JOURNAL OF HEPATO-GASTROENTEROLOGY RESEARCH | ЖУРНАЛ ГЕПАТО-ГАСТРОЭНТЕРОЛОГИЧЕСКИХ ИССЛЕДОВАНИЙ
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Rahmanov Kosim Erdanovich,
Associate Professor of the Department of Surgical Diseases №. 1
Samarkand State Medical Institute
Samarkand, Uzbekistan
Abdurahmanov Diyor Shukurullaevich,
Assistant of the Department of Surgical Diseases № 1
Samarkand State Medical Institute
Samarkand, Uzbekistan
Anarboev Sanjar Alisherovich,
Assistant of the Department of Surgical Diseases № 1
Samarkand State Medical Institute
Samarkand, Uzbekistan
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 taking into account 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
Рахманов Косим Эрданович,
1-сон хирургик касалликлари кафедраси доценти
Самарқанд Давлат тиббиёт институти
Самарқанд, Ўзбекистон
Абдурахмонов Диёр Шукуруллаевич,
1-сон хирургик касалликлари кафедраси ассистенти
Самарқанд Давлат тиббиёт институти
Самарқанд, Ўзбекистон
Анарбоев Санжар Алишерович,
1- сон хирургик касалликлари кафедраси ассистенти
Самарқанд Давлат тиббиёт институти
Самарқанд, Ўзбекистон
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.
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
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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 taking into
account 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), taking into account 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 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
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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, and 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 were 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, taking into account 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.
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
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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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