RU2747419C1 - Method for treatment of patients with cardioesophageal cancer - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, namely to oncology. Based on the results of a comprehensive examination of the patient and the establishment of a diagnosis of cardioesophageal cancer, a decision is made on surgical intervention in the scope of performing a proximal resection of the stomach with resection of the distal esophagus within 10 cm of the indent from the esophageal-gastric junction. To do this, an upper midline laparotomy is performed with the continuation of the incision along the sixth intercostal space on the left, crossing the cartilaginous segments of the costal arch and diaphragm to the level of the esophageal opening. Then the abdominal organs are revised. Next, a proximal resection of the stomach is performed with the formation of a gastric tube from its stump with a diameter of 4 cm, which is moved into the left pleural cavity to the line of resection of the esophagus and the transected esophagus is wrapped with a mobile narrow gastric graft, as in Fig. 2. The resulting loop of the gastric graft is sutured with the esophagus and between themselves with interrupted nylon sutures, then the lumen of the gastric graft is opened, ten interrupted sutures are applied with absorbable suture material on the esophagus and the inner lip of the anastomosis. The outer lips of the gastric graft are sutured, thus avoiding the traditional intussusception of the esophagus into a narrow gastric graft due to the lateral echelon of the esophagus by the walls of the gastric stem duplication. After that, the thoracoabdominal wound is sutured layer-by-layer with mandatory drainage of the left pleural cavity with a Bülau drain with an inner diameter of 10 mm, after 7 days, contrasting of esophagogastroanastomosis with a solution of barium sulfate is carried out, with the consistency of the anastomosis and the absence of streaks of the contrast agent, the trapping drains are removed.EFFECT: method improves both immediate and long-term functional outcomes of operations due to reliability and functionality of the developed reservoir esophageal-gastric junction.1 cl, 1 ex, 3 dwg

Description

The invention relates to medicine, in particular to oncology, and can be used in the surgical treatment of cardioesophageal cancer (CER) type 2 and 3 according to Siewert (1987).

The essence of the invention

With the most relevant forms of ERC for the RF (types 2 and 3 make up 84.4%) with massive spread to the stomach, as an alternative to gastrectomy (GE), radical proximal gastrectomy is performed with the inevitable formation of a narrow gastric graft and original reservoir esophagoenteroanastomosis, which is distinguished by its reliability and functionality. ...

Description of the invention

An increase in the incidence of ERC against the background of a decrease in the overall incidence of gastric cancer determines the relevance of treating tumors of this localization (Davydov M.I. et al., 2003, Onopriev V.I. et al., 2003). Carcinomas of the cardioesophageal junction occupy up to 37% in the structure of all localizations of gastric tumor lesions (Stilidi I.S. et al., 2006). Among the causes of death from malignant neoplasms worldwide, ERC ranks sixth (Cameron A.J., et al., 2002).

Despite the significant advances in surgery, the problem of treating ER remains one of the most difficult (Zubarev M.I. et al., 1998; Stolyarov V.I. et al., 1998; Shoikhet Ya.N. et al., 2005).

Based on a number of objective (patient's age, comorbidity, constitutional features, volume of gastric and esophageal cancerous lesions) and subjective (clinical traditions, personal experience of the operator) factors, the surgeon must make the right choice of surgical access (abdominomediastinal, abdominodiaphragmatic, left or right transpleural) , the volume of the operation (gastrectomy or subtotal proximal gastrectomy, D2 or D3 lymphadenectomy), the type of graft (stomach stump, small intestine, large intestine) and the method of formation of the esophageal anastomosis.

Currently, the volume of the resection stage and the method of reconstruction of the digestive tract, in part, is regulated by the classification of CEP according to Siewert (1987) (Fig. 1, p. 9).

In type I ER, when the center of the tumor is located 1-5 cm above the Z-line of the esophageal-gastric junction, subtotal proximal gastric resection (SPRG) is traditionally performed with resection of the thoracic esophagus with plasty with a wide gastric stem.

In type II EDC, when the center of the tumor is located within 1 cm of the oral Z-line or 2 cm more aboral, it is permissible to perform both SRS and HE (Davydov M.I., Ter-Ovanesov M.D., 2008) and GE (JR Siewert et al., 2007).

In type III EDC with a tumor center 2-5 cm aboral to the Z-line, GE is indicated. The reason for this is the need to retreat the resection border from the visible edge of the tumor by 5 cm or more. As a result, a narrow gastric tube is formed, which, as a rule, is unsuitable for the formation of typical intussusception and "echelon" esophageal anastomoses. Alternatively, gastrectomy with characteristic disorders (asthenia, weight loss, anemia, esophagitis, etc.), the frequency of which reaches 33% (Zubarev PN, 2001).

In addition, there is a 33.4% risk of depressurization of the esophageal-intestinal anastomoses, which is the cause of fatal outcomes in 25-100% of patients with this complication (Chernousov A.F., Kiladze M.A., 1995; Chernousov A.F. et al. ., 2011).

The closest analogue of the proposed by us method of treating patients with type II and III CER according to Siewert by means of SPR with plastic surgery of a thin gastric tube with an original anastomosis is the EGE with the esophageal-intestinal anastomosis of Gilevich-Onopriev. The peculiarity lies in the formation of a reservoir esophageal-small intestinal junction of the end-to-side type. A Brown anastomosis is formed distally between the adductor and abductor knees of the small intestine.

The method has significant disadvantages:

1. "Shutdown" of the duodenum from digestion with the risk of agastral asthenia - 8%, B12 deficiency anemia - 17%, exhaustion - 13.4%.

2. The entry of the active contents of the duodenum into the anastomotic zone, which is accompanied by the development of anastomosis and reflux esophagitis in 12% of patients.

3. The need for an additional interintestinal anastomosis lengthens the operation time and increases the risk of postoperative complications.

The purpose of the invention is to develop a method for imposing intrapleural esophagogastroanastomosis, which is an alternative to HE in the localization of type II and III tumors according to Siewert in the proximal stomach. The method consists in creating a reservoir from a gastric graft with subsequent stitching of the transected esophagus into the latter by end-to-side type, which allows to reduce the frequency of depressurization of the esophageal anastomoses and prevent mortality associated with it, as well as to avoid gastrectomy with traditionally accompanying pathological conditions.

This goal is achieved by the fact that, based on the results of a comprehensive examination of the patient and the diagnosis of type II and III cardioesophageal cancer, a decision is made on surgical intervention in the amount of proximal gastrectomy with resection of the distal esophagus within 10 cm of the indent from the esophageal-gastric junction, for this they perform upper midline laparotomy with the continuation of the incision along the sixth intercostal space on the left and the intersection of the cartilaginous segments of the costal arch, the diaphragm to the level of the esophageal opening, after which the abdominal organs are revised - if the process is recognized as resectable (absence of distant metastases, invasion into neighboring organs and structures), then radical proximal resection of the stomach with the formation of a gastric tube from its stump or 4 cm in diameter (Fig.2a, page 10), which is moved into the left pleural cavity to the line of resection of the esophagus, and the transected esophagus is wrapped with a mobile narrow gastric graft atom, the resulting loop of the gastric graft is sutured to the esophagus and to each other with interrupted nylon sutures (Fig. 2b, page 10), then the lumen of the gastric graft is opened, ten interrupted sutures are applied with absorbable suture material on the esophagus and the inner lip of the anastomosis (Fig.2c, page 10), and then the outer lips of the gastric graft are sutured, thus avoiding the traditional intussusception of the esophagus into a narrow gastric graft due to the horizontal echelon of the esophagus by the walls of the duplication of the gastric stem (Fig.2d, p. 10), after which the thoracoabdominal wound is sutured layer by layer with the obligatory drainage of the left pleural cavity with Bulau drainage with an inner diameter of 10 mm, after 7 days contrasting is performed esophagogastroanastomosis with a solution of barium sulfate, with the consistency of the anastomosis and the absence of leaks of the contrast agent, the trapping drains are removed, the patient is discharged from the hospital for 10-12 days, the criteria for a favorable treatment outcome are improvement of the general condition of the patient, healing of the postoperative wound on the 7-8th day, the level b blood leukocytes, not exceeding 8.6 × 10 ⁹ units per liter.

The proposed method for the formation of esophagogastroanastomosis can be used in patients with extensive proximal resections of the stomach, which usually result in the formation of a narrow gastric stem. The use of the above-described technique can be considered as an alternative to gastrectomy for CER type II and III according to Siewert.

The proposed method for the formation of esophagogastroanastomosis can be used in health care institutions dealing with the surgical treatment of cancer patients to improve the immediate and long-term functional results of operations in type II and III EDC, and can be illustrated by the following clinical observation.

Example

Patient S., 60 years old, was admitted to the thoracoabdominal department of the Volgograd Regional Clinical Oncological Dispensary in a planned manner on 05/18/17 with a referral diagnosis of cardioesophageal cancer.

On admission, he complained of dysphagia with solid food, weight loss of 14 kg in 3 months.

From the anamnesis, it was revealed that he considered himself to be sick for 6 months, when he began to note the above complaints. Since April 2017, he has noted growing weakness. He was examined at the polyclinic at the place of residence, where esophagogastroduodenoscopy was performed and the diagnosis of cardioesophageal cancer was made.

Concomitant diagnosis: ischemic heart disease. PEAKS. Exertional angina. Hypertension 2, risk 4. Postponed stroke (2014, with symptoms of dysarthria).

The patient's condition at admission was assessed as relatively satisfactory. AD-140/90 mm Hg; Heart rate - 76 per minute. Rhythmic pulse, satisfactory filling. Heart sounds are rhythmic, somewhat muffled. The tongue is moist and clean. The abdomen on palpation is soft, painless, participates in the act of breathing.

Laboratory and instrumental examination

EGD from 05/17/2017: at a distance of 38-40 cm from the incisors, the lumen of the esophagus practically does not expand, the walls are rigid. An exophytic tumor is determined that spreads to the cardiac and subcardial parts of the stomach - a biopsy.

On histological examination of the biopsy, the answer is moderately differentiated adenocarcinoma.

On May 18, 2017, X-ray of the stomach was performed: the esophagus was affected by a circular tumor from the level of its supraphrenic region and further along the lesser curvature and lateral walls of the stomach up to the middle third of the body. The epicenter of the tumor is located 5 cm below the line of the cardioesophageal junction. Conclusion: gastroesophageal cancer type III according to Siewert. Dysphagia 1 degree.

In laboratory analyzes, moderate hypochromic anemia (hemoglobin 105 g / l) attracted attention.

After preoperative preparation in a planned manner, on May 24, 2017, the operation was performed: transthoracic proximal subtotal gastrectomy with D3 lymphadenectomy.

An oblique incision from the midline of the abdomen and further along the 6th intercostal space on the left was cut through the skin, cellulose, and a laparotomy was performed. No distant metastases were detected during revision in the abdominal cavity. Thoracotomy, diaphragmotomy up to the esophageal opening. With a detailed revision, the tumor is up to 8 cm in length from the supraphrenic segment of the esophagus to the body of the stomach. The stomach was mobilized with excision of the omentum and ligation of the double-left gastric artery and short vessels. Lymph node dissection was performed on the branches of celiac trifurcation, as well as in the zone of the hepatoduodenal ligament and para-aortic from the diaphragm to the mouth of the inferior mesenteric artery. The esophagus is mobilized in the mediastinum to the level of the inferior pulmonary vein, where it is crossed. With the help of the UO-60 apparatus, the stomach was crossed 5 cm away from the tumor border and a 4-5 cm wide tube was formed from the greater curvature of the stomach. Nodal sutures over the mechanical ones. Extramucosal pyloroplasty was performed. With an urgent morphological examination, there is no tumor growth along the lines of resection of the esophagus and stomach. In connection with the deficiency of the gastric wall (narrow gastric tube), the formation of esophagogastroanastomosis of the end of the esophagus into the reservoir of the duplication of the gastric graft with a double-row suture was performed to create a conduit from the gastric tube around the esophagus. Hemostasis. The left pleural cavity was drained according to Bulau in the 8th intercostal space, with two drains into the mediastinum in the right hypochondrium. Drains under the diaphragm on the left and into the retroperitoneal space, under the liver on the right. The integrity of the diaphragm was restored. Layered sutures on the wound.

The duration of the operation was 220 minutes.

After the operation, the patient was transferred to the intensive care unit, where intensive conservative therapy was carried out.

On the sixth day (05/30/2017) the patient was transferred to the department. Performed contrasting of the anastomosis with barium (Fig. 3, page 11).

The anastomosis is consistent, we pass. Feeding the patient per os was started from the seventh day after the operation.

The patient was discharged from the hospital on the 12th day after surgery in a satisfactory condition.

Summarizing the results obtained, it should be noted that the proposed method of treating ERC allows improving both immediate and distant functional outcomes of operations due to the reliability and functionality of the developed reservoir esophageal-gastric junction.

Bibliography

1. Davydov M.I. et al. Cardioesophageal cancer: classification, surgical tactics, main prognosis factors // Vestn. RONTS RAMS them. N.N. Blokhin. - 2003. - No. 1. - S. 82-88.

2. Davydov M.I., Ter-Ovanesov M.D. Cancer of the proximal stomach: modern classification, tactics of surgical treatment, prognosis factors // BC. 2008. No. 13. P. 914.

3. Zubarev M.I., Sinenchenko G.I., Kobak M.E. et al. Surgical treatment of esophageal and cardiac cancer, complications and dangers // Vestn. hir. - 1998. - T. 157, No. 5. - S. 100-104.

4. Zubarev P.N. Post-resection and post-gastrectomy diseases // Practical Oncology. 2001. No. 3 S. 31-34.

5. Stilidi I.S. Optimized abdominomediastinal access in surgery of gastric cancer with transition to the esophagus / I.S. Stilidi, A.B. Ryabov, V.Yu. Bokhyan // Vestn. RONTS them. N.N. Blokhin Russian Academy of Medical Sciences. - 2006.- T. 17, No. 4. - S. 47-51.

6. Stolyarov V.I., Simonov N.N., Shchukin V.V. Results of simultaneous resection and esophagoplasty in esophageal cancer at the stages of clinical implementation // Vopr. oncol. - 1998. - T. 44, No. 2. - S. 190-195.

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Claims (2)

A method of treating patients with cardioesophageal cancer, including the formation of a reservoir intrapleural anastomosis between the esophagus and the stomach, characterized in that, based on the results of a comprehensive examination of the patient and establishing the diagnosis of cardioesophageal cancer, a decision is made on surgical intervention in the amount of proximal resection of the stomach with resection of the distal esophagus within 10 centimeters indentation from the esophageal-gastric junction, for this, an upper median laparotomy is performed with the continuation of the incision along the sixth intercostal space on the left, the intersection of the cartilaginous segments of the costal arch and diaphragm to the level of the esophageal opening, after which the abdominal organs are revised, then the proximal gastric resection is performed with the formation of the gastric tube his stump with a diameter of 4 cm, which is moved into the left pleural cavity to the line of resection of the esophagus, and the transected esophagus is wrapped with a mobile narrow gastric graft, as in Fig. 2, the resulting loop of the gastric graft is sutured to the esophagus and to each other with interrupted nylon sutures, then the lumen of the gastric graft is opened, ten interrupted sutures are applied with an absorbable suture material on the esophagus and the inner lip of the anastomosis, then the outer lips of the gastric graft are sutured, thus avoiding the traditional intussusception of the esophagus into the narrow gastric graft due to the lateral closure of the esophagus by the walls of the gastric stem duplication, after which the thoracoabdominal wound is sutured in layers with compulsory pleural drainage Bulau with an inner diameter of 10 millimeters, after 7 days, contrasting of the esophagogastroanastomosis with a solution of barium sulfate is carried out, with the consistency of the anastomosis and the absence of streaks of the contrast agent, the trapping drains are removed.

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