RU2635860C2 - Method of determination of inter-segmentary border under segmentectomy in patients with malignant neoplasms of lungs - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: Foley catheter is introduced into the distal fragment of intersected segmental bronchus, through the channel of which the air is supplied. The air-filled tissue of the lung segment acquires pink colour, lighter in comparison with the surrounding atelectasized pulmonary tissue. In this case, a clear inflationary deflationary line corresponding to the intersegmentary plane is determined. Based on the demarcation zone that has been formed in this way, a surgeon sharply or by means of a stapling device divides the lung tissue.

EFFECT: use of the claimed method in medical practice makes it possible to achieve the following technical and therapeutic results: to intraoperationally clearly define the intersegmental border when performing segmentectomy; to minimize damage to the parenchyma of the retained segments and reduce the likelihood of prolonged airflow through pleural drains in postoperative period; to provide an optimal distance from the edge of the tumour neoplasm to the resection line, which in turn is associated with a lower risk of continued growth and tumour recurrence; economic efficiency; to improve the quality of life of patients who underwent surgery for malignant neoplasms in the lungs.

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Description

The invention relates to medicine, in particular to oncology and thoracic surgery.

At present, segmentectomy is becoming increasingly important in oncological surgery, becoming an alternative to lobectomy in the early stages of lung cancer in elderly patients with a pronounced comorbid background and patients with reduced rates of functional respiratory reserves. The gold standard for surgery for metastatic lung disease is atypical resection. But the deep intraparenchymal arrangement of metastasis does not always allow technically performing atypical resection, ensuring radicality (R0). The choice of the volume of sublobar anatomical resection in such cases allows us to expand the scope and extend the prospect of surgical treatment of patients with primary multiple synchronous and metachronic lung tumors, as well as single, multiple, bilateral and recurrent metastases. Segmentectomy belongs to the category of the most complex anatomical resections due to the anatomical variability of angioarchitectonics and the absence of clearly defined intersegmental boundaries of the lung parenchyma. Correct intraoperative determination of the vessels and bronchi of the removed segment can be achieved using a preoperative three-dimensional CT reconstruction with separation and mapping of bronchovascular structures. Nevertheless, intraoperatively, even after ligation of the segmental vessels, there is no demarcation of the boundaries of the segments of the lung. In this regard, the separation of the lung tissue of the segment to be removed from the preserved is one of the most technically difficult stages of sublobar anatomical resection of the lung. The development of new methods for determining new methods for determining intersegmental boundaries in segmentectomy is an urgent area of modern thoracic surgery and oncology.

Closest to the claimed invention is a method for determining the boundaries of lung segments when performing videoassisted anatomical sublobar resection, by insufflation of air into the removed lung segment with a syringe through a long endoscopic needle inserted tangentially into the lumen of the distal stump of a segmental bronchus previously crossed and stitched with an endoscopic stapler (Decalué Lieven Depypere, Stanzi A, Silva Corten LC, Coosemans W, Nafteux P, Moons J, Van Veer H, Van Raemdonck D, De Leyn P. Identification of the intersegmental plane by puncture and insufflations of the tra nsected bronchus during video-assisted thoracoscopic anatomical segmentectomies. 23rd European Conference on General Thoracic Surgery. 31 May - 3 June 2015, Lisbon, Portugal).

However, this method requires the mandatory use of an endoscopic stapler for crossing and bilateral stitching of both the remaining and the removed stump of the segmental bronchus. The inventive method allows us to avoid unnecessary sealing of the bronchus stump to be removed, and to preserve the stored stump manually or with a stapler for open surgery, which is more cost-effective.

The second relevance and even more technically complex analogue of the invention is a method for demarcation of the segment intended for removal by injecting air into the segmental bronchus using intraoperative fibrobronchoscopy using three-dimensional virtual mapping to identify the desired bronchus (Sonobe M, Date H. Technology on partial resection and segmentectomy for early-stage lung cancer. Kyobu Geka. 2016 Jul; 69 (8): 676-80).

However, the known method involves the use of additional intraoperative high-tech research involving a specialist in fibrobrochoscopy and the use of software in order to identify the segmental bronchus to be removed segment.

The invention is aimed at solving the problem of determining intersegmental boundaries during surgical intervention in the amount of sublobar anatomical resection for primary peripheral lung cancer T1AN0M0, stage IA or metastases, the topic of which does not allow for atypical resection with sufficient clearance; minimize damage to the parenchyma of the preserved segments and reduce the likelihood of prolonged air flow through the pleural drainage in the postoperative period; provide the optimal distance from the edge of the tumor to the line of resection.

These technical and therapeutic results in the implementation of the invention are achieved due to the fact that, as in the known methods, they perform thoracotomy and bronchotomy, insufflation of air into the distal stump of the segmental bronchus, intraoperative visualization of the demarcation zone of lung tissue.

A feature of the proposed method is that the proximal stump is sutured, a Foley catheter is inserted into the lumen of the distal stump of the bronchus, the cuff is inflated, air is insufflated through the catheter channel using a syringe or medical bulb, then a clear inflation-deflation line is revealed, and, guided by the formed demarcation line the zone, the acute way, using mono-bipolar coagulation, an ultrasonic scalpel or by means of a stapler, the lung tissue is separated, after which the segment removed, the separation surface of the lung tissue of the preserved segments is covered with BioGlue glue.

A significant difference of the proposed method from analogues is that the air is delivered to the segment to be removed by means of a Foley catheter inserted into the distal fragment of the crossed segmental bronchus and does not require intraoperative fibrobronchoscopy, as well as preliminary processing of the segmental bronchus with a stapler.

Use in clinical practice of the proposed method will allow the separation of the pulmonary parenchyma of the segment to be removed with the neoplasm from the parenchyma of the preserved segments. Observance of the boundaries of intersegmental planes during their separation will allow to achieve greater tightness and reduce the risk of prolonged air flow through the pleural drains in the postoperative period, which in turn will lead to a reduction in the length of hospital stay.

The method is illustrated by a detailed description, clinical examples and illustrations, which depict:

FIG. 1 - a Foley catheter was inserted into the lumen of the distal stump of the bronchus (1).

FIG. 2 - a clear inflation-deflation line (2) is determined, which corresponds to the intersegment plane.

FIG. 3 - separation of pulmonary parenchyma.

The method is as follows.

The patient is operated on in a side position under conditions of one-lung ventilation. An anterolateral thoracotomy along the V intercostal space or, in the case of a video-assisted operation, a minithoracotomy (4 cm) anterior to the anterior edge of musculus latissimus dorsi is used as operative access. After processing the segmental arteries, segmental bronchus is isolated, bronchopulmonary lymph nodes are removed or displaced in the direction of the removed segment. A ligature is placed under the bronchus, after which a bronchotomy is performed. A Foley catheter of the corresponding diameter is inserted into the lumen of the distal stump of the bronchus, the cuff is inflated (Fig. 1). Holding the catheter with tweezers or a soft clip to prevent dislocation into the lumen of the bronchus, air is insufflated through a catheter channel using a syringe or medical bulb. The air-filled segment expands and acquires a pink color, lighter in comparison with the surrounding atelectasized lung tissue. In this case, a clear inflation-deflation line corresponding to the intersegment plane is determined (Fig. 2). Guided by the demarcation zone formed in this way, the surgeon sharply, using mono-bipolar coagulation, an ultrasonic scalpel or by means of a stapler, separates the lung tissue (Fig. 3). The lung segment is removed. The surface corresponding to the separation plane of the lung tissue of the retained segments is coated with BioGlue. After filling the pleural cavity with an antiseptic solution, the ventilation of the lung is resumed, checking the tightness of the lung tissue. Before suturing wounds, the pleural cavity is drained with two silicone drains.

This method allows you to achieve simultaneously two goals:

- minimize damage to the parenchyma of the preserved segments and thereby reduce the likelihood of prolonged air flow through the pleural drainage in the postoperative period;

- ensure the optimal distance from the edge of the tumor to the resection line, which in turn is associated with a lower risk of continued growth and relapse of the tumor.

Clinical examples of the method

Example 1. Patient P., 40 years old, clinical diagnosis: [C74] Cancer of the right adrenal gland pT4N0M1 (hepar), IV tbsp. Surgical treatment in 2011. Progression in 2013: multiple lung metastases. Monochemotherapy with Mitotan (12 months). Progression.

According to the preoperative CT of the chest organs, dynamics was observed in the form of an increase in the size of previously detected formations of both lungs: on the right in the 10th segment, two foci up to 5 mm (previously 4 mm) and up to 12 × 9 mm (previously 8 × 8 mm), in the 6th segment up to 5 mm (previously 3 mm), in the 3 segment up to 5 mm (previously 3 mm); on the left - at the border of S1 + 2 and S3 up to 25 × 25 mm (previously 21 × 21 mm), in S8 up to 7 mm (previously 4 mm), in S10 up to 15 × 13 mm (previously 12 × 10 mm); as well as the lack of sites of low-intensity infiltration in the lower lobe of the right lung. The mediastinum is structural, not displaced. Consolidation of fiber of the anteroposterior mediastinum remained. Hilar lymph nodes were not enlarged. No fluid was detected in the pleural cavities.

At the first stage of surgical treatment of the patient, metastases of the left lung were removed.

Operation: Segmentectomy S III, atypical resection of the lower lobe of the left lung.

Anterolateral thoracotomy on the right along the V intercostal space. During the audit: fluid, adhesions in the pleural cavity, dissemination of the pleura is not. In the lower lobe, 3 subpleural nodular formations with sizes from 5 to 15 mm were determined - after separation of the lower pulmonary ligament using the UO-40 and UO-60 apparatus, atypical marginal resections of the lower lobe with the indicated formations were performed. In addition, nodular formation up to 7 mm in diameter was palpated deep in the parenchyma of the III segment of the upper lobe. Given the topic of education, it was considered appropriate to perform a segmentectomy S III. An anterior mediastinotomy was performed. The superior pulmonary vein, farthing trunk of the pulmonary artery, the last taken to the turnstile. Artery A3 and segmental vein were isolated, separately ligated twice, stitched and crossed. B3 bronchus is isolated, bronchopulmonary lymph nodes are removed. A ligature was made under the bronchus, a bronchotomy was performed. A Foley catheter of the corresponding diameter was inserted into the lumen of the distal stump of the bronchus; the cuff was inflated. Holding the catheter with tweezers to prevent dislocation into the lumen of the bronchus through the catheter channel, air was insufflated by means of a syringe. In accordance with the demarcation lines, lung tissue of segment III was separated from the tissue of the upper lobe using LigaSure and the UO-40 apparatus. The segment has been deleted. The bronchus stump was sutured with separate interrupted sutures. The lines of mechanical sutures on the lung tissue were additionally reinforced with separate 8-shaped sutures. Hemostasis. Washing of the pleural cavity, checking for aerostasis under a layer of fluid - there are no signs of primary failure of the joints on the bronchus and lung tissue. Drainage of the pleural cavity with two silicone drains. The wound was sutured in layers and treated with an antiseptic.

At the second stage of treatment (05.25.2015), the patient underwent a similar operation on the right: segmentectomy S III, atypical resection of the right lung.

The histological conclusion: metastases of adrenocortical cancer.

Postoperative periods were uneventful. Pleural drainage was removed on 2-3 days. Signs of leaks in lung tissue were not observed. During the follow-up examination of the patient in May 2016, no recurrence of lung metastases was revealed, the study of the function of external respiration did not reveal significant deviations from the norm (FEV1-86%), dynamic observation was continued.

Example 2. Patient M., 63 years old, clinical diagnosis: [C 97] Primary multiple metachron cancer: 1) Cancer of the lower ampullar part of the rectum, pT3N0M0, stage II. Combined treatment (preoperative RT + operations of abdominal-perineal extirpation of the rectum) in 2009. Progression of the tumor process (April 2012) - metastases in the liver and lungs. 6 courses of XT, operation (atypical resection of liver S VI on 08/23/2012), 6 courses of n / a XT, atypical resection of the left lung on 05/07/2013, atypical resection of the lower lobe of the right lung, 06/21/2013 6 courses of chemotherapy. Progression in 2014: lung metastases. 6 courses of chemotherapy. Surgical treatment: segmentectomy S I, S IX-X of the left lung 11/13/14. Segmentectomy S IX-X of the right lung 12/25/14. 2) Cancer of the right kidney, I st., T1N0M0. Condition after surgery from 08.23.12. (resection of the right kidney). No signs of progression. 3) Basal cell carcinoma of the scalp skin, condition after RFA from 06.2010. Without signs of progression.

Medical history. In 2009, for stage II rectal cancer at the Moscow Scientific Research Institute for Advanced Medicine. P.A. Herzen underwent combined treatment (RT + surgery). In 2012, the progression of the tumor process in the form of metastatic lesions of the liver and lungs was diagnosed, as well as the formation in the right kidney. Conducted 6 courses of XT + atypical resection of liver S6, resection of the right kidney (diagnosed with primary kidney cancer of the first stage) + 6 courses of XT. In May and July 2013, lung operations (atypical resections) followed by 6 XT courses were performed in stages. In March 2014, a follow-up examination revealed progression of the tumor process in the form of metastases in the lungs. 6 courses of XT were performed, stabilization of the tumor process was noted. 11.13.14 anatomical resection S1, segmentectomy S9, 10 of the left lung were performed. Histological examination No. E 30909-27 / op: in the removed fragments of the left lung (1st, 9-10 segments) metastases of colorectal adenocarcinoma without signs of therapeutic pathomorphism. At the edges of the resection of the bronchus and blood vessels without tumor growth. In bronchopulmonary, root lymph nodes - histiocytosis of the sinuses, anthracosis, nonspecific granulomatous reaction. In December 2014 he was hospitalized in the thoracic department for the implementation of the next stage of surgical treatment.

Operation: Segmentectomy S I, segmentectomy S IX-X of the left lung. Anterolateral thoracotomy along the 5th intercostal space on the left with excision of the previous postoperative scar. Moderately pronounced adhesive process in the pleural cavity. Produced pneumolysis by electrocoagulation. With a further audit: fluid and dissemination in the pleural cavity was not detected. In the root of the lower lobe at the border of the IX-X segments, next to postoperative cicatricial changes, a multinodular tumor-like formation measuring 1.5 × 2 × 2.5 cm was determined. 1 × 1.5 × 3 cm. Other formations in the lung tissue and enlarged intrathoracic lymph nodes were not determined. The topic of metastases did not allow for atypical resections; it was recognized to perform segmentectomy I and segmentectomy IX-X.

The pulmonary ligament is divided. Performed anterior and posterior mediastinotomy. The upper and lower pulmonary veins, the left pulmonary artery were isolated. The anterior and posterior root lymph nodes were isolated and removed. The interlobar sulcus is divided subtotally. The mouths of arteries A2, A4, 5, A6, A8, A9, A10 are highlighted in it. The last two arteries are twice ligated, stitched and crossed. Under them is the bronchus B9-10. A ligature was placed under the bronchus, a bronchotomy was performed. A Foley catheter of the corresponding diameter was inserted into the lumen of the distal stump of the bronchus; the cuff was inflated. Holding the catheter with tweezers to prevent dislocation into the lumen of the bronchus through the catheter channel, air was insufflated by means of a medical pear. The segment demarcation zone coincides with the localization of nodal formations. Marked the boundaries of the segments with a coagulator. B9-10 bronchus was crossed, the proximal stump was sutured with separate Vicryl interrupted sutures. The segments were resected using LigaSure and 1 moves of the UO-60 and UO-40 devices. IX-X segments with formations were removed. The intersegmental surface of the lung was sutured with 8-shaped Vicryl sutures.

Segmental veins of the superior lobe were isolated; VI was twice ligated, clipped and crossed. Artery A1 was isolated, twice ligated, stitched and crossed. The bronchus of I segment is isolated and crossed. A ligature was placed under the bronchus, a bronchotomy was performed. A Foley catheter of the corresponding diameter was inserted into the lumen of the distal stump of the bronchus; the cuff was inflated. Holding the catheter with tweezers to prevent dislocation into the lumen of the bronchus, air is insufflated through a catheter channel through a syringe. Marked demarcation boundaries of the I segment. The segment was resected using LigaSure and 2 strokes of the UO-60 apparatus. Segment deleted. The intersegmental surface of the lung is sutured with 8-shaped Vicryl sutures. Hemostasis. Washing of the pleural cavity with an antiseptic. Aerostasis test - without signs of primary failure of the sutures on the bronchi and lung tissue. Drainage of the pleural cavity with two silicone drains. Layer wound closure. Aseptic sticker.

At the second stage of treatment (December 25, 2014), the patient underwent a similar operation on the right: segmentectomy S IX-X of the right lung.

The histological conclusion: metastases of colorectal adenocarcinoma in the lungs.

Postoperative periods were uneventful. Long-term leakage of lung tissue was not observed. Pleural drainage removed 3-4 days. During the follow-up examination of the patient in July 2016, no recurrence of lung metastases was revealed, the study of the function of external respiration (FEV1 - 40%), continued dynamic observation.

Using the claimed method in medical practice allows to achieve the following technical and therapeutic results:

- Intraoperatively clearly define the intersegmental border when performing segmentectomy;

- minimize damage to the parenchyma of the preserved segments and reduce the likelihood of prolonged air flow through the pleural drainage in the postoperative period;

- to ensure the optimal distance from the edge of the tumor to the resection line, which in turn is associated with a lower risk of continued growth and relapse of the tumor;

- economic efficiency;

- improve the quality of life of patients undergoing surgery for malignant neoplasms in the lungs.

Claims (1)

A method for determining the intersegmental border in segmentectomy in patients with lung malignant neoplasms, including thoracotomy and bronchotomy, air insufflation into the distal stump of the segmental bronchus, intraoperative visualization of the lung tissue demarcation zone, characterized in that the proximal stump is sutured, a bronchitis cervix is inserted into the lumen of the distal stump, the cataract is inserted inflate, air is insufflated through a catheter channel using a syringe or medical pear, then a clear inflationary the flation line, and, guided by the formed demarcation zone, in the acute way, using mono-bipolar coagulation, an ultrasonic scalpel or using a stapler, the lung tissue is separated, after which the segment is removed, the separation surface of the lung tissue of the preserved segments is covered with BioGlue glue.

Images