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III. ХИРУРГИЯ
THE IMPROVEMENT OF MEDICAL TACTICS OF COMBINED ECHINOCOCCOSIS OF RIGHT LUNG AND LIVER
Yeshmuratov T.Sh., Sundetov M.M., Shirtayev B.K., Zharylkapov N.S., Zhunisov N.A., Yeleusizov A.M., Akimniyazova B.B.
National Scientific Center of Surgery named after A.N. Syzganov, Almaty, Kazakhstan Department of thoracic surgery for children and adults
Abstract
The results of treatment of 99 patients with coexistent affection with echinococcosis of right lung and liver, who were in the Department of Thoracic Surgery of the National Scientific Center of Surgery named after A.N. Syzganov for the period 1997-2009, were analyzed. The age of patients ranged from 5 to 67 years old, among 99 patients males - 56 (56.6%), females - 43 (43.4%). 19 patients with coexistent affection with hydatid cysts of the right lung and liver were operated with thoracoscopic method, complications were not observed.
UDC 616.24-002.951.21-089
Оц екпе мен бауырдьщ косарлаотан эхинококкозыньщ емдеу тактикасын жетшд1р
у
Ешмуратов Т.Ш., Сундетов М.М., Ширтаев Б.К., Жарылкапов Н.С., Жунисов Н.А., Елеусизов А.М., Акимниязова Б.Б.
А.Н. Сызрэнов атындаш Улттык, шлыми хирургиялык, орталыш, Алматы, К,азак,стан Балалармен жэне ересектерге арналран кеуде хирургиясы
Ацдатпа
А.Н. Сызганов атындагы Улттык гылыми хирургия орталыгыныщ кеуде хирургиясы бел1мшде 1997 жэне 2009 жылдар аралыгында он, екпе жэне бауырдьщ косарланган эхинококкозымен ауыратын 99 наукастыщ хирургиялык ем1нщ нэтижелер1нщ талдауы жасалган. Наукастардыщ жас мелшер15 жастан 67жаска дейш болды. Ерлер - 56 (56,6%), эйелдер - 43 (43,4%). Торакоскопиялык эдюпен екпе жэне бауырдыщ косарланган эхинококкозымен ауыратын 19 наукаска ота жасалды, аскынулар болган жок.
About the authors:
Temur Sh. Yeshmuratov - Deputy Director General for Commercial and Strategic Development of the NSCS n/a Syzganov, can. med.; Bakhytzhan K. Shirtayev - head of the department of thoracic surgery for children and adults of the NSCS n/a Syzganov, can. med., a high level certificate physician;
Key words:
coexistent echinococcosis, thoracoscopic echinococcectomy
Авторлар туралы:
Ешмуратов Темур Шерханулы - А.Н. Сызганов атын. YFXO Бас директордыщ комерциялык жэне сиратегиялык даму жумыстары жен1ндеп орынба-сары, м.г.к.; Ширтаев Бахытжан Керимбекулы - А.Н. Сызганов атын. YFXO-ныщ балалар мен ересектер кеуде хирургиясы бел1мшес1нщ мещгеруш1с1, м.г.к., жогаргы санатты дэргер.
Туйш сездер
косарланган эхинококкоз,
торакоскопиялык
эхинококкэктомия
Усовершенствование лечебной тактики сочетанного эхинококкоза правого легког
и печени
Ешмуратов Т.Ш., Сундетов М.М., Ширтаев Б.К., Жарылкапов Н.С., Жунисов Н.А., Елеусизов А.М., Акимниязова Б.Б.
Национальный научный центр хирургии имени А.Н. Сызганова, Алматы, Казахстан Отделение торакальной хирургии для детей и взрослых
Аннотация
Проведен анализ результатов лечения 99 больных с сочетанным поражением эхинококкозом правого легкого и печени, находившихся в отделении торакальной хирургии Национального научного центра хирургии им. А.Н. Сызганова за период 1997-2009гг. Возраст больных колебался от 5 лет до 67 лет, из 99 больных лиц мужского пола было 56 (56,6%), женского - 43(43,4%). Торакоскопическим способом оперировано 19 больных с сочетанными поражениями эхинококковыми кистами правого легкого и печени, осложнений не отмечено.
Об авторах:
Ешмуратов Темур Шерханович - заместитель генерального директора по коммерческому и стратегическому развитию ННЦХ им. Сызганова, к.м.н., e-mail: temur07@mail.ru; Ширтаев Бахытжан Керимбеко-вич - заведующий отделением торакальной хирургии для детей и взрослых ННЦХ им. Сызганова, к.м.н., врач высшей категории, хирург, e-mail: shirtaevb@gmail.com;
Ключевые слова
Ключевые слова: сочетанный эхинококкоз, торакоскопиче-ская эхинококкэктомия
Topicality
In Kazakhstan, since 1995, there has been a continuous increase in the incidence of people with echinococcosis. During that time, the disease has increased from 1.4 to 6.4 cases per 100,000 population, i.e .4.57 times, particularly the high growth of the disease observed in three southern provinces [1,2]. Common serious parasitic disease is echinococcosis, and continues to be the national economic and health problem in many countries, including the Republic of Kazakhstan [3,4,5,6]. Polymorphism of the clinical manifestations of lung echinococcosis creates difficulties for the early detection of these patients. This generates a lot of mistakes and complications, the frequency of which varies from 26 to 52% [7,8].
Surgery for echinococcosis of lungs is not technically complex and most surgeons adhere to the principle of conserving organs, when the cavity is eliminated by capitonnage of fibrous capsule in different versions. The tactical problems arise as to the scope and nature of the surgery in complicated forms have not found their solution.
Analysis of the clinical course of combined echinococcosis of lungs conducted in our clinic showed a complete absence of any pathognomonic symptoms of this disease, which is consistent with the observations of other authors.
Surgery is the only method in the treatment of echinococcosis. Currently there are proposed many methods and modifications of surgery to eliminate echinococcosis. This variety of methods of operations for echinococcosis does not indicate a large arsenal of options for surgical treatment, or the imperfection of existing methods, but rather, says about the lack of a universal method. Still there is no systematic evidence to determine exactly indications to a particular method of operation, especially depending on the location, multiple lesions organs of hydatid cysts. At the same time, the incidence of postoperative complications after echinococcectomy remains quite high.
Purpose
Improving results of combined treatment of echinococcosis of the right lung and liver by improving the methods of surgical treatment.
Clinical observation and research methods
The work is based on a study of the results of surgical treatment of 99 patients with combined lesions by echinococcosis of the right lung and liver, were in the Department of Thoracic Surgery of the National Scientific Center of Surgery named after A.N. Syzganov for the period 1997-2009. The age of patients ranged from 5 years to 67 years, Among 99 patients there were 56 males (56.6%), female - 43 (43.4%). Patients on terms of surgical interventions were divided into two groups: the main group - 62 (62,3%) patients, were performed one-stage sequential echinococcectomy of lungs, it consists of three sub-groups: Group 1 -22 (22.2%) patients, were performed one-stage sequential thoracotomy, echinococcectomy of lung and laparotomy, echinococcectomy of liver; Group 2 - 21 (21.1%) patients, were performed a thoracotomy, echinococcectomy of lung and frenicotomy, echinococcectomy of liver; Group 3 - 19 (19.9%) patients, after a one-stage sequential thoracoscopy,
echinococcectomy of lung and frenicotomy, echinococcectomy of liver; the control group - 37 (37,7%) patients, who underwent two-stage surgery with an interval of 2-3 weeks.
The clinical examination included a clarification of history, inspection, palpation, percussion, auscultation.
Laboratory methods (complete blood count with the determination of its group and Rh facilities, coagulation time, serum biochemical studies and proteinogram, coagulation, urinalysis, etc.) can not be attributed to the defining category in the diagnosis of lung and liver hydatidosis, since similar changes may be at a different pathology.
Ray examination included X-rays, computed tomography, ultrasound. Fibrobronchoscopy performed in complicated cases. Computed tomography (CT) was performed in 46 (46.6%) patients. CT plays an important role in the differential diagnosis, significantly expanding the scope of the information received, allows to determine the size and nature of hydatid cysts, relationship of cysts with adjacent organs of the thorax and abdomen.
ECG was performed in all patients. Need to pay attention to the nature of arrhythmias, the displacement of the electrical axis of the heart, the presence of bundle-branch block, diffuse myocardial changes.
Ultrasound scanning (USS) is the most safe, non-invasive and highly informative diagnostic method. USS performed in all patients, as part of the algorithm research. In uncomplicated echinococcosis of lung and liver there ocated fluid formation of a homogeneous structure with clear contours and marked capsul, in complicated echinococcosis revealed the formation of an inhomogeneous hypoechoic structure with a hyperechoic inclusions and fuzzy contours.
Results of the study
When performing combined operations have a certain principle - first performed thoracotomy, echinococcectomy of lung, and then either laparotomy or frenectomy. Such sequence is linked to the fact that while giving anesthesia, mechanical ventilation can damage lung cysts with the development of air violations.
Surgical tactics in combined echinococcosis of right lung and liver cysts depends on the location. Primary-multiple hydatid cysts of the right lung and liver were found in 59 (59.9%) patients, of whom 37 (37.7%) patients, given the prevalence and severity of the general condition, the first step was made thoracotomy, echinococcectomy of right upper lobe. After 2-3 weeks laparotomy, echinococcectomy of liver were performed. When the cyst is located in the upper lobe of the right lung in conjunction with hydatid cyst of the liver to carry out echinococcectomy by thoracofrenectomy way is extremely difficult. This is due to the fact that in order to affect adequate access to the upper lobe of the right lung is necessary to conduct a III intercostal thoracotomy. From this section it is extremely difficult to produce frenectomy with following echinococcectomy of liver to the elimination of the residual cavity. Earlier, in the case of a combination of hydatid cyst of the upper lobe of the right lung with hydatid cyst of the liver, the operation
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ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 2(43)-2015
was carried out in the traditional way. The method consists in sided thoracotomy, echinococcectomy from the upper lobe of the right lung. Then, after the closure of the thoracotomy wound patient is turn over on his/ her back, and perform laparotomy, echinococcectomy from liver. Single-step, sequential operations were made in 62 (62.3%) patients with combined echinococcosis of right lung and liver. Single-step thoracotomy, laparotomy with echinococcectomy of liver was made to 22 (22.2%) patients.
Various simultaneous operations were carried out in 40 patients, who had a single-lesion cyst of the upper lobe of the right lung and the diaphragmatic surface of the liver.
This category of patients depending on the type of operations are divided into two groups. Group I included 21 patients, who were performed proposed method of the operation by intercostal thoracotomy with following frenectomy; II group - 19 patients, who were performed one-step sequential thoracoscopy, echinococcectomy of lung, frenotomy, echinococcectomy of liver.
Analysis of postoperative complications in patients with hydatid cysts of the upper lobe of the right lung and liver indicates that pleural pulmonary complications such as postoperative pneumonia were observed in 4 patients in the control group and in 2 patients of the main group. Postoperative pneumonia resolved conservatively. Complications in the form of exudative pleurisy after removal of the drainage tube from the pleural cavity were observed in 3 patients in the control group and in 2 patients of the main group. All patients were performed a puncture of the pleural cavity. 2 patients had festering laparotomic postoperative wound.
All patients in the control group had a postoperative scar, on the chest and on the stomach after laparotomy. Patients who were operated on proposed procedures on the skin had postoperative scars after thoracotomy and thoracoscopy.
The duration of postoperative period of the main group was 11,9±1,78 days, whereas hospital stay of the control group was 33±2,2 days.
The mean duration of the postoperative period in patients of the main group, who were operated by the proposed method is 22 days less than in the control group, who were operated by the traditional way.
We studied the long-term results of surgical treatment of combined echinococcosis of right lung and liver 65 (65.6%) patients in terms from 6 months to 12 years after surgery by a questionnaire, clinical and outpatient settings. Long-term results were estimated as good, satisfactory and poor.
Long-term result considered a good result in the absence of complaints, satisfactory general condition of the patient, the absence of residual cavities by ultrasound of the liver and changes on chest radiography and proper spirogram.
In the presence of the patient's complaints of cough, shortness of breath on exertion, chest pain on the side of the surgery, the symptoms of chronic bronchitis, move the patient to the light work in a different specialty result was considered as satisfactory.
Poor long-term result was considered when
identifying recurrence of echinococcosis, presence of chronic suppurative acquired diseases of the lungs and pleura (residual cavity with suppuration, the formation of non-parasitic cysts, effects of cirrhosis of the liver, empyema) - which requiring surgical correction, the translation of the patient's disability, and death in connection with the main disease.
Good results were found in 53 (81.5%), satisfactory - in 11 (16.9%), poor - in 1 (1.6%) patients.
Closing
An improved method of simultaneous surgical treatment of hydatid cysts of the upper lobe of the right lung and liver, including thoracotomy in the III intercostal, echinococcectomy of lung, thoracotomy in the VI intercostal in the same skin incision, frenectomy, echinococcectomy of the liver - in all cases allows to reduce the duration of the operation and the duration of the postoperative period, as well as to reduce the financial cost of treatment.
Thoracoscopic echinococcectomy of the right lung and the diaphragmatic surface of the liver, using this method can reduce the risk of intraoperative contamination of germinal elements, reduces of trauma surgery, simplifies access to cyst of the diaphragmatic surface of the liver, reduces the time of anesthesia and operating aggression, helps reduce the time of hospital stay of up to 5-7 bed-days, which is in 3-5 times less than the length of patient days for other methods of operations used in echinococcosis of right lung and liver.
References_
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