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14PROBLEM OF RECURRENCE OF SINGLE-CHAMBER LIVER ECHINOCOCCOSIS AFTER SURGICAL TREATMENT AND WAYS TO SOLVE THEM (LITERATURE REVIEW)
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Saydullaev Z.Ya.1, Vohidov J.J.2, Kamariddinzoda M.K.3
1Saydullaev Zayniddin Yakhshiboevich - Assistant; 2Vohidov Jahongir Jamshedovich - Student;
3Kamariddinzoda Malikabonu Kamariddinovna - Student, DEPARTMENT OF SURGICAL DISEASES, SAMARKAND STATE MEDICAL INSTITUTE, SAMARKAND, REPUBLIC OF UZBEKISTAN
Abstract: the article presents the problem of recurrence of single-chamber liver echinococcosis in the immediate and distant periods after surgical treatment and ways to solve them. A brief literary review of foreign and domestic authors has been carried out. It is necessary to take into account that echinococcectomy, especially recurrent cysts, is a complex surgical intervention, therefore, the experience and qualifications of the surgeon are essential.
Keywords: liver echinococcosis, surgical treatment, echinococcectomy.
The main method of treatment of both primary and recurrent liver echinococcosis is surgical. Surgical intervention in various modifications is used in more than 90% of all patients with liver echinococcosis [2, 18]. At the same time, in practice medicine can follow the " Watch and Wait " approach (to observe and wait) for inactive small echinococcal cysts, since 18-20% of them can remain stable for a long time without any treatment [3, 7].
This approach is based on the observation that cysts with a single-chamber echinococcosis undergo an ambiguous path of development over months or years and which cannot yet be predicted. Expectant management tactics, for example, are recommended for asymptomatic cysts (according to WHO) [5, 17]. It also takes into account the fact that when liver cysts are less than 5 cm deep in the parenchyma, the traditional operative technique is associated with a greater risk of complications. The choice of indications, the nature and volume of the operation, the method of treating the cyst, the need for drainage, the method of eliminating the residual cavity remain the subject of discussion [4, 9, 15]. It should be noted that such a number of different types of surgeries were not proposed for any focal liver disease as with echinococcosis of the liver. Until the mid-90s, traditional surgical interventions were mainly used in the treatment of recurrent liver echinococcosis (REB):
• single-stage removal of an echinococcal cyst without opening the cyst lumen is an ideal echinococcectomy,
• echinococcectomy with the elimination of the cyst cavity by capiton method - closed echinococcectomy,
• echinococcectomy with caponagus or tamponade of the cyst cavity by the omentum and the remaining drainage in it - semi-closed echinococcectomy,
• single stage echinococcectomy with partial or total excision of the fibrous capsule -pericystectomy,
• liver resection together with echinococcal cysts.
Currently, they continue to use traditional echinococcectomies with laparotomy, and also use liver resections, laparoscopic echinococcectomies and percutaneous puncture and drainage methods [3, 16]. Traditional echinococcectomy (with laparotomy, with an opening of the cyst cavity, subsequent removal of the membranes and anti-parasitic treatment of the capsule) is the most common in the regions endemic for echinococcosis, available to a wide range of surgeons. But according to immediate and remote results, not everyone considers it effective against relapses [4, 19].
The opinion of many experts agrees that the main way to reduce the frequency of recurrence of echinococcal disease should be considered the implementation of a closed echinococcectomy, when the cyst is removed without puncture and opening [6, 14, 22]. An open echinococcectomy in primary liver echinococcosis (AED) is performed in exceptional cases when the liver cyst has central localization, or when the patient is in serious condition, in old age [17]. With a closed echinococcectomy, a relapse of the disease was noted in 3% of cases, and with an open echinococcectomy, 18% [6, 10, 18]. The frequency of postoperative complications after traditional operations is 6-80%, and the mortality rate is 3-8% [7, 15]. After the discovery of the migration of germinal elements into pericystic tissues, surgeons began to revise the surgical tactics for echinococcosis of the liver in favor of pericystectomy [8, 15, 21]. Although pericistectomy is rather complicated, all authors note a significant decrease in the number of postoperative complications. Pericistectomy is used in the marginal location of cysts and in the absence of their contact with large vascular secretory elements [10, 11]. In a number of clinics, the number of pericistectomy is 6-35% of all performed operations for liver echinococcosis [20].
It has been proven that traditional echinococcectomy is often accompanied by postoperative complications (including disease recurrences), and radical (total pericystectomy or liver resection) is more effective in preventing relapse, but is characterized by a large number of intraoperative complications [14, 16].
Liver resection performed without treating a cyst ("ideal" resection) is considered the most radical surgery, effective against relapses and various complications in the postoperative period [4, 18]. An analysis of 478 publications on the results of treatment of 1267 patients with liver echinococcosis [17] showed that after radical operations, relapses are significantly (p <0.0001) less frequent than after traditional surgery [14, 21]. Liver resection is not so long ago used for the surgical treatment of echinococcosis, and the indications for it are narrowed due to the high postoperative mortality. Currently, the mortality rate when performing extensive liver resections by diverting echinococcosis varies between 2.4% and 10% [4, 18]. There is a definite tendency towards resection in the surgical treatment of liver echinococcosis, both abroad and in Russia [15, 20]. What matters is that with anatomical liver resection there is no problem of the residual cavity, which is the cause of many complications in the immediate and late postoperative period. Recurrent liver cysts are mainly removed using resection interventions [13]. Liver resections are contraindicated in localizing cysts in the caval andglisson gate (rear sections VIII and IV segments) [11]. For intraparenchymal localization of echinococcus cysts, the most frequently used operations are closed echinococcectomy and omentoplasty [6]. At the same time, a number of authors believe that surgical intervention for liver echinococcosis should be based on organ-sparing principles [12, 17], including because the possibility of residual cysts and the need for reoperation cannot be ruled out. The use of cryosurgery for the treatment of focal liver lesions, including for echinococcosis, is promising [17]. It has been established that cryodestruction leads to the death of parasitic elements and prevents relapses [19].
Scientific advances in recent years have changed the requirements for the choice of treatment for patients with echinococcosis. The choice of access and type of operation is now more often carried out taking into account the location and size of cysts, the presence of complications [14, 19]. For echinococcosis of the liver is characterized by a variety of localization, size, and therefore there can be no universal online access. The most frequently used access is by right hypochondrium according to S. p. Fedorov [9, 11]. For example, with the localization of cysts in the VII-VIII segments, welded to the diaphragm and at large sizes, thoracic access was used less often, more often abdominal access in the right hypochondrium according to Fedorov. When localizing cysts in zone I, II, III segments, upper-median access is more often used [2, 12].
There is no complete clarity regarding the tactics of eliminating a residual cavity after echinococcectomy. Treatment and plugging of a cavity of a cyst were not rarely used before.
Marsupialization in various modifications was considered by some authors to be the least traumatic intervention. This approach is currently not widely used among surgeons, due to several disadvantages: the slow obliteration of the residual cavity; the probability of bleeding in the early and late postoperative period; the formation of biliary fistula; risk of recurrence; the likelihood of postoperative hernia [9, 13].
In the last decade, minimally invasive methods of surgical treatment of echinococcosis have become more widely used [11, 15]. The first percutaneous operations for liver echinococcosis in Russia were successfully carried out in 1986 in the city of Moscow A.N. Lotov and regardless of him A.V. Gavrilin. Despite the opinion that these interventions are simple to perform, they can produce serious intra - and postoperative complications (anaphylactic reactions) [11]. Therefore, these types of interventions are limited to strict selection criteria and are carried out in specialized departments [14]. The absolute contraindication is the localization of cysts in the VII and I segments, relative - the central location of the cyst, the size of more than 10 cm, the presence of daughter bubbles, thickened and calcined walls [15, 17].
Indications for laparoscopic echinococcectomy are: solitary, small and superficially located cysts of the liver [19]. Complicated and multiple cysts of the liver are also attributed to contraindications of laparoscopic echinococcectomy [20]. It is considered possible and appropriate to use minimally invasive surgical methods for the most severe group of elderly patients with echinococcosis, with complex anatomical localization [10, 14]. They are performed in two stages: with a preliminary percutaneous puncture and antiparasitic treatment of the cyst with subsequent laparoscopic echinococcectomy. A number of authors, having analyzed the experience of conducting minimally invasive operations at a number of leading Russian clinics, identified them as the method of choice in the treatment of patients with echinococcosis [10, 14]. However, despite the advantages of percutaneous interventions, they are still far from widespread use because of dangerous complications (for example, anaphylaxis) [15]. WHO recommends that radical treatment methods be used as the basis for the treatment strategy for liver echinococcosis. At the same time, a number of clinics include traditional radical methods (pericystectomy, resection) as appropriate, only when exogenous proliferation of cysts is detected and during massive calcification of the fibrous capsule [12, 19]. Studies show that the frequency of recurrence of the disease after percutaneous interventions and pericystectomy are almost the same [14]. But not everyone agrees that traditional laparotomy intervention in patients with liver echinococcosis is inferior in effectiveness to percutaneous methods and therefore often experienced surgeons prefer it [12, 18].
It is believed that the methods of percutaneous echinococcectomy in combination with chemotherapy with albendazole are safe and effective for the treatment of uncomplicated liver echinococcosis [14, 18]. For example, PAIR - puncture, aspiration, injection, reaspiration , developed by Ben Amoret al., is popular in a number of clinics for the treatment of solitary uncomplicated cysts [15]. But with PAIR, cysts of the type CE2 and CE3b often recur [19]. Percutaneous drainage is used even in the presence of daughter blisters [14]. The only contraindication to percutaneous echinococcectomy is the emergence of germ cells beyond the fibrous capsule (exogenous budding), since it is not possible to act on them as a germicide and this leads to a relapse of the disease [11]. As the literature reviews show, the recurrence rate for percutaneous echinococcectomy depends on the phase of development of the cyst [167]. Another problem of percutaneous echinococcectomy includes cystobiliary fistula, which can develop in 73-90% of patients with echinococcal cysts with a diameter of more than 7.5 cm [15]. The enthusiasm for laparoscopic technology observed in the early days of liver echinococcosis decreased abroad and in Russia. This is due to the lack of experience with such interventions, due to the rigorous selection of a contingent for such operations, as well as the more frequent development of relapses [19]. At the same time, it is believed that laparoscopic liver echinococcectomy, if indicated, is not
inferior to traditional laparotomic intervention by the immediate and distant results and gives a small number of relapses [7, 16].
The indications for the use of video endosurgery technology include uncomplicated echinococcal liver cysts in areas of good visibility, not deep in the liver parenchyma, of medium size, with no signs of suppuration and breakthrough [20]. Thus, on the basis of the analysis of the literature (reviews and published results of numerous studies) it was revealed that in the treatment of AED and REP [1, 19, 22]:
• for small (<5 cm) solitary cysts in phases CE1, C3a, C4 and C5 (according to WHO), the "Watch and Wait" approach is used and, as a rule, they respond well to chemotherapy (albendazole with praziquantel);
• medium and large uncomplicated cysts are treated mainly with a combination of percutaneous echinococcectomy with before and after operating chemotherapy;
• traditional surgical intervention is used for giant cysts (> 10 cm), complications and hard-to-reach locations;
• in case of multiple cysts, suspicion of seeding with germinal elements of an echinococcus, radical operations are used.
It is necessary to take into account that echinococcectomy, especially recurrent cysts, is a complex surgical intervention, therefore the experience and qualifications of the surgeon are essential.
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