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II. ХИРУРГИЯ
МРНТИ 76.29.35
TREATMENT OF
ABOUT THE AUTHORS
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.
ECHINOCOCCOSUS OF LUNGS
Shirtaev B.K., Sundetov M.M., Yerimova N.Zh., Kurbanov D.R.
National Scientific Center of Surgery named after A.N. Syzganov, Almaty, Republic of Kazakhstan
Keywords
Echinococcosis of the lungs, videotoracoscopic echinococcec-tomy, transmediastinal access, albendazol.
Abstract
The results of treatment of 676 patients 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 suggested.
бкпе эхинококкозыньщ eMi
АВТОРЛАР ТУРАЛЫ
Ширтаев Бахытжан Керимбекович
- M.F.K., А.Н.Сызганов атындагы YfXO торакалды жэне балалар хиругиясы бел1мшщ менгерушс
Сундетов Мухтар Магзомович - m.f.k., торакалды хирург.
Еримова Назира Жолды/баевна -
педиатр.
Курбанов Дониер Рахматуллаевич -
торакальды хирург.
Тушн сездер
екпе, эхинококкоз eMi, эхинококэктомия
Ширтаев Б.К., Сундетов М.М., Еримова Н.Ж., Курбанов Д.Р.
А.Н. Сызганов атында™ Улттык, ^шыми хирургия орталь™, Алматы, Казак,стан
Ацдатпа
Б±л ба^ылауда екпе эхинококкозымен ауыратын 676 науа емшщ Hdmxeneßi керсетшген. Этапты жэне 61'р уакытты ею жакты екпе эхинококэктомиясы, курсах, куысыныц эхинококэктомиясы жэне альбендазолмен химиотерапия колданылды. Ота барысындаFы жаракатты темендетужолдары керсетщ!'.
Лечение эхинококкоза легких
ОБ АВТОРАХ
Ширтаев Бахыпжан Керимбекович -
к.м.н., зав. отделением торакальной и детской хирургии ННЦХим. А.Н.Сызганова.
Сундетов Мухтар Магзомович - к.м.н., торакальный хирург.
Еримова Назира Жолдыбаевна -
педиатр.
Курбанов Дониер Рахматуллаевич -
торакальный хирург.
Ширтаев Б.К., Сундетов М.М., Еримова Н.Ж., Курбанов Д.Р.
Национальный научный центр хирургии им. А.Н. Сызганова, Алматы, Казахстан
Ключевые слова
эхинококкоз легких, лечение, эхинококэктомия
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 the researchers takes second place, conceding the hepatic localization of the parasite [1, 2, 3]. The spread of echinococcosis in the Republic of Kazakhstan is due to the fact that it is the leading in the development of sheep breeding [4, 5, 6].
Treatment of echinococcosis to the present day 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 surgery in the hope of success of conservative therapy or self-healing by the death of a parasite with calcification of dead cysts can only increase the risk of complications and reduce the effectiveness of surgical intervention. At the same time, the use of antipara-sitic drugs is one of the important components of the treatment of echinococcosis. In recent years, a lot of publications have appeared on the successful conservative therapy of echinococcosis, so the choice of tactics between conservative treatment and surgical intervention remains relevant [10, 11, 12]. Unfortunately, neither the accurate implementation of the operative intervention, nor the use of effective germicides, nor compliance with the rules of abstinence in the operation and the use of perfect instruments completely exclude the possibility of recurrence of the disease. Therefore, follow-up chemotherapy or anthelmintic therapy is important to influence the small size echinococcus screenings that are not available for visual detection [13, 14, 15].
Albendazol - an anthelmintic preparation of a wide spectrum of action; benzimidazole carba-mate derivative. Albendazol is active against tissue parasites, including cystic echinococcosis and alveolar echinococcosis, caused by the invasion of E.granulosus and E.multilocularis, respectively. According to various authors, Albendazol destroys cysts or significantly reduces their number and size. After treatment with albendazole, the number of nonviable cysts increases to 90% compared with 10% in patients who have not received treatment [3, 16, 17]. A number of authors indicate that the use of Albendazol complete cure is observed only in a small part of patients, and in the majority there is an improvement or stabilization of the process. Multicentre studies evaluating the effectiveness of chemotherapy for echinococcosis, conducted under the auspices of WHO, have shown that the success of therapy (complete or partial) was noted in the treatment of Albendazole in 30-39% of patients, mebendazole - in 14-17% [18, 19, 20].
Currently, Albendazol is widely used to prevent relapses and treat early stages of echinococcosis,
but not all patients are equally successful in chemotherapy with Albendazole, and the reasons for this are not yet clear enough.
Material and methods
This work is based on the analysis of treatment of 676 patients with lung echinococcosis, 327 (48.4%) of whom had a complicated course of the disease. Right lung was affected in 295 (43.6%) patients, left - in 286 (42.3%), in 95 (14.5%) - bilateral defeat. The combined echinococcosis of the lungs and abdominal organs was observed in 176 (26.0%) cases, while in 136 the parasite was located in the lungs and liver, 88 of them had a lesion of the right lung and liver, 36 left lung and liver, 12 - the cysts were located in both the lungs and the liver. In 40 patients, the lung disease was combined with cysts of the omentum, spleen, abdominal cavity and stuffing box.
Echinococcosis of the lungs in the early asymptomatic stage of the disease, as a rule, was detected with preventive X-ray studies. The diagnosis of lung echinococcosis was based on data:
• epidemiological history (place of residence and work);
• clinical picture;
• instrumental diagnostic methods (radiography, computed tomography and ultrasound);
• serological diagnosis (ELISA).
Antiparasitic treatment was carried out according to the standard scheme: albendazole (15 mg / kg / day with body weight less than 60 kg or 400 mg 2 times a 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 lung echinococcosis are performed under general anesthesia with artificial ventilation (IVL) with a single-lumen or doublelumen intubation tubes with separate intubation of the main bronchi. A single-lumen tube ventilates through the main bronchus a healthy lung, and after the main stage of the operation, a transfer to endotracheal 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 coarse perifocal changes and fibrosis in the surrounding pulmonary tissue, as well as with giant centrally located cysts, excessive multiplicity defeat of one or two lobes.
Organ-saving operations were performed in 614 (90.8%) patients.
In the treatment of patients with bilateral echi-nococcal cysts of the lungs (95 patients) depending on the general condition of the patient adhered to
the tactics of phased or one-stage surgical intervention. Two-sided thoracotomy in two stages with an interval of 3-6-8 weeks was performed by 33 patients. In 4 patients, bilateral lung involvement was combined with liver and spleen involvement, after a two-sided phased thoracotomy with lung echino-coccectomy, laparotomy was performed at intervals of 1-2 months.
In 23 (3.4%) cases, a one-stage bilateral tho-racotomy with echinococcectomy was performed, and surgical intervention started from the side where there were cysts that were large in size or threatening complications. However, this method is quite traumatic, it can lead to respiratory failure in the early postoperative period, and the risk of developing festering surgical wounds increases. Therefore, with bilateral echinococcosis of the lungs, in which it is possible to remove Echinococ-cus from the opposite lung from the transmediasti-nal access, simultaneous bilateral echinococcecto-mies were performed.
With combined echinococcosis of the lungs and abdominal organs, surgical intervention should begin with lung echinococcemia, given the possibility of a high risk of complications in the lungs. In our patients, combined echinococcosis was found in 176 (26.0%), 136 of them had a combination of lung and liver cysts, 40 had cysts of the lung and
Figure 1.
Patient P., 25 years old. Chest X-ray before treatment with Albendazol.
Figure 2.
Patient P., 27 years old. Two years after the course of treatment with Albendazol. Screen with a computerized tomography of the chest.
other organs (stuffing bag - 22, spleen - 8, abdominal cavity - 6, large omentum - 4). 52 patients with echinococcosis of the right lung and upper segments of the right lobe of the liver simultaneously in one stage thoracotomy with diaphragmotomy and echinococcectomy of the lung and liver were performed, 84 - lung echinococcectomy, then lapa-rotomy and echinococcectomy from the liver, 27 of them operated in one stage, the rest in two stages with an interval of 4-8 weeks. 40 patients with combined echinococcosis of the lung and abdominal organs after thoracotomy and lung echinococcec-tomy performed laparotomy and echinococcectomy from the omentum bag (22), abdominal cavity (6), large omentum (4) and splenectomy (8) in the second stage in 4-8 weeks.
In order to reduce the traumatism of the operation, to reduce the duration of the operation and the postoperative period, a two-way, one-stage sequential videotoracoscopy with echinococcectomy from both lungs was performed. Videothoracoscopy performed under general anesthesia with separate intubation of the bronchi, which allows you to turn off the ventilation of the lung on the side of the operation. The cyst is covered with napkins moistened with povidone-iodine. Through the thoracoport, a puncture tool with a tubular body is brought to the cyst and a hydatidic liquid is aspirated without removing the needle, 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 of the application of the clips or suturing.
Carrying out videotoracoscopic echinococ-cectomy of the lung allowed to reduce the time of anesthetic and operational aggression, allowed to reduce the duration of the patient's stay in the hospital to 5-7 days, which is 3-5 times less than the duration of the bed-days with other procedures used for lung echinococcosis.
In the postoperative period, 30 patients underwent Albendazol courses in order to prevent relapse of echinococcosis. The average age of the patients studied was 35 years (from 18 to 67 years). The number of men and women was approximately the same - 52% and 48%.
Recurrence of lung echinococcosis in these patients during three years of observation was not noted.
In the presence of a single echinococcal cyst less than 5 cm in diameter or with bilateral multiple echinococcal cysts of the lungs, we conservatively treat Albendazol. Currently, according to the planned scheme, 5 patients with echinococcal cysts are prescribed less than 5 cm in size. Observation for more than a year in 2 patients, in oth-
ers less than one year. Drug allergies to the use of Albendazol in our patients were not noted. There was a decrease in the antibody titer in the blood of unoperated pacintes against the background of Albendazol. According to radiation diagnosis, no noticeable changes were observed.
Among the operated patients who did not take Albendazol, two had liver echinococcosis 2 years after the operation on the lungs. This, apparently, is associated with the reinfusion of echinococcosis in these patients.
In one patient P., 27 years old, with bilateral multiple echinococcosis of the lungs, conservative treatment with Albendazol gave a positive effect. Two years after the start of treatment with Albendazol without surgery, all the echinococcal cysts were killed and cough-off. On the control computer tomogram there is only a single air residual cavity in the left lung (Figures 1, 2, 3).
Conclusion
The methods of simultaneous surgical treatment of bilateral lung echinococcosis with the use of transmediastinal access and videotorakoscopic techniques allow to reduce traumatism of operations, shorten the duration of treatment, and also
relieve patients of the weary expectation of the next stage of operations and repeated anesthesia.
Preliminary data indicate the absence of allergic reactions to Albendazole when applied according to the intended scheme. The absence of relapse of echinococcosis among operated patients taking Albendazol and a decrease in antibody titer in the blood in patients taking Albendazol without surgery, indicates a positive effect of this drug.
Thus, the results of surgical treatment of echi-nococcosis of the lungs depend on the course of the disease (complicated or uncomplicated), on the type of access and volume of surgical intervention for combined lesions and antiparasitic treatment.
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Figure 3.
Patient P., 27 years old. Two years after the course of treatment with Albendazol. In the left lung there is a residual air cavity from the dead echinococ-cal cyst. Screen with a computerized tomography of the chest.
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