Intrathorakale Vakuumtherapie beim Pleuraempyem und Lungenabszess

Zusammenfassung

Hintergrund: Komplizierte Pleuraempyeme oder Lungenabszesse sind entweder durch langwierige Therapien (inklusive Therapieversagen) oder durch einen schlechten Allgemeinzustand des Patienten (Multimorbidität, Sepsis) gekennzeichnet. Die operative Sanierung ist in diesen Fällen oft mit einer erhöhten Morbiditäts- sowie Mortalitätsrate assoziiert. Traditionell neigte man bei diesen Patienten zur primären Anlage eines Thoraxfensters inklusive offener Wundbehandlung, was jedoch immer mit einem langen Krankheitsverlauf und einer Einschränkung der Lebensqualität verbunden war. Die intrathorakale Vakuumtherapie (VAC) bietet hier völlig neue Therapieoptionen in der Behandlung von komplizierten Pleuraempyemen und Lungenabszessen. Methode: Darstellung der eigenen klinischen Erfahrungen verbunden mit selektiver Literaturrecherche über Medline (Schlüsselwörter: VAC, vacuum-assisted closure, thoracic empyema). Ergebnisse: Nach den ersten Erfolgen der extrathorakalen Anwendung der VAC-Therapie wurde das Verfahren auch auf seinen intrathorakalen/pleuralen Einsatz zur Behandlung von Pleuraempyemen und Lungenabszessen mit und ohne Bronchusstumpfinsuffizienz evaluiert. Anfangs erfolgte der Einsatz der intrathorakalen VAC-Therapie über ein Thoraxfenster (mit Rippenresektion), später entwickelten wir ein minimalinvasives Verfahren (Mini-VAC) unter Schonung des knöchernen Brustkorbs. Eine zusätzliche intrapleurale Spülung mit Antiseptika (Mini-VAC-Instill) ist in Fällen einer nachweislichen Keimbesiedlung sehr sinnvoll. Die Vorteile der Mini-Vac/Mini-VAC-Instill sind: sofortige Sekretabsaugung mit rascher lokaler Säuberung, schnelle Keimeradikation mit geringer Gefahr einer erneuten Besiedlung, Verbesserung des Ausdehnungsverhaltens der Lunge sowie kurze Behandlungszeiten mit schnellem Wiederverschluss des Thoraxes. Neben vielen retrospektiven Untersuchungen gibt es bisher lediglich eine Kohortenstudie, bei der die klassische Thoraxfensterung mit der VAC-Therapie verglichen wurde. Die Dauer der Stomasituation sowie das Langzeitüberleben in der VAC-Gruppe waren hier besser als in der Non-VAC-Gruppe. Schlussfolgerung: Die intrathorakale VAC-Therapie (Mini-VAC/Mini-VAC-Instill) ist ein innovatives Verfahren, welches die Wundsäuberung und Wundheilung bei komplizierten Pleuraempyemen und Lungenabszessen fördert. Aufgrund der Vorteile dieses Verfahrens inklusive Verbesserung des Patientenkomforts und der Lebensqualität hat das Verfahren eine rasche und breite klinische Akzeptanz erfahren.

Abstract

Background: Complex pleural empyema or lung abscesses are either characterised by long-standing treatment (including treatment failure) or by a bad general condition of the patient (multiple morbidity, sepsis). The operative rectification is often associated with increased morbidity and mortality rates in these cases. Traditionally, the therapeutic tendency for such patients was towards primary creation of a thoracic window including open wound treatment, but this was always also associated with a long sickness and restrictions in the quality of life. The intrathoracic vacuum treatment (VAC) offers here entirely new options in the treatment of complicated pleural empyema and lung abscesses. Method: We present an illustration of our own clinical experience associated with a selective literature research via Medline (keywords: VAC, vacuum-assisted closure, thoracic empyema). Results: After the initial successes of the extrathoracic application of the VAC treatment, the procedure was also analysed for its intrathoracic/pleural use to treat pleural empyema and lung abscesses with and without bronchus stump insufficiency. Initially, the use of the intrathoracic VAC treatment was carried out via a thoracic window (with rib resection), later we developed a minimally invasive procedure (Mini-VAC) while relieving the osseous thorax. An additional intrapleural rinsing with antiseptics (Mini-VAC-Instill) is very practical in cases of proven germ populations. The benefits of the Mini-Vac/Mini-VAC-Instill are: immediate secretion suction with quick local cleaning, rapid germ eradication with a small risk of a fresh population, improvement of the expansion behaviour of the lung as well as short treatment times with quick reclosure of the thorax. In addition to many retrospective examinations, there has so far only been one cohort study in which the classic thoracic window was compared with the VAC treatment. The duration of the stomatic situation as well as the long-term survival in the VAC group were better here than those in the non-VAC group. Conclusion: The intrathoracic VAC treatment (Mini-Vac/Mini-VAC-Instill) is an innovative procedure that promotes wound cleaning and wound healing in complicated pleural empyema and lung abscesses. Due to the benefits of this procedure, including the improvement of the patientʼs comfort and the quality of life, the procedure has seen a rapid and broad clinical acceptance.

Schlüsselwörter

Vacuum-assisted Closure - VAC - Pleuraempyem - Lungenabszess - Mini-VAC - Mini-VAC-Instill

Key words

vacuum-assisted closure - VAC - pleural empyema - lung abscess - Mini-VAC - Mini-VAC-Instill

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