ECHINOCOCCOSIS (echinococcosis) — the parasitic disease of the person and animals caused by a larval stage of tape helminth of group of tsestodoz of Echinococcus granulosus; it is characterized by damage of a liver, easy and other bodies and fabrics.
The first references about E. meet in works of doctors of antiquity. Hippocrates described E. a liver, having called this defeat of «jecur aqua reptu-lum» (the liver filled with water). He suggested to burn an abdominal wall and an echinococcal cyst the heated iron for the purpose of emptying of a cyst. Scientific antiquities considered echinococcal cysts as expansion limf, vessels and called them gidatidam.
It was succeeded to establish the parasitic nature of a disease later about -
disturbances in 1760 P. S. Palla catfish to an imaginal stage E. granulosus, Batsch parasitizing in intestines of predators, and in 1786 — the larval stage (larvotsist) developing in fabrics of hoofed animals and the person. The term «echinococcus» was for the first time entered in 1801 by Ru-dolfi (To. A. Rudolphi) which studied a parasite and ways of its penetration into a human body. In 1833 Zee-bold (S. Th. E. Siebold) described a shestikryuchny germ of an echinococcus. Later experimentally Leykart proved his communication with developing of echinococcosis (To. G. F. R. Le-uckart, 1850) also established that the echinococcal bubble is a larval stage of development of a tape-worm. AA. Ostrovsky (1862) received a puberal form of a parasite at dogs during the feeding by their echinococcal cysts taken from the person, having proved in such a way that the person is an intermediate owner E. granulosus.
Most often E. meets in Australia, New Zealand, South America, North Africa, the Mongolian People's Republic, in the south of Europe. In the USSR the disease is observed everywhere, but is more often in the south of Ukraine, the North Caucasus, in Kazakhstan, Transcaucasia, the Crimea, Moldova, Buryatia, Yakutia, Chukotka Autonomous Okrug, Western Siberia and a mountain and taiga zone of the Far East. For years of the Soviet power frequency E. in our country considerably decreased thanks to broad holding preventive actions, and also increase in cultural level and welfare of the population.
Etiology. Activator E. the larval stage of the tape helminth relating to the Plathelmintes type, the class Cestoidea (tape-worms), this is. Taeniidae (tapeworms), to the sort Echinococcus, type of Echinococcus granulosus. A life cycle is made with change of two owners. E. granulosus in an imaginal (puberal) stage parasitizes in a small bowel of carnivores (a dog, a wolf, a jackal, a lynx, etc.), to-rye are final (definitivny) owners of a parasite. The larval (bubbly) stage of a parasite — a larvotsist (an echinococcal cyst) — vegetirut in fabrics of a large and small livestock (a camel, a horse, a pig, etc.), and also the person, to-rye are intermediate owners.
Puberal E. granulosus — a small cestode of white color 3,4 — 6,18 mm long, width — 0,47 — 0,98 mm. Is located between fibers of a small bowel, being attached to them by means of a double crown from 38 — 40 kryuchyev and 4 muscular suckers which are localized on a head of steam -
Zita (scolex). The parasite develops slowly, reaches puberty between the 70th and 100th day after hit of ла$воцист in an organism of carnivores — final owners of a parasite. By this time it consists of a head, a neck and 3 — 4 joints (proglottids). The first (from the head) two joints — sexless, the third concentrates hermaphroditic system of bodies (an ovary, a zhel-tochnik, seed plants, etc.). Last
Fig. 1. Gidatidny echinococcus (tape stage of an echinococcus, X20): 1 — a head; 2 — a young proglottid with the undeveloped sexual device; 3 — a hermaphroditic proglottid; 4 — a mature proglottid with the developed uterus; 5 — mature eggs in a uterus; 6 — muscular suckers; 7 — a proboscis from a kryuchyama.
the joint, the largest, is puberal. In it the uterus having side protrusions is located. The uterus contains from 400 to 800 eggs of a rounded or oval shape to dia. 0,030 — 0,036 mm (fig. 1). In each egg there is a shestikryuchny germ (oncosphere) covered with radially ischerchenny cover.
Larvotsista (an echinococcal cyst) represents a bubble to dia. from 1 mm to 40 cm, filled with liquid. Echinococcal cysts with a capacity up to 10 l and more are known. The wall of a cyst consists from internal germinal (germinative) and outside, kutikulyarny, covers. Around an echinococcal bubble as a result of reaction of tissues of the owner the dense fibrous capsule forms. In an embryonic (germinative) membrane, thickness cover 0,01 — 0,025 mm, there is a set of proliferous capsules. The germinal scolex having 4 suckers and on two rows kryuchyev develops in them. A mature scolex is brought out of capsules and freely floats in liquid of an echinococcal bubble, forming so-called gidatidny sand. In the thickness of a germinative cover affiliated bubbles (gi-datid) can be formed of a scolex, to-rye grow inside or outside» P >| endogenous growth, to-ry a thicket is observed at the person, affiliated bubbles come off and freely float in echinococcal liquid. In stay for a while affiliated bubbles there can be grand bubbles which separated from them, the number to-rykh in some cases reaches several tens and even hundreds. All of them contain proliferous capsules. With
an exogenous growth affiliated bubbles accumulate between an outside cover of a maternal bubble and the fibrous capsule. Sometimes the echinococcal bubbles which are especially localized in tissue of lungs do not create either a germinal scolex, or affiliated bubbles, or proliferous capsules, being sterile (atsefalotsis-ta).
Epidemiology. A source of an invasion of the person are the infected animals — final owners of helminth: in the nature — carnivores (wolves, jackals, etc.), in the cultural centers — hl. obr. dogs.
Mature joints E. granulosus filled with eggs are torn away from a body of a parasite and at defecation or independently creep out of an anus of the owner outside and on his body. At the same time from joints the set of eggs is squeezed out. Infection of predators and dogs occurs during the eating of meat and interiors (especially a liver and lungs) (elks, deer, goats, pigs, cows), to-rye larvotsist of an echinococcus contain hoofs. Hoofs catch E., eating the grass contaminated by excrements of the infected carnivores — the main highlighters of eggs of a parasite. The community of dwelling and alimentary bonds according to the scheme a predator — the victim with constant change of owners in community of hoofed animals and carnivores cause existence of the natural centers E., to-rye in the USSR are available in a mountain and taiga zone of the Far East.
Hunting and cattle breeding for extensive: the natural pastures contaminated by excrements of the infected predators lead to infection of page - x. the animals (cows, deer, etc.) eating the contaminated grass and dogs, the Crimea are fed by interiors of the killed wild hoofs. It causes emergence of the mixed centers of an invasion. During the feeding to dogs of the raw interiors of the domestic animals infected with an echinococcus the so-called synanthropic center when change of owners happens among house hoofed animals and dogs is supported. At this page - x. animals catch the eggs of a parasite which got on a grass from intestines of dogs. As (by data A. F. Nose, 1954) allocation of joints of a parasite continues 68 — 133 days, and during the deworming of the infected dog at it is allocated to 20 thousand parasites, this animal has huge value as the source, the carrier and the distributor of helminth contaminating eggs of a parasite of a pasture, reservoirs, kitchen gardens, rooms for animals and the dwelling of the person, causing big extensiveness
of an invasion. Extensiveness of an invasion depends on its intensity, edges is connected with infection of final owners of an echinococcus and is defined by quantity of the animal echinococcal cysts eaten with bodies containing a scolex. From each scolex in intestines of a dog and carnivores the puberal echinococcus can develop.
Big epidemiol. also considerable resistance of eggs of an echinococcus (oncospheres) to influence of adverse environmental factors matters. By data K. I. Scriabin and R. S. Schultz (1929), at t ° 0 ° oncospheres keep full resilience within 116 days. A. F. The nose (1951) proved that oncospheres are invasive at t ° 5 — 20 ° and air humidities from 60 to 80% during three and even four months. In a dry grass at t ° from — 2 ° to 20 ° oncospheres keep the viability up to 6 months. Usual disinfectants are inefficient, only boiling during 20 sec. causes death of oncospheres. Thus, in summertime in a shadow or in a grass of an oncosphere remain invasive rather long time. The person has no epidemiol. value as transfer of a parasite, as a rule, does not come from it.
Infection of the person usually results in the mixed and synanthropic centers from close contact with the infected dogs or at the use of dirty berries and vegetables from the kitchen gardens visited by these animals, and also in the natural centers during the cutting of skins of the struck wild predators or during the use of the contaminated natural water sources. In infection of the person the infested dogs have the greatest value, however the source of infection can appear and the healthy dog, wool a cut is contaminated by eggs of a parasite. Sheep and cows can be mechanical carriers of eggs of an echinococcus, on wool to-rykh from a grass eggs of an echinococcus get. Therefore it is necessary to be careful during the milking of cows and a hairstyle of sheep.
Infection E. dogs and other carnivores results only from eating of bodies by them (a liver, lungs) the domestic or wild hoofs infected E. On it biol. the development cycle of a parasite comes to the end (fig. 2).
Pathogeny and pathological anatomy. At hit in went. - kish. the path of eggs of a parasite their outside cover under the influence of digestive juice is dissolved, and the released oncosphere with the help kryuchyev gets into a mucous membrane of a stomach or a gut from where with
Fig. 2. Development cycle of a gidatidny echinococcus: the eggs
of an echinococcus containing oncospheres (i) are swallowed by vegetarians and the person; from intestines of an oncosphere get into internals, it is preferential in a liver and lungs where echinococcal bubbles develop (4); during the eating of internals carnivores a scolex (3) from echinococcal bubbles in a kishechtsika turns into a puberal parasite (2).
by current of a venous blood or a lymph it is transferred to portal system and is late in a liver. For this reason at E. more often than other bodies the liver is surprised (to 85% of cases). Part of oncospheres, passing hepatic capillaries, through the lower vena cava, the right auricle and a right ventricle on a small circle of blood circulation gets into lungs and settles in them. An insignificant part of oncospheres, getting through an arteriovenous anastomosis, gets to a big circle of blood circulation and therefore it can be brought practically in any body or tissue of a human body (fig. 3). The oncosphere which settled in fabrics within 5 months, turns into a larva — an echinococcal cyst to dia. 5 — 20 mm that demonstrates quite slow development of an echinococcus in tissues of the person and animals. And the size of echinococcal cysts depends on a structure of fabrics, in to-rykh they develop. In lungs echinococcal cysts grow quicker, than in a liver; in bone fabric echinococcal cysts, as a rule, remain small.
In a pathogeny E. the sensitization of an organism ho-
a zyain metabolic products of a parasite is of great importance; it leads to its allergic reorganization. Besides, absorption of products of exchange of a parasite causes intoxication. In this regard weakness, an indisposition, decrease in working capacity, and also the periodic allergic reactions like small tortoiseshell which are usually connected with small anguishes of walls of a cyst are noted. The complete separations of larvo-cysts which are followed by the expiration of the liquid which is contained in them in an abdominal cavity quite often lead to a heavy acute anaphylaxis (see), to planting of abdominal organs the scolex which is contained in a bubble, and also scraps of an embryonic membrane and to development of a so-called secondary echinococcosis.
An important role in a pathogeny E. plays also mechanical impact of the growing bubbles on bodies and fabrics. A scolex is located preferential in peripheral sites of body, and growth of a parasitic cyst, naturally, happens in the direction of the smallest resistance. The beneficial effect on development of a parasite is exerted by
Fig. 3. Diagrammatic representation of possible ways of penetration of an echinococcus into various bodies: from a digestive tract (1) in a liver (2), in a small circle of blood circulation and lungs (3), a big circle of blood circulation (4) and other bodies (shooters designated ways of transfer of oncospheres with a blood flow).
good blood supply of surrounding fabrics.
The struck body, as a rule, is deformed and increased in sizes. Echinococcal cysts can be located both in the depth of body, and on its surface. Macroscopically over an echinococcal cyst protrusion and thinning of fabric of body is defined. At a superficial arrangement of cysts the fibrous capsule is found dense, whitish color, edges it can be soldered to surrounding fabrics. In the capsule deposits of salts of calcium come to light, in some cases calcification of all capsule takes place. Echinococcal cysts have the rounded or oval shape, their size from 1 mm to 40 cm in the diameter. Cysts are filled with transparent liquid and surrounded with a whitish brilliant chitinous cover. In liquid the smallest are weighed white color of a part (scolex). At death of a parasite of a cyst are filled with the purulent or muddy contents in nek-ry cases representing it is purulent - curdled weight. Contents of the echinococcal cysts located in a liver can be painted by bile. In a cavity of one cyst there can be smaller affiliated bubbles surrounded with a whitish thin chitinous cover (tsvetn. tab., Art. 400, fig. 15).
In the fibrous capsule distinguish three layers: internal, adjacent to a chitinous cover, hyaline and a layer of granulyatsionny fabric. The inner layer represents a detritis, in Krom the live and died scolex meets. The hyaline layer consists of the fibers and layers poor in cellular elements. Behind a hyaline layer granulyatsionny fabric is located, edges gets into depth of body. In this layer vessels, nerve fibrils, macrophages, eosinophils, plasmatic and epithelial cells meet.
In the fabrics located around an echinococcal cyst the atrophic changes caused by a prelum at the progressing increase in a cyst are observed. In some cases there are infiltrates consisting generally of eosinophils. Inflammatory changes in zones of parenchymatous bodies, adjacent to an echinococcal cyst, can vary from insignificant to the created cirrhosis (see). In sites of body, free from echinococcal cysts, it is possible to observe a vicarious hypertrophy of a parenchyma.
At death of a parasite and an empyema of cyst the picture of an acute purulent inflammation of its walls develops. In a liver near the suppurated fibrous capsule there is dystrophy of hepatic cells. In the pulmonary fabric surrounding the died parasite atelectases, the centers of a pneumosclerosis and an inflammation, bronchiectasias are observed.
At E. a brain around a cyst the capsule is formed, and near it the smoothness of furrows and expansion of convolutions of the brain, sometimes internal hydrocephaly (see), kruglokletochny infiltration, a thickening of walls of vessels, necrotic changes of nerve fibrils, a gliosis are noted, with a pressure of a cyst upon bones of a skull — their uzuration.
Immunity. It is considered that durable immunity at E. it is not formed, and repeated infections are possible. And there is an opinion that at development of one echinococcal cyst growth of other cysts is as if slowed down.
Clinical picture. AA. it is characterized by a variety of symptoms. Disease irrespective of localization of defeat can be conditionally divided into three stages: the first — latent, or asymptomatic — from the moment of penetration of an oncosphere into an organism to the first symptoms of a disease; the second — emergence of symptoms; the third — emergence of complications.
In the first stage of a disease patients usually do not show complaints. AA. in this period it is found accidentally during operation on other occasion or during professionalilaktichesky rentgenol. survey, is more often at calcification of walls of an echinococcal cyst.
In the second stage of a disease when the cyst reaches the considerable sizes and begins to squeeze surrounding fabrics, the corresponding symptoms appear. At the same time at patients with E. a liver the feeling of weight and arching pains in an anticardium, in right hypochondrium, in the lower half of a thorax are noted. Sometimes pains irradiate in a back, the frenikus-symptom (see) amplifying at an exercise stress can be expressed. Urticaria, an eosinophilia are observed. At a palpation of a stomach it is possible to find tumorous education in epigastriums, the right hypochondrium and other departments of an abdominal cavity. A wedge, manifestations at E. lungs begin with persistent dry cough, a pneumorrhagia, stethalgias. Character, duration and intensity of pains at E. depend on degree of the prelum struck and surrounding bodies.
The third stage is characterized by development of various complications: suppurations, calcifications of an echinococcal cyst, break it in pleural, belly cavities, to intra hepatic and extrahepatic bilious canals (fig. 4) that
Fig. 4. The scheme of possible perforation of echinococcal cysts of a liver in other bodies and fabrics (shooters designated possible ways of break of contents of echinococcal cysts).
usually is followed depending on localization of break by a pain syndrome, an acute anaphylaxis, jaundice, a cholangitis, developing of outside purulent and bilious fistulas.
Duration of everyone wedge, stages E. it cannot be precisely defined since the moment of an invasion does not manage to be determined usually. Besides, duration of each stage depends on localization of a parasitic cyst. So, at E. a liver the first and second stages can proceed for several years. At E. a brain all three stages can be short since even the small echinococcal cyst can quickly lead to heavy nevrol. to complications (to paralyzes, cerebellar frustration, etc.). In some cases the disease is revealed only at emergence of its heavy complications: ascites, jaundice — at E. liver and retroperitoneal space; an atelectasis, the shift of bodies of a mediastinum at E. lung; patol. a change — at E. bones.
True recurrence E., resulting from a reinfestation, meets seldom and shall be considered as an independent recurrent disease. It develops many years later after operational treatment at the persons continuing to live and work in former conditions. The so-called false recurrence arises often, sometimes soon after operation. Usually it is caused by a neradikal-nost of operation, existence of undetected parasitic cysts, disturbance of the equipment of an ekhinokokkektomiya and planting of surrounding fabrics, and also extensiveness rasprostra-
a neniya E. in an abdominal cavity and other bodies. Thus, it is more correct to consider a false recurrence as residual (residual) E. Frequency of emergence residual E. abdominal organs, according to O. B. Milonov (see t. 29, additional materials), 11,8% make.
The diagnosis is based on data of the anamnesis including epidemiological, a wedge, a picture and results of the comprehensive examination including laboratory, radiological, tool, ultrasonic and tracer techniques of a research.
Stay of the patient in areas with high rates of incidence E. and at the same time expressiveness of symptoms of defeat of any body of a chest or abdominal cavity, definition at a palpation of the cystiform painless education in a stomach having smooth spherical shape allow to suspect E., especially if at the same time there is a phenomenon of trembling gi-datid. It is defined as follows: put
a palm with widely divorced fingers on a swelling and with a force tap on a long finger. In the presence of an echinococcal cyst investigating feels characteristic trembling. Suspicion on E., arisen at inspection of the patient, is an absolute contraindication for a diagnostic puncture of a cyst, can lead edges to planting of nearby bodies. If the puncture nevertheless was made and at the same time transparent liquid is received, then, without taking a needle, it is necessary to subject liquid to microscopic examination urgently. In case of detection of elements of a chitinous cover, kryuchyev an echinococcus make urgent operation. For confirmation of the diagnosis E. earlier often carried out anaphylactic test — Kasoni's reaction, regions it is founded that at the people infected E., at intradermal introduction to area of a forearm of 0,1 — 0,2 ml of a sterile filtrate of liquid of an echinococcal bubble there is a local allergic reaction in the form of an itch, a hyperemia and a cutaneous dropsy while in the place of control administration of physiological solution (an inner surface of a forearm of other hand) allergic reaction is absent. As a result of a sensitization of an organism at repeated carrying out reaction of Kasoni development of an acute anaphylaxis is possible. Besides, test can be positive and in the absence of E. as a result of reaction of an organism to introduction of a foreign protein.
Diagnostically the most valuable lab. breakdown is safe
for the patient immunol. the reaction of la of tex-agglutination (see Geljminto logical methods of a research) offered by Fishman (A. Fisch-man, 1960) and studied in our country of V. I. Zorikhina (1964). According to O. B. Milonov and soavt. (1973), at E. this reaction was positive in 96,3% of observations. It was of particular importance at identification of a recurrence E., as unlike Kasoni's reaction it can be reused, without being afraid of development of an acute anaphylaxis. High sensitivity of this reaction allows to apply with success it to early identification of asymptomatic forms E. at mass inspections of the population in areas with high rates of incidence E.
Results improve at simultaneous statement of reaction latex agglutination and indirect hemagglutination (see Hemagglutination). High specificity reactions of double diffusion in gel, and also the most specific method of serological diagnosis — enzyme - an immunological method have (see). Serol. researches are based on immunol. reactions of antibodies of blood serum of the person with the specific antigen allocated from liquid a larvotsist at the person or sheep. As for an immunoenzyme method use the echinococcal antigen which is most purified from heterogeneous and a feather * krestno the reacting components, this method can be applied to differential diagnosis E< and an alveococcosis. Serol. reactions become positive on 7 — the 21st day from the moment of infection.
Rentgenol. the method of a research is the basic at E. easy (fig. 5, 6) is also important in diagnosis of calciphied forms E. a liver and other bodies bryunr ache cavities and AA. bones (fig. 7). Characteristic sign echinococcus
of Fig. 5. The roentgenogram of a thorax at an echinococcosis of lungs (a direct projection):
in the field of an average share of the right lung and in the lower segments of an upper share of the left lung two roundish dark shadows of echinococcal cysts are defined, in other departments the pulmonary drawing is not changed.
Fig. 6. The roentgenogram of a thorax at an echinococcosis of the right lung (a direct projection): lower parts of the right lung are darkened, in the field of an average share the ring-shaped shadow with a fluid level (is specified by an arrow) caused by the echinococcal cyst which broke in a bronchial tube is defined; the left pulmonary field without changes.
a kovy cyst of a lung change of a form of its shadow in different phases of a respiratory cycle (a symptom of Neme-nova) is. For diagnosis use a polyposition research (see), a tomography (see), a bronchography (see), the cholecystography (see) and an intraoperative holangiografiya (see).
An essential role is played ultrasonic diagnosis (see) and a computer tomography (see the Tomography computer), by the sizes and contours of cysts allowing to define accurately spherical or ovoidny
Fig. 7. The roentgenogram of area of the left shoulder joint at an echinococcosis of bones (a direct projection): in the field of an epiphysis and a diaphysis of the left humeral bone and a shovel the multiple enlightenments of irregular shape with roundish contours caused by existence of echinococcal cysts are defined.
forms. It is possible to define by a computer tomography not only a form, the sizes of parasitic cysts and their relationship with each other, but also to precisely reveal localization of cysts in segments of a liver and departments of an abdominal cavity that is extremely important at the choice of the forthcoming quick access. The tracer technique (scanning) lost the dominating diagnostic value, especially at the patients who underwent an operation as the defects of accumulation of radioisotope caused by an operative measure and a recurrence E., it is impossible to differentiate. The selection angiography is applied generally with the differential and diagnostic purpose. If there is no opportunity to carry out an ekhografiya and
a computer tomography, for specification of the diagnosis resort to a laparoscopic research (see Peritoneoskopiya). Considering complexity and an insecurity for sick nek-ry methods of a research (the selection angiography, a laparoscopy), at diagnosis E. at first use simpler methods: serological issledova
niya, survey X-ray analysis, ekhografiya, etc. At the patients who underwent an operation on an occasion E., it is necessary to exclude a possibility of a recurrence of a disease. Diagnosis residual and recurrent E. it is in most cases difficult and
demands a complex research, including an ekhografiya, a computer tomography. use one
is temporary two-three serol. reactions: latex agglutination, indirect hemagglutination and enzymes-immunologists-cheskogo of a method that
the niya increases the diagnostic accuracy of an issledov.
Differential diagnostikuv the first stage is carried out with a similar parasitic disease an alveococcosis (see), but also, with benign tumors (see), cysts of not parasitic origin (see the Cyst), cancer of a liver (see), cancer of a pankreatoduodenalny zone (see the Duodenum, the Pancreas), a polycystosis of abdominal organs, postnecrotic cirrhosis (see).
For differential diagnosis serological tests have crucial importance, to-rye happen positive at E. and an alveococcosis and negative at other volume defeats of bodies, and also data epidemiol. anamnesis. At a survey X-ray analysis of bodies of chest and belly cavities in favor of E. characteristic ring-shaped calcification around the revealed tumorous educations testifies. At ultrasonic investigation sites of defeat do not contain liquid in cases of an alveococcosis, benign and malignant tumors, and at cysts of not parasitic origin there are no symptoms which are observed in the presence in an echinococcal cyst of affiliated bubbles. Postnecrotic cirrhosis is characterized on an echogram by consolidation and reorganization of hepatic fabric with expansion of portal paths that is not observed at E. The described changes can be differentiated by means of a computer tomography more accurately. In doubtful cases carry out angiographic and laparoscopic researches, to-rye with bigger reliability allow to differentiate the above-stated diseases.
Treatment irrespective of localization of process only operational. It shall be carried out whenever possible to earlier terms since eventually development of a parasite inevitably results in prevalence of defeat, hron. intoxications, inf. to complications, disturbance of functions of vitals. The so-called self-healing occurring in connection with death of a parasite, wrinkling and its calcification or break outside occurs extremely seldom and to expect such outcome there are no bases. At the same time the delay with operation complicates its carrying out and worsens the short-term and long-term results.
Operative measure — an ekhi-nokokkektomiya — consists a parasitic cyst with all its contents and covers at a distance (the fibrous capsule is not a cover of a cyst and therefore it can be left on site). This operation is carried out or after opening of a cyst (an open ekhinokokkekto-miya), or without disturbance of its integrity (the closed ekhinokokkektomiya). Operation at E. it is necessary to carry out under an inhalation endotracheal anesthesia (see) using muscle relaxants. Operational access depends on localization of a cyst.
At an open ekhinokokkektomiya after an otgranicheniye of an affected area of body gauze napkins in the center it is made a puncture of a cyst a thick needle and evacuate echinococcal liquid. After that tension of a cyst decreases, and it is a little reduced in sizes. Through the same needle enter for 2 — 3 min. 2% water solution of the formaldehyde killing germinative elements of a parasite. Then open covers of a cyst and by means of a vacuum suction and various tools (web-footed tweezers, Lyuer's clips, soup spoons) delete affiliated and grand bubbles, and also germinal and chitinous covers from a cavity of a cyst. Contents of a cyst are collected in bank and burned. The remained fibrous capsule is in addition processed by 3 — 5% solution of formaldehyde in glycerin for the purpose of destruction of the scraps of a germinative cover, a scolex and small affiliated bubbles which remained on it. Then the fibrous capsule is drained and start elimination of a cavity, the limited fibrous capsule. For this purpose use various ways: sewing up by separate seams from within as the capitonnage offered in 1896 Mr. of P. Del-bet; elimination of a residual cavity by filling with its free edges of the fibrous capsule with the rolling seams. Sometimes this way is combined with introduction to a residual cavity of sites of the big epiploon on a vascular leg having adhesive properties or muscular rags on vascular legs, including a muscular part of a diaphragm. In 1966 A. A. Babur offered a method of sticking up of the cavity which remained in a liver after an ekhinokokkektomiya, and in 1974 O. B. Milonov with sotr. reported about successful elimination of similar cavities by means of MK-2 or MK-6 glues, applied on the surface of a residual cavity with a special needleless injektor (BI-1) that promotes penetration of glue deeply in fabric and gives special durability to adherend surfaces. The open ekhinokokkektomiya should not be mixed with operation of an ekhinokokkotomiya when after opening and removal of contents of a cyst of its wall hem to edges of an operational wound of an abdominal or pleural cavity (see Marsupialization). Due to the education after this operation of outside purulent fistulas and a high postoperative lethality the ekhinokokkotomiya is applied extremely seldom.
The closed ekhinokokkektomiya is carried out by careful enucleating of an echinococcal cyst without opening of its covers. Most often it manages to be made at E. a lung, napr, by Bakulev's method which is in opening of the fibrous capsule, enucleation and removal of a cyst that is facilitated by increase in intra pulmonary pressure in system of the narcotic device and sewing up of a residual cavity. The found bronchial fistulas carefully take in. At a marginal arrangement of an echinococcal cyst of a liver it is easy to remove it entirely together with the small site of the fibrous capsule or a part of body. Similar operation received the name of an ideal ekhinokokkektomiya since at it the possibility of a recurrence E is excluded. as a result of planting of surrounding fabrics. Similar operation is carried out at calcification of covers of a parasitic cyst and the fibrous capsule.
Ekhinokokkektomiya with removal of the fibrous capsule is unreasonable in connection with injury of intervention and danger of bleeding, and also higher lethality in comparison with an ekhinokokkektomiya without removal of the fibrous capsule. Radicalism of similar operation is excessive as existence of germinative echinococcus elements in the fibrous capsule is not proved.
At the considerable sizes of the echinococcal cysts located in the depth of body it is necessary to make an extirpation of a cyst as an economical or expanded resection (see the Lobectomy, the Segmentectomy). At multiple parasitic cysts in any body (a spleen, a kidney, a thyroid gland, an ovary) it is necessary to make its full removal together with the cysts located in it.
At suppuration of echinococcal cysts after them it is openediya and full removal of contents the residual cavity formed by the fibrous capsule should be drained a thick rubber tube, one end a cut through counteropening is removed outside. The operational wound is taken in tightly. After the fall of walls of a cavity and elimination separated a drainage delete.
At multiple E. abdominal organs an operative measure is dismembered on two, sometimes on three stages. First of all delete the cysts constituting the greatest danger to the patient then — the others. Operational treatment residual and recurrent E. always is more difficult and traumatic owing to the commissural process caused by the previous operative measure.
The forecast at a timely and radical operative measure favorable. At residual E. it is possible to expect a favorable outcome only at complete elimination of echinococcal cysts what in some cases requires a numerous operative measure. At started and extended E. forecast adverse. A postoperative lethality at E. a liver, according to various data, makes 3,5 — 16,2%, at E. easy — 0,5 — 1%. The postoperative lethality is especially high at multiple E. abdominal organs and basin (20 — 25%). Self-healing is observed extremely seldom.
Prevention of infection E. people and domestic animals it is based on the actions which are carried out vt. and medical services. In a task vt. services regular inspection on helminthoses, especially in places, unsuccessful on E enters., guard and domestic dogs; their treatment (deworming), a cut is carried out once a quarter; gigabyte. keeping of guard and domestic dogs; extermination of stray dogs; implementation of careful control of meat on slaughters, rejection and destruction of the struck bodies of animals (they shall be burned), prevention of feeding to dogs of the bodies of animals struck with an echinococcus.
The medical service shall carry out constantly explanatory work among workers of livestock production, hunters, dog breeders and members of their families about need to avoid close contact with dogs, to observe a careful gigabyte. the mode (washing of hands after each contact with a dog and before food, not to allow dogs in a bed, etc.) to prohibit children excessively close communication with animals.
The patients operated concerning E., shall be under dispensary observation within 8 — 10 years. Their periodic inspection on existence E. it has to be carried out at least 1 time a year, the first time — 10 — 12 months later after operation that allows to reveal timely residual, and also recurrent E. For identification of early forms E. will organize mobile teams, to-rye carry out medical examination of workers of livestock production and members of their families, using portable fluorographic installations and applying methods it is gray l. diagnoses (latex agglutination, indirect hemagglutination and enzyme-immunologiche-skogo of a method).
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