Zentralbl Chir 2019; 144(S 01): S31-S42
DOI: 10.1055/a-0896-8748
Übersicht
Georg Thieme Verlag KG Stuttgart · New York

Die pleurale Residualhöhle nach Lungenresektion

Residual Pleural Space after Lung Resection
Thomas Lesser
Thorax- und Gefäßchirurgie, SRH Wald-Klinikum Gera, Deutschland
› Author Affiliations
Further Information

Publication History

Publication Date:
27 June 2019 (online)

Zusammenfassung

Bei ca. 10% der Patienten kommt es nach anatomischer Lungenresektion zu einer pleuralen Residualhöhle. Die häufigsten Ursachen sind die Lungenparenchymerkrankung mit verminderter Compliance und die Luftfistel. Tritt bis zum Ende der 4. Woche keine Komplikation auf, ist mit einem unkomplizierten Verlauf (Resorption der Luft) zu rechnen. Bei einer Infektion der Höhle und einer bronchopleuralen Fistel besteht die Gefahr der inneren Aspiration mit Ausbildung einer lebensbedrohlichen Pneumonie. In diesen Fällen ist ein operatives Vorgehen indiziert. Die Wahl des operativen Verfahrens ist eine individuelle Entscheidung, wobei der Allgemeinzustand, Nebenerkrankungen, die Mobilität und Motivation des Patienten, die respiratorische Funktion, die Qualität des Lungengewebes, das Grundleiden sowie dessen Prognose und lokale wie auch systemische Auswirkungen der chronischen Höhleninfektion berücksichtigt werden müssen. Für die operative Therapie einer pleuralen Residualhöhle stehen folgende Verfahren zur Verfügung: Pleuradrainage, Pneumoperitoneum, Pleurazelt, Dekortikation der Lunge, Muskeltransposition, Thorakoplastik, Thorakostoma, Kombinationsverfahren. Die Drainage- oder Dekortikationsverfahren setzen eine ausdehnungsfähige Restlunge voraus. Eine besondere Herausforderung stellt das Postpneumonektomieempyem dar. Zur Vermeidung einer pleuralen Residualhöhle können bereits beim Ersteingriff prophylaktische Maßnahmen (Pleurazelt, Pneumoperitoneum, N.-phrenicus-Blockade) erfolgen.

Abstract

Approximately 10% of patients exhibit a residual pleural space after anatomical lung resection. The most common causes are related to interstitial lung diseases associated with reduced compliance and air leaks. If no complication occurs by the end of the 4th week, an uncomplicated course (absorption of air) can be expected. In the event of pleural space infection and/or bronchopleural fistula, there is a risk of aspiration, with the development of life-threatening pneumonia. In such cases, surgical treatment is indicated. The choice of surgical procedure is an individual decision, whereby the general condition, coexisting diseases, patientʼs mobility and motivation, pulmonary function, the lung tissue quality, the underlying disease with its prognosis and local as well as systemic effects of the pleural space infection must be taken into account. For the surgical therapy of the residual pleural space, the following methods are available: pleural drainage, pneumoperitoneum, pleura tent, lung decortication, space filling muscle transposition, thoracoplasty, thoracostomy, or combined procedures. Pleural drainage and decortication require an expandable lung. Postpneumonectomy empyema poses a particular challenge. To avoid a pleural space in cases of high risk conditions, prophylactic measures (pleural tent, pneumoperitoneum, N. phrenicus blockage) can already be performed during initial intervention.

 
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