RU2478345C1 - Method of surgical treatment of multilocular echinococcosis of liver - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery, and can be used in surgical treatment of patients with multilocular echonococcosis of liver. For this purpose transcutaneous drainage of cyst with further aspiration of its content is performed. After that, scolicide preparation is introduced. As scolicide preparation with 3-minute exposure 1% introduced is water solution of sodium hypochlorite in volume equal 1/3 of volume of aspirated liquid. After that, cyst content is re-aspirated. Procedure is repeated until "pure" aspirated liquid is obtained three times.

EFFECT: method makes it possible to ensure adequate and least traumatic treatment of said pathology without application of X-ray control due to application of definite sequence of techniques, as well as use of scolicide preparation, destroying envelopes of daughter echinococcal cysts.

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Description

The invention relates to medicine, namely to surgery, and can be used for surgical treatment of patients with multi-chamber echinococcosis of the liver.

Echinococcosis is a severe natural focal parasitic disease that poses a serious threat to human health in many countries of the world, including Russia, where there is an increase in the number of patients (Karmazanovsky G.G. Radiation diagnosis of echinococcosis. - M .: Vidar, 2006 ., p. 7).

Despite the improvement of surgical procedures, observance of the rules of parasitism and antiparasitism, the introduction of various chemical and physical methods of influencing the parasite, the results of surgical treatment of multichamber liver echinococcosis are not always satisfactory.

This is due to the fact that during the operation with multi-chamber echinococcosis, it is not always possible to avoid dissemination of the parasite. Aspiration of the contents of a multi-chamber echinococcal cyst, as well as antiparasitic treatment with scolicidal preparations, are associated with great difficulties due to the presence of detritus and daughter cysts. Puncture of the cyst with a trocar often leads to spraying of the contents and contamination of the surrounding tissues. Attempts to open the cyst and remove the daughter cysts with the tool leads to a massive expiration of its contents and the seeding of surrounding tissues, with the subsequent development of relapse (Chernyshov VN Surgery of liver echinococcosis. Samara, 2005, p.96-100).

Since the complication rate after echinococcectomy varies from 10 to 80%, recurrent and residual liver echinococcosis is observed in 10-35% of patients. Mortality even in leading clinics remains high and reaches 3.1-8.6% (Karmazanovsky G.G. Radiation diagnosis of echinococcosis. - M .: Vidar, 2006 - p. 8).

The unsatisfactory results of surgical treatment of liver echinococcosis have necessitated the development of new, gentle and highly effective methods of treatment.

Conducted research on the medical-scientific and patent literature revealed various methods of treating liver echinococcosis.

The most common method is percutaneous puncture, PAIR (Puncture, Aspiration, Injection, Re-Aspirasion) (HGSchipper. Percutaneous evacuation (PEVAC) of multivesicular echinococcal cysts with or without cystobiliary fistulas which contain non-drainable material: first results of a modified PAIR method. International Journal of Gastroenterology and Hepatology 2002; 50: 718-719; Ersan Aygün. The management of liver hydatid cysts by percutaneous drainage. Canadian Journal of Surgery, Vol. 44, No.3, June, 2001, p.204 ) Puncture of an echinococcal cyst is performed under radiation control, its contents are aspirated, then a scolicidal preparation is injected into the cavity, which causes the death of the parasite, after which the scolicidal preparation is re-aspirated. A 95% aqueous solution of ethyl alcohol or a 30% hypertonic NaCl solution is most often used as a scolicidal preparation.

However, the method has a significant drawback - it is used only for single-chamber echinococcal cysts of types 1 and 2 according to the classification of Gharbi (HGSchipper. Percutaneous evacuation (PEVAC) of multivesicular echinococcal cysts with or without cystobiliary fistulas which contain non-drainable material: first results of a modified PAIR method. International Journal of Gastroenterology and Hepatology 2002; 50: 718-719).

Modifications to the PAIR method are also known. In particular, the PAIR-PD method, in which a thin drainage is installed in the cyst cavity for several days. Repeated sanitation of the cyst cavity with a scolicidal preparation is carried out on it, after which the drainage is removed (Gavrilin A.V. et al. Puncture method for treating hydatid cysts of the liver under ultrasound examination. Surgery, 2002, No. 8. - p. 42; Ersan Aygün The management of liver hydatid cysts by percutaneous drainage. Canadian Journal of Surgery, Vol. 44, No. 3, June, 2001, p. 204).

This method also has a significant drawback - it is used only with single-chamber echinococcal cysts of type 1 and 2 according to the Gharbi classification.

Another type of percutaneous treatment is percutaneous drainage (Gavrilin A.V. et al. Puncture method for treating hydatid cysts of the liver under ultrasound guidance, Surgery, 2002, No. 8, p. 42). After performing PAIR-PD with the installation of a 9F drainage, a cystic cavity treatment is carried out for several days. After that, the puncture of the puncture canal is performed up to 20F under radiological control with the installation of a metal sleeve. Bougienage is performed under short-term intravenous anesthesia. A rigid plastic catheter is inserted through the sleeve and fragments of the echinococcal membranes are removed by aspiration, the removal process is controlled fistulographically. To control the removal of the membranes, a flexible fibroscope is inserted into the cyst cavity, with the help of which, under the visual control, the membranes of the echinococcal cyst are completely removed.

This method has a significant drawback - it is mainly used for single-chamber echinococcal cysts of type 1 and 2 according to the Gharbi classification. The method is also accompanied by a high radiation load on the patient and the medical staff, since the manipulations are mainly performed under fluoroscopic control.

A type of percutaneous drainage is the PEVAC method (percutaneous evacuation of cyst content), used to treat patients with multi-chamber echinococcal cysts with or without cystobiliary fistulas which contain non-drainable material: first a modified PAIR method. International Journal of Gastroenterology and Hepatology, 2002, 50: 718-723).

Under ultrasound control, percutaneous puncture of a multi-chamber echinococcal cyst is performed. Aspirate the maximum possible amount of content. Then, under X-ray control according to the Seldinger method, drainage with 12F drainage is performed. Next, replace the 12F drainage with a rigid sheath Amplatz 14-18F. A plastic drainage is introduced through the introducer and fragments of the echinococcal membranes are removed by aspiration, the removal process is controlled by fluoroscopy. After complete removal of the contents of the multi-chamber cyst, a drainage of the appropriate size is installed in it.

The disadvantages of the method are: the possibility of relapse, since there is no scolicidal treatment of the contents of a multi-chamber cyst. The possibility of contamination of the abdominal cavity due to the expiration of the contents of the cyst along the wound canal during Seldinger drainage and drainage replacement is not excluded. It is possible that daughter cysts will remain intact, since fluoroscopy does not provide complete control. There is a radiation load on the patient and medical personnel, since the manipulations are mainly performed under fluoroscopic control.

For the treatment of patients with multichamber echinococcosis of the liver, a method is used that involves the use of a specially designed device for echinococcectomy, which is a set of two fixation troacors with a diameter of 12 mm, the distal part of which has a tapered thread and is sharpened sharply and has a morserator. The treatment is carried out as follows: the morcelator is attached to the suction and introduced into the trocar fixative. With constant aspiration, rotational movements of the trocar produce perforation of the cyst and fixation in the wall of the fibrous capsule. After aspiration of part of the contents into the cavity of the multi-chamber echinococcal cyst, the morcelator of the membrane of the echinococcal cyst is introduced, detritus and daughter cysts are crushed and removed. Scolicidal treatment is carried out both during and after removal of the parasite. The second trocar, if necessary, is used to insert a laparoscope and all manipulations in the cyst cavity can be performed under visual control (Chernyshov VN Surgery of liver echinococcosis. Samara 2005, pp. 97-98; 102).

The disadvantages of this method is that it uses a traumatic laparotomic approach or laparoscopic approach, which has general and local contraindications. Common contraindications are diseases in which it is impossible to carry out any laparoscopic surgery. Local contraindications are intrahepatic cysts, cysts of the I, II and VII segments of the liver, cysts less than 50 mm in size, complicated and recurrent echinococcal cysts. The possibility of contamination of the abdominal cavity during puncture of the cyst with a trocar is not excluded. The use of anesthetics increases the risk of possible complications.

RF patent No. 2140213 (1999, BI No. 30) protected the "Method for the surgical treatment of liver echinococcosis", which provides percutaneous drainage of the cyst, aspiration of its contents, scolicidal treatment of the cavity and removal of the chitinous membrane of the cyst. Percutaneous drainage of an echinococcal cyst under the control of ultrasound is performed with a catheter needle through the liver parenchyma. An aqueous solution of 30-86% glycerol with a 1% solution of diphenhydramine is used as a scolicidal or germicidal agent. Exposure 3-10 minutes. The puncture channel is expanded with bougie. Then carry out microscopic control of the contents of the cyst for the presence and viability of the germinal elements of echinococcus. An extirpation device is introduced through the expanded channel. Then the chitinous membrane is removed from the cyst. Subtle drainage is left to close the residual cavity.

The disadvantages of the method is that it is used only with single-chamber echinococcal cysts of type 1 and 2 according to the classification of Gharbi.

The patent of the Russian Federation No. 2275868 (2006, BIPM No. 13) describes the "Method of one-stage video laparoscopic treatment of multichamber echinococcal liver cysts complicated by biliary fistula". Percutaneous puncture of all cyst chambers available for puncture is performed. Delete the contents of the cameras. Antiparasitic treatment of each chamber is carried out. A fibrous capsule is excised in a volume of no more than a hemisphere. External drainage is carried out by conducting drainage through the tissue of the liver or fibrous capsule into the external opening of the fistula. A lock of the omentum tampons the cavity formed. The gland is sealed to the edge of the excised capsule.

The disadvantages of this method is that they use laparoscopic access, which has general and local contraindications. Common contraindications are diseases in which it is impossible to carry out any laparoscopic surgery. Local are intrahepatic cysts, cysts of the I, II and VII segments of the liver and recurrent echinococcal cysts. The possibility of developing a relapse is not ruled out, since it is technically not always possible to perform percutaneous puncture of all daughter cysts and, accordingly, perform adequate scolicide treatment. The possibility of contamination of the abdominal cavity is not ruled out, due to the expiration of the contents of the cyst during excision of the fibrous capsule. The use of anesthetics increases the risk of possible complications.

RF patent No. 2355436 (2009, BIPM No. 14) protects the "Method for the surgical treatment of liver echinococcosis", which includes percutaneous drainage of the cyst, aspiration of its contents, scolicidal treatment of the cavity and removal of the chitinous membrane of the cyst. Percutaneous drainage of the cyst is performed after 3-4 cm of healthy liver parenchyma. After aspiration of the contents of the cyst into its cavity, in a volume equal to 1 / 4-1 / 3 of the volume of the removed echinococcal fluid, a scolicidal preparation is administered. A change in the scolicidal preparation is carried out once a day for the first 2 days. After the end of the scolicidal treatment, the chitinous membrane of the cyst is removed. For this, a 1% aqueous solution of sodium hypochlorite in a volume equal to 1 / 4-1 / 3 of the volume of the removed echinococcal fluid is injected into the cystic cavity 2-3 times in the daytime for 1-2 hours with intervals of 2-4 hours. Before each change of solution, the cyst cavity is washed with a 1% aqueous solution of sodium hypochlorite. External passive drainage is performed at night and in between washings. The procedure for removing the chitinous membrane of the cyst is carried out within 7-10 days and is completed after the cessation of the passage of its fragments. After that, within 5-7 days 1-2 times a day, the residual cavity is sanitized with 10-15 ml of an antiseptic solution.

The disadvantages of this method is that it is used only with single-chamber echinococcal cysts of type 1 and 2 according to the classification of Gharbi.

The closest in technical essence and adopted as a prototype is a method of surgical treatment of multichamber liver echinococcosis (Saremi F. Percutaneous Drainage of Hydratid Cysts: Use of a New Cutting Deivice to Avoid Leakage. American Journal of Roentgenology 1992; 158: 83-85), providing for percutaneous drainage of the cyst, aspiration of its contents, administration of a scolicidal preparation and sanitation of the residual cavity. After local anesthesia and a small skin incision, a 7 F teflon drainage is installed in the cavity of the multi-chamber echinococcal cyst using the stylet-catheter technique, and the maximum amount of cyst contents is aspirated. Then a scolicidal preparation is injected into the cyst cavity: 20% NaCl or 0.5% silver nitrate with an exposure of 5-10 minutes. After scolicidal treatment, a water-soluble contrast agent and Lunderquist guideline 0.038 "are introduced into the cyst cavity under fluoroscopic control. A dilator 12F is inserted into the cyst cavity through a 7F drain. Then, under the fluoroscopic control, an external metal cannula of the cutting device of 14F is inserted into the cyst cavity through a 12F dilator, and , the catheter and dilator are removed, the internal cutting cannula of the device is introduced and the membranes of the maternal and daughter cysts are fragmented with simultaneous aspiration and irrigation of the polo ty cysts with a scolicidal preparation. In order to completely remove the cyst contents, the device performs rotational and reciprocating movements. After removing the cyst contents, a rigid endoscope is inserted through the external cannula of the cutting device and the cyst cavity is examined. the devices are moved closer to them, and the above procedure is repeated.After complete removal of the membranes and daughter cysts, confirmed by endoscopic control, through zhnuyu cannula cutting device is administered conductor Lunderquist 0,038 ", and the cannula removed. A pig-tail drainage of size 10F is installed through the conductor under fluoroscopic control into the cyst cavity, which is removed after complete obliteration of the cyst cavity.

The disadvantages of the prototype are the lack of effectiveness in the treatment of multichamber echinococcosis of the liver, due to:

1) the high invasiveness of the method, due to repeated manipulations with tools, as well as performing reciprocating and rotational movements with a cutting device.

2) high radiation load on the patient and medical personnel, since the manipulations are mainly performed under fluoroscopic control;

3) the possibility of developing a relapse of the disease, because due to the restriction of the examination of the cyst cavity by a rigid endoscope in the posterior direction, it is possible that fragments of the membranes and entire daughter cysts will remain. Relapse of the disease can also be caused by contamination of the abdominal cavity due to the expiration of the contents of the cyst along the wound channel during the change of instrument;

5) the possibility of developing complications such as intra-abdominal bleeding from the liver parenchyma, as well as the possibility of cyst contents flowing into the abdominal cavity due to a mismatch in the size of the external cannula of the cutting device (14F) and the installed pig-tail drainage (10F).

The aim of the invention is to increase the effectiveness of the treatment of multichamber echinococcosis of the liver.

Effect: the exclusion of radiation exposure to the medical staff and the patient, reducing the invasiveness of the method, as well as reducing the number of complications and relapses of the disease.

This goal is achieved by the fact that surgical treatment of multichamber echinococcosis of the liver involves percutaneous drainage of the cyst, aspiration of its contents, administration of a scolicidal preparation and sanitation of the cavity. As a scolicidal preparation with an exposure of 3 minutes, a 1% aqueous solution of sodium hypochlorite is introduced in a volume equal to 1/3 of the volume of the aspirated liquid. Then re-aspirate the contents of the cyst. The procedure is repeated until three times to obtain a "clean" aspirated fluid. Remediation of the residual cavity is performed with an antiseptic solution until the cyst cavity is completely obliterated and drainage is removed.

Sodium hypochlorite (registration certificate No. 95/178/10 of 04/12/1995) is an inorganic chlorine preparation. It is highly soluble in water, stable in alkaline solutions (pH 12). Cumulates in the skin. Not allergenic. It has a bactericidal effect on staphylococci, Escherichia coli, pseudomonads, viruses, and yeast in concentrations of 100-250 mg / ml. 2-5% solutions are recommended for washing the vagina, oral cavity, nose, pharynx in case of bacterial, viral and fungal diseases (A. Krasilnikov. Antiseptic handbook. - Minsk: Higher school. - 1995, p. 96).

The pharmacological effect of sodium hypochlorite is antiseptic, disinfectant, antimicrobial, detoxifying. It is capable of releasing atomic chlorine, which is the strongest oxidizing agent. Destroys the molecules of any organic substrates. Active against gram-positive and gram-negative bacteria, most pathogenic fungi, protozoa, viruses (Radar Drugs Guide).

The mechanism of action of sodium hypochlorite on protoscolexes and membranes of echinococcal cysts was identified empirically by us. It consists in dissolving the membranes of the echinococcal cyst, and, as our studies have shown, its 1% aqueous solution completely dissolves the membranes of the echinococcal cyst within 2-3 minutes, and causes the death of protoscolexes within 1 minute.

The treatment of multichamber liver echinococcosis is carried out by means of surgical intervention, which involves percutaneous drainage of the cyst under ultrasound control of the Hitachi 525 apparatus. A place for optimal drainage is chosen on the patient’s skin under the control of ultrasound scanning. Under local anesthesia, a skin incision of up to 1 cm is performed. Percutaneous drainage is performed using “Cavity Drainage Devices” (UDPO), manufactured by Minimally Invasive Technologies LLC (MIT) (Russia) with 12F polyethylene fixed drainage with Luer- connector Lok. Drainage is necessary after 3-4 cm of healthy liver parenchyma, which ensures tightness and eliminates the flow of echinococcal fluid into the free abdominal cavity.

After percutaneous drainage of the cyst through drainage with a 20 ml syringe, its contents are aspirated as much as possible.

After aspiration of the contents of the cyst for the purpose of scolicidal treatment and destruction of the membranes of the daughter cysts, as well as the tissue component - maternal detritus, a scolicidal preparation is introduced into the cyst cavity in an amount equal to 1/3 of the volume of the aspirated liquid, which is used as a 1% aqueous solution sodium hypochlorite.

After exposure of the solution for 3 minutes, the contents of the cyst are re-aspirated with a 20 ml syringe.

The procedure is repeated until three times to obtain a "clean" aspirated fluid.

In the postoperative period, the residual cavity is sanitized with an antiseptic solution, for example, a 0.5-1% aqueous solution of the same sodium hypochlorite 1-2 times in the daytime. The rehabilitation procedure is carried out until the cyst cavity is completely obliterated and drainage is removed.

External passive drainage is performed at night and in between breakdowns.

The practical application of the proposed method is illustrated by an example from clinical practice.

Example

Patient S., 43 years old, medical history No. 5885, was admitted to the surgical department No. 1 of the Rostov Regional Hospital No. 2 with a diagnosis of multichamber echinococcal cyst of the right lobe of the liver.

Upon admission to the ward, the patient's condition is relatively satisfactory. He noted complaints of periodic, dull pain in the right hypochondrium. The boundaries of the lungs are normal. Vesicular breathing in all departments, wheezing was not heard. The boundaries of the heart are within normal limits. Heart sounds are clear, rhythmic, no noise. Pulse 73 beats in 1 minute. HELL = 150/100 mm Hg The abdomen on palpation is soft in all departments. With deep palpation in the right hypochondrium, the formation of a tight-elastic consistency, sedentary, painless, larger than 10 cm, was palpated. In the general analysis of blood and urine, no changes were detected. Blood biochemical parameters are within normal limits. The serological reaction to echinococcosis is positive. An X-ray examination of the chest organs revealed no focal and infiltrative changes. Ultrasound of the liver in the projection of the VII segment was determined cyst with a diameter of 107 mm with additional anechogenic cavities along the walls with a diameter of 28 to 38 mm.

The patient underwent surgical treatment of multichamber echinococcosis of the liver according to the claimed method.

A place for optimal drainage was selected on the patient’s skin under the control of ultrasound scanning using the Hitachi 525 apparatus, the trajectory of transhepatic drainage passed bypassing the gall bladder and the main vessels of the liver. Under local anesthesia with a 2% Lidocaine solution - 8 ml, a 1 cm long skin incision was made. Percutaneous drainage was performed using ultrasound scanning using a Device for Cavity Drainage (UDPO), manufactured by MIT LLC (Russia) with polyethylene fixed drainage 12F with Luer-Lok connector. Drainage was performed through 3 cm of healthy liver parenchyma, which ensured tightness and prevented the echinococcal fluid from flowing into the free abdominal cavity.

After percutaneous drainage of the cyst through the drainage with a 20 ml syringe, its contents were aspirated. 300 ml of clear echinococcal fluid was removed. After aspiration of the contents of the cyst for the purpose of scolicidal treatment and dissolution of the membranes, 100 ml of a 1% aqueous solution of sodium hypochlorite was introduced into its cavity by drainage. With an exposure of 3 minutes, the contents of the cyst were aspirated; 160 ml of fluid with fragments of the membranes of the echinococcal cyst were removed. A 1% aqueous solution of sodium hypochlorite in a volume of 120 ml was re-introduced into the cyst cavity through drainage. With an exposure of 3 minutes, the contents of the cyst were aspirated, 210 ml of fluid with fragments of the membranes of the echinococcal cyst was removed. After that, 150 ml of a 1% aqueous solution of sodium hypochlorite was introduced into the cyst cavity through drainage. With an exposure of 3 minutes, the contents of the cyst were aspirated; 150 ml of fluid with fragments of the membranes of the echinococcal cyst were removed. The cyst cavity was sanitized with a 1% aqueous solution of sodium hypochlorite in a volume of 150 ml, with an exposure of 3 minutes until three times to obtain a "clean" aspirated fluid.

In the postoperative period, the residual cavity was sanitized daily with a 0.5% aqueous solution of sodium hypochlorite once a day. The volume of solution used was reduced as the residual cavity was obliterated. External passive drainage was performed at night and in between breakdowns. Remediation was carried out for 24 days until the cyst cavity was completely obliterated and drainage removed.

The patient in satisfactory condition was discharged from the ward.

In the long-term postoperative period, a follow-up ultrasound of the cystic formations in the liver was not detected; at the site of localization of the cyst, the hyperechoic zone of fibrosis was determined.

The proposed method for the surgical treatment of multichamber echinococcosis of the liver was introduced in the surgical department No. 1 of the Rostov Regional Hospital No. 2 and was used in the treatment of 11 patients with multichamber echinococcal liver cysts. The size of the cysts was from 64 mm to 154 mm. All patients in satisfactory condition were discharged from the department. The average hospital stay was 23 days. A follow-up examination of all patients with relapses and residual cavities, according to ultrasound, CT and MRI, was not detected.

Thus, the proposed method for the surgical treatment of multi-chamber echinococcosis of the liver eliminates the radiation load on the medical staff and the patient, reduces the invasiveness of the method, and significantly reduces the number of complications and relapses of echinococcosis of the liver.

Claims (1)

A method of surgical treatment of multicameral liver echinococcosis, which involves percutaneous drainage of a cyst, aspiration of its contents, administration of a scolicidal preparation and sanitation of the residual cavity, characterized in that a 1% aqueous solution of sodium hypochlorite in a volume of 1 is administered as a scalicidal preparation with an exposure of 3 minutes / 3 volume of aspirated fluid, re-aspirate the contents of the cyst, repeat the procedure until three times to obtain a "clean" aspirated fluid.