The relationship of pathophysiological processes in the pleural cavity with coagulated hemothorax and blood patch pleurodesis
Background. Despite widespread introduction of minimally invasive resection techniques into thoracic surgery, pleurodesis remains the only determining method of radical surgical correction in a number of cases. This is especially true in patients with advanced forms of bullous emphysema. At the same time, existing types of pleurodesis cause serious accompanying complications. Taking this into account, a method of blood patch pleurodesis was developed based on the pathophysiology of the processes occurring in the pleural cavity after the blood entering it, which was based on the processes characteristic for the development and transformation of the coagulated hemothorax. The aim of the study was to study the pathophysiology of the pleural cavity with the artificial creation of hemothorax in it. Materials and methods. The control group consisted of 36 patients, in whom hemothorax was caused by penetrating stab-cut wounds of the chest. Of these, 21 patients had small or medium hemothorax, and 15 patients underwent video-assisted thoracoscopic (VATS) evacuation due to the coagulated hemothorax. The main group consisted of 40 patients who had hemothorax due to the performance of VATS resection of the lung and pleurodesis due to bullous emphysema, 24 of them had coagulation “staircase” pleurodesis, in 16 — blood patch pleurodesis according to the developed technique. As the main indicator reflecting the formation of fibrin and fibrinolysis in the pleural cavity, plasminogen was studied, the percentage of activity of which was determined three times in the blood serum and pleural exudate: 1 hour and 24 hours after the operation, and also on the 5th postoperative day. Results. In the first hours after the surgery, the blood plasminogen level decreased in all patients, except those who underwent VATS resection with “staircase” pleurodesis. A day after the operation in the group of patients with small and medium hemothorax, a slow recovery of plasminogen level began, after 5 days its concentration in the blood was completely restored. In patients who underwent evacuation of a coagulated hemothorax, a standard decrease in plasminogen was noted 1 h after the surgery. On the 5th day, the level of plasminogen in the blood recovered only by half. The same values of plasminogen in the time intervals of 1 hour and 5 days were also in the group of patients who underwent blood patch pleurodesis after VATS resection, and 24 hours after blood patch pleurodesis, recovery of the plasminogen level already started. In pleural exudate, there was a moderate decrease in plasminogen in patients who underwent VATS resection with “staircase” pleurodesis and primary surgical treatment with drainage of the pleural cavity 1 hour after the operation, and then its uniform recovery by the 5th day. Patients with coagulated hemothorax had a deeper plasminogen level decrease 1 hour after the surgery and a uniform but not definitive recovery to the 5th day. Blood patch pleurodesis led to a sharp decrease in plasminogen in pleural exudate 1 hour after the operation, and its level did not increase by the 5th day. Conclusions. The decrease in plasminogen in pleural exudate was a direct reflection of the exhausting effect of autoblood. Blood patch pleurodesis is an intervention that simulates the processes occurring in the pleural cavity with coagulated hemothorax in a more “soft” version. With it, there is an inhibition of liquor fibrinolysis, similar to that of in coagulated hemothorax.
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