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21
III. ХИРУРГИЯ
МРНТИ 76.29.50
ABOUT THE АUTHORS
Shirtaev Bakhytzhan Kerimbekovich -
MD, PhD, the branch manager of toracic and child surgery department NSSC named by Syzganov A. N.
Sundetov Mukhtar Magzomovich -
MD, PhD, thoracic surgeon.
Erimova Nazira Joldybayevna -
MD, pediatr.
Kurbanov Donior Rakhmatullaevich -
MD, thoracic surgeon.
Akilbekov Saken Dzhumatovich -
Associated professor, Higher School of Medicine, Al-Farabi KazNU.
DIAGNOSTICS AND TREATMENT OF LUNG ECHINOCOCCOSIS
Shirtaev B.K.1, Sundetov M.M.1, Kurbanov D.R.1, Erimova N.Z.1, Khalykov K.U.1, Akilbekov S.D.2
1National Scientific Center of Surgery named after A.N. Syzganov, Almaty, Kazakhstan 2Al-Farabi Kazakh National University, Almaty, Kazakhstan
Keywords
Echinococcosis of the lungs, videothoracoscopic echinococ-cectomy, transmediastinal access, albendozole
Abstract
The paper presents the results of treatment of 676 patients with pulmonary echinococcosis. The methods of stage-by-stage and one-stage bilateral echinococcectomy from the lungs, from the lungs and organs of the abdominal cavity and chemotherapy with Albendozol were used. Ways to reduce the trauma of operations are proposed.
АВТОРЛАР ТУРАЛЫ
Ширтаев Бахытжан Керимбекович
- M.F.K., А.Н.Сызганов arbiHMaFbi УГХО торакалды жэне балалар хиругиясы бел1мш1ц мецгерушю!
Сундетов Мухтар Магзомович -
m.f.k., торакалды хирург.
Еримова Назира Жолдыбаевна -
педиатр.
Курбанов Дониер Рахматуллаевич -
торакалды хирург.
Акильбеков Сакен Джуматович -
доцент, ЖММ, Эл-Фараби атындаFы КазУУ
бкпе эхинококкозын аньщтау жэне емдеу
Ширтаев Б.К.1, Сундетов М.М.1, Курбанов Д.Р.1, Еримова Н.Ж.1, Халыков К.У.1, Акылбеков С.Д.2
1А.Н. Сыз?анов атында?ы Улттык, ?ылыми хирургия орталы^ы, Алматы, Казахстан 2Эл-Фараби атында?ы Казак ¥лттык университету Алматы, Казакстан
Туйш сездер
9кпе эхинококкозы, видеоторакоскопиялык эхинокок-кэктомия, трансмедиастинальдык колжелмдш, альбендозол
Ацдатпа
Осы жумыста вкпе эхиноккозы бар 676 наукастыц емдеу нэтижелер1 усынылган. 9кпеден, екпеден жэне курса; куысы MYшелерiнен б1р мезетт1к жэне кезецдж ею жактты эхинококкэктомия эдютер1 жэне Албендозол хи-миотерапиясы пайдаланылды. Оталардыц жаракаттылы^ын темендету эдiстерi усынылды.
ОБ АВТОРАХ
Ширтаев Бахытжан Керимбекович -
к.м.н., зав. отделением торакальной и детской хирургии ННЦХим. А.Н.Сызганова.
Сундетов Мухтар Магзомович - к.м.н., торакальный хирург.
Курбанов Дониер Рахматуллаевич -
торакальный хирург.
Еримова Назира Жолдыбаевна -
педиатр.
Халыков Кадырбек Улыкпанулы -
торакальный хирург.
Акильбеков Сакен Джуматович -
доцент кафедры клинических дисциплин ВШМ КазНУ им. Аль-Фараби
Диагностика и лечение эхинококкоза легких
Ширтаев Б.К.1, Сундетов М.М.1, Курбанов Д.Р.1, Еримова Н.Ж.1, Халыков К.У1, Акильбеков С. Д.2
Национальный научный центр хирургии им. А.Н. Сызганова, Алматы, Казахстан 2Казахский Национальный университет им. Аль Фараби, Алматы, Казахстан
Ключевые слова
Эхинококкоз легких, видеото-ракоскопическая эхинококкэктомия, трансмедиастинальный доступ, албендозол
Аннотация
В работе представлены результаты лечения 676 пациентов с эхинококкозом легких. Использованы способы поэтапной и одномоментной двусторонней эхинококкэктомии из легких, из легких и органов брюшной полости и химиотерапия Албендозолом. Предложены способы снижения травматичности операций.
Introduction
Echinococcosis of the lungs, according to researchers, ranks second, yielding to the hepatic localization of the parasite [1, 2, 3]. The spread of echinococcosis in the Republic of Kazakhstan is associated with the fact that it is the leader in the development of sheep breeding [4, 5, 6].
Echinococcosis treatment still remains a problem that has not been finally solved [3, 4, 7, 8, 9]. Most researchers believe that the only radical treatment for echinococcosis of all localizations is surgical. Delay with the operation in the hope of the success of conservative therapy or self-healing due to the death of the parasite with calcification of the dead cysts can only increase the risk of complications and reduce the effectiveness of surgery. At the same time, the use of antiparasitic drugs is one of the important components of the treatment of echinococcosis. In recent years, many publications have appeared on the successful conservative therapy of echinococcosis, therefore the question of the choice of tactics between conservative treatment and surgical intervention remains relevant [10, 11, 12]. Unfortunately, neither the accurate performance of the surgical intervention, nor the use of effective germicides, nor the observance of the ablasticity rules during the operation and the use of perfect instrumentation completely exclude the possibility of a relapse of the disease. Therefore, the subsequent chemotherapy or anthelmintic therapy is of great importance for influencing the screenings of echinococcus of small sizes, which are not available for visual detection [11, 12].
Albendazole is a broad-spectrum anthelmintic drug; a benzimidazole carbamate derivative. Alben-dazole is active against tissue parasites, including cystic echinococcosis and alveolar echinococco-sis, caused by the invasion of E. granulosus and E. multilocularis, respectively. According to various authors, Albendazole destroys cysts or significantly reduces their quantity and size. After treatment with albendazole, the number of non-viable cysts increases to 90% compared to 10% in untreated patients [3, 8, 9]. A number of authors indicate that the use of Albendazole, a complete cure is noted in only a small proportion of patients, and in the majority there is an improvement or stabilization of the process. Multicenter studies evaluating the effectiveness of chemotherapy for echinococcosis, conducted under the auspices of the WHO, showed that the success of therapy (full or partial) was noted with treatment with Albendazole in 30-39% of patients, with mebendazole in 14-17% [4, 7, 10].
Currently, Albendazole is widely used for the prevention of relapses and the treatment of early stages of the development of echinococcosis, but chemotherapy with Albendazole is not equally suc-
cessful in all patients and the reasons for this are not yet clear enough.
Material and research methods
This work is based on the analysis of treatment of 676 patients with pulmonary echinococcosis, 327 (48.4%) of whom had a complicated course of the disease. The right lung was affected in 295 (43.6%) patients, the left lung - in 286 (42.3%), and in 95 (14.5%) - bilateral damage. Combined echinococcosis of the lungs and abdominal organs was observed in 176 (26.0%) cases, while in 136 the parasite was localized in the lungs and liver, and 88 of them had damage to the right lung and liver, in 36 - to the left lung and liver, in 12 - cysts were located in both lungs and liver. In 40 patients, lung damage was combined with cysts of the omentum, spleen, abdominal cavity and omental bursa.
Echinococcosis of the lungsat the early asymptomatic stage of the disease, as a rule, they were detected during prophylactic X-ray studies. Diagnosis of echinococcosis of the lungs based on the data:
• epidemiological history (place of residence and work);
• clinical picture;
• instrumental diagnostic methods (X-ray, computed tomography and ultrasound);
• serological diagnostics (ELISA).
Antiparasitic treatment was carried out according to the standard scheme: albendazole (15 mg / kg / day with a body weight of less than 60 kg or 400 mg 2 times / day with a body weight of more than 60 kg) for 28 days, up to 3 courses with a two-week break.
Results
Operations for pulmonary echinococcosis are performed under general anesthesia with artificial lung ventilation (IVL) single-lumen or double-lumen endotracheal tubes with separate intubation of the main bronchi. A single lumen tube is ventilated through the main bronchus of a healthy lung, and after the main stage of the operation, the transfer to endotracheal mechanical ventilation is carried out [21]. Lung resection was performed in 62 (9.2%) cases: with large festering cysts occupying the volume of almost the entire lobe (two lobes) with the presence of irreversible gross perifocal changes and fibrosis in the surrounding lung tissue, as well as with giant centrally located cysts, excessive multiplicity lesions of one or two lobes.
Organ-preserving operations were performed in 614 (90.8%) patients.
When treating patients with bilateral echinococ-cal cysts of the lungs (95 patients), depending on the general condition of the patient, the tactics of a staged or one-stage surgical intervention were
followed. Bilateral thoracotomy in two stages with an interval of 3-6-8 weeks was performed in 33 patients. In 4 patients, bilateral lung damage was combined with damage to the liver and spleen; after bilateral staged thoracotomy with pulmonary echi-nococcectomy, they underwent laparotomies with an interval of 1-2 months.
In 23 (3.4%) cases, a simultaneous bilateral thoracotomy with echinococcectomy was performed, and the surgical intervention was started from the side where there were cysts that were large in size or threatened with complications. However, this method is quite traumatic, it can lead in the early postoperative period to respiratory failure, and the risk of developing suppuration of surgical wounds increases. Therefore, in case of bilateral pulmonary echinococcosis, in which it is possible to remove echinococcus from the opposite lung from the transmediastinal approach, simultaneous bilateral echinococcectomy was performed.
In case of combined echinococcosis of the lungs and abdominal organs, surgical intervention should be started with echinococcectomy of the lung, given the possibility of a high risk of complications in the lungs. In our patients, combined echinococcosis was found in 176 (26.0%), of whom 136 had a combination of lung and liver cysts, 40 had cysts of the lung and other organs (omental bursa - 22, spleen - 8, abdominal cavity - 6, large oil seal - 4). 52
Figure 1.
7 - Patient P., 25 years old. Plain chest x-ray before treatment with Albendozole.
Figure 2.
7 - Patient P., 27 years old. Two years after courses of treatment with Albendozole. Screen from computed tomography of the chest.
patients with echinococcosis of the right lung and upper segments of the right lobe of the liver simultaneously underwent one stage thoracotomy with diaphragmotomy and echinococcectomy of the lung and liver, 84 patients - echinococcectomy of the lung, then laparotomies and echinococcectomies from the liver, and 27 of them were operated on in one stage two stages with an interval of 4-8 weeks.
In order to reduce the trauma of the operation, to reduce the duration of the operation and the postoperative period, bilateral simultaneous sequential videothoracoscopy with echinococcec-tomy from both lungs was performed. Videotho-racoscopy is performed under general anesthesia with separate intubation of the bronchi, which allows you to turn off the ventilation from the lung on the side of the operation. The cyst is covered with napkins moistened with povidone-iodine. Through the thoracoport, a puncture instrument with a tubular body is brought to the cyst and the hydatid fluid is aspirated, without removing the needle, the bed of the echinococcal cyst is treated with 70% alcohol or 10% povidone-iodine solution for 3 minutes. The fibrous capsule is opened and the chitinous membrane is removed. The cavity of the fibrous capsule is eliminated, depending on the size, by applying clips or suturing.
Conducting videothoracoscopic echinococcec-tomy of the lung made it possible to reduce the time of anesthetic and surgical aggression, and made it possible to reduce the patient's stay in the hospital to 5-7 bed-days, which is 3-5 times less than the duration of bed-days with other methods of operations used for pulmonary echinococcosis.
In the postoperative period, 30 patients had Al-bendozole courses to prevent recurrence of echino-coccosis. The average age of the studied patients was 35 years (from 18 to 67 years). The number of men and women was approximately same - 52% and 48%.
Relapse of pulmonary echinococcosis was not observed in these patients during three years of follow-up.
In the presence of a single echinococcal cyst less than 5 cm in diameter or with multiple bilateral echinococcal cysts of the lungs, conservative treatment with Albendozole is performed. Currently, according to the planned scheme, 5 patients with echinococcal cysts less than 5 cm in size have been assigned. Follow-up is carried out for more than a year in 2 patients, in others it is carried out for less than one year. There was no drug allergy to Alben-dozole in our patients. There was a decrease in the titer of antibodies in the blood in non-operated patients while taking Albendozole. According to the data of radiation diagnostics, there are no noticeable changes.
Among the operated patients who did not take Albendozole, two of them were diagnosed with liver echinococcosis 2 years after lung surgery. This is apparently due to the reinvasion of echinococcosis in these patients.
In one patient P., 27 years old, with bilateral multiple pulmonary echinococcosis, conservative treatment with Albendozol gave a positive effect. Two years after starting treatment with Albendozole without surgery, all echinococcal cysts died and were coughed up. On the control computed tomo-gram there is only a single air residual cavity in the left lung (Figures 1, 2, 3).
Conclusions
The methods of simultaneous surgical treatment of bilateral pulmonary echinococcosis using transmediastinal access and videothoracoscopic technique can reduce the trauma of operations, shorten the duration of treatment, and also relieve patients from the painful waiting for the next stage of operations and repeated anesthesia.
References
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The preliminary data obtained indicate the absence of allergic reactions to Albendazole when used according to the intended scheme. The absence of recurrence of echinococcosis among operated patients taking Albendozole and a decrease in the titer of antibodies in the blood in patients taking Albendozole without surgery indicates a positive effect of this drug.
Thus, the results of surgical treatment of pulmonary echinococcosis depend on the course of the disease (complicated or uncomplicated), on the type of access and the amount of surgery for combined lesions and antiparasitic treatment.
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Figure 3.
7 - Patient P., 27 years old. Two years after courses of treatment with Albendozole. In the left lung there is a residual air cavity from the dead echinococcal cyst. Screen from computed tomography of the chest.
