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The choice of treatment of patients with liver echinococcosis in children
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Salimov Shavkat Teshaevich, doctor of medical sciences, director of Republican Scientific-Practical Center of Minimally Invasive and Endovisual Surgery of childhood, professor of the department «General and pediatric surgery» of Tashkent Medical Academy
Abdusamatov Bobir Zakirovich, doctor of philosophy, assistant of the department «General and pediatric surgery» of Tashkent Medical Academy
Vakhidov Alisher Shavkatovich, doctor of medical science, deputy director of Republican Scientific-Practical Center of Minimally Invasive and Endovisual Surgery of childhood
E-mail: [email protected]
The choice of treatment of patients with liver echinococcosis in children
Abstract: For the Article by Salimov Sh. T. as co-author on the topic: “The choice of treatment in patients with hepatic echinococcosis in children”. The article analyzes the results of treatment of 96 patients aged 3 to 18, who underwent laparoscopic echinococcectomy between 2007 and 2015. Solitary echinococcosis was detected in the liver of 66 (68.8 %) patients, multiple (two or more cysts) — in 30 patients (31.2 %). A total of 147 echinococcus cysts were removed.
Of the 96 taken laparoscopic liver echinococcectomy in 7 (7.3 %) cases due to intrahepatic localization of the cyst and due to technical difficulties, conversion was required.
Residual cavities located in the anterior segments of the liver — were laparoscopically sutured inside. Rigid RC (residual cavities) of IV-V liver segments in the vicinity of the gate of the liver and gall bladder were dabbed with greater omentum. Fibrous capsule of residual cavity of visceral surface of the liver was excised circularly within the liver tissue and external drainage was performed. Medium and large size of the residual cavity of VI-VII and VIII segments of the liver, after excision of the fibrous capsule was drained as well. In fine and small residual cavity of echinococcus cyst was performed laparoscopic coagulation of the inner wall of the fibrous capsule with abdominiza-tion without drainage
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In 89 (92.7 %) patients after laparoscopic liver echinococcectomy postoperative period was much more favorable than after traditional echinococcectomy. Patients intensified by the end of 1-2 days. 5 (5.2 %) patients had bile leakage on drainage, which independently docked at 8-11 day, suppuration of the residual cavity was observed in — 3 (3.1 %), non-parasitic cyst formation in the late period was observed in 7 (8.3 %) patients. The average hospital stay in the postoperative period was 6.5 ± 0.5 bed days.
Laparoscopic elimination of residual cavity at echinococcectomy liver with kapitonnage, external drainage, ab-dominization, omentoplasty methods is accompanied by a significant attenuation of the cavity and extends the subsequent elimination of the residual cavity.
Keywords: echinococcosis, liver, surgical treatment, children.
The rapid development of modern endovideosurgery technologies significantly expand the list of possible surgical procedures performed by minimally invasive means. Interest in use of modern laparoscopic technology in liver echinococcosis caused by the fact that traditional interventions are accompanied by severe surgical trauma and long-term rehabilitation of patients [2; 4; 8].
According to M. A. Aliev etc al. [3], the broad introduction endovideosurgery treatment of parasitic cysts in liver prevents mainly following: the likelihood of contamination of the abdominal cavity, the lack of an effective method of disinfection, the problem of eliminating the residual cavity of liver [1; 6].
Until now, surgeons not reached unanimity in the selection methods of processing the fibrous capsule and ways to eliminate residual cavities arising after echinococcectomy [10; 12].
Despite the large number of investigations that proved the invasion scoleces of fibrous sheath, the ratio of surgeons to this issue remains controversial. Series of clinicians consider leaving the fibrous sheath with careful antiparasitic treatment is quite reasonable, and other a radical operation is considered complete removal of the fibrous capsule [7; 9].
Traditional removal of hydatid cysts of liver by laparotomy and body surgeries blowing pushes them to the rank of operations of despair. A number of children’s surgical clinics designed testimony and introduced into clinical practice of minimally invasive methods of treatment of parenchymal
organscysts: laparoscopic and percutaneous puncture-removal ofwhich have an undeniable advantage safety of organ. Overview of the current state of the problem points to the absence of diagnostic difficulties in echinococcosis of abdominal cavity and need to justify a single treatment and tactical concepts, to find the most radical way of getting rid of the child from minimally invasive parasitic liver cysts [5; 11; 13].
The purpose of research — to evaluate the therapeutic tactics and ways to improve the elimination of residual cavities after laparoscopic echinococcectomy of liver in children.
Material and research methods. In the period from 2007 to 2015 we analyzed the results of treatment of 96 patients aged 3 to 18 years who underwent laparoscopic echinococcectomy with the principles aparasitics. Solitary echinococcosis was detected in liver — in 66 (68.8 %) patients, multiple (two or more cysts) -in 30 patients (31.2 %).
Among the patients we observed a primary hydatid - in 81 (84.4 %), recurrent - in 15 (15.6 %) children. There were removed 147 echinococcosis cysts (EC).
When analyzing the clinical materials we have adhered to the EC classification by size and scope of the proposed by A. T. Pulatov (1983). Among them, small EC of liver were in 9 (9.4 %), small - in 26 (27.1 %), secondary in 43 (44.8 %), large in 18 (18.7 %).
The most frequently (over 70.8 %) EC were located in the right lobe of liver, in 26 (16.6 %) patients had defeated both lobes (Table 1).
Table 1. - Distribution of patients according to localization of cysts
Localization Fine cyst Small cyst Average cyst Big cyst
Right proportion 4 (4.2 %) 15 (15.6 %) 24(25.0 %) 9 (9.4 %)
Left proportion 2 (2.1 %) 8 (8.3 %) 12 (12.5 %) 6 (6.3 %)
Both proportion 3 (3.1 %) 3 (3.1 % 7 (7.3 %) 3 (3.1 %)
The right lobe of the most frequently localized in EC V-VI-Vn-Vni, the left lobe — II-III segment (Table 2).
During the investigation of patients we used traditional methods of research: clinical and biochemical blood tests, immunological tests, ultrasound and CT of the abdomen.
Clinical and biochemical blood parameters were determined in all patients at admission and during the treatment.
A survey of various forms of echinococcosis liver using ultrasound showed that in most cases, using ultrasonography can get detailed information for setting a definite diagnosis. Ultrasonography of the abdomen and retroperitoneal
space was performed on devices «Aloka 1100» and «Phil-ips Clear Vue 350 ». They use sensors of linear and convex type with an operating frequency of 3.5; 5 and 7.2 MHz.
MSCT was performed only in cases of doubt, for the differential diagnosis festering EC differentiation of parasitic and non-parasitic cysts of liver, with recurrent lesions as well as with multiple cysts and combined lesions of other organs of the abdominal cavity. MSCT was performed in 47 (23.1 %) children, with apparatus “Brilliance 64 Philips" and “Ge, Light Speed 64”, which allowed to determine the exact topographic localization of EC communication of the great vessels, the size, the volume of the cyst.
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The choice of treatment of patients with liver echinococcosis in children
Table 2. - The distribution of patients depending on the number and localization of EC in liver segments
Liver segments Quantity of cysts %
II 8 5.4
II-III 5 3.4
IV 13 8.8
III-IV 7 4.9
V 19 12.9
V-VIII 11 7.5
IV-V 9 6.1
VI 10 6.8
V-VI 13 8.8
V-VI-VII 8 5.4
VII 19 12.9
VIII 18 12.2
VI-VII-VIII 7 4.9
Altogether 147 100
Results and discussion
Since 2007, in our clinic at the echinococcosis disease of the abdominal cavity, we give preference endovisual-laparo-scopic echinococcectomy of the benefits that are undeniable, compared with traditional “open” echinococcectomy. With regard to the method of percutaneus-puncture, which has recently become widely practiced in adult surgery, we take this method very carefully consider the use of this method due to the possibility of dissemination the parasite of abdominal cavity. It is known that even in the structure of EC of adult and child are distinguished by different characteristics. Children very rarely observed calcification cysts relatively thin chi-tinous shell and the pressure in the cavity of the EC is higher than in adults, so now the most optimal believe laparoscopic echinococcectomy.
In all cases, removal of cysts bed under hepatic and/or under the diaphragmatic region, depending on the localization of cysts drainage.
In 89 (92.7 %) patients after laparoscopic liver echinococcectomy in postoperative period was significantly more favorable than after traditional echinococcectomy. Patients intensified by the end of 1-2 days. In 5 (5.2 %) patients had bile leakage of drainage, which independently docked at 8-11 hours, festering
Hitherto 96 taken laparoscopic liver echinococcectomy in 7 (7.3 %) cases, in connection with intrahepatic localization of cysts and because of technical difficulties required conversion; followed by “open” traditional echinococcectomy.
When laparoscopic echinococcectomy satisfy the following necessary stages of intervention:
To comply with the principles aparazitic operations to avoid getting the contents of the EC in the abdomen, the operation zone cover with gauze soaked in a solution of 100 % glycerol, a cyst summed belay tube electric pumps.
- Puncture of the cyst with the evacuation of the liquid contents of electric pumps.
- Opening of the fibrous capsule cysts, removal of chitin shells were left with the evacuation of the contents.
- Antiparasitic treatment of residual cavity echinococcosis wall.
- Revision of residual cavities, the complete removal of the cuticular membrane and detection of biliary fistulas using endovideoscopic residual cavity of the liver.
- If find gall fistula his coagulated with endoscopic bipolar coagulator or sewn thread Ethibond № 3.0-4.0.
The elimination of the residual cavity (RC) is the final stage of liver surgery for liver echinococcosis. RC that located in the anterior segments of the liver with a thin wall of fibrous capsule unrigid laparoscopic sutured inside. Rigid RC in IV-V liver segments in the vicinity of the gate of the liver and gall bladder dab greater omentum. Fibrous capsule RC visceral surface of the liver was excised circularly within the liver tissue was performed and external drainage. Medium and large size of the residual cavity in VI-VII and VIII liver segments, we are also after excision of the fibrous capsule drained. The RC with small and little EC after the above described steps necessary laparoscopy performed coagulation of the inner wall of the fibrous capsule abdominisation of RC without drainage (Table 3).
RC noted in — 3 (3.1 %), education, non-parasitic cysts in the long-term period was observed in 7 (8.3 %) patients (Table 4).
In 4 cases, the formation of non-parasitic cysts larger than 5 cm. and in 2 patients with suppuration of the residual cavity under ultrasound failed to produce a percutaneous drainage. In these patients, postoperative complications were observed. The average hospital stay in the postoperative period was 6.5 ± 0.5 bed-days.
Table 3. - Methods for elimination of residual cyst cavity after laparoscopic liver echinococcectomy
Types of laparoscopic management Quantity of cysts n = 147
abs. %
Laparoscopic suturing echinococcectomy of residual cavity inside 37 25.2
Laparoscopic partial excision echinococcectomy fibrous capsule, swabbing to backfilling of residual cavity 28 19.0
Laparoscopic partial excision echinococcectomy fibrous capsule with external drainage 51 34.7
Laparoscopic partial excision echinococcectomy fibrous capsule unipolar coagulation of the inner wall of the fibrous capsule abdominisation of residual cavity without drainage 31 21.1
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Conclusion:
Laparoscopic liquidation RC echinococcectomy capiton-nage of liver, external drainage, abdominisation, omentoplasty accompanied by a significant decrease of the size of the cavity and extends the capabilities ofthe subsequent liquidation of RC.
Laparoscopic elimination of residual cavities reduces the incidence of postoperative complications, reduce the duration of postoperative hospital treatment of the patient.
Application endovideosurgery intervention echinococcosis of liver disease in children, showed its obvious benefits, which makes them promising direction in Pediatric Surgery.
References:
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Table 4. - Postoperative complications after laparoscopic liver echinococcectomy
Types of complications Laparoscopic echinococcectomy n = 89
Suppuration of the residual cavity 2 (2.2 %)
Forming nonparasitic cysts 7 (7.9 %)
Bile leakage from residual cavity 5 (5.6 %)
Altogether 15 (16.9 %)
Hodjimuratova Gulnora Abduvaliyevna, Republican Perinatal center of ministry of Public Health of Uzbekistan, obstetrician and gynecologist E-mail: [email protected]
The state of hemostasis in patients with premature abruptio of normally situated placenta in women with thrombophilia
Abstract: In article the questions, concerning features of a hemostasis of pregnant women are considered at placentary insufficiency, with the increased maternal and perinatal risk at aberrations in system of regulation of an aggregate state of blood against thrombophilia.
Keywords: placental abruption, thrombophilia, pregnancy.
Actuality. The acute placental insufficiency, which devel- Despite the fact that this complication of pregnancy and child-
ops as a result ofpremature abruptio of normally situated pla- birth, occurs with a frequency up to 0.5-1.2 %, it is always
centa, presents specific clinical problem in modern obstetrics. considered as a state of vital danger, as in 30 % of cases it is
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