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PURULENT-SEPTIC AND SPECIFIC COMPLICATIONS IN SURGICAL TREATMENT OF ESOPHAGUS THORACIC PART TUMOR
Nazirov Feruz Gafurovich, doctor of Medicine, academician of AC of Uzbekistan, director of the Republican Specialized Scientific-Practical Centre of Surgery named after Academician V. Vakhidov Gulamov Olimjon Mirzakhidovich, Ph D., the chief of esophagus and stomach surgery department at the Republican Specialized Scientific-Practical Centre of Surgery named after Academician V. Vakhidov Muzaffarov Farukh Umarovich, Ph D., a hospital doctor at the Republican Specialized Scientific-Practical Centre of Surgery named after Academician V. Vakhidov
Akhmedov Akrom Rustamovich, a hospital doctor at the Republican Specialized Scientific-Practical Centre of Surgery named after Academician V. Vakhidov
Tashkent, Uzbekistan E-mail: dofr.med@mail.ru
PURULENT-SEPTIC AND SPECIFIC COMPLICATIONS IN SURGICAL TREATMENT OF ESOPHAGUS THORACIC PART TUMOR
Abstract: The article is devoted to the topical problem - purulent-septic and specific complications which occur at the expanded operations on the esophagus with locally distributed and some disseminated forms of esophageal cancer; to discussing of modern treatment tactics of this formidable complications form; to the assessing of the possibilities for using new technologies and antibiotic therapy.
Keywords: esophageal cancer, specific complication, purulent-septic complication.
Introduction
About 5.2 millions of death cases due to malignant tumors are registered all over the world annually and esophageal cancer is the reason for 900 thousands of them. Esophageal cancer is distinguished by a high mortality. And about 70% of patients die during 1 year after the diagnosing. These sad digits are firstly connected with the fact that in 70-805 of cases esophageal cancer is already revealed at the late development stages when it is difficult to hope for successful treatment outcome and long life. The highest rate of esophageal cancer morbidity is in China, Iran and in the Central Asia countries - about 100 people to 100 thousands of population annually get ill in Uzbekistan [1-2; 4].
450000 patients are annually performed surgeries due to the cancer with a lethality in 30-70%. At an average up to 125 radical surgeries for treating esophageal cancer are performed at the leading hospitals of Uzbekistan a year, 450-550 patients are undergone chemotherapy and radiation therapy. A general mortality makes up from 13 to 36% during the first years after esophageal cancer diagnosing. A high post-operative lethality is conditioned by different complications.
A general quantity of post-operative complications by different authors data significantly varies from 55% to 70%
[3, 7-8]. The most frequent postoperative complications are pneumonia, atelectasis, purulent pleuritis, empyema and their frequency makes up 19-50% [1; 4; 6]. The appearance of bronchopulmonary complications is conditioned by the severity of performed surgeries, their duration, denervation at lymphodissection, due to a high stem vagotomy and bronchial tubes drain function abnormality [4; 6; 8]. The other infectious complications can be as follows: postoperative wound infection of chest, abdominal wall or neck; subphrenic space abscess; septic conditions in 2-17% of cases [1; 5]. From our point of view and by other authors' investigation results the causes of infection and purulent-septic complications are anastomosis sutures inefficiency and transplant necrosis.
Aim
To analyze the causes of infectious complications development in patients with the cancer of thoracic esophagus in early postoperative period; to develop the methods for their prevention and treatment.
Material and methods
216 patients with the cancer of thoracic esophagus were performed surgeries at the Esophagus and Stomach Surgery Department of our centre from 1994 to 2018. There were 101
Section 7. Medicine
(46.76%) females and 115 (53.24%) males. 139 (64.35%) among them were at capable and 75 (34.3%) - at mature age.
The basic parts of the performed surgeries were: extirpation or multilayer resection of esophagus; lymphodissection; formation of esophageal transplant from greater curvature of stomach, forming of esphagogastroanastomosis. At the end of the surgery the draining of the chest, mediastinum, abdominal cavity and neck wound have been performed. All operations were one-phase during 5-6 hours.
Results
Anastomosis between esophagus stump and transplant were formed at the neck level in 216(100%) cases, the approaches were defined subject to the tumor localization. In 159(73.6%) patients abdominocervical approach has been used and in 49(26.4%) - thoraco-abdominocervical one. A surgical injury can also cause the development of purulent complications subject to the type of approach.
In all 216(100%) patients a predisposing factor to the development of purulent complication was alimentary cachexia associated with dysphagia. According to the dysphagia rate by Chernayvskiy A. A. (1991), the patients were randomized as follows: rate I (dysphagia only to hard food) - 50(23.1%), rate II (dysphagia to hard and solid food) - 140(64.8%), rate III (dysphagia to hard, solid and fluid food) - 21(9.7%) and rate IV (full esophageal obstruction) was 5(2.3%) patients. As we mentioned above, one of the reason for purulent complications development is anastomosis sutures inefficiency (in 43(19.9%) cases) and it has a direct relation with a method of anastomosis formation, but in this study we will not discuss these moments.
According to the surgical treatment results there were different purulent-septic complications in the wound area in 37(17.1%) patients and in broncho-pulmonary system - 39 (18%) cases.
In all cases of bronchopulmonary complications in 76(35.2%) patients we studied a bacterial origin and sensi-
tivity to antibacterial agents. Pathologic samples from wound area, anastomosis, drain, bronchus lumen were taken with adherence of safety. The results analysis has shown that the following pathogenic micro-organisms were revealed: Pseu-damonas aerogenosus (29%), Stafillococcus aureus (37%).
Sensitivity to antibacterial agents was as follows: Aminoglycosides (Amikacin) - highly sensitive; Cephalosporines, gentamycin - medium sensitive; the other drugs including fluoroquinolones - stable. Amikacin being highly sensitive was used in combination with metronidazole (1gr 2 times a day, 7 days). During antribacterial therapy we carried out microbiological control and study the immune status of organism. C-reactive protein varied in the range of90-100mg/l at the beginning of inflammatory process. The patients usually recovered after 7-10 days. Antiseptic drugs were used for wounds d-bridement. There were also performed the following procedures at the treatment of bronchopulmonary complications: a bronchoscopic sanation, drugs inhalation by the way of insufflations, respiratory gymnastics, percussion and others.
Conclusions
1. Surgical treatment of esophageal cancer is very labour-intensive process. Esophageal anastomosis sutures inefficiency (19.9%), purulent inflammations of lungs and pleural cavities (17.1%) and surgical wounds suppurations (18%) negatively influenced on treatment results.
2. A rational use of highly sensitive antibacterial agents in combination with other essential drugs in early postoperative period made possible to prevent purulent complications development in 140(64.8%) patients. In 68(31.5%) cases with bronchopulmonary and specific complications antibacterial therapy was effective in 90% of cases. The cause of the lethal outcomes in 10.5% of patients were purulent-septic complications.
3. Nowadays at purulent-septic complications the method of antibacterial agent choice are Aminoglycosides.
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