Pulmonary hydatid cyst excision

Pulmonary hydatid cyst disease or pulmonary hydatidosis is a disease caused by larvae of Echinococcus granulosus in the lungs. It is a common parasitic disease of humans and animals in pastoral areas. In Xinjiang, Ningxia, Qinghai, Gansu, Tibet, Inner Mongolia and other regions, the incidence rate is high, and there are also a few cases reported in other provinces. In recent years, with the development of animal husbandry and transportation and the increase of population mobility, the incidence of pulmonary hydatid cyst disease has increased. Since the 1980s, people have begun to try to treat echinococcosis with drugs. Gil-Grande et al (1983) were treated with mebendazole and the effective rate was 36% to 94%. Morris et al (1985) applied this drug to treat 22 people, 15 of whom achieved some relief. The results of Aggarwal and Wali are different from the above, and 10 cases have no obvious effect. Since the drug must pass through the wall of the hydatid to reach the germ layer to function, the efficacy of the drug is related to the thickness of the cyst wall. The drug has a certain effect on the young, small cystic hydatid cyst, and has no obvious effect on the hydatid cyst with thick wall thickness, and the failure rate and recurrence rate of the drug are high, and the side effects are also large. Therefore, the most effective treatment for pulmonary hydatid disease is still surgery. The drug is only used as an adjuvant therapy for those who have poor lung function and cannot undergo surgery or surgery to prevent rupture of the hydatid. The incidence of echinococcosis rupture and infection is high, so it is advisable to have early surgery after diagnosis. Treatment of diseases: pulmonary hydatid disease Indication Pulmonary hydatid cyst disease or pulmonary hydatidosis. Preoperative preparation Precautions should be taken to prevent colds before surgery and to avoid severe coughing, so as to avoid sudden rupture of cysts. For patients with cysts and suppurative infections, antibiotics and supportive treatment should be given before surgery. If necessary, body position drainage should be performed to reduce infection and secretion. Preoperative preparation should also include examination of other organs in the body to understand the presence or absence of hydatid cysts in the liver and other organs. Surgical procedure 1. Selection of incisions Single-lung lung hydatid performed left or right thoracotomy according to the location of the lesion. Complex echinococcosis often involves several organs and multiple different parts. It is necessary to choose a suitable surgical approach, and strive to achieve "all kinds of mouths," to minimize the number of operations and reduce the pain and economic burden of patients. (1) Two lung lesions or left lung and liver lesions were treated with a mediastinal sternal incision. The lung lesions are treated first on the heavier side and the lighter side is treated. In the left lung and liver lesions, the left lung lesion was treated first, and then the incision was slightly extended to the mid-abdominal incision to treat liver lesions. The mediastinal sternal incision is worse than the unilateral thoracotomy, and is not suitable for cases of severe rupture, extensive adhesion, empyema and so on. (2) At the same time, the right lung and the top of the liver are involved in the hydatid cyst, and the first chest operation is performed through the right chest incision. Applicable to non-infectious or infectious echinococcosis. (3) The 10th intercostal pleural effusion of the right intercostal approach was used to treat the hepatic cyst of the liver. Under the B-ultrasound positioning, select the appropriate part of the right 10th intercostal space to cut the skin, subcutaneous and intercostal muscles in turn, carefully dissociate, push the pleura away from the pleura, and cut the diaphragm to treat the cystic cyst of the liver. This path does not open the chest, has little effect on heart and lung function, and can also avoid the chance of chest contamination and infection. 2. Surgical methods (1) Total cystectomy: The hydatid cyst is removed together with a small amount of lung tissue around it, and is only used for small hydatid cysts at the edge of the lung. (2) Internal capsule puncture removal: It is a traditional surgical method, which is suitable for patients with complications or lesions. It is not suitable for complete removal of internal capsules. After the chest is opened, the adhesion in the thoracic cavity is separated, the cyst is exposed, and several large gauze pads are padded around the cyst to protect the chest and lung tissue, preventing the capsule from rupturing and surrounding pollution. The outer capsule portion exposed on the surface of the lung is covered with gray-white fibrin and has no vascular distribution. Prepare two sets of aspirator, three-way thick needle for puncture. After puncturing the cyst, the cystic fluid is quickly aspirated. When the cystic fluid is aspirated, the inner capsule separates from the outer capsule and collapses. The outer capsule wall is lifted by the Alice pliers, the outer capsule is cut, the suction device is sucked out, and the sac is used. Use a forceps or a toothless to remove the inner wall of the capsule. The inner capsule is easily broken and must be carefully removed. The cyst is scrubbed with 3% hydrogen peroxide and hypertonic saline. (3) Complete enucleation of internal capsule: It is suitable for cases where the hydatid cyst has more than 1/3 of the surface of the lung and there are no complications such as infection. If the removal is successful, the recurrence can be completely avoided, which is the most ideal surgical method. A wet gauze pad is placed under the lungs and in the chest cavity to fully expose the lung hydatid cyst. On the gray-white outer capsule fiber wall, the outer capsule wall is cut at the front of the blade, and the anesthesia is required to be smooth or paused. The scalpel should be tilted at 30° and the force should be even. Or use a blade to scrape. Excessive force can cause the internal capsule to rupture. When the small opening of the outer capsule is just opened, the surgeon should use a finger to protect the inner capsule, and then quickly use the scissors to enlarge the incision to prevent the outer capsule incision from being suddenly decompressed, and the local pressure of the inner capsule suddenly increases, causing the internal capsule to rupture. The enlarged outer capsule incision should be slightly larger than the diameter of the inner capsule, and can also be used as a "ten" incision. When peeling the inner and outer capsules, the stripper or finger should focus on the inner surface of the outer capsule to avoid squeezing the inner capsule. After the inner and outer capsules are completely separated, the anesthesiologist should swell the lungs. With the airflow in different directions around the inner capsule (especially the bottom surface of the inner capsule) and the thrust of the lung expansion, the entire cyst can fall into the basin containing the saline. The authors report a complete enucleation of the internal capsule with a success rate of 90.5% (211/233). Successful experience is: 1 anesthesia should be stable, the incision should be adequately exposed; 2 before cutting the outer capsule, use a large gauze towel to raise the diseased lung as much as possible, so that the cyst approaches or exceeds one end of the incision; 3 when the outer capsule is cut, the suspension is required Ventilation; 4 external capsule incision should be large enough to facilitate the removal of cysts; 5 anesthesiologist gradually lungs and help to change the patient's position, so that the cyst is easy to move out of the chest. The complete removal rate of hydatid cysts with a diameter of about 10 cm is high. In the case of a failed case, the cysts were all <5 cm in diameter, and the cyst wall was relatively thin, and often located deeper in the lungs, with poor exposure and rupture. 3. Treatment of external capsule residual cavity There are several treatment methods for the residual cavity of the outer capsule left after the removal of the inner capsule. Currently, the following two methods are often used. (1) Pulmonary dish surgery: remove the infected capsule, purulent secretion and necrotic lung tissue, trim the non-functional tissue around the outer capsule, and then repeatedly rinse the residue with 3% hydrogen peroxide. The cavity and chest cavity were rinsed with metronidazole and saline. After repeated washing of the residual cavity, the bronchospasm is sutured with a small round needle 4 or a absorbable suture, and the large bronchotomy should be double-layered and sutured with 2 to 3 layers. When suturing bronchospasm, it should be sutured on normal lung tissue. If the needle is too shallow, it is sewn on the lung tissue with weak edema. When the lung expands or coughs, the knot disappears and bronchospasm occurs. If the cystic cavity is large, multiple layers of overlapping embedding should be performed, which can reduce the dead space on the one hand and prevent postoperative drainage and infection; on the other hand, multi-layer suture, so that most of the bronchotomy at the bottom of the residual cavity It can be tightly sutured to prevent air leaks after surgery. In the process of repairing bronchospasm, the residual cavity is filled with physiological saline, the lungs are pressurized, and the bronchospasm can produce bubbles, which makes it easy to find bronchospasm. This test can be repeated until all bronchial fistulas in the residual cavity are tightly sutured. After trimming around the outer capsule cavity, the "8" intermittent suture was performed throughout the week to prevent bleeding and air leakage. The entire outer capsule is formed into a shallow dish surface, a so-called dish surgery. Advantages of disc surgery: 1 can use anterior lateral incision, less interference with lung function, less chance of aspiration pneumonia; 2 maximum retention of lung tissue; 3 easy to repair bronchospasm; 4 lead flow smooth, reduce chest cavity Fluid and infection; 5 simplifies the operation. (2) Closed suture of residual cavity: remove the debris and necrotic lung tissue in the outer capsule cavity, repeatedly flush the cyst cavity, no functional tissue trimming around the capsule, repair the bronchospasm, and sew the outer capsule from deep to shallow. Cavity, this can also strengthen the repair of bronchospasm to prevent postoperative air leaks. Residual closed suture is suitable for small, non-infected residual cavities. Infected heavier residual cavity is prone to infection after surgery, it is not appropriate to use residual cavity closure suture, this method is more likely to reduce lung function than disc-shaped surgery. 4. Treatment of complex pulmonary hydatid disease Complex pulmonary hydatid disease can be divided into the following types: 1 cyst occupying most or all of the thoracic cavity, accompanied by large area of lung collapse and obstructive pneumonia, mediastinal shift; 2 cyst rupture infection, formation of infectious worms Disease and purulent hydatid cystic bronchospasm; 3 simultaneous presence of lung, liver or multiple echinococcosis involving the left and right lungs; 4 intrahepatic hydatid cyst suddenly broke into the chest, bronchi, biliary tract, forming hepatic bronchospasm, hepatic pleural cholestasis , biliary obstruction and so on. (1) Selection of lobectomy and disc surgery: The surgical method of simple pulmonary hydatidosis is relatively simple and the recognition is relatively consistent. However, for complex echinococcosis, the treatment method is confusing, and many people advocate the use of lobectomy with lesions for infected or giant lung hydatidosis. However, it has been observed from practice: 1 large area, multiple ruptures, rupture of echinococcosis caused by large area of lung collapse and obstructive pneumonia, mostly due to mechanical compression, after the disc surgery, the residual lung can fully expand; 2 Rupture echinococcosis, some internal capsules are completely coughed, intraluminal infections are filled with pus; some internal capsules are incompletely coughed out, forming infection lesions, and different degrees of chronic fibrosis appear in adjacent tissues around the capsule. Such cases are resistant. At the same time of infection, disc-shaped surgery can still achieve satisfactory results; 3 truly irreversible lung lesions, one is that the infected lesions are long-term communication with the larger bronchus, causing bronchiectasis (rarely), and the other is exposed to the lungs. The outer capsule of the hydatid is thickened, the fibrous tissue is proliferated and calcified, and the latter is the part that needs to be removed for the disc surgery. Therefore, it is not appropriate to over-emphasize lung resection for cases of complex pulmonary hydatidosis. Practice has proved that for the above types of lesions, removal of the internal capsule or removal of the infected lesions while performing lung dish surgery, the effect is quite satisfactory. Pulmonary resection is limited to those with significant bronchiectasis, massive hemoptysis, severe infection, extensive lung fibrosis, or suspected lung cancer. (2) Treatment of hepatic thoracic perforating echinococcosis: huge hepatic echinococcosis, intracavitary pressure and chest negative pressure constitute a huge pressure difference, easy to break through the diaphragm into the chest or bronchus, forming liver, pleural effusion or liver, bronchus Hey. If the bronchus is broken, the original lesion in the liver should be removed and external drainage should be performed to interrupt the drainage of the bronchus. Transabdominal or rib arch cutting, taking a small pleural chest and abdomen combined incision, can achieve the purpose of clearing the lesion and external drainage. When the diagnosis of rupture into the thoracic cavity and bronchus is clear, the emergency department opens the thoracic surgery, removes the foreign body in the thoracic cavity, cuts the diaphragm, removes the hepatic primary lesion, and drains the chest and lesions.