RU2761748C1 - Method for integrated treatment of stomach cancer in growth in the body of the pancreas - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to oncology and surgery. After the completion of neoadjuvant chemoradiation therapy, a midline laparotomy is performed. Allocate the right gastroepiploic vessels, ligate them separately, cross and remove the lymph nodes of the sixth group. The right gastric artery is isolated at the base, ligated, transected and removed from the fifth group lymph nodes. The duodenum is transected 1 cm distal to the pylorus. The stump of the duodenum is peritonized with a purse-string suture and splen-sparing corpocaudal resection of the pancreas is performed while preserving the splenic vein. The left gastric vessels are isolated at the base, they are ligated separately, the lymph nodes of the 7th, 8th, 9th and 11th groups are crossed and removed. The stomach is resected at the level of the lower pole of the spleen. The drug is removed in a single block. A posterior colic gastroenteroanastomosis is formed on a Roux loop, additionally covered with a number of serous-muscular sutures, and an interintestinal anastomosis is formed with a single-row suture.

EFFECT: method allows to increase the resectability of locally and regionally advanced gastric cancer and radicalism of surgical intervention, to implement the principles of organ-preserving treatment, to reduce the number of postoperative complications, to improve the quality of life of patients and to increase the survival rate, the method is reproducible, well tolerated by patients and safe.

1 cl, 2 dwg, 1 ex

Description

The invention relates to medicine, namely to oncology and surgery, and can be used in the treatment of locally advanced gastric tumors.

According to various authors, the majority of patients at the time of diagnosis of gastric cancer have a widespread stage. Early cancer accounts for only 10% of all new cases, and in 83% of patients at the time of detection of the disease they have metastases in the regional lymph nodes, 53.8% die within 1 year after diagnosis (Kaprin A.D., Starinskiy V.V. Petrova GV status of cancer care the population of Russia in 2019. Moscow:.. they MNIOI PA Herzen - branch FGBU "NMIRTS" Ministry of Health Rossii 2020: page 250).. Up to 60-80% of patients have an advanced form of the disease with severe complications and invasion of a stomach tumor into neighboring organs. In patients with invasion of stomach tumors to surrounding organs and tissues and metastases to regional lymph nodes (pT4bN +), the prognosis is poor, five-year survival rate is 20-30%. However, the implementation of combined surgical interventions, as well as the use of additional methods of antitumor effects, can increase the life expectancy of patients (Medina-Franko H., Contreras-Saldivar A., Ramos-De La Medina A. Surgery for stage IV gastric cancer // Am. J Surg. - 2004. - Vol. 187 (4). - P. 543-546; Isozaki H., Tanaka N., Tanigawa N., Okajima K. Prognostic factors in patients with advanced gastric cancer with macro scopic invasion to adjacent organs treated with radical surgery // Gastric Cancer. - 2000. - Vol.3. - P.202 210; Beeharry MK, Zhang TQ, Liu WT, Gang ZZ. Optimization of perioperative approaches for advanced and late stages of gastric cancer: clinical proposal based on literature evidence, personal experience, and ongoing trials and research. World J Surg Oncol. 2020; 18 (1): 51).

The incidence of invasion of stomach tumors into the pancreas is about 20%. Taking into account the localization of the invasion, three variants of the surgical situation are fundamentally distinguished - in the head, body and tail of the pancreas. The volume of radical surgical intervention when a stomach tumor grows into the body of the pancreas inevitably includes gastrectomy, splenectomy and corpocaudal resection of the pancreas (Boyko V.V., Lazirsky V.A., Savvi S.A., Lykhman V.N. Combined resection stomach and pancreas in the surgical treatment of locally advanced gastric cancer. // International Medical Journal - 2012.- No. 1, pp. 68-73).

However, this treatment is a mutilating operation with a high incidence of postoperative complications.

As a prototype, adopted a method of multivisceral radical resection in a single block with preservation of the spleen in gastric cancer T4 (Cotta-Pereira, R., Awad, M., Mello, CE, & Iglesias, AC (2010). Multivisceral radical en bloc resection with spleen preservation in T4 gastric cancer. BMJ case reports, 2010, bcr0220102782). The method includes gastrectomy, the tumor is resected by block removal of the entire stomach (total gastrectomy), segment III of the liver, as well as the body and tail of the pancreas (partial pancreatectomy), performing D2 lymphadenectomy and preserving the splenic vessels.

However, this method is associated with the removal of the entire stomach (gastrectomy), the absence of a preoperative stage of treatment, which is associated with an increase in the number of postoperative complications and a deterioration in the quality of life of patients, and is also incompatible with multimodal therapy and does not increase the survival rate of patients, which limits its use.

The technical result of the proposed invention is to increase the resectability of gastric tumors and increase the radicalism of the operation, as well as the preservation of the proximal stomach and spleen.

These technical results are achieved due to the fact that, as in the known method, neoadjuvant chemoradiation therapy is performed, distal subtotal gastric resection D2, radical corpocaudal resection of the pancreas with preservation of the splenic vessels and spleen.

A feature of the proposed method is that after the completion of neoadjuvant chemoradiation therapy, a midline laparotomy is performed, the gastrocolic ligament is dissected, the right gastroepiploic vessels are isolated, they are separately tied, the lymph nodes of the sixth group are transected and removed, then the hepato-gastric ligament is dissected at the base of the right gastric artery, ligate, cross and remove the lymph nodes of the fifth group, then the duodenum is crossed 1 cm distal to the pylorus, the duodenal stump is peritonized with a purse-string suture and splen-sparing corpocaudal resection of the pancreas is performed, and then the pancreatic mucosa is preserved with the preservation of the pancreatic mucosa fiber along the common hepatic and initial section of the splenic artery, isolate the left gastric vessels at the base, ligate them separately, cross and remove the lymph nodes of the 7th, 8th, 9th and 11th groups, perform gastric resection at the level of the lower pole of the spleen, the preparation is removed as a single block, the posterior colic gastroenteroanastomosis is formed on the Roux loop, additionally covered with a number of serous-muscular sutures and the interintestinal anastomosis is formed with a single-row suture, drainage is installed in the subhepatic space and in the bed of the pancreas, the operation is completed by the anterior layer-by-layer suturing.

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

FIG. 1 - Scheme of the operation: a) 1 - germination of a stomach tumor into the body of the pancreas; b) the removed part of the pancreas and stomach with preservation of the spleen, 2 - preserved splenic vessels.

FIG. 2 - Photo of the operating field: 1 - germination of a stomach tumor into the pancreas; 3 - in the white circle, the sutured stump of the pancreas head; 2 - preserved splenic vessels (yellow arrow).

The method is carried out as follows.

A patient with locally advanced gastric cancer, after the completion of neoadjuvant therapy: 2 courses of induction chemotherapy FLOT + chemoradiation therapy in SOD 46 Gy against the background of chemotherapy with capecitabine and oxaliplatin drugs - midline laparotomy is performed. An audit is performed, distant metastases are excluded. The gastro-colonic ligament is dissected. Allocate the right gastroepiploic vessels, separately ligate, cross, remove the lymph nodes of the sixth group. The hepato-gastric ligament is dissected, the right gastric artery is isolated at the base, the lymph nodes of the fifth group are ligated, transected and removed. The duodenum is transected 1 cm distal to the pylorus. The stump of the duodenum is peritonized with a purse-string suture. A splen-sparing corpocaudal resection of the pancreas is performed with preservation of the splenic vein. Fiber is mobilized and displaced to the preparation along the common hepatic and initial section of the splenic artery, left gastric vessels are isolated at the base, ligated separately, lymph nodes of 7, 8, 9 and 11 groups are crossed and removed. The stomach is resected at the level of the lower pole of the spleen. The drug is removed as a single block (Fig. 1 a, b). A posterior-colic gastroenteroanastomosis is formed on a Roux-en-Y loop and is additionally covered with a serous-muscular suture nearby. An interintestinal anastomosis is formed with a single-row suture. Hemostasis. The abdominal cavity is sanitized. Drainage is installed in the subhepatic space and in the pancreatic bed. A control examination for hemostasis and foreign bodies is performed, after which the anterior abdominal wall is sutured in layers and aseptic stickers are applied.

In the postoperative period, the patient is routinely managed with control of the discharge through the drains. The drainage is removed 5-7 days after the operation.

Clinical example.

Patient S., born in 1960 was admitted to the clinic on 09/10/2020. Diagnosis at admission: Stomach cancer with T4bN2M0 - stage IVA.

Neoadjuvant treatment was carried out: 2 courses of induction chemotherapy FLOT, chemoradiation therapy with RR 2 Gy to OD 46 Gy against the background of chemotherapy with capecitabine (during the entire course of radiation therapy) and oxaliplatin (1 and 21 days of radiation therapy). уcT4bN2M0 IVA stage.

Surgical treatment was performed: spleno-preserving distal subtotal gastric resection D2 with corpocaudal resection of the pancreas. The patient was transported to the operating room. Median laparotomy was performed under combined endotracheal anesthesia with artificial ventilation. During revision: liver, peritoneum, pelvic organs - no features. The stomach tumor is located in the antrum on the posterior surface, grows into the body of the pancreas in an area of 3x3.5 cm. In the lesser curvature and in the hepato-gastric ligament, enlarged, dense lymph nodes are palpated. The gastrocolic ligament was dissected. The right gastroepiploic vessels were isolated, separately tied, transected, and group 6 lymph nodes were removed. The hepato-gastric ligament was dissected, the right gastric artery was isolated at the base, ligated, transected, and group 5 lymph nodes were removed. The duodenum is transected 1 cm distal to the pylorus. The stump of the duodenum is peritonized with a purse-string suture. Using a Harmonic scalpel, a corpocaudal resection of the pancreas was performed with preservation of the splenic vein (splen-preserved), the short veins were transected. Fiber was mobilized and shifted to the preparation along the common hepatic and initial section of the splenic artery, the left gastric vessels were isolated at the base, tied separately, transected; removed lymph nodes 9, 7, 8, and 11 groups (Figure 2). The stomach was resected. The drug was removed as a single block. Formed posterior colic gastroenteroanastomosis on the Roux loop, additionally covered with a number of serous-muscular sutures. Formed interintestinal anastomosis with a single-row suture. Hemostasis. Sanitation of the abdominal cavity. Drainage in the subhepatic space and in the bed of the pancreas. Control examination for hemostasis - dry, no foreign bodies. Layer-by-layer suturing of the anterior abdominal wall. Aseptic stickers.

In the postoperative period, the patient underwent usual management with control of the discharge along the drain. The postoperative period was uneventful. The drainage from the resection area was removed on the 4th day. The onset of peristalsis was noted on the 3rd day after the operation. The chair was gone on the 6th day. The patient was discharged in satisfactory condition on the 11th day.

The proposed method makes it possible to increase the resectability of locally and regionally advanced gastric cancer and radicalism of surgical intervention, implement the principles of organ-preserving treatment, reduce the number of postoperative complications, improve the quality of life of patients and increase the survival rate. The method is reproducible, well tolerated by patients and safe.

Claims (1)

A method of complex treatment of gastric cancer during invasion of the pancreas into the body, including neoadjuvant chemoradiation therapy, distal subtotal resection of the stomach D2, radical corpocaudal resection of the pancreas with preservation of the splenic vessels and spleen, characterized in that after the completion of neoadjuvant laparotomy therapy -the colon ligament, the right gastroepiploic vessels are isolated, they are separately ligated, the lymph nodes of the sixth group are crossed and removed, then the hepato-gastric ligament is dissected, the right gastric artery is isolated at the base, the lymph nodes of the fifth group are ligated, cut and removed, then the duodenum cut 1 cm distal to the pylorus, the duodenal stump is peritonized with a purse-string suture and splen-sparing corpocaudal resection of the pancreas is performed with preservation of the splenic vein, then mobilized and displaced to the prep arata fiber along the common hepatic and initial section of the splenic artery, isolate the left gastric vessels at the base, ligate them separately, cross and remove the lymph nodes of the 7th, 8th, 9th and 11th groups, perform gastric resection at the level of the lower the poles of the spleen, the preparation is removed as a single block, the posterior colic gastroenteroanastomosis is formed on the Roux loop, additionally covered with a number of serous-muscular sutures and the interintestinal anastomosis is formed with a single-row suture, drainage is installed in the subhepatic space and in the bed of the pancreas, the operation is completed by layer-by-layer suturing of the anterior wall.

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