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Рахманов Косим Эрданович,
Доцент кафедры хирургичеких болезней №1
Самаркандский государственный медицинский институт
Абдурахманов Диёр Шукуруллаевич,
Ассистент кафедры хирургичеких болезней №1
Самаркандский государственный медицинский институт
Анарбоев Санжар Алишерович,
Ассистент кафедры хирургичеких болезней №1
Самаркандский государственный медицинский институт
ТАКТИКО-ТЕХНИЧЕСКИЕ АСПЕКТЫ У БОЛЬНЫХ ЭХИНОКОККОЗОМ
АННОТАЦИЯ
На основании анализа историй болезни 327 пациентов с эхинококкозом печени (ЭП) разработана
тактика хирургического лечения с учетом оптимального доступа в зависимости от локализации кисты;
определены показания для декомпрессии желчных путей, в том числе и с применением эндоскопической
техники.
Ключевые слова:
эхинококкоз, эхинококкэктомия, ЭРПХГ, папиллосфинктеротомия.
Рахманов Косим Эрданович,
1-сон хирургик касалликлари кафедраси доценти
Самарқанд Давлат тиббиёт институти
Абдурахмонов Диёр Шукуруллаевич,
1-сон хирургик касалликлари кафедраси ассистенти
Самарқанд Давлат тиббиёт институти
Анарбоев Санжар Алишерович,
1- сон хирургик касалликлари кафедраси ассистенти
Самарқанд давлат тиббиёт институти
ЖИГАР ЭХИНОКОККОЗИ БИЛАН КАСАЛЛАНГАН БЕМОРЛАРДА ЖАРРОХЛИК ТАКТИКАСИ
АННОТАЦИЯ
Жигар эхинококкози (ЖЭ) билан касалланган 327 беморда касаллик анамнезини таҳлил қилиш асосида
кистанинг локализациясига боғлиқликка оптимал кириш имкониятини ҳисобга олган ҳолда жарроҳлик даволаш
тактикаси ишлаб чиқилди; эндоскопик усуллардан фойдаланган ҳолда, ўт йўлларини декомпрессиялаш
кўрсаткичлари аниқланди.
Калит сўзлар:
эхинококкоз, эхинококектомия, ЭРПХГ, папиллосфинктеротомия.
Rakhmanov Kosim Erdanovich,
Associate Professor of the Department of Surgical Diseases No. 1
Samarkand State Medical Institute
Abdurakhmanov Diyor Shukurullaevich,
Assistant of the Department of Surgical Diseases No. 1
Samarkand State Medical Institute
Anarboev Sanjar Alisherovich,
Assistant of the Department of Surgical Diseases No. 1
Samarkand State Medical Institute
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TACTICAL AND TECHNICAL ASPECTS IN PATIENTS WITH LIVER ECHINOCOCCOSIS
ANOTATION
Based on the analysis of the case histories of 327 patients with liver echinococcosis (LE), surgical treatment
tactics were developed considering optimal access depending on the location of the cyst; indications for biliary tract
decompression, including using endoscopic techniques, were determined.
Key words:
echinococcosis, echinococcectomy, ERPH, papillosphincterotomy.
Echinococcosis is a dangerous natural focal
parasitic disease of domestic animals and humans,
occurring sporadically and endemically. Areas that are
endemic for echinococcosis include Mountainous areas,
echinococcosis is included in the who list of diseases
requiring
radical
eradication.
The
problem
of
echinococcosis remains relevant, since the disease is
quite common, and treatment issues are becoming
debatable. Among the lesions of various organs and
tissues with echinococcosis, the frequency of liver
damage is 44-84 % [1,2,3,4,5]. Prevalence of
echinococcosis inabout all of them the incidence of
echinococcosis in the region is 1 per 10,000 inhabitants,
in the Republic of Uzbekistan 0.39 per 1000 inhabitants
(2017). the Incidence of echinococcosis in the region is 4
times higher than the incidence in the Republic of
Uzbekistan [7,8,9,10]. The problem of surgical treatment
of liver echinococcosis still remains relevant in many
regions of Uzbekistan [8,9,10,11,12,13,14]. 483 patients
with echinococcosis were operated on in the 1st clinic of
Samgmi from 2005 to 2018, 327 of them were diagnosed
with LE. the difficulties of effective surgical treatment
are due to the lack of a generally recognized optimal
treatment option, depending on the location of the cyst,
the condition of the cyst. fibrotic capsule and the lack of a
single view on the methods of treatment of the fibrotic
bed after removal of the cyst [16,17,18,19,20,21,22].
Improvement of modern diagnostic methods and
introduction of new high-tech methods of surgical
treatment did not give the expected results [24,25,26,27].
There is no consensus among surgeons about the scope of
operations for liver echinococcosis complicated by bile
duct damage. Postoperative complications in the form of
retention of residual cavities, their suppuration,
development of cholangitis, prolonged bile flow, often
with the formation of an external biliary fistula, are still
frequent and relapse of the disease [26,28,30]. The main
reason for the development of these complications is
inadequate treatment of the fibrous cyst capsule and its
capitonage. to increase the effectiveness of these key
stages of surgery, pre-and intraoperative detection of bile
ducts opening into the cyst cavity is very important
[28,29,30,31]. The aim of the study was to determine a
method for improving the immediate results of surgical
treatment of liver echinococcosis, and to develop the
most rational tactics of surgical treatment.
Materials and methods. The work is based on the
analysis of medical records of 327 patients. The main
group included 152 patients. There are 85 women and 67
men among them. Damage to the right lobe was detected
in 102 patients, the left lobe in 14, damage to both lobes
in 11 patients, and 24 patients had combined liver and
other organ damage. Indications for surgery and the
choice of optimal access for them were made considering
the location of the cyst and the nature of complications.
The choice of access depended on the topical location of
the cyst. When cysts were localized in the second and
third segments, echinococcectomy was performed from
the upper end of the spine. – median access [28], if the
first, fourth, fifth, and sixth segments were affected –
from the subcostal segment [24], if they were located in
the seventh and eighth segments, thoracotomy with
diaphragmotomy was performed [23]. one patient had a
combined access (thoracotomy, laparotomy), considering
echinococcal lesion of the left lung and right lobe of the
liver. Giant cysts, multiple cysts of both lobes of the liver
in 9 cases required transverse laparotomy or total median
laparotomy. laparoscopic surgery was performed in five
patients. One patient underwent videothoracoscopic
surgery. operation for echinococcosis of the right lung
and right lobe of the liver the diagnostic Algorithm
included clinical laboratory examinations, ultrasound
examination of the liver, computed tomography, chest x-
ray, ERPHG. Several patients (10) underwent liver MRI.
This complex of examinations allowed us to obtain an
accurate segmental localization of cysts, their size,
number, and signs of a complicated course of the disease,
such as mechanical jaundice, suppuration of the cyst,
connection of the cyst with the bile ducts, and cyst
breakthrough into the biliary system. In complex
diagnostic cases with the goal of for the differential
diagnosis of echinococcosis and liver cancer in 3 patients,
an angiographic study was performed. Only the
information received in full allowed us to solve the
tactical issues of the upcoming surgical intervention. The
comparison group consisted of 175 patients. Of these,
103 are women, 72 are men. In this group, the right lobe
was affected in 126 patients, the left lobe in 22, both
lobes in 12 patients, and combined liver and other organ
damage in 15 cases. The main operative approach in this
group of patients was the right subcostal one, and ERCP
was performed for the purpose of follow-up examination.
only in the presence of jaundice.
Research results. We believe that determining
the most rational surgical approach and timely detection
of cystobiliary fistulas (CBF) is a key factor in reducing
the likelihood of postoperative complications. One of the
most severe complications of EP is the rupture of cyst
contents into the bile ducts, which occurs in 6-63% of
cases [2,8,9,10]. According to our study, this
complication occurred in 73 people, which was 22.3%.
The clinical picture of getting the contents of an
echinococcal cyst into the bile ducts is due to the
diameter of the CBS and its level a breakthrough in the
biliary tract. Depending on the severity of the clinical
picture, we distinguish three degrees of manifestation of
CBF. The first degree was diagnosed in 22 patients (6.7%)
with severe mechanical jaundice and cholangitis, which
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occurred due to the breakthrough of the cyst contents into
the large lobar hepatic ducts. All patients in this group
showed signs of liver failure with severe intoxication,
pain, chills, and hyperthermia. The second degree was
detected in 23 patients (7%). in this group of patients,
symptoms of inflammation predominated due to the
formation of CBF with segmental duct, suppuration of
the echinococcal cyst, the development of cholangiogenic
abscesses. We assigned 28 patients (8.6%) to the third
degree, who did not have clinical manifestations of
echinococcal cyst communication with the bile ducts,
which was explained by the small size of the perforation
opening (no more than 1.5 mm) and, as a rule, the
integrity of the chitinous membranes was preserved. The
main group included 29 patients with varying degrees of
cyst breakthrough manifestations (8 patients with severe
mechanical jaundice and cholangitis, 11 patients with
inflammatory manifestations of CBF, and 10 patients
with a mild clinical course of this complication). The
diagnostic algorithm in patients of this group included
clinical and laboratory, ultrasound, x-ray, and endoscopic
examination methods. Special attention was paid to
ultrasound and computed tomography, which specified
the location, size, nature of the cyst contents, its relation
to the surrounding organs, large vessels and liver ducts.
ERPHG was used in all patients, with 25 patients
diagnosed with CBS before surgery. in patients of the
main group, the tactics and scope of treatment measures
depended on the degree of damage to the bile ducts. for
the treatment of patients with the first degree of
communication with the bile ducts we apply a three-stage
tactic of conducting therapeutic measures. The first
(preoperative) stage includes methods aimed at
decompression of the biliary tract and treatment of acute
cholangitis.
All
patients
underwent
endoscopic
papillosphincterotomy (EPST) after EPCG, and 7 of them
managed to extract fragments of the chitinous membrane
from the common bile duct. six patients underwent
nasobiliary drainage of the biliary tract with rehabilitation
of the bile ducts and administration of antibiotics after
EPST and removal of chitinous membranes. The second
stage of treatment is open surgery with the definition of
the most rational access, ensuring optimal treatment of
the cyst cavity. Argon-enhanced electrocoagulation was
used
at
the
main
stages
of
the
operation
(thoracophrenolaparotomy,
laparotomy,
cystotomy,
excision of the fibrous capsule, hemo and cholestasis). all
22
patients
underwent
echinococcectomy.
For
antiparasitic and antibacterial treatment of the cyst cavity,
80-100% glycerin or 3% hydrogen peroxide solution was
used. Our experience, as well as literature data, show that
glycerol or a solution of hydrogen peroxide have a rapid
destructive effect not only on protoscolexes, but also on
acephalocysts of hydatid Echinococcus, while the shells
of live echinococcal cysts are impermeable to these
substances, which eliminates their toxic effect on the
div. The fistula opening was sutured from the side of
the fibrous capsule with atraumatic suture material. In
order to maximize the reduction of the residual cavity, the
fibrous capsule was excised along the border with
unchanged liver tissue, followed by its capitonage or
suturing with turning the cyst wall into its cavity.
Capitonage of the residual cavity was carried out mainly
by vertical pouch seams, which allowed evenly bring
together the walls of the fibrous capsule, without
interfering with the separation of exudate. Sutures were
applied in several rows, along the liver ducts along the
wall of the fibrous capsule to the bottom and on the
opposite side in the opposite direction until the residual
cavity was closed. Open echinococcectomy was
performed in 2 patients with signs of suppuration of the
cyst
cavity,
semi-closed
echinococcectomy
with
capitonage of the residual cavity on thin drainage was
performed in 2 patients, and closed echinococcectomy
with drainage of the abdominal cavity was performed in
the remaining patients. In 8 patients, echinococcectomy
was supplemented with biliary drainage. of the Central
nervous system, considering the pronounced phenomena
of cholangitis. drainage of the choledochus according to
Vishnevsky was performed in 4 patients, according to
Ker – in 2 patients, separate drainage of the right and left
hepatic ducts was performed in 2 patients. the third stage
of treatment was drug correction in the postoperative
period, aimed at correcting hyperbilirubinemia and
bacterial complications. Patients with second-degree
cystobiliary fistulas in the presence of cholangiogenic
abscesses and suppuration of the echinococcal cyst
underwent
open
(16)
and
semi-closed
(7)
echinococcectomy with opening and drainage of
cholangiogenic cysts. abscesses (2), treatment was
performed in one stage, as in patients with the third
degree of manifestation of CBF. In recent years, in
addition to the listed methods for diagnosing bile duct
lesions in EP, the method of chromatic intraoperative
visualization of cystobiliary fistulas has been used by
puncturing an aqueous solution of methylene blue into
the biliary tract, which allowed 5 patients to detect small
(up to 1.5 mm in diameter) cystobiliary fistulas during
surgery. Discussion. So, patients with second and third
degree CBF underwent one-stage treatment, which
consisted of autopsy, rehabilitation and antiparasitic
treatment of the residual cavity, elimination of the biliary
fistula from the fibrous capsule by electrocoagulation or
suturing with atraumatic suture material and elimination
of the residual cavity. In case of prolonged bile flow in
the postoperative period (more than 5 days), which was
noted in 6 patients of the main group, PST was performed,
against which bile flow stopped on 6-7 days. In the main
group, 107 patients had uncomplicated echinococcosis,
they underwent closed echinococcectomies (89), 5 of
them laparoscopically, liver resection (1), and perfect
echinococcectomy
(8),
14
have
a
semi-closed
echinococcectomy. Postoperative complications were
registered in 27 patients (17.76%). Among the patients of
the main group, 29 patients (23.01%) were admitted and
treated with recurrent cysts. 10 patients were diagnosed
with rare complications of EP in the form of cyst bursting
into the abdominal and pleural cavities, diaphragm
necrosis, etc. (table 1). Fatal outcome was recorded in
three patients of the main group, which was 1.97%. Of
the 175 patients with EP in the comparison group, 64
cases of complicated course were noted (36.6%). 87 of
them underwent closed echinococcectomy, 17-semi-
closed and 71 patients underwent open echinococcectomy.
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Table 1
The nature of identified complications in patients with liver echinococcosis
Complications
Main group
Comparison group
n = 152
%
n = 175
%
Breakthrough of an echinococcal cyst into the pleural cavity
2
1,3
1
0,57
Necrosis of the diaphragm
1
0,66
-
-
Cystobiliary fistulas of the first degree
8
5,3
14
8
Second-degree cystobiliary fistulas
11
7,2
12
8
Third-degree cystobiliary fistulas
10
6,6
18
10,3
Cyst breakthrough into the abdominal cavity
4
2,6
5
2,8
Exudative pleurisy
2
1,3
1
0,57
Suppuration of an echinococcal cyst
6
4
11
6,3
Breakthrough in the tracheobroncheal tree
1
2,8
-
-
Total
45
29,6
64
36,6
46 patients (26.28%) were admitted with
recurrent cysts. the mortality rate in the comparison
group was 4 people, which was 2.28%. In the
postoperative
period,
EP
patients
developed
complications (table 2).
Table 2
Complications in the early postoperative period in patients of both groups with liver echinococcosis
Complications
Main group
Comparison group
n = 152
%
n = 175
%
Bile discharge
6
3,95
16
9,14
Residual cavity
9
5,92
17
9,71
Subhepatic abscess
1
0,66
3
1,72
Intraoperative anaphylactic reaction
1
0,66
-
-
Hepatopleural and peritonopleural fistulas
1
0,66
-
-
Pleural empyema
2
1,32
3
1,72
Postoperative wound suppuration
7
4,6
10
5,71
Total
27
17,76
49
28
The analysis revealed that the development of
postoperative complications in the form of residual
cavities, prolonged bile flow is primarily associated with
inadequate surgical access, ineffective capitonage, and
incomplete revision of the cyst cavity. Improvement of
diagnostic methods and surgical tactics allowed us to
reduce the number of postoperative complications in the
form of residual cavities by 10.24 %.
Conclusion. thus, the problem of preventing the
development of complications after echinococcectomy
can be solved by a full-fledged preoperative diagnosis,
which includes a full range of clinical, laboratory and
instrumental examinations. Choosing the most rational
surgical approach for each patient allows you to perform
a thorough visual control, clarify the configuration of the
cyst, its connection with the ducts, and eliminate them.
Reliable capitonage of the residual cavity by vertical
sutures
and
decompression
by
endoscopic
papillosphincterotomy in the pre-or postoperative period
this period allows you to achieve a full recovery of
patients.
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