RU2768457C1 - Method for resection and reconstruction of great vessels of mediastinum in patients with malignant neoplasm of upper lobe of right lung with tumour involvement of great vessels - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery, oncology. Tumour is mobilized and lymphodissected from left to right. Left brachiocephalic vein is separated. Tributaries flowing into it are ligatured and transected, except for left subclavian and internal jugular veins. Then the superior vena cava, right internal jugular and subclavian veins are mobilized, and vascular holders are applied on them. Before application of vascular clamps, unfractionated heparin 5000 units is injected intravenously to the patient. Then the length of the bypass shunt is determined from the left brachiocephalic vein, the latter is transected. Bulldog clamp is applied on the proximal end, and the distal end is ligated. Lateral squeezing of the right internal jugular vein is performed 2–3 cm above the confluence zone with the right subclavian vein. End-to-side anastomosis is applied with 5/0 prolene suture between the left brachiocephalic vein and the right internal jugular vein. Vascular clamps are removed; blood flow is opened along the left brachiocephalic vein. Vascular clamps are applied proximal to the anastomosis on the internal jugular vein, the subclavian vein and obliquely on the confluence of the superior vena cava. Blood flow from the right internal jugular vein is carried out via the bypass from the left brachiocephalic vein into the superior vena cava. Right subclavian and internal jugular veins and the confluence of the superior vena cava are transected. Tumour with confluence of the right subclavian and internal jugular veins, the right brachiocephalic vein and a part of the confluence of the superior vena cava is removed. Remaining part of the confluence of the superior vena cava is closed with 5/0 blanket suture, thus avoiding stenosis of the reconstruction area. Clamp is removed, an end-to-end anastomosis is made with prolene 5/0 between the right subclavian and internal jugular veins. Vascular clamps are removed; blood flow is restored.

EFFECT: method allows performing radical surgery in patients with malignant neoplasms of upper lobe of right lung with tumour invasion of right brachiocephalic vein, performing venous resection and reconstruction, avoiding complications associated with cerebral venous hypertension, reducing a rate of thrombosis of the reconstruction area by using proper vessels.

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Description

SUBSTANCE: invention relates to medicine, namely to surgery, oncology, and can be used in the removal of a malignant tumor of the upper lobe of the right lung, extending to the right brachiocephalic vein and to the confluence of the right subclavian and internal jugular veins.

A tumor lesion of the superior vena cava (SVC) system is diagnosed more often with lung cancer localized in the upper lobe of the right lung, or mediastinal tumors (thymoma, thymus cancer, germ cell tumors, etc.). Primary tumors of the venous wall of the SVC system are a rare indication for surgical treatment (see Surgery of the Superior Vena Cava: Resection and Reconstruction; Federico Venuta, Erino Rendina, Giorgio Coloni).

According to Z. Zhang et al. The 1-, 3-, and 5-year survival after reconstruction of the SVC system in case of chest cancer is 83.3%, 41.7%, and 25%, respectively (see Application of vascular repair and reconstruction in surgical treatment of superior vena cava syndrome caused by thoracic tumor; Zhenlong Zhang, Xiaojie Pan, Hanfan Qiu, Tianxing Guo, Debin Ou, Hang Ding DOI: 10.7507/1002-1892.201610036).

After radical surgical treatment of thymus cancer with involvement of the main veins, the overall 3- and 5-year survival rates are 80% and 58.1%, respectively (see Superior Vena Cava Replacement for Thymic Malignancies; Giulio Maurizi, Camilla Poggi, Antonio D'Andrilli, Camilla Vanni, Anna Maria Ciccone, Mohsen Ibrahim, Claudio Andreetti, Simone Maria Tierno, Federico Venuta, Erino Angelo Rendina DOI: 10.1016/j.athoracsur.2018.08.060).

Five-year survival after radical removal of a mediastinal tumor that affects the SVC and its branches reaches 60% according to Dartevelle et al. (See Dartevelle PG, Chapelier AR, Pastorino U, et al. Long-term follow-up after prosthetic replacement of the superior vena cava combined with resection of mediastinal-pulmonary malignant tumors. J Thorac Cardiovasc Surg 1991;102:259-265 ). Patients with lung cancer have a less favorable prognosis: only 30% of patients survive the five-year milestone. Patients with regional lymph node involvement (N2) have a poor prognosis (see Yildizeli B, Dartevelle PG, Fadel E, et al: Results of primary surgery with T4 non-small cell lung cancer during a 25-year period in a single center: the benefit is worth the risk Ann Thorac Surg 86:1065-1075, 2008 Dong-Seok Lee, Raja M. Flores, Management of NSCLC Invading the Superior Vena Cava Operative Techniques in Thoracic and Cardiovasculary Surgery 22:224 234 https:// doi.org/10.1053/j.optechstcvs.2018.06.005).

Therefore, the expansion of the scope of surgical intervention due to venous resection for tumors of the chest is justified for tumors of the mediastinum and lung cancer.

A complete median sternotomy is the approach of choice for tumors of the mediastinum and cancer of the upper lobe of the right lung that extends into the right brachiocephalic vein. This access allows wide exposure of the mediastinum, adequate lymph node dissection, and the possibility of expanding access to the neck (cervicosternotomy). The sternotomy can also be converted to the Masaoka approach if a wider field is required to visualize the right lung and subclavian vessels.

Resection and reconstruction of the SVC system is considered a serious technical problem due to the possible negative consequences of clamping the right brachiocephalic vein and SVC (see Gonzalez-Fajardo JA, Garcia-Yuste M., Florez S., Ramos G., Alvarez T., Coca JM Hemodynamic and cerebral repercussions arising from surgical interruption of the superior vena cava Experimental model J Thorac Cardiovasc Surg 1994;107:1044-1049). With initial occlusion of the SVC or right brachiocephalic vein, with lateral compression of the vein with a Satinsky clamp, hemodynamic disturbances usually do not develop. In the case of clamping with blood flow arrest on the initially passable SVC, venous hypertension develops in the brain with the possible occurrence of intracranial hemorrhages, cerebral edema, as well as a potentially lethal decrease in cardiac output due to a decrease in inflow to the right atrium.

Anticoagulant therapy is mandatory during the vascular phase: intravenous bolus injection of unfractionated heparin 5000 ME before clamping and continued in the immediate postoperative period.

It is necessary to minimize the time of stopping the venous outflow from the brain, especially when the SVC system is initially patent. In mediastinal cancer and cancer of the upper lobe of the right lung, tumor mobilization must be performed from left to right, removal of the formation from the right half of the mediastinum is usually performed after vascular reconstruction. Temporary shunts (catheters) can be used to reduce the time it takes to clamp vessels during resection and venous reconstruction. However, catheter thrombosis may occur; in addition, the shunt covers part of the surgical field and makes it difficult to apply the anastomosis. Due to the smaller diameter, they do not provide adequate unloading of the venous bed.

In order to reduce venous hypertension in the SVC system at the stage of vascular clamping, it is possible to use venous-venous bypass (according to the system of the left internal jugular vein - femoral vein) (see Superior vena cava reconstruction under the left internal jugular vein to left femoral vein bypass support Jun Ba, Runsheng Peng, Hui Shi, Chunsheng Wang DOI: 10.1177/0267659117702002). To perform this technique, a heart-lung machine, cannula installation, and pronounced systemic heparinization are required, which increases the cost of the operation, the frequency of possible complications (bleeding, thrombosis of the cannula access).

If more than 30% of the circumference of the vein wall is affected, marginal resection and venous plasty are not possible without disturbances in the hemodynamics of the reconstruction zone. In such cases, the defect can be closed with an autovenous patch, pericardial or bovine pericardial patch, artificial patch (see Piccione Jr, W, Faber LP, Warren WH. Superior vena caval reconstruction using autologous pericardium. Ann Thorac Surg 1990; 50:417-419) . Own tissues are most attractive for reconstruction, due to the low probability of developing thrombotic complications. When using an autovein, additional access is required to take the graft, which increases the time of the operation. Options for the use of the femoral and great saphenous veins are proposed. However, the use of veins of the lower extremities makes it difficult to use venous access for infusions during surgery and in the postoperative period, since intravenous infusions into the upper extremities are not possible with this type of intervention. Since they lead to an overload of the ERW system and increase the risk of developing thrombotic complications.

Prosthetics of the right brachiocephalic and SVC is a common type of reconstruction. Reconstruction is usually performed with a linear PTFE prosthesis (see A Programmed Procedure of Prosthetic Reconstruction of the Superior Vena Cava for Thoracic Tumors via Median Thoracotomy DOI: 10.3779/i.issn. 1009-3419.2017.11.05).

A number of authors suggest using autopericardium or bovine pericardium sewn in the form of a tube. When forming a graft, an additional suture line also increases the risk of thrombosis in the reconstruction zone.

MM. Zubair et al. showed the possibility of sampling the femoral vein as an autovein. However, additional access to the graft is required, an increase in intervention time, and possible violation of the venous outflow of the lower limb (see Superior Vena Cava Reconstruction Using Femoropopliteal Vein as a Panel Graft; M. Mujeeb Zubair, Cassidy A. Duran, Eric K. Peden 2017 Oct ; 32(7):613-615. DOI: https://doi.org/10.1016/j.avsg.2017.03.185).

It should be taken into account that the diameter of the great saphenous vein of the thigh does not correspond to either the diameter of the SVC or the brachiocephalic vein. Additional suture lines are required (suturing two segments, forming a helical suture), which increases the risk of thrombosis in the reconstruction zone.

From the literature, a method for reconstructing the system of the superior vena cava with a synthetic prosthesis is known (see A Programmed Procedure of Prosthetic Reconstruction of the Superior Vena Cava for Thoracic Tumors via Median Thoracotomy DOI: 10.3779/i.issn.1009-3419.2017.11.05). However, the use of synthetic material increases the risk of thrombosis of the reconstruction zone, requires aggressive anticoagulant therapy; requires a complete stop of blood flow through the system of the superior vena cava with a high risk of complications associated with cerebral venous hypertension (edema, hemorrhage).

The technical result in the removal of a malignant tumor of the upper lobe of the right lung, extending to the right brachiocephalic vein and to the confluence of the right subclavian and internal jugular veins, is the development of a method to avoid complications associated with cerebral venous hypertension, to reduce the frequency of thrombosis of the reconstruction zone through the use of their own vessels and to carry out adequate venous reconstruction of vessels after their resection.

The technical result is achieved by the fact that after the mobilization of the tumor and lymph node dissection performed from left to right, the left brachiocephalic vein is isolated, the tributaries flowing into it, except for the left subclavian and internal jugular veins, are ligated and crossed, then the superior vena cava, the right internal jugular and subclavian veins are mobilized , impose vascular holders on them, before the imposition of vascular clamps, unfractionated heparin 5000 IU is intravenously injected into the patient, then the length of the bypass shunt from the left brachiocephalic vein is determined, the latter is crossed, a bulldog-type clamp is applied to the proximal end, the distal end is ligated, a lateral depressing the right internal jugular vein with a Satinsky clamp 2-3 cm above the confluence zone with the right subclavian vein, an end-to-side anastomosis with a 5/0 prolene suture is performed between the left brachiocephalic vein and the right internal jugular vein, the vascular clamps are removed, the blood flow is opened on the left brachiocephalic vein, impose vascular clamps proximal to the anastomosis on the internal jugular vein, subclavian vein and obliquely - on the confluence of the superior vena cava, blood flow from the right internal jugular vein is carried out along the shunt from the left brachiocephalic vein to the superior vena cava, cross the right subclavian and internal jugular veins, confluence of the superior vena cava, the tumor with the confluence of the right subclavian and internal jugular veins, the right brachiocephalic vein and part of the confluence of the superior vena cava is removed, the remaining part of the confluence of the superior vena cava is sutured with a 5/0 prolene suture, avoiding stenosis of the reconstruction zone, the clamp is removed, anastomosis is performed end - to the end with a 5/0 prolene between the right subclavian and internal jugular veins, the vascular clamps are removed, the blood flow is restored.

When implementing this method, resection of the right brachiocephalic vein is performed for malignant tumors of the upper lobe of the right lung and mediastinum, vascular reconstruction is performed by local tissues. The proposed method allows avoiding complications associated with cerebral venous hypertension, reducing the frequency of thrombosis in the reconstruction zone through the use of one's own vessels, and carrying out adequate reconstruction.

The essence of the method is illustrated by the following figures.

In FIG. 1 shows a CT scan of the chest with bolus contrast (sagittal section) - a tumor lesion of the right brachiocephalic vein.

In FIG. Figure 2 shows a CT scan of the chest with bolus contrast (coronal section) - a tumor lesion of the right brachiocephalic vein.

Figure 3 shows a CT scan of the chest with bolus contrast (axial slice) - tumor lesion of the right brachiocephalic vein.

In FIG. 4 (A, B) shows an intraoperative photo, the tumor was removed, the right brachiocephalic vein was reconstructed with the left brachiocephalic vein.

In FIG. 5 shows a photo of the preparation.

The method is carried out as follows.

Perform a Masaoka type access. In the process of traditional tumor mobilization, the resectability of the tumor is assessed, during which the size and location of the latter, the presence and extent of tumor invasion of the main vessels of the mediastinum are specified. After that, in the presence of tumor invasion of the right brachiocephalic vein with spread to the confluence of the right subclavian and internal jugular veins (see Fig. 1), a shunt is formed from the left brachiocephalic vein (see Fig. 2). An end-to-side anastomosis is made between the left brachiocephalic vein and the right internal jugular vein, and blood flow is opened through the shunt. Resection is performed as a single block of the tumor with the confluence of the right subclavian and internal jugular veins, the right brachiocephalic vein and part of the confluence of the superior vena cava (see Fig. 3). Then a reconstructive stage is performed - with a non-absorbable monofilament thread on an atraumatic needle, a part of the remaining part of the confluence of the superior vena cava is sutured with a twisting vascular suture, a direct anastomosis is applied between the ends of the right subclavian and internal jugular veins (see Fig. 2). Vascular clamps release and restore blood flow.

The inventive method of tumor invasion of the vein was tested in 2 patients. No hospital mortality was recorded.

No complicated course of the early postoperative period was observed, and there were no thrombotic complications in this group of patients.

We give a clinical example of the application of the method.

Patient Ch., born in 1981 was admitted to the National Medical Research Center of Oncology with complaints of dry cough, hoarseness, which he had noted since November 2019. In January 2020, he noted the appearance of headaches. Was examined by an ENT doctor, a pulmonologist at the place of residence.

CT scan of the chest revealed a tumor of the anterior mediastinum with invasion of the upper lobe of the right lung, the right brachiocephalic vein.

On May 25, 2020, a thoracoscopy operation was performed, a biopsy of the tumor of the right lung was performed. Cytological analysis: cytogram suggests extracellular myxoid chondrosarcoma. Histological analysis - sclerosing mediastinitis.

06/02/2020 consulted in telemedicine mode at the National Medical Research Center of Oncology of the Ministry of Health of Russia: it was recommended: additional examination in the conditions of the National Medical Research Center of Oncology of the Russian Ministry of Health to verify the tumor and decide on the advisability of surgical treatment with resection of the confluence of the brachiocephalic veins and, possibly, resection of the right subclavian arteries.

Revision of histological preparations (videothoracoscopy (VTS), biopsy of the mediastinal tumor from the place of residence): in the biopsy, a fragment of fibrous tissue with infiltration of hyperchromic cells, suspicious of tumor, most likely lymphoid. There is not enough material for immunohistochemical (IHC) studies; according to clinical indications, it is recommended to study a larger amount of material.

On June 19, 2020, a PTS operation was performed on the right, a biopsy of the tumor of the upper mediastinum. IHC dated 07/03/2020: the morphological picture and immunophenotype of tumor cells are characteristic of low-differentiated TTF-1-negative adenocarcinoma, it is not possible to specify the histobelonging.

On July 3, 2020, the CDO Council made the diagnosis: Cancer of the upper lobe of the right lung T4N0M0, stage IIIA, with invasion of the brachiocephalic veins in the area of confluence, the right subclavian artery. Condition after VTS on the right, tumor biopsy 06/19/2020. Cl. gr. 2. 2 courses of preoperative polychemotherapy (cyclophosphamide, doxorubicin, cisplatin) are indicated. Transferred satisfactorily, without adverse toxic reactions.

SRCT of the chest organs dated 06/10/2020: a tumor of the upper mediastinum 3.4 x 3.0 x 3.9 cm, sprouts the upper lobe of the right lung, the right brachiocephalic vein, envelops the right subclavian artery 180 degrees for up to 2.8 cm without signs of invasion into the lumen (from the level of discharge of the CCA). Adjacent to the vertebral artery for up to 0.9 cm without signs of invasion into the lumen. The vertebral vein is not contrasted, possibly due to tumor invasion.

SRCT of the chest organs dated 08/11/2020: a tumor of the upper mediastinum on the right 2.6 x 1.6 x 2.8 cm, a decrease in size since 06/2020 (3.4 x 3.0 x 3.9 cm), sprouts the upper lobe of the right lung, the right brachiocephalic vein, envelops the right subclavian artery 180 degrees for up to 1.5 cm without signs of invasion into the lumen (from the level of the CCA discharge). Adjacent to the vertebral artery for up to 0.6 cm without signs of invasion into the lumen. The vertebral vein is not contrasted.

On June 15, 2020, angiography of the brachiocephalic arteries was performed: the extracranial part of the brachiocephalic arteries (right and left carotid, subclavian, vertebral arteries) without hemodynamically significant stenoses. The vertebral arteries are symmetrical in diameter on both sides. Data for the germination of the wall, extravasal compression of the right subclavian, vertebral arteries were not revealed. The intracranial section of the brachiocephalic arteries was without hemodynamically significant changes. The circle of Willis is closed.

The operation was performed from the Masaoka approach (cervical-sternal-thoracotomy), removal of the tumor, resection of the vagus and phrenic nerve, mediastinal pleura, confluence of the internal jugular and subclavian veins, right brachiocephalic vein, confluence of the brachiocephalic veins, shunting of the left brachiocephalic vein, right-sided upper lobectomy, mediastinal lymph node dissection diaphragmatic plication.

Performed venous reconstruction of the right brachiocephalic vein by the claimed method. The postoperative period proceeded without complications. The patient was discharged in a satisfactory condition on the 23rd day of the postoperative period. Further, the patient was examined at the outpatient stage after 3 months, data for local recurrence of the disease was not revealed. According to CT angiography of the chest, the area of venous reconstruction is passable.

The result of the IHC study: the morphological picture and immunophenotype of tumor cells in the volume of the studied material (PanCK+, CK7+, TTF1+/-, NapsinA+/-) are characteristic of lung adenocarcinoma with germination into the upper mediastinum.

Thus, the application of the proposed method allows to perform a radical operation in patients with cancer of the upper lobe of the right lung with tumor invasion of the right brachiocephalic vein, to perform venous resection and reconstruction.

The developed method allows to significantly increase the resectability of patients with cancer of the upper lobe of the right lung, extending to the right brachiocephalic vein, to improve the immediate and long-term results of surgical treatment.

Claims (1)

A method for resection and reconstruction of the main vessels of the mediastinum in patients with a malignant neoplasm of the upper lobe of the right lung with a tumor lesion of the main vessels, which consists in the fact that after the mobilization of the tumor and lymph node dissection performed from left to right, the left brachiocephalic vein is isolated, the tributaries flowing into it are ligated and crossed , except for the left subclavian and internal jugular veins, then the superior vena cava, the right internal jugular and subclavian veins are mobilized, vascular holders are applied to them, before applying vascular clamps, unfractionated heparin 5000 units is intravenously injected into the patient, the length of the bypass shunt from the left brachiocephalic vein is determined, the latter is crossed, a bulldog clamp is applied to the proximal end, the distal end is ligated, the right internal jugular vein is squeezed 2-3 cm above the confluence zone with the right subclavian vein, an end-to-side anastomosis is performed with a 5/0 rolen thread between the left brachiocephalic vein and the right internal jugular vein, the vascular clamps are removed, the blood flow is opened along the left brachiocephalic vein, vascular clamps are applied proximal to the anastomosis on the internal jugular vein, subclavian vein and obliquely - on the confluence of the superior vena cava, blood flow from the right of the internal jugular vein is carried out along a shunt from the left brachiocephalic vein to the superior vena cava, the right subclavian and internal jugular veins are crossed, the confluence of the superior vena cava, the tumor with the confluence of the right subclavian and internal jugular veins, the right brachiocephalic vein and part of the confluence of the superior vena cava is removed, proleno The rest of the confluence of the superior vena cava is sutured with a 5/0 twist suture, avoiding stenosis of the reconstruction zone, the clamp is removed, an end-to-end anastomosis is performed with a 5/0 prolene between the right subclavian and internal jugular veins, the vascular clamps are removed, and blood flow is restored.

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