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описание клинического случая
U.D.C. 616-089;617.5
Zh.A. Doskaliev, A.I. Kolos, E.B. Aitzhanov,T.I. Sarsengaliev, A.P. Savchuk, D.Zh.Saparbay, A.N. Taganova.
JSC « National scientific medical centre» Astana city, Kazakhstan
successful surgical treatment of the patient with left pleural
cavity haemangioma after two inefficient surgeries
Haemangioma of the intra chest localization is very rare and dangerous disease affecting on young age people [1]. This tumor differs the morphological variety caused by a difficult anatomic structure of a chest wall, a pleura, a lung, and mediastinum. The usual radiological research conducted in the preoperative period, doesn't give a complete representation of a tumor, its relation to the main vessels and boundary organs. Choice method for haemangioma diagnostics is the computer tomography (CT) executed with intravenous contrast strengthening and image reconstruction in 3D. The direct indication is the selective ekstrakranial arteriography, which allows to receive detailed data about tumor localization, its form, sizes, to study internal vascular structure, to reveal arterial and venous ways of inflow and blood [2] outflow. Underestimation of all aspects of pathological process before operation can put operating surgeons in a difficult situation.
The clinical example given by us proves that patients need full inspection and carrying out surgery in the conditions of the clinic having the hitech diagnostic equipment and qualified doctors.
The patient M, 29 years, police, arrived in surgical department of JSC" NSMC" on 07.10.2012 with the diagnosis: Haemangioma of the left chest wall, pleura. Condition after two operations (February, April, 2011). The disease was diagnosticated in February 2011 by passing fluorography. There was found pathological shadow on the left costal side of the chest wall. The auxiliary investigation was carried out, X-ray of the thorax in direct and lateral projections are executed. There was found a focal hemisphere shadow with well-defined, ragged, interal edge, at the level of the II-IV rib's edges ,which protruded in a left pleural cavity.
The patient was admitted to the Regional Cancer Center, where he was (19.02.2011) operated on.The dissection of the soft tissues on the left suprascapular region was made. The attempt to remove the tumor was unsuccessfull. The intraoperative blood loss was about 3 liters. The wound was closed by muscles, the swab was left in the wound. After stabilization of the patient, the correction of anemia, he was taken to a second operation in the Regional Oncology Center.
17.04.2011g. - Operation left-sided anterolateral thoracotomy with additional resection of the anterior segment II-III-IV ribs. However, despite the wide online access, to resect the tumor wasn't exsected. The attempt of haemangioma exsection caused profuse bleeding. Intrapleural blood loss was over before 3l.The operations ended, after the bleeding was supressed. Hereafter the patient was treated in outpatient clinic by changing the bandages. Patient was consulted by thoracic surgeon of JSC «NSMC.» Patient wasadmitted in surgical departmentfor further examination and surgical treatment in the clinic.
On the time of admission the patient's condition was assessed as satisfactory. Proper nutrition, athletic build. Skin's color was normal. At the physical examination of the patient we found a wide rough postoperative scar in the left suprascapular region and hypermobility of the left scapula. On anterolateral surface of the left had a large scar after thoracotomy with anterior chest retraction by the resected ribs. Auscultation in the left lung listens weakened breathing without wheezing. The patient was performed computed tomography of thoracic segment with contrast enhancement (Picture.1).
Picture. 1 - CT thoracic segment Patient M., 29 years old from 12.10.2012g - The anterolateral chest wall on the left is rendered irregular growth, with clear irregular contours, irregular structure due to the presence of multiple tortuous vascular elements
The tumor displaces the lungs, heart to the right. Of the left subclavian artery in the anterior and distal segments of the tumor blood vessels depart 2. Laterally from hemangiomas leaves wide tributary that flows into the left subclavian vien.Partially resected II-III-IV ribs on the left.
Conclusion-CT picture of tumors (haemangioma) of the front of the left chest wall, pleura Condition after reoperation with resection of fragments of ribs.
Consider the vascular nature of the tumor, its location in a hazardous area, it was decided to perform CT thoracic segment with intravenous contrasting. It was found that the tumor actively accumulates a contrast agent, resulting in clearly visible and discharge vessels. To determine vascular collaterals, choosing the optimal surgical approach to the patient was made extracranial selective arteriography (Picture 2).
Picture. 2 - Multislice computed tomography of the thoracic aorta and its extracranial branches patient M., 29 years old from 20.10.2012g. Thoracic aorta is not changed. Right: the brachiocephalic trunk (BTSS) subclavian artery (RCA), common carotid artery (CCA), external carotid artery (ECA), internal carotid artery (ICA), vertebral
artery (PA) is not changed
On the left in front of the projection of the chest wall tumor visualized irregular shape with sharp jagged contours size 16h12h10 cm, heterogeneous structures by vascular shadows looped type. The second segment segment of the left subclavian artery and extending from his abnormal blood vessels that penetrate into the tumor clearly contrasted. Venous trunk, leaving the tumor and run into the left subclavian vein. Conclusion: CTA
giant haemangioma of the left chest wall, pleura, associated with the subclavian vessels.
Taking into account the results of CTA, we decided to use the supraclavicular longitudinal access to highlight a.subclavia sinistra, with the aim of taking it to the turnstile and temporal compression during the operation, the main access to the best operating elected anterolateral thoracotomy through the old scar. Into the operating team the vascular
surgeon was included.
25.10.2012g. Operation: Mobilizing the left subclavian artery through the supraclavicular access. Retorakotomiy, pneumolysis, removal of the hemangioma with a permanent clamping a. subclaviasinistra.
After dissection of the soft tissues over the left clavicle, the second segment of subclavian artery was mobilized through the supraclavicular access,it is taken to turnstile.The anterolateral thoracotomy was made on the left along the old scar,front segment s of II-III-IV ribs were exsected in the results of previous operations. By dissection of the muscles in the wound adhered thickened parietal pleura. The pleura had solid adhesions with lungs .Adhesions especially solid in the apical and apical-costal departments. Pneumolysis was made mainly by sharp method with coagulation. There was found a tumor on the chest wall in the anterior-lateral part,which extends from the subclavian artery to the level of the IV rib. The tumor grows into the
soft tissue of suprascapular region. In the process of the separating tumor 7 branches of a.subclavia sinistra were ligated and crossed . During dissection tourniquet on a. subclavia sinistra clamped for 20-30 minutes, which significantly reduced the hemorrhage.
Step by step with technical difficulties made allocation of a tumor which had a vascular structure, was characterized expressed cicatricial process because of previous two surgeries. In the same way were methodically allocated, tied up and venous taking-away branches are crossed. Tumor was removed radically. Control hemostasis, tightness of the lung. In the pleural cavity summed silicone drain. Intermuscular by a thin catheter, both filed with the skin, connected to Byulau. Wound sutured in layers. Aseptic sticker. Superimposed thoracic bandage with locking roller to eliminate the flotation of the chest wall. Intraoperative blood loss was 200 ml.
Stages of the operation are shown in Picture 3.
Picture 3 - The stages of operation (separation the haemangioma with
clamping a.subclavia.)
Macroscopic assessment of an operational preparation. The tumor sizes - 16kh12kh10sm. It
is presented by two fragments, consisting of the
vessels filled with dark blood, fibrous and fatty tissue.
Picture.4 - Operational preparation- tumor of a vascular structure with
cavity existence
The final histological conclusion mixed haemangioma (capillary and cavernous) with significant stromal component
Picture. 5 shows histological structure of removed tumor. The tumor consisted of irregularly arranged in a fibrous stroma vascular capillary and cavernous type with areas of active proliferation of endothelial cells. . There are fat and muscle tissue in tumor structure.
Picture 5 - histological preparations of removed tumor (hematoxylin and eosin stain (capillary type))
Uncomplicated postoperative course. On the first day the patient was in the intensive care unit, where he performed fluid therapy, pain management, control the number and cellular composition of discharge to drainage. Hemodynamic parameters were stable: blood pressure numbers 120/70 mm Ha Pulse rate of
110 per minute. CVP-2 sm. After the correction of hypovolemia pulse became less-90 per minute. CVP stabilized at 8 sm of w. The next day the patient was transferred to the surgical ward of the department. On plain film of 26.10.2012: Left lung expanded, mediastinum normal configuration (Fig. 6).
Pic. 6 - X-ray image Patient M., 29 years after operation.Left lung expanded, the cupula of the diaphragm is differentiated. Mediastinum is
normal configuration
Blood hemoglobin after surgery were within 118 g / L, erythrocyte-4.7h1012 / l.The quantity of exudates from the drain was about 280 ml a day. The drain was removed on the 5-th day after operation. Wound regeneration per primum. 01.11.2012 the patient was discharged for outpatient clinic monitoring.
Thus, it is necessary to conduct a complete examination, including CT in angio mode with reconstruction images in 3D, as well as selective
angiography to obtain a complete picture of haemangioma, its vascular collaterals, which is an important condition for the choice of surgical approach and method. This kind of operations should certainly be included in the list of high-specialized medical care and run central clinics of Kazakhstan.
References:
Boyko V., Krasnoyaruzhsky AG Korzh PN, V. Tkachenko, Surgical treatment of compression syndrome with mediastinal tumors // Proceedings of the II International Congress "Current trends in modern cardiothoracic surgery" - St. Petersburg, 2012 - P. 194-5.
Douglas S. Katz, R. Keyvin Mac, Stuart A. Greskin Secrets rentgenologii.-Saint-Petersburg, 2003-C. 72-77.
Материал поступил в редакцию 24.11.2012 г.
УДК 616.9
Н.Н.Медведева, Г.К. Нуртазина, В.С. Торопеева, Б.О. Жармагамбетова, С.К. Кенжебаева
Городская детская инфекционная больница, г. Астана, Казахстан
клинико - инструментальные аспекты диагностики болезни гиршпрунга у детей
Одним из тяжелых врожденных заболеваний желудочно-кишечного тракта у детей является болезнь Гиршпрунга. По данным разных авторов частота колеблется от 1:20 000 до 1:1 000. Мальчики болеют в 4-5 раз чаще девочек. Основная причина развития болезни Гиршпрунга - нарушение парасимпатической иннервации, характеризующийся агенезией ганглиев подслизистого и мышечно-кишечного нервных сплетений. В связи с этим нарушается функция аганглионарного участка кишки. Отсутствие нормальной перистальтики делает невозможным продвижение содержимого кишечника через суженный сегмент, что ведет к ее функциональной обтурации. Кишка, расположенная выше зоны сужения, расширяется, стенки её гипертрофируются, вследствие чего развивается мегаколон. В большинстве случаев болезнь Гиршпрунга диагностируется в младенчестве. Трудности диагностики у детей первого года жизни связаны с наличием относительно компенсированных форм заболевания.
В зависимости от длины аганглионарного сегмента выделяют 3 формы болезни Гишпрун-га: острую, подострую, хроническую.
Приводим пример нашего наблюдения по-дострой формы болезни Гиршпрунга. Подострая форма болезни Гиршпрунга развивается при меньшей протяженности аганглионарного участка кишки.
Ребенок С., возраст 3 месяца, родился от 1 первой беременности, 1 срочных родов. Течение беременности и родов без особенностей. Ребенок на грудном вскармливании, но последнюю неделю - на смешанном, так как мама включила в рацион ребенка искусственные смеси. С рождения у ребенка отмечалась задержка стула,
периодическое срыгивание, постоянное вздутие живота. До поступления в наш стационар ребенок не обследован.
Заболел ребенок остро с повышения температуры тела до 38-38,50С, катаральных проявлений (заложенность носа, кашель). В последующем вирусемия сохранялась в течение 5 дней, кашель с постепенным усилением, симптомы интоксикации с нарастанием, с первых дней болезни отмечался жидкий водянистый стул 1-2 раза за сутки, с последующим усилением до 5- 6 раз. Ребенок пониженного питания. Кожные покровы бледные, чистые, тургор снижен. В легких аускультативно - наличие локальной симптоматики в виде ослабленного дыхания, хрипов нет. Перкуторно - притупление легочного звука в нижних отделах. Тоны сердца ритмичные, приглушенные. Обращало на себя внимание выраженное вздутие живота и контурирование петель кишечника через брюшную стенку. Живот при пальпации мягкий, безболезненный. Печень на 3 см ниже края реберной дуги, селезенка не увеличена. Стул отмечался водянистый, пенистый, секреторного типа. Ребенок госпитализирован в стационар с проявлениями респираторно-вирус-ной инфекции, осложненной двусторонней пневмонией.
Учитывая клинико - анамнестические данные, задержку стула с рождения, данные объективного осмотра, у ребенка также была заподозрена болезнь Гиршпрунга.
При обследовании в общем анализе крови отмечается ускорение СОЭ до 34 мм/час, ней-трофилез (с/я-75,6%). В копрограмме - лейкоциты до 25-30 в поле зрения, слизь++, йод, бакте-рии++. Бактериологическое обследование кала на кишечную группу - отрицательное. На УЗИ
