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III. SURGERY
MINI-ACCESS AT COLLAPSOSURGICAL TREATMENT OF PATIENTS WITH FIBROTIC CAVERNOUS PULMONARY TUBERCULOSIS WITH BROAD DRUG RESISTANCE
Erimbetov K.D., Adenov М.М., Bektursinov B.U., Aubakirova Е.А., Ibraev ZhAJurgumbaev BA, Imakhaev А.К., Abdullina А.G., Arynbaeva A.B., Kanlybaeva L.N.
National Scientific Center of Phthisiopulmonology, Almaty, Kazakhstan
Abstract
Analyzed the results of the collapse-surgical method of treatment using a mini-access in 10 patients with fibrous-cavernous tuberculosis with extensive drug resistance. The effectiveness of surgical treatment in the main group was achieved in 9 (90.0%) patients versus 19 (63.3%) patients in the control group. Performed accesses did not affect the effectiveness of surgical treatment. There is a difference in cosmetic effect: advantage in length of access from 6 to 8 cm versus large incision bordering the scapula.
Дэр^е тeзiмдi фиброзды-кавернозды екпе Ty6ep^e3i бар наукастарлы коллапсохирургиялык емдеудщ шагын жолы
Еримбетов К.Д., Аденов М.М., Бектурсинов Б.У., Аубакиров Е.А., Ибраев Ж.А., Тургумбаев Б.А., Имахаев А.К., Абдуллина А.Г., Арынбаева А.Б., Канлыбаева Л.Н.
Улттык, фтизиопульмонология ?ылыми орталь™, Алматы, Казахстан
МРНТИ 76.29.35
Erimbetov K.D. -
orcid.org/0000-0002-9264-510X
Adenov М.М. -
orcid.org/0000-0002-0994-2569
Bektursinov B.U. -
orcid.org/0000-0003-1251-4466
Aubakirova Е.А. -
orcid.org/0000-0001-5537-151X
Ibraev Zh.A. -
orcid.org/0000-0002-1895-0608
Turgumbaev B.A. -
orcid.org/0000-0001-7123-4232
Imakhaev А.К. -
orcid.org/0000-0002-8265-001X
Abdullina A.G. -
orcid.org/0000-0003-1169-6640
Arynbaeva A.B. -
orcid.org/0000-0002-0213-4091
Kanlybaeva L.N. -
orcid.org/0000-0001-6342-5055
Keywords
extensively drug-resistant tuberculosis, thoracomyoplasty, silicone implant, valve bronchoblockation
Ацдатпа
Дэрiге твзiмдi фиброзды-кавернозды екпе туберкулез'1 бар 10 наукастыц мини колжетiмдiлiп бойынша коллапсохирургияльщ емдеу эдюшщ нэтижелерi талданды. Бакылау тобындагы 19 (63,3%) наукаска карсы непзп rnnTafbi 9 (90,0%) наукасхирургиялык емдеудiц тиiмдiлiгiне колжеткiздi. Орындалган колже^мдш^ер хирургиялык емдеудiц тиiмдiлiпне эсер еткен жок. Косметикалык эсерлер бойынша айырмашылыктар бар: кесiндiнiц улкен жиет калакшасына карсы 6-8 см аралыгындагы колжетiмдiлiктiц узындыгы бойынша басымдык.
Туйш сездер
улкен липома, жуйке компрессиясы, ауырсыну синдромы
Мини доступ при колллапсохирургическом лечении больных с фиброзно-кавернозным туберкулезом легких с широкой лекарственной устойчивостью
Еримбетов К.Д., Аденов М.М., Бектурсинов Б.У., Аубакиров Е.А., Ибраев Ж.А., Тургумбаев Б.А., Имахаев А.К., Абдуллина А.Г., Арынбаева А.Б., Канлыбаева Л.Н.
Национальный Научный Центр фтизиопульмонологии, Алматы, Казахстан
Аннотация
Анализированы результаты коллапсохирургического способа лечения из мини доступа у 10 больных с фиброз-но-кавернозным туберкулёзом с широкой лекарственной устойчивостью. Эффективность хирургического лечения в основной группе достигнута у 9(90,0%) больных против 19(63,3%) больных контрольной группы. Выполненные доступы не повлияли на эффективность хирургического лечения. Имеется различие в косметическом эффекте: преимущество по длине доступа от 6 до 8 см против большого окаймляющего лопатку разреза.
Ключевые слова
Туберкулёз с широкой лекарственной устойчивостью, торакомиопластика, силиконовый имплант, клапанная бронхоблокация
Table 1.
Age structure of operated patients in the main and control groups
Table 2.
Disease duration in patients of the main and control groups
Introduction Treatment of extensively drug-resistant fibrotic cavernous tuberculosis (XDR-FCT) is one of the complex problems of modern Phthisi-ology, associated with the severity of irreversible morphological changes in the lung tissue. The presence of mycobacteria with resistance to most of the available antituberculous drugs (anti-TB) significantly reduces the effectiveness of chemotherapy treatment. Thus, according to various authors, the effectiveness of various chemotherapy regimens with the I,II line drugs and new modern repurposed drugs is achieved 30-68% of cases[1,2,3]
The limited effects of chemotherapy for the treatment of this patients, there are hopes for surgical treatment. However, due to the large patho-morphological changes, the prevalence of the tuberculosis process, the presence of concomitant pathology in most patients and the severity of functional disorders of the respiratory system, it is not always possible to perform radical resection. Some authors reported, that only 10% of patients can have surgery, but patients with extensively drug-resistant tuberculosis (XDR-TB) show postoperative complications [4,5,6,7,8].
According To A. El'kina, Yu. M. Repin et al. it is noted that 42% of those operated patients with XDR-TB had postoperative complications, and the mortality rate was 25% of cases [9]. The high percentage of postoperative complications and high mortality rate are also confirmed by our research [10].
An alternative for this category of patients is collapsosurgical interventions [11,12,13,14]. Available various modifications of thoracoplasty have the disadvantage, such as cosmetic defect of the chest, poor posture, scapula indentation on the side of the operation, a large postoperative scar in the projection of the scapula, etc., which often leads to refusing of young patients from this type of surgery. With this in mind, at surgical treatment of pulmonary tuberculosis and multiple-drug resistant tuberculosis department of National Scientific Center of Phthisiopulmonology(NSCP), we developed a technique of thoracoplasty using a silicone implant in combination with a mini-access broncho-
blocation, which allows performing the operation by an 6-8 cm incision and eliminates the above disadvantages of thoracoplasty (patent of the Republic of Kazakhstan for invention No. 34636-2019/0141.1 from 16.10.2020y.)
Aim of the study
Determine the effectiveness of thoracoplasty using a silicone implant in combination with XDR-FCT.
Materials and methods
There were analyzed results of thoracoplasty method using a silicone implant in combination with bronchoblockation from mini-access in 10 patients with XDR-FCT.
The control group consisted of 30 patients who underwent a similar method of thoracoplasty from a standard incision, bordering the scapula.
In the analyzed main group, there were 8(80%) males and 2 (20%) females. The control group consisted of 19 female patients (63.3%) and 11 male patients(36.7%).
The age of the analyzed groups was shown in Table 1.
The table revealed that both groups were operated on mainly by young people under 40 years of age.
All patients in the main and control groups were diagnosed with extensively and multiple drug-resistant fibrotic cavernous tuberculosis.
In the main group, the right upper-lobe localization of the pathological process was in 5 (50%) patients and was similarly located on the left.
In the control group, the localization of the tuberculosis process in the left upper-lobe was in 13(43.3%) and right-sided in 17(56.7%) patients.
In both groups, the duration of pulmonary tuberculosis disease lasted from 2 to more years (Table 2).
Fibrobronchoscopy was performed in all patients of the analyzed groups before surgery with a biopsy from the bronchial mucosa. In the main group, 3(30%) had infiltrative - ulcerative tuberculous endobronchitis, 3(30%) had cicatricial stenosis
Group Age Total
20-29 30-39 40-49 50 and more
Abs % Abs % Abs % Abs % Abs %
Main 4 40 1 10 3 30 2 20 10 100
Control 10 33,4 14 46,6 4 13,3 2 6,7 30 100
Group Dise ase dur from 5 ation (ye ¡ars) Abs tal
Main 2 20 4 40 4 40 10 100
Control 12 40 15 50 3 10 30 100
of various degrees, and 4(40%) had endobronchitis without signs of active inflammation on the side of the lesion by the pathological process.
In the control group, 11 (36.7%) patients had active tuberculous endobronchitis, 7 (27.3%) had stenosis of various degrees, and 12 (40.0%) had endobronchitis without signs of active inflammation.
Based on bacteriological and molecular genetic studies of sputum in the main group, 4 (40%) patients were found to have multiple drug resistance and 6 (60.0%) had broad drug resistance. In the control group, multiple drug resistance was detected in 3(10.0%) and in 27(90.0%) broad drug resistance. All patients had a failure from previous courses of chemotherapy.
All patients in the analyzed groups were prescribed different chemotherapy regimens in accordance with the drug resistance test.
In the main group, 5 (50%) patients received second-line (reserve) drugs, and 5 (50%) patients received a treatment regimen of new reprofiled anti-TB drugs.
In the control group, the treatment regimen consisted of reserve line drugs.
The chemotherapy regimens from the reserveline anti-TB drugs contained aminoglycosides (Am/ Km/Cm), fluoroquinolones(Ofx/Mfx), cycloserine (Cs), thiamides(Eto/Pto), PASC(Pas), and the treatment regimens from new anti-TB and repurposed drugs included bedaquillin(Bdg), delamanide(Dlm), linezolid(Lzd), clofazamine (CFZ)
The main indication for surgical treatment in the analyzed groups was the presence of pronounced destructive changes in the lungs and the lack of effect from chemotherapy.
All patients of the main and control groups underwent collapsosurgical interventions using a silicone breast implant as a filling material with pre-valvular bronchoblockation of the draining bronchus of the affected lung sections.
The difference in the method of operations in the main group was access to the extrapleural region. It was carried out from a mini incision up to 6-8cm long, against the incision bordering the scapula in the control group. In the future, the course of the operation was similar in both groups.
In both groups, surgical interventions were performed during up to 12 months of the intensive treatment phase.
For effective collapse of the lung, up to 4-5 ribs were fragmentally resected and a bed was created in the extrapleural area for the silicone implant, which was selected by diameter and height (Table 3).
In the postoperative period, monthly x-ray monitoring of the collapsed lung area after thoracoplasty was performed using this method, sputum sampling for the presence of mycobacterium tuberculosis (M.tb) and dynamic monitoring of the state of bronchoblockers.
Evaluation of the effect of mini access with this method of collapsosurgical intervention on the achievement of selective collapse of the affected area of the lung and at the same time on the effectiveness of treatment was determined by the following criteria:
• Based on the results of sputum tests for M.tb by microscopy, bacteriological seeding on Lowenstein-Jensen medium, BACTEC
• On the closure of the decay cavity (cavern) during x-ray tomography studies
Results, discussion
As a result of surgical interventions performed against the background of adequate chemotherapy in patients of the analyzed groups and dynamic follow-up, the following disease outcomes were obtained (Table 4).
As can be seen from Table 4, the outcomes of complex treatment of patients determined after bacteriological sputum tests after treatment were obtained in all 30 patients of the control group and
Group Extrapleural thoracoplasty Total
Four ribs Five ribs Six ribs
Main 4(40%) 6(60,0%) - 10
Control 20(66,7%) 7(23,3%) 3(10,0%) 30
Table 3.
Types of thoracoplasty in the main and control groups
Groups
№ outcomes Main (n-10) Control (n-30)
1 Cured 7(70,0) 19(63,3)
2 Treatment completed 2(20,0%) -
3 Treatment failure - 8(26,7%)
4 Died - 3(10,0%)
5 Continue treatment 1(10,0%)
6 Treatment success 9(90,0%) 19(63,3%)
Table 4.
Treatment outcomes of patients in the main and control groups
Table 5.
Control X-Ray tomography studies in the main and control groups
№ Groups Reduction in cavern cavity Complete closure of the cavern Total
1 Main 2(20,0) 7(70,0%) 9
2 Control 8(26,7%) 22(73,3%) 30
in 9 of the main group. However, a positive outcome (treatment success) of surgical treatment with chemotherapy in patients of the main group was achieved in 9(90%) patients. One patient in this group has not yet completed a full course of chemotherapy. In the control group, treatment success was achieved in 19 (63.3%) patients.
After completion of treatment and observation of patients, control x-ray examinations were performed(Table 5).
As shown in Table 5, surgical interventions with different access sizes in the main and control groups achieved almost the same degree of effective collapse of the affected lung area. Cavern closure in the main group in 70.0%, in the control group in 73.3% of patients. Incomplete collapse occurred in 2 (20.0%) patients of the main group and in 8 (26.7%) patients of the control group.
Analysis of treatment failures and the "Died" outcome in 11(36.7%) patients in the control group showed that their causes were incomplete cavern closure and active tuberculosis process in the bronchi at the time of surgery, which progressed in the postoperative period and led to the continuation of bacterial excretion in 8(26.7%) patients and the development of respiratory failure in 3(10.0%)patients with a lethal outcome.
During dynamic monitoring of the state of valvular bronchial blockers in 3(10.0%) patients, the
latter were removed after 1 month due to the progression of the active tuberculosis process in the bronchi. In the main group of indications for removal of bronchopleural not revealed.
The effectiveness of surgical treatment in the main group was achieved in 9 (90.0%) patients versus 19 (63.3%) patients in the control group. On high efficiency treatment in the main group, in our opinion, was the use of new reprofiled drugs as becquelin, linezolid, Dalmane in 5(50%) patients.
Thus, the analysis of collapse surgery results in patients with drug-resistant pulmonary tuberculosis showed that the performed approaches in both methods did not affect the effectiveness of surgical treatment. There is a difference only in the cosmetic effect: the advantage in the length of access from 6 to 8 cm against a large incision bordering the shoulder blade (Fig. 1).
Conclusion
1. Application collapsosurgical intervention in patients with drug-resistant pulmonary tuberculosis with the use of silicone implant in combination with valve bronchoblockation from mini incision access is a promising way to eliminate cosmetic defect of the chest wall.
2. Effectiveness collapsosurgical intervention increases on the background of chemotherapy regimens using new reprofiled anti-TB drugs.
Figure 1.
Type of postoperative scar: A-control group; B-main group (mini incision access)
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