{"id":1390,"date":"2013-03-25T11:31:23","date_gmt":"2013-03-25T11:31:23","guid":{"rendered":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=1390"},"modified":"2013-06-11T07:16:07","modified_gmt":"2013-06-11T07:16:07","slug":"2-diagnostika-hrudnich-onemocneni-2","status":"publish","type":"page","link":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=1390","title":{"rendered":"2 Diagnostika hrudn\u00edch onemocn\u011bn\u00ed"},"content":{"rendered":"

2.1 Vy\u0161et\u0159ovac\u00ed metody<\/h3>\n

2.1.1 Anamn\u00e9za<\/h4>\n

P\u0159i z\u00edsk\u00e1v\u00e1n\u00ed anamn\u00e9zy se lze dop\u00e1trat v\u011bt\u0161iny symptom\u016f z\u00e1kladn\u00edho onemocn\u011bn\u00ed i velk\u00e9 \u010d\u00e1sti komorbidit. Zna\u010dn\u00fd pod\u00edl kandid\u00e1t\u016f hrudn\u00ed chirurgie trp\u00ed chronickou obstruk\u010dn\u00ed bronchopulmon\u00e1ln\u00ed nemoc\u00ed (CHOPN), \u0159ada z nich m\u00e1 jinou v\u00e1\u017enou chorobu. C\u00edlen\u011b je t\u0159eba v anamn\u00e9ze p\u00e1trat po prob\u011bhl\u00e9 tuberkul\u00f3ze, po diabetes mellitus, kardiovaskul\u00e1rn\u00edch onemocn\u011bn\u00edch, koron\u00e1rn\u00edch p\u0159\u00edhod\u00e1ch, plicn\u00edch interstici\u00e1ln\u00edch chorob\u00e1ch, plicn\u00edch z\u00e1n\u011btech a po trombembolick\u00e9 nemoci. Ka\u0161el je \u010dast\u00fdm dominuj\u00edc\u00edm projevem \u0159ady nitrohrudn\u00edch afekc\u00ed. Ka\u0161el trvaj\u00edc\u00ed d\u00e9le ne\u017e 4 t\u00fddny nebo zm\u011bna jeho charakteru u chronicky poka\u0161l\u00e1vaj\u00edc\u00edho ku\u0159\u00e1ka nut\u00ed vylou\u010dit plicn\u00ed rakovinu. Ka\u0161el v\u00e1zan\u00fd na polknut\u00ed sousta ukazuje na tracheoezofage\u00e1ln\u00ed p\u00ed\u0161t\u011bl, p\u0159i no\u010dn\u00edm ka\u0161li a p\u00e1len\u00ed \u017e\u00e1hy je t\u0159eba vylou\u010dit gastroezofage\u00e1ln\u00ed reflux. Intermitentn\u00ed masivn\u00ed purulentn\u00ed expektorace ukazuje na bronchiekt\u00e1zie, ka\u0161el typicky prov\u00e1z\u00ed embolii plicnice \u010di m\u011bstn\u00e1n\u00ed krve v mal\u00e9m ob\u011bhu p\u0159i levostrann\u00e9 srde\u010dn\u00ed insuficienci. Chronick\u00e1 nebo zvy\u0161uj\u00edc\u00ed se expektorace upozor\u0148uje na chronickou infekci v d\u00fdchac\u00edch cest\u00e1ch. D\u016fle\u017eit\u00e9 je posoudit tak\u00e9 efektivitu expektorace. Bolesti na hrudi mohou b\u00fdt v souvislosti s inflamac\u00ed, nap\u0159\u00edklad u pleuropneumonie, u n\u00e1doru jsou zp\u016fsobeny invaz\u00ed do pohrudnice, skeletu \u010di sval\u016f hrudn\u00ed st\u011bny a \u010dasto jsou v\u00e1z\u00e1ny na ventila\u010dn\u00ed pohyby \u010di ka\u0161el. Je t\u0159eba posoudit dyspnoe, jej\u00ed\u017e z\u00e1va\u017enost pom\u011brn\u011b p\u0159esn\u011b koreluje s limitem kardiorespira\u010dn\u00ed rezervy. Dysfagie prov\u00e1z\u00ed nejen onemocn\u011bn\u00ed samotn\u00e9ho j\u00edcnu, m\u016f\u017ee b\u00fdt tak\u00e9 zp\u016fsobena \u00fatlakem j\u00edcnu zven\u010d\u00ed n\u00e1dorem nebo z\u00e1n\u011btliv\u00fdm procesem, do j\u00edcnu mohou pror\u016fstat nap\u0159. tumory \u0161t\u00edtnice, tracheobronchi\u00e1ln\u00edho stromu, plic i pleury. Chrapot spolu s teplotami a bolestmi v krku ukazuje na infekci, tich\u00fd afebriln\u00ed v\u00fdvoj je op\u011bt suspektn\u00ed z neoplazie kdekoli v pr\u016fb\u011bhu rekurent\u016f. Lev\u00fd vratn\u00fd nerv, kter\u00fd m\u00e1 del\u0161\u00ed cestu mediastinem, m\u016f\u017ee b\u00fdt posti\u017een \u010dast\u011bji. Tak\u00e9 \u00fadajo hemopt\u00fdze je velmi varuj\u00edc\u00ed. Kou\u0159en\u00ed je nep\u0159\u00edzniv\u00fd faktor, kter\u00fd ukazuje na mo\u017en\u00e9 komplikace. Zat\u00edmco neku\u0159\u00e1ci maj\u00ed poopera\u010dn\u00ed plicn\u00ed komplikace do 10 %, t\u011b\u017ec\u00ed ku\u0159\u00e1ci asi ve 40 %. Dal\u0161\u00ed ot\u00e1zka by m\u011bla sm\u011b\u0159ovat k ab\u00fazu alkoholu. Je t\u0159eba se zeptat tak\u00e9 na p\u0159edchoz\u00ed operace, zejm\u00e9na hrudn\u00ed.<\/p>\n

2.1.2 Klinick\u00e9 vy\u0161et\u0159en\u00ed<\/h4>\n

V r\u00e1mci celkov\u00e9ho hodnocen\u00ed je t\u0159eba nep\u0159ehl\u00e9dnout an\u00e9mii, kter\u00e1 prov\u00e1z\u00ed generalizovan\u00e9 plicn\u00ed novotvary. Naopak pletora dan\u00e1 polyglobuli\u00ed m\u016f\u017ee ukazovat na nemoci srdce, plicn\u00edho intersticia \u010di pokro\u010dilou CHOPN. Ikterus ukazuje na metastatick\u00e9 posti\u017een\u00ed jater, psychick\u00e1 a neurologick\u00e1 symptomatologie na metast\u00e1zy karcinomu plic do CNS. P\u0159i vy\u0161et\u0159en\u00ed hlavy a krku m\u016f\u017ee b\u00fdt nalezena Hornerova tri\u00e1da p\u0159i infiltraci kr\u010dn\u00edho sympatiku, c\u00edlen\u011b je t\u0159eba p\u00e1trat po uzlin\u00e1ch na krku i v axil\u00e1ch. Oslaben\u00e9 a vymizel\u00e9 d\u00fdchac\u00ed fenom\u00e9ny a zkr\u00e1cen\u00fd poklep mohou b\u00fdt d\u00e1ny jak infiltrac\u00ed pl\u00edce, tak v\u00fdpotkem. P\u00edskoty a vrzoty nad ob\u011bma k\u0159\u00eddly prov\u00e1zej\u00ed CHOPN, lokalizovan\u00e9 b\u00fdvaj\u00ed u bronchi\u00e1ln\u00edch striktur a bronchiekt\u00e1zi\u00ed. Stridor je p\u0159\u00edznakem t\u011bsn\u00e9ho tracheobronchi\u00e1ln\u00edho z\u00fa\u017een\u00ed. P\u0159i auskultaci srdce je nutn\u00e9 p\u00e1trat po \u0161elestech \u010di patologick\u00fdch ozv\u00e1ch a zachytit odchylky od pravideln\u00e9ho rytmu. P\u0159i vy\u0161et\u0159en\u00ed b\u0159icha lze nahmatat metastaticky posti\u017een\u00e1 j\u00e1tra, p\u0159\u00edpadn\u011b jinou rezistenci v b\u0159i\u0161e. V t\u0159\u00edslech je t\u0159eba p\u00e1trat po uzlin\u00e1ch, na kon\u010detin\u00e1ch pak vy\u0161et\u0159it pulzace tepen a p\u00e1trat po otoc\u00edch.<\/p>\n

2.1.3 Funk\u010dn\u00ed vy\u0161et\u0159en\u00ed plic<\/h4>\n

P\u0159esn\u011bj\u0161\u00ed predikci rizik nitrohrudn\u00edho v\u00fdkonu a mo\u017en\u00fdch komplikac\u00ed umo\u017e\u0148uj\u00ed funk\u010dn\u00ed plicn\u00ed testy. Funk\u010dn\u00ed vy\u0161et\u0159en\u00ed plic sest\u00e1v\u00e1 z vyhodnocen\u00ed respira\u010dn\u00ed mechaniky (spirometrie) a z posouzen\u00ed funkce plicn\u00edho parenchymu (transportu plyn\u016f na alveolokapil\u00e1rn\u00ed membr\u00e1n\u011b).<\/p>\n

Spirometrie<\/h6>\n

Ze spirometrick\u00fdch parametr\u016f byla d\u0159\u00edve pou\u017e\u00edv\u00e1na vit\u00e1ln\u00ed kapacita (VC), st\u0159edn\u00ed v\u00fddechov\u00e1 rychlost FEV 25\u201375 a z objem\u016f minutov\u00e1 ventila\u010dn\u00ed kapacita (MVV). V dne\u0161n\u00ed dob\u011b se vyu\u017e\u00edv\u00e1 ze spirometrick\u00fdch parametr\u016f tak\u0159ka v\u00fdhradn\u011b usilovn\u00fd v\u00fddech objemu za 1 sekundu (FEV1), a to jak v absolutn\u00edch hodnot\u00e1ch (v ml), tak v procentech n\u00e1le\u017eit\u00e9 hodnoty. Empiricky jsou stanoveny hodnoty FEV1, p\u0159i kter\u00fdch jsou provediteln\u00e9 jednotliv\u00e9 typy plicn\u00edch resekc\u00ed s p\u0159ijateln\u00fdm rizikem. Pneumonektomie je akceptovateln\u00e1 p\u0159i FEV1 nad 2,0 l, lobektomie p\u0159i 1,5 l. Je\u0161t\u011b d\u016fle\u017eit\u011bj\u0161\u00ed \u00fadaj je odhadovan\u00e1 poopera\u010dn\u00ed hodnota FEV1 \u2013 ppoFEV1 (projected postoperative FEV1), kterou lze vypo\u010d\u00edtat jako zlomek:<\/p>\n

ppoFEV1 = preFEV1 \u00d7 po\u010det zachovan\u00fdch segment\u016f\/po\u010det v\u0161ech segment\u016f,<\/p>\n

nebo<\/p>\n

ppoFEV1 = preFEV1 \u2013 n \u00d7 preFEV1,
\nkde n je procento perfuze p\u0159edpokl\u00e1dan\u00e9ho rozsahu plicn\u00ed resekce.<\/i><\/p>\n

Hodnota ppoFEV1 800 ml je podle studi\u00ed na emfyzematozn\u00edch pacientech pova\u017eov\u00e1na za nepodkro\u010ditelnou mez pro jakoukoli plicn\u00ed resekci, p\u0159i poklesu FEV1 pod tuto hodnotu doch\u00e1z\u00ed k retenci CO2. Orienta\u010dn\u00ed hodnoty ztr\u00e1ty ventila\u010dn\u00edch funkc\u00ed pro jednotliv\u00e9 typy plicn\u00edch resekc\u00ed lze odhadovat podle rozsahu odstran\u011bn\u00e9ho plicn\u00edho parenchymu. Po pravostrann\u00e9 pneumonektomii lze o\u010dek\u00e1vat ztr\u00e1tu 60 % ventilace, po levostrann\u00e9 40 %. Odstran\u011bn\u00ed jednotliv\u00fdch lalok\u016f indukuje ztr\u00e1tu 10\u201325 % ventila\u010dn\u00ed rezervy, na jeden segment se ode\u010d\u00edt\u00e1 5 %.<\/p>\n

Hodnocen\u00ed funkce plicn\u00edho parenchymu<\/h6>\n

U nemocn\u00fdch s interstici\u00e1ln\u00edmi plicn\u00edmi afekcemi se mohou vyskytovat poruchy transportu krevn\u00edch plyn\u016f na alveolokapil\u00e1rn\u00ed membr\u00e1n\u011b. P\u0159i vy\u0161et\u0159en\u00ed krevn\u00edch plyn\u016f jsou hodnoty PaO2 < 8 kPa (60 mm Hg) nebo PaCO2 > 6 kPa (45 mm Hg) pova\u017eov\u00e1ny za kontraindikaci resekce. Velmi dob\u0159e vyu\u017eiteln\u00fdm testem je i stanoven\u00ed difuzn\u00ed kapacity pro kysli\u010dn\u00edk uhelnat\u00fd (diffusing capacity for carbon monoxid, DLCO). Tato metoda byla p\u016fvodn\u011b vypracov\u00e1na pro posuzov\u00e1n\u00ed difuze, nicm\u00e9n\u011b hodnoty DLCO velmi dob\u0159e koreluj\u00ed s velikost\u00ed celkov\u00e9ho povrchu alveolokapil\u00e1rn\u00ed membr\u00e1ny funk\u010dn\u00ed pl\u00edce. S t\u00edmto parametrem se d\u00e1 pracovat podobn\u011b jako s FEV1, lze po\u010d\u00edtat ppoDLCO (projected postoperative DLCO), hodnota men\u0161\u00ed ne\u017e 40 % kontraindikuje v\u011bt\u0161\u00ed resekci.<\/p>\n

Kardiopulmon\u00e1ln\u00ed funkce<\/h6>\n

Celkov\u00fd stav kardiorespira\u010dn\u00edho apar\u00e1tu lze hodnotit na r\u016fzn\u00fdch \u00farovn\u00edch. Nejjednodu\u0161\u0161\u00edm testem je ch\u016fze do schod\u016f. Tolerance 3 poschod\u00ed bez du\u0161nosti ukazuje na \u00fanosnost pneumonektomie, 2 poschod\u00ed na \u00fanosnost lobektomie. Velmi p\u0159esn\u00fdm ukazatelem je maxim\u00e1ln\u00ed spot\u0159eba kysl\u00edku p\u0159i z\u00e1t\u011b\u017ei VO2max (spiroergomerie, b\u011bhem step-testu, p\u0159i \u0161estiminutov\u00e9m testu ch\u016fze \u2013 six minute walk test \u2013 6MWT). Hodnota 6MWT < jako 2000 krok\u016f odpov\u00edd\u00e1 VO2max pod 15 ml\/kg\/min, koreluje s poklesem saturace O2 v\u00edce ne\u017e 4 %. Tyto hodnoty jsou spojeny se signifikantn\u00edm n\u00e1r\u016fstem morbidity i mortality. Hodnota VO2max pod 10 ml\/kg\/min kontraindikuje jakoukoli plicn\u00ed resekci.<\/p>\n

M\u011b\u0159en\u00ed tlaku v plicnici: klidov\u00e9 hodnoty st\u0159edn\u00edho tlaku v plicnici nad 40 torr nebo elevace nad tuto hodnotu po zasvorkov\u00e1n\u00ed plicnice kontraindikuj\u00ed pneumonektomii.<\/p>\n

P\u0159ehled mezn\u00edch hodnot jednotliv\u00fdch parametr\u016f dovoluj\u00edc\u00edch plicn\u00ed resekci ur\u010dit\u00e9ho rozsahu ukazuje tabulka 1:<\/p>\n

V\u011bt\u0161ina krit\u00e9ri\u00ed byla nastavena empiricky a ov\u011b\u0159ena prax\u00ed na velk\u00e9m po\u010dtu \u00fasp\u011b\u0161n\u011b proveden\u00fdch plicn\u00edch resekc\u00ed. Zat\u00edmco riziko operace u nemocn\u00fdch, kte\u0159\u00ed jsou nad mezn\u00ed hodnotou jednotliv\u00fdch parametr\u016f, dovedeme pom\u011brn\u011b p\u0159esn\u011b odhadnout, kvantifikovat riziko operace u nemocn\u00fdch pod touto hranic\u00ed je velmi obt\u00ed\u017en\u00e9. Existuj\u00ed v\u0161ak i souborn\u00e9 pr\u00e1ce, kter\u00e9 hodnot\u00ed v\u00fdsledky operac\u00ed u nemocn\u00fdch s v\u00e1\u017en\u011bj\u0161\u00ed poruchou kardiorespira\u010dn\u00edho apar\u00e1tu.<\/b><\/p>\n

2.1.4 Celkov\u00e9 hodnocen\u00ed zdravotn\u00edho stavu<\/h4>\n

Jednoduchou \u0161k\u00e1lou, kter\u00e1 hodnot\u00ed celkov\u00fd stav pacienta tak, aby se dala odhadnout mo\u017en\u00e1 progn\u00f3za a eventu\u00e1ln\u00ed tolerance jednotliv\u00fdch terapeutick\u00fdch krok\u016f, je Karnofsk\u00e9ho index (tab. 2).<\/p>\n\n\n\n\n\n\n\n\n\n
Tabulka 1<\/span>
\nMezn\u00ed parametry pro jednotliv\u00e9 plicn\u00ed resekce<\/span><\/td>\n<\/tr>\n
<\/td>\nMVV (%)<\/strong><\/td>\nFEV1 (l)<\/strong><\/td>\nDLCO (%)<\/strong><\/td>\n\n

VO2<\/strong>
\n(ml\/kg\/min)<\/span><\/strong><\/p>\n<\/td>\n

\n

Poschod\u00ed<\/strong>
\n(n)<\/span><\/strong><\/p>\n<\/td>\n<\/tr>\n

Pneumonektomie<\/td>\n55<\/td>\n2,0<\/td>\n60<\/td>\n20<\/td>\n3<\/td>\n<\/tr>\n
Lobektomie<\/td>\n40<\/td>\n1,5<\/td>\n50<\/td>\n15<\/td>\n2<\/td>\n<\/tr>\n
Segmentektomie<\/td>\n35<\/td>\n1,0<\/td>\n45<\/td>\n12<\/td>\n1<\/td>\n<\/tr>\n
P\u0159edpoklad poop<\/td>\n35<\/td>\n0,8<\/td>\n40<\/td>\n10<\/td>\n1<\/td>\n<\/tr>\n
* Zkratky vysv\u011btleny v textu<\/i><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

 <\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
Tabulka 2<\/span>
\n Karnofsk\u00e9ho index<\/span><\/td>\n<\/tr>\n
Definice<\/strong><\/td>\nProcenta<\/strong><\/td>\nKrit\u00e9ria<\/strong><\/td>\n<\/tr>\n
Schopen norm\u00e1ln\u00ed aktivity a pr\u00e1ce, \u017e\u00e1dn\u00e1 speci\u00e1ln\u00ed p\u00e9\u010de nen\u00ed nutn\u00e1<\/td>\n100<\/td>\nNorm\u00e1ln\u00ed stav, bez pot\u00ed\u017e\u00ed<\/td>\n<\/tr>\n
Schopen norm\u00e1ln\u00ed aktivity a pr\u00e1ce, \u017e\u00e1dn\u00e1 speci\u00e1ln\u00ed p\u00e9\u010de nen\u00ed nutn\u00e1<\/td>\n90<\/td>\nSchopen b\u011b\u017en\u00e9 aktivity, men\u0161\u00ed zn\u00e1mky nemoci<\/td>\n<\/tr>\n
Schopen norm\u00e1ln\u00ed aktivity a pr\u00e1ce, \u017e\u00e1dn\u00e1 speci\u00e1ln\u00ed p\u00e9\u010de nen\u00ed nutn\u00e1<\/td>\n80<\/td>\nNorm\u00e1ln\u00ed aktivita s \u00fasil\u00edm, p\u0159\u00edznaky nemoci<\/td>\n<\/tr>\n
Neschopen pr\u00e1ce, schopen \u017e\u00edt doma a postarat se o v\u011bt\u0161inu pot\u0159eb, r\u016fzn\u00e1 pomoc nutn\u00e1<\/td>\n70<\/td>\nObstar\u00e1 se, neschopen pr\u00e1ce, b\u011b\u017en\u00e9 aktivity<\/td>\n<\/tr>\n
Neschopen pr\u00e1ce, schopen \u017e\u00edt doma a postarat se o v\u011bt\u0161inu pot\u0159eb, r\u016fzn\u00e1 pomoc nutn\u00e1<\/td>\n60<\/td>\nV\u011bt\u0161inou se obstar\u00e1, vy\u017eaduje p\u0159\u00edle\u017eitostnou pomoc<\/td>\n<\/tr>\n
Neschopen pr\u00e1ce, schopen \u017e\u00edt doma a postarat se o v\u011bt\u0161inu pot\u0159eb, r\u016fzn\u00e1 pomoc nutn\u00e1<\/td>\n50<\/td>\nVy\u017eaduje soustavnou p\u00e9\u010di a \u010dastou zdravotn\u00ed p\u00e9\u010di<\/td>\n<\/tr>\n
Neschopen postarat se o sebe, vy\u017eaduje zdravotnickou pomoc \u010di hospitalizaci, hroz\u00ed rychl\u00e1 progrese nemoci<\/td>\n40<\/td>\nNeschopn\u00fd, vy\u017eaduje zvl\u00e1\u0161tn\u00ed p\u00e9\u010di<\/td>\n<\/tr>\n
Neschopen postarat se o sebe, vy\u017eaduje zdravotnickou pomoc \u010di hospitalizaci, hroz\u00ed rychl\u00e1 progrese nemoci<\/td>\n30<\/td>\nZ\u00e1va\u017en\u011b omezen\u00fd, hospitalizace indik., smrt nehroz\u00ed<\/td>\n<\/tr>\n
Neschopen postarat se o sebe, vy\u017eaduje zdravotnickou pomoc \u010di hospitalizaci, hroz\u00ed rychl\u00e1 progrese nemoci<\/td>\n20<\/td>\nVelmi nemocn\u00fd, hospitalizace indik., smrt nehroz\u00ed<\/td>\n<\/tr>\n
Neschopen postarat se o sebe, vy\u017eaduje zdravotnickou pomoc \u010di hospitalizaci, hroz\u00ed rychl\u00e1 progrese nemoci<\/td>\n10<\/td>\nMoribundn\u00ed, hroz\u00ed fat\u00e1ln\u00ed pr\u016fb\u011bh<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

2.1.5 Zobrazovac\u00ed metody<\/h4>\n

Skiagram hrudn\u00edku<\/h6>\n

Skiagram hrudn\u00edku je a v nejbli\u017e\u0161\u00ed dob\u011b z\u016fstane z\u00e1kladn\u00ed zobrazovac\u00ed metodou v pneumologii. Krom\u011b standardn\u00ed zadop\u0159edn\u00ed projekce je indikov\u00e1na i projekce bo\u010dn\u00ed z d\u016fvodu mo\u017en\u00e9 sumace centr\u00e1ln\u011b ulo\u017een\u00fdch l\u00e9z\u00ed vlevo se srde\u010dn\u00edm st\u00ednem a baz\u00e1ln\u00edch lo\u017eisek s kupulemi br\u00e1ni\u010dn\u00edmi. Podle nativn\u00edho sn\u00edmku lze v n\u011bkter\u00fdch p\u0159\u00edpadech stanovit t\u00e9m\u011b\u0159 jistou diagn\u00f3zu, n\u011bkdy lze vyslovit suspekci na n\u00e1dorovou l\u00e9zi. Bohu\u017eel, asi 4 % nemocn\u00fdch s plicn\u00edm n\u00e1dorem maj\u00ed sn\u00edmek bez patologie a p\u0159ibli\u017en\u011b u jedn\u00e9 p\u011btiny nemocn\u00fdch s plicn\u00edm novotvarem b\u00fdv\u00e1 l\u00e9ze patrn\u00e1 na sn\u00edmku p\u0159ehl\u00e9dnuta. V \u0159ad\u011b p\u0159\u00edpad\u016f d\u00e1 nativn\u00ed sn\u00edmek informace relevantn\u00ed pro staging (velikost tumoru, lokalizace, p\u0159\u00edtomnost satelitn\u00edch lo\u017eisek, invaze do skeletu \u017eeber, v\u00fdpotek).<\/p>\n\n\n\n
\n

\"Obr.<\/a>

Obr. 1
Karcinom horn\u00edho laloku prav\u00e9 pl\u00edce (skiagram)<\/p><\/div><\/td>\n

\n

\"Obr.<\/a>

Obr. 2
N\u00e1dorov\u00e1 kaverna prav\u00e9 pl\u00edce (CT)<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

Radiologick\u00e1 krit\u00e9ria stanoven\u00e1 v\u00edcem\u00e9n\u011b empiricky pom\u00e1haj\u00ed v diferenci\u00e1ln\u00ed radiologick\u00e9 diagnostice. Pro malignitu sv\u011bd\u010d\u00ed velikost l\u00e9ze nad 3 cm, lokalizace v horn\u00edm laloku, spikulace, nep\u0159\u00edtomnost, resp. excentricita kalcifikac\u00ed, nep\u0159\u00edtomnost satelitn\u00edch l\u00e9z\u00ed, progrese v \u010dase (obr. 1).<\/p>\n

V\u00fdpo\u010detn\u00ed tomografie\u00a0(computed tomography \u2013 CT)<\/h6>\n

Je neju\u017eite\u010dn\u011bj\u0161\u00ed metodou v neinvazivn\u00ed diagnostice plicn\u00edho karcinomu (obr. 2). Vzhledem k tomu, \u017ee je zna\u010dn\u011b z\u00e1visl\u00e1 jak na vlastnostech p\u0159\u00edstroje, tak na zvolen\u00e9m vy\u0161et\u0159ovac\u00edm protokolu, lze takto z\u00edskat kvantitativn\u011b i kvalitativn\u011b rozd\u00edln\u00e9 informace, kter\u00e9 mohou b\u00fdt tak\u00e9 zcela rozd\u00edln\u011b interpretov\u00e1ny. Ka\u017ed\u00fd plicn\u00ed chirurg by m\u011bl b\u00fdt schopen ode\u010d\u00edtat plicn\u00ed skeny s\u00e1m, proto\u017ee m\u00e1 k porovn\u00e1n\u00ed kliniku nemocn\u00e9ho a zku\u0161enost z opakovan\u00fdch konfrontac\u00ed opera\u010dn\u00edch n\u00e1lez\u016f s n\u00e1lezy zobrazovac\u00edch metod. CT je dobr\u00fdm pomocn\u00edkem pro navigaci invazivn\u00edch diagnostick\u00fdch v\u00fdkon\u016f \u2013 transpariet\u00e1ln\u00edch biopsi\u00ed \u010di hrudn\u00edch punkc\u00ed a dren\u00e1\u017e\u00ed (obr. 2).<\/p>\n

Virtu\u00e1ln\u00ed bronchoskopie<\/h6>\n

Postprocesingov\u00e9 zpracov\u00e1n\u00ed \u00fadaj\u016f z po\u010d\u00edta\u010de dovoluje trojdimenzion\u00e1ln\u00ed rekonstrukci. Takto lze vytvo\u0159it nap\u0159. v\u011brn\u00fd obraz pr\u016fdu\u0161kov\u00e9ho stromu (virtu\u00e1ln\u00ed bronchoskopii, kter\u00e1 je v\u00fdhodn\u00e1 u nemocn\u00fdch, kte\u0159\u00ed norm\u00e1ln\u00ed bronchoskopii netoleruj\u00ed), u l\u00e9z\u00ed, kter\u00e9 nejsou bronchoskopem dostupn\u00e9 (za strikturou) v r\u00e1mci poopera\u010dn\u00edch kontrol (obr. 3).<\/p>\n

Magnetick\u00e1 rezonance\u00a0(magnetic resonance imaging, MRI)<\/h6>\n

V r\u00e1mci b\u011b\u017en\u00e9ho klinick\u00e9ho vyu\u017eit\u00ed nep\u0159in\u00e1\u0161\u00ed z\u00e1sadn\u011bj\u0161\u00ed zm\u011bnu kvality informace, m\u00e1 ale v\u00fdhodu nulov\u00e9 radia\u010dn\u00ed z\u00e1t\u011b\u017ee. Samotn\u00e1 pl\u00edce obsahuje m\u00e1lo vody, proto nevytv\u00e1\u0159\u00ed dostate\u010dn\u011b siln\u00fd MR sign\u00e1l. Mediastin\u00e1ln\u00ed uzliny lze diagnostikovat p\u0159esn\u011bji vzhledem k mo\u017enosti zobrazen\u00ed v libovoln\u00e9 rovin\u011b. Jednozna\u010dnou p\u0159ednost p\u0159ed CT m\u00e1 MRI u Pancoastova tumoru, zejm\u00e9na v posouzen\u00ed invaze do \u017eeber, obratl\u016f a brachi\u00e1ln\u00edho plexu a p\u0159\u00edpadn\u00e9 intraspin\u00e1ln\u00ed propagace (obr. 4). Modern\u00ed p\u0159\u00edstroje vybaven\u00e9 pot\u0159ebn\u00fdm softwarem nav\u00edc dovoluj\u00ed s vysokou p\u0159esnost\u00ed zobrazit c\u00e9vn\u00ed struktury. Vy\u0161\u0161\u00ed p\u0159esnost ne\u017e CT dosahuje MRI tak\u00e9 p\u0159i posouzen\u00ed invaze do hrudn\u00ed st\u011bny, br\u00e1nice, mediastina \u010di perikardu.<\/p>\n\n\n\n
\n

\"Obr.<\/a>

Obr. 3
Virtu\u00e1ln\u00ed tracheoskopie po sutu\u0159e ruptury pr\u016fdu\u0161nice s norm\u00e1ln\u00edm n\u00e1lezem<\/p><\/div><\/td>\n

\n

\"Obr.<\/a>

Obr. 4
MRI rekonstrukce po roz\u0161\u00ed\u0159en\u00e9 pravostrann\u00e9 pneumonektomii, \u0161ipka ozna\u010duje zbytkovou pleur\u00e1ln\u00ed dutinu<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

Sonografie<\/h6>\n

Sonografie hrudn\u00edku b\u00fdv\u00e1 n\u011bkdy neopr\u00e1vn\u011bn\u011b opom\u00edjena. Dovoluje nap\u0159\u00edklad diagnostiku v\u00fdpotk\u016f nebo ohrani\u010den\u00fdch nitrohrudn\u00edch kolekc\u00ed, p\u0159\u00edpadn\u011b umo\u017e\u0148uje spolehlivou navigaci p\u0159i punkc\u00edch, biopsi\u00edch \u010di dren\u00e1\u017e\u00edch.<\/p>\n

Scintigrafie skeletu<\/h6>\n

Rutinn\u011b je vyu\u017e\u00edv\u00e1na k vylou\u010den\u00ed kostn\u00edch metast\u00e1z malobun\u011b\u010dn\u00e9ho karcinomu, u nemalobun\u011b\u010dn\u00fdch tumor\u016f je indikov\u00e1na pouze u symptomatick\u00fdch pacient\u016f (bolesti, hmatn\u00e1 lo\u017eiska) a p\u0159i elevaci n\u011bkter\u00fdch s\u00e9rov\u00fdch parametr\u016f (ALP, Ca). Vy\u0161et\u0159en\u00ed samo o sob\u011b je vzhledem ke sv\u00e9 citlivosti zna\u010dn\u011b nespecifick\u00e9 s vysok\u00fdm po\u010dtem fale\u0161n\u011b pozitivn\u00edch v\u00fdsledk\u016f. K detekci lo\u017eisek s patologick\u00fdm kostn\u00edm metabolismem se pou\u017e\u00edv\u00e1 nej\u010dast\u011bji 99 mTc fosf\u00e1tu. Zv\u00fd\u0161en\u00ed akumulace nad 10 % v\u016f\u010di pozad\u00ed je pova\u017eov\u00e1no za patologii. Ov\u011b\u0159en\u00ed n\u00e1lezu je nutn\u00e9, bu\u010f pomoc\u00ed jin\u00fdch zobrazovac\u00edch metod (preferov\u00e1no je MRI), cestou funk\u010dn\u00edch metod (PET, PET-CT), nebo biopticky.<\/p>\n

\"Obr.<\/a>

Obr. 5
Recidiva karcinoidu ve spojn\u00e9m bronchu 15 let po horn\u00ed lobektomii (PET-CT)<\/p><\/div>\n

 <\/p>\n

Pozitronov\u00e1 emisn\u00ed tomografie (PET )<\/h6>\n

Do t\u00e9to metody byly vkl\u00e1d\u00e1ny pom\u011brn\u011b zna\u010dn\u00e9 nad\u011bje, proto\u017ee jde o kombinaci morfologick\u00e9ho a funk\u010dn\u00edho vy\u0161et\u0159en\u00ed, kter\u00e9 by se m\u011blo vyzna\u010dovat vysokou specificitou i senzitivitou. Vyu\u017e\u00edv\u00e1 principu zv\u00fd\u0161en\u00e9ho metabolismu gluk\u00f3zy n\u00e1dorovou tk\u00e1n\u00ed. Po pod\u00e1n\u00ed 18fluoro-2-deoxy-D-gluk\u00f3zy (FDG) doch\u00e1z\u00ed k jej\u00edmu zv\u00fd\u0161en\u00e9mu vychyt\u00e1v\u00e1n\u00ed rychleji metabolizuj\u00edc\u00ed tk\u00e1n\u00ed, tato gluk\u00f3za je fosforylov\u00e1na hexokin\u00e1zou na FDG–6-fosf\u00e1t a d\u00e1le nem\u016f\u017ee b\u00fdt metabolizov\u00e1na. Tento metabolit kumulovan\u00fd v lo\u017eisku vyd\u00e1v\u00e1 beta z\u00e1\u0159en\u00ed \u2013 pozitrony. Ty jsou p\u0159i n\u00e1razu na okoln\u00ed j\u00e1dra anihilov\u00e1ny, emitovan\u00e9 gama paprsky pak lze zachytit krystalov\u00fdmi detektory. PET vykazuje pom\u011brn\u011b vysokou spolehlivost v diferenci\u00e1ln\u00ed diagnostice fok\u00e1ln\u00edch plicn\u00edch l\u00e9z\u00ed o pr\u016fm\u011bru v\u011bt\u0161\u00edm ne\u017e 10 mm. V p\u0159\u00edpad\u011b mediastin\u00e1ln\u00ed lymfadenopatie jsou zat\u00edm v\u00fdsledky rozpa\u010dit\u00e9, nicm\u00e9n\u011b v kombinaci PET-CT b\u00fdv\u00e1 popisov\u00e1na a\u017e 100% specificita a 95% senzitivita (obr. 5). Tak\u00e9 posouzen\u00ed rezidu\u00e1ln\u00ed nemoci po induk\u010dn\u00edch re\u017eimech je kontroverzn\u00ed ot\u00e1zkou. Jak v tumoru, tak i v uzlin\u00e1ch z\u00e1konit\u011b prob\u00edhaj\u00ed reparativn\u00ed zm\u011bny, u kter\u00fdch je nutno p\u0159edpokl\u00e1dat tak\u00e9 zv\u00fd\u0161en\u00fd metabolismus, co\u017e ur\u010dit\u00fdm zp\u016fsobem limituje spolehlivost tohoto vy\u0161et\u0159en\u00ed. Ur\u010dit\u00fdm p\u0159\u00ednosem PET je mo\u017enost vylou\u010dit okultn\u00ed vzd\u00e1len\u00e9 metast\u00e1zy v jedn\u00e9 dob\u011b.<\/p>\n

2.1.6 Bronchoskopie<\/h4>\n

Hrudn\u00ed chirurgii si dnes nelze p\u0159edstavit bez pomoci endoskopie. Rigidn\u00ed bronchoskopie se nyn\u00ed prov\u00e1d\u00ed tak\u0159ka v\u00fdhradn\u011b v terapeutick\u00fdch intenc\u00edch, diagnostick\u00e1 bronchoskopie vyu\u017e\u00edv\u00e1 v\u00fdhod flexibiln\u00edch fibrooptick\u00fdch vl\u00e1ken. Videobronchoskopie nav\u00edc profituje z mo\u017enosti v\u00fdznamn\u00e9ho zv\u011bt\u0161en\u00ed obrazu p\u0159i velmi uspokojiv\u00e9 ostrosti zobrazen\u00ed. B\u00fdv\u00e1 indikov\u00e1na na podklad\u011b suspektn\u00edho rentgenologick\u00e9ho n\u00e1lezu s c\u00edlem opticky, histologicky \u010di cytologicky potvrdit nebo vylou\u010dit patologick\u00fd proces a odhadnout jeho rozsah. Optick\u00fd n\u00e1lez m\u016f\u017ee b\u00fdt neoby\u010dejn\u011b variabiln\u00ed, od nepatrn\u00fdch zm\u011bn a\u017e po exulcerovan\u00e9 krv\u00e1cej\u00edc\u00ed l\u00e9ze obturuj\u00edc\u00ed velk\u00e9 d\u00fdchac\u00ed cesty, nicm\u00e9n\u011b a\u017e 40\u201350 % plicn\u00edch karcinom\u016f je mimo dosah klasick\u00e9 optiky, miniaturizace instrument\u00e1ria v\u0161ak dnes dovoluje nahl\u00e9dnout a\u017e do plicn\u00ed periferie (alveoloskopie). V p\u0159\u00edpad\u011b perifern\u00edch l\u00e9z\u00ed si lze vypomoci pomoc\u00ed MRI navigace. Za p\u0159\u00edm\u00e9 optick\u00e9 zn\u00e1mky n\u00e1doru lze pova\u017eovat exofytick\u00e9 a polyp\u00f3zn\u00ed l\u00e9ze, infiltraci \u010di nepravidelnost endobronchi\u00e1ln\u00ed slizni\u010dn\u00ed v\u00fdstelky \u010di ztr\u00e1tu chrupav\u010dit\u00e9 kresby. Nep\u0159\u00edm\u00e9 zn\u00e1mky jsou d\u00e1ny tlakem n\u00e1doru \u010di uzliny na bronchus z vn\u011bj\u0161ku, projevuj\u00ed se jako z\u00fa\u017een\u00ed nebo roz\u0161\u00ed\u0159en\u00ed kariny. Pomoc\u00ed bronchoskopie lze z\u00edskat materi\u00e1l k cytologick\u00e9mu vy\u0161et\u0159en\u00ed cestou aspirace bronchi\u00e1ln\u00edho sekretu, sond\u00e1\u017ee \u010di v\u00fdplachu bronchu, bronchoalveol\u00e1rn\u00ed lav\u00e1\u017ee, kart\u00e1\u010dkov\u00e9 abraze, punkce n\u00e1doru a transbronchi\u00e1ln\u00ed, resp. transtrache\u00e1ln\u00ed punkce. V\u011bt\u0161\u00ed vzorek k histologick\u00e9mu vy\u0161et\u0159en\u00ed lze v\u011bt\u0161inou z\u00edskat pouze p\u0159\u00edmou, nap\u0159. kl\u00ed\u0161\u0165kovou biopsi\u00ed. Topografick\u00e9 \u00fadaje z\u00edskan\u00e9 touto cestou maj\u00ed z\u00e1sadn\u00ed v\u00fdznam p\u0159i volb\u011b rozsahu resekce u centr\u00e1ln\u00edch n\u00e1dor\u016f a v \u00favaze o bronchoplastick\u00fdch a tracheoplastick\u00fdch v\u00fdkonech. \u010casn\u00e1 diagnostika recidiv v pah\u00fdlu bronchu je bez bronchoskopick\u00fdch kontrol v r\u00e1mci follow-up nemysliteln\u00e1. Na okraj je t\u0159eba zm\u00ednit fluorescen\u010dn\u00ed bronchoskopii, kter\u00e1 vyu\u017e\u00edv\u00e1 bu\u010f rozd\u00edln\u00e9 autofluorescence zdrav\u00e9 a n\u00e1dorov\u00e9 tk\u00e1n\u011b, nebo detekuje fluorescenci fotosenzitivuj\u00edc\u00edch l\u00e1tek v r\u00e1mci fotodynamick\u00e9 diagnostiky. Je\u0161t\u011b modern\u011bj\u0161\u00ed metodou je zobrazen\u00ed \u00fazk\u00fdm svazkem sv\u011btla (narrow band imaging, NBI), kter\u00e9 k identifikaci patologie bronchi\u00e1ln\u00ed sliznice vyu\u017e\u00edv\u00e1 r\u016fznou hloubku odrazu paprsk\u016f sv\u011btla o rozd\u00edln\u00fdch, p\u0159esn\u011b definovan\u00fdch d\u00e9lk\u00e1ch (obr. 6, 7).<\/p>\n\n\n\n
\n

\"Obr.<\/a>

Obr. 6
Flexibiln\u00ed bronchoskop se zdrojem sv\u011btla<\/p><\/div><\/td>\n

\n

\"Obr.<\/a>

Obr. 7
Endobronchi\u00e1ln\u00ed n\u00e1lez karcinomu<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

2.1.7 Endosonografie<\/h4>\n

Endoskopick\u00e1 ultrasonografie si vydobyla svou pozici v kardiologii jako endo-ezofage\u00e1ln\u00ed ultrasonografie (EEUS), v hrudn\u00ed chirurgii lze tuto cestu vyu\u017e\u00edt k diagnostice l\u00e9z\u00ed j\u00edcnu a v jeho t\u011bsn\u00e9m okol\u00ed, nap\u0159\u00edklad k diagnostice mediastin\u00e1ln\u00ed lymfadenopatie. Endobronchi\u00e1ln\u00ed ultrasonografie (EBUS) analogicky dovoluje diagnostiku afekc\u00ed tracheobronchi\u00e1ln\u00edho stromu a lo\u017eisek v jeho bl\u00edzkosti, tedy jak v pl\u00edci, tak v mediastinu. Pokud je vy\u0161et\u0159en\u00ed prov\u00e1d\u011bno radi\u00e1ln\u00ed sondou, zobrazuje v \u0159ezu jednotliv\u00e9 vrstvy st\u011bny vy\u0161et\u0159ovan\u00e9 trubice (j\u00edcnu \u010di pr\u016fdu\u0161ky) a sousedn\u00ed struktury. Za pou\u017eit\u00ed line\u00e1rn\u00ed sondy v real-time modu lze za kontroly obrazu prov\u00e1d\u011bt navigovan\u00e9 biopsie sporn\u00fdch l\u00e9z\u00ed. EEUS a EBUS byly v hrudn\u00ed chirurgii zpopularizov\u00e1ny jako komplement\u00e1rn\u00ed postupy k mediastinoskopii pro invazivn\u00ed staging mediastina u karcinomu plic, proto\u017ee ka\u017ed\u00e1 z vyjmenovan\u00fdch metod m\u00e1 m\u00edsta, kam nedohl\u00e9dne (pro mediastinoskop a EBUS jsou nap\u0159. nedosa\u017eiteln\u00e9 uzliny doln\u00edho kompartmentu, p\u0159i EEUS nelze dohl\u00e9dnout na prav\u00e9 paratrache\u00e1ln\u00ed, p\u0159edn\u00ed mediastin\u00e1ln\u00ed a preaort\u00e1ln\u00ed uzliny).<\/p>\n

2.1.8 Transpariet\u00e1ln\u00ed biopsie<\/h4>\n

T\u00edmto zp\u016fsobem lze ov\u011b\u0159it perifern\u00ed plicn\u00ed l\u00e9ze stejn\u011b jako afekce dosahuj\u00edc\u00ed mediastina nebo vych\u00e1zej\u00edc\u00ed z pleury \u010di hrudn\u00ed st\u011bny. K punkci se pou\u017e\u00edvaj\u00ed tenk\u00e9 jehly (Silverman), tru-cut jehlami lze z\u00edskat v\u00e1le\u010dek tk\u00e1n\u011b k histologick\u00e9mu vy\u0161et\u0159en\u00ed. Zaveden\u00ed jehly je mo\u017en\u00e9 u perifern\u00edch l\u00e9z\u00ed c\u00edlit sonograficky, obvykle se v\u0161ak pou\u017e\u00edv\u00e1 skiaskopick\u00e1 nebo CT navigace.<\/p>\n

Nej\u010dast\u011bj\u0161\u00ed komplikac\u00ed je pneumotorax (20 %), jeho riziko zvy\u0161uje emfyzemat\u00f3zn\u00ed p\u0159estavba pl\u00edce. Pouzepolovina takto zp\u016fsoben\u00fdch pneumotorax\u016f vy\u017eaduje hrudn\u00ed dren\u00e1\u017e. Hemopt\u00fdza se dostavuje asi v 10 % p\u0159\u00edpad\u016f.<\/p>\n

2.2 Chirurgick\u00e9 vy\u0161et\u0159ovac\u00ed metody<\/h3>\n

Biopsie supraklavikul\u00e1rn\u00edch uzlin<\/h6>\n

Jedn\u00e1 se o 3\u20135 cm dlouhou incizi nad medi\u00e1ln\u00edm koncem kl\u00ed\u010dku, kter\u00e1 exponuje preskalenickou tukov\u011b-lymfatickou tk\u00e1\u0148 p\u0159i \u00faponu m. scalenus anterior. P\u0159i preparaci mus\u00ed b\u00fdt \u0161et\u0159en n. frenicus, prob\u00edhaj\u00edc\u00ed po p\u0159edn\u00ed plo\u0161e tohoto svalu. Pot\u0159eba explorovat supraklavikul\u00e1rn\u00ed uzliny je pov\u011bt\u0161inou d\u00e1na pozitivn\u00edm n\u00e1lezem zobrazovac\u00edch metod (USG, CT, PET). V p\u0159\u00edpad\u011b dob\u0159e hmatn\u00e9 uzliny nad kl\u00ed\u010dkem je v\u011bt\u0161inou dostate\u010dn\u00e1 punk\u010dn\u00ed biopsie, negativn\u00ed histopatologick\u00fd n\u00e1lez indikuje chirurgickou biopsii. Pozitivita supraklavikul\u00e1rn\u00ed uzliny u rakoviny plic ur\u010duje N3 lymfadenopatii, u karcinomu \u017ealudku (Sorgiusova uzlina) jde o vzd\u00e1lenou metast\u00e1zu, v obou p\u0159\u00edpadech se jedn\u00e1 o inoperabiln\u00ed stav.<\/p>\n

Mediastinoskopie<\/h6>\n
\"Obr.<\/a>

Obr. 8
Biopsie bifurka\u010dn\u00edch uzlin cestou klasick\u00e9 mediastinoskopie<\/p><\/div>\n

Ko\u017en\u00ed \u0159ez je veden 2 cm nad jugulem ve vhodn\u00e9 ko\u017en\u00ed \u0159ase. Ost\u0159e se prot\u00edn\u00e1 m. platysma a\u017e k \u00fapon\u016fm m. sternocleidomastoideus. Infrahyoidn\u00ed svaly je mo\u017en\u00e9 ve st\u0159edn\u00ed \u010d\u00e1\u0159e rozd\u011blit a mobilizovat later\u00e1ln\u011b. Tupou preparac\u00ed se odhrne pretrache\u00e1ln\u00ed tuk a pronikne k pretrache\u00e1ln\u00ed fascii. Levou brachiocephalickou \u017e\u00edlu, a. anonymu a dist\u00e1ln\u011bji oblouk aorty je nutn\u00e9 odtla\u010dit prstem od pr\u016fdu\u0161nice ventr\u00e1ln\u011b. Po zaveden\u00ed mediastinoskopu lze bioptovat paratrache\u00e1ln\u00ed a p\u0159edn\u00ed bifurka\u010dn\u00ed uzliny (obr. 8). Mediastinoskopie tedy m\u016f\u017ee u karcinomu plic rozli\u0161it N2 a N3 posti\u017een\u00ed, a pokud jsou bioptov\u00e1ny hilov\u00e9 uzliny (pozice 10), lze rozli\u0161it mezi posti\u017een\u00edm N1 a N2 uzlin. V ur\u010dit\u00fdch situac\u00edch m\u016f\u017ee b\u00fdt mediastinoskopie n\u00e1pomocna v posouzen\u00ed resekability centr\u00e1ln\u00edch n\u00e1dor\u016f, zejm\u00e9na n\u00e1dor\u016f v prav\u00e9m tracheobronchi\u00e1ln\u00edm \u00fahlu (diagn\u00f3za invaze do horn\u00ed dut\u00e9 \u017e\u00edly \u010di do st\u011bny pr\u016fdu\u0161nice). Za obecnou indikaci mediastinoskopie se d\u00e1le pova\u017euje diferenci\u00e1ln\u00ed diagnostika lymfadenopati\u00ed a tumor\u016f p\u0159edn\u00edho mediastina. Diagnostick\u00e1 v\u00fdt\u011b\u017enost mediastinoskopie je limitov\u00e1na t\u00edm, \u017ee uzliny pod\u00e9l a p\u0159ed obloukem aorty (pozice 5 a 6), stejn\u011b jako uzliny doln\u00edho mediastin\u00e1ln\u00edho kompartmentu (zadn\u00ed bifurka\u010dn\u00ed z pozice 7, pozice 8 a 9) jsou touto cestou nedostupn\u00e9. Videomediastinoskopie m\u00e1 v\u00fdhodu zv\u011bt\u0161en\u00ed obrazu na monitoru.<\/p>\n

Mediastinotomie<\/h6>\n

Parastern\u00e1ln\u00ed mediastinotomie (Chamberlainova operace) slou\u017eila v d\u0159\u00edv\u011bj\u0161\u00ed dob\u011b k diferenci\u00e1ln\u00ed diagnostice uzlinov\u00fdch syndrom\u016f a tumor\u016f p\u0159edn\u00edho mediastina. V klasick\u00e9 podob\u011b se jedn\u00e1 o \u0161esticentimetrovou incizi nad chrupav\u010ditou \u010d\u00e1st\u00ed 2. \u017eebra, po jej\u00ed resekci je t\u0159eba ligovat mamm\u00e1rn\u00ed c\u00e9vn\u00ed svazek a proniknout extrapleur\u00e1ln\u011b do mediastina. V dne\u0161n\u00ed dob\u011b tento p\u0159\u00edstup do zna\u010dn\u00e9 m\u00edry supluj\u00ed m\u00e9n\u011b invazivn\u00ed operace (mediastinoskopie, VTS, VATS). Pokud v\u0161ak tyto alternativy sel\u017eou, je tato cesta pln\u011b opr\u00e1vn\u011bn\u00e1 zejm\u00e9na k biopsii tumor\u016f p\u0159edn\u00edho mediastina nebo k posouzen\u00ed lymfadenopatie v aortopulmon\u00e1ln\u00edm ok\u00e9nku \u010di mediastin\u00e1ln\u00ed invaze u tumor\u016f horn\u00edho laloku vlevo.<\/p>\n

Torakoskopie a videotorakoskopie<\/h6>\n
\"Obr.<\/a>

Obr. 9
Porty pro videotorakoskopii v poloze na z\u00e1dech pro operaci v p\u0159edn\u00edm mediastinu<\/p><\/div>\n

Videotorakoskopie v posledn\u00ed dob\u011b nahradila jednostrann\u00e9 postupy (p\u0159edn\u00ed mediastinotomii, p\u0159edn\u00ed mediastinoskopii) a v n\u011bkter\u00fdch indikac\u00edch z\u010d\u00e1sti i klasickou mediastinoskopii (obr. 9). Zpravidla b\u00fdv\u00e1 indikov\u00e1na k definitivn\u00ed diagnostice plicn\u00edch a pleur\u00e1ln\u00edch proces\u016f a uzlin nedostupn\u00fdch mediastinoskopi\u00ed (uzliny aortopulmon\u00e1ln\u00ed, preaort\u00e1ln\u00ed pozice 5 a 6 a uzliny doln\u00edho mediastin\u00e1ln\u00edho kompartmentu pozice 8 a 9). Krom\u011b stagingu uzlinov\u00e9ho posti\u017een\u00ed m\u016f\u017ee p\u0159in\u00e9st tak\u00e9 z\u00e1sadn\u00ed informace o resekabilit\u011b tumoru, event. jeho generalizaci.Podm\u00ednkou pro videotorakoskopii je kolaps pl\u00edce na operovan\u00e9 stran\u011b. Obvykle se zav\u00e1d\u011bj\u00ed dva 10milimetrov\u00e9 pracovn\u00ed kan\u00e1ly, jeden pro optiku a druh\u00fd pro pracovn\u00ed n\u00e1stroj. P\u0159i pot\u0159eb\u011b adheziol\u00fdzy, preparace \u010di manipulace s pl\u00edc\u00ed je mo\u017en\u00e9 zav\u00e9st dal\u0161\u00ed porty, obvykle men\u0161\u00edho pr\u016fsvitu.Po videotorakoskopii se obvykle dr\u00e9nuje pohrudni\u010dn\u00ed dutina.<\/p>\n

Torakotomie<\/h6>\n

V\u0161echny v\u00fd\u0161e uveden\u00e9 metody vedou ke spr\u00e1vn\u00e9 diagn\u00f3ze a p\u0159\u00edpadn\u011b k ur\u010den\u00ed stadia nemoci a\u017e v 90 % p\u0159\u00edpad\u016f. Jinak nezb\u00fdv\u00e1 ne\u017e se uch\u00fdlit k probatorn\u00ed torakotomii, kter\u00e1 dovoluje korelovat n\u00e1lezy paraklinick\u00fdch vy\u0161et\u0159en\u00ed se skute\u010dn\u00fdm rozsahem prim\u00e1rn\u00edho n\u00e1doru, potvrdit \u010di vylou\u010dit jeho operabilitu, posoudit afekce na pleu\u0159e \u010di v mediastinu nebo vyhodnotit stav stejnostrann\u00fdch mediastin\u00e1ln\u00edch uzlin.<\/p>\n

2.3 Opera\u010dn\u00ed p\u0159\u00edstupy do hrudn\u00edku<\/span><\/h3>\n
Torakotomie<\/h6>\n

Anterolater\u00e1ln\u00ed torakotomie<\/strong><\/p>\n

Dovoluje v\u00fdkony na horn\u00edm a st\u0159edn\u00edm laloku prav\u00e9 pl\u00edce, men\u0161\u00ed kardiochirurgick\u00e9 operace \u010di reoperace a p\u0159\u00edmou srde\u010dn\u00ed mas\u00e1\u017e. Cestou oboustrann\u00e9 p\u0159edn\u00ed torakotomie, p\u0159\u00edpadn\u011b torakosternotomie lze prov\u00e9st oboustrannou plicn\u00ed transplantaci. Vhodn\u00e1 poloha je na z\u00e1dech s podlo\u017een\u00edm operovan\u00e9 strany. Ko\u017en\u00ed \u0159ez je veden nad 4. mezi\u017eeb\u0159\u00edm v submamm\u00e1rn\u00ed r\u00fdze od sternoklavikul\u00e1rn\u00edho sklouben\u00ed po p\u0159edn\u00ed axil\u00e1rn\u00ed \u010d\u00e1ru. Tk\u00e1\u0148 prsu je uvoln\u011bna v nezbytn\u00e9 m\u00ed\u0159e a mobilizov\u00e1na proxim\u00e1ln\u011b od pektor\u00e1ln\u00ed fascie, disekce dist\u00e1ln\u00edch stern\u00e1ln\u00edch \u00fapon\u016f m. pectoralis major dovoluje odsunout tento sval proxim\u00e1ln\u011b. Interkost\u00e1ln\u00ed svaly se prot\u00ednaj\u00ed p\u0159i horn\u00ed hran\u011b \u017eebra. Pro z\u00edsk\u00e1n\u00ed \u0161ir\u0161\u00edho p\u0159\u00edstupu si lze pomoci prot\u011bt\u00edm \u017eebern\u00ed chrupavky a p\u0159eru\u0161en\u00edm interkost\u00e1ln\u00ed svaloviny a pleury later\u00e1ln\u011b daleko za hranici ko\u017en\u00edho \u0159ezu. V later\u00e1ln\u00edch parti\u00edch torakotomie je pak nutno protnout medi\u00e1ln\u00ed partie m. serratus anterior (obr. 10).<\/p>\n

Posterolater\u00e1ln\u00ed torakotomie<\/strong><\/p>\n

Je klasick\u00fdm p\u0159\u00edstupem k v\u011bt\u0161\u00edm plicn\u00edm resekc\u00edm vyjma apik\u00e1ln\u00edch l\u00e9z\u00ed. Dovoluje tak\u00e9 v\u00fdkony na hrudn\u00edm \u00faseku pr\u016fdu\u0161nice, j\u00edcnu, na srdci a na descendentn\u00ed aort\u011b. Touto cestou se tak\u00e9 prov\u00e1d\u011bj\u00ed jednostrann\u00e9 plicn\u00ed transplantace. Nemocn\u00fd le\u017e\u00ed na opa\u010dn\u00e9m boku, m\u00edrn\u011b vyto\u010den vp\u0159ed, na stole lomen\u00e9m v tup\u00e9m \u00fahluv \u00farovni \u00fahlu lopatky, co\u017e dovoluje rozvinut\u00ed interkost\u00e1ln\u00edch prostor. D\u016fle\u017eit\u00e1 je fixace nemocn\u00e9ho ke stolu a vyv\u00e1z\u00e1n\u00ed pa\u017e\u00ed dop\u0159edu, kter\u00e9 vyt\u00e1hne margo vertebralis scapulae. Ko\u017en\u00ed \u0159ez sleduje p\u0159ibli\u017en\u011b zvolen\u00fd interkost\u00e1ln\u00ed prostor, za\u010d\u00edn\u00e1 v p\u0159edn\u00ed axil\u00e1rn\u00ed linii a ot\u00e1\u010d\u00ed se kolem \u00fahlu lopatky. Pod k\u016f\u017e\u00ed a podko\u017e\u00edm je masivn\u00ed \u0161irok\u00e1 svalovina m. latissimus dorsi, kterou je t\u0159eba protnout v cel\u00e9 \u0161\u00ed\u0159i. Dorz\u00e1ln\u011b se pak prot\u00edn\u00e1 ventr\u00e1ln\u00ed \u010d\u00e1st m. trapezius. Dist\u00e1ln\u00ed dekonexe m. serratus anterior obna\u017e\u00ed \u017eebra v rozsahu \u2154 torakotomie. Uvoln\u011bn\u00ed tohoto svalu od m. latissimus dorsi a od hrudn\u00ed st\u011bny je ale v\u011bt\u0161inou dosta\u010duj\u00edc\u00ed pro z\u00edsk\u00e1n\u00ed p\u0159ehledu a pro uspokojiv\u00e9 rozev\u0159en\u00ed torakotomie (obr. 11).<\/p>\n\n\n\n
\n

\"Obr.<\/a>

Obr. 10
Anterolater\u00e1ln\u00ed torakotomie<\/p><\/div><\/td>\n

\n

\"Obr.<\/a>

Obr. 11
Posterolater\u00e1ln\u00ed torakotomie<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Axil\u00e1rn\u00ed (Atkinsova) torakotomie<\/strong><\/p>\n

V dne\u0161n\u00ed dob\u011b m\u00e1 pouze z\u0159\u00eddkav\u00e9 uplatn\u011bn\u00ed. D\u0159\u00edve byla elegantn\u00edm p\u0159\u00edstupem k hrudn\u00edmu sympatiku \u010di apexu pl\u00edce posti\u017een\u00e9mu bul\u00f3zn\u00edm emfyz\u00e9mem. Dnes jsou tyto indikace tak\u0159ka v pln\u00e9 re\u017eii miniinvazivn\u00edch postup\u016f, nicm\u00e9n\u011b ur\u010ditou renesanci tato torakotomie zaznamenala v r\u00e1mci VTS a VATS, kdy lze touto cestou vyjmout z hrudn\u00edku plicn\u00ed tk\u00e1\u0148 neodstranitelnou portem \u010di minitorakotomi\u00ed. Poloha nemocn\u00e9ho na stole je later\u00e1ln\u00ed s pa\u017e\u00ed abdukovanou do 90\u00b0 a vyv\u00e1zanou na hrazdu. Obloukovit\u00fd ko\u017en\u00ed \u0159ez je veden v doln\u00ed partii medi\u00e1ln\u00ed st\u011bny axily mezi svalov\u00fdmi valy m. pectoralis a m. latissimus dorsi. Tukov\u00e1 tk\u00e1\u0148 axily je odpreparov\u00e1na tup\u011b vzh\u016fru za identifikace n. intercostobrachialis, kter\u00fd ozna\u010duje 2. mezi\u017eeb\u0159\u00ed, a za \u0161et\u0159en\u00ed n. thoracicus longus, kter\u00fd prob\u00edh\u00e1 st\u0159edem opera\u010dn\u00edho pole. P\u0159\u00edstup do hrudn\u00edku je sjedn\u00e1n 3. mezi\u017eeb\u0159\u00edm, interkost\u00e1ln\u00ed svalovina a pleura jsou protnuty v rozsahu p\u0159esahuj\u00edc\u00edm linii ko\u017en\u00edho \u0159ezu.<\/p>\n

\"Obr.<\/a>

Obr. 12
Pod\u00e9ln\u00e1 sternotomie<\/p><\/div>\n

Sternotomie<\/h6>\n

St\u0159edn\u00ed sternotomie<\/strong><\/p>\n

Byla vypracov\u00e1na pro \u0159e\u0161en\u00ed mediastin\u00e1ln\u00ed tuberkul\u00f3zy. Dnes je nejobvyklej\u0161\u00edm p\u0159\u00edstupem kardiochirugick\u00fdm a ve v\u0161eobecn\u00e9 hrudn\u00ed chirurgii je obl\u00edbena pro jednoduchost a v\u0161eobecnou pou\u017eitelnost. Ze sternotomie lze p\u0159ehledn\u011b prov\u00e9st v\u011bt\u0161inu anatomick\u00fdch plicn\u00edch resekc\u00ed s v\u00fdjimkou lev\u00e9ho doln\u00edho laloku. Tento p\u0159\u00edstup umo\u017e\u0148uje \u0159e\u0161it tumory p\u0159edn\u00edho mediastina, retrostern\u00e1ln\u00ed strumy, afekce kr\u010dn\u00edho a hrudn\u00edho \u00faseku pr\u016fdu\u0161nice i komplikace hojen\u00ed t\u011bchto struktur. Je v\u00fdhodn\u00fd i pro sanaci oboustrann\u00fdch afekc\u00ed (metast\u00e1z, bul\u00f3zn\u00edho emfyz\u00e9mu).<\/p>\n

Poloha nemocn\u00e9ho je na z\u00e1dech s podlo\u017een\u00edm pod lopatkami. Ko\u017en\u00ed \u0159ez je veden od jugula pod me\u010d\u00edk. Elektrokauterem jsou protnuty interklavikul\u00e1rn\u00ed vazy, pektor\u00e1ln\u00ed fascie, periost sterna a linea alba. Tupou preparac\u00ed je pak otev\u0159en retrostern\u00e1ln\u00ed prostor shora (s ohledem na brachiocefalickou \u017e\u00edlu a a. anonyma) a zdola pod me\u010d\u00edkem. Po vizualizaci st\u0159edn\u00ed linie je protnuta kost mechanick\u00fdm, pneumatick\u00fdm \u010di elektrick\u00fdm sternotomem (obr. 12). Stern\u00e1ln\u00ed rozv\u011bra\u010d je doporu\u010deno nasazovat na doln\u00ed partii sternotomie z d\u016fvodu prevence poran\u011bn\u00ed plexus brachialis.<\/p>\n

Parci\u00e1ln\u00ed sternotomie, sternotorakotomie<\/strong><\/p>\n

Parci\u00e1ln\u00ed sternotomie dovoluje operovat men\u0161\u00ed l\u00e9ze v horn\u00edm p\u0159edn\u00edm mediastinu (nap\u0159. thymus, retrostern\u00e1ln\u00ed struma, trachea). Parci\u00e1ln\u00ed sternotomie s paraleln\u00edmi incizemi supraklavikul\u00e1rn\u011b a infraklavikul\u00e1rn\u011b (interkost\u00e1ln\u011b) p\u0159ipom\u00edn\u00e1 otev\u0159enou knihu, a tak je i naz\u00fdv\u00e1na (open book incision). Princip sternotomie je analogick\u00fd, jak je pops\u00e1no v\u00fd\u0161e, supraklavikul\u00e1rn\u00ed incize dovoluje expozici apik\u00e1ln\u00edch struktur shora a infraklavikul\u00e1rn\u00ed zevnit\u0159, v\u010detn\u011b hilov\u00fdch struktur pl\u00edce. Poloha nemocn\u00e9ho je na z\u00e1dech, s elevac\u00ed doty\u010dn\u00e9 strany asi o 20\u00b0. Samotn\u00e1 sternotomie dosahuje v\u011bt\u0161inou 3. nebo 4. mezi\u017eeb\u0159\u00ed a v t\u00e9to v\u00fd\u0161i se lom\u00ed later\u00e1ln\u011b (obr. 13).<\/p>\n

Torakosternotomie (clamshell incision)<\/strong><\/p>\n

Jedn\u00e1 se o extenzivn\u00ed p\u0159\u00edstup vyu\u017e\u00edvan\u00fd p\u0159i oboustrann\u00fdch plicn\u00edch transplantac\u00edch, m\u00e9n\u011b v kardiochirurgii, p\u0159i operac\u00edch oboustrann\u00fdch plicn\u00edch l\u00e9z\u00ed a p\u0159i t\u011b\u017ek\u00fdch hrudn\u00edch traumatech (obr. 14). Poloha nemocn\u00e9ho je na z\u00e1dech na podlo\u017een\u00ed ve tvaru H (v\u00e1lec pod rameny, pod p\u00e1te\u0159\u00ed a pod p\u00e1nv\u00ed). To umo\u017e\u0148uje roz\u0161\u00ed\u0159it torakotomii dostate\u010dn\u011b later\u00e1ln\u011b. Ko\u017en\u00ed \u0159ez je veden bilater\u00e1ln\u011b submamm\u00e1rn\u011b, je vyhled\u00e1no 4. mezi\u017eeb\u0159\u00ed, v n\u011bm podv\u00e1z\u00e1ny mamm\u00e1rn\u00ed c\u00e9vy a sternum\u00a0je mezi t\u011bmito mezi\u017eeb\u0159\u00edmi protnuto. Z\u00edskan\u00fd p\u0159ehled o srdci, velk\u00fdch c\u00e9v\u00e1ch, p\u0159edn\u00edm mediastinu a plicn\u00edch hilov\u00fdch struktur\u00e1ch je ide\u00e1ln\u00ed. Sutura sternotorakotomie mus\u00ed b\u00fdt velmi zodpov\u011bdn\u00e1 zejm\u00e9na u imunosuprimovan\u00fdch pacient\u016f po transplantaci, ale i tak se \u010dasto (asi v 10 % p\u0159\u00edpad\u016f) komplikuje.<\/p>\n\n\n\n
\n

\"Obr.<\/a>

Obr. 13
Parci\u00e1ln\u00ed sternotorakotomie<\/p><\/div><\/td>\n

\n

\"Obr.

Obr. 14
Torakosternotomie<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

2.4 Literatura<\/h3>\n
    \n
  1. Ginsberg RJ. Atlas of clinical oncology. Lung cancer. Hamilton: BC Decker Inc; 2002.<\/li>\n
  2. Klein J. Chirurgie karcinomu plic. Praha: GradaPublishing; 2006.<\/li>\n
  3. Kolek V, Ka\u0161\u00e1k V. Pneumologie. Praha: Maxdorf;2010.<\/li>\n
  4. Pafko P, Lischke R, et al. Plicn\u00ed chirurgie. Opera\u010dn\u00edmanu\u00e1l. Praha : Gal\u00e9n; 2010.<\/li>\n
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    2.1 Vy\u0161et\u0159ovac\u00ed metody 2.1.1 Anamn\u00e9za P\u0159i z\u00edsk\u00e1v\u00e1n\u00ed anamn\u00e9zy se lze dop\u00e1trat v\u011bt\u0161iny symptom\u016f z\u00e1kladn\u00edho onemocn\u011bn\u00ed i velk\u00e9 \u010d\u00e1sti komorbidit. Zna\u010dn\u00fd pod\u00edl kandid\u00e1t\u016f hrudn\u00ed chirurgie trp\u00ed chronickou obstruk\u010dn\u00ed bronchopulmon\u00e1ln\u00ed nemoc\u00ed (CHOPN), \u0159ada z nich m\u00e1 jinou v\u00e1\u017enou chorobu. C\u00edlen\u011b je t\u0159eba v anamn\u00e9ze p\u00e1trat po prob\u011bhl\u00e9 tuberkul\u00f3ze, po diabetes mellitus, kardiovaskul\u00e1rn\u00edch onemocn\u011bn\u00edch, koron\u00e1rn\u00edch p\u0159\u00edhod\u00e1ch, plicn\u00edch interstici\u00e1ln\u00edch […]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":1347,"menu_order":10,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-1390","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1390","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1390"}],"version-history":[{"count":20,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1390\/revisions"}],"predecessor-version":[{"id":1664,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1390\/revisions\/1664"}],"up":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1347"}],"wp:attachment":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1390"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}