RU2736118C2 - Method of esophagus resection in patients with malignant esophageal fistula - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specifically to oncology and surgery. On the right, in the seventh intercostal space 1 cm outside of the scapular line, install a valveless trocar with diameter of 10 mm, in the fifth intercostal space on the middle axillary line a valveless trocar is placed with diameter of 12 mm, and a valveless trocar of diameter 5 mm in the ninth intercostal space along the posterior axillary line on the right. Ultrasonic scalpel is used to dissect a mediastinal pleura between an esophagus and a pericardium, a right lung gut, a trachea, wherein separation of the mediastinal pleura begins from the diaphragm. Esophagus is mobilized above and below the tumor so that its lateral wall is visible. Further, the mediastinal pleura is dissected between an esophagus and a hemiazygos vein, and a dissection is performed from a hemiazygos vein. Then a hemiazygos vein is clipped and crossed. Mediastinal pleura is dissected to a right subclavian artery between an esophagus and a backbone. Esophagus is taken to the gauze hanger above and below the tumor site. Esophagus is crossed in a dome of the right pleural cavity and traction in caudal direction behind a distal end of the crossed esophagus is performed; it is mobilized and esophageal vessels are transected. Distal end of the esophagus below the fistula and the tumor is transected; the preparation is removed. Pleural cavity is washed with warm physiologic saline of sodium chloride. Further behind the right lung and in the dome of the pleural cavity along the anterior surface of the right lung, tube 1 cm in diameter is attached to the costal-diaphragmal sine of PHV. Patient is turned on his / her back and performed Witzel gastrostomy and cervicotomy to the left along the anterior edge of the sternocleidomastoid muscle, end esophagostomy.

EFFECT: method enables performing esophageal excision in weakened and age patients with malignant esophageal fistula, reducing traumatism, improving treatment results in this category of patients.

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Description

The invention relates to medicine, namely to surgery, and can be used to treat patients with a complicated course of esophageal cancer - with perforation of the esophageal tumor into the mediastinum.

Esophageal cancer ranks sixth in the structure of mortality associated with malignant neoplasms. At the same time, according to some researchers, it was noted that worldwide esophageal cancer is one of the most frequently recorded causes of cancer death; in 2013, 440,000 people died from this pathology. The five-year survival rate varies from 15% to 25%, the best results are associated with those cases when the disease was detected in the early stages (Enzinger PC, Mayer RJ. Esophageal cancer. // N Engl J Med. 2003; 349: 2241-2252). Esophageal cancer can be complicated by fistula formation.

The pathological communication between the esophagus and adjacent organs and structures, caused by the tumor process, is called malignant esophageal fistula (hereinafter referred to as MES) (Pennathur, A., Gibson, MK, Jobe, BA & Luketich, JD Oesophageal carcinoma. Lancet. 381, 400– 412). FZP are a big problem in modern surgery and oncology. Mortality in this category of patients in the world's best surgical centers reaches 80%. To date, there is no approved algorithm for the management of patients with FDD. The number of clinical observations in most works that consider this problem does not exceed 5 people, and the authors' conclusions are mainly based on a retrospective analysis of individual cases of perforation of malignant tumors of the esophagus (Ghulam Abbas, MD, Matthew J. Schuchert, MD, Brian L Pettiford, MD, Arjun Pennathur, MD, James Landreneau, Joshua Landreneau, James D. Luketich, MD, Rodney J. Landreneau, MD. Contemporaneous management of esophageal perforation // Surgery. - 2009. - No. 4 (146). - P. 749–756).

It should be noted that at present there is no single approved algorithm for the diagnosis and treatment of patients with FD. As for the volume of surgical interventions for FZP, there is no consensus among the authors - some suggest minimally invasive procedures - esophageal stenting along with drainage of the mediastinum and pleural cavity; others insist on the need for esophagectomy.

The clinical picture in patients with malignant esophageal fistulas depends on the presence of a communication of the esophagus with the respiratory tract - in the presence of such a cough is observed with an admixture of blood, saliva and food. When the esophagus communicates with the mediastinum, mediastinitis occurs, when communicating with the pleural cavity - pneumothorax and pleural empyema. The classic Makler triad characteristic of spontaneous esophageal rupture (Boerhaave syndrome) is not seen in patients with FDD. Most of the x-ray symptoms detected on plain chest x-ray, such as subcutaneous emphysema in the neck and chest, pneumothorax, hydrothorax, and pneumomediastinum do not develop immediately after the formation of FAD and are not specific (Pennathur, A., Gibson, MK, Jobe , BA & Luketich, JD Oesophageal carcinoma. Lancet. 381, 400-412 (2013)). According to researchers, the greatest accuracy in detecting malignant esophageal fistulas is computed tomography of the chest organs with oral administration of a water-soluble contrast (Ferlay, J., Soerjomataram, I. & Ervik, M. et al . GLOBOCAN 2012v1.0, Cancer Incidence and Mortality Worldwide IARC Cancer; Morgan, RA, Ellul, JP, Denton, ER, Glynos, M., Mason, RC, and Adam, A. Malignant esophageal fistulas and perforations (management with plastic-covered metallic endoprostheses). // Radiology. 1997 ; 204: 527-532). Analysis of images obtained with CT scan allows to assess the presence and prevalence of contrast agent leakage, to determine the topography of the fistula and the relationship with adjacent organs. In the work of Ferguson et al., (1997) noted that it is necessary to individually approach each case of FD, taking into account the severity of the patient's condition and the local spread of the tumor. Somatically safe patients with localized disease are offered a standard esophagectomy with esophageal plasty. According to the authors, stenting and operations to “turn off” the esophagus from the digestive tract should be used in patients in serious condition and when radical removal of the tumor is impossible (Ferguson MK. Esophageal perforation and caustic injury: management of perforated esophageal cancer. // Dis Esophagus. 1997 Apr; 10 (2): 90-4). In terminal patients, symptomatic treatment should be considered. At the same time, the authors noted that more than 50% of patients who did not undergo surgery or underwent esophageal stenting died, and in the group of patients who underwent esophageal resection mortality was at the level of 10%. These indicators are comparable to those of some clinics for elective esophagectomies for cancer; the authors emphasize that aggressive surgical treatment should be carried out in a selected group of patients. These data are confirmed by Chinese researchers who analyzed 36 cases of esophageal cancer perforation in search of the most optimal approach to the treatment of malignant esophageal fistula. In the selected group, perforation in the right lung was in 14 cases, in the mediastinum in 17 cases, and in the trachea in 5 cases. Open surgery was performed in 34 patients, simultaneous plastic surgery from 3 approaches was performed in 16 cases, and in 15 patients plastic surgery was delayed. 3 patients died. The authors concluded that the results of aggressive surgical treatment of esophageal cancer perforation were better than those of conservative management (Pennathur, A., Gibson, MK, Jobe, BA & Luketich, JD Oesophageal carcinoma. Lancet. 381, 400-412 (2013) ). At the same time, other authors published data on the effective use of self-expanding, polyurethane-coated, metal stents in patients with advanced tumor and metastatic disease [Campion JP, Boudelat D., Launois B .. Surgical treatment of malignant esophagotracheal fistulas, // Am J Surg, 1983, vol. 146 (pg. 641-646); Ferlay, J., Soerjomataram, I. & Ervik, M. et al . GLOBOCAN 2012v1.0, Cancer Incidence and Mortality Worldwide. IARC Cancer Base No. 11. Lyon, France: International Agency for Research on Cancer (2013); Schweigert M, Sousa HS, Solymosi N, Yankulov A, Fernadz MJ, Beattie R, Dubecz A, Rabl C, Law S, Tong D, Petrov D, Schäbitz A, Stadlhuber RJ, Gumpp J, Ofner D, McGuigan J, Costa- Maia J, Witzigmann H, Stein HJ. Spotlight on esophageal perforation: A multinational study using the Pittsburgh esophageal perforation severity scoring system. // J Thorac Cardiovasc Surg. 2016 Apr; 151 (4): 1002-9).

Thus, according to the literature, the following options for managing patients with malignant esophageal fistula are proposed:

- conservative symptomatic therapy;

- endoscopic stenting without mediastinal drainage;

- endoscopic stenting with mediastinal drainage

- resection of the esophagus with simultaneous plastic surgery;

- resection of the esophagus without plastic, with the formation of an esophagostomy and gastrostomy;

- drainage of the mediastinum, pleural cavity - the method of "controlled fistula".

The question of one-stage esophagogastroplasty after esophagectomy remains controversial, since some authors advocate minimally invasive techniques in patients with FD, others prefer esophagectomy.

Thus, in the treatment of patients with esophageal cancer, complicated by the formation of an esophageal fistula and its communication with the mediastinum, there are a number of difficulties associated with the difficulty of choosing one or another surgical intervention.

The prototype is a method of esophageal resection (RU 2500358 C1). The method includes the left thoracoabdominal access in the 6th intercostal space, diaphragmotomy, mobilization of the distal esophagus in the posterior mediastinum and the proximal stomach in the abdominal cavity, resection of the mobilized parts of the esophagus and stomach, the formation of an intrapleural esophageal-gastric anastomosis, the surgical suturing of the diaphragm and the fact that a partial diaphragmotomy is performed with a partial dissection of the left dome of the diaphragm and the preservation of the esophageal opening of the diaphragm, for this the diaphragm is incised 4-5 cm from the costal arch towards the esophageal opening of the diaphragm.

However, a significant disadvantage of this technique is the high trauma and impossibility of using the method in elderly and debilitated patients, as well as a high percentage of complications.

The technical result is a resection of the esophagus in weakened, aged patients with a malignant esophageal fistula communicating with the mediastinum.

The technical result is achieved by the fact that, as in the known method, the left thoracoabdominal access in the 6th intercostal space, diaphragmotomy, mobilization of the distal esophagus in the posterior mediastinum and the proximal stomach in the abdominal cavity, resection of the mobilized esophagus and stomach, the formation of intrapleural esophageal gastric anastomosis, suturing of the diaphragm and the surgical wound, characterized in that a partial diaphragmotomy is performed with a partial dissection of the left dome of the diaphragm and preservation of the esophageal opening of the diaphragm, for this the diaphragm is incised 4-5 cm from the costal arch towards the esophageal opening of the diaphragm.

A feature of the proposed method is that on the right in the 7th intercostal space, 1 cm outward from the scapular line, a thoracoport with a diameter of 10 mm is installed, a thoracoport with a diameter of 12 mm and a thoracoport with a diameter of 5 mm in the 9th intercostal space along the posterior right axillary line, if not right lung collapses under the left-side one-lung ventilation, the insufflation is carried out CO ₂ to 8 mm Hg perform audit right pleural cavity, esophagus imaged perforated tumor and with ultrasonic scalpel operate dissection mediastinal pleura between the esophagus and the pericardium, the gate of the right lung, the trachea, and the division of the mediastinal pleura begins from the bottom of the diaphragm, the esophagus is mobilized above and below the tumor so that its controllable wall is visible, then the mediastinal pleura is dissected between the esophagus and the hemi-unpaired vein and from the hemi-unpaired vein downward dissect, then m clipping and crossing the semi-unpaired vein, dissecting the mediastinal pleura between the esophagus and the spine to the right subclavian artery, taking the esophagus on gauze covers above and below the tumor site, crossing the esophagus in the dome of the right pleural cavity and traction in the caudal direction for the distal end of the transected esophagus, its mobilize and cross the esophageal vessels, if the esophageal tumor cannot be completely separated from the pericardium, main bronchi, trachea, aorta and other structures of the mediastinum, then R2 resection is performed, leaving the tumor tissue, and the surface of the tumor tissue left is coagulated and clipped around the perimeter with tantalum with staples, the distal end of the esophagus, below the fistula and tumors are crossed, the drug is removed, the pleural cavity is repeatedly washed with warm saline sodium chloride solution, then behind the right lung and into the dome of the pleural cavity along the anterior surface of the right lung, set to the costal diaphragm the small sinus of the PVC tube with a diameter of 1 cm, the patient is turned over on his back and gastrostomy according to Witzel and cervicotomy on the left along the anterior edge of the sternocleidomastoid muscle, end esophagostomy are performed.

The invention is illustrated by a detailed description, a clinical example and illustrations, which depict:

FIG. 1 - Patient O., SKT, sagittal sections. The contrast flowed into the mediastinum from the esophagus.

FIG. 2 - Patient O., removed esophagus with tumor and malignant esophageal fistula.

FIG. 3 - Patient O., formed end esophagostomy.

FIG. 4 - Patient O., Formed gastrostomy.

The method is carried out as follows.

Under conditions of general anesthesia with intubation of the left main bronchus and one-pulmonary (left-sided) mechanical ventilation, in the patient's prone position on the operating table (Prone-position), after processing the operating field and delimiting it with a sterile operating material, through an incision 1 cm long in 7- intercostal space 1 cm outward from the scapular line on the right, a thoracoport with a diameter of 10 mm is installed, then, under visual control, a thoracoport with a diameter of 12 mm is installed in the 5th intercostal space along the mid-axillary line on the right and a thoracoport with a diameter of 5 mm in the 9th intercostal space along the posterior axillary line on right. For thoracoscopy, 30 degree optics are used. CO ₂ insufflation up to 8 mm Hg. carried out only if the right lung does not collapse under conditions of left-sided one-lung ventilation. Revision of the right pleural cavity is performed, the esophagus with a perforated tumor is visualized. Using an ultrasound scalpel (for example, Harmoic), the mediastinal pleura is dissected between the esophagus and pericardium, the gate of the right lung, and the trachea. The division of the mediastinal pleura begins from the bottom, from the diaphragm. The esophagus is mobilized above and below the tumor so that its controllateral (left) wall is visible. Next, the mediastinal pleura is dissected between the esophagus and the hemi-unpaired vein. The direction of dissection is carried out downward from the hemi-unpaired vein. Then, the semi-unpaired vein is clipped and transected, the mediastinal pleura is dissected between the esophagus and the spine to the right subclavian artery. The esophagus is taken on gauze straps above and below the tumor site. Further, in the dome of the right pleural cavity of the esophagus, the esophagus is crossed using the Eshelon apparatus, a blue cassette 60 mm long. Traction is performed in the caudal direction for the distal end of the transected esophagus. It is mobilized and the esophageal vessels are crossed using the Ligasure 5 mm electrolysis apparatus. In the event that the esophageal tumor cannot be completely separated from the pericardium, main bronchi, trachea, aorta and other structures of the mediastinum, then R2 resection is performed, leaving the tumor tissue. The surface of the left tumor tissue is coagulated and clipped around the perimeter with tantalum staples - for subsequent radiation therapy. The distal end of the esophagus (below the fistula and tumor) is transected using a 60 mm Eshelon linear stapler (blue cassette). Next, the drug is removed using an endocontainer. The pleural cavity is repeatedly washed with warm (39 Gy. Celsius) saline sodium chloride solution. PVC tubes with a diameter of 1 cm are installed to the costophrenic sinus, behind the right lung and into the dome of the pleural cavity along the anterior surface of the right lung. The patient is turned over on his back, a Witzel gastrostomy is performed according to the standard technique and a cervicotomy on the left along the anterior edge of the sternocleidomastoid muscle, end esophagostomy.

Clinical example.

Patient O., 86 years old, complained of the impossibility of taking solid and liquid food, abundant saliva, periodic vomiting. According to EGD data, a tumor of the middle third of the esophagus was detected, which completely blocks the lumen. Endoscopic stenting was deemed impossible due to the impossibility of safe guidewire placement. According to the histological findings - squamous cell carcinoma, G1. According to fluoroscopy, the contrast does not enter the stomach. According to the CT scan of the OGK and OBP, a tumor of the middle third of the esophagus, without invasion into neighboring organs, and also without signs of damage to regional lymph nodes, distant metastases were not detected. Concomitant pathology: ischemic heart disease. Diffuse cardiosclerosis. Hypertension stage II, grade 2, risk of CVC 4. Exertional angina pectoris, FC 2. CH I. ECOG 1. Considering the clinic of grade 3 dysphagia, the patient was planned to form a nutritional gastrostomy. The next day after hospitalization, at 07.00, she turned to the doctor on duty with complaints of fever up to 38.5 C, chills, chest pain, swelling of the neck. Examination revealed subcutaneous emphysema on the left neck, SCT of the OGK - esophageal cancer, pneumomediastinum. When adopting a water-soluble contrast, a delimited leak into the paraesophageal space. The contrast output beyond the esophagus into the mediastinum is visualized - signs of fistula (Fig. 1). The diagnosis was made: cancer of the middle third of the esophagus, cT4NxM0, complicated by the formation of a malignant esophageal fistula.

The patient was transported to the operating room, where she underwent thoracoscopy, subtotal esophagectomy according to the proposed method. A single block removed the esophagus and malignant fistula (Fig. 2), formed an esophagostomy (Fig. 3) and gastrostomy (Fig. 4). Postoperative diagnosis: cancer of the middle third of the esophagus (squamous cell carcinoma) pT3N0M0 IIА stage, G1, 3 class gr., Complicated by disintegration and formation of a malignant esophageal fistula.

The patient was discharged from the department in a satisfactory condition 2 weeks after the operation. Follow-up: 6 months, no signs of progression.

The use of the proposed method in clinical practice made it possible to remove the esophagus in weakened and aged patients with a malignant esophageal fistula and improve the results of treatment in this category of patients.

Claims (3)

1. A method of resection of the esophagus in patients with malignant esophageal fistula, characterized in that on the right, in the seventh intercostal space 1 cm outward from the scapular line, a thoracoport with a diameter of 10 mm is installed, a thoracoport with a diameter of 12 mm and a thoracoport with a diameter of 5 mm in the ninth intercostal space along the posterior axillary line on the right, revision of the right pleural cavity is performed, the esophagus with a perforated tumor is visualized and, using an ultrasonic scalpel, the mediastinal pleura is dissected between the esophagus and the pericardium, the gate of the right lung, the trachea, and the separation of the mediastinal pleura from the bottom begins , the esophagus is mobilized above and below the tumor so that its controllateral wall is visible, then the mediastinal pleura is dissected between the esophagus and the hemi-unpaired vein and dissection is carried out from the hemi-unpaired vein downward, then clipped and transected, the semi-unpaired vein is dissected to the right subcutaneous the mediastinal pleura between the esophagus and the spine, the esophagus is taken on gauze covers above and below the site of the tumor, the esophagus is crossed in the dome of the right pleural cavity and traction is performed caudally for the distal end of the transected esophagus, it is mobilized and crossed over the esophageal vessels, the distal end of the esophagus, below the fistula and tumor, cross, the drug is removed, the pleural cavity is washed with warm saline sodium chloride solution, then behind the right lung and into the dome of the pleural cavity along the anterior surface of the right lung, tubes with a diameter of 1 cm are placed to the costal-diaphragmatic sinus of the PVC, the patient is turned on his back and perform gastrostomy according to Witzel and cervicotomy on the left along the anterior edge of the sternocleidomastoid muscle, end esophagostomy. 2. The method according to claim 1, characterized in that if the right lung does not collapse under conditions of left-sided one-lung ventilation, CO2 insufflation is carried out up to 8 mm Hg. 3. The method according to claim 1, characterized in that if it is impossible to completely separate the esophageal tumor from the mediastinal structures, R2 resection is performed, leaving the tumor tissue, and the surface of the tumor tissue left is coagulated and clipped along the perimeter with tantalum clips.

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