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18UDC: 616-089.819
PALLIATIVE PERCUTANEOUS TRANSHEPATIC INTERVENTIONS IN COMPLICATED LIVER
ALVEOCOCCOSIS
Turar A. Yermekov, Shamil M. Chingyshpayev International higher school of medicine, Bishkek, Kyrgyzstan
Abstract
Introduction. The article presents the experience of transcutaneous transhepatic drainage of the decay cavity in complicated liver alveococcosis. This intervention was used in the complex of both palliative care and in the preparation of the patientfor radical surgical intervention. The results of the treatment of20 patients with complicated liver alveococcosis are reflected. The effectiveness of transcutaneous transhepatic interventions tofacilitate patients' condition and/orprepare themfor extensive surgical operations compared to open methods of drainage ofalveococcal caverns has been shown.
The aim of this article is to evaluate the effectiveness of transcutaneous transhepatic interventions on the biliary system and the decay cavity (caverns) of the liver alveococcosis as palliative therapy for complicated forms of the disease.
Materials and methods. The work was based on the results of the examination and treatment of 20 patients with complicated liver alveococcosis who were in hospital treatment in surgical clinics in Bishkek between 2010 and 2019. All patients have transhepatic drainage of the decay cavity in combination with external cholangiostomy.
The results. After drainage of the decay cavity and transhepatic drainage of the bile ducts in all patients, there was an improvement in the general condition with a decrease in purulent intoxication and symptoms of mechanicaljaundice.
Conclusions. Transcutaneous drainage of the decay cavity in complicated liver alveococcosis combinedwith percutaneous transhepatic endobiliary interventions is an effective palliative therapy and a choice concerning open surgical drainage methods.
Keywords: liver alveococcosis, decay cavity, transhepatic drainage, palliative therapy, liver resection.
ПАЛЛИАТИВДИК ТЕРИАРКЫЛУУ ТРАНСГЕПАТИКАЛЫК КИЙЛИГИШУУЛвР БООРДУН АЛЬВЕОКОККОЗУНУН OTYU1YTIKETKEH
ФОРМАСЫНДА
Турар А. Ермеков, Шамиль M. Чынгышпаев Эл аралык медицина жогорку мектеби, Бишкек, Кыргызстан
Кыскача мазмуну
Kupuuiyy■ Макалада боордун алъвеококкозунун отушуп кеткен формасында колдонулган нируу квцдойун тери аркылуу трансгепатикалык дренаждоо тажрыйбасы келтирилген. Бул медициналык кийлигишуу паллиативдик дарылоо комплексинде жана бейтапты радикалдык
Corresponding author: MD, PhD, Turar A. Yermekov, International higher school of medicine cell: +996 777 776326, email: [email protected]
хирургияга даярдоодо колдонулган. Изилдввнун жыйынтыгы катары боордун татаал алъвеококкозу менен ооруган 20 бейтапты дарылоонун натыйжалары чагылдырылды. Жана ошондой эле оорулуулардын абалын жецилдетууде жана/же аларды ири хирургиялык операцияларга даярдоодо алъвеококкалдык квцдвйлврду ачык дренаждоо ыкмаларына Караганда тери аркылуу трансгепатикалык кийлигишуулврдун жогору натыйжалуулугу кврсвтулгвн.
Бул макаланын максаты - оорунун татаалдашкан турлврундв паллиативдик терапия катары вт системасына жана боор алъвеококкозунун чируу квцдвйунв тери аркылуу трансгепатикалык кийлигишуулврдун натыйжалуулугун баалоо.
Колдонулган материалдар жана ыкмалар. Бул эмгек 2010-2019-жылдар аралыгында Бишкектеги хирургиялык клиникаларга боордун алъвеококкозунун втушуп кеткен формасы менен жаткырылган 20 бейтапты текшеруунун жана дарылоонун натыйжаларына негизделген. Бардык бейтаптарга тышкы холангиостомия менен айкалыштырып, чируу коцдвйун трансгепатикалык дренаждоо жасалды.
Алынган жыйынтыктар. Чируу квцдвйунун жана от жолдорунун трансгепатикалык дренажынан кийин, бардык бейтаптар аларда ириц интоксикациясынын жана обструктивдуу сарыктын белгилери твмвндвп, жалпы абалынын жакшыргандыгын кврсотушту.
Келтирилген тыянак. Боордун алъвеококкозунун втушуп кеткен формасында тери аркылуу трансгепатикалык эндобилиардык кийлигишуулвр менен айкалыштырылган чируу коцдвйун тери аркылуу трансгепатикалык дренаждоо ыкмасы ачык хирургиялык дренаж ыкмаларына Караганда жогору натыйжалуу паллиативдик терапия жана тандоо варианты болуп эсептелет.
Негизги свздвр: боордун алъвеококкозу, чируу квцдвйу, трансгепатикалык дренаж, паллиативдик терапия, боордунрезекциясы.
ПАЛЛИАТИВНЫЕ ЧРЕСКОЖНЫЕ ТРАНСПЕЧЕНОЧНЫЕ ВМЕШАТЕЛЬСТВА ПРИ ОСЛОЖНЕННОМ АЛЬВЕОКОККОЗЕ ПЕЧЕНИ
Турар А. Ермеков, Шамиль М. Чынгышпаев Международная высшая школа медицины, Бишкек, Кыргызстан
Аннотация
Введение. В статье представлен опыт чрескожного транспеченочного дренирования полости распада при осложненном алъвеококкозе печени. Данное вмешательство применялось в комплексе как паллиативного лечения, так и в подготовке больного к радикальному оперативному вмешательству. Отражены результаты лечения 20 больных с осложненным альвеококкозом печени. Показаны эффективность чрескожных транспеченочных вмешательств для облегчения состояния больных и/или подготовки их к обширным хирургическим операциям по сравнению с открытыми методами дренирования альвеококковых каверн.
Цель данной статьи - оценить эффективность чрескожных транспеченочных вмешательств на билиарной системе и полости распада (каверны) альвеококка печени в качестве паллиативной терапии при осложненных формах заболевания.
Материалы и методы. В основу работы легли результаты обследования и лечения 20 больных с осложненным альвеококкозом печени, находившихся на стационарном лечении в хирургических клиниках г. Бишкек за период с 2010 по 2019 годы. Всем больным произведено транспеченочное дренирование полости распада в сочетании с наружной холангиостомией.
Полученные результаты. После дренирования полости распада и транспеченочного дренирования желчных протоков у всех больных отмечалось улучшение общего состояния со снижением гнойной интоксикации и симптомов механической желтухи.
Выводы. Чрескожное транспеченочное дренирование полости распада при осложненном альвеококкозе печени в сочетании с чрескожными транспеченочными эндобилиарными вмешательствами является эффективной паллиативной терапией и вариантом выбора по отношению к открытым оперативным методам дренирования.
Ключевые слова: алъвеококкоз печени, полость распада, транспеченочное дренирование, паллиативная терапия, резекции печени.
Introduction
Surgical treatment of patients with liver alveococcosis continues to be an extremely urgent problem of modern surgical hepatology due to the prevalence of expanded and complicated forms of the disease [1,3]. The infiltration growth of alveococcal nodes with germination into the biliary system, collar and hepatic veins, lower hollow vein, diaphragm, as well as the presence of metastases, significantly limit the possibility of radical operations and often require liver transplantation of this category of patients [7,8]. With the development of surgical techniques to perform extensive liver resections, the use of transplantation technologies increased the possibilities for radical operations without liver transplantation [6,8]. At the same time, a significant number of patients in need of both palliative care and preparation for radical surgical treatment [2] remain. Also need to optimize the issues of preoperative diagnosis and application of mini-invasive therapies [4,5]. Our study's goal was to evaluate the efficiency of transcutaneous transhepatic interventions on the biliary system and the decay cavity (caverns) of the liver alveococcosis as a component of palliative therapy in complicated forms of the disease. Material and methods
The work was based on the results of the examination and treatment of 20 patients with complicated liver alveococcosis, who were in hospital treatment in surgical clinics in Bishkek between 2010 and 2019. Of these, women were 9 (45%), men 11 (557%). The patients ranged in age from 22 to 62.
When all patients received complaints of an increase in body temperature to 38-39.5C, chills, feelings of heaviness and pain in the right rib and epigastria, nausea, sub-icteric and icteric staining of the skin and sclera, dark color of urine, in 5 patients symptoms of portal hypertension with the presence of ascites. In blood tests there was leukocytosis with a shift to the left, hypo- and dysproteinemia, an increase in ESR to 55 mm/h, the level of total
bilirubin ranged from 55mmol/l to 650mmol/L, liver transaminases rates from 100 ED to 250ED, PTI from 40% to 70%. The duration of jaundice syndrome ranged from 1 month to 9 months. The couse of the intoxication-temperature reaction from 5 to 10 days.
An ultrasound tomography with dopplerography was for all patients performed as screening examination. At the same time, all patients have an expansion of intrahepatic bile ducts of varying degrees from 3 to 10mm with significant deformation and the presence of thick sludge. In 4 patients, there was bilobar liver damage, of which one patient has a massive cavity of decay in the left lobe of the liver with a diameter of about 15-16cm and a cavity of decay with a diameter of 10-11 cm in the 8th segment of the liver, with germination in the portal vein, hepatic veins, and inferior cava vein, with a pronounced ascites. In 3 patients, large decay cavities in 4, 7, and 8 segments of the liver with a 14-15cm diameter with germination in the hepatic veins and inferior cava vein. In 4 patients, decay cavities were found in the left lobe of the liver with a lesion of 1, 2-3, and 4 segments of the liver.
Twelve patients had a lesion of the right liver lobe with the localization of decay cavities in 5,6,7,8 segments of the liver.
In all patients on ultrasound examination noted liquid contents in the alveococcal cavern, then to the periphery calcified dense masses and phenomena of biliary cirrhosis of the liver. All patients are given percutaneous transhepatic drainage of the alveococcosis decay cavity under ultrasound control, followed by the introduction of X-ray contrast under the X-ray television. When draining, we used a modified method on Seldinger. For puncture, 19G 7-9cm length needles were used to drain the cavity with 8-12Fr diameter X-ray contrast catheters.
In the first stage, the patient is an ultrasound of the liver and the optimal point and trajectory of the puncture is determined. There should be no large
vessels and bile ducts in the needle's path, the distance to the cavern cavity should be minimal, if possible in the projection of the greatest diameter or at the bottom of the cavern for the best outflow of contents, the next is local anesthesia of all layers of the abdominal wall and liver capsules. After that, the puncture is made under ultrasound control of the needle with a conductor at the end. When the needle enters the liquid contents, the conductor is pushed inward to a slight stop and the needle is removed. It should be noted. The density up to the stony of the affected liver parts should be noted when carrying the needle in parenchyma.
In the second stage, directly drained on the
conductor is performed. In all cases, the channel was repeatedly booed by 5-8 Fr, after which a super-rigid conductor and a soft draining catheter with a diameter of 8-12Fr were carried out. According to the catheter, the release of the the ply-necrotic excretion is released, often with a mixture of bile in the amount of 100 to 500ml. After emptying, water-soluble X-ray contrast substance was injected into the cavity and the volume of lesion, the presence of fistulas, etc. was assessed.
The picture (Figure 1) shows a cavity of decay in the right lobe of the liver with the presence of a biliary fistula and germination of the diaphragm with the presence of a broncho-biliary fistula.
Figure 1 1-cavity decay, 2-bile fistula, 3-bronchial-biliary fistula
In the absence of bile separated from the cavity of decay and the presence of dilated intrahepatic bile ducts simultaneously carried out percutaneous endobiliary drainage under ultrasound control.
Figure 2 contrasts the decay cavities in the left and right lobes of the liver and the installed catheters in the bile duct and the alveococcosis destruction cavity:
Figure 2 la,b - alveococcosis destruction cavities, 2- catheter in the bile duct, 3 - catheter in the decay cavity
Subsequently, the cavity of a cavern and intrahepatic bile ducts were washed with antiseptic solutions, antibacterial therapy, hepatoprotective and detoxification therapy.
Results
After draining the decay cavity and ensuring the outflow of the ply-necrotic and bile in all patients already for the 2nd day, there was an improvement in the general condition, normalization of body temperature, decrease in the rates of leukocytosis and cholemic intoxication. At the same time, the reduction in hepatic transaminase rates was much slower than in isolated blocks of the biliary system due to the onset or already development of the phenomena of biliary cirrhosis of the liver. There was also a decrease in the amount of decay separated from the cavity and its purification by 3-4 days. The bile debit from cholangiostoma decreased from 700-800ml to 300-400 ml per day. The level of total bilirubin also reduced to 35-50 micromole/1 by 10-14 days. There were no complications associated with the manipulations. Conclusions
Conducting percutaneous transhepatic drainage of the alveococcal cavity in patients with severe clinical symptoms of the decay cavity's suppuration is a minimally invasive effective method reducing ply intoxication in patients with complicated alveococcosis of the liver.
The use of transcutaneous drainage of the decay cavity in complicated liver alveococcosis combined with percutaneous transhepatic endobiliary interventions is a complex palliative therapy and a choice in relation to open surgical drainage methods.
Transcutaneous transhepatic minimally invasive interventions under local anesthesia in patients with severe liver dysfunctions are the safest than surgical interventions under general anesthesia. Percutaneous transhepatic minimally invasive interventions can improve the quality of life and prolong the lives of patients and prepare them for extensive liver resections and/or liver transplantation.
Conflict of interest: The material and methods outlined in the article are original and do not cause conflicts of interest on anyone's side.
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