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SURGERY
INVENTION
Patent of the Russian Federation RU2282403

METHOD OF OPERATIONAL TREATMENT OF DISTAL CANCER

METHOD OF OPERATIONAL TREATMENT OF DISTAL CANCER

The name of the inventor: Zherlov Georgy Kirillovich (RU); Zykov Dmitry Vitalyevich (RU); Koshel Andrey Petrovich (RU); Alexander Karpovich (RU); Baranov Andrey Igorevich (RU); Vorobyov Vladimir Maksimovich (RU)
The name of the patent holder: Zherlov Georgiy Kirillovich (RU); Zykov Dmitry Vitalyevich (RU); Koshel Andrey Petrovich (RU); Alexander Karpovich (RU); Baranov Andrey Igorevich (RU); Vorobyov Vladimir Maksimovich (RU)
Address for correspondence: 634050, Tomsk, Moscow highway, 2, SibGMU, IP department, NG. Zubarevoi
Date of commencement of the patent: 2005.05.16

The invention relates to medicine, surgery, can be used in the surgical treatment of stomach cancer. Mobilize the stomach. Perform a radical lymphadenectomy D 2 . Perform subtotal distal resection of the stomach. In addition, at the stage of mobilization of the stomach, the gastro-diaphragm ligament is crossed. Bottom of the stomach and short gastric arteries are exposed. Perform lymphodissection of the left paracardial lymph nodes. The method reduces the risk of developing locoregional metastases without increasing the number of early postoperative complications and without worsening the blood supply of the stump of the stomach.

DESCRIPTION OF THE INVENTION

The invention relates to medicine, to surgery, specifically to methods of surgical treatment of distal stomach cancer.

The closest to the proposed method is the method proposed by AF Chernousov and co-author. [1] who performed subtotal distal resection of the stomach in the early cancer (T 1 ) of the middle and lower third of the stomach or the advanced differentiated cancer (T 2 -T 4 ) of the lower third of the stomach in the absence of precancerous changes in other parts of the stomach. The standard volume of lymphadenectomy (D 2 ) for this operation is the removal of 1,3-9, 11p and 12 groups of lymph nodes. In accordance with the work of the authors, the mobilization of the stomach is performed by a small curvature from the abdominal section of the esophagus to the pylorus with the inclusion of peri-gastric nodes of this region in the preparation (Groups 1, 3, and 5). To perform adequate lymphodissection, the common hepatic, splenic artery, celiac trunk and hepatoduodenal ligament vessels are skeleton, displacing the fatty tissue and lymph nodes towards the removed preparation. The left gastric artery is bandaged near the place of its retreat from the celiac trunk and, together with lymph nodes, is included in the drug to be removed. Due to the large curvature, mobilization is carried out at the intersection of 1-2 lower short gastric arteries and continues towards the gatekeeper, including the group of lymph nodes in the preparation 4a, 4b and 6. Thus, from the entire ligamentous apparatus, a gastro-diaphragm ligament is retained, in which the branches of the lower diaphragmatic artery, participating in the blood supply of the stomach stump together with the short arteries of the stomach, pass. The left paracardial (2nd group) lymph nodes for a given volume of lymphadenectomy remain intact due to the fact that according to the classification of the Japanese Society for the Study of Stomach Cancer (JRSGC) this group belongs to third-order lymphatic reservoirs (N 3 ) when the tumor is localized in the middle or Lower third of the stomach.

According to the data of a number of authors both in domestic and in foreign literature, the results of the study of left paracardial lymph nodes removed during radical gastrectomy performed for gastric cancer of different localization are presented. The frequency of detection of lymphogenous metastases in this group of nodes when the tumor affects the distal parts of the stomach is 0-2% according to Fukagawa T. et al. [2] and up to 6.7% according to Khvastunov RA. And co. [3]. The question of so-called "skipping" metastasis, which affects lymphatic high-grade (N 3 ) collectors in intact lymph nodes of the second and sometimes even the first lymphatic collectors, remains discus- sible.

The known method is not sufficiently effective, due to the occurrence of possible complications in the form of disease progression. The new technical task is to increase the effectiveness of treatment by reducing the number of complications.

This task is solved by a new method of surgical treatment of distal stomach cancer, including mobilization of the stomach, radical D2 lymph dissection followed by subtotal distal gastrectomy, and during the mobilization of the stomach, the gastric and diaphragmatic ligament is further intersected, the stomach bottom and short gastric arteries are exposed and the lympho- dissection of the left paracardial Lymphonoduses.

The method is carried out in the following way: under endotracheal anesthesia, in the patient's position on the back of the upper, middle-medial laparotomy access, the stomach is mobilized in small curvature in the traditional way described above [1], with simultaneous dissection of the peri-gastric lymph nodes and lymph nodes of the common hepatic, left gastric, splenic Arteries, celiac trunk and hepatoduodenal ligament. When the stomach is mobilized along the large curvature, the whole ligamentous apparatus, including the gastro-diaphragm ligament, completely crosses, while releasing the stomach bottom and short gastric arteries. The left paracardial lymph nodes are removed in compliance with the principle of ablasticism - in an exceptionally acute way, adhering to the advent of exposed vessels, shifting the fatty tissue that is being removed to the side of the drug, while crossing no more than 1-2 distal short arteries. After resection of the stomach, a small stump remains, the food of which is maintained by retained short gastric and posterior gastric arteries.

This method can be performed with combined operations: subtotal distal gastrectomy in combination with splenectomy, pancreas resection or resection of the left adrenal gland. Restoration of gastrointestinal continuity is possible with any of the methods described in the literature (Billroth-I, Billroth-II, on the closed loop of the small intestine on the Rhine) [1].

After practicing the skill, the proposed method does not occupy an experienced surgeon for more than 10 minutes, thereby substantially not increasing the duration of the operation.

The proposed method was performed on 16 patients, with T 2 stages of tumor invasion in 12 patients, T3 in 3 and T4 in 1. In 13 patients, the tumor was localized in the anthropyloric department, in 3 patients in the lower third of the body of the stomach. When comparing early postoperative complications in the group of patients with lymphodissection in the proposed way (n = 16) with a group of patients operated according to the traditional method (n = 15, in 3 patients, T 2 stage of tumor invasion, 11 - T 3 and 1 - T 4 , the tumor was localized in the anthropyloric department in 13 patients, in the lower third of the body of the stomach - in 2 patients), no significant differences were found. In the study group, no patient showed an inconsistency of the anastomosis of the stump of the stomach stump, which indicates sufficient blood supply. With subtotal distal resection of the stomach with removal of this group of lymph nodes without interference on adjacent organs, there was no increase in lymphatic drainage, drainage from the abdominal cavity was removed on day 3-4 (as in the group without dissection of left paracardial lymph nodes), patients were discharged from the hospital under the supervision of an oncologist Polyclinics for 7-9 days after surgery in a satisfactory condition. In the postoperative period, the patients underwent chemotherapy courses according to standard schemes in accordance with the final pathomorphological diagnosis. At the subsequent control observation of these patients in terms of up to 1 year of locoregional or distant metastasis of the oncological process was not revealed.

It should be noted that in a pathoanatomical study of stained sections of distant left paracardial lymph nodes in the group of patients we studied, metastasis was detected in one patient (6.25%).

The effectiveness of the proposed method is demonstrated by the following clinical example:

Patient V., 55 years old entered the planned procedure in 1 surgical department of GB No. 2 in Seversk on January 14, 2002 with the diagnosis:

The main disease: cancer of the body of the stomach. T 3 N 2 M 0 .

Background disease: Chronic. Gastritis with decreased secretion.

Concomitant disease: NDC by mixed type.

The diagnosis is based on the history and instrumental examination.

From an anamnesis of the disease: he considers himself to be a patient since 1998, after the first time during gastrointestinal examinations with GDDS, stomach ulcers were revealed, histological examination revealed colonic metaplasia. After, in the same year with repeated biopsy from the stomach, cells of the ring-cell carcinoma were determined. Hospitalized in hospital with a diagnosis of stomach cancer 2 tbsp. In a hospital with repeated histological studies, atypia was not detected. The final diagnosis was a peptic ulcer, the patient was taken to a dispensary observation. For the period from 1998 to December 2001 the condition was stable, while the data for the peptic ulcer of the stomach, colonic metaplasia, in other organs of focal pathology were not revealed, the complaints about this disease were not disturbed. On December 9, 2001, with a regular FGS, a biopsy was taken, a histological report No. 19792: a cystic cell carcinoma of the stomach.

At inspection:

FGDU from 15.01.02: The esophagus is not changed, the cardia is closed. The stomach has a clear liquid. The gastric mucosa is atrophied in the distal section with shallow surface erosions. In the lower third of the body of the stomach along the front wall, closer to a small curvature, there is an epithelializing ulcer with a defect in the center of up to 5 mm, the edges are raised infiltrated (infiltration site up to 1.5 cm, with convergence folds when biopsy is fragmented, the material is taken for cytology. Close, freely pass, KDP without features.

Conclusion: Cancer of the body of the stomach. Erosive gastritis.

Ultrasonography of the stomach from 15.01.04: The videoendoscope GIF-1T140 is freely passed into the esophagus, then into the stomach. The scanning of the walls of the stomach and perigastric space with the help of an ultrasonic probe with a scanning frequency of 20 MHz was performed. The wall of the stomach is uniformly ten-layered throughout. By the large curvature of the body of the stomach are located multiple convoluted folds in the lower third of the body along the anterior wall closer to the middle third there is a section of infiltration up to 3 cm in length, the laminated structure is broken up to the serous layer with involvement of it. Perigastric lymph nodes are not visualized. Free fluid in the abdominal cavity is not determined.

Conclusion: Cancer of the body of the stomach.

17.01.02 under endotracheal anesthesia the patient performed an operation - subtotal distal resection of the stomach according to Ru, radical lymphadissection of D 2 with removal of left paracardial lymph nodes. Complications during the operation was not. Drainages from the abdominal cavity are removed for 4 days, the gastric tube is removed for 5 days. The patient was discharged from the hospital in a satisfactory condition for 8 days. The definitive histological conclusion №799 from 01/31/02: Ring-cell carcinoma of the stomach, tumor germination through all layers of the stomach wall. Removal of the stomach within the unchanged tissue. Metastasis of the tumor in 2, 3, 7 group l / nodes, the remaining lymph nodes have the usual structure.

At control examinations in the postoperative period for 3 years, including FGD, x-ray of the stomach stump with barium, ultrasound of the abdominal cavity organs, lung radiography and electrogastrography, there was no data for the progression of the underlying disease. The abnormal motor function of the stomach in the form of a dumping syndrome and tachigastrium was completely stopped by 12 months on the background of outpatiently standard conservative measures (prokinetic prenatal reception, capsule intake of the gastrointestinal tract of the gastrointestinal tract) at 3 and 6 months after surgery.

Thus, the proposed method of lymphodissection with subtotal distal resection of the stomach does not increase the number of early postoperative complications, does not worsen blood supply to the stomach stump, reducing the risk of development of locoregional metastases in cancer of the distal stomach.

BIBLIOGRAPHY

1. Chernousov AF, Polikarpov SA, Voronov ME, Mollyaniyazov M.М. Subtotal distal resection of the stomach in cancer - indications and immediate results // Surgery. - №10. - 2004 - C.4-8.

2. Fukagawa T. et al. Immunohistochemically detected micrometastases of the lymph nodes in patients with gastric carcinoma // Cancer. - V.92 (4). - 2001. - P.753-60.

3. Khvastunov RA, Shirokov AV, Shereshkov A.Yu., Begratov TB. Extended D 3 -intervention in gastric cancer // Modern oncology. - T.6. - No. 1 - 2004

CLAIM

A method for the surgical treatment of distal stomach cancer, including mobilization of the stomach, radical D2 lymph dissection followed by subtotal distal resection of the stomach, characterized in that during the mobilization of the stomach, the gastro-diaphragm ligament is further intersected, the stomach bottom and short gastric arteries are exposed and the lympho- dissection of the left paracardial lymph nodes .

print version
Date of publication 06.01.2007gg