Комп’ютерна томографія і відеотораколапароскопія при діагностиці та лікуванні местнораспространенной раку стравоходу і шлунку

Computed tomography and videothoracolaparoscopy in diagnosis and treatment of the invasive esophageal and stomachcancer

Republican Research Oncological Center, Tashkent, Uzbekistan.

Комп’ютерна томографія і відеотораколапароскопія при діагностиці та лікуванні местнораспространенной раку стравоходу і шлунку

Республіканський онкологічний науковий центр МОЗ РУз, м. Ташкент, Узбекистан.

Комп’ютерна томографія і відеотораколапароскопія за останні роки міцно зайняли одне з провідних місць при обстеженні та лікуванні хворих на рак стравоходу і шлунку [1, 4, 6, 8]. По суті, КТ є єдиним рентгенологічним методом, що дозволяє отримувати пряме зображення стінки при дисфагії, без попереднього контрастування.

Торакоскопія і лапароскопія дозволяють визначити резектабельность пухлинного процесу при раку стравоходу і шлунку, значно знижуючи кількість експлоратівних торакотомій і лапаротомий.

The problem of diagnosis and treatment of the esophageal and stomach invasive cancer is one of the important problems in the current clinical oncology. According to the data of MIDavidov and AFChernousova 70-80% of the patients with esophageal and stomach cancer admitted to the hospital at the III-IV stage of the process [3, 4].

Computed tomography and videothoracolaparoscopy has been occupied one of the leading places in examination and treatment of the patients with cancer of the esophagus and stomach over the last years [1, 6, 8]. Really CT is the unique roentgenological method allowing obtaining the direct images of the wall and dysphagia without preliminary contrasting.

The identification of suprastenotic enlarged sites of the esophagus completely 9-16 ED HU on the tomograms in comparison with normal esophageal wall completely 50-70 ED HU is characteristic for esophageal cancer. In some cases of esophagus and gastric cancer with use of CT there may be determination of the level of tumorous impairment, extension of the process, invasion presence into the adjacent organs, increase of lymph nodes and presence of the distant metastases [5, 6] .

Nevertheless, the CT capacity in the diagnosis of gastric and esophageal invasive cancer has been shown in the literature insufficiently [2, 9, 12].

The great attention ahs been paid to the min-invasive methods of the distribution of the malignant process in the thoracic and abdominal cavities for last time. Thus, thoracoscopy is widely used in the oncological practice in the patients with pulmonary, pleura and mediastinal neoplasms, for obtaining of the morphological verification of tumor process, elucidation of its distribution degree [1, 6, 11].

The use of endoscopic technique in the diagnosis and treatment of the organs of thoracic and abdominal cavities has more than 40-year history. However, these investigations getting wide distribution in the oncological practice in the patients with oncopathology of the lungs, pleura, mediastinum and genitalia organs have not obtained sufficiently wide distribution among patients with esophageal and gastric cancer because there has not been clearly determined their limits, capacities , indications and contraindications to thoracoscopy and laparoscopy in this group of patients.

Last time there are found works devoted to the methods of thoraco-and laparoscopic surgeries in esophageal and stomach cancer, but these works present singular cases [8, 10].

In the Thoracic department of the Republican Research Oncological Centre of the Republic of Uzbekistan during the period from 2005 to

the plan of investigation of the patients with esophageal and stomach cancer including roentgenoscopy and (or) roentgenography of the thoracic chest, contrast esophageal and stomach roentgenoscopy,EPGDS and ultrasonography of the mediastinal and abdominal cavity organs additionally computed tomography and diagnostic thoraco-and (or) laparoscopy were included.

The investigation were performed on the computed tomography of the 3d generation "SOMATOM UR" of firm "SIMENS". Scanning with step

were performed from cervical esophageal site to the organs of small pelvis. According to the indications immediately before investigation the esophagus and stomach were contrasted with oral administration of 20 ml 50% Verographin’s solution dissolved in the 200-500 ml of water. For evaluation of the CT results there were use such criteria as sensitivity and specificity of the CT. The sensitivity characterizes the method possibility of this disease identification, and specificity shows exclusion of disease, that is, reliability of the negative result of investigation.

Endoscopic interventions were carried out with use of videosurgical complex of firms "KARL STORZ" and "AUTO SUTURE". In cases of impairment of the upper and middle third of the esophagus there were performed diagnostic thoracoscopy, in lesion of the lower third of the esophagus and stomach – the diagnostic laparoscopy.

Under our observation there were 48 patients with esophageal cancer and proximal site of the stomach. The males were 18, females -20. The range of age in the patients was the following: 31-40 years in 5 patients, 41-50 – in 10 s, 51-60 – in 20, 61-70 – in 7, and 71-80 – in 5 patients. The youngest patient was of 35 years old, the oldest one – of 79 years. The majority of patients were at the age of 41-50 years.

The cancer of the upper third of the esophagus with invasion into the upper thoracic part was diagnosed in 4 patients, cancer of the middle third of the esophagus – in 14, of the lower third – in 10, of the middle and lower third of the esophagus – in 10 patients.

The cancer of cardioesophageal area was found in 9 patients and total stomach cancer with lesion of the esophageal lower third in one patient.

In all the cases there was obtained comprehensive diagnostic information including features of the morphological investigation that allowed further performance of adequate therapeutic measurements. Analysis of histological investigation showed the following results: adenocarcinoma was revealed in 10 cases, squamous cell carcinoma – in 30 patients, esophageal melocarcinoma in 4 patients, and leiomyosarcoma – in 4 cases.

The stage T2 NOMO was diagnosed in 2 patients, T2 N1MO – in 4, T3 T1MO – in 4, T3N2MO – in 5 cases, T3N2M1 – in 5 cases, T4M1O – in 10 cases, T4N2MO – in 10, and T4N2M1 – in 8 cases.

After performance of KT 10 (20,8%) the patients were refused of radical operation due to presence of clear signs of tumor invasion into aorta, trachea.

The rest 38 (79,2%) patients the tumor respectability was determined during thoraco-or laparoscopy.

After laparoscopy the patients were performed radical surgeries: operation type by Lewis – in 3 patients, operation by Garlock-Osava in 3 patients, abdominal-cervical extirpation of the esophagus – in 2 patients, gastrectomy with abdominocervical extirpation of the esophagus because of found total gastric cancer with invasion into the esophageal lower third part.

After diagnostic thoracoscopy the operation by Liewis was performed in 5 patients, operation by Kirshner-Nakayama in 2 patients, abdominocervical extirpation of the esophagus in 3 patients.

The 19 (39,6%) patients were refused in radical operation because of identification of tumor invasion into the adjacent organs and tissues and (or) identification of tumor process dissemination into the organs the thoracic and abdominal cavities. Of them in 15 cases there was performed bougieurage and endoprosthetics of the area of ??tumor process and gastrostomy in 4 cases.

The patients which tumor process was considered as non-resectable the endoprosthetics orgastrostomy were made from minilaparotomic approach that resulted in earlier activation of the patients and earlier their discharge from the hospital after endoprosthetics or onset of the conservative radiochemotherapy after gastrostomy.

There were no any complications after thoracoscopy and laparoscopy in the patients.

1. Inclusion of the computed tomography of the organs of thoracic and abdominal cavities into the plan of examination of the patients with esophageal and stomach cancer allows determination of the tumor lesion level, process expansion, presence of the enlarged lymph nodes.

Computed tomography allows identification of the tumor process invasion in the advanced cases.

2. The enlarged image on the monitor screen provides to reveal small pathological masses on the pleura, peritoneum and other organs those were invisible in use of other methods of investigation.

3. Thoracoscopy and laparoscopy allow determination of the respectability of the tumorous process in the esophageal and stomach cancer considerably lowering the number of exploratory thoracotomies and laparotomies.

4. Identification of the signs of non-resectability during thoraco-and laparoscopy allows patient activation at the earlier period and onset of the conservative therapy and refuse from it in advanced cases and shortening of the hospitalization period.

5. The insignificant injuries and number of complications of videoendoscopic surgery allows reduction of medicamental costs.

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