the features of surgical treatment of echinococcus of

the lungs in children

j.А. shamsiev

Samarkand State Medical Institute, Republic of Uzbekistan

The results of surgical treatment 315 children with echinococcosis of lungs were studied. The patients were divided to 3 groups according to features of technique of echinococcectomy in different periods of action of the clinic. 123 (39,0%) patients, who underwent antiparasitic manipulation with 2-5% solution of formalin in the period 1998-2001 years, were included in the 1^st group. In the 2^nd group there were included 110 (35.0%) patients, whom echinococcus cyst of lung was treated with slolution of glycerol in room temperature in the period 2002-2005 years. 3^rd group was 82 (26.0%) patients, whom glycerol with 70˚С temperature was used as germicide during 2006-2010 years. Besides that in this group surgical minimal approaches were used, which in many cases was completed with fiberoptic endoscopy revision of fibrous capsule. There was showed that developing of surgical tactics, wide using of minithoracotomy, facilities of videoassisted manipulations, processing of a cavity of echinococcus cyst with hot glycerol, individual approach to suture of remanded cavity proceed decreasing of postoperative complications’ rate to 7 times (from 21,9% to 3,6%) and in-patient treatment duration after surgery almost twice.

Keywords: echinococcosis, children, surgical treatment, miniapproach, postoperative complications.

Uzbekistan is located in one of the world's five endemic focuses of echinococcosis. Every year in our country about this parasitic disease it has been performed 4.5 thousand surgical operations [3]. Due to the long asymptomatic duration and the absence of pathognomonic symptoms of echinococcosis often diagnosed at later stages, when a variety of complications have been come out, the frequency of which varies from 15 to 52%, which significantly affects the duration of the disease, reduces the effectiveness of treatment [1, 2, 5-7].

According to operative information gathered in accordance with the Orders of the Ministry of Health of the Republic of Uzbekistan № 73 of 15.02.2002, at the general structure of patients with echinococcosis children make up 20.4% [3]. The disease takes them much heavier, manifested by chronic intoxication of the human organism with disorders of homeostasis system, most common by multiple and combined injures [5].

Traditional approaches, used in surgical treatment of echinococcosis, particularly in children, differs by traumatic duration, often greatly exceeds the severity of its intervention on the affected organ [1, 4]. In addition, broad sections, which have traditionally resorted to surgery hydatid disease, no longer meet modern requirements of cosmetics and miniinvasive surgical interventions.

Aim: To look for improving methods of the results of surgical treatment of echinococcosis in children.

Materials and methods.

It has been studied the results of surgical treatment of 315 children with isolated (247) and combined (68), pulmonary echinococcosis admitted to the Samarkand branch of pediatric surgery of the Republican specialized scientific-practical center of Pediatrics. Depending on the particular technology implementation echinococcectomy at different periods of operation at our clinic, all patients were divided into 3 groups. In Group 1 (1998-2001) it has been included 123 children (39.0%), which antiparasitic treatment was carried out by 2-5% formalin solution. In group 2 (2002-2005) it has been included 110 (35.0%) patients with lung echinococcosis cyst treated with a solution of glycerol at room temperature. In the third group (2006-2010) it has been included 82 (26.0%) patients who had been used as a germicide glycerol, heated to 70˚C. In addition, patients in this group, we made extensive use of minimal access surgery, which in some cases supplemented by fibroendoscopical revision of the cavity of fibrous capsule.

Patients in all three groups were matched by age (table 1). A large part of them (73%) were children of school age.

Table 1

Distribution of the patients due to age

Group of patients	Age of the patients, years old						In general
	3-7		7-12		12-15
	abs.	%	abs.	%	abs.	%	abs.	%
1 (1998-2001)	26	21,1	53	43,1	44	35,8	123	100
2 (2002-2005)	35	31,8	43	39,1	32	29,1	110	100
3 (2006-2010)	24	29,3	36	43,9	22	26,8	82	100
In general	85	27,0	132	41,9	98	31,1	315	100

Taking into consideration the comparability of patients in groups according to the number of lesions and complicated duration of disease (Table 2), it should be noted that in children there is a high frequency of multiple (42.9%) and complicated (51.4%) cysts of the lung.

Table 2

Distribution of the patients with echinococcosis of lungs depending on the type of the disease

Type of injuries	Group of patients						In general, n=315
	1 group, n=123		2 group, n=110		3 group, n=82
	abs.	%	abs.	%	abs.	%	abs.	%
Solitar	91	74,0	87	79,1	66	80,5	180	57,1
Multiple	32	26,0	23	20,9	16	19,5	135	42,9
Non-complicated	56	45,5	50	45,5	47	57,3	153	48,6
Complicated	67	54,5	60	54,5	35	42,7	162	51,4

At the same time it should be noted that during the period of our observations, since 1998 a steady downward trend in the frequency of multiple and complicated cysts of the lung, which is probably associated with improved early diagnosis of the disease process in our region.

Bilateral lesion of echinococcus diagnosed in 39 (12.4%) children, of whom bilateral-solitary process was occurred in 25 (64.1%) patients, bilateral plural process - in 4 (10.3%) patients, solitary process on the one side and multiple process in the other side - in 10 (25.6%) patients. In 68 (21.6%) patients had lung echinococcosis combined with liver disease and other rare localizations of echinococcosis.

In the structure of the lung complications of echinococcosis 90.7% were festering cysts with their subsequent burst in the bronchus (59.9%), in the pleural cavity (10.5%) or in the bronchus and the pleural cavity (3.7%) (table 3).

Table 3

Structure of complications of echinococcal cysts of the lungs

Complication	Group of patients						In general
	1 group		2 group		3 group
	abs.	%	abs.	%	abs.	%	abs.	%
Suppuration with burst to the bronchus	39	58,2	36	60,0	22	62,9	97	59,9
Suppuration of the cysts	14	20,9	9	15,0	4	11,4	27	16,7
Suppuration and burst to the pleural cavity	5	7,5	6	10,0	6	17,1	17	10,5
Suppuration and burst to the bronchus and to the pleural cavity	1	1,5	4	6,7	1	2,9	6	3,7
Burst to the bronchus	7	10,4	4	6,7	2	5,7	13	8,0
Burst to the pleural cavity	1	1,5	1	1,7	-	-	2	1,2
In general	67	100,0	60	100,0	35	100,0	162	100,0

It is believed that the burst of non-infected cysts is greater risk in terms of dissemination of the process - such patients were 15 (9.2%).

In the presence of multiple echinococcosis of one lung removal of all cysts was carried out simultaneously in stages. We followed the tactics two-moment surgical interventions. In bilateral lung injures in 39 (12.4%) patients surgical treatment of echinococcosis was performed in stages (Table 4), first on one and then on another lung with a maximum shortening inter-stage period of 2 to 4 weeks.

Taking into consideration the well-known shortcomings of the standard surgical approach - a wide thoracotomy, as well as taking into account the possibility of topical diagnostics of modern endovizualization, we have worked with in 2002 is widely used methods of topical minithoracotomy (table 4).

During minithoracotomy under intubation narcosis it was carried out skin incision no more than 5-6 cm in IV-VII intercostal space, depending on the topical localization of hydatid cyst between media-clavicular and the posterior axillary lines on the affected side.

Table 4

Distribution of the patients with echinococcosis of lungs depending on the surgical access

Access	Group of patients						In general
	1 group		2 group		3 group
	abs.	%	abs.	%	abs.	%	abs.	%
Wide thoracotomy	102	82,9	17	15,4	2	2,4	121	38,4
Two-moment wide thoracotomy on both sides	21	17,1	1	0,9	-	-	22	7,0
In general	123	100	18	16,3	2	2,4	143	45,4
Minithoracotomy	-	-	84	76,4	71	86,6	155	49,2
Two-moment minithoracotomy on both sides	-	-	8	7,3	9	11,0	17	5,4
In general	-	-	92	83,7	80	97,6	172	54,6
In general	123	100	110	100	82	100	315	100

On the giant cysts that spread to more than one lobe, the optimal approach was the best available in the VI intercostal space. In cysts that are located within one upper lobe, the operational access was in the IV or V intercostal space. Access in the VII intercostal space was carried out with distal localization of echinococcus cyst. In most cases, preference is given surgical access in the V-VI intercostal space. Muscle mass was pushed in the blunt manner, with use electrocoagulator we in the unipolar mode crossed fibers of intercostal muscles. Pleural cavity were opened, and revealed the echinococcus cyst. Cyst led up to the wound. Later echinococcectomy did not differ from the traditional.

Results and discussion.

Already at the stage of development in 2002, our surgeons at once gave his preference for the new access. The technique is simple and fast implementation, low blood loss, it is convenient for the implementation of the basic stages of intervention at the correct preoperative topic diagnosis, there is much more easily during the postoperative period. Patients in group 2, in which we started to introduce minithoracotomy, the proportion of these approaches has reached 83.7% (table 4). In recent years, almost all children with pulmonary echinococcosis we surgically operated through minithoracotomic access. Only 2 (2.4%) patients, from the third group we had to go to the conversion thoracotomic wounds: in one because of multiple lesions of the lower and upper lobe of right lung, the other due to the presence of massive adhesions in the pleural cavity, and the need to perform a full pneumolizis.

In uncirculated adhesive process to mobilize lung can be successfully carried out through minithoracotomic access by video-assisting. After videoendosurgical dissection of adhesions it was much easier to injury echinococcus cysts located in the costal surface of the lung within 7-8 cm from thoracotomnogominiodissection. Video-endoscopic technique we used on the stage echinococcectomy in 23 (18.3%) children third group, mainly for additional endoscopic revision of difficult angles and recesses of deep-lying cysts and sinuses of the pleural cavity (in patients with burst cyst into the pleural cavity). During the video-endoscopy in 3 patients were removed during surgery unnoticed small daughter bubbles. The advantages of this method over conventional inspection of the inner walls of the fibrous capsule and pleural sinuses are twenty-fold increase in the image on the TV monitor screen, expanding the viewing angle from the side of optics, good lighting zone inspection.

The high frequency of complicated forms of pulmonary echinococcosis, reaching 51.4%, reflected in the structure of the performed surgical interventions, where the proportion of semi-closure of the residual cavity with a fibrous membrane at the bottom of the abandonment of drainage was 42.5% (table 5).

Table 5

The character of the surgical interventions in echinococcosis of lungs

Surgical operation	Group of patients						In general
	1 group		2 group		3 group
	abs.	%	abs.	%	abs.	%	abs.	%
Ideal echinoccocectomy	4	3,3	2	1,8	1	1,2	7	2,2
Closed echinoccocectomy	71	57,7	57	51,8	46	56,1	174	55,2
Semi-closed echinoccocectomy	48	39,0	51	46,4	35	42,7	134	42,5
In general	123	100	110	100	82	100	315	100

Note. During removing several cysts in one patient it was taking into consideration the biggest intervention.

An important technical point in the performance of a semi-closed echinococcectomy is the imposition of tight pleurorizic sutures. In all other cases, we tried to completely eliminate bed of parasite by suturing due to Bobrov Spasokukotsky method that we could perform in 174 (55.2%) patients. These types of operations can be attributed the ideal echinococcectomy, implemented in 7 (2.2%) patients, when, after extraction of the entire chitin shell free edge of the fibrous capsule was excised, and the remainder of the shell was sutured by the use of one-row interrupted sutures.

In our patients there were not absolute indications for performing lobectomy and pulmonectomy. In uncomplicated duration the drainage tube was removed from the pleural cavity after 2-3 days (in general in 3,9 ± 0,07 days) after the x-ray investigation with the full unfolding of the operated lung (table 6).

Table 6

The results of the complex surgical treatment of patients with echinococcosis of lungs

Indexes	Group of patients
	1 group, n=123	2 group, n=110	3 group, n=82
Duration of the hospital staying, bed-days	21,4±1,16	20,4±0,79	14,0±0,41
Duration of staying in ICU, days.	4,5±0,15	2,42±0,21	1,4±0,07
Duration of hospital treatment after operation, days.	17,1±1,04	14,4±0,79	9,9±0,44
Duration of the surgical operation, min	60,4±1,31	47,2±1,93	32,0±1,14
Periods of normal body temperature, days.	9,0±0,74	5,9±0,69	3,7±0,39
Periods of removing drainage from pleural cavity, days.	4,8±0,33	3,0±0,31	2,9±0,07
Periods of removing drainage from residual cavity, days.	23,0±2,86 (48)*	15,5±1,18 (51)*	13,4±0,78 (35)*

Note. * – number of patients

At the same time we were not in a hurry in removing the drainage tube of the residual lung cavity: as a rule, they were removed after on average of two weeks after the operation. This period is necessary for reliable obliteration of the pleural cavity around intrapulmonary tube and the residual cavity itself.

The active use minithoracotomic accesses in the 2-d and 3-rd groups had a positive impact on the timing of finding the children in the ICU and subsequently in the hospital, the baby's body temperature normalization (table 6).

In patients of group 3 due to the use and facilitation techniques minithoracotomy elimination of "complex" residual cavities by suturing them to the drainage we could halve the duration of the intervention and thus reduce its invasiveness. That is, in technically complex situations, we do not try at all costs fully take in the cavity of the fibrous capsule, exposing the child at risk of intra-and postoperative iatrogenic (due to damage to blood vessels, respiratory tract suturing, deformation of lung tissue, increased thoracotomy wounds, etc.). Rapid obliteration of residual cavity in the drainage tube, we think contributes to the thermal and chemical effects of glycerol on the hot walls of the fibrous capsule in contact with the effect of sclerotherapy and the establishment of a permanent negative pressure inside the cavity due to Bobrow valvular banks. In addition, an effective means of preventing one of the most common postoperative complications in children - suppuration of residual cavity is to find the drain pipe inside the fibrous capsule. It was noted above (table 3) that the initial signs of suppuration echinococcal cysts were present in 147 (46.7%) patients, and the frequency of postoperative suppuration of residual cavity during treatment with glycerol at room temperature (group 2, 2002-2005) and hot-glycerol (third group, 2006-2010), and sufficiently wide (42.5% of patients) of cyst drainage operations did not exceed 1.8 and 1.2% (table 7).

Table 7

The frequency of postoperative complications in patients with echinococcosis of lungs

Complication	Group of patients						In general, n=315
	1 group, n=123		2 group, n=110		3 group, n=82
	abs.	%	abs.	%	abs.	%	abs.	%
Pleuritis	6	4,9	2	1,8	1	1,2	9	2,9
Suppuration of the operation wound	11	8,9	6	5,5	1	1,2	18	5,7
Suppuration of residual cavity	8	6,5	2	1,8	1	1,2	11	3,5
Bleeding	2	1,6	—	—	—	—	2	0,6
In general	27	21,9	10	9,1	3	3,6	40	12,7

Note. In the presence of in one patient 2 and more complications it was taken into consideration the most severe complication.

The set of technical and tactical decisions aimed at reducing trauma intervention, taking advantage of videoendosurgery, non-closure of the basal lung zones contributed to the prevention of postoperative intrapleural reliable bleeding - since 2002 we have these complications were not observed. Occur very rarely have pleurisy and postoperative wound infections, the overall incidence of postoperative complications was reduced from 21.9 to 3.6%.

Conclusion

The improvement of surgical treatment of echinococcosis of lungs, the wide use minithoracotomic approaches, opportunities video-assisting interventions, treatment of echinococcal cysts cavity by hot glycerol, individual approach to the closure of the residual cavity contribute to reducing the number of postoperative complications in 7 times (from 21.9 to 3.6%) and timing hospital treatment after surgical operation almost in half.

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