{"id":1418,"date":"2013-03-25T11:34:00","date_gmt":"2013-03-25T11:34:00","guid":{"rendered":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=1418"},"modified":"2013-06-11T07:23:17","modified_gmt":"2013-06-11T07:23:17","slug":"3-onemocneni-hrudni-steny-a-pohrudnice-2","status":"publish","type":"page","link":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=1418","title":{"rendered":"3 Onemocn\u011bn\u00ed hrudn\u00ed st\u011bny a pohrudnice"},"content":{"rendered":"<h3>3.1 Anatomie hrudn\u00ed st\u011bny a pleur\u00e1ln\u00ed dutiny<\/h3>\n<p style=\"text-align: justify;\">Hrudn\u00edk m\u00e1 tvar komol\u00e9ho ku\u017eele ohrani\u010den\u00e9ho horn\u00ed hrudn\u00ed aperturou, muskuloskelet\u00e1ln\u00edmi komponentami hrudn\u00edho ko\u0161e a doln\u00ed hrudn\u00ed \u00a0aperturou. Horn\u00ed hrudn\u00ed apertura topografcky, ne anatomicky, odd\u011bluje kr\u010dn\u00ed prostor od hrudn\u00edku, m\u00e1 ledvinovit\u00fd tvar, tvo\u0159\u00ed ji manubrium sterna, kostoklavikul\u00e1rn\u00ed sklouben\u00ed, prvn\u00ed dv\u011b \u017eebra a t\u011blo 1. hrudn\u00edho obratle. Horn\u00ed hrudn\u00ed aperturou prob\u00edh\u00e1 \u0159ada d\u016fle\u017eit\u00fdch struktur (j\u00edcen, trachea, tepny oblouku aorty, p\u0159\u00edtoky horn\u00ed dut\u00e9 \u017e\u00edly, br\u00e1ni\u010dn\u00ed, bloudiv\u00e9 a vratn\u00e9 nervy). Kupula pleur\u00e1ln\u00ed a apex pl\u00edce na obou stran\u00e1ch dosahuj\u00ed nad \u00farove\u0148 horn\u00ed hrudn\u00ed apertury, jsou kryty \u010d\u00e1st\u00ed hlubok\u00e9 kr\u010dn\u00ed fascie (suprapleur\u00e1ln\u00ed, Sibsonovy). Kost\u011bn\u00e1 \u010d\u00e1st hrudn\u00edho ko\u0161e je tvo\u0159ena hrudn\u00ed kost\u00ed, kter\u00e1 se skl\u00e1d\u00e1 z rukojeti, t\u011bla a me\u010d\u00edku. Rukoje\u0165 (manubrium sterni) je skloubena s kl\u00ed\u010dky a chrupavkami prvn\u00edch \u017eeber. T\u011blo (corpus) hrudn\u00ed kosti artikuluje s 2.\u20137. \u017eebrem. Me\u010d\u00edk (processus xiphoideus) je chrupav\u010dit\u00fd, osifkuje po 30. roce \u017eivota. Nikdy neosifkuj\u00edc\u00ed osteochondr\u00e1ln\u00ed junkce (a kostovertebr\u00e1ln\u00ed klouby) dovoluj\u00ed ventila\u010dn\u00ed pohyby hrudn\u00ed st\u011bny. Prvn\u00edch 7 p\u00e1r\u016f \u017eeber naz\u00fdv\u00e1me prav\u00fdmi, proto\u017ee jsou skloubeny p\u0159\u00edmo se sternem. Osm\u00e1, dev\u00e1t\u00e1 a des\u00e1t\u00e1 \u017eebra ozna\u010dujeme jako neprav\u00e1, proto\u017ee jejich chrupavky spoluutv\u00e1\u0159ej\u00ed \u017eebern\u00ed oblouk, na sternum se neup\u00ednaj\u00ed. 11. a 12. p\u00e1r \u017eeber je voln\u00fd, tato \u017eebra artikuluj\u00ed pouze s p\u0159\u00edslu\u0161n\u00fdmi obratli. Br\u00e1nice odd\u011bluje hrudn\u00edk od b\u0159i\u0161n\u00ed dutiny na \u00farovni me\u010d\u00edku, \u017eebern\u00edho oblouku, 12. p\u00e1ru \u017eeber a 12. obratle (doln\u00ed hrudn\u00ed apertura).<\/p>\n<p style=\"text-align: justify;\">Dutina hrudn\u00ed je zevnit\u0159 vystl\u00e1na pariet\u00e1ln\u00ed pleurou (pohrudnic\u00ed), kter\u00e1 kryje kupulu jako pleura cervik\u00e1ln\u00ed, \u017eebr\u016fm odpov\u00edd\u00e1 pleura kost\u00e1ln\u00ed, br\u00e1nici dia\ue02cragmatick\u00e1, mediastinu pak mediastin\u00e1ln\u00ed. Pohrudnice p\u0159ech\u00e1z\u00ed v oblasti plicn\u00edch hil\u016f a plicn\u00edho ligamenta na pl\u00edci, kterou pokr\u00fdv\u00e1 v\u010detn\u011b interlob\u00e1rn\u00edch z\u00e1\u0159ez\u016f jako pleura viscer\u00e1ln\u00ed (poplicnice). Mezi ob\u011bma pleurami je \u0161t\u011brbinovit\u00fd prostor vypln\u011bn\u00fd nepatrn\u00fdm mno\u017estv\u00edm ser\u00f3zn\u00ed pleur\u00e1ln\u00ed tekutiny, kter\u00e1 dovoluje pl\u00edci klouzat v hrudn\u00edm ko\u0161i b\u011bhem respira\u010dn\u00edch pohyb\u016f. V klidu je v pleur\u00e1ln\u00ed dutin\u011b negativn\u00ed tlak p\u0159ibli\u017en\u011b \u20135 cm H20, kter\u00fd m\u016f\u017ee p\u0159i usilovn\u00e9m n\u00e1dechu klesnout a\u017e na \u201360 cm H2O, p\u0159i Valsalvov\u011b man\u00e9vru lze vyvinout p\u0159etlak kolem + 40 cm H20. P\u0159i klidov\u00e9 respiraci osciluje tlak v pleur\u00e1ln\u00edm prostoru mezi \u201315 a 0 cm H2O.<\/p>\n<h3>3.2 Onemocn\u011bn\u00ed hrudn\u00ed st\u011bny<\/h3>\n<h4>3.2.1 Vrozen\u00e9 vady a deformity<\/h4>\n<p>Vrozen\u00e9 vady hrudn\u00edku postihuj\u00ed nej\u010dast\u011bji p\u0159edn\u00ed hrudn\u00ed st\u011bnu, d\u011bl\u00edme je do \u010dty\u0159 skupin:<\/p>\n<ul>\n<li>vp\u00e1\u010den\u00fd hrudn\u00edk (pectus excavatum),<\/li>\n<li>pta\u010d\u00ed hrudn\u00edk (pectus carinatum),<\/li>\n<li>Poland\u016fv syndrom,<\/li>\n<li>roz\u0161t\u011bp sterna (v\u010detn\u011b ectopia cordis).<\/li>\n<\/ul>\n<h5>3.2.1.1 Vp\u00e1\u010den\u00fd hrudn\u00edk (pectus excavatum)<\/h5>\n<p style=\"text-align: justify;\">Jedn\u00e1 se o nej\u010dast\u011bj\u0161\u00ed vrozenou deformitu hrudn\u00edku s incidenc\u00ed p\u0159ibli\u017en\u011b 1\/400 narozen\u00fdch. Je 4\u00d7 \u010dast\u011bj\u0161\u00ed u chlapc\u016f, v\u011bt\u0161ina onemocn\u011bn\u00ed je diagnostikov\u00e1na v prvn\u00edch letech \u017eivota. Patofyziologick\u00fdm podkladem t\u00e9to vady je angulace a deprese doln\u00ed \u010d\u00e1sti sterna s dorz\u00e1ln\u00ed angulac\u00ed p\u0159\u00edslu\u0161n\u00fdch ventr\u00e1ln\u00edch \u00fasek\u016f \u017eeber. Deformace nemus\u00ed b\u00fdt symetrick\u00e1, \u010dastou komorbiditou je skoli\u00f3za, dokonce jsou pops\u00e1ny kombinace pectus carinatum a excavatum. P\u0159\u00ed\u010dina t\u00e9to vady nen\u00ed jednozna\u010dn\u011b vysv\u011btlena, uva\u017euje se o chybn\u00e9m r\u016fstu \u017eebern\u00edch chrupavek v obdob\u00ed fet\u00e1ln\u00edho r\u016fstu a o nefyziologick\u00e9m tahu vaz\u016f spojuj\u00edc\u00edch vnit\u0159n\u00ed plochu sterna s br\u00e1nic\u00ed. Vrozen\u00e9 deformity hrudn\u00edku jsou \u00a0\u010dast\u011bj\u0161\u00ed u pacient\u016f s Marfanov\u00fdm syndromem, lze p\u0159edpokl\u00e1dat souvislost s chybn\u00fdm v\u00fdvojem mezenchym\u00e1ln\u00edch tk\u00e1n\u00ed. Klinicky se vada projevuje r\u016fzn\u011b hlubok\u00fdm vp\u00e1\u010den\u00edm doln\u00ed \u010d\u00e1sti p\u0159edn\u00ed hrudn\u00ed st\u011bny, manubrium sterna a artikulace prvn\u00edch dvou \u017eeber jsou v\u017edy v norm\u00e1ln\u00ed pozici. Diagnostika nen\u00ed slo\u017eit\u00e1, deformita je patrn\u00e1 na prvn\u00ed pohled, u\u017e proto s sebou nese i vedlej\u0161\u00ed psychosoci\u00e1ln\u00ed aspekty (deprese, sociopatick\u00e9 poruchy zv\u00fdrazn\u011bn\u00e9 zejm\u00e9na b\u011bhem adolescence). Dal\u0161\u00ed vy\u0161et\u0159en\u00ed jsou nutn\u00e1 pro indikaci v\u00fdkonu. Na CT lze pom\u011b\u0159it Haller\u016fv index (pom\u011br mezi \u0161\u00ed\u0159kou hrudn\u00edku a sternovertebr\u00e1ln\u00ed distanc\u00ed), pokud je v\u011bt\u0161\u00ed ne\u017e 3,5, je operace indikov\u00e1na. Vp\u00e1\u010den\u00fd hrudn\u00edk b\u00fdv\u00e1 asociov\u00e1n s arytmiemi a prolapsem mitr\u00e1ln\u00ed chlopn\u011b, z tohoto d\u016fvodu je nutn\u00e9 podrobn\u00e9 kardiologick\u00e9 vy\u0161et\u0159en\u00ed, z\u00e1t\u011b\u017eov\u00fd test a vy\u0161et\u0159en\u00ed plicn\u00edch funkc\u00ed.<\/p>\n<p style=\"text-align: justify;\">Terapie: Konzervativn\u00ed l\u00e9\u010dba (rehabilitace, dechov\u00e9 cviky) m\u00e1 z\u0159eteln\u00fd efekt naprosto v\u00fdjime\u010dn\u011b a je rezervov\u00e1na jen pro nejleh\u010d\u00ed asymptomatick\u00e9 formy. Byla pops\u00e1na \u0159ada korek\u010dn\u00edch opera\u010dn\u00edch postup\u016f, za typick\u00fd je mo\u017en\u00e9 pova\u017eovat extrapleur\u00e1ln\u00ed kombinaci korek\u010dn\u00ed osteotomie v m\u00edst\u011b nejv\u011bt\u0161\u00ed angulace sterna, subperichondr\u00e1ln\u00ed resekce \u017eebern\u00edch chrupavek a fixaci takto mobilizovan\u00e9ho segmentu sterna v po\u017eadovan\u00e9 pozici Kirschnerov\u00fdmi dr\u00e1ty \u010di dlahou (obr. 1).<\/p>\n<p style=\"text-align: justify;\">V posledn\u00edch letech byla Nussem vypracov\u00e1na miniinvazivn\u00ed metoda, kter\u00e1 je zalo\u017eena na nekrvav\u00e9 repozici vp\u00e1\u010den\u00e9ho segmentu sterna pomoc\u00ed speci\u00e1ln\u00edho elevatoria s fixac\u00ed retrostern\u00e1ln\u00ed dlahou z bodov\u00e9ho p\u0159\u00edstupu za kontroly videotorakoskopick\u00e9 optiky (obr. 2, 3).<\/p>\n<h5>3.2.1.2 Pta\u010d\u00ed hrudn\u00edk (pectus carinatum)<\/h5>\n<p style=\"text-align: justify;\">Tato vrozen\u00e1 deformita je m\u00e9n\u011b \u010dast\u00e1, okolnosti vzniku jsou stejn\u011b m\u00e1lo prozkoum\u00e1ny jako u pectus excavatum, obvi\u0148ov\u00e1no je p\u0159er\u016fst\u00e1n\u00ed p\u0159edn\u00edch \u010d\u00e1st\u00ed \u017eebern\u00edch chrupavek vedouc\u00ed ke k\u00fdlovit\u00e9 protruzi sterna. Podle lokalizace protruze rozezn\u00e1v\u00e1me typ chondrogladiol\u00e1rn\u00ed a chondromanubri\u00e1ln\u00ed, vada m\u016f\u017ee b\u00fdt symetrick\u00e1 i asymetrick\u00e1, s r\u016fzn\u011b z\u0159etelnou rotac\u00ed sterna. Symptomatologie je minim\u00e1ln\u00ed, nejv\u011bt\u0161\u00edm probl\u00e9mem adolescent\u016f je estetick\u00fd dojem a z toho plynouc\u00ed psychosoci\u00e1ln\u00ed pot\u00ed\u017ee. Diagnostika je klinick\u00e1, CT, event. 3D rekonstrukce m\u016f\u017ee zobrazit kontury hrudn\u00edku a nasm\u011brovat okolnosti reparace. Chirurgick\u00e1 intervence p\u0159in\u00e1\u0161\u00ed dobr\u00e9 v\u00fdsledky, jednotliv\u00e9 kroky jsou podobn\u00e9 jako u pectus excavatum: 1\u20132 korek\u010dn\u00ed osteotomie sterna a resekce \u017eebern\u00edch chrupavek (u chondromanubri\u00e1ln\u00edho typu u\u017e od 2. chrupavky), kter\u00e9 dovoluj\u00ed depresi stern\u00e1ln\u00edho segmentu do odpov\u00eddaj\u00edc\u00ed polohy, a r\u016fzn\u00e9 modifikace\u00a0metod fixuj\u00edc\u00edch sternum v pot\u0159ebn\u00e9 poloze na nezbytnou dobu.<\/p>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0441.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 1 \u2013 Princip korekce vp\u00e1\u010den\u00e9ho hrudn\u00edku otev\u0159enou cestou\" alt=\"Obr. 1 \u2013 Princip korekce vp\u00e1\u010den\u00e9ho hrudn\u00edku otev\u0159enou cestou\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0441.png\" width=\"200\" height=\"203\" \/><\/a><p class=\"wp-caption-text\">Obr. 1<br \/>Princip korekce vp\u00e1\u010den\u00e9ho hrudn\u00edku otev\u0159enou cestou<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0451.png\"><img decoding=\"async\" title=\"Obr. 2 \u2013 Princip miniinvazivn\u00ed korekce vp\u00e1\u010den\u00e9ho hrudn\u00edku\" alt=\"Obr. 2 \u2013 Princip miniinvazivn\u00ed korekce vp\u00e1\u010den\u00e9ho hrudn\u00edku\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0451.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 2<br \/>Princip miniinvazivn\u00ed korekce vp\u00e1\u010den\u00e9ho hrudn\u00edku<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #ffffff;\" colspan=\"2\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0461.png\"><img decoding=\"async\" title=\"Obr. 3 \u2013 Retrostern\u00e1ln\u011b ulo\u017een\u00e1 dlaha fixuje vp\u00e1\u010den\u00fd segment v uspokojiv\u00e9 pozici\" alt=\"Obr. 3 \u2013 Retrostern\u00e1ln\u011b ulo\u017een\u00e1 dlaha fixuje vp\u00e1\u010den\u00fd segment v uspokojiv\u00e9 pozici\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0461.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 3<br \/>Retrostern\u00e1ln\u011b ulo\u017een\u00e1 dlaha fixuje vp\u00e1\u010den\u00fd segment v uspokojiv\u00e9 pozici<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h5 style=\"text-align: justify;\">3.2.1.3 Poland\u016fv syndrom<\/h5>\n<p style=\"text-align: justify;\">Jedn\u00e1 se o vz\u00e1cn\u00e9 onemocn\u011bn\u00ed charakterizovan\u00e9 hypoplazi\u00ed a\u017e aplazi\u00ed struktur p\u0159edn\u00ed st\u011bny hrudn\u00ed, prov\u00e1zenou \u010dasto anom\u00e1liemi prsu a prst\u016f. Z\u00e1va\u017enost projev\u016f m\u016f\u017ee kol\u00edsat od pouh\u00e9 hypoplazie stern\u00e1ln\u00ed porce velk\u00e9ho pektor\u00e1ln\u00edho svalu p\u0159i zachovan\u00e9m skeletu a\u017e po \u00faplnou aplazii obou prsn\u00edch sval\u016f prov\u00e1zenou chyb\u011bn\u00edm p\u0159edn\u00edch \u00fasek\u016f 2.\u20135. \u017eebra a spojenou s impres\u00ed hrudn\u00ed st\u011bny. P\u0159\u00edslu\u0161n\u00fd prs m\u016f\u017ee b\u00fdt hypoplastick\u00fd nebo \u00fapln\u011b chyb\u011bt, v\u010detn\u011b bradavky. Sou\u010d\u00e1st\u00ed syndromu jsou deformity prst\u016f (brachydaktylie, syndaktylie). P\u0159i m\u00e9n\u011b z\u00e1va\u017en\u00fdch defektech nen\u00ed rekonstrukce nutn\u00e1, pouze u d\u00edvek je vhodn\u00e1 augmentace (symetrizace) prsu za p\u0159edpokladu stabiln\u00ed hrudn\u00ed st\u011bny. Pokud chyb\u00ed segment p\u0159edn\u00ed hrudn\u00ed st\u011bny, je indikov\u00e1na rekonstruk\u010dn\u00ed operace za pou\u017eit\u00ed \u017eebern\u00edch \u0161t\u011bp\u016f z druh\u00e9 strany \u010di ciz\u00edho materi\u00e1lu. Vzhledem k obvykl\u00e9mu chyb\u011bn\u00ed \u010di hypoplazii m\u011bkk\u00fdch tk\u00e1n\u00ed se zde uplat\u0148uj\u00ed metody plastick\u00e9 chirurgie (posuny svalov\u00fdch lalok\u016f, modelace prsu).<\/p>\n<h5>3.2.1.4 Roz\u0161t\u011bp sterna (v\u010detn\u011b ectopia cordis)<\/h5>\n<p style=\"text-align: justify;\">Vrozen\u00e9 vady sterna jsou vz\u00e1cn\u00e9, ale mohou m\u00edt dramatick\u00fd obraz a kritick\u00fd v\u00fdvoj. D\u011bl\u00edme je na tyto entity:<\/p>\n<ul>\n<li>roz\u0161t\u011bp sterna,<\/li>\n<li>cervik\u00e1ln\u00ed ektopie srdce,<\/li>\n<li>hrudn\u00ed ektopie srdce,<\/li>\n<li>torakoabdomin\u00e1ln\u00ed ektopie srdce.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">P\u0159i roz\u0161t\u011bpu sterna je srdce ve sv\u00e9 spr\u00e1vn\u00e9 anatomick\u00e9 pozici. U cervik\u00e1ln\u00ed ektopie prolabuje srdce defektem horn\u00ed poloviny sterna, \u010dasto je spojeno s hlavou. U hrudn\u00ed ektopie je srdce vytla\u010deno defektem sterna dop\u0159edu, nen\u00ed kryto m\u011bkk\u00fdmi tk\u00e1n\u011bmi.U torakoabdomin\u00e1ln\u00ed ektopie je srdce kryto a dislokov\u00e1no do abdomin\u00e1ln\u00ed dutiny defektem br\u00e1nice.Reparace roz\u0161t\u011bpu sterna je snadn\u00e1 u novorozenc\u016f,kdy elasticita hrudn\u00edku dovoluje p\u0159\u00edmou suturu sterna dr\u00e1tem \u010di syntetick\u00fdm vst\u0159ebateln\u00fdm vl\u00e1knem bezvyvol\u00e1n\u00ed \u00fatlaku srdce. V pozd\u011bj\u0161\u00edm v\u011bku je n\u00e1prava slo\u017eit\u011bj\u0161\u00ed, lze si vypomoci parastern\u00e1ln\u00edmi chondrotomiemi, kter\u00e9 dovol\u00ed aproximaci obou stern\u00e1ln\u00edch polovin. V p\u0159\u00edpad\u011b nutnosti lze vyu\u017e\u00edt autologn\u00ed \u0161t\u011bpy z chrupavek a \u017eeber. Implantace ciz\u00edho materi\u00e1lu se nedoporu\u010duje z d\u016fvodu vy\u0161\u0161\u00edho rizika infek\u010dn\u00edch komplikac\u00ed a probl\u00e9m\u016f dan\u00fdch dal\u0161\u00edm v\u00fdvojem skeletu. \u0158e\u0161en\u00ed srde\u010dn\u00ed ektopie je podstatn\u011b n\u00e1ro\u010dn\u011bj\u0161\u00ed,a to z d\u016fvodu nedostatku m\u011bkk\u00fdch tk\u00e1n\u00ed, resp. k\u016f\u017ee ke kryt\u00ed srdce, \u010dasto toti\u017e b\u00fdv\u00e1 p\u0159\u00edtomen i defekt b\u0159i\u0161n\u00ed st\u011bny. Samotn\u00e1 operace je v\u011bt\u0161inou dvoudob\u00e1, v prvn\u00ed dob\u011b je srdce kryto ko\u017en\u00edm nebo muskulokut\u00e1nn\u00edm lalokem, ve druh\u00e9 dob\u011b se reponuje srdce a reparuje defekt p\u0159edn\u00ed st\u011bny hrudn\u00ed. Navzdory \u00fasp\u011bch\u016fm perinatologie a novorozeneck\u00e9 chirurgie b\u00fdv\u00e1 ale poopera\u010dn\u00ed pr\u016fb\u011bh \u010dasto nep\u0159\u00edzniv\u00fd d\u00edky kompresi srdce p\u0159i jeho kryt\u00ed a p\u0159idru\u017een\u00fdm (nejen srde\u010dn\u00edm) vad\u00e1m. Ur\u010dit\u00fdm preventivn\u00edm \u0159e\u0161en\u00edm takov\u00fdch stav\u016f je dokonal\u00e1 prenat\u00e1ln\u00ed diagnostika a p\u0159\u00edpadn\u00e9 ukon\u010den\u00ed t\u011bhotenstv\u00ed.<\/p>\n<h4>3.2.2 Syndrom horn\u00ed hrudn\u00ed apertury<\/h4>\n<p style=\"text-align: justify;\">Syndrom horn\u00ed hrudn\u00ed apertury je soubor p\u0159\u00edznak\u016f dan\u00fdch \u00fatlakem podkl\u00ed\u010dkov\u00fdch c\u00e9v a brachi\u00e1ln\u00edho plexu v cervikoaxil\u00e1rn\u00edm pr\u016fb\u011bhu v anatomicky definovan\u00fdch \u00fa\u017ein\u00e1ch. D\u0159\u00edve m\u011bl \u0159adu podtyp\u016f a synonym (skalenov\u00fd syndrom, hyperabduk\u010dn\u00ed syndrom, syndrom prvn\u00edho nebo kr\u010dn\u00edho \u017eebra, kostoklavikul\u00e1rn\u00ed syndrom). Proto\u017ee se v\u0161ak symptomatologie jednotliv\u00fdch entit p\u0159ekr\u00fdv\u00e1, stejn\u011b jako jejich anatomick\u00e9 a patofyziologick\u00e9 podklady, pou\u017e\u00edv\u00e1 se dnes obecn\u00fd pojem syndrom horn\u00ed hrudn\u00ed apertury (thoracic outlet syndrom). Cervikoaxil\u00e1rn\u00ed tunel, kter\u00fdm p\u0159ech\u00e1zej\u00ed c\u00e9vy a nervov\u00e9 struktury na pa\u017ei, d\u011bl\u00ed pr\u016fb\u011bh 1. \u017eebra na dv\u011b \u010d\u00e1sti: proxim\u00e1ln\u00ed, kter\u00e1 se d\u00e1le d\u011bl\u00ed na kostoklavikul\u00e1rn\u00ed prostor a skalenov\u00fd troj\u00faheln\u00edk, a dist\u00e1ln\u00ed, vlastn\u00ed axilu. K \u00fatlaku neurovaskul\u00e1rn\u00edch struktur predisponuj\u00ed oba odd\u00edly proxim\u00e1ln\u00ed \u010d\u00e1sti. Kostoklavikul\u00e1rn\u00ed prostor je ohrani\u010den kl\u00ed\u010dkem a prvn\u00edm \u017eebrem, \u00fapon m. scalenus ant. ho d\u011bl\u00ed na anteromedi\u00e1ln\u00ed \u010d\u00e1st, kudy prob\u00edh\u00e1 podkl\u00ed\u010dkov\u00e1 \u017e\u00edla, a posterolater\u00e1ln\u00ed \u010d\u00e1st s pr\u016fb\u011bhem tepny a brachi\u00e1ln\u00edho plexu. Prostor ohrani\u010den\u00fd pr\u016fb\u011bhem m. scalenus anterior a medius, kaud\u00e1ln\u011b limitovan\u00fd\u00a01. \u017eebrem, kter\u00fdm prostupuje plexus brachialis a tepna pod klavikulu, se naz\u00fdv\u00e1 skalenov\u00fd troj\u00faheln\u00edk (obr. 4).<\/p>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_048.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 4 \u2013 Skalenov\u00fd troj\u00faheln\u00edk (AS \u2013 a. subclavia, VS \u2013 v. subclavia, MSA \u2013 m. scal. anterior, MSM \u2013 m. scal. medius, PB \u2013 plexus brachialis, C \u2013 clavicula)\" alt=\"Obr. 4 \u2013 Skalenov\u00fd troj\u00faheln\u00edk (AS \u2013 a. subclavia, VS \u2013 v. subclavia, MSA \u2013 m. scal. anterior, MSM \u2013 m. scal. medius, PB \u2013 plexus brachialis, C \u2013 clavicula)\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_048.png\" width=\"200\" height=\"145\" \/><\/a><p class=\"wp-caption-text\">Obr. 4<br \/>Skalenov\u00fd troj\u00faheln\u00edk<br \/>(AS \u2013 a. subclavia, VS \u2013 v. subclavia, MSA \u2013 m. scal. anterior, MSM \u2013 m. scal. medius, PB \u2013 plexus brachialis, C \u2013 clavicula)<\/p><\/div>\n<p style=\"text-align: justify;\">P\u0159\u00ed\u010din komprese nervov\u011bc\u00e9vn\u00edho svazku je mnoho, nej\u010dast\u011bj\u0161\u00ed jsou anatomick\u00e9 (z\u00fa\u017een\u00ed kostoklavikul\u00e1rn\u00edho prostoru nebo skalenov\u00e9ho troj\u00faheln\u00edku), vrozen\u00e9 (kr\u010dn\u00ed \u017eebro, hypertrofie proc. transversus7. obratle, zdvojen\u00e9 \u010di rudiment\u00e1rn\u00ed prvn\u00ed \u017eebro, vazivov\u00e9 pruhy mezi t\u011bmito strukturami) nebo traumatick\u00e9 (zlomeniny kl\u00ed\u010dku, 1. \u017eebra). Symptomatologie je d\u00e1na \u00fatlakem c\u00e9v nebo \u010dast\u011bji nerv\u016f, m\u016f\u017ee b\u00fdt kombinovan\u00e1. Typick\u00fdmi projevy jsou parestezie a bolesti posti\u017een\u00e9 kon\u010detiny vyj\u00e1d\u0159en\u00e9 v\u00edce v inerva\u010dn\u00ed oblasti n. ulnaris. Komprese podkl\u00ed\u010dkov\u00e9 tepny zp\u016fsobuje chlad kon\u010detiny, hypestezii, snadnou unavitelnost a difuzn\u00ed bolesti. P\u0159\u00edznaky \u017eiln\u00ed obstrukce jsou m\u00e9n\u011b \u010dast\u00e9 d\u00edky \u010detn\u00fdm kolater\u00e1l\u00e1m do povod\u00ed v. jugularis, typick\u00fd obraz (cyan\u00f3za, tepl\u00fd otok, roz\u0161\u00ed\u0159en\u00ed podko\u017en\u00edch \u017eil, bolest) m\u00e1 akutn\u00ed tromb\u00f3za podkl\u00ed\u010dkov\u00e9 \u017e\u00edly. V\u0161echny p\u0159\u00edznaky se obvykle manifestuj\u00ed nebo zhor\u0161uj\u00ed p\u0159i abdukci pa\u017ee a hyperextenzi krku. Diagnostika nen\u00ed jednoduch\u00e1. Krom\u011b p\u00e1tr\u00e1n\u00ed po skelet\u00e1ln\u00edch abnormit\u00e1ch (RTG, CT, MRI) lze pou\u017e\u00edt klinick\u00e9 testy, kter\u00e9 sleduj\u00ed oslaben\u00ed \u010di vymizen\u00ed pulzu na art. radialis:<\/p>\n<ul>\n<li>skalenov\u00fd test \u2013 n\u00e1dech, extenze krku, oto\u010den\u00ed hlavy na stranu,<\/li>\n<li>kostoklavikul\u00e1rn\u00ed test \u2013 vojensk\u00fd postoj \u2013 ramena dozadu a dol\u016f,<\/li>\n<li style=\"text-align: justify;\">hyperabduk\u010dn\u00ed test \u2013 hyperabdukce pa\u017ee do\u00a0180 stup\u0148\u016f.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\"><span style=\"text-align: justify;\">Nejv\u011bt\u0161\u00ed v\u00fdznam m\u00e1 vy\u0161et\u0159en\u00ed neurofyziologick\u00e9, resp. elektromyografick\u00e9 \u2013 sledov\u00e1n\u00ed rychlosti p\u0159enosu potenci\u00e1l\u016f uln\u00e1rn\u00edm nervem (ulnar nerve conduction velocities \u2013 UNCV). Norm\u00e1ln\u00ed rychlost je 72m\/s, sn\u00ed\u017een\u00ed pod 70 m\/s je p\u0159\u00edznakem nervov\u00e9 dysfunkce. Terapie m\u016f\u017ee b\u00fdt konzervativn\u00ed: fyzioterapie, rehabilitace. Pokud nevede k \u00fasp\u011bchu (UNCV z\u016fst\u00e1v\u00e1 pod 60m\/s a p\u0159etrv\u00e1vaj\u00ed pot\u00ed\u017ee), je indikov\u00e1na chirurgick\u00e1 intervence. Bylo vypracov\u00e1no mnoho sofistikovan\u00fdch postup\u016f pro operace kr\u010dn\u00edho \u017eebra, elongovan\u00fdch p\u0159\u00ed\u010dn\u00fdch v\u00fdb\u011b\u017ek\u016f \u010di skalenov\u00fdch sval\u016f. Postupn\u011b se uk\u00e1zalo, \u017ee z\u00e1kladn\u00edm a spole\u010dn\u00fdm anatomick\u00fdm podkladem v\u011bt\u0161iny probl\u00e9m\u016f je prvn\u00ed \u017eebro a \u017ee jeho odstran\u011bn\u00ed (a p\u0159\u00edpadn\u00e1 resekce kr\u010dn\u00edho \u017eebra) vede k \u00fasp\u011bchu asi u 90 % nemocn\u00fdch. Zb\u00fdvaj\u00edc\u00ed ot\u00e1zka (jak\u00fdm p\u0159\u00edstupem) byla vy\u0159e\u0161ena ve prosp\u011bch transaxil\u00e1rn\u00ed resekce, kter\u00e1 d\u00e1v\u00e1 nejlep\u0161\u00ed p\u0159ehled a nejm\u00e9n\u011b komplikac\u00ed. V p\u0159\u00edpad\u011b reintervence je k prvn\u00edmu \u017eebru, resp. jeho zbytku, obvykl\u00fd zadn\u00ed transmuskul\u00e1rn\u00ed p\u0159\u00edstup.<\/span><\/p>\n<h4>3.2.3 Z\u00e1n\u011btliv\u00e1 onemocn\u011bn\u00ed hrudn\u00ed st\u011bny<\/h4>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0501.png\"><img decoding=\"async\" class=\" \" title=\"Obr. 5 \u2013 Poststernotomick\u00e1 osteomyelitida s retrostern\u00e1ln\u00edm abscesem\" alt=\"Obr. 5 \u2013 Poststernotomick\u00e1 osteomyelitida s retrostern\u00e1ln\u00edm abscesem\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0501.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 5<br \/>Poststernotomick\u00e1 osteomyelitida s retrostern\u00e1ln\u00edm abscesem<\/p><\/div>\n<p style=\"text-align: justify;\">Hrudn\u00ed st\u011bna m\u016f\u017ee b\u00fdt posti\u017eena z\u00e1n\u011btem bu\u010f v cel\u00e9 tlou\u0161\u0165ce, nebo se inflamace omezuje na jednotliv\u00e9 vrstvy. Pr\u016fb\u011bh z\u00e1n\u011btu k\u016f\u017ee, podko\u017e\u00ed a m\u011bkk\u00fdch tk\u00e1n\u00ed se neli\u0161\u00ed od podobn\u00fdch onemocn\u011bn\u00ed jinde na t\u011ble, posti\u017een\u00ed skeletu m\u00e1 sv\u00e9 typick\u00e9 konsekvence. Spektrum patogen\u016f je \u0161irok\u00e9, v\u011bt\u0161inou lze vykultivovat stafylokoky, streptokoky, E. coli, pseudomon\u00e1dy, d\u0159\u00edve byly \u010dast\u00e9 tuberkul\u00f3zn\u00ed infekce, i dnes nalezneme aktinomyk\u00f3zu \u010di bakteroidy. Diagnostika flegmon\u00f3zn\u00edho z\u00e1n\u011btu m\u011bkk\u00fdch tk\u00e1n\u00ed je klinick\u00e1 (teplota, zarudnut\u00ed, otok, bolest), laboratorn\u00ed (leukocyt\u00f3za, elevace CRP), p\u0159i podez\u0159en\u00ed na lokalizovan\u00e1 lo\u017eiska (abscesy) a k vylou\u010den\u00ed komunikace nap\u0159. s pleur\u00e1ln\u00ed dutinou je indikov\u00e1no sono, p\u0159\u00edpadn\u011b CT. Abscesy se mohou vyvinout pod silnou vrstvou sval\u016f (subpektor\u00e1ln\u00ed) \u010di pod lopatkou (subskapul\u00e1rn\u00ed), tehdy je klinick\u00e1 symptomatologie sp\u00ed\u0161e celkov\u00e1, lok\u00e1ln\u00ed n\u00e1lez nep\u0159esv\u011bd\u010div\u00fd, pomoc zobrazovac\u00edch metod je nezbytn\u00e1. Prim\u00e1rn\u00ed infekt skeletu (sternum, \u017eebra, chrupavky) je extr\u00e9mn\u011b vz\u00e1cn\u00fd, b\u00fdvaj\u00ed popisov\u00e1ny sternoklavikul\u00e1rn\u00ed osteoartritidy u diabetik\u016f. Daleko \u010dast\u011bji se setk\u00e1v\u00e1me se z\u00e1n\u011btliv\u00fdm posti\u017een\u00edm pevn\u00fdch struktur hrudn\u00ed st\u011bny po kardiochirurgick\u00e9 nebo torakochirurgick\u00e9 operaci. Nej\u010dast\u011bj\u0161\u00ed takovou komplikac\u00ed je infikovan\u00e1 dehiscence sterna po kardiochirurgick\u00fdch v\u00fdkonech, kde k rozvoji osteomyelitidy p\u0159isp\u00edv\u00e1 devaskularizace sterna dan\u00e1 odb\u011brem mamm\u00e1rn\u00edho svazku a \u010dast\u00e9 komorbidity (ateroskler\u00f3za, diabetes) (obr. 5). Osteomyelitida \u017eebra po torakotomii nen\u00ed \u010dast\u00e1. Inflamace se m\u016f\u017ee roz\u0161\u00ed\u0159it do hrudn\u00ed st\u011bny pod\u00e9l steh\u016f, hrudn\u00edch dr\u00e9n\u016f nebo pod\u00e9l lalok\u016f p\u0159i fenestraci hrudn\u00edku. L\u00e9\u010dba z\u00e1n\u011btu m\u011bkk\u00fdch tk\u00e1n\u00ed spo\u010d\u00edv\u00e1 v \u0159\u00e1dn\u00e9 dren\u00e1\u017ei, excizi nekrotick\u00fdch tk\u00e1n\u00ed a v p\u0159\u00edpad\u011b flegmon\u00f3zn\u00edho posti\u017een\u00ed s celkov\u00fdmi p\u0159\u00edznaky tak\u00e9\u00a0v pod\u00e1n\u00ed \u00fa\u010dinn\u00e9 antibiotick\u00e9 terapie. Posti\u017een\u00ed skeletu m\u00e1 v\u011bt\u0161inou prolongovan\u00fd pr\u016fb\u011bh a vy\u017eaduje resekci posti\u017een\u00fdch kost\u00ed a chrupavek. V p\u0159\u00edpad\u011b osteomyelitidy sterna b\u00fdv\u00e1 ztr\u00e1ta tk\u00e1n\u00ed v\u00fdznamn\u00e1 a ke slovu p\u0159ich\u00e1zej\u00ed metody rekonstruk\u010dn\u00ed chirurgie (stabilizace sterna a vypln\u011bn\u00ed defektu muskulokut\u00e1nn\u00edm lalokem). V posledn\u00ed dob\u011b byla \u0159ada takov\u00fdch defekt\u016f \u00fasp\u011b\u0161n\u011b zhojena pomoc\u00ed uzav\u0159en\u00e9ho dren\u00e1\u017en\u00edho syst\u00e9mu (vacuum closed therapy, VAC).<\/p>\n<p style=\"text-align: justify;\">Mondorova choroba (aseptick\u00e1 flebitida podko\u017en\u00edch \u017eil p\u0159edn\u00ed st\u011bny hrudn\u00ed) ani Tietzeho syndrom (aseptick\u00e9 zdu\u0159en\u00ed prvn\u00edch \u017eebern\u00edch chrupavek) mezi infek\u010dn\u00ed z\u00e1n\u011bty nepat\u0159\u00ed a chirurgickou l\u00e9\u010dbu obvykle nevy\u017eaduj\u00ed.<\/p>\n<h4>3.2.4 N\u00e1dory hrudn\u00ed st\u011bny<\/h4>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0521.png\"><img decoding=\"async\" title=\"Obr. 6 \u2013 Skelet\u00e1ln\u00ed metast\u00e1za karcinomu ledviny (ozna\u010dena \u0161ipkou)\" alt=\"Obr. 6 \u2013 Skelet\u00e1ln\u00ed metast\u00e1za karcinomu ledviny (ozna\u010dena \u0161ipkou)\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0521.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 6<br \/>Skelet\u00e1ln\u00ed metast\u00e1za karcinomu ledviny (ozna\u010dena \u0161ipkou)<\/p><\/div>\n<p style=\"text-align: justify;\">Prim\u00e1rn\u00ed n\u00e1dory hrudn\u00ed st\u011bny jsou vz\u00e1cn\u00e9, daleko \u010dast\u011bji nal\u00e9z\u00e1me v hrudn\u00edm skeletu metast\u00e1zy n\u00e1dor\u016f jin\u00e9 prim\u00e1rn\u00ed lokalizace (karcinom ledviny, prsu, prostaty, plic) (obr. 6). Neobvykl\u00e9 nen\u00ed ani p\u0159\u00edm\u00e9 pror\u016fst\u00e1n\u00ed n\u00e1dor\u016f plic \u010di prsu do hrudn\u00ed st\u011bny, stejn\u011b jako lok\u00e1ln\u00ed recidiva t\u011bchto tumor\u016f v hrudn\u00ed st\u011bn\u011b. Prim\u00e1rn\u00ed novotvary hrudn\u00ed st\u011bny zahrnuj\u00ed \u0161irokou \u0161k\u00e1lu benign\u00edch i malign\u00edch mezenchym\u00e1ln\u00edch neoplazi\u00ed, m\u00e9n\u011b po\u010detn\u00e9 jsou epitelov\u00e9 n\u00e1dory a hemoblastomy. P\u0159ehled nej\u010dast\u011bj\u0161\u00edch prim\u00e1rn\u00edch diagn\u00f3z:<\/p>\n<p><strong>benign\u00ed n\u00e1dory:<\/strong><\/p>\n<ul>\n<li>osteochondrom<\/li>\n<li>chondrom<\/li>\n<li>lipom<\/li>\n<li>fibrom<\/li>\n<li>neurilemom<\/li>\n<\/ul>\n<p><strong>semimalign\u00ed n\u00e1dory<\/strong><\/p>\n<ul>\n<li>desmoid<\/li>\n<\/ul>\n<p><strong>malign\u00ed n\u00e1dory:<\/strong><\/p>\n<ul>\n<li>malign\u00ed histiocytom<\/li>\n<li>plazmocyt\u00e1rn\u00ed myelom<\/li>\n<li>lymfom<\/li>\n<li>Ewing\u016fv sarkom<\/li>\n<li>liposarkom<\/li>\n<li>leiomyosarkom<\/li>\n<li>rhabdomyosarkom<\/li>\n<li>chondrosarkom<\/li>\n<li>osteosarkom<\/li>\n<li>neurofibrosarkom<\/li>\n<li>hemangiosarkom<\/li>\n<\/ul>\n<p style=\"text-align: justify;\"><strong>Osteochondrom<\/strong> je nej\u010dast\u011bj\u0161\u00edm benign\u00edm kostn\u00edm n\u00e1dorem, p\u0159edstavuje asi 50 % benign\u00edch n\u00e1dor\u016f \u017eeber. Formuje se v d\u011btstv\u00ed a jeho r\u016fst pokra\u010duje a\u017e do ukon\u010den\u00ed kostn\u00ed maturace. Vyr\u016fst\u00e1 z kortexu jako exost\u00f3za v oblasti metaf\u00fdz \u017eeber a je kryt chrupav\u010ditou \u010depi\u010dkou. Bolestiv\u00fd n\u00e1dor rostouc\u00ed i v dosp\u011blosti hroz\u00ed malignizac\u00ed, mus\u00ed b\u00fdt odstran\u011bn.<\/p>\n<p style=\"text-align: justify;\"><strong>Chondrom<\/strong> je tak\u00e9 pom\u011brn\u011b \u010dast\u00fd. Je tvo\u0159en lal\u016f\u010dky hyalinn\u00ed chrupavky, nej\u010dast\u011bji vyr\u016fst\u00e1 v oblasti p\u0159edn\u00edch kostochondr\u00e1ln\u00edch junkc\u00ed. Jeho odli\u0161en\u00ed od lowgrade chondrosarkomu je obt\u00ed\u017en\u00e9 a\u017e nemo\u017en\u00e9, v\u017edy mus\u00ed b\u00fdt resekov\u00e1n v bezpe\u010dn\u00fdch hranic\u00edch.<\/p>\n<p style=\"text-align: justify;\"><strong>Desmoid<\/strong> b\u00fdv\u00e1 nej\u010dast\u011bji lokalizov\u00e1n na hrudn\u00edku, v oblasti ramenn\u00edho pletence a subskapul\u00e1rn\u011b. Typicky obaluje nervov\u00e9 struktury a c\u00e9vy horn\u00ed hrudn\u00ed apertury, pa\u017ee a krku. Je tvo\u0159en v\u0159etenit\u00fdmi bu\u0148kami, vyr\u016fst\u00e1 ze sval\u016f a fasci\u00ed a \u0161\u00ed\u0159\u00ed se pod\u00e9l nich. Po nekompletn\u00edm odstran\u011bn\u00ed torpidn\u011b recidivuje, nemetast\u00e1zuje. Recidivy je nutn\u00e9 \u0159e\u0161it reexciz\u00ed, enkapsulaci d\u016fle\u017eit\u00fdch struktur radioterapi\u00ed.<\/p>\n<p style=\"text-align: justify;\"><strong>Malign\u00ed fibr\u00f3zn\u00ed histiocytom<\/strong> je nej\u010dast\u011bj\u0161\u00edm zhoubn\u00fdm n\u00e1dorem hrudn\u00ed st\u011bny. Objevuje se mezi\u00a05.\u20137. deceniem. Je tvo\u0159en v\u0159etenit\u00fdmi fibroblasty v lobul\u00e1rn\u00edch \u010di roho\u017ekovit\u00fdch formac\u00edch, mezi kter\u00fdmi jsou vmeze\u0159eny jednojadern\u00e9 histiocyty a osteoklasty. Vyzna\u010duje se radiorezistenc\u00ed a chemorezistenc\u00ed, jedin\u00fdm \u0159e\u0161en\u00edm je dostate\u010dn\u011b \u0161irok\u00e1 resekce.<\/p>\n<p style=\"text-align: justify;\"><strong>Chondrosarkom<\/strong> je jeden z \u010dast\u011bj\u0161\u00edch zhoubn\u00fdch tumor\u016f \u017eeber (obr. 7). Vyr\u016fst\u00e1 nej\u010dast\u011bji z p\u0159edn\u00edch kostochondr\u00e1ln\u00edch junkc\u00ed. Je vz\u00e1cn\u00fd u mlad\u0161\u00edch lid\u00ed, v\u011bt\u0161inou nebolestiv\u00fd a pomalu rostouc\u00ed. Histologick\u00e9 rozli\u0161en\u00ed mezi chondrosarkomem a chondromem je obt\u00ed\u017en\u00e9, i nejist\u00e1 l\u00e9ze mus\u00ed b\u00fdt resekov\u00e1na dostate\u010dn\u011b \u0161iroce.<\/p>\n<p style=\"text-align: justify;\"><strong>Rhabdomyosarkomy<\/strong> jsou n\u00e1dory ni\u017e\u0161\u00edho a d\u011btsk\u00e9ho v\u011bku, rostou rychle, \u010dasto jsou regresivn\u011b zm\u011bn\u011bny (nekr\u00f3zy, krv\u00e1cen\u00ed). Chovaj\u00ed se invazivn\u011b, \u010dasto metast\u00e1zuj\u00ed. L\u00e9\u010dba je kombinovan\u00e1 (chirurgie n\u00e1sledovan\u00e1 radioterapi\u00ed a kombinovanou chemoterapi\u00ed).<\/p>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0541.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 7 \u2013 Chondrosarkom hrudn\u00ed st\u011bny resekovan\u00fd spolu s \u010d\u00e1st\u00ed br\u00e1nice\" alt=\"Obr. 7 \u2013 Chondrosarkom hrudn\u00ed st\u011bny resekovan\u00fd spolu s \u010d\u00e1st\u00ed br\u00e1nice\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0541.png\" width=\"200\" height=\"120\" \/><\/a><p class=\"wp-caption-text\">Obr. 7<br \/>Chondrosarkom hrudn\u00ed st\u011bny resekovan\u00fd spolu s \u010d\u00e1st\u00ed br\u00e1nice<\/p><\/div>\n<p><strong>Ewing\u016fv sarkom<\/strong> je primitivn\u00ed kulatobun\u011b\u010dn\u00fd neuroektoderm\u00e1ln\u00ed tumor (PNET). Jedn\u00e1 se o nej\u010dast\u011bj\u0161\u00ed malignitu hrudn\u00ed st\u011bny u d\u011bt\u00ed. Typick\u00e9 pro n\u00e1dor jsou periost\u00e1ln\u00ed formace novotvo\u0159en\u00e9 kostn\u00ed tk\u00e1n\u011b. \u0160\u00ed\u0159\u00ed se d\u0159e\u0148ovou dutinou, proto je nutn\u00e1 exstirpace cel\u00e9ho posti\u017een\u00e9ho \u017eebra a dal\u0161\u00edch \u017eeber nad a pod l\u00e9z\u00ed. Je vysoce malign\u00ed, \u010dasn\u011b metast\u00e1zuje, proto po operaci n\u00e1sleduje oz\u00e1\u0159en\u00ed a kombinovan\u00e1 chemoterapie, kter\u00e1 je indikovan\u00e1 i pro l\u00e9\u010dbu diseminovan\u00fdch n\u00e1dor\u016f.<\/p>\n<p style=\"text-align: justify;\">Klinicky jsou n\u00e1dory hrudn\u00ed st\u011bny v\u011bt\u0161inou asymptomatick\u00e9, zejm\u00e9na v po\u010d\u00e1te\u010dn\u00edch stadi\u00edch. Pozd\u011bji se projevuj\u00ed jako hmatn\u00e1, pomalu rostouc\u00ed n\u00e1dorov\u00e1 masa s p\u0159\u00edznaky dan\u00fdmi ulo\u017een\u00edm (bolesti, interkost\u00e1ln\u00ed neuralgie, par\u00e9zy nerv\u016f, syndrom horn\u00ed dut\u00e9 \u017e\u00edly). Diagn\u00f3za je zalo\u017eena na klinick\u00e9m vy\u0161et\u0159en\u00ed (\u0159ada nepokro\u010dil\u00fdch n\u00e1dor\u016f nemus\u00ed b\u00fdt hmatn\u00e1) a na zobrazovac\u00edch metod\u00e1ch. MRI m\u00e1 v\u00fdhodu p\u0159esn\u011bj\u0161\u00ed diferenciace od okoln\u00edch (zejm\u00e9na vaskul\u00e1rn\u00edch a nervov\u00fdch) struktur. Proto\u017ee v\u0161ak v\u011bt\u0161inou p\u00e1tr\u00e1me i po eventu\u00e1ln\u00edch metast\u00e1z\u00e1ch \u010di p\u0159\u00edpadn\u00e9m prim\u00e1rn\u00edm n\u00e1doru, je v\u00fdhodn\u011bj\u0161\u00ed CT nebo PETCT. L\u00e9\u010dba n\u00e1dor\u016f hrudn\u00ed st\u011bny je preferen\u010dn\u011b chirurgick\u00e1. P\u0159ed definitivn\u00edm \u0159e\u0161en\u00edm je po\u017eadov\u00e1na validn\u00ed biopsie, kter\u00e1 vylou\u010d\u00ed nechirurgick\u00e1 onemocn\u011bn\u00ed (lymfomy, metast\u00e1zy nepoznan\u00e9ho p\u016fvodu). Bioptick\u00fd kan\u00e1l (punk\u010dn\u00ed \u010di chirurgick\u00fd) mus\u00ed b\u00fdt zahrnut do pl\u00e1nu definitivn\u00ed resekce. Efekt chemoterapie a radioterapie je limitov\u00e1n, v adjuvantn\u00edm re\u017eimu lze indikovat radioterapii p\u0159i pozitivn\u00edch nebo nejist\u00fdch resek\u010dn\u00edch lini\u00edch. L\u00e9\u010dba generalizovan\u00fdch stav\u016f je syst\u00e9mov\u00e1.<\/p>\n<h4>3.2.5 Opera\u010dn\u00ed v\u00fdkony na hrudn\u00ed st\u011bn\u011b<\/h4>\n<h5>3.2.5.1 Resekce hrudn\u00ed st\u011bny<\/h5>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0551.png\"><img decoding=\"async\" title=\"Obr. 8 \u2013 Resek\u010dn\u00ed linie po \u0161irok\u00e9 excizi (HS \u2013 hrudn\u00ed st\u011bna, B \u2013 br\u00e1nice, J \u2013 j\u00e1tra)\" alt=\"Obr. 8 \u2013 Resek\u010dn\u00ed linie po \u0161irok\u00e9 excizi (HS \u2013 hrudn\u00ed st\u011bna, B \u2013 br\u00e1nice, J \u2013 j\u00e1tra)\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0551.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 8<br \/>Resek\u010dn\u00ed linie po \u0161irok\u00e9 excizi (HS \u2013 hrudn\u00ed st\u011bna, B \u2013 br\u00e1nice, J \u2013 j\u00e1tra)<\/p><\/div>\n<p style=\"text-align: justify;\">Pro prim\u00e1rn\u00ed n\u00e1dory hrudn\u00ed st\u011bny plat\u00ed \u010dty\u0159centimetrov\u00fd rozsah makroskopick\u00fdch negativn\u00edch resek\u010dn\u00edch lini\u00ed. Dal\u0161\u00ed z\u00e1sadou je resekce nejm\u00e9n\u011b jednoho neposti\u017een\u00e9ho \u017eebra nad a pod makroskopick\u00fdm n\u00e1dorem. Stejn\u00e9 z\u00e1sady plat\u00ed pro direktn\u00ed invazi n\u00e1dor\u016f plic \u010di prsu do hrudn\u00ed st\u011bny. U benign\u00edch l\u00e9z\u00ed a sekund\u00e1rn\u00edch novotvar\u016f jsou tolerov\u00e1ny dvoucentimetrov\u00e9 bezpe\u010dnostn\u00ed linie. Ko\u017en\u00ed incize b\u00fdv\u00e1 vedena nad tumorem, m\u011bla by zauj\u00edmat bioptick\u00fd kan\u00e1l a v p\u0159\u00edpad\u011b infiltrace pat\u0159i\u010dn\u00fd bezpe\u010dnostn\u00ed lem. Neposti\u017een\u00e9 extratorak\u00e1ln\u00ed svaly by m\u011bly b\u00fdt \u0161et\u0159eny, stejn\u011b jako jejich c\u00e9vn\u00ed z\u00e1soben\u00ed pro event. n\u00e1slednou rekonstrukci (m. latissimus dorsi, m. pectoralis major), vlastn\u00ed svaly hrudn\u00ed st\u011bny (interkost\u00e1ln\u00ed) jsou sou\u010d\u00e1st\u00ed resekovan\u00e9ho bloku. V p\u0159\u00edpad\u011b prim\u00e1rn\u00edho malign\u00edho n\u00e1doru nebo direktn\u00ed invaze plicn\u00edho karcinomu do hrudn\u00ed st\u011bny za\u010d\u00edn\u00e1 explorace rozsahu posti\u017een\u00ed otev\u0159en\u00edm pleur\u00e1ln\u00ed dutiny z torakotomie mezi\u017eeb\u0159\u00edm pod nebo nad prvn\u00edm neposti\u017een\u00fdm \u017eebrem. Provede se palpa\u010dn\u00ed ov\u011b\u0159en\u00ed lok\u00e1ln\u00edho rozsahu n\u00e1doru a stanoven\u00ed bezpe\u010dn\u00fdch resek\u010dn\u00edch lini\u00ed (obr. 8). Tuto f\u00e1zi lze doplnit nebo nahradit videotorakoskopickou reviz\u00ed. Pokud nen\u00ed za\u0161l\u00e1 pohrudni\u010dn\u00ed dutina, je p\u0159ehled v\u011bt\u0161inou v\u00fdborn\u00fd. I v p\u0159\u00edpad\u011b direktn\u00ed penetrace n\u00e1doru do plic nebo naopak lze takto vymezit bezpe\u010dn\u00fd rozsah resekce dostate\u010dn\u011b p\u0159esn\u011b. Po vymezen\u00ed resek\u010dn\u00edch lini\u00ed prob\u00edh\u00e1 vlastn\u00ed resekce v\u011bt\u0161inou zdola v tomto sledu:1. p\u0159eru\u0161en\u00ed interkostomuskul\u00e1rn\u00ed junkce nad okrajem 2. neposti\u017een\u00e9ho \u017eebra,2. transsekce bloku hrudn\u00ed st\u011bny ve ventr\u00e1ln\u00edch a dorz\u00e1ln\u00edch lini\u00edch v odpov\u00eddaj\u00edc\u00ed vzd\u00e1lenosti od tumoru,3. prot\u011bt\u00ed posledn\u00edho \u00faseku hrudn\u00ed st\u011bny nad prvn\u00edm neposti\u017een\u00fdm (resp. 1. anatomick\u00fdm) \u017eebrem. Interkost\u00e1ln\u00ed svazky ventr\u00e1ln\u011b i dorz\u00e1ln\u011b je t\u0159eba b\u011bhem resekce bezpe\u010dn\u011b ligovat. Infiltrovan\u00e9 struktury a tk\u00e1n\u011b podez\u0159el\u00e9 z invaze (pleura, pl\u00edce, perikard, br\u00e1nice, svaly, lopatka) je t\u0159eba resekovat en bloc v z\u00e1jmu kompletn\u00ed (R0) resekce.V p\u0159\u00edpad\u011b n\u00e1dor\u016f typick\u00fdch intramedul\u00e1rn\u00ed propagac\u00ed (Ewing\u016fv sarkom) je t\u0159eba posti\u017een\u00e1 \u017eebraresekovat cel\u00e1 (prot\u011bt\u00ed v chrupav\u010dit\u00e9 \u010d\u00e1sti ventr\u00e1ln\u011ba exartikulace dorz\u00e1ln\u011b).<\/p>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0571.png\"><img decoding=\"async\" title=\"Obr. 9 \u2013 Princip rekonstrukce defektu hrudn\u00ed st\u011bny\" alt=\"Obr. 9 \u2013 Princip rekonstrukce defektu hrudn\u00ed st\u011bny\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0571.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 9<br \/>Princip rekonstrukce defektu hrudn\u00ed st\u011bny<\/p><\/div>\n<h6>3.2.5.1.1 Rekonstrukce<\/h6>\n<p style=\"text-align: justify;\">Rekonstrukce hrudn\u00ed st\u011bny nen\u00ed nutn\u00e1 u mal\u00fdch defekt\u016f, resekci jednoho \u017eebra lze \u0159e\u0161it perikost\u00e1ln\u00ed suturou nebo pomoc\u00ed perikost\u00e1ln\u00edch lalok\u016f sousedn\u00edch \u017eeber. Defekty subskapul\u00e1rn\u011b do v\u00fd\u0161e 4. \u017eebra nemus\u00ed b\u00fdt rekonstruov\u00e1ny, proto\u017ee jsou kryty lopatkou a jej\u00edm masivn\u00edm svalstvem. Pokud doln\u00ed okraj resekovan\u00e9ho segmentu dosahuje do ni\u017e\u0161\u00edch mezi\u017eeb\u0159\u00ed, hroz\u00ed zapad\u00e1n\u00ed lopatky do defektu, rekonstrukce je nutn\u00e1. V dorz\u00e1ln\u00edch parti\u00edch a v later\u00e1ln\u00ed konvexit\u011b hrudn\u00edku nemus\u00ed b\u00fdt rekonstrukce stabiln\u00ed, samotn\u00e1 polypropylenov\u00e1 s\u00ed\u0165ka stabilizuje hrudn\u00ed st\u011bnu v\u011bt\u0161inou uspokojiv\u011b (obr. 9, 10).V p\u0159\u00edpad\u011b resekc\u00ed p\u0159edn\u00edho segmentu hrudn\u00edku je kosmetick\u00fd i funk\u010dn\u00ed defekt natolik v\u00fdznamn\u00fd, \u017ee je rigidn\u00ed rekonstrukce (nap\u0159\u00edklad sendvi\u010dovou polypropylenovou s\u00ed\u0165kou s kostn\u00edm cementem) metodou volby. Ke stabilizaci z\u00e1platy lze samoz\u0159ejm\u011b vyu\u017e\u00edt kovov\u00e9 (titanov\u00e9) dlahy \u010di autotransplant\u00e1ty \u017eeber. N\u00e1sleduje rekonstrukce m\u011bkk\u00fdch tk\u00e1n\u00ed, nej\u010dast\u011bji posunem ploch\u00fdch sval\u016f z okol\u00ed (m. latissimus dorsi, m. pectoralis major, m. rectus abdominis, m. trapezius). Pokud se nedost\u00e1v\u00e1 k\u016f\u017ee, jsou tyto svaly transponov\u00e1ny v podob\u011b muskulokut\u00e1nn\u00edch lalok\u016f.<\/p>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0581.png\"><img decoding=\"async\" title=\"Obr. 10 \u2013 Uz\u00e1v\u011br defektu hrudn\u00ed st\u011bny polypropylenovou s\u00ed\u0165kou\" alt=\"Obr. 10 \u2013 Uz\u00e1v\u011br defektu hrudn\u00ed st\u011bny polypropylenovou s\u00ed\u0165kou\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0581.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 10<br \/>Uz\u00e1v\u011br defektu hrudn\u00ed st\u011bny polypropylenovou s\u00ed\u0165kou<\/p><\/div>\n<h5>3.2.5.2 Resekce sterna<\/h5>\n<p style=\"text-align: justify;\">Sternum m\u00e1 z\u00e1sadn\u00ed pod\u00edl na mechanice d\u00fdch\u00e1n\u00ed, proto je vhodn\u00e9 alespo\u0148 \u010d\u00e1st kosti, jeli neposti\u017een\u00e1, ponechat (obr. 11).<\/p>\n<p style=\"text-align: justify;\">Spolu s resekovanou hrudn\u00ed kost\u00ed je zvykem resekovat odpov\u00eddaj\u00edc\u00ed \u017eebern\u00ed chrupavky, p\u0159\u00edpadn\u011b i \u010d\u00e1sti ventr\u00e1ln\u00edch \u00fasek\u016f \u017eeber (obr. 12).<\/p>\n<p style=\"text-align: justify;\">Pokud to rozsah infiltrace dovoluje, v\u00fdhodou je zachov\u00e1n\u00ed alespo\u0148 jednoho vnit\u0159n\u00edho mamm\u00e1rn\u00edho c\u00e9vn\u00edho svazku pro p\u0159\u00edpadnou dal\u0161\u00ed rekonstrukci lalokem p\u0159\u00edm\u00e9ho b\u0159i\u0161n\u00edho svalu.<\/p>\n<p style=\"text-align: justify;\">Rekonstrukce chyb\u011bj\u00edc\u00ed p\u0159edn\u00ed st\u011bny hrudn\u00ed by m\u011bla b\u00fdt rigidn\u00ed (sendvi\u010d polypropylen\/kostn\u00ed cement, polymetylmetakryl\u00e1tov\u00e1 desti\u010dka, pevn\u00e1 s\u00ed\u0165ka+ autotransplant\u00e1ty \u017eeber \u010di titanov\u00e9 dlahy) (obr. 13,14).<\/p>\n<p style=\"text-align: justify;\">V p\u0159\u00edpad\u011b septick\u00fdch defekt\u016f (poststernotomick\u00e1 osteomyelitida) je prim\u00e1rn\u00ed rigidn\u00ed rekonstrukce obt\u00ed\u017en\u00e1, pou\u017e\u00edv\u00e1 se kombinace osteosynt\u00e9zy (resuturadr\u00e1ty, dlahy), VAC syst\u00e9mu s p\u0159\u00edpadnou odlo\u017eenou rekonstrukc\u00ed m\u011bkk\u00fdch tk\u00e1n\u00ed svalov\u00fdmi laloky \u010di omentem.<\/p>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0611.png\"><img decoding=\"async\" title=\"Obr. 11 \u2013 PET-CT tumoru sterna (plazmocytom)\" alt=\"Obr. 11 \u2013 PET-CT tumoru sterna (plazmocytom)\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0611.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 11<br \/>PETCT tumoru sterna (plazmocytom)<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0601.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 13 \u2013 Sendvi\u010dov\u00e1 z\u00e1plata (kostn\u00ed cement mezi dv\u011bmi vrstvami polypropylenu)\" alt=\"Obr. 13 \u2013 Sendvi\u010dov\u00e1 z\u00e1plata (kostn\u00ed cement mezi dv\u011bmi vrstvami polypropylenu)\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0601.png\" width=\"200\" height=\"153\" \/><\/a><p class=\"wp-caption-text\">Obr. 13<br \/>Sendvi\u010dov\u00e1 z\u00e1plata (kostn\u00ed cement mezi dv\u011bmi vrstvami polypropylenu)<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0621.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 12 \u2013 P\u0159edn\u00ed st\u011bna hrudn\u00ed po resekci proxim\u00e1ln\u00edch 2\/3 sterna\" alt=\"Obr. 12 \u2013 P\u0159edn\u00ed st\u011bna hrudn\u00ed po resekci proxim\u00e1ln\u00edch 2\/3 sterna\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0621.png\" width=\"200\" height=\"136\" \/><\/a><p class=\"wp-caption-text\">Obr. 12<br \/>P\u0159edn\u00ed st\u011bna hrudn\u00ed po resekci proxim\u00e1ln\u00edch 2\/3 sterna<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0631.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 13px; line-height: 19px; text-align: start;\" title=\"Obr. 14 \u2013 Sendvi\u010dov\u00e1 s\u00ed\u0165ka fixovan\u00e1 do defektu p\u0159edn\u00ed hrudn\u00ed st\u011bny\" alt=\"Obr. 14 \u2013 Sendvi\u010dov\u00e1 s\u00ed\u0165ka fixovan\u00e1 do defektu p\u0159edn\u00ed hrudn\u00ed st\u011bny\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0631.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 14<br \/>Sendvi\u010dov\u00e1 s\u00ed\u0165ka fixovan\u00e1 do defektu p\u0159edn\u00ed hrudn\u00ed st\u011bny<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h5>\u00a03.2.5.3 Torakoplastika<\/h5>\n<p style=\"text-align: justify;\">Torakoplastikou ozna\u010dujeme odstran\u011bn\u00ed \u017eeber z hrudn\u00ed st\u011bny dovoluj\u00edc\u00ed jej\u00ed trval\u00fd kolaps, kter\u00fd slou\u017e\u00ed k obliteraci chronick\u00fdch dutin \u010di infikovan\u00fdch zbytkov\u00fdch prostor\u016f (chronick\u00e9 kaverny, postpneumonektomick\u00e9 empy\u00e9my). Tato metoda byla kdysi st\u011b\u017eejn\u00edm krokem kolapsoterapie tuberkul\u00f3zy. D\u00edky efektivn\u00ed chemoterapii byla torakoplastika t\u00e9m\u011b\u0159 eliminov\u00e1na z opera\u010dn\u00edho rejst\u0159\u00edku jako v\u00fdkon velmi n\u00e1ro\u010dn\u00fd a mutiluj\u00edc\u00ed, zat\u00ed\u017een\u00fd vysokou morbiditou a mortalitou. P\u0159esto i v sou\u010dasnosti existuje skupina nemocn\u00fdch, u kter\u00fdch m\u016f\u017ee b\u00fdt odpov\u00eddaj\u00edc\u00ed torakoplastika definitivn\u00edm \u0159e\u0161en\u00edm z\u00e1va\u017en\u00e9ho a komplikovan\u00e9ho stavu. Torakoplastiky d\u011bl\u00edme na:<\/p>\n<ul>\n<li>intrapleur\u00e1ln\u00ed,<\/li>\n<li>extrapleur\u00e1ln\u00ed,<\/li>\n<li>plomb\u00e1\u017ee,<\/li>\n<li>limitovan\u00e9 torakoplastiky.<\/li>\n<\/ul>\n<h6>3.2.5.3.1 Intrapleur\u00e1ln\u00ed torakoplastika<\/h6>\n<p style=\"text-align: justify;\">Byla vypracov\u00e1na Schedem. P\u0159\u00edstupem byla dlouh\u00e1 U incize m\u011bkk\u00fdch tk\u00e1n\u00ed, kter\u00e1 vytvo\u0159ila \u0161irok\u00fd lalok k\u016f\u017ee a extraskelet\u00e1ln\u00edch sval\u016f hrudn\u00ed st\u011bny (m. latissimus, m. serratus ant.). T\u00edmto lalokem byla po resekci \u017eeber, interkost\u00e1ln\u00edch svazk\u016f a pariet\u00e1ln\u00ed pleury kryta takto vznikl\u00e1 \u0161irok\u00e1 rann\u00e1 plocha (kolabovan\u00e1 pl\u00edce nebo mediastinum). Tato operace vedla k t\u011b\u017ek\u00e9 deformit\u011b hrudn\u00edku, anestezii odpov\u00eddaj\u00edc\u00ed hrudn\u00ed a b\u0159i\u0161n\u00ed st\u011bny, k poopera\u010dn\u00edm st\u0159evn\u00edm paral\u00fdz\u00e1m, doznala \u0159ady modifikac\u00ed, v sou\u010dasnosti u\u017e se nepou\u017e\u00edv\u00e1.<\/p>\n<h6>3.2.5.3.2 Extrapleur\u00e1ln\u00ed torakoplastika<\/h6>\n<p style=\"text-align: justify;\">Pou\u017e\u00edv\u00e1 se dodnes. Za klasickou je pova\u017eov\u00e1na Alexandrova t\u0159\u00edst\u00e1\u017eov\u00e1 operace, p\u0159i kter\u00e9 se v n\u011bkolikat\u00fddenn\u00edch intervalech odstra\u0148uj\u00ed \u017eebra od p\u0159edn\u00ed st\u011bny a pohrudnice\u00a0axil\u00e1rn\u00ed \u010d\u00e1ry a\u017e k hlavi\u010dk\u00e1m (1.\u20133., 4.\u20137., 8.\u201311.). P\u0159i tot\u00e1ln\u00ed torakoplastice se odstra\u0148uje prvn\u00edch 11 \u017eeber, p\u0159i parci\u00e1ln\u00ed 10 a m\u00e9n\u011b. P\u0159i roz\u0161\u00ed\u0159en\u00e9 jsou nav\u00edc resekov\u00e1ny i p\u0159edn\u00ed \u00faseky horn\u00edch \u017eeber v z\u00e1jmu dosa\u017een\u00ed lep\u0161\u00edho kolapsu apik\u00e1ln\u00edch l\u00e9z\u00ed. P\u0159i Alexandrov\u011b operaci jsou \u017eebra resekov\u00e1na subperiost\u00e1ln\u011b, kolaps hrudn\u00ed st\u011bny je uspokojiv\u00fd, ponechan\u00fd periost \u017eeber umo\u017e\u0148uje vznik kostn\u00edch regener\u00e1t\u016f, kter\u00e9 \u010dasem torakoplastiku stabilizuj\u00ed. Vedou se spory, zda resekovat prvn\u00ed \u017eebro, jeho\u017e odstran\u011bn\u00ed spolu s resekc\u00ed transverz\u00e1ln\u00edch v\u00fdb\u011b\u017ek\u016f horn\u00edch hrudn\u00edch obratl\u016f vede k v\u00e1\u017en\u00fdm skoli\u00f3z\u00e1m a poruch\u00e1m hybnosti ramenn\u00edho pletence. Tento krok m\u016f\u017ee b\u00fdt uspokojiv\u011b nahrazen apikol\u00fdzou (tedy uvoln\u011bn\u00edm apexu pl\u00edce a m\u011bkk\u00fdch tk\u00e1n\u00ed kaud\u00e1ln\u011b sm\u011brem k obliterovan\u00e9 dutin\u011b). Nev\u00fdhodou t\u00e9to operace je d\u00e9letrvaj\u00edc\u00ed instabilita hrudn\u00ed st\u011bny.<\/p>\n<p style=\"text-align: justify;\">Jinou alternativou k \u0159e\u0161en\u00ed apik\u00e1ln\u00edch l\u00e9z\u00ed je Bj\u00f6rkova osteoplastick\u00e1 operace, p\u0159i kter\u00e9 jsou stup\u0148ovit\u011b resekov\u00e1ny dorz\u00e1ln\u00ed \u00faseky proxim\u00e1ln\u00edch \u017eeber v nar\u016fstaj\u00edc\u00ed d\u00e9lce tak, aby mohly b\u00fdt fixov\u00e1ny dr\u00e1tem k \u017eebru kaud\u00e1ln\u011b od lo\u017eiska, kter\u00e9 je t\u0159eba zkolabovat.<\/p>\n<h6>3.2.5.3.3 Plomb\u00e1\u017ee<\/h6>\n<p style=\"text-align: justify;\">Jedn\u00e1 se o operace, kdy dutinu kolabujeme extrapleur\u00e1ln\u011b, extrafasci\u00e1ln\u011b \u010di extraperiost\u00e1ln\u011b ulo\u017een\u00fdm materi\u00e1lem (paraf\u00edn, vlastn\u00ed krev, vazel\u00ednov\u00e1 g\u00e1za, silikon, tuk, metakryl\u00e1tov\u00e9 kuli\u010dky). S vypracov\u00e1n\u00edm technik omentoplastiky a myoplastiky ztratily plomb\u00e1\u017ee ciz\u00edm materi\u00e1lem v\u00fdznam. Andrewsova torakomyoplastika je ur\u010dena k \u0159e\u0161en\u00ed men\u0161\u00edch povrchn\u011b ulo\u017een\u00fdch infek\u010dn\u00edch lo\u017eisek. Sest\u00e1v\u00e1 ze subperiost\u00e1ln\u00ed resekce \u017eeber nad dutinou, otev\u0159en\u00ed lo\u017eiska l\u016f\u017ekem \u017eebra a kyret\u00e1\u017ee nekrotick\u00e9 a granula\u010dn\u00ed tk\u00e1n\u011b. N\u00e1sleduje fixace pleuromuskuloperiost\u00e1ln\u00edho laloku do spodiny dutiny po\u010detn\u00fdmi U stehy.<\/p>\n<h6>3.2.5.3.4 Limitovan\u00e9 torakoplastiky<\/h6>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0651.png\"><img decoding=\"async\" title=\"Obr. 15 \u2013 Limitovan\u00e1 torakoplastika pro baz\u00e1ln\u00ed empy\u00e9m (ozna\u010deno \u0161ipkou)\" alt=\"Obr. 15 \u2013 Limitovan\u00e1 torakoplastika pro baz\u00e1ln\u00ed empy\u00e9m (ozna\u010deno \u0161ipkou)\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0651.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 15<br \/>Limitovan\u00e1 torakoplastika pro baz\u00e1ln\u00ed empy\u00e9m (ozna\u010deno \u0161ipkou)<\/p><\/div>\n<p style=\"text-align: justify;\">Slou\u017e\u00ed ke zmen\u0161en\u00ed infikovan\u00fdch zbytkov\u00fdch prostor\u016f po (p\u0159i) resekc\u00edch pl\u00edce. \u017debra jsou resekov\u00e1na v nezbytn\u00e9m rozsahu tak, aby nebyla ohro\u017eena stabilita hrudn\u00ed st\u011bny a neprojevilo se paradoxn\u00ed d\u00fdch\u00e1n\u00ed (obr. 15).<\/p>\n<h3>3.3 Onemocn\u011bn\u00ed pleury<\/h3>\n<h4>3.3.1 Pleur\u00e1ln\u00ed v\u00fdpotek<\/h4>\n<p style=\"text-align: justify;\">Patologick\u00e9 nahromad\u011bn\u00ed tekutiny v pleur\u00e1ln\u00ed dutin\u011b se naz\u00fdv\u00e1 fluidotorax, podle charakteru v\u00fdpotku m\u016f\u017ee j\u00edt o hydrotorax (ser\u00f3zn\u00ed tekutina), pyotorax \u010di empy\u00e9m (hnis, z\u00e1n\u011btliv\u00fd v\u00fdpotek), hemotorax (krev) \u010di chylotorax (chylus). V\u00fdpotek ozna\u010dujeme za transsud\u00e1t, pokud obsahuje m\u00e9n\u011b ne\u017e 30 g b\u00edlkoviny na litr a m\u00e1 specifickou v\u00e1hu men\u0161\u00ed ne\u017e 1,016. Vy\u0161\u0161\u00edmi hodnotami obou veli\u010din je charakterizov\u00e1n exsud\u00e1t. Pokud je v dutin\u011b pohrudni\u010dn\u00ed z\u00e1rove\u0148 vzduch, mluv\u00edme o fluidopneumotoraxu, podle charakteru v\u00fdpotku m\u016f\u017ee j\u00edt nap\u0159. o hemopneumotorax \u010di pyopneumotorax.<\/p>\n<h4>3.3.2 Pneumotorax<\/h4>\n<p style=\"text-align: justify;\">Pneumotorax (PNO) je klasifikov\u00e1n jako akumulace vzduchu v pohrudni\u010dn\u00ed dutin\u011b, kter\u00e9 odpov\u00edd\u00e1 kolaps p\u0159\u00edslu\u0161n\u00e9 pl\u00edce.<\/p>\n<ul style=\"text-align: justify;\">\n<li>Sekund\u00e1rn\u00ed spont\u00e1nn\u00ed pneumotorax (SSPNO) je d\u016fsledkem preexistuj\u00edc\u00ed plicn\u00ed nemoci \u2013 chronick\u00e9 obstruk\u010dn\u00ed choroby plicn\u00ed, plicn\u00edho emfyz\u00e9mu, plicn\u00ed fibr\u00f3zy, tuberkul\u00f3zy apod.<\/li>\n<li>Traumatick\u00fd pneumotorax je d\u016fsledkem \u00farazov\u00e9ho d\u011bje, p\u0159i kter\u00e9m je poran\u011bna hrudn\u00ed st\u011bna, p\u0159\u00edpadn\u011b tracheobronchi\u00e1ln\u00ed strom, pl\u00edce nebo j\u00edcen.<\/li>\n<li>Iatrogenn\u00ed pneumotorax je d\u016fsledkem invazivn\u00edch l\u00e9\u010debn\u00fdch postup\u016f, kanylace horn\u00ed dut\u00e9 \u017e\u00edly a transpariet\u00e1ln\u00ed biopsie plic jsou nej\u010dast\u011bj\u0161\u00edm vyvol\u00e1vaj\u00edc\u00edm d\u011bjem. Zvl\u00e1\u0161tn\u00ed formou je terapeutick\u00fd pneumotorax pou\u017e\u00edvan\u00fd d\u0159\u00edve ke kolapsoterapii plicn\u00ed tuberkul\u00f3zy.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">Pokud nen\u00ed poru\u0161ena hrudn\u00ed st\u011bna, pova\u017eujeme pneumotorax za <b>uzav\u0159en\u00fd. <\/b>Penetruj\u00edc\u00ed poran\u011bn\u00ed hrudn\u00ed st\u011bny zp\u016fsobuj\u00ed pneumotorax <b>otev\u0159en\u00fd<\/b>. Pokud se l\u00e9ze v hrudn\u00ed st\u011bn\u011b, pr\u016fdu\u0161ce \u010di pl\u00edci chov\u00e1 ventilov\u00fdm zp\u016fsobem, to znamen\u00e1, \u017ee p\u0159i n\u00e1dechu se do pleur\u00e1ln\u00ed dutiny dost\u00e1v\u00e1 porce vzduchu, kter\u00e1 nem\u016f\u017ee b\u00fdt za v\u00fddechu evakuov\u00e1na, hovo\u0159\u00edme o pneumotoraxu <b>tenzn\u00edm<\/b>. Defekt hrudn\u00ed st\u011bny v\u011bt\u0161\u00ed, ne\u017e je pr\u016f\u0159ez pr\u016fdu\u0161nice, hrub\u00fdm zp\u016fsobem naru\u0161uje mechaniku d\u00fdch\u00e1n\u00ed, p\u0159i n\u00e1dechu proud\u00ed vzduch dovnit\u0159 poran\u011bn\u00e9ho hemitoraxu a zp\u016fsobuje p\u0159esun mediastina na zdravou stranu, p\u0159i v\u00fddechu je mezihrud\u00ed naopak p\u0159etla\u010dov\u00e1no na stranu poran\u011bnou. Tomuto jevu se \u0159\u00edk\u00e1 vl\u00e1n\u00ed mediastina. Pl\u00edce posti\u017een\u00e9 strany je kolabovan\u00e1, plicn\u00ed parenchym druh\u00e9 strany tak\u00e9 nepracuje, pouze neefektivn\u011b sleduje pohyby hrudn\u00ed st\u011bny a br\u00e1nice. Jedn\u00e1 se o z\u00e1va\u017en\u00fd, \u017eivot ohro\u017euj\u00edc\u00ed stav, podobn\u011b jako v p\u0159\u00edpad\u011b tenzn\u00edho pneumotoraxu. Oba tyto stavy pova\u017eujeme za n\u00e1hl\u00e9 p\u0159\u00edhody hrudn\u00ed. Zat\u00edmco hlavn\u00ed p\u0159\u00ed\u010dinou respira\u010dn\u00edho selh\u00e1n\u00ed u otev\u0159en\u00e9ho pneumotoraxu je porucha mechaniky d\u00fdch\u00e1n\u00ed, v p\u0159\u00edpad\u011b tenzn\u00edho pneumotoraxu dominuje porucha n\u00e1vratu \u017eiln\u00ed krve k srdci. Nas\u00e1v\u00e1n\u00ed a akumulace vzduchu v pohrudni\u010dn\u00ed dutin\u011b ventilem v hrudn\u00ed st\u011bn\u011b (nebo v tracheobronchi\u00e1ln\u00edm stromu) vedou k postupn\u00e9mu stla\u010den\u00ed p\u0159\u00edslu\u0161n\u00e9 pl\u00edce k hilu, kone\u010dn\u00fdm d\u016fsledkem je p\u0159etla\u010den\u00ed mediastina na prot\u011bj\u0161\u00ed stranu p\u016fsob\u00edc\u00ed \u00fatlak, resp. angulaci a za\u0161krcen\u00ed obou dut\u00fdch \u017eil a kompresi druh\u00e9 pl\u00edce.<\/p>\n<p style=\"text-align: justify;\">Jako <b>kompletn\u00ed <\/b>ozna\u010dujeme pneumotorax s \u00fapln\u00fdm kolapsem pl\u00edce. <b>\u010c\u00e1ste\u010dn\u00fd <\/b>PNO vznik\u00e1 tehdy, kdy je pl\u00edce udr\u017eov\u00e1na v \u010d\u00e1ste\u010dn\u00e9m rozvinut\u00ed sr\u016fsty. <b>Pl\u00e1\u0161\u0165ov\u00fdm <\/b>pneumotoraxem rozum\u00edme malou akumulaci vzduchu v pohrudni\u010dn\u00ed dutin\u011b se separac\u00ed pohrudnice\/poplicnice men\u0161\u00ed ne\u017e 2,5 cm.Klinick\u00e9 projevy nekomplikovan\u00e9ho PNO jsou nev\u00fdrazn\u00e9 a nespecifick\u00e9: bolest na hrudn\u00edku, du\u0161nost, ka\u0161el. V\u00e1\u017enost jejich manifestace nar\u016fst\u00e1 s t\u00ed\u017e\u00ed p\u0159\u00edpadn\u00e9ho onemocn\u011bn\u00ed plic a m\u00edrou kolapsu pl\u00edce. Nejv\u00e1\u017en\u011bj\u0161\u00ed symptomatologii (du\u0161nost, cyan\u00f3za, zv\u00fd\u0161en\u00e1 n\u00e1pl\u0148 kr\u010dn\u00edch \u017eil, celkov\u00e1 deteriorace, tachykardie, kardiorespira\u010dn\u00ed selh\u00e1v\u00e1n\u00ed) m\u00e1 tenzn\u00ed pneumotorax. Pr\u016fb\u011bh m\u016f\u017ee b\u00fdt perakutn\u00ed, je d\u00e1n p\u0159eta\u017een\u00edm mediastina na neposti\u017eenou stranu, \u00fatlakem neposti\u017een\u00e9 pl\u00edce, velk\u00fdch \u017eil a n\u00edzkotlak\u00fdch srde\u010dn\u00edch odd\u00edl\u016f.<\/p>\n<p style=\"text-align: justify;\">Diagnostika je klinick\u00e1 (hypersonorn\u00ed poklep, vymizen\u00ed d\u00fdchac\u00edch fenom\u00e9n\u016f, men\u0161\u00ed d\u00fdchac\u00ed pohyby na posti\u017een\u00e9 stran\u011b). K potvrzen\u00ed sta\u010d\u00ed zadop\u0159edn\u00ed, event. i bo\u010dn\u00fd skiagram hrudn\u00edku. CT slou\u017e\u00ed sp\u00ed\u0161e k posouzen\u00ed zm\u011bn plicn\u00edho parenchymu, je p\u0159\u00ednosn\u011bj\u0161\u00ed a\u017e po reexpanzi pl\u00edce. V diferenci\u00e1ln\u00ed diagn\u00f3ze je t\u0159eba pom\u00fd\u0161let na objemn\u00e9 plicn\u00ed buly, plicn\u00ed cysty nebo br\u00e1ni\u010dn\u00ed herniaci. Terapie m\u016f\u017ee b\u00fdt konzervativn\u00ed, u asymptomatick\u00fdch nemocn\u00fdch s pl\u00e1\u0161\u0165ov\u00fdm pneumotoraxem pouze observace, p\u0159\u00edpadn\u011b jednor\u00e1zov\u00e1 aspirace, u symptomatick\u00fdch nemocn\u00fdch hrudn\u00ed dren\u00e1\u017e. U nemocn\u00fdch se sekund\u00e1rn\u00edm pneumotoraxem na podklad\u011b ne\u0159e\u0161iteln\u00e9 malignity m\u00e1 m\u00edsto chemick\u00e1 pleurod\u00e9za, stejn\u011b jako u nemocn\u00fdch inoperabiln\u00edch z jin\u00fdch d\u016fvod\u016f. Prevence recidivy u nemocn\u00fdch v riziku (pot\u00e1p\u011b\u010di, letci) a terapie recidiv je a\u017e na v\u00fdjimky chirurgick\u00e1. Z\u00e1kladem je revize a o\u0161et\u0159en\u00ed zdroje \u00faniku (nap\u0159. apik\u00e1ln\u00ed resekce, staplerov\u00e1 sutura), nem\u00e9n\u011b v\u00fdznamn\u00e9 je dosa\u017een\u00ed pevn\u00e9 pleurod\u00e9zy, dnes v\u011bt\u0161inou videotorakoskopicky kombinac\u00ed apik\u00e1ln\u00ed pleurektomie a mechanick\u00e9 pleurod\u00e9zy (pleurabraze kost\u00e1ln\u00ed a diafragmatick\u00e9 pleury). V t\u00e9to podob\u011b lze o\u010dek\u00e1vat asi 95\u201397% \u00fasp\u011b\u0161nost intervence. Prvn\u00ed pomoc\u00ed u tenzn\u00edho pneumotoraxu je bezprost\u0159edn\u00ed dren\u00e1\u017e nebo alespo\u0148 punkce hrudn\u00edku \u0161irokou jehlou. Aktivn\u00ed s\u00e1n\u00ed nen\u00ed podm\u00ednkou, chlope\u0148 nebo alespo\u0148 vodn\u00ed ventil jsou vhodn\u00e9.<\/p>\n<h4>3.3.3 Empy\u00e9m<\/h4>\n<div style=\"width: 160px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0681.png\"><img decoding=\"async\" class=\" \" title=\"Obr. 16 \u2013 Lokalizovan\u00fd empy\u00e9m v kostofrenick\u00e9m \u00fahlu\" alt=\"Obr. 16 \u2013 Lokalizovan\u00fd empy\u00e9m v kostofrenick\u00e9m \u00fahlu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0681.png\" width=\"150\" \/><\/a><p class=\"wp-caption-text\">Obr. 16<br \/>Lokalizovan\u00fd empy\u00e9m v kostofrenick\u00e9m \u00fahlu<\/p><\/div>\n<p style=\"text-align: justify;\">Hrudn\u00ed empy\u00e9m je nahromad\u011bn\u00ed hnisu v pohrudni\u010dn\u00ed dutin\u011b. M\u016f\u017ee j\u00edt o neohrani\u010den\u00fd proces postihuj\u00edc\u00ed celou pohrudni\u010dn\u00ed dutinu (empyema completum), nebo je hnisav\u00e1 kolekce v pohrudni\u010dn\u00ed dutin\u011b ohrani\u010dena (empyema saccatum). Lokalizovan\u00e9 empy\u00e9my jsou nej\u010dast\u011bji ulo\u017eeny n\u00e1st\u011bnn\u011b dorzobaz\u00e1ln\u011b, paramediastin\u00e1ln\u011b, parakardi\u00e1ln\u011b, supradiafragmaticky nebo v interlob\u00e1rn\u00edch \u0161t\u011brbin\u00e1ch (obr. 16).Etiologicky se jedn\u00e1 v\u017edy o komplikaci jin\u00e9ho onemocn\u011bn\u00ed, podle vyvol\u00e1vaj\u00edc\u00edho p\u016fvodce je d\u011bl\u00edme na:<\/p>\n<ul>\n<li>empy\u00e9m nespecifick\u00fd,<\/li>\n<li>empy\u00e9m specifick\u00fd,<\/li>\n<li>empy\u00e9m mykotick\u00fd,<\/li>\n<li>empy\u00e9m parazit\u00e1rn\u00ed,<\/li>\n<li>empy\u00e9m sm\u00ed\u0161en\u00fd.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">Nadpolovi\u010dn\u00ed v\u011bt\u0161ina empy\u00e9m\u016f vznik\u00e1 jako komplikace pneumonie (parapneumonick\u00fd empy\u00e9m), asi t\u0159etina vznik\u00e1 v d\u016fsledku nitrohrudn\u00edch operac\u00ed nebo \u00faraz\u016f hrudn\u00edku, m\u00e9n\u011b \u010dast\u00e9 jsou dal\u0161\u00ed p\u0159\u00ed\u010diny (perforace j\u00edcnu, bronchiekt\u00e1zie, sekvestrace plicn\u00ed, parazit\u00e1rn\u00ed \u010di specifick\u00e9 empy\u00e9my).<\/p>\n<p>Pr\u016fb\u011bh empy\u00e9mu d\u011bl\u00edme do t\u0159\u00ed typick\u00fdch stadi\u00ed:<\/p>\n<ul>\n<li>stadium exsudativn\u00ed,<\/li>\n<li>stadium fibropurulentn\u00ed,<\/li>\n<li>stadium organizace (fibrotorax).<\/li>\n<\/ul>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0691.png\"><img decoding=\"async\" title=\"Obr. 17 \u2013 Chronick\u00fd empy\u00e9m s nedostate\u010dnou reexpanz\u00ed pl\u00edce po dren\u00e1\u017ei\" alt=\"Obr. 17 \u2013 Chronick\u00fd empy\u00e9m s nedostate\u010dnou reexpanz\u00ed pl\u00edce po dren\u00e1\u017ei\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0691.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 17<br \/>Chronick\u00fd empy\u00e9m s nedostate\u010dnou reexpanz\u00ed pl\u00edce po dren\u00e1\u017ei<\/p><\/div>\n<p style=\"text-align: justify;\">V prvn\u00ed, exsudativn\u00ed f\u00e1zi, kter\u00e1 trv\u00e1 1\u20132 t\u00fddny, doch\u00e1z\u00ed k pr\u016fniku bakteri\u00ed do p\u016fvodn\u011b steriln\u00edho parapneumonick\u00e9ho exsud\u00e1tu a k inflamatorn\u00edm zm\u011bn\u00e1m pariet\u00e1ln\u00ed, m\u00e9n\u011b viscer\u00e1ln\u00ed pleury. Zpo\u010d\u00e1tku tekut\u00fd v\u00fdpotek z\u00edsk\u00e1v\u00e1 na koncentraci b\u00edlkovin a fibrinua st\u00e1v\u00e1 se visk\u00f3zn\u00edm, resp. gelatin\u00f3zn\u00edm.<\/p>\n<p style=\"text-align: justify;\">Druh\u00e9, fibropurulentn\u00ed stadium trv\u00e1 op\u011bt asi 1\u20132 t\u00fddny, je charakterizov\u00e1no leukocyt\u00e1rn\u00ed z\u00e1n\u011btlivou reakc\u00ed, tvorbou typick\u00e9ho hnisu a ukl\u00e1d\u00e1n\u00edm siln\u00fdch fibrinov\u00fdch n\u00e1let\u016f zejm\u00e9na na pariet\u00e1ln\u00eda diafragmatick\u00e9 pleu\u0159e.<\/p>\n<p style=\"text-align: justify;\">Nakonec, ve stadiu organizace, doch\u00e1z\u00ed k vytvo\u0159en\u00ed siln\u00e9 pyogenn\u00ed membr\u00e1ny, do fibrinov\u00fdch depozit pror\u016fstaj\u00ed fibroblasty, jimi produkovan\u00e1 kolagenn\u00ed vl\u00e1kna postupn\u011b\u00a0svra\u0161\u0165uj\u00ed slupku empy\u00e9mu do pevn\u00e9 vazivov\u00e9 desky, u tot\u00e1ln\u00edho empy\u00e9mu a\u017e \u00fapln\u00e9ho krun\u00fd\u0159e utla\u010duj\u00edc\u00edho odpov\u00eddaj\u00edc\u00ed pl\u00edci. Granula\u010dn\u00ed tk\u00e1\u0148 postihuje do nevelk\u00e9 hloubky i subpleur\u00e1ln\u00ed plicn\u00ed parenchym a mezi\u017eebern\u00ed tk\u00e1n\u011b. Postupn\u00e9 vyzr\u00e1v\u00e1n\u00ed vazivov\u00e9 tk\u00e1n\u011b, kter\u00e9 za\u010d\u00edn\u00e1 asi t\u0159et\u00ed t\u00fddenod vzplanut\u00ed infekce pleur\u00e1ln\u00edho prostoru, kon\u010d\u00ed asipo 5\u20138 t\u00fddnech uv\u011bzn\u011bn\u00edm pl\u00edce v hemitoraxu, kter\u00fd je zmen\u0161en p\u0159esunem mediastina na posti\u017eenou stranu, elevac\u00ed br\u00e1nice a z\u00fa\u017een\u00edm mezi\u017eeb\u0159\u00ed. D\u016fsledkem je ur\u010dit\u00fd, u kompletn\u00edho empy\u00e9mu v\u00e1\u017en\u00fd limit ventila\u010dn\u00edch parametr\u016f.Klinick\u00e9 p\u0159\u00edznaky empy\u00e9mu v\u011bt\u0161inou navazuj\u00ed na p\u0159edchoz\u00ed pneumonick\u00e9 projevy. Rekurence febrili\u00ed, du\u0161nost, zchv\u00e1cenost, pleur\u00e1ln\u00ed bolest, v\u00e1hov\u00fd \u00fabytek, tachykardie spolu s p\u0159etrv\u00e1v\u00e1n\u00edm \u010di n\u00e1r\u016fstem laboratorn\u00edch parametr\u016f z\u00e1n\u011btu (sedimentace, leukocyt\u00f3za, CRP) indikuj\u00ed zado-p\u0159edn\u00ed a bo\u010dn\u00fd rentgenogram. P\u0159i sporn\u00e9m n\u00e1lezu je vhodn\u00e9 CT vy\u0161et\u0159en\u00ed k posouzen\u00ed rozsahu a lokalizace empy\u00e9mu event. k c\u00edlen\u00ed dren\u00e1\u017ee. Definitivn\u00ed d\u016fkaz lze z\u00edskat pomoc\u00ed diagnostick\u00e9 punkce nebo p\u0159\u00edmo dren\u00e1\u017e\u00ed. Makroskopick\u00fd pr\u016fkaz hnisu, pozitivn\u00ed bakteriologick\u00fd n\u00e1lez, pokles pH ve v\u00fdpotku pod 7,2 a n\u00edzk\u00e1 hladina gluk\u00f3zy ve v\u00fdpotku jsou typick\u00fdmi zn\u00e1mkami empy\u00e9mu.V\u017edy je t\u0159eba odebrat vzorek exsud\u00e1tu k mikrobiologick\u00e9mu vy\u0161et\u0159en\u00ed na nespecifickou aerobn\u00ed i anaerobn\u00ed a specifickou infekci i na pl\u00edsn\u011b.Empy\u00e9m v\u00e1zan\u00fd\u00a0na perforaci za\u017e\u00edvac\u00edho traktu (Boerhaave\u016fv syndrom, polept\u00e1n\u00ed j\u00edcnu, perforace j\u00edcnov\u00fdch anastom\u00f3z \u010di tubusu \u017ealudku po n\u00e1hrad\u011b j\u00edcnu), resp. jeho p\u0159\u00ed\u010dinu lze prok\u00e1zat pomoc\u00ed ezofago(gastro)grafie vodnou kontrastn\u00ed l\u00e1tkou, endoskopick\u00e9 vy\u0161et\u0159en\u00ed je rizikov\u00e9. Pr\u016fkaz bronchopleur\u00e1ln\u00ed p\u00ed\u0161t\u011ble \u010di dehiscence pah\u00fdlu pr\u016fdu\u0161ky je naopak obvykle bronchoskopick\u00fd.<\/p>\n<p style=\"text-align: justify;\">Parapneumonick\u00fd empy\u00e9m je nej\u010dast\u011bji vyvol\u00e1n stejn\u00fdmi mikroorganismy jako samotn\u00e1 pneumonie (<i>Strept. pneumoniae, Staph. aureus, Strept. pyogenes, Klebsiella sp., Klebsiella pneumoniae, Pseudomonas aeruginosa, Proteus species, Escherichia coli, Enterobacter<\/i>, u aspirac\u00ed a u imunokompromitovan\u00fdch nemocn\u00fdch jsou \u010dast\u011bj\u0161\u00ed gramnegativn\u00ed bakterie \u2013 <i>Bacteroides, Peptococcus, Peptostreptococcus, Fusobacterium<\/i>, v\u011bt\u0161inou v kombinaci).<\/p>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0711.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 18 \u2013 Exstirpovan\u00fd vak empy\u00e9mu (empy\u00e9mektomie)\" alt=\"Obr. 18 \u2013 Exstirpovan\u00fd vak empy\u00e9mu (empy\u00e9mektomie)\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0711.png\" width=\"200\" height=\"173\" \/><\/a><p class=\"wp-caption-text\">Obr. 18<br \/>Exstirpovan\u00fd vak empy\u00e9mu (empy\u00e9mektomie)<\/p><\/div>\n<p style=\"text-align: justify;\">V prvn\u00edch dvou\u00a0stadi\u00edch je mo\u017en\u00e1 konzervativn\u00ed l\u00e9\u010dba, kter\u00e1 spo\u010d\u00edv\u00e1 v rychl\u00e9 evakuaci hnisav\u00e9 kolekce, lok\u00e1ln\u00ed debacilaci dutiny, potla\u010den\u00ed infekce syst\u00e9movou l\u00e9\u010dbou a v rychl\u00e9 reexpanzi pl\u00edce. Dren\u00e1\u017e se prov\u00e1d\u00ed nejl\u00e9pe pod sonografickou \u010di CT navigac\u00ed, jedn\u00edm nebo v\u00edce siln\u00fdmi dr\u00e9ny. Po zalo\u017een\u00ed dren\u00e1\u017ee je v\u00fdhodn\u00e9 aktivn\u00ed s\u00e1n\u00ed i s vy\u0161\u0161\u00edm podtlakem a proplachy empy\u00e9mov\u00e9 dutiny antiseptick\u00fdmi roztoky (obr. 17).\u00a0Pokud je exsud\u00e1t hust\u00fd, lze k degradaci fibrinu pou\u017e\u00edt lok\u00e1ln\u011b aplikovan\u00e1 fibrinolytika (streptokin\u00e1zu, urokin\u00e1zu, hyaluronid\u00e1zu). S rozvojem miniinvazivn\u00edch metod nab\u00fdv\u00e1 v \u010dasn\u00fdch stadi\u00edch empy\u00e9mu na v\u00fdznamu videotorakoskopie \u010di videoasistovan\u00e1 hrudn\u00ed chirurgie, jejich\u017e nejv\u011bt\u0161\u00edm benefitem je jednor\u00e1zov\u00e1 a rychl\u00e1 mechanick\u00e1 toaleta (debridement) empy\u00e9mov\u00e9 dutiny. Ve t\u0159et\u00edm stadiu empy\u00e9mu je konzervativn\u00ed i VTS\/VATS l\u00e9\u010dba pov\u011bt\u0161inou nemo\u017en\u00e1 nebo ne\u00fasp\u011b\u0161n\u00e1, pak je nam\u00edst\u011b definitivn\u00ed chirurgick\u00e1 l\u00e9\u010dba (fenestrace, empy\u00e9mektomie, pleurektomie\/ dekortikace, raritn\u011b i torakoplastika) (obr. 18).<\/p>\n<p style=\"text-align: justify;\">Posttraumatick\u00fd empy\u00e9m se v \u0159ad\u011b aspekt\u016f li\u0161\u00ed od klasick\u00fdch parapneumonick\u00fdch afekc\u00ed. V\u011bt\u0161inou je d\u016fsledkem zbytkov\u00e9ho hemotoraxu, proto nem\u00edv\u00e1 \u010dasnou exsudativn\u00ed f\u00e1zi. B\u00fdv\u00e1 dob\u0159e a pevn\u011b ohrani\u010den\u00fd, pouh\u00e1 dren\u00e1\u017e m\u00e1lokdy vede k uspokojiv\u00e9mu vyhojen\u00ed.Poopera\u010dn\u00ed (poresek\u010dn\u00ed) empy\u00e9m b\u00fdv\u00e1 \u010dasto spojen s bronchopleur\u00e1ln\u00ed p\u00ed\u0161t\u011bl\u00ed. Pokud je net\u011bsnost prok\u00e1z\u00e1na na \u00farovni lob\u00e1rn\u00edho bronchu, lze dos\u00e1hnout \u00fasp\u011bchu konzervativn\u00edm postupem (dren\u00e1\u017e, reexpanze pl\u00edce), resuturou bronchu nebo dokon\u010duj\u00edc\u00ed resekc\u00ed ve velk\u00e9 v\u011bt\u0161in\u011b p\u0159\u00edpad\u016f. Nejob\u00e1van\u011bj\u0161\u00ed komplikac\u00ed hrudn\u00ed chirurgie je tzv. postpneumonektomick\u00fd empy\u00e9m. Ten m\u016f\u017ee vzniknout i samostatn\u011b, ale \u010dast\u011bji je spojen s p\u00ed\u0161t\u011bl\u00ed \u010di dehiscenc\u00ed pah\u00fdlu kmenov\u00e9 pr\u016fdu\u0161ky. Dehiscence pah\u00fdlu bronchu m\u00e1 specifickou symptomatologii. Projevuje se vyka\u0161l\u00e1n\u00edm v\u011bt\u0161\u00edho mno\u017estv\u00ed sangvinoletn\u00edho sputa, kter\u00e9 je obvykle spojeno s poklesem hladiny tekutiny v operovan\u00e9m hemitoraxu patrn\u00fdm na rentgenogramu. \u010cast\u011bji b\u00fdv\u00e1 na prav\u00e9 stran\u011b a u diabetik\u016f. \u010cetnost t\u00e9to komplikace se odhaduje na 1\u201315 % pneumonektomi\u00ed, letalita dosahuje 50 %. Akutn\u00edm \u0159e\u0161en\u00edm, resp. prvn\u00ed pomoc\u00ed je \u0159\u00e1dn\u00e1 dren\u00e1\u017e pohrudni\u010dn\u00ed dutiny siln\u00fdm dr\u00e9nem nebo zalo\u017een\u00ed pleurostomie (torakoskomie) a polohov\u00e1n\u00ed na operovanou stranu. C\u00edlem je zabr\u00e1nit zat\u00e9k\u00e1n\u00ed infikovan\u00e9ho obsahu pleur\u00e1ln\u00ed dutiny do dehiscentn\u00ed pr\u016fdu\u0161ky p\u0159i inspiraci, kter\u00e9 vede pravideln\u011b k pneumonii kontralater\u00e1ln\u00ed pl\u00edce s fat\u00e1ln\u00edmi d\u016fsledky.\u010casn\u00e9 p\u00ed\u0161t\u011ble lze potom \u0159e\u0161it resuturou (z d\u016fvodu obykle kr\u00e1tk\u00e9ho pah\u00fdlu obt\u00ed\u017en\u011b), resekc\u00ed bifurkace (p\u0159i empy\u00e9mu s jasn\u00fdm rizikem), uz\u00e1v\u011brem bronchu muskuloplastikou \u010di omentoplastikou nebo obliterac\u00ed pohrudni\u010dn\u00ed dutiny torakoplastikou.U pozdn\u00edch p\u00ed\u0161t\u011bl\u00ed s chronick\u00fdm empy\u00e9mem lze kombinovat uz\u00e1v\u011br pr\u016fdu\u0161ky muskuloplastikou \u010di omentoplastikou s obliterac\u00ed zbytkov\u00e9 dutiny pomoc\u00ed torakoplastiky.<\/p>\n<h4>3.3.4 Hemotorax<\/h4>\n<p style=\"text-align: justify;\">Hemotorax je nahromad\u011bn\u00ed krve v pleur\u00e1ln\u00edm prostoru. Netraumatick\u00fd hemotorax je velmi vz\u00e1cn\u00fd. P\u0159\u00ed\u010dinou mohou b\u00fdt metastatick\u00e9 \u010di tuberkul\u00f3zn\u00ed posti\u017een\u00ed pleury, vrozen\u00e9 i z\u00edskan\u00e9 poruchy koagulace (hemofilie, antikoagula\u010dn\u00ed terapie, trombocytopenie), nemoci nitrohrudn\u00edch c\u00e9v (ruptura hrudn\u00ed aorty), katameni\u00e1ln\u00ed hemotorax vznik\u00e1 v souvislosti s menstruac\u00ed \u010di syndromem hrudn\u00ed endometri\u00f3zy. Daleko nej\u010dast\u011bj\u0161\u00ed p\u0159\u00ed\u010dinou hemotoraxu je trauma hrudn\u00edku (viz kapitola traumatologie hrudn\u00edku), v\u010detn\u011b iatrogenn\u00edch poran\u011bn\u00ed (hrudn\u00ed punkce, dren\u00e1\u017ee, kanylace centr\u00e1ln\u00edch \u017eil, plicn\u00ed biopsie).Symptomatologie hemotoraxu je nespecifick\u00e1 a je v\u011bt\u0161inou d\u00e1na komorbiditami \u010di sp\u00ed\u0161e p\u0159idru\u017een\u00fdmi poran\u011bn\u00edmi. Na nitrohrudn\u00ed krv\u00e1cen\u00ed ukazuje \u00farazov\u00fd d\u011bj sm\u011b\u0159uj\u00edc\u00ed na horn\u00ed polovinu t\u011bla, \u0161okov\u00fd stav, du\u0161nost, hypotenze, vymizel\u00e9 d\u00fdchac\u00ed fenom\u00e9ny a pohyby na posti\u017een\u00e9 stran\u011b hrudn\u00edku, zkr\u00e1cen\u00fd poklep, p\u0159\u00edpadn\u011b krepitace skeletu hrudn\u00edho ko\u0161e.<\/p>\n<p style=\"text-align: justify;\">Hemotorax je klinicky a rentgenologicky zjistiteln\u00fd p\u0159i objemu nad 250 ml. U asymptomatick\u00fdch nemocn\u00fdch s negativn\u00edm rentgenogramem se doporu\u010duje opakovat sn\u00edmek v intervalu 6\u201312 hodin. P\u0159i sporn\u00e9m n\u00e1lezu odkryje CT i minim\u00e1ln\u00ed PNO \u010di mal\u00e9 mno\u017estv\u00ed tekutiny. Revidovat r\u00e1nu se nedoporu\u010duje pro nebezpe\u010d\u00ed zp\u016fsoben\u00ed PNO a riziko kontaminace pleur\u00e1ln\u00ed dutiny. V p\u0159\u00edpad\u011b prok\u00e1zan\u00e9ho PNO \u010di n\u00e1lezu akumulovan\u00e9 tekutiny u penetruj\u00edc\u00edho poran\u011bn\u00ed je indikov\u00e1na hrudn\u00ed dren\u00e1\u017e. Je to nejlep\u0161\u00ed prevence rezidu\u00e1ln\u00edho hemotoraxu, kter\u00e1 dovoluje sledovat trend krv\u00e1cen\u00ed v \u010dase a p\u0159\u00edpadn\u011b indikovat revizi.Hemotorax d\u011bl\u00edme na:<\/p>\n<ul>\n<li>mal\u00fd hemotorax (do 500 ml),<\/li>\n<li>st\u0159edn\u00ed hemotorax (od 500 do 1500 ml),<\/li>\n<li>velk\u00fd hemotorax (nad 1500 ml akumulovan\u00e9 krve).<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">Masivn\u00ed krv\u00e1cen\u00ed z hrudn\u00edho dr\u00e9nu vy\u017eaduje torakotomii, minim\u00e1ln\u00ed trvaj\u00edc\u00ed odpad z dr\u00e9nu m\u016f\u017ee b\u00fdt o\u0161et\u0159en torakoskopicky za p\u0159edpokladu hemodynamick\u00e9 stability. Indikace torakotomie ve vztahuk evakuovan\u00e9mu mno\u017estv\u00ed krve je trvale diskutov\u00e1na.Emergentn\u00ed torakotomie je obvykle indikov\u00e1na, pokud odpad krve do dr\u00e9nu p\u0159es\u00e1hne:<\/p>\n<ul>\n<li>jednor\u00e1zov\u011b 1500 ml,<\/li>\n<li style=\"text-align: justify;\">300 ml ve t\u0159ech hodin\u00e1ch n\u00e1sleduj\u00edc\u00edch po zaveden\u00ed\u00a0dr\u00e9nu.P\u0159\u00edsn\u011bj\u0161\u00ed auto\u0159i dokl\u00e1daj\u00ed, \u017ee mortalita rapidn\u011b stoup\u00e1 p\u0159i celkov\u00e9 sekreci nad 1500 ml za 24 hodin.Dosa\u017een\u00ed tohoto mno\u017estv\u00ed tedy pova\u017euj\u00ed za indikaci revize.<br \/>\nNaprost\u00e1 v\u011bt\u0161ina plicn\u00edch poran\u011bn\u00ed vy\u017eaduj\u00edc\u00ed chtorakotomii je o\u0161et\u0159iteln\u00e1 za cenu minim\u00e1ln\u00ed ztr\u00e1ty parenchymu (koagulace, p\u0159e\u0161it\u00ed, pro\u0161it\u00ed staplerem \u010di neanatomick\u00e9 plicn\u00ed resekce, tk\u00e1\u0148ov\u00e1 lepidla). Anatomick\u00e9 resekce jsou vynucen\u00e9 u t\u011b\u017ek\u00fdch lacerac\u00ed s nereparovateln\u00fdm posti\u017een\u00edm sekund\u00e1rn\u00edch hilov\u00fdch struktur. Pneumonektomie je opr\u00e1vn\u011bn\u00e1 pouze p\u0159i vy\u010derp\u00e1n\u00ed v\u0161ech dostupn\u00fdch prost\u0159edk\u016f k z\u00e1chran\u011b pl\u00edce, jako ultimum refugium je prov\u00e1zena vysokou mortalitou. U stabiln\u00edch nemocn\u00fdch je alternativou konzervativn\u00edho postupu videotorakoskopie s ov\u011b\u0159en\u00edm, ev. o\u0161et\u0159en\u00edm zdroje krv\u00e1cen\u00ed, toaletou pohrudni\u010dn\u00ed dutiny a c\u00edlenou dren\u00e1\u017e\u00ed.Poran\u011bn\u00ed jin\u00fdch nitrohrudn\u00edch struktur je diskutov\u00e1no v kapitole traumatologie hrudn\u00edku.<\/li>\n<\/ul>\n<h4>3.3.5 Chylotorax<\/h4>\n<p style=\"text-align: justify;\">Chylus (lymfa, m\u00edza) je specificky zbarven\u00e1 t\u011bln\u00ed tekutina (smetanov\u011b b\u00edl\u00e1, n\u011bkdy charakteru b\u00edl\u00e9 k\u00e1vy), obsahuj\u00edc\u00ed v\u00edce jak 1,1 g triglycerid\u016f v jednom litru hrudn\u00edho v\u00fdpotku. D\u00e1le obsahuje chylomikrony, cholesterol, ionty, b\u00edlkoviny a bun\u011b\u010dn\u00e9 elementy (zejm\u00e9na lymfocyty). Za vysok\u00fd pod\u00edl tuk\u016f v chylu jsou zodpov\u011bdn\u00e9 intestin\u00e1ln\u00ed m\u00edzovody, kter\u00e9 se spojuj\u00ed s lumb\u00e1ln\u00edmi m\u00edzovody do cisterna chyli, odkud vych\u00e1z\u00ed ductus thoracicus. Hrudn\u00ed m\u00edzovod vstupuje do hrudn\u00edku skrze hiatus aorticus, klade se vpravo mezi aortu, obratlov\u00e1 t\u011bla, v. azygos a stoup\u00e1 prav\u00fdm mediastinem asi do v\u00fd\u0161e Th6. Odtud sm\u011b\u0159uje \u0161ikmo vzh\u016fru za aort\u00e1ln\u00ed oblouk na levou stranu zadn\u00edho mediastina, p\u0159ib\u00edr\u00e1 bronchopulmon\u00e1ln\u00ed a mediastin\u00e1ln\u00ed m\u00edzn\u00ed c\u00e9vy (v\u011bt\u0161inou pouze levostrann\u00e9), pokra\u010duje mezi tracheu a j\u00edcen a obloukem \u00fast\u00ed do angulus venosus sinister). Lymfa z prav\u00e9ho hemitoraxuje obvykle dr\u00e9nov\u00e1na do slab\u0161\u00edho ductus lymphaticus dexter, kter\u00fd kon\u010d\u00ed v angulus venosus dexter.Chylotorax je nahromad\u011bn\u00ed chylu (m\u00edzy) v pohrudni\u010dn\u00ed dutin\u011b. Vznik\u00e1 poru\u0161en\u00edm celistvosti m\u00edzovodu \u00farazem \u010di p\u0159etlakem na kter\u00e9koli \u00farovni jeho pr\u016fb\u011bhu. Poran\u011bn\u00ed dist\u00e1ln\u00edho m\u00edzovodu se tedy projevuje pravostrann\u00fdm v\u00fdpotkem, poran\u011bn\u00ed proxim\u00e1ln\u011b od Th5 levostrann\u00fdm v\u00fdpotkem, oboustrann\u00fd chylotorax nen\u00ed \u010dast\u00fd.Chylotorax d\u011bl\u00edme na:<\/p>\n<ul>\n<li>traumatick\u00fd,<\/li>\n<li>iatrogenn\u00ed,<\/li>\n<li>netraumatick\u00fd,\n<ul>\n<li>kongenit\u00e1ln\u00ed,<\/li>\n<li>inflamatorn\u00ed,<\/li>\n<li>n\u00e1dorov\u00fd,<\/li>\n<li>jin\u00fd.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">Nej\u010dast\u011bji pozorujeme iatrogenn\u00ed chylotorax v souvislosti v nitrohrudn\u00ed operativou, tato komplikace m\u016f\u017ee prov\u00e1zet jakoukoli nitrohrudn\u00ed operaci, stejn\u011b jako v\u00fdkony v oblasti podkl\u00ed\u010dku, nadkl\u00ed\u010dku, kupuly pleur\u00e1ln\u00ed a doln\u00ed poloviny krku vlevo. Po abdomin\u00e1ln\u00edch operac\u00edch (lymfadenektomie, operace na br\u00e1nici) se chylotorax vyskytuje z\u0159\u00eddka. M\u00e9n\u011b \u010dasto vznik\u00e1 chylotorax v souvislosti s tup\u00fdm \u010di penetruj\u00edc\u00edm poran\u011bn\u00edm hrudn\u00edku nebo krku, perinat\u00e1ln\u00ed poran\u011bn\u00ed jsou vz\u00e1cn\u00e1.<\/p>\n<p style=\"text-align: justify;\">Netraumatick\u00fd p\u016fvod maj\u00ed v\u00fdpotky dan\u00e9 n\u00e1dorovou infiltrac\u00ed mediastina hemoblastomy, plicn\u00edmi, j\u00edcnov\u00fdmi nebo jin\u00fdmi mediastin\u00e1ln\u00edmi novotvary. Chylotorax obvykle prov\u00e1z\u00ed plicn\u00ed lymfangiomyomat\u00f3zu, m\u016f\u017ee komplikovat tuberkul\u00f3zu, sarkoid\u00f3zu, plicn\u00ed a mediastin\u00e1ln\u00ed myk\u00f3zy, mediastinitidu \u010di parazit\u00e1rn\u00ed infekce. Kongenit\u00e1ln\u00ed p\u016fvod chylotoraxu dan\u00fd anom\u00e1li\u00ed \u010di aplazi\u00ed m\u00edzovodu je vz\u00e1cn\u00fd.Symptomatologie chylotoraxu b\u00fdv\u00e1 v\u011bt\u0161inou nev\u00fdrazn\u00e1, je d\u00e1na postupn\u00fdm \u00fatlakem mediastin\u00e1ln\u00edch struktur, pokud je poran\u011bn\u00ed duktu p\u0159i neporu\u0161en\u00e9 pleu\u0159e. \u010cast\u011bji se projevuje du\u0161nost z \u00fatlaku pl\u00edce p\u0159i prim\u00e1rn\u00ed komunikaci duktu s pohrudni\u010dn\u00ed dutinou \u010di po sekund\u00e1rn\u00edm provalen\u00ed chylomu z mediastina do pohrudni\u010dn\u00ed dutiny. Akutn\u00ed pr\u016fb\u011bh a vznik tenzn\u00edho chylotoraxu je vz\u00e1cn\u00fd. Vzhledem k del\u0161\u00edmu pr\u016fb\u011bhu m\u00edzovodu vpravo je \u010dast\u011bj\u0161\u00ed pravostrann\u00fd v\u00fdpotek, oboustrann\u00fd chylotorax je vz\u00e1cn\u00fd. V diagnostice m\u00e1 krom\u011b obvykl\u00fdch krok\u016f (klinick\u00e9 vy\u0161et\u0159en\u00ed, makroskopick\u00e9 posouzen\u00ed v\u00fdpotku) prioritu biochemie. Hodnoty triglycerid\u016f nad 1,1 g\/l ve v\u00fdpotku a vy\u0161\u0161\u00ed koncentrace cholesterolu ve v\u00fdpotku ne\u017e v s\u00e9ru ukazuj\u00ed na chylotorax. Po d\u00e9letrvaj\u00edc\u00ed dren\u00e1\u017ei pak lze v s\u00e9ru zaznamenat hypolipidemii, hypoproteinemii, hypokalemii a pokles po\u010dtu lymfocyt\u016f. CT pom\u016f\u017ee vylou\u010dit p\u0159\u00edpadnou mediastin\u00e1ln\u00ed patologii, lymfografie m\u00e1 p\u0159i prim\u00e1rn\u00ed diagnostice v\u00fdznam limitovan\u00fd. U poopera\u010dn\u00edch stav\u016f je t\u0159eba po\u010d\u00edtat s ur\u010dit\u00fdm bezp\u0159\u00edznakov\u00fdm intervalem, dan\u00fdm obvykle parenter\u00e1ln\u00ed nebo m\u00e1lo tu\u010dnou peror\u00e1ln\u00ed v\u00fd\u017eivou. Typick\u00fd chyl\u00f3zn\u00ed charakter hrudn\u00edho sekretu je pak konstatov\u00e1n a\u017e po pln\u00e9 peror\u00e1ln\u00ed z\u00e1t\u011b\u017ei, k potvrzen\u00ed lze pou\u017e\u00edt nap\u0159\u00edklad peror\u00e1ln\u011b podanou smetanu.Terapie chylotoraxu m\u016f\u017ee b\u00fdt konzer vativn\u00ed, po plicn\u00edch resekc\u00edch, kdy b\u00fdvaj\u00ed poran\u011bny men\u0161\u00ed lymfatick\u00e9 c\u00e9vy, b\u00fdv\u00e1 \u00fasp\u011b\u0161n\u00e1 asi ve \u00be p\u0159\u00edpad\u016f. U poran\u011bn\u00ed kmene m\u00edzovodu (nap\u0159. po resekc\u00edch j\u00edcnu, operac\u00edch aorty) je \u00fasp\u011b\u0161nost konzervativn\u00ed l\u00e9\u010dby ni\u017e\u0161\u00ed. Z\u00e1kladn\u00edmi kroky jsou beztukov\u00e1 dieta, l\u00e9pe kompletn\u00ed p\u0159eru\u0161en\u00ed peror\u00e1ln\u00edho p\u0159\u00edjmu a pln\u00e1 parenter\u00e1ln\u00ed v\u00fd\u017eiva, hrudn\u00ed dren\u00e1\u017e a pe\u010dliv\u00e1 monitorace vnit\u0159n\u00edho prost\u0159ed\u00ed. P\u0159i denn\u00ed ztr\u00e1t\u011b tekutin hrudn\u00edm dr\u00e9nem mus\u00ed b\u00fdt deplece tekutin, albuminu a elektrolyt\u016f pe\u010dliv\u011b substituov\u00e1na. Pokus o konzervativn\u00ed l\u00e9\u010dbu by nem\u011bl trvat d\u00e9le ne\u017e 14 dn\u00ed, proto\u017ee hroz\u00ed t\u011b\u017ek\u00e1 hypoproteinemie a rozvrat vnit\u0159n\u00edho prost\u0159ed\u00ed. P\u0159\u00edsn\u011bj\u0161\u00ed auto\u0159i doporu\u010duj\u00ed operovat ji\u017e po 7 dnech neust\u00e1vaj\u00edc\u00ed chyl\u00f3zn\u00ed sekrece z dr\u00e9novan\u00e9ho hemitoraxu.Chirurgick\u00e1 l\u00e9\u010dba spo\u010d\u00edv\u00e1 ve vyhled\u00e1n\u00ed m\u00edzovodu (nebo p\u0159\u00edmo jeho l\u00e9ze) a v jeho podvazu. I u levostrann\u00fdch v\u00fdpotk\u016f v\u011bt\u0161inou vol\u00edme p\u0159\u00edstup zprava, proto\u017ee m\u00edzovod je \u010dast\u011bji poran\u011bn ve sv\u00e9m dist\u00e1ln\u00edm pr\u016fb\u011bhu. Nec\u00edlen\u00e1 ligatura pravideln\u011b vede ke zhojen\u00ed i u poran\u011bn\u00ed v proxim\u00e1ln\u00ed \u010d\u00e1sti. K identifikaci ductus thoracicus, resp. \u00faniku lymfy m\u016f\u017ee poslou\u017eit pod\u00e1n\u00ed200 ml smetany \u010di olivov\u00e9ho oleje enter\u00e1ln\u00ed sondou p\u0159ed zah\u00e1jen\u00edm operace. Za stejn\u00fdm \u00fa\u010delem se aplikovala metylenov\u00e1 mod\u0159 subkut\u00e1nn\u011b, kter\u00e1 zbarvila chylus, bohu\u017eel tak\u00e9 okoln\u00ed tk\u00e1n\u011b, co\u017e v kone\u010dn\u00e9m d\u016fsledku hled\u00e1n\u00ed m\u00edzovodu sp\u00ed\u0161e komplikovalo. Vlastn\u00ed ligatura m\u016f\u017ee b\u00fdt c\u00edlen\u00e1 na vyhledan\u00e9m duktu, pokud nen\u00ed nalezen, lze masivn\u011b podv\u00e1zat nebo pro\u0161\u00edt ve\u0161ker\u00e9 tk\u00e1n\u011b mezi aortou, j\u00edcnem a v. azygos, obvykle zprava, cestou torakotomie, videotorakoskopicky nebo videoasistovan\u011b. \u00dasp\u011bch lze o\u010dek\u00e1vat asi v 80\u201390 % p\u0159\u00edpad\u016f. Vlevo v horn\u00edm mediastinu lze ductus thoracicus vyhledat na j\u00edcnu mezi p\u00e1te\u0159\u00ed, obloukem aorty a levou podkl\u00ed\u010dkovou tepnou. Tato cesta se vyu\u017e\u00edv\u00e1, pokud chylotorax vznikl v souvislosti s intervenc\u00ed v horn\u00edm mediastinu, retroklavikul\u00e1rn\u011b nebo na krku. Extratorak\u00e1ln\u011b lze ductus thoracicus podv\u00e1zat, pro\u0161\u00edt \u010di zaklipovat transhiat\u00e1ln\u011b laparoskopicky \u010di otev\u0159enou cestou.Alternativn\u011b nebo jako metodu dopl\u0148uj\u00edc\u00ed lze prov\u00e9st pleurektomii, po kter\u00e9 se chylus sn\u00e1ze vst\u0159eb\u00e1v\u00e1 velkou rannou plochou a posl\u00e9ze dojde k obliteraci pohrudni\u010dn\u00ed dutiny a pleurod\u00e9ze. U malign\u00edch nejen chyl\u00f3zn\u00edch v\u00fdpotk\u016f lze prov\u00e9st talkovou pleurod\u00e9zu, talek m\u016f\u017ee b\u00fdt nahrazen Bleomycinem.<\/p>\n<h4>3.3.6 N\u00e1dory pleury<\/h4>\n<p>Pleura b\u00fdv\u00e1 posti\u017eena malign\u00edm mezoteliomem, sekund\u00e1rn\u00edmi novotvary v r\u00e1mci generalizace nitrohrudn\u00edch i extratorak\u00e1ln\u00edch n\u00e1dor\u016f, z\u0159\u00eddka b\u00fdv\u00e1 diagnostikov\u00e1n solit\u00e1rn\u00ed fibr\u00f3zn\u00ed tumor pleury, jin\u00e9 neoplazie pleuru postihuj\u00ed jen v\u00fdjime\u010dn\u011b.<\/p>\n<h5>3.3.6.1 Malign\u00ed mezoteliom<\/h5>\n<p style=\"text-align: justify;\">Malign\u00ed mezoteliom je n\u00e1dor vych\u00e1zej\u00edc\u00ed z mezotelov\u00e9 v\u00fdstelky pleur\u00e1ln\u00ed dutiny, p\u0159i sv\u00e9m r\u016fstu vytv\u00e1\u0159\u00ed uzlovit\u00e1 lo\u017eiska rozeset\u00e1 difuzn\u011b po pariet\u00e1ln\u00ed i viscer\u00e1ln\u00ed pleu\u0159e, kter\u00e1 postupn\u011b spl\u00fdvaj\u00ed a vedou k v\u00fdrazn\u00e9mu n\u00e1dorov\u00e9mu ztlu\u0161t\u011bn\u00ed pleury. M\u016f\u017ee indukovat malign\u00ed v\u00fdpotek nebo naopak obliteraci pleur\u00e1ln\u00edho prostoru, infiltraci perikardu, mediastina, hrudn\u00ed st\u011bny, extratorak\u00e1ln\u011b obvykle nemetast\u00e1zuje. Z histologick\u00e9ho hlediska jej d\u011bl\u00edme na:<\/p>\n<ul>\n<li>epiteloidn\u00ed mezoteliom,<\/li>\n<li>sarkomatoidn\u00ed mezoteliom,<\/li>\n<li>bif\u00e1zick\u00fd mezoteliom,<\/li>\n<li>desmoplastick\u00fd mezoteliom.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">Grading se u mezoteliomu neuv\u00e1d\u00ed, TNM klasifikace odr\u00e1\u017e\u00ed posti\u017een\u00ed pariet\u00e1ln\u00ed, viscer\u00e1ln\u00ed pleury, infiltraci pl\u00edce, resekabilitu, extratorak\u00e1ln\u00ed \u0161\u00ed\u0159en\u00ed, lymfadenopatii a vzd\u00e1len\u00e9 metast\u00e1zov\u00e1n\u00ed. Je prok\u00e1z\u00e1na kauz\u00e1ln\u00ed souvislost mezi t\u00edmto onemocn\u011bn\u00edm, expozic\u00ed azbestu a opi\u010d\u00edm virem SV40. P\u0159edpokl\u00e1d\u00e1 se, \u017ee incidence tohoto novotvaru bude stoupat nejm\u00e9n\u011b do roku 2020, medi\u00e1n p\u0159e\u017eit\u00ed je mezi 6\u201312 m\u011bs\u00edci. Klinick\u00e9 p\u0159\u00edznaky jsou nespecifick\u00e9, bolest na hrudi, du\u0161nost, v 80 % b\u00fdv\u00e1 v dob\u011b diagn\u00f3zy p\u0159\u00edtomen v\u00fdpotek, v laborato\u0159i trombocyt\u00f3za. RTG, CT, p\u0159\u00edpadn\u011b PETCT zobraz\u00ed v\u00fdpotek nebo uzlovit\u00e9 ztlu\u0161t\u011bn\u00ed pleury, definitivn\u011b rozhoduje biopsie pleury (c\u00edlen\u00e1 \u010di nec\u00edlen\u00e1, pleuroskopick\u00e1, torakoskopick\u00e1).<\/p>\n<p style=\"text-align: justify;\">Z\u00e1kladn\u00edm l\u00e9\u010debn\u00fdm postupem je chirurgick\u00e1 resekce \u2013 pleuropneumonektomie. M\u00e9n\u011b radik\u00e1ln\u00ed je pleurektomie, p\u0159\u00edpadn\u011b dekortikace. Po t\u011bchto operac\u00edch se m\u016f\u017ee rozvinout syst\u00e9mov\u00e1 nemoc, proto b\u00fdv\u00e1 l\u00e9\u010dba obvykle kombinovan\u00e1 \u2013 v adjuvantn\u00edm nebo neoadjuvantn\u00edm re\u017eimu. V posledn\u00ed dob\u011b se preferuj\u00ed multimod\u00e1ln\u00ed postupy \u2013 chirurgie a\/nebo radioterapie kombinovan\u00e1 s chemoterapi\u00ed, biologickou l\u00e9\u010dbou, imunoterapi\u00ed \u010di hypertermickou cytostatickou l\u00e9\u010dbou. Ve vybran\u00fdch centrech a na selektovan\u00fdch souborech pacient\u016f lze dosahovat p\u0159ekvapiv\u011b dobr\u00fdch v\u00fdsledk\u016f. U nemocn\u00fdch ve stadiu III a IV je metodou volby chemoterapie. V sou\u010dasnosti se pou\u017e\u00edv\u00e1 pemetrexed v monoterapii \u010di kombinaci nebo kombinovan\u00e1 chemoterapie na b\u00e1zi antracyklin\u016f \u010di platiny.<\/p>\n<h5>3.3.6.2 Solit\u00e1rn\u00ed fibr\u00f3zn\u00ed tumor pleury<\/h5>\n<p style=\"text-align: justify;\">Jedn\u00e1 se o relativn\u011b vz\u00e1cn\u00fd n\u00e1dor vych\u00e1zej\u00edc\u00ed ze submezotelov\u00e9 mezenchym\u00e1ln\u00ed tk\u00e1n\u011b v\u011bt\u0161inou viscer\u00e1ln\u00ed, vz\u00e1cn\u011bji pariet\u00e1ln\u00ed pleury. Je tvo\u0159en v\u0159etenit\u00fdmi bu\u0148kami uspo\u0159\u00e1dan\u00fdmi do snopc\u016f odd\u011blen\u00fdch fibr\u00f3zn\u00edm stromatem. Je obvykle stopkat\u00fd, \u010dasto asymptomatick\u00fd. Objemn\u011bj\u0161\u00ed n\u00e1dory se projevuj\u00ed du\u0161nost\u00ed, ka\u0161lem, bolest\u00ed na hrudi a \u00fanavnost\u00ed, co\u017e je zp\u016fsobeno \u00fatlakem pl\u00edce a mediastin\u00e1ln\u00edch struktur. V diagnostice hraje rozhoduj\u00edc\u00ed \u00falohu CT a transpariet\u00e1ln\u00ed biopsie. Terapie je chirurgick\u00e1 \u2013 odstran\u011bn\u00ed p\u0159\u00edstupem odpov\u00eddaj\u00edc\u00edm velikosti tumoru s resekc\u00ed vaskul\u00e1rn\u00ed stopky, kter\u00e1 v\u011bt\u0161inou vych\u00e1z\u00ed z pl\u00edce. Obvykle je pova\u017eov\u00e1n za benign\u00ed, recidivy jsou vz\u00e1cn\u00e9. Asi 10% tumor\u016f se chov\u00e1 zhoubn\u011b, za krit\u00e9ria malignity se pova\u017euj\u00ed mitotick\u00e1 aktivita (v\u00edce jak 4 mit\u00f3zy v 10 pol\u00edch), p\u0159\u00edtomnost nekr\u00f3z a v\u00fdpotku, vysok\u00e1 celularita a pleiomorfie bun\u011bk.<\/p>\n<h5>3.3.6.3 Metastatick\u00e9 n\u00e1dory pleury<\/h5>\n<p style=\"text-align: justify;\">Pleura b\u00fdv\u00e1 nej\u010dast\u011bji posti\u017eena adenokarcinomem plic, prsu, ovaria. M\u00e9n\u011b \u010dast\u00fd je pleur\u00e1ln\u00ed rozsev n\u00e1dor\u016f \u0161t\u00edtn\u00e9 \u017el\u00e1zy, pankreatu, ledviny, \u017ealudku, tra\u010dn\u00edku, rekta a mezenchym\u00e1ln\u00edch malign\u00edch novotvar\u016f. P\u0159i difuzn\u00edm posti\u017een\u00ed pleury je mnohdy obt\u00ed\u017en\u00e9 odli\u0161it tyto neoplazie od nediferencovan\u00fdch forem mezoteliomu nejen opticky, ale i za pou\u017eit\u00ed imunohistochemick\u00e9 anal\u00fdzy. Ke stanoven\u00ed spr\u00e1vn\u00e9 diagn\u00f3zy je nezbytn\u00e1 validn\u00ed biopsie, u solit\u00e1rn\u00edch l\u00e9z\u00ed a p\u0159i kontrole prim\u00e1rn\u00edho n\u00e1doru je mo\u017en\u00e9 chirurgick\u00e9 odstran\u011bn\u00ed. Typick\u00fdm postupem je v\u0161ak paliace obvykl\u00e9ho n\u00e1dorov\u00e9ho v\u00fdpotku talkovou pleurod\u00e9zou.<\/p>\n<h3>3.4 Opera\u010dn\u00ed v\u00fdkony p\u0159i onemocn\u011bn\u00ed pohrudnice<\/h3>\n<h4>3.4.1 Pleurod\u00e9za<\/h4>\n<p style=\"text-align: justify;\">Pleurod\u00e9za je operace, kterou se sna\u017e\u00edme dos\u00e1hnout pevn\u00e9ho sr\u016fstu mezi pariet\u00e1ln\u00ed a viscer\u00e1ln\u00ed pleurou, resp. obliterace pleur\u00e1ln\u00edho prostoru. U benign\u00edch onemocn\u011bn\u00ed se prov\u00e1d\u00ed v r\u00e1mci terapie spont\u00e1nn\u00edho pneumotoraxu spolu s reviz\u00ed pl\u00edce a p\u0159\u00edpadn\u00fdm uz\u00e1v\u011brem zdroje \u00faniku vzduchu, v\u011bt\u0161inou torakoskopicky. Pevn\u00e9 pleurod\u00e9zy lze dos\u00e1hnout pleurabraz\u00ed, tedy skarifikac\u00ed n\u00e1st\u011bnn\u00e9 a br\u00e1ni\u010dn\u00ed pleury smotkem prolenov\u00e9 s\u00ed\u0165ky nebo abrazn\u00ed kuli\u010dkou \u010di kart\u00e1\u010dkem. V\u00fdjime\u010dn\u011b se u benign\u00edch l\u00e9z\u00ed pou\u017e\u00edv\u00e1 chemick\u00e1 pleurod\u00e9za koncentrovanou (40%) gluk\u00f3zou, d\u0159\u00edve tetracyklinem, termick\u00e1 pleurod\u00e9za se prov\u00e1d\u00ed koagulac\u00ed, biologick\u00e1 aplikac\u00ed vlastn\u00ed krve do pleur\u00e1ln\u00ed dutiny. U malign\u00edch v\u00fdpotk\u016f je c\u00edlem pleurod\u00e9zy trval\u00e1 obliterace pleur\u00e1ln\u00ed dutiny. Zde spol\u00e9h\u00e1me na talkovou chemickou pleurod\u00e9zu, prov\u00e1d\u011bnou v\u011bt\u0161inou tak\u00e9 torakoskopicky. Obvykle vysta\u010d\u00edme se dv\u011bma porty (pro optiku a talkovou trysku). P\u0159edpokladem \u00fasp\u011bchu je dokonal\u00e9 ods\u00e1t\u00ed v\u00fdpotku, uvoln\u011bn\u00ed cel\u00e9 pl\u00edce, pudr\u00e1\u017e kost\u00e1ln\u00ed, diafragmatick\u00e9 a mediastin\u00e1ln\u00ed pleury a dokonal\u00e1 reexpanze pl\u00edce. Talek indukuje aseptick\u00fd z\u00e1n\u011bt, operace selh\u00e1v\u00e1, pokud pevn\u00e1 n\u00e1dorov\u00e1 pleura nedovoluje dokonal\u00e9 rozvinut\u00ed pl\u00edce zaru\u010duj\u00edc\u00ed d\u00e9letrvaj\u00edc\u00ed kontakt obou pleur\u00e1ln\u00edch list\u016f.<\/p>\n<h4>3.4.2 Pleurektomie<\/h4>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0751.png\"><img decoding=\"async\" title=\"Obr. 19 \u2013 Videotorakoskopick\u00e1 pleurektomie\" alt=\"Obr. 19 \u2013 Videotorakoskopick\u00e1 pleurektomie\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0751.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 19<br \/>Videotorakoskopick\u00e1 pleurektomie<\/p><\/div>\n<p style=\"text-align: justify;\">Pleurektomie je odstran\u011bn\u00ed pleury chirurgickou cestou. Nej\u010dast\u011bji se prov\u00e1d\u00ed v z\u00e1jmu dosa\u017een\u00ed obliterace pleur\u00e1ln\u00ed dutiny p\u0159i sekund\u00e1rn\u00ed prevenci recidiv spont\u00e1nn\u00edho pneumotoraxu, \u010dasto b\u00fdv\u00e1 kombinov\u00e1na s pleuroabraz\u00ed \u010di jinou formou pleurod\u00e9zy. Prov\u00e1d\u00ed se v rozsahu cel\u00e9 kost\u00e1ln\u00ed pleury (pleurektomie tot\u00e1ln\u00ed), v horn\u00ed polovin\u011b hrudn\u00edku (proxim\u00e1ln\u011b od v. azygos vpravo resp. od v\u00fd\u0161e oblouku aorty vlevo) jako pleurektomie subtot\u00e1ln\u00ed, nebo jako pleurektomie apik\u00e1ln\u00ed, kdy je odstran\u011bna pouze pleura v kupule a zbyl\u00e1 pleura kost\u00e1ln\u00ed a br\u00e1ni\u010dn\u00ed je o\u0161et\u0159ena pleurabraz\u00ed. Pleuru je mo\u017en\u00e9 odd\u011blit od endotorak\u00e1ln\u00ed fascie tupou preparac\u00ed vcelku jednodu\u0161e bez v\u011bt\u0161\u00edho krv\u00e1cen\u00ed, proto je v\u00fdhodn\u00e9 vyu\u017e\u00edt miniinvazivn\u00ed chirurgii (VTS\/VATS) (obr. 19).<\/p>\n<p style=\"text-align: justify;\">Zvl\u00e1\u0161tn\u00edm typem operace je tzv. radik\u00e1ln\u00ed pleurektomie, pou\u017e\u00edvan\u00e1 v terapii lokalizovan\u00fdch forem malign\u00edho mezoteliomu. Jej\u00edm principem je dos\u00e1hnout v prvn\u00ed etap\u011b pevn\u00e9ho sr\u016fstu pariet\u00e1ln\u00ed a viscer\u00e1ln\u00ed pleury, proto se jako inici\u00e1ln\u00ed krok prov\u00e1d\u00ed v r\u00e1mci diagnostick\u00e9 operace talkov\u00e1 pleurod\u00e9za. V odstupu n\u011bkolika t\u00fddn\u016f se indikuje vlastn\u00ed operace, kdy je odstran\u011bna posti\u017een\u00e1 pariet\u00e1ln\u00ed, br\u00e1ni\u010dn\u00ed a mediastin\u00e1ln\u00ed pleura spolu s p\u0159irostlou pleurou viscer\u00e1ln\u00ed, v\u010detn\u011b pleury vyst\u00fdlaj\u00edc\u00ed interlobia. Jedn\u00e1 se o \u0161etrn\u011bj\u0161\u00ed alternativu extrapleur\u00e1ln\u00ed pneumonektomie. Jde o \u010dist\u011b cytoreduktivn\u00ed operaci, ale p\u0159i radik\u00e1ln\u00ed pleurektomii je \u0161et\u0159en plicn\u00ed parenchym, tento benefit vyva\u017euje do jist\u00e9 m\u00edry vy\u0161\u0161\u00ed \u201eradikalitu\u201c extrapleur\u00e1ln\u00ed pneumonektomie. Prov\u00e1d\u00ed se otev\u0159enou cestou, c\u00edlem je tup\u011b, event. i ost\u0159e uvolnit ztlu\u0161t\u011blou pariet\u00e1ln\u00ed, br\u00e1ni\u010dn\u00ed a mediastin\u00e1ln\u00ed pleuru ve smyslu pleurektomie v cel\u00e9 plo\u0161e pleur\u00e1ln\u00ed dutiny a\u017e k plicn\u00edmu hilu, odkud pak preparace pokra\u010duje na pleuru viscer\u00e1ln\u00ed, kterou je nutn\u00e9 postupn\u011b sloupnout z cel\u00e9ho povrchu posti\u017een\u00e9 pl\u00edce, v\u010detn\u011b interlob\u00e1rn\u00edch \u0161t\u011brbin. N\u011bkdy je v\u00fdhodn\u011bj\u0161\u00ed opa\u010dn\u00fd postup: pokud je sr\u016fst pariet\u00e1ln\u00ed a viscer\u00e1ln\u00ed pleury dostate\u010dn\u011b pevn\u00fd, lze proniknout ost\u0159e t\u011bsn\u011b pod viscer\u00e1ln\u00ed pleuru a pl\u00edci uvolnit kompletn\u011b v t\u00e9to rovin\u011b disekce a\u017e k plicn\u00edmu hilu na zp\u016fsob subpleur\u00e1ln\u00ed dekortikace. Tato f\u00e1ze je v\u011bt\u0161inou sledov\u00e1na kontrolovateln\u00fdm krv\u00e1cen\u00edm a \u00fanikem vzduchu z dekortikovan\u00e9 pl\u00edce. Potom se dokon\u010d\u00ed vlastn\u00ed pleurektomie odd\u011blen\u00edm obou srostl\u00fdch pleur\u00e1ln\u00edch list\u016f od hrudn\u00ed st\u011bny, mediastina a br\u00e1nice. Velk\u00e9 opatrnosti je t\u0159eba p\u0159i izolaci hilov\u00fdch a mediastin\u00e1ln\u00edch c\u00e9vn\u00edch struktur (vpravo horn\u00ed dut\u00e1 \u017e\u00edla, v. azygos, vlevo zejm\u00e9na odstupy interkost\u00e1ln\u00edch c\u00e9v z descendentn\u00ed aorty), vhodn\u00e9 je \u0161et\u0159it br\u00e1ni\u010dn\u00ed nerv.<\/p>\n<h4>3.4.3 Dekortikace<\/h4>\n<div style=\"width: 160px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0771.png\"><img decoding=\"async\" title=\"Obr. 20 \u2013 Princip empy\u00e9mektomie\" alt=\"Obr. 20 \u2013 Princip empy\u00e9mektomie\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0771.png\" width=\"150\" \/><\/a><p class=\"wp-caption-text\">Obr. 20<br \/>Princip empy\u00e9mektomie<\/p><\/div>\n<p style=\"text-align: justify;\">Vlastn\u00ed dekortikac\u00ed rozum\u00edme odstran\u011bn\u00ed pyogenn\u00ed membr\u00e1ny empy\u00e9mu z povrchu pl\u00edce p\u0159i zachov\u00e1n\u00ed neporu\u0161en\u00e9 viscer\u00e1ln\u00ed pleury. Vzhledem k \u010dasov\u00fdm faktor\u016fm vyzr\u00e1v\u00e1n\u00ed vaziva empy\u00e9mov\u00e9 kapsy je proveden\u00ed pom\u011brn\u011b snadn\u00e9 mezi 4.\u20138. t\u00fddnem od vzniku empy\u00e9mu, pozd\u011bji je \u201eatraumatick\u00e1\u201c dekortikace za \u0161et\u0159en\u00ed viscer\u00e1ln\u00ed pleury podstatn\u011b obt\u00ed\u017en\u011bj\u0161\u00ed a\u017e nemo\u017en\u00e1. Tehdy si lze vypomoci m\u0159\u00ed\u017ekovit\u00fdmi n\u00e1\u0159ezy ztlu\u0161t\u011bl\u00e9 poplicnice analogicky jako u konstriktivn\u00ed perikarditidy, kter\u00e9 dovol\u00ed alespo\u0148 \u010d\u00e1ste\u010dnou reexpanzi pl\u00edce. Pokud je ale pl\u00edce \u201ezazd\u011bn\u00e1\u201c do pevn\u00e9 hroudy, lze se spol\u00e9hat na fakt, \u017ee perifern\u00ed oblasti plicn\u00edho parenchymu jsou dlouhodob\u00fdm kolapsem m\u00e1lo vzdu\u0161n\u00e9 a dekortikaci je mo\u017en\u00e9 prov\u00e9st pod \u00farovn\u00ed viscer\u00e1ln\u00ed pleury jako u malign\u00edho mezoteliomu. P\u0159i \u0161etrn\u00e9m st\u0159\u00edd\u00e1n\u00ed ostr\u00e9 a tup\u00e9 preparace jekapil\u00e1rn\u00ed krv\u00e1cen\u00ed nevelk\u00e9 stejn\u011b jako alveol\u00e1rn\u00ed \u00fanik. Dostate\u010dn\u00e1 reexpanze je nejlep\u0161\u00ed prevenc\u00ed recidivy empy\u00e9mu, stejn\u011b jako vydatn\u00e1 dren\u00e1\u017e pohrudni\u010dn\u00ed dutiny po operaci. Pokud dekortikovan\u00e1 pl\u00edce nejev\u00ed tendenci rozvinout se do cel\u00e9 dutiny pohrudni\u010dn\u00ed, je n\u011bkdy nezbytn\u00e9 p\u0159ipojit k dekortikaci\/pleurektomii limitovanou torakoplastiku. Pokud se poda\u0159\u00ed prov\u00e9st pleurektomii\/dekortikaci cel\u00e9 empy\u00e9mov\u00e9 kapsy bez jej\u00edho otev\u0159en\u00ed (v\u011bt\u0161inou u lokalizovan\u00fdch empy\u00e9m\u016f), hovo\u0159\u00edme o <b>empy\u00e9mektomii <\/b>(obr. 20).<\/p>\n<h4>3.4.4 Pleurostomie<\/h4>\n<p style=\"text-align: justify;\">Vytvo\u0159en\u00ed hrudn\u00edho ok\u00e9nka resekc\u00ed jednoho a\u017e dvou \u017eeber na nejni\u017e\u0161\u00edm bod\u011b empy\u00e9mov\u00e9 dutiny p\u0159edstavuje prvn\u00ed pomoc a n\u011bkdy i definitivn\u00ed \u0159e\u0161en\u00ed postpneumonektomick\u00e9ho empy\u00e9mu, stejn\u011b jako \u0159e\u0161en\u00ed nekolikvovan\u00fdch \u0161patn\u011b dr\u00e9novateln\u00fdch \u010di septovan\u00fdch empy\u00e9m\u016f u rizikov\u00fdch pacient\u016f, kte\u0159\u00ed nemohou b\u00fdt l\u00e9\u010deni n\u00e1ro\u010dn\u011bj\u0161\u00edm zp\u016fsobem (pleurektomie\/dekortikace, torakoplastika). Od doby, kdy byla pleurostomie zavedena do praxe, doznala tato metoda \u0159ady modifikac\u00ed, ale z\u00e1kladn\u00ed principy, \u0161irok\u00e9 otev\u0159en\u00ed pleur\u00e1ln\u00ed \u010di empy\u00e9mov\u00e9 dutiny resekc\u00ed dvou \u017eeber v nejni\u017e\u0161\u00edm bod\u011b a fixace k\u016f\u017ee k pariet\u00e1ln\u00ed pleu\u0159e dovoluj\u00edc\u00ed snadn\u00e9 p\u0159evazy, z\u00fastavaj\u00ed platn\u00e9 dodnes (obr. 21).<\/p>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0801.png\"><img decoding=\"async\" title=\"Obr. 21 \u2013 Fenestrace hrudn\u00edku pro postpneumonektomick\u00fd empy\u00e9m\" alt=\"Obr. 21 \u2013 Fenestrace hrudn\u00edku pro postpneumonektomick\u00fd empy\u00e9m\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0801.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 21<br \/>Fenestrace hrudn\u00edku pro postpneumonektomick\u00fd empy\u00e9m<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0791.png\"><img decoding=\"async\" title=\"Obr. 22 \u2013 Princip rekonstrukce br\u00e1nice a perikardu po extrapleur\u00e1ln\u00ed pneumonektomii\" alt=\"Obr. 22 \u2013 Princip rekonstrukce br\u00e1nice a perikardu po extrapleur\u00e1ln\u00ed pneumonektomii\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_0791.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 22<br \/>Princip rekonstrukce br\u00e1nice a perikardu po extrapleur\u00e1ln\u00ed pneumonektomii<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h4>3.4.5 Extrapleur\u00e1ln\u00ed pneumonektomie<\/h4>\n<p style=\"text-align: justify;\">Extrapleur\u00e1ln\u00ed pneumonektomie je v kombinovan\u00e9m protokolu metodou volby l\u00e9\u010dby I. a II. stadia malign\u00edho mezoteliomu. Principem je odstran\u011bn\u00ed pl\u00edce spolu s posti\u017eenou viscer\u00e1ln\u00ed, pariet\u00e1ln\u00ed, mediastin\u00e1ln\u00ed a br\u00e1ni\u010dn\u00ed pleurou. Za\u010d\u00e1tek operace je podobn\u00fd pleurektomii pro fibrotorax, do spr\u00e1vn\u00e9 vrstvy, tedy na \u00farove\u0148 endotorak\u00e1ln\u00ed fascie, se lze dostat \u0161irokou torakotomi\u00ed 6. mezi\u017eeb\u0159\u00edm s prot\u011bt\u00edm 7., event. i 6. \u017eebra v dorz\u00e1ln\u00edm pr\u016fb\u011bhu. C\u00edlem je uvolnit neporu\u0161en\u00fd vak od hrudn\u00ed st\u011bny sm\u011brem k plicn\u00edmu hilu. Pravostrann\u00e1 operace: tup\u00e1 preparace za\u010d\u00edn\u00e1 sm\u011brem do kupuly, kde je t\u0159eba \u0161et\u0159it podkl\u00ed\u010dkovou \u017e\u00edlu, plexus brachialis a n. recurrens. Po uvoln\u011bn\u00ed pleur\u00e1ln\u00ed kupuly se postupuje ventr\u00e1ln\u011b k p\u0159echodu kost\u00e1ln\u00ed a mediastin\u00e1ln\u00ed pleury, kde je t\u0159eba zachovat mamm\u00e1rn\u00ed c\u00e9vy, a\u017e nad horn\u00ed dutou \u017e\u00edlu a perikard. Dorz\u00e1ln\u011b se uvol\u0148uje paravertebr\u00e1ln\u00ed pleura a\u017e k pr\u016fdu\u0161nici a perikardu, je nutn\u00e9 vyhnout se poran\u011bn\u00ed horn\u00ed dut\u00e9 \u017e\u00edly a v. azygos, n. phrenicus m\u016f\u017ee b\u00fdt ob\u011btov\u00e1n. J\u00edcen je nutn\u00e9 od pleur\u00e1ln\u00edho vaku odd\u011blit a vypreparovat zadn\u00ed plochu plicn\u00edho hilu a pr\u016fdu\u0161ku. Pak se postupuje stejn\u00fdm zp\u016fsobem a\u017e do kostofrenick\u00e9ho \u00fahlu, po uvoln\u011bn\u00ed kostodiafragmatick\u00e9ho pleur\u00e1ln\u00edho z\u00e1hybu je nutn\u00e9 uvolnit pleuru od br\u00e1nice, v\u011bt\u0161inou nelze jinak ne\u017e za cenu cirkul\u00e1rn\u00ed resekce br\u00e1nice. V\u00fdhodn\u00fd je extraperitone\u00e1ln\u00ed postup, ne v\u017edy je v\u0161ak provediteln\u00fd. Kruh disekce okolo bronchovaskul\u00e1rn\u00ed stopky uzav\u00edr\u00e1me preparac\u00ed kostomediastin\u00e1ln\u00edho pleur\u00e1ln\u00edho \u00fahlu a\u017e na later\u00e1ln\u00ed st\u011bnu osrde\u010dn\u00edku. V t\u00e9to f\u00e1zi,\u00a0pokud to nebylo nutn\u00e9 ji\u017e d\u0159\u00edve, se resekuje posti\u017een\u00fd perikard \u0161iroce kolem \u017eiln\u00edch \u00fast\u00ed, resp. od \u00fast\u00ed doln\u00ed dut\u00e9 \u017e\u00edly a\u017e nad \u00fast\u00ed horn\u00ed dut\u00e9 \u017e\u00edly, takto lze vypreparovat plicnici transperikardi\u00e1ln\u011b vpravo od horn\u00ed dut\u00e9 \u017e\u00edly v Allisonov\u011b recessu nebo mezi dutou \u017e\u00edlou a aortou v recessu Thielov\u011b. C\u00e9vn\u00ed struktury o\u0161et\u0159ujeme typicky. P\u0159eru\u0161en\u00ed pr\u016fdu\u0161ky je posledn\u00edm krokem resek\u010dn\u00ed f\u00e1ze, k uz\u00e1v\u011bru pou\u017e\u00edv\u00e1me stapler a pokra\u010duj\u00edc\u00ed suturu. Zb\u00fdv\u00e1 rekonstruovat br\u00e1nici a perikard, ob\u011b struktury lze nahratit ePTFE z\u00e1platou, kterou je t\u0159eba na perikardu fenestrovat (obr. 22).<\/p>\n<p style=\"text-align: justify;\">Vlevo za\u010d\u00edn\u00e1 operace analogicky uvoln\u011bn\u00edm pleur\u00e1ln\u00edho vaku do kupuly, do p\u0159edn\u00edho mediastina za \u0161et\u0159en\u00ed mamm\u00e1rn\u00edho svazku a dozadu a\u017e k p\u00e1te\u0159i. Opatrnosti si zaslou\u017e\u00ed oblouk aorty a jeho v\u011btve, n. vagus, kter\u00fd obsahuje i vl\u00e1kna vratn\u00e9ho nervu, v. hemiazygos, prob\u00edhaj\u00edc\u00ed po p\u0159edn\u00ed plo\u0161e oblouku aorty, p\u0159i preparaci kostovertebr\u00e1ln\u00edho pleur\u00e1ln\u00edho z\u00e1hybu descendentn\u00ed aorta a jej\u00ed interkost\u00e1ln\u00ed odstupy. Dist\u00e1ln\u00ed j\u00edcen je t\u0159eba od prepar\u00e1tu odd\u011blit ost\u0159e nebo tup\u011b. Dal\u0161\u00ed postup u\u017e je analogick\u00fd jako vpravo: extraperitone\u00e1ln\u00ed resekce br\u00e1nice, resekce perikardu, o\u0161et\u0159en\u00ed hilov\u00fdch c\u00e9v, p\u0159eru\u0161en\u00ed a uz\u00e1v\u011br bronchu, rekonstrukce br\u00e1nice a perikardu, hrudn\u00ed dren\u00e1\u017e. Ve specializovan\u00fdch centrech v kombinovan\u00fdch protokolech dosahuje p\u011btilet\u00e9 p\u0159e\u017eit\u00ed po extrapleur\u00e1ln\u00ed pneumonektomii pro mezoteliom intervalu mezi10\u201320 %, epiteloidn\u00ed varianta je prognosticky p\u0159\u00edzniv\u011bj\u0161\u00ed.<\/p>\n<h3>3<span style=\"font-size: 1.17em;\">.5 Literatura<\/span><\/h3>\n<ol>\n<li style=\"text-align: justify;\">Barker WL. Thoracoplasty. Chest Surg Clin N Am.1994;4:593.<\/li>\n<li style=\"text-align: justify;\">Becker HD, Hohenberger W, Junginger T, SchlagPM. Chirurgick\u00e1 onkologie. Praha: Grada Publishing; 2005.<\/li>\n<li style=\"text-align: justify;\">Fiala P, Musil J, et al. Onemocn\u011bn\u00ed pleur\u00e1ln\u00edhoprostoru. Praha: Gal\u00e9n; 2008.<\/li>\n<li style=\"text-align: justify;\">Kolek V, Ka\u0161\u00e1k V, Va\u0161\u00e1kov\u00e1 M, a kol. Pneumologie. Praha: Maxdorf; 2011.<\/li>\n<li style=\"text-align: justify;\">Pafko P. Z\u00e1klady speci\u00e1ln\u00ed chirurgie. Praha: Gal\u00e9n; 2008, doc. MUDr. Eli\u0161ka Sovov\u00e1, Ph.D., MBAs. 385.<\/li>\n<li style=\"text-align: justify;\">Pafko P, Lischke R, et al. Plicn\u00ed chirurgie. Opera\u010dn\u00ed manu\u00e1l. Praha: Gal\u00e9n; 2010.<\/li>\n<li style=\"text-align: justify;\">Pearson GF, Cooper JD, Deslauriers J, Ginsberg RJ, Hiebert CA, Patterson GA, Urschel HC. Thoracic surgery. New York: Churchill Livingstone;2002.<\/li>\n<li style=\"text-align: justify;\">Pichlmaier H, Childberg FW. Thoraxchirurgie.Heidelberg: Springer; 2006.<\/li>\n<li style=\"text-align: justify;\">Proch\u00e1zka J. Resekce plic. Praha: SZN; 1954.<\/li>\n<li style=\"text-align: justify;\">\u0158eh\u00e1k F, \u0160mat V. Chirurgie plic a mediastina. Praha: Avicenum; 1986.<\/li>\n<li style=\"text-align: justify;\">Sch\u00fctzner J, \u0160mat V, a kol. Myasthenia gravis. Praha: Gal\u00e9n; 2005.<\/li>\n<li style=\"text-align: justify;\">Stolz S, Pafko P. Komplikace v plicn\u00ed chirurgii.1. vyd\u00e1n\u00ed. Praha: Grada Publishing; 2010.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"<p>3.1 Anatomie hrudn\u00ed st\u011bny a pleur\u00e1ln\u00ed dutiny Hrudn\u00edk m\u00e1 tvar komol\u00e9ho ku\u017eele ohrani\u010den\u00e9ho horn\u00ed hrudn\u00ed aperturou, muskuloskelet\u00e1ln\u00edmi komponentami hrudn\u00edho ko\u0161e a doln\u00ed hrudn\u00ed \u00a0aperturou. Horn\u00ed hrudn\u00ed apertura topografcky, ne anatomicky, odd\u011bluje kr\u010dn\u00ed prostor od hrudn\u00edku, m\u00e1 ledvinovit\u00fd tvar, tvo\u0159\u00ed ji manubrium sterna, kostoklavikul\u00e1rn\u00ed sklouben\u00ed, prvn\u00ed dv\u011b \u017eebra a t\u011blo 1. hrudn\u00edho obratle. Horn\u00ed hrudn\u00ed aperturou [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":1347,"menu_order":15,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-1418","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1418","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=1418"}],"version-history":[{"count":20,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1418\/revisions"}],"predecessor-version":[{"id":1674,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1418\/revisions\/1674"}],"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=1418"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}