Improving the eff ectiveness of surgical treatment of destructive diseases of the lungs and pleura in the provision of specialised care in modern conditions

Objective. To determine the optimal scope of diagnostic and therapeutic measures in patients with destructive lung and pleural diseases, to evaluate the possibilities of digital data processing and densitometry for the prevention and treatment of complications of these diseases in the provision of specialised care in modern conditions. Materials and methods. The study is based on the analysis of the results of treatment of 107 patients with destructive processes in the lungs and pleura (52 military personnel and 55 civilians) complicated by pleural empyema with bronchopleural communication. Results. Pulmonary and pleural complications developed in 88.4% of patients with heterogeneous parenchyma structure determined by computed tomography densitometry. Fibrotic or emphysematous changes in the parenchyma during digital data processing and densitometry were determined objectively, which became the basis for the objective determination of personalised treatment tactics, monitoring of the treatment process and evaluation of the results. Conclusions. Treatment of patients with destructive diseases of the lungs and pleura should be carried out in highly specialised medical care facilities, computed tomography of the chest cavity with the use of specialised applications and fibrobronchoscopy allow individualising treatment tactics, and densitometry and analysis of intrathoracic structural changes allow assessing the effectiveness of treatment and the stages of the pathological process.

In peacetime, destructive lung and pleural disease is seen in 15-17% of patients with community-acquired pneumonia.About 10% of patients have pulmonary and pleural complications that require surgical treatment.Martial law activates factors that increase the incidence of tuberculosis [1,2].Open and closed chest trauma has a significant impact on the development and progression of destructive lung and pleural diseases, significantly increasing the incidence of pulmonary and pleural complications [3].Mine-blast wounds are in the first place.Penetrating chest wounds account for a relatively small proportion of total wounds, but they are not always adequately diagnosed not only in the field but also in hospitals, which can have delayed tragic consequences.In the Russian-Ukrainian war, personal protective equipment was used for the first time in any military action, which dramatically changes the nature and severity of combat injuries [4].
While primary care is being implemented and improved according to modern protocols, implementing advanced algorithms, specialised treatment is highly variable and largely depends on non-systemic factors such as clinic equipment, local protocols of the facility, patient route, etc.
In today's reality, hospitalisation in healthcare facilities with specialised care is possible even in second-tier units, which requires the implementation of new patient-centred strategies integrated into the overall care system [1,5].Effective cooperation between civilian and military medicine has become paramount to preventing large-scale casualties [6].
Explosive injuries can easily develop into acute respiratory distress syndrome, which requires timely diagnosis and treatment [7].According to statistics published by Ukrainian medics, more than 70% of all Ukrainian combat casualties are caused by artillery and rocket attacks, which leads to a significant number of polytrauma to many organ systems [3].
The progression of complications in a fairly short period of time is accompanied by extremely complex and sometimes irreversible consequences.
Often, the severity of a patient's condition is determined by injuries/diseases that are currently directly life-threatening; other pathological conditions that do not pose a direct threat to the patient's life are relegated to the background.Non-critical respiratory disorders are often among the secondary ones.Rapid and accurate identification and assessment of this so-called background pathology in the provision of specialised care in modern conditions is necessary for the objective detection of respiratory system diseases and their complications that require appropriate management [8].Of particular note is the contingent of patients with destructive lung and pleural diseases, developed empyema, especially with broncho-pleuro-thoracic complications.
In specialised facilities, in-depth examinations can detect pathophysiological changes in the affected tissues in patients with inflammatory or infectious diseases at an early stage.These changes usually occur before the onset of clinical symptoms and the development of anatomical changes

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detected by radiological methods.Currently, hybrid imaging methods such as positron emission tomography/computed tomography can provide functional and morphological information for the early diagnosis of infectious and inflammatory diseases [9].
One of the promising methods of objective assessment of patients with destructive lung and pleural diseases is the use of densitometric parameters of the lung parenchyma and intrathoracic structures, which allows standardising the condition of patients, comparing them adequately, and identifying essential and less important actions in the management [10].
At the time of writing, the number of scientific papers on specialised care for patients with destructive lung and pleural diseases and subsequent severe broncho-pleuro-thoracic complications was quite limited.We found retrospective series of observations with low standardisation and a limited number of patients.The statistical methods used in all series of observations are insufficient to report significant differences in treatment.
The aim of the study is to determine the optimal scope of diagnostic and therapeutic measures in patients with destructive lung and pleural diseases, to evaluate the possibilities of digital data processing and densitometry for the prevention and treatment of complications of these diseases in the provision of specialised care in modern conditions.

Materials and methods
The work is based on the analysis of the results of treatment of 107 patients with destructive processes in the lungs and pleura at the National Institute of Phthisiology and Pulmonology (now the National Research Centre of Phthisiology, Pulmonology and Allergology) who had surgical complications, including pleurothoracic fistula.Patients with typical lung abscesses and bronchiectasis, whose treatment tactics did not differ, were not included in this study and were not included in the analysis.
The main group consisted of 52 servicemen who were diagnosed with destructive lung and pleural diseases during medical evacuation and subsequently received specialised medical care and pleuro-obstructors.There were 47 men (90.4%) and 5 women (9.6%).Forty-seven (90.4%) patients had consequences of mine-blast trauma, and developed broncho-pleuro-thoracic complications after surgical interventions performed during the medical evacuation and treatment stages.In 5 (9.6%) patients who had such complications, there were nonspecific inflammatory processes of the chest cavity (PAP).No ranking was used, as the most difficult patients with broncho-pleuro-thoracic fistulas were purposefully admitted.
A group of 55 patients with broncho-pleuro-thoracic complications in the form of pleural empyema with broncho-pleural communication was selected as a control group.
Both groups were treated according to the developed algorithm for the complex treatment of patients with destructive lung and pleural diseases complicated by bronchopleural communication.
The condition of the airway mucosa was assessed during fibrobronchoscopy (FBS), which was performed under local anaesthesia with a fibrobronchoscope (Olympus BF PE\TE 2 (Japan).The FBS included: examination of the trachea, main and partial, segmental and subsegmental bronchi to detect endobronchial pathology and signs of tuberculous mucosal lesions.Also, if necessary, the tracheobronchial tree was rehabilitated in the postoperative period and the effectiveness of the treatment was assessed.The bronchological picture was assessed according to the classification of J. Lemoine, supplemented by G. I. Lukomskyi.
In order to establish the levels of densitometric indices of computed tomography (CT) of the OOP in various variants of pathological damage, the study was performed on a CT scanner Aquilion TSX-101A manufactured by Toshiba (Japan) with recording of the study results on digital media.
For data processing, the K-Pacs workstation was used to measure the density of lung tissue lesions in a selected area of the axial CT scan, and the DICOM VIEVER PHILIPS software, which allows determining the densitometric parameters of the region of interest (ROI) on multiple slices and saving the results in a table.For each slice, the software determines the minimum, maximum, mean value in Hounsfield units (OX) and standard deviation in three dimensions.Video-assisted thoracic surgery (VATS) was performed according to the generally accepted rules of thoracic surgery under general anaesthesia with single-pulmonary or split endobronchial intubation.
According to the developed algorithm, the patient underwent a CT scan of the OGP to determine the location, volume of the lesion, condition and densitometric characteristics of the affected and unaffected lung parenchyma and pleural contents, location, size and configuration of the empyema cavity.Depending on the results obtained, further surgical tactics were determined.In case of low density of pleural contents (up to 10 OX) and uncomplicated configuration of the residual pleural cavity, we were limited to its adequate drainage.In case of complicated configuration of the residual pleural cavity, videothoracoscopy was performed, during which intrapleural adhesions were dissected, effusion and purulent masses, fibrin layers, pleural fusions, hypertrophied pleura were removed, samples for histological and microbiological examination were taken, the cavity was sanitised with an antiseptic solution, the optimal drainage sites were determined and drains were installed.
After drainage or surgical intervention, video fibrobronchoscopy was performed to determine the draining bronchus by contrasting the pleural cavity with a dye with 3.0% UJCS.2024 May/June; 91(3) The Ukrainian Journal of Clinical Surgery hydrogen peroxide solution and its valve occlusion.Subsequently, round-the-clock aspiration from the pleural cavity via drains was provided.
Patients received basic anti-inflammatory, antimicrobial and symptomatic therapy, taking into account the densitometric parameters of the lung.In case of emphysematous type of lung parenchyma ( 800.0 OX), pneumoperitoneum was used.When pathological foci were detected in the lung with densitometric signs of high activity of the pathological process ( 30.0 OX), intensive specific (in tuberculosis) or non-specific antimicrobial therapy was prescribed.
According to the densitometric parameters of the intrathoracic structures, a personalised therapy was formed based on the objective characteristics of the pathological process in terms of lesions, spread and control at the stages of treatment.
Parametric and non-parametric statistics were used to analyse the data.The choice of method depended on whether the numerical series under study followed a normal distribution.This was checked using the special function NORM-SAMP_1 developed for Excel.The statistical significance of the differences between independent observations for the numerical series that followed a normal distribution was assessed using the two-sample Student's t-test, and for all other series using the nonparametric two-sample Wilcoxon's W-test.The statistical significance of differences in proportions (percentages) was assessed using Fisher's exact angular transformation.

Results
The assessment of preliminary diagnostic measures showed that under martial law, it is in specialised institutions that in-depth examination and implementation of optimal treatment tactics for both military personnel and civilians with destructive lung and pleural diseases is possible.
Men predominated in both groups; also, patients of working age predominated in both groups (Table 1).There were no statistically significant differences in these criteria.
According to our data, the occurrence and development of severe broncho-pleuro-thoracic complications directly depended on the time elapsed before hospitalisation in a specialised institution.Thus, 48 (92.3%) patients in the main group had more than 4 episodes of treatment with surgical interventions of varying degrees of complexity.In the control group, only 6 (10.9%) patients were treated for a long time in several surgical hospitals.
It is characteristic that the involvement of "intermediate" hospitals as stages of care was accompanied only by a deterioration in the general condition of patients and progression of the area of lung parenchyma destruction according to the CT scan of the acute lung injury.Errors in the assessment of the affected lung parenchyma in 95% of patients led to leakage and infection of the pleural cavity.
Performing complex intrathoracic interventions in noncore hospitals, especially multistage ones, in a significant number of patients led to specific broncho-pleuro-thoracic complications.All patients included in the study had previously been treated in non-core inpatient facilities and hospitals.
At the tertiary stage of providing highly specialised care to this patient population, the problem of treating trophic lesions and pressure ulcers arises.To increase the effectiveness of treatment, given the complexity of multiple injuries, the often presence of metal structures that significantly restricted the patient's movement, reconstructive surgery on the thoracic frame that made it impossible for the patient to move actively and laterally, it was considered necessary to pay special attention to preventing the development of trophic disorders in accordance with generally accepted recommendations.
The studied patients were divided according to the pathology that caused the broncho-pleural communication (Table 2).
The complicated configuration of the residual pleural cavity prompted videothoracoscopy with dissection of intrapleural effusions, sanitation of the pleural cavity from purulent UJCS.2024 May/June; 91(3) The Ukrainian Journal of Clinical Surgery masses and fibrin layers.Microbiological studies of pleural biopsies showed antibiotic resistance in 31 (59.6%)patients of the main group and 9 (16.7%)patients of the control group.
The use of perfusion systems and thoracoscopic rehabilitation of the pleural cavity allowed the use of bronchial occlusive devices for adequate pathogenetic therapy of patients with broncho-pleural and broncho-pleuro-thoracic complications.Bronchial occlusion as a factor in preventing pleural cavity infection created conditions for healing of parenchymal defects.
Among the main clinical symptoms, manifestations of intoxication were observed in 31 (59.6%)patients of the main group and 14 (25.5%)patients of the control group.Functional insufficiency of the main homeostasis maintenance systems (due to concomitant pathology or complications of the underlying disease) occurred in 9 (17.3%)patients of the main group and 5 (9.1%) patients of the control group.
We have accumulated positive experience in using vacuum systems for wound cleaning and granulation, as well as the use of enteral protein mixtures to maintain blood protein levels as an effective means of improving the results of surgical treatment of patients with destructive lung and pleural diseases.
It was noted that it is advisable to avoid interventional interventions as much as possible and to limit the drainage of the pleural cavity before the patient is admitted to a specialised hospital.Patients who did not undergo resectional interventions stayed in the hospital for 34 days, which is 45.2% less than the length of stay in the hospital for patients who underwent surgical interventions on the lung parenchyma in similar clinical situations of PHE damage.
Certain peculiarities have also been established with regard to the rehabilitation of the pleural cavity in pleural and broncho-pleuro-thoracic complications.With a density of pleural contents up to 10 OX and an uncomplicated configuration of the residual pleural cavity, adequate drainage was the final method of treatment without further surgical interventions in 5 (9.6)% of patients in the main group.
The study patients were distributed according to the CT scan of the lung parenchyma before treatment (Table 3).
Densitometry and the use of specialised applications to evaluate the information obtained by CT of the ONH allow determining an individualised treatment strategy.
The analysis of the obtained images began with a standard view (Fig. 1).
Specialised applications (e.g.3dSlicer) allow visualising the structure of the lung parenchyma, highlighting areas of reduced density or increased consistency.Easy marking of intrathoracic structures and automatic generation of diagnostic reports of densitometric characteristics of lung segments make it possible to formulate a surgical intervention plan, determine the optimal level of bronchial blockade, and objectively assess the dynamics of treatment (Fig. 2).

Fig. 3. CT scan of the OGP when viewed by 3dSlicer viewer (automated report). Mine-blast trauma, lung contusion, visualisation of the location, extent of the contusion zone
and its densitometric characteristics.

The Ukrainian Journal of Clinical Surgery
CT scan of the acute lung injury in patients with broncho-pleuro-thoracic complications allowed to assess the adequacy of drainage, the spread of the pathological process in the lung parenchyma, and the condition of intrathoracic structures.
Comparison of CT axial slice histograms is the basis for automated monitoring of treatment effectiveness and development of clinical decision support programs (Fig. 3).
Assessment of the parenchymal density around the ROI helps to determine whether the parenchymal suture needs to be reinforced or whether Teflon spacers are required.If stiffness is detected, it is advisable to consider the use of additional drainage of the pleural cavity.Observations.
A patient (a serviceman) with mine-blast trauma on the background of lung contusion developed upper lobe destructive pneumonia with subsequent abscessing and bronchopleural communication (Fig. 4).At the secondary stage of medical care, a sublobar resection of the upper lobe was performed to eliminate the complication, but in the postoperative period, parenchymal sutures failed with the formation of a bronchopleural communication, pleural empyema, which was further complicated by a pleuro-thoracic fistula (Fig. 5).

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The patient underwent videothoracoscopic rehabilitation of the pleural cavity with repeated drainage, valvular occlusion of the upper lobe bronchus, followed by round-the-clock aspiration through the drainage and the application of a vacuum system to the fistula area (Figs. 6,7).The patient recovered.
Pulmonary and pleural complications developed mainly in patients with heterogeneous parenchymal structure determined by computed tomography (88.4%).Both fibrotic and emphysematous areas of the parenchyma were detected and significant standard deviations of density were observed.The areas of the lung that had deviations in density later proved to be the morphological and functional basis for the occurrence of pulmonary and pleural complications.In injuries, the altered, increased density of the parenchyma within 3 to 4 weeks was manifested by pulmonary destruction and the formation of pleural effusion.Ineffective treatment led to the development of acute pleural empyema.
In the case of fibrous or emphysematous unchanged parenchyma, the planning of further treatment took into account the worse compliance of the lungs after endobronchial valve occlusion, provided for collapse therapy and intensification of pleural aspiration in the early period after the main stage.
The endobronchial valve was removed after complete clinical and radiological cure and the absence of pathological foci with a density of 30.0 OH.

Discussion
Undoubtedly, the effectiveness of surgical treatment of patients with destructive lung and pleural pathology depends largely on objective circumstances, among which the place and scope of care are the most important.However, the sufficiency of objective criteria to take into account these circumstances, their definition and implementation in practice carry a significant reserve for increasing the efficiency, reducing the duration and improving the overall results of medical care for these patients.
The bloodiest war in the last 80 years has significantly impaired the functioning of the medical infrastructure, making it particularly difficult to provide highly specialised care to patients.Time, a multifaceted and significant component in the formula for successful treatment, has a significant impact on the effectiveness of surgical treatment.An objective assessment of the patient's condition reduces the time required for both decision-making and repair of damage.Based on the above, we have formulated and substantiated proposals that can improve the efficiency of medical care for a certain contingent of patients.
This work does not take into account the impact of comorbidities on the course of the disease that was the focus of attention, nor does it analyse the impact of trauma severity on the course of traumatic disease.However, the study of the peculiarities of the course of destructive lung and pleu-ral diseases and the identification of its key aspects reveals ways to introduce automated image analysis systems and the use of standardised decision support systems without losing the individualisation of treatment depending on the individual characteristics of each patient.Objectification of morphological changes and stratification of patients will facilitate the implementation of optimal treatment and diagnostic measures based on international experience in providing care and optimal treatment tactics.

Conclusions
1.It is advisable to treat destructive diseases of the lungs and pleura in specialised institutions (thoracic hospitals).
2. Treatment measures at the primary and secondary levels of medical care for patients with destructive lung and pleural diseases should be limited to the scope provided for by the relevant protocols, and should not include lung resection or other surgical interventions to close bronchopleural connections without urgent indications; radical treatment is recommended in highly specialised medical care facilities.
3. In the event of bronchopleurothoracic complications, CT of the chest with the use of specialised applications and FBS allow determining individualised treatment tactics for destructive diseases of the lungs and pleura.
4. Complicated course of pulmonary lesions and development of pulmonary and pleural complications were observed in 88.4% of patients with altered parenchymal structure.
5. Densitometry and analysis of intrathoracic structural changes allow to assess the patient's initial condition, treatment effectiveness and determine the stages of the pathological process.
6.The use of specialised applications for evaluating CT scan data made it possible to assess the preoperative anatomy and condition of the lung, to reconstruct vascular and hollow structures, affected segments and the wound canal, which contributed to the effectiveness of surgical treatment of patients with destructive lung and pleural diseases.
Funding.There were no external sources of funding or support.No honoraria or other compensation was paid.
Author contributions.All authors contributed equally to this work.
Conflict of interest.The authors who participated in this study have declared that they have no conflicts of interest regarding this manuscript.
Consent for publication.All authors have read and approved the final version of the manuscript.All authors have agreed to the publication of this manuscript.
Ethical aspects.All procedures performed in the study with the involvement of patients complied with ethical standards for clinical practice and the Declaration of Helsinki, 1964, as amended.

Fig. 1 .
Fig. 1.CT scan of the chest in standard view.Mine blast injury, shrapnel in the chest wall that penetrated the pleura and lung.Ovals indicate areas of lung contusion.

Fig. 2 :
Fig. 2: CT scan of the chest when viewed with the 3dSlicer viewer (automated report).Mine blast injury, shrapnel in the chest wall that penetrated the pleura and lung.Visualisation of the location, extent of the lung contusion zone, densitometric characteristics of the ROI in the form of an automated table.

Fig. 4 .
Fig. 4. General view of the wound at the beginning of treatment(see text for explanation).

Fig. 7 .
Fig. 7. General view of the wound before treatment.