ГБУЗ «Московский городской научно-практический центр борьбы с туберкулезом Департамента здравоохранения г. Москвы», Клиника № 2, Москва, Россия Цель исследования: поиск наилучших подходов к хирургическому лечению перфоративных туберкулезных язв кишечника у больных с поздними стадиями ВИЧ-инфекции� Проанализирован опыт хирургического лечения 136 пациентов с ВИЧ-инфекцией и туберкулез-ными язвами кишечника� Пациенты были разделены на четыре группы в зависимости от вида выполненного оперативного вмешательства и послеоперационной тактики� У пациентов с ВИЧ-инфекцией и перфоративными туберкулезными язвами кишечника выполнение резекции участка кишки с язвами и на-ложение отсроченного анастомоза (после стиханий явлений перитонита) или ушивание перфоративных язв, назоинтестинальная интубация и программная санация брюшной полости являются наиболее оптимальным способом хирургического лечения, что в сочетании с адекватной противотуберкулезной терапией позволяет снизить процент послеоперационных осложнений и уменьшить летальность� ключевые слова: ВИЧ-инфекция, туберкулез кишечника, резекция кишки, межкишечный анастомоз, перитонит, назоинтестинальная ин-тубация /2075-1230-2017-95-9-19-24 За последние годы в РФ отмечено увеличение числа случаев туберкулеза органов брюшной по-лости (ТОБП), частота которого колеблется от 3 до 16% среди других внелегочных локализаций туберкулеза [2, 3, 5]� ТОБП составляет около чет-верти среди внелегочных локализаций туберкулеза у больных с поздними стадиями ВИЧ-инфекции� Наиболее грозным осложнением ТОБП является перфорация специфических язв кишечника с ле-тальностью до 80%� Трудности лечения больных этой категории обусловлены поздним выявлением ТОБП, протекающего с выраженной интоксикаци-ей, легочно-сердечной недостаточностью, иммуно-дефицитом и недостаточностью нутритивного ста-туса� Это приводит к быстрому прогрессированию перитонита и развитию полиорганной недостаточ-ности [1, 4, 6-9]� Цель исследования: поиск наилучших подходов к хирургическому лечению перфоративных тубер-кулезных язв кишечника у больных с поздними стадиями ВИЧ-инфекции� Материалы и методы Хирургическое лечение проведено 136 пациен-там с перфоративными туберкулезными язвами кишечника, находившимся на лечении в хирурги-ческом отделении Московского городского науч-но-практического центра борьбы с туберкулезом в 2003-2013 гг� Мужчин было 103 (75,7%), женщин -33 (24,3%), возраст больных -от 21 до 51 года, у всех пациентов была ВИЧ-инфекция 4В стадии� В ком-плекс обследования пациентов входили рентгено-логические (обзорная рентгенография и КТ органов
At the current stage of development of urology, selection of the surgical method for cases of severe obstructive diseases of the upper urinary system remains a challenge. This study aimed to explore the results of application of a buccal graft (BG) to remedy extended recurrent strictures and obliterations of the distal ureter. Seven patients with the mentioned diseases had undergone surgery: for six of them, the method of choice was complete BG ureteroplasty, one had onlay ureteroplasty. One intervention was laparoscopic, the remaining surgeries were open. The length of the replaced ureteral defect was 5–8 cm. In five cases, the flap was additionally vascularized with the iliac muscle, in one we used omentum tissue, in another — both the iliac muscle and the omentum. There were no fatalities registered, nor severe complications as per the Clavien–Dindo classification. The patients were followed-up for 4–18 months; as of today, no recurrence cases were identified. Control examinations showed complete patency of the neoureter and good vascularization of the BG. Thus, this method can be an option in cases disallowing distal ureter restoration with tissues of the patient's own urinary tract or segments of the gastrointestinal tract.
Purpose of the study. Surgical treatment of extended strictures and obliterations of the ureter is still a complicated problem of modern urology. The aim of the study was to analyze our own experience of ureteral replacement plastic surgery with buccal graft, i.e buccal ureteroplasty (BU) with its extended strictures/obliterations.Patients and methods. We’ve observed 25 patients who underwent BU. The lower third of the ureter was affected in 3 (12.0 %) cases, the lower third and the mouth of the ureter was affected in 7 people (28.0 %), the middle third in 2 (8.0 %), the upper third in 5 patients (20.0 %), the combined lesion of the upper third of the ureter and the pelvic‑ureteral segment (PUS) was in 8 (32.0 %) patients. All patients underwent repeated operations on a ureter, all revealed a significant comorbid background. The surgery was performed with a tubularized buccal graft in 13 (52.0 %), the onlay technique was applied in 12 (48.0 %). Laparoscopic surgery was performed in 10 (40.0 %) patients, surgical aid was carried out in an open way in 15 (60 %).Results. Severe complications according to the Clavien‑Dindo classification, requiring hospitalization of patients in the intensive care unit with organ dysfunction, as well as lethal outcomes were absent. The follow‑up period of patients ranged from 1 to 57 months (an average of 14.7 months). One patient after laparoscopic BU with a tubular graft had a short (1 mm) stenosis in the anastomosis area for 6 months of follow‑up, which was successfully eliminated by laser endoureterotomy. During the entire follow‑up period, residual hydronephrosis was recorded in 4 patients (16.0 %) against the background of complete patency of the anastomosis. A control flexible ureteroscopy performed in 16 (64.0 %) patients did not reveal rejection of the buccal graft. There are still 20 patients under our supervision.Conclusion. Our experience shows that the implementation of BU is possible on any part of the VMP using various techniques. This operation can be regarded as the "second" line of surgical treatment of strictures and obliterations of the ureter, especially after unsuccessful attempts of other reconstructions in a group of patients with severe concomitant pathology.
Introduction. Reconstruction of the distal ureter after exposure to radiation energy on the pelvic organs remains an important problem in modern urology. The use of tissues of the own urinary tract in these cases is not always possible due to their deficiency in this category of patients, and the formation of an anastomosis by intestinal segments is often unjustified due to the high degree of trauma of enteroplastics. Materials and methods. To improve the immediate and long-term results of surgical treatment of extended strictures and obliterations of the distal ureter, we have developed a new method of its reconstruction – laparoscopic ureteroplasty of the distal ureter with tubularized buccal graft. This surgary was performed on a 36-year-old patient after extirpation of the uterus with appendages and the upper third of the vagina due to malignant neoplasm and several courses of radiation therapy. The length of the replaced ureteral defect was 6 cm. Results. The use of a tubularized buccal graft is an affordable alternative to these operations, and the laparoscopic technique allows one to achieve better anastomosis and reduce the number of postoperative complications. The immediate results of this operation are encouraging in terms of the possibility of its use in this category of patients. Conclusion. Laparoscopic ureteroplasty with tubularized buccal graft may be one of the promising options for the reconstruction of the distal ureter in case of its extended obliteration. The possibilities of this operation will be studied as experience is gained and as long-term postoperative observation of patients is observed.
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