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37
II. ХИРУРГИЯ
THE RESULTS OF SURGICAL AND MEDICINAL METHODS OF TREATMENT OF LIVER ECHINOCOCCOSIS
Kaniyev Sh.A.12, Baimakhanov Zh.B.1, Doskhanov M.O.1, Nurlanbayev E.K.1, Serikuly E.1, Skakbayev A.S.1, Birzhanbekov N.N.1, Baiguisova D.Z.1, Barlybai R.A.1, Sadykov C.T.1, Chormanov A.T.1, Medeubekov U.Sh.1, Kausova G.K.2, Medeubekov U.Sh.1, Seisembayev M.A.1, Baimakhanov B.B.1
1JSC "Syzganov's National Scientific Centre of Surgery", Almaty, Republic of Kazakhstan, Kazakhstan's Medical University "Kazakhstan School of Public Health", Almaty, Republic of Kazakhstan.
Abstract
The article presents epidemiology, diagnosis and treatment of the cystic liver echinococcosis. The methods of treatment of the liver echinococcosis performed in our clinic in the framework of the scientific and technical project, planned for 2017-2019, on the topic of "Development of scientifically validated optimal surgical and medicamentous methods of treatment of the liver echinococcosis". Comparative analyzes of the results of medical, surgical and combined methods of treatment of the liver echinococcosis are presented.
МРНТИ 76.29.34
ABOUT THE AUTHORS
Kaniyev Shokan Ahmedbekovich-
Surgeon-Department of Hepatopancreatobi-liary Surgery and liver Transplantation, JSC NSCS named after A.N. Syzganov. BaimakhanovZhasulan Bolatbekovich
- Cand. of Med Sci., Chief Scientific Officer Division of HPB and LT JSC NSCS named after A.N. Syzganov.
Baiguisova Dinara Zulkhanaevna
- Doctor of Radiation Diagnostics, Head of the Department of Radiation Methods of Research JSC NSCS named after A.N. Syzganov. Kausova Galina Kalyevna
- Doct. of Med. Sci., Professor, Kazakhstan's Medical University " Kazakhstan School of Public Health "
Medeubekov Ulugbek Shalkarovich
- Deputy Chairman of the Board of JSC NSCS named after A.N. Syzganov, dr.med., professor. E-mail: medeubek@mail.ru Seisembayev Manas Ahmedjarovich
- Doct.of Med. Sci., Professor, JSC NSCS named after A.N. Syzganov. Baimakhanov Bolatbek Bimendievich-Doct. of Med. Sci., Professor, Chairman
of the Board JSC NSCS named after A.N. Syzganov.
Keywords
echinococcosis, liver, pericystectomy, albendazole
Бауыр эхинококкозын хирургиялык жэне дэр1-дэрмекпен емдеу тэсшдершщ нэтижелер1
Каниев Ш.А.12,Баймаханов Ж.Б.1, Досханов М.О.1, Нурланбаев Е.К.1, Серикулы Е.1, Б1ржанбеков Н.Н.1, С^а^баев А.С.1, Байгуисова Д.З.1, Барлыбай Р.А.1, Садыков Ч.Т.1, Чорманов А.Т.1, Каусова Г.К.12, Медеубеков У.Ш.1, Сейсембаев М.А.1, Баймаханов Б.Б.1
1«А.Н. Cbi3faHOB атында™ Улттык, ^шыми хирургия орталь™» АК
2«^амдык Денсаулык сактау œofapû мектебь» Казакстандык медицина университет!
Ацдатпа
Б±л макалада авторлар бауырдыц цистт\ эхинококкозыныц эпидемиологиясын, диагностикасын жэне емдеу тэс\л\н ±сынган. «Бауыр эхинококкозын емдеуд\ц гылыми непзделген оцтайлы хирургиялык жэне медикамен-тозды эдicтерiн эз\рлеу» такырыбына 2017-2019 жылдарга арналып, есептелген гылыми-техникалык жобаны \ске асыру шецбер\нде б\зд\ц клиникамызда бауыр эхинококкозын емдеу эд\стер\ сипатталган. Бауыр эхинококкозын емдеуд\ц медикаментозды, хирургиялык пен к±рамдастырылган эд\стер\ нэтижелер\н\ц салыстырма талдауы келт\р\лген.
АВТОРЛАР ТУРАЛЫ
Каниев Шоцан Ахмедбекулы - А.Н. Сызганов атындагы ¥лттык гылыми хирургия орталыгыныц дэр!'гер хирургы Баймаханов Жасулан Болатбекулыы
- м.г.к, А.Н. Сызганов атындагы Улттык гылыми хирургия орталыгыныц Бас гылыми кызметкер\
Байгуисова Динара Зулхарнаевна
- А.Н. Сызганов атындагы Улттык гылыми хирургия орталыгыныц сэулел\ тэсшдермен зерттеу бел\м\нщ мецгерушю, сэулел\ зерттеу дэргер\ Каусова Галина Калиевна - м.г.д., «Когамдык Денсаулык сактау жогары мектебЬ казакстандык медицина университетмц %огамдык денсаулык жэне элеуметтк гылым кафедрасыныц профессоры.
Медеубеков ¥лыцбек Шалцарулыы
- А.Н. Сызганов атындагы Улттык гылыми хирургия орталыгыныц баскарма Терагасыныц гылыми-клиникалык кызеттер женшдеп орынбасары, м.г.д., профессор. medeubek@mail.ru Сейсембаев Манас Ахмеджарулы -м.г.д, профессор, А.Н. Сызганов атындагы Улттык гылыми хирургия орталыгыныц Бас гылыми кызметкер\
Баймаханов Болатбек Бимендее-вич - д.м.н, профессор, А.Н. Сызганов атындагы Улттык гылыми хирургия орталыгыныц Баскарма терагасы
Туйш сездер
эхинококкоз, бауыр, перицистэктомия, альбендазол.
ОБ АВТОРАХ
Каниев Шокан Ахмедбекович - врач хирург Национального научного центра хирургии им. А.Н. Сызганова. Баймаханов Жасулан Болатбекович
- к.м.н, главный научный сотрудник Национального научного центра хирургии им. А.Н. Сызганова. Байгуисова Динара Зулхарнаевна -врач лучевой диагностики, заведующая отделом лучевых методов исследования Национального научного центра хирургии им. А.Н. Сызганова. Каусова Галина Калиевна - д.м.н, профессор кафедры Общественное здоровье и социальные науки, Казахстанского медицинского университета«Высшая Школа Общественного Здравоохранения». Медеубеков Улугбек Шалхарович -заместитель Председателя правления по научно-клинической деятельности АО ННЦХим. А.Н. Сызганова, д.м.н., профессор, e-mail: medeubek@mail.ru Сейсембаев Манас Ахмеджарович - д.м.н, профессор, главный научный сотрудник Национального научного центра хирургии им. А.Н. Сызганова.
Баймаханов Болатбек Бимендеевич - д.м.н, профессор, Председатель правления Национального научного центра хирургии им. А.Н. Сызганова.
Ключевые слова
эхинококкоз, печень, перицистэктомия, альбендазол.
Результаты хирургических и медикаментозных методов
лечения эхинококкоза печени
Каниев Ш.А.1,2, Баймаханов Ж.Б.1, Досханов М.О.1, Нурланбаев Е.К.1, Серикулы Е.1, Биржанбеков Н.Н.1, Скакбаев А.С.1, Байгуисова Д.З.1, Барлыбай Р.А.1, Садыков Ч.Т.1, Чорманов А.Т.1, Каусова Г.К.12, Медеубеков У.Ш.1, Сейсембаев М.А.1, Баймаханов Б.Б.1
1А0 «Национальный научный центр хирургии им. А.Н. Сызганова»
казахстанский медицинский университет «Высшая Школа Общественного Здравоохранения»
Аннотация
В статье представлены эпидемиология, диагностика и лечение цистного эхинококкоза печени. Освещены методы лечения эхинококкоза печени, выполняемые в нашей клинике в рамках реализации научно- технического проекта рассчитанного на 2017-2019г., на тему «Разработка научно-обоснованных оптимальных хирургических и медикаментозных методов лечения эхинококкоза печени». Приведены сравнительные анализы результатов медикаментозного, хирургического и комбинированного метода лечения эхинококкоза печени.
Introduction
One of the actual problems in the abdominal surgery of Kazakhstan is the cystic liver echinococcosis caused by the ribbon helminth Echinococcus granulosus. According to the Committee of Consumer right Protection of the Republic of Kazakhstan, the incidence of echinococcosis among the rural population is growing in dynamics. The cause of the increase in the incidence of human echinococcosis is associated with non-compliance of the population with rules for keeping pets, inadequate control of the number of neglected animals, de-worming of service and domestic dogs. Nowadays, echinococcosis in Kazakhstan has become ubiquitous, whereas in the early 90's it was registered mainly in the southern region. Over the past almost 20 years, the incidence rate has increased 4.5 times (1993 - 1.3 per 100 thousand population, 2010 - 5.8). Given the relatively young age of patients, the high incidence of disability in repeated operations, the problem of surgical treatment of liver echinococcosis in endemic regions of Kazakhstan becomes more important every year. Despite the successes in the surgical treatment of the above-mentioned disease, the question of the optimal amount of surgical intervention remains open. According to the European protocols, with uncomplicated and giant forms of echinococcosis of the liver and lungs, antiparasitic therapy with albendazole at a dosage of 800 mg (10-15 mg / kg body weight)
per day with subsequent follow-up is preferred. The introduction of this method of treatment, namely, conservative therapy without surgical intervention, is presents a great practical interest, because it reduces the risk of complications, deaths, relapses of the disease and reduces the costs of treatment of echinococcosis.
The aim of the study. To compare the results of the use of surgical and combined methods of treatment of liver echinococcosis, and identify the most optimal method of treatment of LE with the aim of reducing the recurrence of the disease.
Materials and methods
In the NSCS named after A.N. Syzganov from January 2017 to July 2018, 61 patients with a diagnosis of primary liver echinococcosis who were divided into 4 groups were treated in the framework of the scientific project «Development of scientifically-based optimal surgical and medicamentous methods for the treatment of liver echinococcosis» .
1 st group: pericycystectomy (with capsule removal) with the appointment of an antiparasitic drug -21-patient;
2 nd group: pericystectomy without antiparasitic therapy-13 patients;
3rd group: operation of echinococcectomy with the abandonment of the capsule and the appointment of an antiparasitic drug, 12 patients;
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ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 3-2018
4 th group: conservative therapy without surgical intervention (the patient receives only antiparasitic drug «Albendazole») - 18 patients.
The average age was 38 years (21-68). In the sex ratio, female patients predominated among the patients-57% (26 cases). The proportion of men was 43% (20 cases). All patients underwent instrumental laboratory diagnostics in the preoperative period in order to verify the diagnosis. It is worth noting that laboratory methods of research in echi-nococcosis are not specific and allow us to obtain only auxiliary information to clarify the diagnosis. In this case, all patients in the preoperative period were immunoassayed for echinococcosis. To clarify the size, number and location of liver cysts, computed tomography (CT) and ultrasound (ultrasound) of the abdominal cavity were performed. The average size of the cysts was 10.8 cm (6.5-20.5). The presence of cysts in the right lobe of the liver was observed in 23 (50%) patients, in the left lobe -6 (13%) patients, bilobar location -17 (37%) patients. Staging of liver echinococcosis was performed on the basis of ultrasound results, according to the WHO classification from 2003 (Fig. 1).
Treatment of patients with cystic liver echino-coccosis assumed an individual approach with consideration in each case of a possible combination of different treatment options. Patients who had a cyst size of less than 5 cm, stage CE1-CE3 took conservative therapy at an outpatient level, starting therapy with albezole was 10-15 mg / kg / day in 2 divided doses, with no side effects. The effectiveness of antiparasitic treatment was assessed by the following criteria: positive dynamics in ultrasound (reduction in the size of cysts, transition to CE4-CE5), on CT and MRT-control - decrease in lesion volume, signs of calcification.
Surgical treatment with indication for surgical intervention was carried out in accordance with the international recommendations of WHO.
Radical surgical treatment is pericystectomy. The technique of the operation consisted in stratification of the fibrous capsule of the echinococcal cyst from the parenchyma of the liver along the sub-adventential layer, where the large and smaller vascular duct elements along the line of separation on the liver surface clipped and ligated. This method of peritsistektomy of liver can avoid the occurrence of various postoperative hemorrhagic and biliary complications, which caused by the phased and thorough ligation of all vascular structures.
Non-radical surgery - echinococcectomy, traditional intervention, without removing the fibrous capsule.
Results and discussion
Intermediate analysis was performed between patients who underwent a radical operation - peri-cystectomy (groups 1,2, n = 34) and non-radical surgery - echinococcectomy (group 3, n = 12).
The distribution of patients is given in Table 2.
The average duration of the operation for performing radical interventions was 220 (105-540) min, which in comparison with non-radical operations was 178.6 (100-330) (Table 3). The average length of stay after pericystectomy was 7.5 (4-20) days, and when performing echinococcectomy -10.2 (6-16). Relaparotomy in both groups was not observed.
Analysis of the results of surgical treatment of patients who had performed traditional liver echinococ-cectomy showed no early postoperative complications. Postoperative complications were observed in 4 patients who underwent pericystectomy in the form
Figure 1.
Classification of ultrasound images of echino-coccal cysts WHO 2003
Table 2.
Preoperative patient data
Table 3.
Operational characteristics
pericystectomy echinococcectomy
№ (N=34) average (min-max) (N=12) average (min-max) p-value
Age 36.3 (18-66) 40 (24-70) ns
Sex(f./m/) 10/24 (10/2) < 0.05
BMI 22.7 (17-31.2) 24 (18-29) ns
Positive ELIZA to EL MaM.34 02.œeë ns
Quantity of cysts 1.5 (1-4) 2(1-3) ns
size(cm) 11 (7.0-25.0) 10.6(6.0-16.0) ns
Right lobe 17(50%) 6 (50 %) ns
Left lobe 5 (14,7%) 1 (8.3 %) ns
Bilobular location 12(35,3%) 5 (41,6 %) ns
< 2segment 19 (55.9%) 10 (83.3 %) ns
> 3 segments 15 (44,1%) 2 (16.7 %) ns
pericystectomy echinococcectomy p-value
(N=34) (N=12)
Operation time (min) 220 (105-540) 178,6 (100-330) ns
Relaparotomy 0 0 -
complications 4 (11,7%) 0 ns
Blood loss (ml) 249.6 (50-1500) 71 (20-250) < 0.01
Table 4.
Operational characteristics
№ pericystectomy echinococcectomy p value
(N=34) (N=12)
n/o ocëowHeHMfl
Bilobular complications 3(8.8%) 0 ns
abscess 1 (2.9%) 0 ns
A/O bed-days 7.5 (4-20) 10.2 (6-16) < 0.05
Complications by Clavien Dindo
Grade 1 0 0
Grade 2 0 0
Grade 3a 4 0 ns
Grade 3b 0 0
Grade 4 0 0
Relapse 0 0
of fluid clusters. (Table 4). All patients were cured with puncture interventions under the supervision of ultrasound. Biliary fistulas, as a rule, were closed independently up to 30 days after the operation.
Based on the analysis of the results of surgical treatment of patients with liver echinococcosis, it should be noted that until now pericystectomy remains the main type of treatment performed in our clinic.
In 18 patients who took conservative therapy at an outpatient level, there was a positive dynamics in ultrasound and CT in the form of a decrease in the size of the cysts, a transition in the CE4-CE5 stage, and signs of calcification.
During the observation period in all of the study groups, including group 4, there was no relapse of the disease.
Conclusion
The study is at the stage of continuation of recruitment of patients into groups for control studies. Based on the data obtained so far, conservative therapy without surgical intervention (group 4, the patient receives only antiparasitic drug «Albendazole») is effective in liver echinococcosis up to 5 cm in size. Also, in the treatment of liver echinococcosis with a size of more than 5 cm, a radical operation is pericystectomy, is an eco-
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BECTHÈK XMPyPfMM KA3AXCTAHA № 3-2018
nomically and socially effective method of surgical intervention (less than the number of days in the hospital, early recovery of the patient's ability to work, p <0.05).
In connection with the effectiveness of the above-described methods of treatment, it is advisable to continue working on this STP for more accurate prediction and identification of the optimal method of treatment of liver echinococcosis with
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