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21
II. ХИРУРГИЯ
УДК 616.24.002.5:579.252.55
ABOUT THE AUTHORS
Erimbetov Kulakhmet Dildahmetovich,
surgeon of the department of surgical treatment of pulmonary tuberculosis with multidrug resistance, NSCP RK. e-mail: k.d.erimbetov@mail.ru
Bektursinov Bakytzhan Umirgalievich,
Head of the Department of Surgical Treatment of Pulmonary Tuberculosis with Multidrug Resistance, NSCP RK. e-mail: bakhytzhan85@inbox.ru
Ibraev Zhasulan Akhmetovich, surgeon of the department of surgical treatment of pulmonary tuberculosis with multidrug resistance, NSCP RK.
Aubakirov Yerzhan Aripkhanuly, surgeon of the department for surgical treatment of pulmonary tuberculosis with multidrug resistance, NSCP RK.
Algozhin Erkebulan Zhedelkhanovich,
Director of the representative office of the NGO "Partners for the Health" in the Republic of Kazakhstan
Rashitov Makhmudzhan Razikulovich,
head of the observational study of the "endTB" project NGO "Partners for the Health" in the Republic of Kazakhstan
Keywords
Organization of surgical care, thoracic surgery, combined Echinococcus, multidisciplinary
approach
АВТОРЛАР ТУРАЛЫ
Еримбетов Купахмет Дипьдахметупы,
KP YF0ü, кептеген дэршерге тез!мдi екпе туберкулезн хирургиялык емдеу белiмшесiнiц хирург дэрiгерi. e-mail: k.d.erimbetov@mail.ru
Бектурсинов Бакытжан Умиргапиупы,
KP YF0O, кептеген дэршерге тез!мдi екпе туберкулезн хирургиялык емдеу белiмшесiнiц жетекшс e-mail: bakhytzhan85@inbox.ru
Ибраев Жасупан Ахметупы,
KP YF0O, кептеген дэршерге гез!мдi екпе туберкулезн хирургиялык емдеу белiмшесiнiц хирург дэр!герi.
Аубакиров Ержан Арипханупы,
KP YF0O, кептеген дэршерге гез!мдi екпе туберкулезн хирургиялык емдеу белiмшесiнiц хирург дэр!герi.
Апьгожин Еркебупан Жедепьханупы,
KP-дагы «Денсаулык уш1н серкестк» ТЭБ екiлдiгiнiц директоры
Рашитов Махмуджан Разикупович,
KP-дагы «Денсаулык уш1н серкестк» ТЭБ«endTB» обсервациялык зерттеу жобасыныц жегежс
Тужн сездер
Дэрг тезiмдi туберкулез, хирургиялык ем, жаца жэне кайта профильденген дэрлермен химитерапия, резекциялык материал
EXPERIENCE OF SURGICAL TREATMENTS OF XDR-TB PATIENTS WITH NEW AND REPURPOSED PREPARATIONS CHEMOTHERAPY
Yerimbetov K.D., Bektursinov B.U., IbrayevZh.A., Rashitov M.R., Algozhin E.Zh., Aubakirov E.A., Toxanbayeva B.T.
National scientific center of phthisiopulmonology, Ministry of health of the Republic of Kazakhstan, NGO «Partners In Health», Almaty, Kazakhstan
Abstract
Performed analysis of experience sing surgical methods of treatment of 22 patients with M/XDR-TB with chemotherapy by new and repurposed preparations. Clinical surgical efficiency was achieved in 20 (91.0%) patients with mortality in 2 (9.0%) patients.Of the 14 patients who completed the full course of chemotherapy, the outcomes of treatment were "Cured" in 7 (31.8%), "treatment completed" in -5 (22.7%) patients, and "died" in 2 (14.3%). Other 8 (36.4%) patients continue treatment. The outcome "Treatment success" was obtained in 12 (85.7%) patients.
Кецейтшген дэр1ге тез1мд1 туберкулезд1 жаца жэне кайтапрофильденген дэршермен химиотерапия фонында хирургиялык емдеу эд1стер1н колдану тэж1рибес1
Еримбетов К.Д., Бектурсинов Б.У., Ибраев Ж.А.,
Рашитов М.Р., Альгожин Е.Ж. Аубакиров Е.А.,Токсанбаева Б.Т.
КР ДСМ «Улттык, фтизиопульмонология ?ылыми орталы^ы», МЕ¥ «Партнеры во имя здоровья», Алматы, Казакстан
Ацдатпа
Жаца кайта профилирленген туберкулезге карсы дэршердц химиотерапиясыныц фонында туберкулезд'щ кецейт'лген дэрге тезiмдi турi бар 22 наукаска хирургиялык емдеу эдстерн колдану тэжiрибесiнiц нэтижелерiне талдау жург'шлд'!. Наукастардыц елiм-жiтiмi 2 (9,0%) болса, 20 (91,0%) наукаста клиникалык хирургиялык ти'мдЫк аныкталды. Химиотерапияныц толык курсынан еткен 14 наукастан 7(31,8%) «ЕмделдЬ>, 5(22,7%) «емдеуаякталды», 2(14,3%) «кайтысболды»дегеннэтижелер алынды. Kßnган 8 (36,4%) наукас емалудыжалгастырыпжатыр. 12 (85,7%) наукаста «Емдеу сэттi еттi» деген корытынды бар.
Опыт применения хирургических методов лечения у больных ШЛУ ТБ на фоне химиотерапии новыми и перепрофилированными препаратами
Еримбетов К.Д., Бектурсинов Б.У., Ибраев Ж.А.,
Рашитов М.Р., Альгожин Е.Ж. Аубакиров Е.А.,Токсанбаева Б.Т.
Национальный научный центр фтизиопульмонологии МЗ РК, НПО «Партнеры во имя здоровья», Алматы, Казахстан
Аннотация
Проведен анализ результатов опыта применения хирургических методов лечения у 22 больных М/ ШЛУ ТБ на фоне химиотерапии новыми перепрофилированными противотуберкулезными препаратами. Клиническая хирургическая эффективность достигнута у 20 (91,0%) больных при летальности у 2 (9,0%) больных.
Из 14 больных, завершивших полный курс химиотерапии исходы «Вылечен» получен у 7 (31,8%), «лечение завершено» у 5 (22,7%) больных, «умер» у 2 (14,3%). Остальные 8 (36,4%) пациентов продолжают лечение. Исход «Успех лечения» получен у 12 (85,7%) больных.
Introduction
The Drug-resistant tuberculosis has become one of the main obstacles to control this disease [1-4] The World Health Organization reports that the number of patients who suffer from rifampicin or multidrug-resistant tuberculosis is increasing annually. In addition, the treatment success rates achieved worldwide are suboptimal, barely exceeding 50%. This proportion is reduced up to 25% patients with extensively drug-resistant tuberculosis [1,2,5].
Thus, the cure of the vast majority of patients with M / XDR-TB is relevant [6].
The modern WHO protocols for chemotherapy with new and redesigned drugs contain recommendations on the use of surgical methods for treating M / XDR-TB patients, but at the same time, there are no reliable sources in the literature on the development of indications and terms for surgical interventions at the stages of an individual treatment regimen using new a and re-profiled drugs, on the effectiveness of their usage, there are no publications on microbiological studies of resection material in abacillated patients with various tuberculosis and lung after chemotherapy with new drugs and developed, especially when destructive processes [7].
Therefore, the study of the above issues is important and relevant for modern phthisiology.
The purpose of the study: - to give a preliminary assessment of the results of surgical treatment methods on the outcomes of treatment of patients with XDR-TB with chemotherapy with new and redesigned drugs.
Materials and methods
The main goal is to achieve the study, we have performed a descriptive analysis of the results of the use of surgical methods of treatment in 22 patients with M / XDRTB on the background of chemotherapy with new and redesigned drugs.
In the analyzed group, the number of men was 13 (59.1%), women - 9 (40.9%). In most cases, in the analyzed group, there were young people from 20 to 40 years old, the proportion of which was 77.3% , one child 5 years old (4.5%,), from 41 to 50 years old, 3 (13.62%) and one patient had 51 years old (4.5%).
According to the clinical forms, the patients were distributed as follows: the vast majority of 18 (81.9%) patients had fibro-cavernous pulmonary tuberculosis of different localization, 2 (9.1%) were diagnosed with pulmonary tuberculosis, and one (4.5%) infiltrative tuberculosis complicated by em-
АВТОРЛАР ТУРАЛЫ
Еримбетов Кулахмет Дильдахметович, врач-хирург отделения хирургического лечения легочного туберкулеза с множественной лекарственной устойчивостью, ННЦФ РК e-mail: k.d.erimbetov@mail.ru
Бектурсинов Бакытжан Умиргалиевич, Руководитель отделения хирургического лечения легочного туберкулеза с множественной лекарственной устойчивостью, ННЦФ РК e-mail: bakhytzhan85@inbox.ru
Ибраев Жасулан Ахметович, врач-хирург отделения хирургического лечения легочного туберкулеза с множественной лекарственной устойчивостью, ННЦФ РК
Аубакиров Ержан Арипханулы, врач-хирург отделения хирургического лечения легочного туберкулеза с множественной лекарственной устойчивостью, ННЦФ РК
Альгожин Еркебулан Жедельханович,
Директор представительтсва НПО «Партнеры во имя здоровья» в РК
Рашитов Махмуджан Разикулович,
руководитель обсервационного исследования проекта «endTB» НПО Партнеры во имя здоровья» в РК
Ключевые слова
М/ШЛУ ТБ, хирургическое лечение, химиотерапия новыми и перепрофиллированными препаратами, резекционный материал, микробиологические исследования
pyema of the pleura, in the other, empyema of the pleura.
According to the localization of the process, the majority of 15 (68.2%) patients had a right-sided lesion of the lungs with the tuberculosis process, and the remaining 7 (31.9%) patients had left-sided damage.
The prevalence of the tuberculous process in the lungs in the analyzed group of patients was different: lung damage was observed in 10 (45.4%) patients, lung lobes in 7 (31.8%) patients, segments in 3 ((13.6%), damage pleura in 2 (9.1%) patients.
The disease duration in 14 (63.6%) patients ranged from one year to 5 years, in 6 (27.3%) patients - 8-10 years, and in 2 (9.1%) - more than 16 years.
For all patients, the decision of the centralized CVCC, based on the drug resistance test, the clinical protocol recommended by WHO and the methodological recommendations of the NSCF MH RK "Practical recommendations for the use of short-term, standard and individual treatment regimens for RU and M / XDR-TB using new and redesigned anti-TB drugs" from 2018, treatment regimens with new and redesigned drugs were prescribed [8].
According to drug resistance tests, all patients had multidrug-resistant tuberculosis and corresponded to category IV: among them, 17 (77.3%) had XDR-TB, 3 (13.6%) had pre-XDR-TB, and 2 (9.1%) - MDR-TB. Among them, in 2 sick children, an individual treatment regimen was prescribed in connection with reliable contact with parents with M / XDR-TB, and in 2 patients with pulmonary tuberculomas after examining the resection material.
The prior to the use of chemotherapy in patients with chemotherapy with the use of new and redesigned drugs, bacterial excretion was noted in 20 (91.0%) patients, with the exception of 2 (9.1%) patients with tuberculomas.
The Chemotherapy treatment was controlled and was planned for 20 months.
The individual treatment regimen included drugs of at least five drugs with confirmed preserved sensitivity of the MBT from the following list: Lfx (Mfx), Cm (Am), Pto, Cs, Lzd, Cfz, Bdq, Dlm, Z, E, H (high dose), PAS, Amx / Clv, Imp / Cln.
Doses were prescribed in accordance with the weight category.
The Patients took all drugs (daily dose) in a controlled manner throughout the course of treatment. Bdq (or Dlm) was prescribed for 6 months and extended to 12 months or more by the decision of the Central Control Commission in cases where the remaining regimen was not effective enough (less than 3 effective drugs) and the tolerability of new drugs was good.
When conducting controlled chemotherapy in the IRL mode, all patients strictly observed the assessment of the condition of patients at the begin-
ning of treatment, during and after treatment according to the treatment monitoring schedule.
The monitoring schedule for monitoring the treatment of patients of the analyzed group, as well as compliance with pharmacovigilance, in order to identify unwanted (AE) and serious adverse events (AE), was carried out by responsible specialists of the End TB project and the NSCF.
Due to the long history of the disease and repeated chemotherapy courses, all patients before the operation suffered from many concomitant diseases: chronic gastritis, duodenitis, cholecystitis, anemia, chronic hepatitis, chronic obstructive pulmonary disease, pyelonephritis, etc. The presence of concomitant diseases was not a contraindication to surgical intervention , since symptomatic therapy during preoperative preparation allowed to stabilize the course of these problems levany and did not prevent the implementation of surgical interventions regarding the main process.
During the period of chemotherapy for patients, various undesirable phenomena arose associated with the use of anti-TB drugs, which were resumed after detoxification therapy and normalization of intoxication indicators.
In general, in the analyzed group only 3 (13.6%) patients had a temporary withdrawal of drugs. In other cases, drug tolerance was satisfactory.
Against the background of chemotherapy, taking into account the clinical and radiological dynamics and bacteriological studies of sputum in patients of this group, which characterize the stabilization of the pulmonary tuberculosis process, various surgical procedures have been performed.
The main indication for surgical intervention in this category of patients was the presence of extensive destructive changes in the lungs that did not have a tendency to reverse development.
In all patients, in terms of preoperative preparation and prevention of postoperative complications, bronchological studies of the lungs were performed, which were accompanied by a biopsy and ALS sampling from the proposed resection sites for lobectomy, pulmonectomy ..
In order to prepare patients for collapse surgery, pleurectomy, decortication, thorough rehabilitation of empyema cavities with bacteriological control was carried out.
In the postoperative period, all resection material was subjected to pathomorphological and microbiological examination.
The clinical effectiveness of the use of surgical treatment methods was assessed by the occurrence of postoperative complications, and the effectiveness of the entire complex treatment of these patients, taking into account the chemotherapy, was carried out according to the outcome of treatment.
Results
The nature of surgical interventions is presented in table 1.
In the postoperative period, 2 (9.0%) patients died, of which, in the early postoperative period, one patient died from pulmonary embolism after pneumonectomy, the other patient from cardiopulmonary insufficiency A 2 months after TMPL surgery.
In other cases of postoperative complications were not observed:
- In 11 (50.0%) patients, after segmental resections and lobectomies, the lungs were completely straightened.
- In 6 (27.3%) cases after pneumonectomy, the hemitorax is completely filled with the formation of fibrothorax, without mediastinal displacement
- In 4 (18.2%) patients after TML, in the zones of collapse, a complete decline in caverns was noted.
- In one case, after pleurectomy and decortica-tion, the lung is completely straightened and without signs of a residual cavity
Thus, the clinical effectiveness of surgical interventions in the early postoperative period was
achieved in 20 (91.0%) patients.
Treatment outcomes for M / XDR-TB patients are presented in Table 2.
As shown in the table, as a result of the use of surgical treatment methods with chemotherapy with new and redesigned drugs in M / XDR-TB patients, outcomes were obtained in 14 (63.6%) patients. Of these, "Treatment success" was established in 12 (85.7%) ) patients, 2 (14.3%) patients died from pulmonary embolism.
The remaining patients continue treatment.
Thus, the use of surgical methods in patients with M / XDR-TB with the use of the treatment regimen with new and redesigned drugs made it possible to achieve clinical efficacy in 20 (91.0%) cases, and the outcome "treatment success" of the entire complex treatment was established in 12 (85,7%) of 14 (63.6%) patients who have completed chemotherapy to date. Despite the small number of studies, cultural studies of resection material in abacillated patients at the time of surgery indicate the effectiveness of new and redesigned drugs in treatment regimens.
Number of patients Number of patients
absolute number %
The Segmental resection 5 22,7
Lobectomy 6 27,3
Pneumonectomy 6 27,3
Thoracomyoplasty 3 13,7
Thoracomyoplasty using a silicone implant in combination with valvular bronchial block 1 4,5
Pleurectomy, decortication 1 4,5
Total 22 100,0
Outcomes Number of Patients (n-22) %
Cured 7 31,8
Treatment completed 5 22,7
Treatment failure - -
Died 2 9,1
Continues treatment 8 36,4
Table 1.
The nature of surgical interventions in patients with M / XDR-TB
Table 2.
Outcomes of complex treatment of the analyzed group of patients with M / XDR-TB
References
1. World Health Organization. Global tuberculosis report 2015. Document WHO/HTM/TB/2015. Geneva, World Health Organization, 2015.
2. World Health Organization. Global tuberculosis report 2016. Document WHO/HTM/TB/2016. Geneva, World Health Organization, 2016.
3. L^nroth K, Migliori GB, Abubakar I, et al. Towards tuberculosis elimination: an action framework for low-incidence countries. Eur Respir J 2015; 45: 928-952.
4. D'Ambrosio L, Dara M, Tadolini M, et al. Tuberculosis elimination: theory and practice in Europe. Eur Respir J 2014; 43: 1410-1420;
5. Migliori GB, Sotgiu G,Gandhi NR, et al. Drug resistance beyond extensively drug-resistant tuberculosis: individual patient data meta-analysis. Eur
Respir J 2013; 42: 169-179.
6. Grzybowski S, Enarson DA. The fate of cases of pulmonary tuberculosis under various treatment programmes. Bull Int Union Tuberc Lung Dis 1978; 53: 70-75.
7. Michael Marrone, Giovanni Battista Migliori, Yerim-betov K.D, Giovanni Sotgiu., et.al. The role of surgery in the treatment of pulmonary TB and multidrug-and extensively drug-resistant TB /World Health organization(WHO), Regional offis for Europe, 2014.
8. Практические рекомендации по использованию краткосрочных, стандартных и индивидуальных режимов лечения РУ и М/ШЛУ ТБ с примене-ниемновых и перепрофилированных противотуберкулезных препаратов /ННЦФ МЗ РК, 2018.
