Возможности хирургического лечения у больных при сочетанной патологии ВИЧ/туберкулез
Резюме
Цель - определить эффективность хирургического лечения у
больных с коморбидной патологией ВИЧ/туберкулез.
Материал и методы. Доля операций у больных ВИЧ-инфекцией составила 4,4%
(25 операций) ВИЧ, туберкулез из 572 радикальных резекции легких, выполненных
по поводу туберкулеза легких. Для оценки эффективности хирургических
методов было сформировано 2 группы сравнения: 1-я группа - 23 прооперированных
пациента, 2-я группа - 25 пациентов без хирургического лечения.
Результаты. При определении вида и объема оперативных вмешательств
у больных ВИЧ-инфекцией предпочтение отдавалось малотравматичным операциям,
хирургическое лечение назначалось планово, с участием в лечении
врача-инфекциониста, после проведения курса антиретровирусной терапии в
предоперационном периоде и достижения количества CD4+-T-лимфоцитов
>200 кл/мкл. Проведенные операции были эффективными в 100% случаев,
послеоперационные осложнения и летальность отсутствовали. В резецированном
участке легкого у всех обнаружены микобактерии туберкулеза, почти половина
- множественная (МЛУ) и широкая лекарственная устойчивость (ШЛУ).
Послеоперационная летальность отсутствовала. В 1-й группе спустя 2 года
после операции сняты с учета почти 70%, в группе без операции только 4% (р=0,00001).
Заключение. При сравнительном анализе выявлено, что применение
хирургического пособия сокращает сроки лечения и повышает его эффективность.
Ключевые слова:хирургическое лечение, ВИЧ, туберкулез
Финансирование. Исследование не имело спонсорской поддержки.
Конфликт интересов. Авторы заявляют об отсутствии конфликта интересов.
Для цитирования: Бородулина Е.А., Рогожкин П.В., Пискун В.В.
Возможности хирургического лечения у больных при сочетанной патологии
ВИЧ/туберкулез // Клиническая и экспериментальная хирургия. Журнал имени
академика Б.В. Петровского. 2021. Т. 9, № 4. С. 118-123. DOI: https://doi.org/10.33029/2308-1198-2021-9-4-118-123
HIV-infection is a
factor that has a negative impact on the epidemiology of
tuberculosis. According to the World Health Organization (WHO) and
other sources since 2006 and at present, the number of cases of
tuberculosis with concurrent HIV-infection has increased by 2.9 times [1,
2]. This is due to the fact that the possibility of
tuberculosis contraction in HIV-positive individuals is 100
times higher than in HIV-negative people [3, 4]. Increasing number of
comorbid TB diseases/HIV is associated with high mortality [5-11]. The
disease affects mainly people of young and working-age [5, 10, 11].
The search for optimal methods of treatment is an actual problem [12,
13]. Surgical treatment is one of the methods in complex treatment that
allows increasing the effectiveness of treatment [14-17]. The
surgical methods of treatment effectiveness for patients
with tuberculosis combined with HIV-infection is still to be studied
[18, 19].
Material and methods
in 2016-2017, 572
radical lung resections were performed for pulmonary tuberculosis, while the
proportion of operations in patients with HIV-infection was 4.4% (25
cases). There was held an analysis of surgeries in patients with pulmonary
tuberculosis combined with HIV-infection. To assess the effectiveness of the inclusion
of surgical methods in treatment, two comparison groups of patients
were formed: 1 - group of 23 patients who were operated, 2 - group of
25 patients without surgical treatment. Efficacy was evaluated by the
criterion of deregistration after recovery.
Results
the gender and age
characteristics of patients, social aspects and the method of detecting
pulmonary tuberculosis in the comparison groups were studied. In the 1st group,
there were 11 men (47.8%), 12 women (52.2%). In the 2nd group,
there were 12 (52.2%) men and 11 (42%) women, respectively (χ2=0.08;
p=0.7817). The average age of
the 1st group was 32.6±1.52 [95%; confidence
interval (CI) 25.48-35.79] and the 2nd group was 33.16±1.36 [95%;
CI 30.34; 35.98] (U=280.5; p=0.893). In terms of social
characteristics and the methods of detecting pulmonary tuberculosis, the
comparison groups did not have significant differences. In both
groups, most patients were unemployed, 15 (65.2%) patients in 1st group,
and 15 (60.0%) patients in 2nd group. A history of drug
abuse was observed in 8 (34.8%) patients in the 1st group
and in 10 (40.0%) patients in the 2nd group. 5 (21.7%)
patients in 1st group and 5 (20.0%) patients in 2nd group
stayed in a correctional labor institution. The groups are comparable for
comparative analysis.
In the 1st group,
tuberculosis was detected using annual large picture frame
photoroentgenography 9 (39.1%), during examination at the AIDS center
6 (26.1%), during complaints in the general medical network 5
(21.7%), during examination at a tuberculosis dispensary as contact 3 (13.0%).
In the 2nd group,
tuberculosis was detected using annual large picture frame
photoroentgenography 8 (32.0%), during examination at the AIDS center
7 (28.0%), during complaints in the general medical network 6
(24.0%), during examination at a tuberculosis dispensary as contact 4 (16.0%).
The main method
for detecting tuberculosis in both groups was annual large picture frame
photoroentgenography.
In most cases, 11
(47.2%) patients in 1st group and 14 (56.0%) patients in 2nd group,
HIV-infection was diagnosed before pulmonary tuberculosis. The index
did not have significant differences between groups, but in the first
group there were more patients and amounted to 56% χ2=0.32 (р=0.57).
HIV-infection was
detected during examination for tuberculosis in 8 (34.8%) patients from the 1st group
and 7 (28.0%) patients in the 2nd group, all these
patients were tested for HIV for the first time χ2=0.26 (p=0.6125). Much less often patients were already
registered with a phthisiatrician with a diagnosis of pulmonary tuberculosis,
in the 1st group there were 4 (17.4%) people and in the 2nd group
- 4 (16.0%) people χ2=0,02 (р=0.8972).
CD4-lymphocyte
count was determined in all patients at the time of admission. In the 1st group 459.09+46.41
[95% CI 362.84; 555.33], in the 2nd -429.64±47.07 [95% CI
332.49; 526.79] (p=0.476).
14 (60.9%)
patients received antiretroviral therapy before surgery. Before the operation,
the level of CD4+-T-lymphocytes averaged 459.09±46.41 cells/ml.
The
characteristics of the clinical forms of tuberculosis in the groups had no
significant differences.
According to the
forms of the tuberculous process, the patients were diagnosed with: tuberculoma
in the 1st group - 19 (82.6%), in the 2nd group
- 19 (76.0%), fibrous-cavernous pulmonary tuberculosis 3 (13%) and 4
(16.0), χ2=0.08 (р=0.7719), cavernous tuberculosis 1 (4.4%) and 2 (8.0%)
χ2=0.27 (р=0.6015) (see Table 1).
Table 1. Clinical forms of tuberculosis in patients of the
studied groups
Note. ABS - absolute; DST - drug susceptibility testing.
* - including DST
analyzes obtained from surgical material.
Pulmonary
tuberculoma was detected to be the main form χ2=q.32 (p=0.5733). According to
the characteristics of the prevalence of the tuberculous process,
decay cavities in the operated lung among all patients were χ2=0.17 (p=0.6828) equally in the majority
of those observed in the groups. Fibrous-cavernous pulmonary tuberculosis was
limited in volume of the lesion within one lobe of the lung.
This allowed them to apply surgical treatment, there were a minimum
number of such patients.
After the
operation, a macroscopic examination of the surgical material was carried out;
the presence of a cavity of destruction in tuberculoma (or
tuberculomas) was observed in 12 of 19 cases (63.1%). At the time of
registration, mycobacterium tuberculosis (MBT+) was detected in 11
(47.8%) patients in the 1st group and 12 (48.0%) in the 2nd group,
χ2=0.0001 (p=0.9904). At the same
time, in all these cases, mycobacteria in sputum were detected by
bacterioscopy, molecular-genetic methods (GeneXpert MTB/RIF), on liquid
nutrient media with automatic registration BACTEC MGIT and inoculation on a
standard Lowenstein-Jensen medium. Among patients with a positive MBT
test, a drug susceptibility test (DST) of mycobacterium tuberculosis (MBT)
was performed. Multidrug resistance or extensive drug resistance was
detected in 11 (47.8%) patients of the 1st group and 9
(36.0%) of the 2nd group χ2=0.69 (p=0.4064).
There were no significant differences in the groups in
terms of clinical forms of pulmonary tuberculosis, bacterial excretion and
results of drug sensitivity.
All patients before the operation received specific
anti-tuberculosis therapy according to standard antibacterial chemotherapy
regimens. The decision to prescribe surgical treatment was made after
the completion of the intensive phase of chemotherapy; patients with
multidrug resistance and extensive drug resistance took specific
antibacterial drugs for at least 6 months before surgery.
When analyzing opportunistic pathology (see Table 2),
one of the most frequently diagnosed diseases was chronic viral hepatitis
type C (n=15; 65.2% in the 1st group
and n=15; 60.0% in the 2nd group)
χ2=0.14 (p=0.7091).
Chronic viral hepatitis type B was not detected in patients of the 1st group, in
the 2nd group it was detected in 1 (4.0%) patient χ2=0.94
(p=0.3324). Chronic bronchitis was in
2 (8.7%) patients in the 1st group and in 3
(12.0%) patients in the 2nd group χ2=q.14 (p=0.7081). Alcoholism in the 1st group was
observed in 6 (26.1%) patients, in the 2nd group it was
also observed in 6 (24.0%) patients χ2=0.03 (p=0.8675). There were 5 (21.7%)
active drug addicts in the 1st group, in the 2nd -
7 (28.0%). χ2=0.25 (p=0.6168).
There were no differences in concomitant and opportunistic diseases
in the groups, all diseases are associated with social factors, which in
most cases determine the presence of HIV-infection.
Table 2. Concomitant diseases and
addictions in patients in comparison groups
The structure of the performed radical operations in
the first group of patients is shown in Table 3.
Table 3. Types of surgical interventions in operated patients (n=23)
Note. ABS - absolute.
Patients underwent the following operations: lung
resection (within 1-2 segments) - 15 (65.2%) people; polysegmental lung
resection - 5 (21.7%) people; lobectomy - 1 (4.3%) person; bilateral
resection (within 1-2 segments on each side) - 2 (8.7%) patients. A
total of 23 operations were performed. In patients with a diagnosis of
fibrocavernous tuberculosis (3 people), the following operations were
performed: 1 lobectomy, 1 polysegmental resection, 1 lung
resection within 1-2 segments. A patient with cavernous pulmonary
tuberculosis (1 person) underwent polysegmental resection. Major surgeries
(combined resection of the lung, bilobektomiya, pneumonectomy) in
this group of patients were not performed. Intraoperative and
postoperative complications were absent, all patients were discharged in
satisfactory condition. Postoperative wounds healed by
primary intention, there was no slow expansion of the lung
and residual cavities. The operations were effective in all patients.
The average hospital stay for HIV-infected patients was 52±1.1 bed days
and did not have statistically significant differences from the
indicator among all operated patients. 5 (21.7%) patients
who underwent a long stage of preoperative chemotherapy stayed in
hospital for more than 70 days. Postoperative complications among all
operated patients in 2016-2017 were <1%. Postoperative
mortality in 2016-2017 was absent.
After 2 years (≈24 months) of observation, an analysis
of the effectiveness of treatment of patients in the comparison groups was
performed (see Table 4).
Table 4. Treatment results after 2 years (≈24 months)
In the 1st group, 16 (69.6%) patients
were removed from the dispensary registration with recovery, χ2=22.51
(p=0.00001), which is significantly more often compared with non-operated
patients. 4 (17.4%) patients were transferred to the 3rd group of
dispensary registration and continue to be registered, reactivation of the
tuberculous process in the postoperative period was observed in 1 (4.3%)
patient, death as a result of progression of HIV-infection was also observed in
1 (4.3%) patient.
The results of treatment of patients in the 2nd group
differed significantly: 1 (4.0%) patient was removed from the dispensary
registration with recovery, 9 (36.0%) patients were transferred to
the 3rd group of dispensary registration and continue
to be registered, progression of the tuberculous process was observed in 3
(12.0%) patients, death due to progression of HIV-infection was observed
in 3 (12.0%) patients. 7 (28.0%) patients continue to be in the
former dispensary registration group, in the 1st group
there were no such patients χ2=7.54 (p=0.0060).
Conclusion
Surgical treatment was prescribed as planned, with the
participation of an infectious disease doctor in treatment, after a course
of antiretroviral therapy was carried out in the preoperative
period and a CD4+-T- lymphocyte count of >200 cells/pL
was achieved. When determining the type and volume of surgical
intervention in patients with HIV-infection, preference was given to
low-traumatic operations. The operations performed were 100% effective,
there were no postoperative complications and mortality.
MBT was found in all situations in the resected area
of the lung. Half of the identified mycobacteria had multidrug and
extensive drug resistance. There was no postoperative mortality.
CD4-lymphocyte counts in all operated patients were >400 cells/μL. All
patients received antiretroviral therapy before surgery and completed the
main course of chemotherapy.
During treatment of patients with comorbidity of
HIV-infection and tuberculosis, the use of surgical methods of treatment
has shown its effectiveness.
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