Introduction. The article presents the results of photodynamic therapy (PDT) of extrahepatic bile ducts (EBD) and large duodenal papilla (LDP) cancer in inoperable patients. The technique of its carrying out and ways of delivery of laser light guides to various parts of biliary tract are described. Efficiency of PDT for cancer of LDP and separately for cancer of EBD was determined. The dependence of patients' life expectancy on the number of PDT sessions during a year was revealed and the comparative analysis of two groups of photosensitizers (PS) efficiency was carried out.Research purpose: to estimate the effectiveness of photodynamic therapy (PDT) in treatment of VUC and IBD cancer; to determine the reasonability of repeated PDT courses and time intervals between them; to compare the effectiveness of photosensitizers Photodetazine and Photosens in treatment of these patients.Materials and Methods. The study was based on a comparative analysis of life expectancy in inoperable groups of patients with VVC and IBD cancer. The main group consisted of 29 patients (including 20 patients with IBD cancer) who were treated by PDT besides biliary operations. Control group consisted of 50 patients (14 of them with BDZ cancer), only biliary drainage interventions were used in their treatment. The number of PDT courses performed was from 1 to 3 during the year. A total of 29 patients underwent 52 courses of PDT. We used two photosensitizers from different groups: Fotoditazin (chlorine derivative E6) – was used in 18 patients and Photosense (phthalocyanine derivative) – was used as PS in 11 patients. Assessment of treatment efficacy was based on determining the median survival according to the Kaplan-Meier method.Results. Median survival time in the main group was 18 months [95% CI: 15.9; 20.1], in the comparison group (without PDT) – 7 months [95% CI: 5.1; 8.9]. In patients with IBD cancer, the median survival for PDT was 18 months [95% CI: 16; 20], and 12 months [95% CI: 9.25; 14.75] in the comparison group. Life expectancy for patients with BDS cancer ranged from 1 to 60 months. Median survival time was 17 months [95% CI: 12; 21] in case of Fotosens – 18 months [95% CI: 16; 19]. In the group of patients who underwent one PDT session during a year, median survival time was 12.5 months [95% CI: 10; 15], in the group of patients who underwent 2 or more sessions, median survival time was 23 months [95% CI: 18; 28].Conclusions. Photodynamic therapy in combination with draining interventions on bile ducts is an effective method of therapy of inoperable forms of IVC and IBD carcinoma in high risk patients. Variants of delivery of laser radiation for PDT are developed. Repeated sessions of PDT at intervals of 4-6 months potentiate the effectiveness of palliative therapy and increase life expectancy of patients. The effectiveness of Fioditazine and Photosense in PDT was found to be similar. Fotoditazine showed a lower number of complications.
РезюмеОбоснование: Опухоль Клацкина -холангиокарцинома долевых и общего печеночного протоков (рак ворот печени), локализующаяся проксимальнее места слияния общего печеночного и пузырного протоков (до начала сегментарных печеночных протоков второго порядка). В настоящее время в комплексной терапии пациентов с неоперабельными стадиями внепеченочной холангиокарциномы рекомендовано использование фотодинамической терапии (ФДТ), что достоверно увеличивает продолжительность жизни в сравнении с изолированной паллиативной терапией.Описание клинического случая: Представленный клинический случай демонстрирует успешное применение ФТД у пациентки с холангиокарциномой бифуркации общего печеночного протока T4N1M1, Bismuth-IV в сочетании с наружным дренированием желчных протоков с целью разрешения механической желтухи.Заключение: Показан значительный эффект ФТД у пациентки с неоперабельной опухолью Клацкина. Применение ФТД увеличивает продолжительность жизни в сравнении со средней выживаемостью на фоне проведения паллиативной терапии.Ключевые слова: Клинический случай, фотодинамическая терапия, внепеченочная холангиокарцинома Конфликт интересов. Авторы заявляют об отсутствии конфликта интересов.Странадко Евгений Филиппович, д. м. н., профессор, руководитель отделения лазерной онкологии и фотодинамической терапии Лобаков Александр Иванович, д. м. н., профессор кафедры хирургии факультета усовершенствования врачей Морохотов Владимир Александрович, доцент кафедры хирургии факультета усовершенствования врачей, врач-хирург Рябов Михаил Владимирович, к. м. н., старший научный сотрудник отделения лазерной онкологии и фотодинамической терапии Карпов Николай Владимирович, младший научный сотрудник, врач-хирург Морозов Сергей Валентинович, д. м. н., профессор кафедры хирургии факультета усовершенствования врачей, врачхирург, онколог Шубин Валерий Константинович, научный сотрудник, врач-хирург Богомазов Юрий Константинович, к. м. н., врач-колопроктолог
INTRODUCTION: Ulcerative colitis is a severe disease significantly reducing the patient’s quality of life. Approximately one third of patients per year suffering from this disease have indications for a surgical treatment — colectomy with ileostomy. Subsequently, not all patients appear suitable for reconstructive surgery, for which reason they are doomed to a life-long ileostomy. These facts stimulate us to search for new methods of treatment of the rectal stump remaining after colectomy. In this study, 10 patients having been operated for ulcerative colitis and having rectal proctitis, underwent a single session of photodynamic therapy. The effectiveness of photodynamic therapy was controlled before the session and one month after it using rectoscopy with rectal mucosa biopsy. Endoscopy results were evaluated on Shroeder and UCEIS scales. The results of histological examination were evaluated on Geboes scale. Maximum accumulation of Photoditazin in rectal stump affected with ulcerative proctitis, was determined after 1.5–2 hours. Upon achievement of this maximum, fluorescence of the rectal mucosa 10.8 times exceeded the initial level, while in the intact tissues, fluorescence increases only 2.8 times. After a session of photodynamic therapy, the level of fluorescence of the rectal mucosa reduced 3.11 times, which indicates a photochemical reaction (positive photobleaching) in the tissue. In evaluation of effectiveness of photodynamic therapy after a month, 9 patients of 10 showed improvement of endoscopic and histologic picture. In 2 patients, remission was achieved, in 7, the activity of ulcerative proctitis declined from moderate to mild level. In one patient, no changes were revealed on evaluated scales. In 90% of patients, a single session of photodynamic therapy showed a positive effect, but taking into account a small sample size and the absence of control group, further data collection with subsequent statistical analysis is planned. CONCLUSION: Photodynamic therapy of rectal stump in the operated patients with ulcerative proctitis can be considered an additional method of treatment and preparation for reconstructive surgery for formation of ileorectal anastomosis.
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