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11
II. ХИРУРГИЯ
ÄK: 616-233-007-64 TREATMENT OF CONGENITAL BRONCHIECTASIS
ABOUT THE AUTHORS
Shirtaev Bakhytzhan Kerimbekovich - Head of the Department of Thoracic and Pediatric Surgery, Ph.D.
Sundetov Mukhtar Magzomovich -thoracic surgeon highest category, Ph.D.
e-mail: [email protected]
Kassenbayev Ruslan Zhumahanovich -thoracic surgeon.
Voronin Denis S. -pediatric surgeon of the first category.
Kurbanov Doniyor Rakhmatullaevich -thoracic surgeon.
Erimova Nazira Zholdybaevna -pediatrician.
B.K. Shirtaev, M.M. Sundetov, R.Zh. Kasenbaev, D.S. Voronin, D.R. Kurbanov, N.Zh. Erimova
National Scientific Center of Surgery named A.N. Syzganov, Almaty, Republic of Kazakhstan
Keywords
congenital bronchiectasis, surgery, long-term results.
Abstract
The experience of surgical treatment of 433 patients with congenital bronchiectasis. Number of children and adolescents (60.9%) was more than adults (39.1%).
The most frequently performed lower lobectomy (35.1%), extirpation of the bronchi (22.2%), and combined resection (17.6%). In children and adults, the character of surgical interventions were similar, except for the phased bilateral lung resections, which performed more than in adults (3.4% vs. 10.0%). Adult patients have a longer history of the disease, so they more frequent (84,1%) have dense and extensive adhesions in the pleural cavity. The incidence of early postoperative complications in children was 10.6%, while adult reached 20.7%. The most frequent complications in the operated children were intrapleural bleeding (2.65%) and atelectasis (2.65%) of the operated lobe or lung. Adults more often had bronchial fistulas (4,1%) and festering wounds (7,7%). In the long-term period from 1 year to 22 years were examined 190 operated patients. Good results (complete recovery) were observed in 63.8% of children, which was significantly higher than the results of surgical treatment of adult patients (47.9%). All unsatisfactory results were observed in patients with bilateral lesions in the lungs and residual bronchiectasis in the operated lung.
Examination of patients in the long term period showed that timely diagnosis and early surgery reduces the risk of postoperative complications, improves long-term results.
Туа бггкен бронхоэктаздьщ eMi
АВТОРЛАР ТУРАЛЫ
Ширтаев Бахытжан Кер1мбек±лы - Кеуде жене балалар хирургиясы бел/мшес/н/ц мецгерушю, м.г.к.
Сундетов Мухтар Магзомулы -жогары дэрежел/ кеуде хирургÎ, м.г.к.,
e-mail: [email protected]
Касенбаев Руслан Ж±махан±лы -кеуде хирург/.
Воронин Денис Сергеевич - б!р!нш1 дэрежел! балалар хирургы.
Курбанов Дониер Рахматулла±лы - кеуде хирург!.
Еримова Назира Жолдыбайкызы -педиатр.
Туйш сездер
туа бткен бронхоэктаздар, хирургия, алшакталган нэтижелер.
Ширтаев Б.К., Сундетов М.М., Касенбаев Р.Ж., Воронин Д.С., Курбанов Д.Р., Еримова Н.Ж.
Алматы каласы, Казахстан Республикасы
А.Н. Сь№анов атындаш ¥лттык шлыми хирургиялык орталык
Ацдатпа
Бронхоэктазасы туа пайда болеан 433 пациентердщ хирургиялык; емдеу тэж!рибес! керсетлген. Балалар мен жасетр'шдердщ (60,9%) саны ересек адамдардыц (39,1%) санынан улкен болды.
Ец кеп орындалеандары: теменгi лобэктомия (35,1%), бронхылардыц экстирпациясы (22,2%) жэне аралас комбинациялы резекция (17,6%). Ересек адамдарда кеб!рек орындалеан (3,4% салыстыреанда 10,0%) екпен!ц кезецд!к еюжакты резекциясын коспаганда, балалар мен ересек адамдарда оперативтi араласу шамамен б!рдей болды. Ересек наукастарда аурудыц ±зак анамнезi байкалады, сондыктан оларда екпекап кабатында жиi (84,1% дей!н) калыц жэне аукымды спайктар кездесед!. Балаларда операциядан кемнгi ерте аскынулардыц жи!л!гi 10,6%, ал ересектерде 20,7% дейiн жеткен. Операциядан еткен балаларда '¡шк екпекап кансыраулар (2,65%) жэне операциядан еткен белiктiœ немесе екпенiœ ателектазалары (2,65%) ец кеп кездеселн аскынулар болды. Ересектерде кебiнесе бронхтык терецжаралар (4,1%) жэне жараныц iрiœдеуi (7,7%) кездесп. 1 жастан 22 жас аральеындаеы кец периодты мерз 'шде операциядан еткен 190 пациенттер тексер!лд!. Балалардыц 63,8%-ында жаксы нэтижелер(толыктай жазылу) байкалды, ал б±л ересек наукастардыц (47,9%) хирургиялык емдеу ндтижелерiнен артык. Барлык канаеаттанеысыз нэтижелер екпенц еюжакты закымдануы жэне операциядан еткен екпедеп резиудальдi бронхоэктазасы бар наукастарда белгiлендi.
Пациенттердi кеШнп периодта тексеру келес корытындыларды керсетп: уакытында етюзшген диагностика жэне ерте оперативт араласу операциядан кеШнп аскынулардыц кауЫн темендетед'1, кейшп ндтижелердiœ керсеткiштерiн арттырады.
Лечение врожденных бронхоэктазов
Ширтаев Б.К., Сундетов М.М., Касенбаев Р.Ж., Воронин Д.С., Курбанов Д.Р., Еримова Н.Ж.
Национальный научный центр хирургии им. А.Н. Сызганова, г. Алматы, Республика Казахстан
Аннотация
Представлен опыт хирургического лечения 433 пациентов с врожденными бронхоэктазами. Детей и подростков (60,9%) было больше чем взрослых (39,1%).
Наиболее часто выполнялись нижняя лобэктомия (35,1%), экстирпации бронхов (22,2%) и комбинированные резекции (17,6%). У детей и взрослых характер оперативных вмешательств был примерно одинаковым, за исключением поэтапных двусторонних резекций легких, которых у взрослых выполнено больше (3,4% против 10,0%). Взрослые больные имеют более длительный анамнез заболевания, поэтому у них чаще (до 84,1%) встречаются плотные и обширные спайки в плевральной полости. Частота ранних послеоперационных осложнений у детей составляла 10,6%, а у взрослых достигала до 20,7%. Наиболее частыми осложнениями у оперированных детей были внутриплевральные кровотечения (2,65%) и ателектазы (2,65%) оперированной доли или легкого. У взрослых чаще встречались бронхиальные свищи (4,1%) и нагноения раны (7,7%). В отдаленном периоде в сроки от 1 года до 22 лет обследованы 190 оперированных пациентов. Хорошие результаты (практическое выздоровление) отмечены у 63,8% детей, что достоверно выше результатов хирургического лечения взрослых больных (47,9%). Все неудовлетворительные результаты отмечены у больных с двусторонними поражениями легких и резидуальными бронхоэктазами в оперированном легком.
Обследование пациентов в отдаленном периоде показало, что своевременная диагностика и раннее оперативное вмешательство снижает риск возникновения послеоперационных осложнений, улучшает показатели отдаленных результатов.
ОБ АВТОРАХ
Ширтаев Бахытжан Керимбекович
- Зав. отделением торакальной и детской хирургии, к.м.н.
Сундетов Мухтар Магзомович
- торакальный хирург высшей категории, к.м.н., e-mail: [email protected]
Касенбаев Руслан Жумаханович -торакальный хирург.
Воронин Денис Сергеевич -детский хирург первой категории.
Курбанов Дониер Рахматуллаевич
- торакальный хирург.
Еримова Назира Жолдыбаевна -педиатр.
Ключевые слова
врожденные бронхоэктазы, хирургия, отдаленные результаты.
Most thoracic surgeons have expressed opinion about the necessity of early surgery on childrens , because congenital bronchial dilation leads to infection of the bronchial contents and re-aggravation of the inflammatory process. [1, 2, 3, 4]. But some pediatricians have the reserved attitude towards surgery in children, adhering to long-term follow tactics for sick children and re-examinations to decide of necessity of surgical intervention [5, 6]. Over the last 25 years in our clinic operated 433 patients with congenital bronchiectasis. This constituted 50.9% of all operated patients with congenital lung disease in the same period. The age of patients ranged from 2 to 65 years. Children and adolescents (60,9%) was more than adults (39,1%).
For examination of patients used chest radiography, CT scan of the lungs, bronchography, bronchoscopy, spirography, lung scintigraphy and angiopulmonography. In all cases of congenital bronchiectasis were confirmed by postoperative pathologic studies.
In 2.1% of cases the disease was asymptomatic and detected at routine radiological surveys. The first symptoms of disease in the majority patients (72.7%) from early childhood were persistent cough with mucous and purulent sputum, intermittent fever, malaise and weakness. Diagnostic bronchoscopy observed a direct correlation between the volume of anatomical changes in the bronchi, the nature and prevalence of inflammatory changes.
Computed tomography was performed on 132 patients with suspected congenital bronchiectasis . Verification was carried out according to bronchog-raphy and surgical intervention. Bronchiectasis were detected in 78 patients. Sensitivity of computed tomography in diagnosis of bronchiectasis was 93.6% and specificity - 88.8%. Thus, computed tomography allows to establish the localization of bronchiectasis, their prevalence and to identify the volume of surgery without invasive procedures.
Bronchographic studies have shown that most congenital bronchiectasis was localized in the left lung - 66,7%. The most common combination was congenital bronchiectasis of the lower lobe with lingula or with middle lobe, and most rare - a combination of lesions of the upper and middle lobes. Bilateral lung involvement was detected in 22.4% of patients, the most frequent combinations were bronchiectasis of the lower and the middle lobe (Pic. 1).
Objective information about the state of the pulmonary capillary blood flow gives scintigraphy. Were examined 67 patients. In assessing the scintigraphic data in 33 (49.3%) patients found a decrease in accumulation of the radiopharmaceutical in the form of focal changes with rounded shape, lung picture was deformed. In 34 (50.7%) patients noted a sharp decline in the alveolar-capillary blood flow up to its complete absence in pathological areas of the lung tissue.
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Pic. 1
Bronchography. Bronchi-ectasis of the lower lobe of the left lung
Angiopulmonography showed complete absence of contrast in the affected part of the lung in 8 (12.5%) patients. During angiopulmonography determined pulmonary artery pressure. In all patients, regardless of the prevalence of bronchiecta-sis, pulmonary artery pressure was within the normal range (average dynamic blood pressure below 20 mm Hg).
Almost all patients were operated in the period of remission. Volume and character of surgical interventions are presented in Table 1. The most commonly performed lower lobectomy (35.1%), extirpation of bronchi (22.2%) and combined resection (17.6%). Surgery on left lung were performed in more than 1.5 times more often. In children and adults surgery technique were similar, except staged bilateral lung resections, which performed more in adults (3.4% vs. 10.0%).
In determining the most appropriate surgical tactics is striving for maximum removal of the affected part of the lung which irreversibly lost its function, and at the same time striving for maximum preservation of unaltered lung tissue [7]. Therefore, while maintaining the airiness and blood flow in the localization of bronchiectasis, we often used the
method of extirpation altered bronchus in children (21.9%), and adults (22.5%) (Pic. 2).
Adult patients have a longer history of the disease, so they are more likely (to 84.1%) have a dense and extensive adhesions in the pleural cavity. This leads to an increase traumatism and duration of the operation that extends the postoperative period. The frequency of early postoperative complications in children was 10.6%, and in adults reached to 20.7%. The most frequent complications in the operated children were intrapleural bleeding (2.65%) and atelectasis (2.65%) of the operated lung lobe. In adults more commonly found bronchial fistulas (4.1%). Early postoperative complications occurred more often combined lung resections (53.6%), lobec-tomy (25.0%) and the extirpation of the bronchi (10.7%), which coincides with the frequency of their performance.
In the long-term period from 1 year to 22 years were examined 190 operated patients. Good long-term results were evaluated with the full recovery and full ability to work, absence of cough, acute inflammation (bronchitis, pneumonia), normal or near-normal indicators of external respiration (VC,
Table 1
Character of surgical interventions in patients with congenital bronchiectasis
Type of surgery Children % Adults % Total %
Pneumonectomy 2 0,8 2 1,2 4 0,9
Bilobectomy 13 4,9 14 8,3 27 6,2
Lobectomy
upper 1 0,4 1 0,2
middle 24 9,1 15 8,9 39 9,0
lower 96 36,4 56 33,1 152 35,1
Combined resection 53 20,1 23 13,6 76 17,6
Segmental resection 8 3,0 4 2,4 12 2,8
Extirpation of bronchi 58 21,9 38 22,5 96 22,2
Staged bilateral lung resection 9 3,4 17 10,0 26 6,0
Total 264 100 169 100 433 100
long-term results Good results Satisfactory results Unsatisfactory results
age children Adults children Adults children Adults
number 60 46 13 19 21 31
% 63,8% 47,9% 13,8% 19,8% 22,4% 32,3%
P <0,05 >0,05 >0,05
Pic. 2
Scheme of extirpation of bronchi in congenital bronchiectasis.
Table 2
Character of long-term results in operated patients
FVC, MVL) , absence of inflammatory changes during bronchoscopy and pathological changes in X-ray studies and bronchoscopy.
Under satisfactory long-term results, we realized a state of patients with persistent improvement of general condition, but with occasional cough with mucopurulent or purulent sputum, exacerbation of inflammatory diseases (bronchitis, pneumonia), which were no more than once a year. External breathing parameters may be reduced to 60% and bronchoscopy mainly limited endobronchitis different characteristics.
Unsatisfactory postoperative results were evaluated when the inflammatory process has progressed in the bronchopulmonary system: the presence of persistent cough with purulent sputum, and frequent pneumonia (more than 2 times per year). Usually the presence of varying degrees of disability. External breathing parameters, less than 60%. At bronchoscopy widespread or diffuse purulent
References
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The survey results are presented in Table 2.
Good results (practical recovery) were observed in 63.8% of children, which is significantly higher than the results of surgical treatment of adult patients (P<0,05). All unsatisfactory results observed in patients with bilateral lesions and residual bron-chiectasis in the operated lung.
Conclusion
For early diagnosis of congenital bronchiecta-sis need a comprehensive examination, the active use of such highly informative and non-invasive methods, such as computer tomography. Examination of the patients in the long term showed that timely diagnosis and early surgery reduces the risk of postoperative complications and improves long-term results.
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