Purpose. To describe the clinical case of pulmonary aspergilloma with step-by-step surgical treatment. Surgical treatment of aspergilloma is justified in the case of ineffective drug therapy and life-threatening complications. The high risk of developing surgical complications on the background of immunodeficiency of different origins may be an obstacle to radical intervention. The course of aspergillosis can significantly limit the ability to compensate for background diseases such as diabetes. The case of a stage approach in preoperative preparation of a patient with severe diabetes mellitus and aspergilloma is presented. In the first stage, a video-assisted thoracoscopy of aspergilloma was performed with histological examination; evacuation of detritus and mycelium by transthoracic drainage and topical diabetes treatment. In the second stage: standard lower lobectomy and postoperative drug therapy with antifungal drugs. Observationsup to 2 years after treatment with favorable course are analyzed. Conclusions. Aspergilloma is one form of aspergillosis that requires surgical treatment. Lack of effective correction of comorbidities may be an obstacle to one-step intervention because of the high risk of surgical complications. The use of video thoracoscopy in the diagnosis and stage treatment of this pathology is appropriate due to the minimal trauma of the intervention, which can be used for preoperative preparation and to obtain good results of radical treatment in this category of patients.

Хірургічна стабілізація каркасу грудної клітки: досвід

У статті проаналізовано досвід багаторічного використання металоостеосинтезу ребер за допомогою спиць та пластин для хірургічної стабілізації каркасу грудної клітки при травмі. Встановлено, що використання методу має ознаки комплексного підходу; основний термін застосування – відстрочений (89,1% випадків); використання даного методу дає змогу досягти добрих безпосередніх результатів у 91,9% випадків; частка післяопераційних ускладнень становить 6,8%. Стабілізація переломів ребер є абсолютно необхідною процедурою під час надання допомоги постраждалим з переломами ребер і груднини. Вибір методу хірургічної стабілізації залежить від стану хворого, досвіду клініки та/або хірурга, джерела фінансування.

Objective: to improve the treatment results of patients with pleural empyema (PE) by developing a method of empyema stage diagnosing and expanding the indications for VATS. Materials and methods. The treatment results of patients with PE were analyzed. Patients with nonspecific parapneumonic EP stages 1 and 2 (according to the EACTS classification) who underwent VATS were included in the study. Prior to surgery, on the first or second day after admission to the hospital, the patient was subjected to ultrasound examination of the pleural cavities with the diaphragm excursion determination. Diaphragmatic relative mobility was calculated as the ratio of diaphragm excursion on the affected side to the healthy one. Based on the endoscopic picture and the morphological examination of the biopsy material (pleura) results the disease stage was determined. Results. The study included 67 patients with PE (men – 50, women – 17). The first stage of EP was diagnosed in 30 cases (men – 22, women – 8), the second – in 37 (men – 28, women – 9). The mean age was 46.36 ± 14.01 years. It was found that at the first stage the median of diaphragmatic relative mobility – 0.596 (0.444; 0.714) was significantly greater than at the second stage – 0.078 (0.048; 0.118), P < 0.0001. By ROC analysis the sensitivity of the proposed method was found to be 0.933; specificity 0.973; cut point = 0.255; AUC = 0.0977. Conclusions. Determination of the diaphragm relative excursion in patients with EP is characterized by high sensitivity (0.933) and specificity (0.973) in the differential diagnosis of disease stages 1 and 2. The stage 2 recognition allows to establish indications for the use of VATS, enabling the treatment results improvement and reducing the length of hospital stay.

Objective. To evaluate the effectiveness of thoracoscopic operations and to study the clinical and epidemiological characteristic of patients with pleural empyema (PE).Materials and Methods. A retrospective analysis of 51 patients with PE treatment results has been done. All participants were examined by standard clinical and laboratory tests, X-rays and CT scans of the chest, ultrasound of pleural cavities. All patients (n = 51, 100 %) were subject to thoracoscopic interventions.Results. The average age of patients was 44.4 +/- 14.7 years. Men prevailed among them -36 (71 %). The first stage of PE was diagnosed in 18 (35 %) patients, and the second -in 33 (65 %). Almost all patients (50 patients -98 %) had been treated in other hospitals before hospitalization to a specialized department. Diagnostics of PE and patients admission to the thoracic surgery department took place on the 2-3 week of disease in 70 % of cases. The main types of surgery on the first stage of PE were: thoracoscopy with targeted drainage of pleural cavity and pleural biopsy (n = 4, 22 %); video-assisted thoracoscopic surgery (VATS) with destruction of fibrinous adhesions (n = 14; 78 %). It has been done at the second stage of PE: VATS pneumolysis (n = 22; 67 %) and VATS decortication of lung (n = 11; 33 %). The positive results of pleural exudates bacteriological analysis have been obtained from 9 patients (18 %). The median of pleural exudation duration at the first stage of PE was 5 days (4, 6), at the second stage -6 (5, 9) days (p = 0.058). Good results were obtained in 33 patients (65 %), satisfactory -in 15 (29 %), unsatisfactory -in 3 (6 %). The median of hospital stay duration was 18 (16; 21). There have not been lethal outcomes.Conclusions. Diagnosis of pleural empyema is a complex task and requires a broad introduction of modern techniques (CT and ultrasound). Standard microbiological testing is not effective in the diagnosis of PE pathogens, due to imperfection of anaerobic bacteria methods of detection and previous antibiotic therapy. The use of VATS in patients with PE on the first and the second stage is effective and reasonable, leads to good and satisfactory results in 95 % and 94 % of cases respectively.

The article described a rare clinical case of retrosternal follicular thyroid cancer located in the posterior mediastinum. The tumor was 11 cm in diameter, originating from the lower section of the right thyroid lobe, descended down retrosternally, while bulging out the internal jugular vein and common carotid artery. The tumor descended in the posterior mediastinum, from behind the subclavian artery and vein, adjoining posterior - to the back of the esophagus, medial – to the trachea, anterior - to the superior vena cava, and bordered the lower arc of the subclavian vein, inferior right - to the right main bronchus, and caused compression of structures described above. With such a location of the tumor and its size performing surgery by cervical access poses serious technical difficulties, while sternotomy does not fully ensure adequate and secure access to the posterior mediastinal tumor. Therefore, the most efficient access in the case of retrosternal goiter located in the posterior mediastinum would be the combination of thoracotomy in the fifth intercostal space with cervical access via the front of the neck.

The article described a rare clinical case of retrosternal follicular thyroid cancer located in the posterior mediastinum. The tumor was 11 cm in diameter, originating from the lower section of the right thyroid lobe, descended down retrosternally, while bulging out the internal jugular vein and common carotid artery. The tumor descended in the posterior mediastinum, from behind the subclavian artery and vein, adjoining posterior to the back of the esophagus, medial – to the trachea, anterior to the superior vena cava, and bordered the lower arc of the subclavian vein, inferior right to the right main bronchus, and caused compression of structures described above. With such a location of the tumor and its size performing surgery by cervical access poses serious technical difficulties, while sternotomy does not fully ensure adequate and secure access to the posterior mediastinal tumor. Therefore, the most efficient access in the case of retrosternal goiter located in the posterior mediastinum would be the combination of thoracotomy in the fifth intercostal space with cervical access via the front of the neck.