RU2288646C2 - Method for operative treatment of cardioesophageal cancer - Google Patents

Abstract

FIELD: medicine, esophageal and gastric surgery.

SUBSTANCE: one should carry out diaphragmotomy from esophageal diaphragmatic opening at transferring left diaphragmatic stem at the angle of 70° against costal arch from the left along draining with drainage applied along posterior surface up to the lung's top that enables to develop the chance for more optimal access to the organs of abdominal and pleural cavity from the left that keeps the principles of operation radicalness, technical simplicity of applying intrapleural esophageal anastomoses and makes it efficient at applying in senile and weakened patients at accompanying pathology.

EFFECT: higher efficiency of therapy.

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Description

The invention relates to medicine, namely to surgery, and can be used in the surgical treatment of cardioesophageal cancer (CEP) of type II, III (according to Sievert).

Surgical treatment of cancer of the cardioesophageal region continues to be one of the most complex problems of modern clinical oncology. Cancer of the proximal stomach with passage to the esophagus is characterized as a high-grade tumor with lymphogenous metastasis to the lymph collectors of both the abdominal cavity and the mediastinum. In the literature to date, there is no single approach in choosing the most rational access and, accordingly, the volume of surgical intervention in the treatment of patients with cancer of the cardioesophageal region. Surgical access to a large extent determines the effectiveness of the operation. Of particular relevance is the issue of surgical access for cardiac cancer in the elderly and debilitated patients with concomitant cardiorespiratory diseases.

There is a method of surgical treatment of cardioesophageal cancer, which consists in the implementation of combined thoracoabdominal access in the 7th intercostal space on the left along the Osawa-Garlock (M.I. Davydov, I.N. Turkin, I.S. Stilidi and other Cardioesophageal cancer: classification, surgical tactics, main prognosis factors // Bulletin of the Russian N. Blokhin Russian Oncology Research Center, Russian Academy of Medical Sciences - No. 1 - 2003. - P.82-88), in which gastrectomy is performed from a single left-sided abdominal-thoracic access, proximal gastric resection with lower thoracic resection esophagus. The known method allows under visual control to mobilize the esophagus to the level of the aortic arch, perform lymphodissection to the level of bifurcation of the trachea and form a high anastomosis.

However, the disadvantage of this method is the difficulty in execution, trauma, significant blood loss and a large number of pulmonary complications.

There is a method of surgical treatment of cardioesophageal cancer by left thoracophrenotomy (operation Sweet) (D.G. Mustafin, M.R. Pankova, P.N. Zlygostev and others. Transpleural operations in cardioesophageal cancer. // Oncology: Surgery of the esophagus and cardiac department stomach. - 1995.- P.55-57).

Despite a good approach to the affected segment of the esophagus, the convenience of applying an esophageal-gastric anastomosis, a complete revision of the chest and abdominal cavity, the known method has a drawback, namely, the difficulty in performing extended D2-D4 lymphadenectomy and combined operations.

The closest to the achieved positive result is the method of surgical treatment of cardioesophageal cancer by laparotomy with sagittal diaphragmotomy according to A.G. Savinykh (V.S. Rogacheva, P.D. Fomin. Esophagus surgery (errors and dangers). - M., 1983. - P.29-31; A.F. Chernousov, V.S. Silverstov, F.S. Kurbanov. Gastric plastic surgery for cancer and benign structures. - M .: Medicine, 1990. - P.68-78), consisting in the fact that they perform dissection of supraphysical, lower paraesophageal and bifurcation lymph nodes, resect the distal th esophagus with the formation of anastomosis to the level of the lower pulmonary vein.

The disadvantage of this method is significant difficulties in the formation of a high anastomosis in the posterior mediastinum during resection of the lower third of the esophagus, as well as when the tumor germinates the mediastinal pleura, and in a number of observations of the lung, the inability to comply with the basic principles of the radical operation. In the group of patients operated from the Savinykh access, the frequency of detection of tumor elements along the esophagus resection line was the highest (M.I. Davydov, I.N. Turkin, I.S. Stilidi et al. Cardioesophageal cancer: classification, surgical tactics, the main factors of the forecast. // Bulletin of the Russian N. Blokhin Russian Research Center for Medical Sciences. - No. 1. - 2003.)

A positive result of the claimed method is to reduce the morbidity, increase the reliability of the formation of intrapleural anastomosis due to the optimal accessibility in performing dual-zone abdomino-mediastinal lymphadenectomy (D2, 2S) and the possibility of performing the claimed method in elderly and debilitated patients with concomitant pathology.

A positive result of the claimed method (laparophrenotomy on the left) is achieved by performing diaphragmotomy with opening the pleural cavity to the left after laparotomy at an angle of 70 °, and the diaphragm is opened from the diaphragmatic opening of the esophagus to the costal arch to the VII intercostal space, thereby providing optimal access to the abdominal and pleural organs cavity on the left, with the ability to perform dual-zone abdomino-mediastinal lymphatic dissection (D2 2S). Due to the fact that the costal arch is not crossed and true thoracotomy is not performed in the 7th intercostal space, the less traumatic is the method, which allows free formation of esophageal anastomoses in the posterior mediastinum to the aortic arch, without using special tools, as in the prototype.

The method is as follows.

The patient is placed on the operating table. The table is tilted towards the operating surgeon at an angle of 20 °, a roller is placed under the back at the level of the xiphoid process. Under general anesthesia, the surgical field is treated with chlorhexedine twice, the upper middle laparotomy is performed, the abdominal cavity is revised, then the abdominal segment of the esophagus is mobilized and the posterior mediastinum is revised. In the case of resectability of the process, a diaphragmotomy is made from the diaphragmatic opening of the esophagus with the intersection of the left diaphragm leg in an oblique direction at an angle of 70 ° towards the costal arch from the left to the VII intercostal space. The wound is expanded with Seagal expanders. The stomach and esophagus are mobilized with a large and small omentum with dual-zone lymphodissection (2D 2S) with intersection and ligation of the vessels of the stomach. Subtotal proximal resection of the stomach with resection of the lower third of the esophagus is performed, anastomosis is formed intrapleurally on the left at the level of the bifurcation of the trachea or lower. After revision of the abdominal and thoracic cavities and additional hemostasis, the diaphragm is sutured with separate nylon sutures from the costal arch to the stump of the stomach with the latter being sutured to the diaphragm. A probe is inserted into the stomach stump transnasally for decompression of the anastomosis for 2-3 days. A drainage is installed in the pleural cavity in the VII intercostal space along the posterior axillary line with several openings to remove residual air and postoperative exudate and it is laid along the posterior surface to the apex of the lung. The laparotomic wound is sutured in layers.

For the anatomical and physiological justification of surgical treatment of cardioesophageal cancer according to the claimed method, anthropometric measurements with the study of access parameters were performed in 10 observations in an anatomical experiment. The optimal parameters were identified: the depth of the wound - 16.2 cm, the inclination of the operative action - 65 °, the angle of the operational action - 40 °.

Clinical example

Patient A., 63 years old, was admitted with complaints of difficulty in passing solid, rough food and weight loss of up to 5 kg. Concomitant pathology: coronary heart disease - atrial fibrillation, normform, NIB, hypertension II, moderate risk of complications. With esophagogastroscopy, the esophagus is freely passable. Starting from 40 cm, ulcerative infiltrative cancer is determined in the cardial part of the stomach with a transition to the dentate and the lesser curvature of the body of the stomach measuring 2 × 2 cm. The histological diagnosis is adenocarcinoma.

An operation was performed from access according to the proposed method (laparophrenotomy on the left). During the audit revealed a tumor in the cardioesophageal region with a transition along the lesser curvature to the subcardia, a dense ulcerative-infiltrative form of 2 × 2 cm. No distant metastases were detected. An extended combined subtotal proximal gastrectomy with a resection of the lower third of the esophagus, with splenectomy and bizonal abdominomediastinal lymphatic dissection (D2 2S) was performed. Formed submersible invagination esophagogastroanastomosis according to M.I. Davydov. The immediate postoperative course is smooth. Relaxation of the diaphragm and, in this regard, pulmonary complications were not observed. Drainage from the pleural cavity was removed on the 4th day, nasogastric tube - on the 3rd day.

The patient was discharged on the 14th day after surgery in a satisfactory condition. Examined after 1, 3, 6 months. Complaints of dysphagia, burning behind the sternum, no pain. With control fluoroscopy and FGS, the mucous membrane of the esophagus is pink throughout, the anastomosis is well passable, there are no signs of esophagitis; Barium suspension passes freely in portions and enters the stomach. The diaphragm in a polypositional study standing, lying adequately involved in the act of breathing.

Thus, the claimed method provides the most optimal volume of surgery, especially with locally advanced cardioesophageal cancers, with dual-zone abdominomediastinal lymphadenectomy (D2 2S), technical ease of performing higher esophageal intrapleural anastomoses on the left. Especially relevant is the application of the claimed method in elderly and debilitated patients with concomitant pathology.

Claims (1)

A method for the surgical treatment of cardioesophagic cancer, which consists in performing laparotomy with a diaphragmotomy, characterized in that the diaphragmotomy is performed from the esophagus of the diaphragm with the left leg of the diaphragm intersected at an angle of 70 ° to the costal arch on the left, followed by drainage of the pleural cavity with drainage, which is laid along the back to the top surface lung.