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DOI: http://dx.doi.org/10.20534/ESR-17-1.2-116-120
Krotov Nikolay Fedorovich, FGBI "Oncology Institute named by N. N. Petrov" of Russian Ministry of Health, Saint-Petersburg, Russia E-mail: [email protected] Sabirov Djahongir Ruzievich, National Cancer Research Center, Ministry of Healthcare of the Republic of Uzbekistan
Tashkent, Uzbekistan Head of the Military Medical Faculty at the Tashkent Medical Academy, Tashkent Uzbekistan E-mail: [email protected] Rasulov Abdugaffar Elmanovich, National Cancer Research Center, Ministry of Health of the Republic of Uzbekistan, Tashkent
E-mail: [email protected]
Minimally invasive esophagectomy in esophageal cancer: treatment options
Abstract: Purpose. Defining the role of minimally invasive surgery in the surgical treatment of esophageal cancer. Materials and Methods: Retrospective analyses of 285 simultaneous surgical interventions were carried out. Men — 129 (45.2%), women — 156 (54.8%), mean age was — 54.6 years.
Results and discussion: 253 (89%) patients were operated with stage II and III of disease. Surgery performed by method ofMcKeown — 28 (9,8%), by Lewis- 48 (16.8%), Trans hiatal Esophagectomy — 38 (13.3%) and Video-assisted Trans hiatal Esophagectomy — 171 (60%) on patients. Time spent on intervention in the operation Lewis-346,5 ± 42,8min., at McKe-own-390 ± 32.5 min., at Video-assisted Transhiatal Esophagectomy 329,1 ± 28,5 min. Mortality after surgery Lewis-8 (16.6%) with Transhiatal Esophagectomy and Video-assisted Transhiatal Esophagectomy -1 (0.6%). 5-year survival rate after surgery by McKeown-21,5%, by Lewis-16,2%, Transhiatal Esophagectomy + Video-assisted Transhiatal Esophagectomy — 10.1%. Keywords: esophageal cancer, surgery, minimally invasive intervention, the survival rate.
Introduction Surgeons), there are several types of approaches: 1. Minimally inva-
Due to the increasing of life expectancy of the population of the sive esophagectomy with anastomosis in the neck. 2. Minimally inglobe especially in developed countries, the incidence of malignant vasive esophagectomy with intrapleural anastomosis. 3. Laparoscop-tumors has the tendency to be increased. Among the most common ic assisted esophagectomy combined with standard thoracotomy malignant tumors, esophageal cancer ranks to eighth in the world overlay intrapleural anastomosis. 4. Laparoscopic assisted esopha-statistics with a specific weight of 3.8% [6]. In Uzbekistan, in the gectomy combined with minithoracotomy and overlay intrapleural structure of the Esophageal Carcinoma (EC) is on the 10th place anastomosis. 5. Laparoscopically assisted esophagectomy combined with a specific weight of 3.6% [4]. In the structure of the world EC with standard thoracotomy with the imposition of the cervical anas-mortality is on the 6th place [3]. Five-year survival of patients with tomosis. 6. Thoracoscopic esophagectomy combined with a lapa-EC up to the date does not exceed 10-15% [1; 2]. rotomy, with imposing cervical anastomosis [6; 9].
Despite the tremendous pace of development of high technol- Given the analysis of the literature aim of our study to define
ogy with their application in surgical practice it is impossible to im- the role of minimally invasive surgery in the surgical treatment of prove the long-term results of treatment of EC using only opera- esophageal cancer. tions. Surgical treatment as the primary method of exposure can be Material and methods.
applied only in the initial forms of EC [5; 7]. The study included 285 simultaneous experience of surgical pro-
Low sensitivity of the tumor to existing chemotherapy drugs, pal- cedures in patients with malignant thoracic esophagus disease, carried liative and short-term effect ofradiation therapy do surgery treatment out by Research Cancer Center of the Republic of Uzbekistan of the as a choice of treatment for patients with esophageal cancer [3; 5; 6]. Ministry of Health in the period from 2000 to 2011. The localization Application of minimally invasive interventions while maintain- of the tumor in the thoracic esophagus (TE) was diagnosed in 10 ing oncologic adequacy securely finds its place in surgical practice in (3.5%) patients in the middle chest region (MCR) in 104 (36.5%), Western Europe, USA and Asia. Video endoscopic surgery being in the lower thoracic (LT) in 171 (60%). The study group was alternative cavitary intervention has a number of significant advan- men — 129 (45.2%), women — 156 (54.8%). The age group ranged tages over traditional ones. Today, there are different approaches and from 20 to 77 years, mean age — 54.6 years. By age, the patients techniques ofvideoendoscopic operations on the esophagus [8; 9]. were distributed as follows (the WHO classification): from 18 to According to the classification ofminimally invasive esophagec- 44 years — 42 (14.7%), from 45 to 64 years — 191 (67,1%), from tomy proposed by AUGIS (Association of Upper Gastrointestinal 65 to 74 years — 50 (17, 5%), aged 75 and older — 2 (0.7%). History
of the disease at the time ofhospitalization was up to 3 months — 138 (48.4%), 4-6 months — 56 (19.6%) and more than 6 months — 91 (31.9%). The degree of dysphagia: I — 9 (3,2%), II — 127 (44,5%), III — 138 (48.4%) and IV — 11 (3.8%). According loss from baseline body weight: 53 (18.6%) patients weight loss is not detected, at 102 (35.8%) patients with body weight loss amounted to 1 to 10%, from 124 (43.5%) of 11 to 20% and 6 (2.1%) 21-30%.
All patients were subjected to surgical treatment of complex survey. It assesses the overall condition of the patient, the cardiovascular and respiratory system. Instrumental examination included spiral computed tomography of the chest and abdomen, x-ray of the esophagus, fibroezofagogastroduodenoskopy, endosonogra-phy of the esophagus, ultrasound of soft tissues of the neck and abdomen, fibrolaringo-traheo-bronchoscopy. Squamous cell carcinoma was verified in 269 (94.4%) patients, adenocarcinoma in 16 (5.6%). Stage of cancer of the esophagus was determined by objective data on the basis of the seventh edition of the TNM classification of malignant tumors Stage IIa (T2N0M0; T3N0M0) — 32 (11.2%), Stage IIb (T1N1M0; T2N1M0) — 179 (62,8%), III stage (T3N1M0; T4 (any)N (any)M0) — 74 (25.9%).
Preoperative preparation was carried out in a fairly short period of time. Correction of hypovolemia, hypoproteinemia, anemia, electrolyte disorders, blood glucose, blood rheology disorders were conducted; blood pressure and improve tropisms infarction were normalized. Much attention was paid to the preparation of the respiratory system, using therapeutic inhalation, mucolytics, bron-chodilators, incentive spirometry, etc. In the cases of dysphagia and weight loss of more than 10% of the original course enteral, parenteral or mixed feeding for at least 7-10 days has been conducted. They sought to achieve a positive nitrogen balance.
Options for surgical intervention on the basis of the location and extent of tumor the functional parameters of patients were car-
a)
Figure 1. (a) and photo (b) video-assisted
Operation McKeown (triple-available operation) is performed with 28 (9.8%) patients. Operation Ivor-Lewis made to 48 (16.8%) patients. The main stages of the operation did not differ from the standard conventional techniques. All patients after surgical treatment had radiation therapy and if indicated chemotherapy.
Results and discussion
253 (89%) patients were operated on with stage II and III disease. According to the intraoperative histological study radical operations were made to 90% of patients. In our work we were directed to results of surgical treatment according to the number and nature of intra- and postoperative complications according to the type of
ried out. In all cases esophago-gastroplasty has been performed. For example, the localization of the tumor process in Thoracic Esophagus (TE) with the spread of Middle Chest Region (MCR) and with symptoms of compression of the trachea bifurcation standard operation by McKeown performed (right thoracotomy + laprotomy + cervicotomy) applying Esophago-gastro-anastomosis on the neck on the left side. When localization of tumor in Middle Chest Region and Lower Thoracic following type of surgery were selected: Ivor-Lewis operation was performed in patients with higher functional performance and trans hiatal esophagoectomy (TE) with gastro plastic and overlay esophago-gastro-anastomosis (EGA) on the neck to patients with lower functional performance were carried out.
TE is made to 209 (73.3%) patients. In our work we analyzed the shortcomings of the standard TE in 38 (18.2%) patients treated before 2004., and Republic Cancer Research Centre staff of the Ministry of Health of Uzbekistan introduced into clinical practice the hybrid technique of video-assisted trans hiatal esophagectomy (VATHE). This mediastinal stage of the mobilization of the esophagus and lymph node dissection at the Esophageal Carcinoma, especially localized at or below the bifurcation of the trachea during TE performed using video-assisting endosurgical instruments and endoscopic equipment operating — release of the esophagus, adequate lymph node dissection, careful hemo-and lymphostasis carried out under Endovisual control. When lymph node dissection was removed paraesophageal, mediastinal rear, left and right paratracheal, bifurcation, right tracheobronchial lymph node group. Coagulation and dissection of tissue produced mainly by thoraco-scopic instruments. In case of difficulties for differentiation of tissues near the tumor manual palpation were used (because most of the patients were operated in the III stage of the process). The remaining steps were carried out by TE conventional technique. VATHE was performed in 171 (60%) patients (Figure № 1).
b)
trans hiatal mobilization of the esophagus.
surgical interventions (McKeown operation — 28 (9.8%), the operation Ivor-Lewis- 48 (16.8%), TCE — 38 (13.3%) and VATHE — 171 (60%)). Intraoperative complications were observed in only 2 cases which were associated with rupture of the membranous portion of the trachea during surgery of McKeown in mobilizing Thoracic Esophagus. Both complications were successfully eliminated by the closure of the tracheal wall defect.
Evaluation of the effectiveness of different methods of surgical intervention were performed according to the amount of blood loss, time spent on performing surgery, the number of postoperative hospital days, the frequency of pulmonary complications, as
well as the frequency of early postoperative interventions according to the type of surgery.
Revealed statistically significant difference in the time spent on the intervention, and the average duration of Ivor-Lewis operation was 346.5 ± 42,8min., while the figure for the operation McKeown
was 390 ± 32.5 min., and for VATHE 329.1 ± 28,5 min. The average length of the esophagus with adequate lymph node dissection based on the mobilization of the type of operation are shown in Table 1. In the group VATHE the figure was 40.1 minutes.
I McKeown О Льюиса ТХЭ ВАТХЭ
Figure 2. The duration of surgical interventions
The volume of intraoperative blood loss noted in the Group's operations: the operation by McKeown — 390,3ml, by Ivor-Lewis — 380,6 ml. Under VATHE the figure was — 407,5ml. In 258
(90.5%) were assessed as diffuse hemorrhage in 27 (9.5%) were the source ofbleeding lesions of small branches ofthe aorta 1 (3.5%); 5 (10.4%); 4 (10.5%); and 17 (9.9%), respectively on groups.
Figure 3. Indicators of intraoperative blood loss
In the early postoperative mediastinal bleeding was observed in 5 patients (1 (3.7%), and 2 (4.3%) 0 and 2 (1.2%), respectively, in groups), which was eliminated by conservative measures. Lymphor-rhea of postoperative mediastinal noted in 28 (9.8%) patients (14.3%) 5 (10.4%) 7 (22.6%) and 12 (7.5%), respectively), which
liquidated independently from 3 to 9 days.
In the early postoperative period in 109 (38.2%) patients showed various complications of the lungs, pleura and heart (16 (57.1%) 32 (66.7%) 11 (28.9%) and 50 (29.2%), respectively, by groups). The comparative data are summarized in Table № 1.
Table 1. - Ratio of various postoperative complications to the type of surgical intervention
№ Operation Pneumonia Pleuritis Empyema Arrhythmia Total
1 McKeown surgery 3 (10,7%) 9 (32,1%) 1 (3,5%) 3 (10,7%) 16 (57,1%)
2 Ivor-Lewis surgery 5 (10,4%) 12 (25%) 4 (8,3%) 11 (22,9%) 32 (66,7%)
3 Transhiatal Esophagectomy 1 (2,6%) 4 (10,5%) - 6 (15,8%) 11 (28,9%)
4 Video-assisted Transhiatal Esophagectomy 10 (5,8%) 26 (15,2%) 1 (0,6%) 13 (7,6%) 50 (29,2%)
Total 19 (6,6%) 51 (24,9%) 6 (2,1%) 33 (11,6%) 109 (38,2%)
As seen in Table 3 pleural complications of pleurisy observed performing a wide thoracotomy. The main cause of pleural empy-more in McKeown surgery group (32.1%) and operations Ivor- ema in Ivor-Lewis operation group was the failure of welds intraLewis (25%), which is associated with the traditional technique of pleural EGA. In the group of patients with empyema VATE found
only with 1 patient (0.6%), postoperative pneumonia in only 5.8% of patients due to the lack of a wide thoracotomy, the possibility of early mobilization of patients after surgery, earlier recovery of functions of the respiratory system.
Fixed postoperative mortality observed in 17 (5.9%) cases. Comparative indicators of deaths, its causes and due to the type of surgical intervention are shown in Table № 2.
Table 2. - The lethality incidence with respect to the type of operations, and causes of death.
№ Type of surgery Amount of surgery FAS PE AMI Pneumonia Brain stroke Total
1 McKeown surgery 28 (9,8%) - - - 1 (3,5%) - 1 (5,9%)
2 Lewis surgery 48 (16,8%) 6 (12,5%) 1 (2,1%) - - 1 (2,1%) 8 (16,6%)
3 TE 38 (13,3%) 2 (5,3%) - 1 (5,3%) - 3 (7,8%)
4 VATE 171 (60%) 1 (0,6%) 3 (1,7%) 1 (0,6%) - - 5 (2,9%)
5 Total 285 (100%) 7 (2,4%) 6 (2,1%) 1 (0,3%) 2 (0,7%) 1 (0,3%) 17 (5,7%)
Thus, the highest mortality rate observed in Lewis 8 operation group (16.6%), the most frequent cause of death was a failure of anastomosis sutures FAS 6 (12.5%). In the group of TCE and VATHE EGA suture failure was the cause of death in only 1 (0.6%) — the bleeding of the main blood vessels of the neck. In all cases of pulmonary embolism occurred in those patients who were initially identified pronounced abnormalities in the cardiac
activity. The average postoperative hospital stay was 19.7 days (20.5; 20.4; 19.6 and 18.5, respectively, in groups) in 268 patients (285 patients with postoperative mortality of17 cases).
Analysis of the survival of183 patients (monitoring other cases going on), depending on the type of surgery showed the following results: the 5-year survival rate after surgery McKeown — 21,5%, Ivor-Lewis — 16,2%, TCE + VATHE — 10.1% (Figure 4.)
Figure 4. The survival rate of patients with esophageal cancer.
Conclusions
1. Application mini invasive procedure at the stage of selection of the esophagus and mediastinal lymph node dissection, videoassisted, endoscopic operating technique allows to observe the principles of oncological surgery, significantly increases the value of lymphadenectomy performed, hemostasis, reduces the risk of damage of structures without increasing the overall trauma surgery.
2. Video-assisted TE enables early mobilization of patients after surgery (less pain due to lack of access thoracotomy), early restora-
tion of function of the respiratory system.
3. Minimally invasive surgical interventions in patients with esophageal cancer have widely introduced into clinical practice specialized hospitals that have extensive experience in performing the traditional interventions of similar scope. We are convinced that in the near future minimally invasive radical surgery will take a more active position in the structure of surgical interventions in patients with tumors of the gastrointestinal tract.
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DOI: http://dx.doi.org/10.20534/ESR-17-1.2-120-123
Sabirov Maksud Atabaevich, PhD, head of Department of therapeutic directions № 2 of Tashkent State Dental Institute Senior Researcher of Tashkent Pediatric Medical Institute
Tashkent, Uzbekistan
Remodeling the left heart chambers in patients with arterial hypertension and chronic kidney disease
Abstract: The objective of the research is to study the structural and functional condition of the left heart chambers in patients with chronic kidney disease (CKD). The research involved 254 patients; the main group consisted of 214 CKD patients and the control group included 40 people to compare. The patients in the main group suffered from CKD of the third stage (eGFR with 30-59 ml/min/m 2). The arterial hypertension and the decrease of eGFR were the criteria to enroll the patients in the study. The present research has shown that in case of CKD, the left heart chambers remodeling is observed that manifests by disturbance of early diastolic filling, myocardium hypertrophy, dilatation of the cavities and the tendency to decrease systolic LV functions correlating with a decrease in filtration functions of the kidneys and intensity of secondary hyperparathyroidism.
Keywords: Chronic kidney diseases, arterial hypertension, left ventricular hypertrophy.
Aim: The objective of the research is to study the structural and functional condition of the left heart chambers in patients with chronic kidney disease (CKD).
Material and Methods
The research involved 254 patients; the main group consisted of 214 CKD patients and the control group included 40 people to compare. The patients in the main group suffered from CKD of the third stage (eGFR with 30-59 ml/min/m 2). The arterial hypertension and the decrease of eGFR were the criteria to enroll the patients in the study. According to etiology, chronic glomerulonephritis was diagnosed in 178 patients of the main group, chronic pyelonephritis was diagnosed in 26 patients; the etiologic diagnosis was not made to the rest 10 patients. Diabetes and other endocrinological diseases, systemic vasculitis, valve lesions and congenital heart defects, non-sinusoid pace maker (imposed rhythm, fibrillation, idioventricular rhythm), neoplasia, acute infectious diseases, diseases of the central nervous system, and the refusal of the patient to participate were the criteria of exclusion of the patients from the research.
The clinical picture in patients with CKD consisted of classical symptoms: arterial hypertension was found out in 100% of patients, edema — in 167 patients (78.04%), skin itching and peripheral neuropathy — in 72 patients (33.64%). Such impairment of the central nervous system as encephalopathy, tremor, muscles cramps and im-potency was observed in 115 patients (53.74%); the reduction of muscle mass and arthropathy were found in 53 patients (24.77%). The GIS impairment manifested as nausea, anorexia, pancreatitis were observed in 119 patients (55.61%). The impairment of the
cardiovascular system like angina pectoris, cardiac arrhythmia and pericarditis were diagnosed in 160 patients (74.77%), the blood system impairment in the form of anemia and thrombocytopenic purpura were found in 172 patients (80.72%).
The comparison group consisted of two cohorts of patients: the ones with arterial hypertension (AH) without any kidneys damage (the AH group of 20 patients) and healthy volunteers with the healthy kidneys and cardiovascular system (the CG of 20 people).
The groups differed in the age of the members: the representatives of the AH group were significantly elder than the ones from the CKD and CG groups (<0.001 for both comparison groups) which did not differ from each other. According to the level ofAP, SAP and DAP, the AH group significantly (p<0.001) exceeded the index characteristic for the CG. In the CKD group, AP significantly exceeded not only the average value in the CG group (p<0.001), but also in the AH group (p<0.01). The filtering function of the kidneys was preserved and comparable in the AH and CG. It was diminished in the CKD group (p<0.001 in comparison with both groups) that was a criterion to include the patients in the research. All the patients with CKD have taken the standard basic therapy for at least three months before the start of the research, though AP was not completely controlled. The basic therapy [1] consisted ofvalsartan, i. e. angiotensin receptor blocker II of type 1 in the dose of 160 mg a day, aspirin, i. e. antiagregant in the dose of 100 mg a day, and according to the indication: loop diuretics (in edema syndrome), carvedilol, i. e. beta-adrenoblocker (in tachycardia and other rhythm disorders), atorvastatin (in dislipidemia), allopurinol (in hyperuricemia over
