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II. ХИРУРГИЯ
THE CURRENT STATE AND PROBLEMS OF THE ORGANIZATION OF SURGICAL TREATMENT OF COMBINED ECHINOCOCCOSIS OF THE CHEST AND ABDOMINAL ORGANS (LITERATURE REVIEW)
Akimniyazova B.B., Kausova G.K., Yeshmuratov T.S.
Kazakhstan's medical university «KSPH», Center of modern medicine «Mediterra»,
National Center of surgery named after A.N. Syzganov, Almaty, Kazakhstan
UDC 614.2-616.24-089-616082
МРНТИ 76.29.50
ABOUT THEАUTHORS
Yeshmuratov T.S. - Head of the Department of thoracic surgery and pulmonology of center of the modern medicine "Mediterra"
AkimniyazovaB.B. - PhD student of KSPH
Abstract
Combined Echinococcosis of the chest and abdomen is one of the causes of morbidity and disability in the Republic of Kazakhstan. The incidence, according to statistics, in 2017 per 100,000 people was 217 cases of Echinococcosis (1). The article reviewed the organization of surgical care in the combined Echinococcosis of the chest and abdominal organs, from these data there are obvious problems in the health care system and the necessity of the optimize the diagnosis and treatment.
Кеуде жэне ш куысы агзаларыньщ аралас эхинококкозын хирургиялык емдеушщ ^ipri жагдайы мен проблемалары (Эдеби шолу)
Акимниязова Б.Б., Каусова Г.К., Ешмуратов Т.Ш.
«ВШОЗ» Казак,стандык, медицина университет «Mediterra» Заманауи медицина орталы^ы
«А.Н. Сыз?анов атында?ы мемлекеттiк хирургия орталы^ы», Алматы, Казахстан
Keywords
Organization of surgical care, thoracic surgery, combined Echinococcus, multidisciplinary approach
АВТОРЛАР ТУРАЛЫ
Ешмуратов Т. Ш. - «Mediterra»заманауи медицина орталы^ыныц кеуде хирургиясы жэне пульмонология департаментiнiц басшысы.
Акимниязова Б. Б. - КДСЖМ PhD докторанты
Ацдатпа
Кеуде жэне ш куысынын аралас эхинококкозы Казахстан Республикасында ауру мен MY^eKriKriH, себептерШ'щ 6ipi. Статистиаа сэйкес, 2017 жылы 100 000 адамга шащандагы 217 ауруда эхинокок-коз болды (1). Макалада кеуде жэне ш куысынын мYшелерiнiн эхинококкозындагы хирургиялык кемек кeрсетудi уйымдастыру кдрастырылган, денсаулык сактау щйесШдеп айкын езект.i мэселелер, диа-гностикасы мен емдеун онтайландыру кщеттю туралы деректер усынылган.
Туйш сездер
Хирургиялык кемек керсету, кеуде хирургиясы, аралас эхинококков, мультидисциплинарлык эдс
Современное состояние и вопросы организации хирургического лечения сочетанного эхинококкоза органов грудной клетки и брюшной полости
Акимниязова Б.Б., Каусова Г.К., Ешмуратов Т.Ш.
Казахстанский медицинский университет «Высшая школа общественного здравоохранения» Центр современной медицины «Mediterra», Алматы, Казахстан
Аннотация
Сочетанный эхинококкоз органов грудной клетки и брюшной полости является одной из причин заболеваемости и инвалидизации в Республике Казахстан (РК). Заболеваемость, согласно статистике, в 2017 году на 100 000 человек составляло 217 случаев эхинококкоза (1). В статье проведен обзор по организации хирургической помощи при сочетанном эхинококкозе органов грудной клетки и брюшной полости, из приведенных данных очевидны имеющиеся проблемы в системе здравоохранения и необходимость оптимизации диагностики и лечения.
ОБ АВТОРАХ
Ешмуратов Т.Ш. - Руководитель департамента торакальной хирургии и пульмонологии центра современной медицины "Mediterra"
Акимниязова Б.Б. - PhD докторант ВШОЗ
Ключевые слова
Организация хирургической помощи, торакальная хирургия, сочетанный эхинококкоз, муль-тидисциплинарный подход
Relevance
The basis for the development of the health care system has always been and still is the improvement of the organization of medical care to the population. In the current environment of severe economic changes and deterioration of the general health of the population, improvement of the organization and quality of surgical care takes a leading place in the reform of the health care system of the Republic of Kazakhstan (2,3).
In recent years, there have been significant changes in the dynamics and level of surgical morbidity, which was a consequence of various economic changes in the country, namely, an increase in the private health care sector, a reduction in the number of medical and preventive institutions, and the lack and shortage of qualified professinals, especially in rural areas. Accordingly, the population's access to adequate surgical care has decreased (4,5).
The current stage of health care reform is related to the development of conceptual provisions of the new economic mechanism. The main directions of formation of health care perspective model are optimization of planning and financing, development and introduction the innovative technologies into medical care organization, increase of professional potential of health care workers, optimization of legislative activity and correction of normative-legal base of health care, improvement of drug supply, increase of efficiency of management and provision of quality of medical care, creation of a complex multidisciplinary approach to health care (6,7,8).
Parasitic diseases, according to WHO, are the cause of death in more than 32% of cases. Echino-coccosis is one of the most dangerous zoo-anthropogenic diseases. Echinococcosis is widespread in various regions of Kazakhstan. Surgical method is the main one in the treatment of Echinococcosis. Despite the successes achieved in the surgery of the disease, its treatment remains a complex problem. Proof of this is a large number of postoperative complications 6.7-47.5%, high lethality up to 4.5%-10.2% and a significant incidence of recurrence of the disease 3.3-54%, prolonged postoperative bedday (21.9-62 days). Difficulties in surgical treatment of echinococcosis are related to the lack of sufficiently effective methods to optimize the algorithm of patient care at both the diagnostic and treatment levels (9).
A number of dissertations and monographs have been devoted to the treatment of Echino-coccosis, indicating the growing and continuing interest of scientists in many aspects of the disease. Despite this, many issues of surgical treatment of lungs Echinococcosis remain controversial and have not been fully resolved: indications and contraindications and tactics in different locations of the Echinococcal cyst, increased efficiency of
surgical interventions, tactics in combined, bilateral, complicated and giant forms. Also the most interesting area are the issues of application of new technologies in the complex surgical treatment of lung Echinococcosis; the problem of bilateral lung Echinococcosis, surgical tactics, validity of singlestage sequential operations on lungs, sequence of single-stage sequential operations remains controversial. Accordingly, problematic issues have a significant impact on the results of treatment of these patients, on the level of disability, mortality and quality of life of the population (10).
The peculiarity of the lungs Echinococcosis clinic is relatively early and quite frequent addition of such complications as perforation of the Echi-nococcal cyst in the bronchial or pleural cavity, suppuration of the cyst, pulmonary bleeding. In the case of complicated course of the disease with the presence of intoxication of the body and functional disorders of the cardiovascular system, the lungs, indicated preoperative preparation, consisting in antibacterial therapy, desensitization, tonic treatment, rehabilitation of the tracheobronchial tree.
There has been insufficient study of singlestage sequential surgeries for combined liver and lung Echinococcosis, and simultaneous right and left lung Echinococcosis. This technique has not become part of the daily practice of surgeons. There is disagreement over the tactics for bilateral lung Echinococcosis. The sequence of surgery is a contentious issue, as is the safety of single-stage operations (11).
A number of authors recommend starting the operation from the side of the most severe defeat, where there are signs of complications. If this is not the case, giant cysts or cysts that threaten to break should be removed first. In case of bilateral multiple lung echinococcosis with equal cysts size, it is necessary to operate on the side where there are more cysts in the lung. In case of bilateral single cystic lung lesion, when cysts are approximately the same size and have no signs of complications (bleeding, breakthrough, suppuration, etc.), the order of operation has not the practical importance. There are proposals to operate in a one-step sequence and even in a one-step two brigades . However, opponents of one-stage operations on the lungs, lungs and liver believe that such operations are more prestigious than expedient.
When choosing a tactic for bilateral lung Echinococcosis, according to some authors, it is advisable to perform consecutive surgery first on one lung and then on the other lung at intervals of 1-3 months. However, supporters of one-stage operations on the lungs indicate that after removal of the cyst on the one side, the remaining Echinococ-cal cyst on the other side begins to grow with the
following formidable complications and therefore recommend operating on another lung without discharging patient from the hospital at as short an interval as possible (15-20 days). Full longitudinal transverse access to remove Echinococcal cysts from both lungs is also offered. However, this method is very traumatic and the incision does not allow for a complete and thorough revision of the pleural cavity with adequate echinococcectomy. This access also makes pneumolysis very difficult (12).
A combination of lung and abdominal Echinococ-cosis and other abdominal organs is not uncommon. One common combination is lung and liver damage. Surgical tactics and the choice of the sequence of surgery on the lung or liver should be decided on a strictly individual basis, depending on the nature of the lesion, the number of cysts, their size and localization. In uncomplicated combined Echinococcosis of the lungs and other organs it is customary to first remove the cyst from the lung, as the lung has a rapid growth of the cyst and a high risk of early complications, such as perforation in the bronchi, pleura, festering cysts. At the expressed clinical symptomatology at the combined Echinococcosis of lung and liver the one-stage echinococcosis through pleural access is expedient. It is customary to perform dia-phragmotomy for liver access, followed by careful closure of diaphragm wounds. According to RAMS 2002, it is convenient to perform from thoracophre-nolaparotomy on VII intercostal space with the intersection of the cartilage of VII or VIII ribs, which gives a wide view for a thorough revision, allows you to radically remove the cysts from the thoracic cavity and lower right lung. The authors performed surgeries through this access in 278 patients and confirmed the reliability and radicality of the operation and the absence of postoperative complications (13).
In recent years, along with successful percutaneous drainage of solitary cysts of kidneys, abscesses and liver non-parasitic cysts, puncture aspiration of Eechinococcosis under ultrasound control has become an effective method of treatment of some forms and locations of liver Echino-coccosis, especially in patients with increased risk of surgery. There is also evidence of the treatment of complicated Echinococcal cysts of the lung by transthoracic percutaneous cysts drainage.
The accumulated experience of various en-dovideoscopic operations also allowed to perform lung echinococcectomy using endovideothoracic technique. The problem of relapse during the operation was solved by treatment of the parasite's lair after hot steam echinococcectomy and other scolecticides. However, the authors note the complexity of intraoperative preventions of bronchogen-ic dissemination of germinal elements and difficulties in the elimination of residual cavity in the lung,
suggesting to supplement it with minithoracotomy in difficult cases. Currently, the number of endovid-eosurgical interventions in surgery is estimated at tens of thousands, these operations are increasingly used in the treatment of a number of diseases of the chest and abdominal cavity (14).
Widespread use of minimally invasive and, above all, endovideosurgical methods of surgery seemed to have led to the desired results, namely, to a reduction in the time of surgical access (the duration of the operation is much longer than with traditional access, the indicator decreases with the experience of the surgeon (D.V. Seliverstova, 1995), less tissue traumatization, good cosmetic effect, reduction of pain syndrome, to reduce the length of stay in hospital and the temporary disability of patients and, accordingly, their more rapid work and social rehabilitation. HoHowever, as the number of endovideosurgical interventions is increasing and they are becoming more widespread, non-specific complications, both intra- and postoperative, have emerged.
In a number of foreign and domestic literary sources the technical nuances of the majority of currently performed endovideosurgical operations are considered in detail, but both general and specific indications and contraindications to them are not always clearly defined. In a number of cases, excessive passion for discussing technical aspects of these operations leads to less coverage of no less important issues of examination of patients, general tactics of their management and adequate determination of indications for surgical treatment with justification of the advisability of the recommended option of surgical intervention - traditional ("open") or endovideosurgical (thoracoscopic) (15).
In various sections of the surgery there are carried out researches aimed at comparative analysis of parameters of traumatism of operative interventions, quality of life of patients, economic efficiency of various types of surgical treatment (endovideosurgical, traditional, mini-accesses) that allows to evaluate and demonstrate the effectiveness and expediency of these or those, to specify the indications to them.
The study of immediate and distant results of surgical treatment has shown that the course of the postoperative period is largely associated with the localization and size of the surgical wound rather than with the volume of surgery in a thoracic or abdominal cavity. In this regard, the study of the results of surgery should take into account such a factor as traumatism (so-called surgical stress).
Summarizing numerous literary data of leading specialists of anesthesiologists and reanimators, P.S. Vetshev et al. (2002) provide the following definition of surgical stress: a set of general (nonspecific) and local (specific, depending on the area of op-
eration and its nature) pathophysiological reactions of the body in response to emergency exposure of a specific type. Surgical stress is assessed by assessing the hormonal response to surgical trauma, changes in respiratory function parameters, and the number and nature of analgesics required for adequate analgesic pain relief in the postoperative period, among other factors.
According to WHO experts and leading specialists, the efficiency of surgical treatment is assessed by the quality of life of patients in the postoperative period. When studying the quality of life, it can be clearly imagine the essence of the clinical problem, choose the most rational approach to treatment that meets the needs of the patient, and, most importantly, to assess its effectiveness by parameters that are at the intersection of the scientific approach of surgeons and the subjective point of view of the patient. It is believed that the influence of surgical treatment on the quality of life in the distant
future has not been studied yet, and it is impossible to judge with a full measure of objectivity the advantages and disadvantages of this or that type of surgical operation.
Quality of life is an integral characteristic of a person's physical, psychological, emotional and social functioning based on his subjective perception.
Despite the presence of many works on treatment tactics in the case of Echinococcosis isolated chest, in a combined lesion of the chest and abdominal cavity, there is no optimal algorithm for diagnosis and treatment of this category of patients. In the available literature we have not found any works related to the complex analysis of the results of different types of surgical operations at combined Echinococcosis with the subsequent evaluation of the quality of life in the postoperative period. In this connection, it is necessary to develop the public health system by improving the organization of medical care to the population.
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