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18
II. ХИРУРГИЯ
REATMENT OF
ECHINOCOCCOSUS OF LUNGS
Baimakhanov B.B.1, Chormanov A.T.1, Shirtaev B.K.1, Yerimova N.Zh.1, Enin E.A.1, Sundetov M.M.1, Kurbanov D.R.1, Akilbekov S.D.2
1National scientific centre of surgery named after A.N. Syzganov Republican Higher medical college, Almaty, Kazakhstan
Abstract
The results of treatment of 676patients with lung echinococcosis are presented. The methods of phased and simultaneous bilateral echinococcectomy from the lungs, from the lungs and organs of the abdominal cavity and chemotherapy with Albendazol were used. Methods for reducing traumatic operations are sug-ggsted.
MPHTM 76.29.35 ABOUT THE АUTHORS
Baimakhanov Bolatbek Bimendeevich-
Chairman of the Board Syzganov's National Scientific Center of Surgery, MD, professor.
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.
Yerimova Nazira Zholdybayevna
- MD, pediatrician.
Kurbanov Doniyor Rakhmatullaevich
- MD, thoracic surgeon.
Akilbekov Saken Dzhumatovich -
Deputy Director of the Republican Higher Medical College on International Relations. asakeiiddyatioo.com
Keywords
Echinococcosus of lung, treatment, echinococcectomy
бкпе эхинококкозыньщ eMi
Баймаханов Б.Б.1, Чорманов А.Т.1, Ширтаев Б.К.1, Еримова Н.Ж.1, Енин Е.А.1, Сундетов М.М.1, Курбанов Д.Р.1, А^ылбеков С.Д.2
1А.Н. Сызганов атында™ Улттык, гылыми хирургия орталы™ 2Республикалык жоfары медициналык колледжу Алматы, Казакстан
А^дяата
Бул бакылауда вкпе эхинококкозымен ауыратын 676 наукас ем1н1ц нэтижелер1 кврсетшген. Кезецдi жэне 61р уакытты ею жакты вкпе эхинококэктомиясы, курсах, куысыныц эхинококэктомиясы жэне альбендазолмен химиотерапия колданылды. Ота барысындагы жаракатты твмендету жолдары кврсетщь
АВТОРЛАР ТУРАЛЫ
Баймаханов Болатбек Бимендеулы
- «А.Н. Сызганов атындагы Ултгык гылыми хирургия орталыры» Баскарма Тврагасы, м.ьд., профессор.
Ширтаев Бахытжан Керимбекович
- м.ьк., А.Н.Сызганов атындагы YfXO торакалды жэне балалар хиругиясы 6влiмiнiц мецгеруша
Сундетов Мухтар Магзомович
- M.F.K., торакалды хирург.
Еримова Назира Жолдыбаевна
- педиатр.
Курбанов Дониер Рахматуллаевич
- торакальды хирург.
Ацылбеков Сэкен Жумзтулы -
Халыкаралык катынастар бойынша Республикалыкжогары медициналык колледжшщ директорыныц орынбасары. asakenddyahoo.com
ТуЙ1И сездер
9кпе эхинококкозы, ем, эххннокозктомия
Лечение эхинококкоза легких
Баймаханов Б.Б.1, Чорманов А.Т.1, Ширтаев Б.К.1, Еримова Н.Ж.1, Енин Е.А.1, Сундетов М.М.1, Курбанов Д.Р.1, Акильбеков С.Д.2
Национальный научный центр хирургии им. А.Н. Сызганова Республиканский высший медицинский колледж, Алматы, Казахстан
Аннсгтция
В работе представлены результаты лечения 676 пациентов с эхннозоззозом легких. Использованы способы поэтапной и одномоментной двусторонней эхннозоззэттомнн из легких, из легких и органов брюшной полости и химиотерапия Албендозолом. Предложены способы снижения травматичности операций.
ОБ АВТОРАХ
Баймаханов Болатбек Бимендеевич
- Председатель Правления АО«Национальный научный центр хирургии им. А.Н. Сызганова», д.м.н., профессор.
Ширтаев Бахытжан Керимбекович -
к.м.н., зав. отделением торакальной и детской хирургии ННЦХ им. А.Н.Сызганова.
Сундетов Мухтар Магзомович
- к.м.н., торакальный хирург.
Еримова Назира Жолдыбаевна
- педиатр.
Курбанов Дониер Рахматуллаевич
- торакальный хирург.
Акильбеков Сакен Джуматович -
Земеститель Директора Республиканского Высшего медицинского колледжа по международным отношениям.
asakenddyatioo.com
Ключевые слова
Эхинококков легких, лечение, экиннокозэтомин
Cytomegalovirus is the most common and significant infection in children after liver transplantation with the development of episodes of CMV infection or CMV disease. CMV infection is associated with an increased risk of biliary atresia and graft loss. According to R. Razonable, the incidence of CMV infection in the population is 60 to 100% [1]. The incidence of CMV infection in patients after liver transplantation is in a wide range from 13 to 75%, which is associated with various schemes of prevention of CMV infection, the degree of im-munosuppression, various methods of confirming the presence of infection, and various follow-up periods after transplantation [2]. In the Korean J. Kim study, the incidence of active CMVI was 55.7%, CMV disease 5.5%, such data were obtained from an analysis of 618 patients from 1996 to 2009, and the methods of prevention and treatment varied [3]. In the J. Bowman study, rates of detection of active CMV among children after liver transplantation who did not receive preventive antiviral therapy were obtained at 40%, with mortality rates of about 19% [4]. According to the Japanese study of Y. Kawanoa among children after related liver transplantation, the level of CMV infection was 36.3%, 16 of whom had a CMV disease rate of 60.6%.
Material and methods
Since March 2016g. 18 liver transplants from a living related donor in children were performed. The age of the patients ranged from 6 months to 8 years (Table 1). Of these, 15 (83.3%) patients with biliary atresia
(Fig. 1). The number of girls is 10 (66.7%) and boys 5 (33.3%). At the time of diagnosis, most of the children registered a formed cirrhosis of the liver.
Results and discussion
All recipients with positive quantitative parameters of PCR received CMV-specific immunoglobulin 3-5 months before the operation. The left lateral sector was transplanted to 15 patients with biliary atresia from CMV of the seropositive related lifelong donor (D+/R+) 13 donors and from CMV 1 seronegative donor (D-/R +), 1 to the simultaneous transplantation (liver and kidney) 2 patients with cirrhosis of the liver in the outcome of autoimmune hepatitis. In all children, biliary atresia was combined with a cytomegalovirus infection, 7 of them with an active form (Table 2, 3). The observation period is from 14 days after the operation to 2 years.
After the operation, a three-component immu-nosuppressive therapy was performed (predniso-lone, Sellsept, Tacrolimus). Activation was noted in 2 patients with inactive form of CMV. In 2 children, neurologic symptoms developed - 1 with active form of CMV and in 1 child it was associated with a toxic effect of immunosuppressive therapy (tacrolimus), which was managed by conservative methods of treatment. All children with cytomegalovirus infection received antiviral therapy with valganciclovir at a rate of 18 mg/kg for 1 month, against which the virus load in children with an active CMV phase was reduced. Six months after the operation, in all children, the quality of PCR for CMV was negative. At 9
Table 1
Liver transplant characteristics.
Recipient characteristics Age 0 - 2 y.o Age 2 - 8 y.o CMV seropositive (IgG positive) CMV infection PCR DNA positive
Total numbers 15 3 18 7
Biliary atresia 15 О 15 7
Autoimmune hepatitis О 2 2 О
Primary hyperoxaluria О 1 1 О
Figure 1
The main contingent of recipients.
Indicators N Average Standard deviation Median Interquartile range
Bilirubin 18 288,1 180,7 272,0 184,0
Bilirubin direct 18 219,2 126,1 230,5 140,7
Protein 18 53,7 7,1 53,5 11,6
Albumin total 18 27,9 7,5 26,5 13,1
INR 18 1,6 0,6 1,5 1,0
Creatinine 18 44,0 89,6 22,3 19,3
ALT 18 193,6 145,0 179,5 120,8
AST 18 267,4 180,8 209,0 248,8
PELD 18 20,6 5,1 19,5 6,0
BMI 18 17,8 3,9 16,5 7,1
Lymphocytes 18 42,0 16,7 43,5 17,0
CMV titer 7 698,0 129,6 740,0 206,0
Table 2
Laboratory indicators, PELD, BMI, CMV titer.
Indicators, n=17 Abs. %
Ascite
Yes 17 94,4
No 1 5,6
Encephalopathy
1 6 33,3
Min 12 66,7
CMV
Negative 11 61,1
Positive 7 38,9
Table 3
The frequency of encephalopathy, ascites and active CMV.
months after liver transplantation, 1 patient with an inactive form of CMV had an increase in viral load.
It should be noted local, extraordinary defeat of individual organs in the liver recipient.
Patient K., 7 years old. Diagnosis "Condition after orthotopic transplantation of the left lateral liver sector from a living related donor from 23.05.2016 in connection with cirrhosis of the autoimmune etiology. Long-term drug-induced immunosuppression". On May 2016, an operation was performed to implant the left lateral liver sector from a living related donor - from the father.
Immunosuppressive therapy is three-component, against which the child has diarrhea. Received vancomycin and metronidazole for the sanation of Clostridium difficile. 12 months after the operation, a biopsy from a liver transplant and duodenum was taken, where nonalcoholic fatty liver transplant dystrophy, stage of fibrosis II and enterit (Fig. 2 - a, b). It was not found when examining a potential donor for fatty dystrophy (Fig. 2 - c). Dietotherapy, ursodeoxycholic acid was used at the rate of 15mg/ kg and essential phospholipids, against which there was a decrease in hepatic samples. In the analyzes: ALT-91U/l, AST-63U/L, total bilirubin - 4.7 mg/dL, GGTP - 19U/L, alkaline phosphatase - 378U/ L, tacrolimus concentration - 4.4ng/ml. CMV seroposi-
tive (IgG), PCR on CMV was negative (blood, saliva, feces, biopsy).
Subsequent biopsy from the liver 24 months after the operation due to the increase in transaminases to 250U/l, the appearance of a stool to 5-6-7 times a day, uncontrolled with symptomatic treatment. Clostridium difficile - negative, PCR of CMV blood, saliva negative, intestinal biopsy from three loci and feces on PCR was positive. Results of liver biopsy - steatohepatitis. On a biopsy specimen from the intestine of morphological data, no specific enteritis was found for CMV «owl's eye». (Fig. 2 - d, e, f). Treatment - valcyte and immunoglobulin against CMV, after which there was a positive dynamics.
Conclusions
1. The combination of antiviral prophylaxis and preventive therapy is no less effective than prolonged antiviral therapy.
2. Valganciclovir is as effective as ganciclovir for the treatment of CMV disease in liver transplant recipients.
3. Our experience confirms the role of cytomega-lovirus infection in the development of biliary atresia with the formation of liver cirrhosis and requires adequate follow-up after liver transplantation.
Figure 2
a - liver transplant b - colon c - donor's liver d - «owl's eye» e - liver transplant f - colon
References
1. Razonable, R.R. Management of CMV infection and disease in transplant patients [Text] / Razonable R.R., Emery V.C. // Herpes : the journal of the IHMF. - 2004. - № 3 (11). - P. 77-86. 114
2. Effect of early EBV and/or CMV viremia on graft function and acute cellular rejection in pediatric liver transplantation [Text] / Indolfi G., Heaton N., Smith M. [et al.] // Clin Transplant. - 2012. - № 1 (26). - P. E55-E61.
3. Is cytomegalovirus infection dangerous in cytomegalovirus-seropositive recipients after liver transplantation? [Text] / Kim J. M., Kim S. J., Joh J. W. [et al.] // Liver transplantation: official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society. - 2011. - № 4 (17). - P. 446-455.
4. https://s3-us-west-2.amazonaws.com/courses-images/wp-content/uploads/sites/1094/2016/11/03175802/0SC_ Microbio_25_03_CMV.jpg
