Taking into account the data from the World Health Organization on the insufficient level of therapeutic success in the treatment of MDR and XDR pulmonary TB, surgical treatment is necessary in regions with a high frequency of drug-resistant cases.
ВведениеХарактерной особенностью последних десяти-летий является увеличение частоты рецидивов ту-беркулеза как после терапевтического, так и после хирургического лечения [1,2,5,8,13]. Многие хи-рурги связывали это в первую очередь с увеличени-ем частоты лекарственной устойчивости микобак-терий туберкулеза [3,6,20,21].Несмотря на все возрастающую роль хирургии в лечении легочного туберкулеза и ее высокую непо-средственную эффективность, проблема послеопе-рационных рецидивов туберкулеза остается серьез-ным сдерживающим фактором на пути ее широкого применения. Частота послеоперационных рециди-вов, по данным изученной нами литературы, со-ставляет в среднем 5,7% и имеет в последние годы тенденцию к увеличению.
Background: The long history of the struggle against tuberculosis (TB) inspired us to develop a new minimally invasive technique of thoracoplasty with videothoracoscope control (VATP). The aim of this study was to determine its efficacy.Methods: We conducted a retrospective single-center study of a cohort of patients operated on between 1999 and 2017. Two hundred eight patients who were indicated for thoracoplasty with verified TB with cavities in the upper lobe/S6 were enrolled in this study. Treatment outcomes were assessed based on Laserson criteria and active TB absence verified with CT.Results: Intraoperative and postoperative complications were observed in 15 (7.2%) and 4 (2.0%) cases, respectively. There were no 30-day mortalities. VATP with curative intent succeeded in 88% of cases according to Laserson criteria and active TB absence verified with computed tomography (CT). Clinical improvement (sputum negativity, closure of caverna, and lack of reactivation for 3 years) was achieved in 81% of cases. Conclusions: Comparing the successful results of this technique in the cohort of multidrug-resistant (MDR) TB patients with the outcomes of treatment of MDR TB worldwide (77% vs. 55%, respectively), the VATP technique is shown to be efficacious and thus recommended.Clinical trial registry number: ISRCTN67743278.
ГУ Центральный НИИ туберкулеза РАМН Москва В статье анализированы результаты хирургического лечения 515 больных, оперированных по поводу распространенного деструктивного туберкулез легких. Установлено, что применение оригинальной тактики и техники медиастинальной лимфаденэктомии позволило существенно улучшить результаты хирургического лечения распространенного деструктивного туберкулеза.Ключевые слова: деструктивный туберкулез легких, медиастинальная лимфаденэктомия.
ель исследования. Показать трудность диагностики и лечения пациентки при поражении легких сочетанной инфекцией туберкулезными и нетуберкулезными микобактериями. Результаты. Исходя из рентгенологической картины, анамнеза и данных обследования пациентке установили диагноз: фиброзно-кавернозный туберкулез левого оперированного легкого в сочетании с микобактериозом, осложненный аспергиллезом, кровохарканьем, кахексией и дыхательной недостаточностью. Учитывая отсутствие положительной динамики после 7 месяцев химиотерапии и наличие рецидивирующих легочных кровотечений, больной выполнили хирургическое лечение -пневмонэктомию с ВАТС отсроченной торакопластикой слева. Послеоперационный период был неосложненный. При контрольном обследовании через год после операции пациентка была в удовлетворительном состоянии, трудоспособна.Обсуждение. При сочетании туберкулеза и микобактериоза мы часто встречаем двусторонние, хронически текущие процессы с деформацией бронхов в виде бронхоэктазов. Для установления диагноза и контроля динамики лечения наиболее важны данные компьютерной томографии и бактериоскопии.Заключение. Приведенный клинический случай иллюстрирует большую роль лучевых методов в диагностике сочетанных случаев туберкулеза и микобактериоза, определении показаний к хирургическому лечению и контроле лечения. Хотя постановка диагноза микобактериоз только по рентгенологической картине не представляется возможной, несомненна определяющая роль этого метода для контроля состояния пациента и динамики заболевания.
The purpose of the study was to improve quality of surgical treatable of destructive pulmonary tuberculosis in patients with diabetes.Materials and methods. D.B. Giller and employees of the Department of Phthisiopulmonology and Thoracic Surgery of the First Moscow State Medical University M.I. Sechenov performed operations on 200 patients with diabetes due to tuberculosis. Group 1 was mustered from 78 patients from 2004 to 2009. Group 2 was mustered from 122 patients from 2011 to 2017.Results. An analysis of the results showed that after 31 operations, 27 (13.5%) patients from both groups developed 33 complications. The second group (6,6 %) had fewer complications after surgery than the first group (24,4%) 3.7 times. The first group had more vulnerary and bronchopleural complications than the second group. 12 patients (15,4%) of the first group and 6 patients (4,9%) of the second group had bronchopleural complications (empyema, residual cavity, delayed expansion of the lung and intrapleural bleeding). 2 patients died in the hospital (30-day mortality was 0.66%) after 303 surgical intervention in both groups. 1 patient (0.9%) died after 106 surgical intervention in the first group. 1 patient (0.5%) died after 197 surgical intervention in the second group. The full effect was achieved in 75 (96.2%) patients in the first group and 114 (93.4%) in the second group. The survival value of patients of the second group was 100% after 1 year, 98% after 2 years, 98.8% after 3 years, 96.9% after 4 years, 95.2% after 5 years. The surgical treatable affected the occupational rehabilitation of patients from group 2. 61.5% of patients from group 2 became able to work after 1 year. 64.5% of patients from group 2 became able to work after 5 years.Conclusion. If doctors will use our tactics in patients with destructive pulmonary tuberculosis and diabetes, the risk of complications after surgery dropped and reactivation of tuberculosis will not occur.
Objective. To increase efficiency of cavitary pulmonary tuberculosis treatment by developing modern indications and technology of extrapleural pneumolysis with filling material.Material and methods. We reviewed 25 patients with cavitary pulmonary tuberculosis and bacterial excretion who had undergone extrapleural pneumolysis with different types of filling material in 2004–2015. In 16 cases, we performed surgery in patients with one lung.Results. 56% of operated patients demonstrated extensively drug-resistant TB, 40% had multidrug-resistant TB. Cavities were closed and bacterial excretion ceased in 92% of patients at discharge. Long-term results with observation period from 1 to 12 years were analyzed in 24 patients, 17 (71%) of them had complete clinical efficacy.Conclusion. Extrapleural pneumolysis is a mini-invasive surgical treatment that can prove positive effect in patients with non-fibrotic changes in a cavity wall and pathological process in upper parts of the lungs.
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