figure 1.
Scheme of rupture of the main bronchus
left side, a lateral thoracotomy was performed in the 3rd intercostal space on the right. By dissecting the parietal pleura in the projection of the trachea and the posterior edge of the lung root, access to the mediastinum was made. With technical difficulties, the right main bronchus was isolated. Immediately after carina, the right main bronchus is sharply deformed, narrowed, repre-
Figure 2.
Fibrobronchoscopy on admission
Figure 3.
Computed tomography of the chest organs on admission
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Figure 4.
Operation diagram
Figure 5.
Fibrobronchoscopy at discharge
sented by a scar conglomerate up to the level of the upper lobe bronchus. The right vagus nerve and the proximal part of the unpaired vein are involved in the scar. After mobilization of the unpaired vein and n. vagus, a transverse intersection of the right main bronchus was made at the level of deformation. The lumen of the bronchus is obliterated, its wall is scarred. Scar tissue at both ends is excised to healthy tissue. The distal edge is 3 mm to the level of the upper lobe of the bronchus, the proximal edge is directly on the carina. An end-to-end bronchial anastomosis was applied with nodular sutures (PDS 4/00), with
a lumen of 13 mm (Figure 4). The length of the resected bronchus is 18 mm. The operation was completed by draining the pleural cavity.
Over the next few days, the patient received hormonal, antibacterial and inhalation therapy. In the first days after the operation, a pronounced hypoventilation of the right lung, fluid in the pleural cavity was noted on the chest X-ray. The postoperative period was uneventful. The drainage tube was removed on the tenth day after the operation. Fibrobronchoscopy from 23.12.19 (Figure 5): On the right main bronchus at the level of the carina there is an annular narrowing covered with fibrin, with a diameter of up to 0.9 cm. Below immediately begins the mouth of the upper lobar and intermediate bronchi. The patient was discharged in a satisfactory condition on the twenty-fifth day after the operation.
Discussion
An analysis of the literature shows that with active surgical treatment tactics, the majority of patients with tracheobronchial injuries helps to avoid late complications, in the form of cicatri-cial stenosis of the trachea and main bronchi. In our case, the patient turned in a month after the chest injury. Subsequently, what influenced the course of the operation and the patient's management tactics. One of the key roles in such situations is played by the factor of the time of delivery of the victim to the medical center, the beginning and execution of the operation.
Conclusion
Thus, in the treatment of ruptures of the main bronchi, the method of choice is an emergency thoracotomy and open suturing of the ruptures.
Also, early diagnosis and surgical treatment can avoid cicatricial stenosis of the main bronchi. To establish the rupture of the main bronchi both in the early and late period, a comprehensive study is necessary: CT of the chest organs and endoscopy. Fibrobronchoscopy is the main and main method of diagnosis and control of the effectiveness of the performed operation.
Proper surgical tactics and timely surgery allow you to achieve a good result.
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