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UDC 616.329:616.33:616.342-089
SURGICAL TACTICS BY SUBMUCOSAL MASSES OF THE ESOPHAGUS, STOMACH AND 12-PERSONAL DUODENUM
Altai State Medical University, Barnaul
V.A. Gankov, S.A. Maslikova, A.F. Lazarev, V.I. Oskretkov
Currently, the leading method of treatment of non-epithelial submucosal formations of the upper part of the digestive tract (NSF of the UPDT) remains operative treatment, which allows to radically remove the pathological process, but this depends on the prevalence of the tumor process, the absence of metastases that are possible with GIST of the esophagus, stomach and duodenum. Recently, the standard of treatment of patients with GIST of the esophagus, stomach and duodenum, which includes such volume of surgical intervention as removal of the tumor within the healthy tissues, was defined, departing from the borders of the tumor by 1-2 cm, without carrying out lymphodissection, since metastases to the lymph nodes with GIST are rare. It is impossible to differentiate between leiomyoma and GIST without performing immunohistochemical research using the CD117 and Kit-67 markers, and using other GIST markers.
Key words: non-epithelial submucosal formations of the upper digestive tract, immunohistochemical examination, GIST of esophagus, stomach and duodenum.
Mesenchymal tumors account for 2.7% of all esophageal tumors, usually located in the middle and lower thirds, with 50-70% being leiomyomas [1, 2, 3, 4]. There is a group of non-epithelial tumors - GIST (Gastro-Intestinal Stromal Tumors), which are similar in clinical and macroscopic pattern to true tumors of neurogenic and smooth muscle differentiation, but differ in their immune-his-tochemical and ultrastructural characteristics. The complexity of preoperative morphological diagnosis of these tumors lies in their submucosal location [5, 6, 7]. The existing methods of biopsy in endoscopic methods do not allow taking material from the submucosal layer. Depending on the size of the tumor, localization, its histological structure, the volume of operative treatment of patients with benign submucous tumors of the esophagus and stomach is determined by the introduction of video endosurgical interventions [8, 9, 10, 11]. Thus, in the presence of severe somatic pathology and small size of benign tumors, dynamic observation is possible [12, 13].
Treatment of patients with non-epithelial sub-mucosal formations of the upper part of the digestive tract (NSF of the UPDT) is still an actual topic. This is due to an increase in the cases of detection of patients with NSF of the UPDT, as well as the emergence of new diagnostic methods and surgical intervention in these patients [14].
In connection with the development and improvement of surgical treatment of patients with NSF of the UPDT, including GIST of the esophagus, stomach and duodenum, the use of mini-invasive technologies in the treatment of NSF of the UPDT can be considered an adequate alternative to open interventions.
Objective: To improve the results of surgical treatment of patients with benign NSF of the UPDT and GIST of the esophagus, stomach and duode-
num by the introduction of minimal invasive technologies.
Materials and methods
The work is based on the results of observation and surgical treatment of 123 patients with NSF of the UPDT. 79 of them were hospitalized in the general surgery clinic on the basis of FSHI "City Hospital No. 12" in Barnaul in 1998-2016, 15 patients - in the Diagnostic Center of Altai Krai under dynamic supervision, and 29 patients with GIST of the esophagus and stomach, operated in the Altai Regional Oncology Dispensary. The ratio of women and men between the ages of 20 and 77 was 2:1. The average age of patients with benign NSF of the UPDT and GIST esophagus, stomach and duodenum was 57 years.
The complex of the examination included fiberoptic esophagogastroduodenoscopy (FEGDS) with targeted fine-needle mucosal biopsy, endoscopic ultrasound of the UPDT, X-ray examination of the esophagus of the stomach and duodenum, ultrasound of the abdominal cavity organs, MSCT of the abdominal cavity aimed at establishing, verifying the diagnosis of the submucosal neoplasm and assessing the functional state esophagus, stomach and duodenum in this pathology. And also an assessment of the pain syndrome in patients on a visual analogue scale was made, long-term results were studied using the questionnaire (the international questionnaire SF-36).
The studies were aimed at diagnosing the NSF, namely, finding out the localization of tumors in the esophagus, stomach and duodenum, the degree of invasion in the organ wall (submucosal, muscle layers, own muscle plate of the mucosa), interaction with other organs, histological characteristics of the tumor in the preoperative period
for the further choice of the method of operative treatment of patients.
Based on the survey results obtained, it can be concluded that each survey method has its own characteristics that are not inherent in other research methods. Thus, by FEGDS, it is possible to detect localization, consistency, ulceration (or erosion, hyperemia) over neoplasms, mobility of the mucosa above the tumor, smooth or tuberous surface of the tumor. Ectopia of the pancreas in the stomach is characterized by the presence of an excretory duct in the center of the neoplasm. However, only according to the FEGDS data, benign NSFs and GIST of the esophagus, stomach and duodenum cannot be distinguished from each other.
Puncture biopsy of the mucosa of the esophagus or stomach above the tumor reveals morphological changes in the mucous membrane, but does not reveal changes in the submucosa, where benign NSF and GIST of the esophagus, stomach and duodenum are located.
According to the results of endoscopic ultrasound of UPDT, it is possible to find out in which layer the tumor is located, to assume its morphological structure. Leiomyomas are characterized by hypoechogenity, clear contours and a heterogeneous structure. In rare cases, there are hypo-, an- or hyperechoic inclusions. Almost the same picture is observed in GIST - hypoechogenity, clear contours, heterogeneous structure, the presence of hypo-, an- and hyperechoic inclusions. Lymphatic nodes are not enlarged.
According to X-ray data, it is possible to detect the presence of neoplasms more than 1 cm in diameter. For the NSFs of the esophagus, stomach and duodenum, the sharpness of the contours, the mobility of the tumor and the dislocation of the tumor are characteristic. Peristalsis according to X-rays of the esophagus, stomach and duodenum is preserved in all patients. "Niches" against the background of the filling defect were detected in two patients with benign NSF of the esophagus, stomach and duodenum, and in patients with GIST of UPDT, "niches" were not found.
The main method for differential diagnosis of leiomyoma and GIST is an IGC-test, with which it is possible to clarify the morphological characteristics of the tumor using the markers GIST-CD117 and Kit-67. Thus, out of 95 patients examined, in 44 there was confirmed the presence of a tumor. However, to date, this study is possible only after surgery, because during the puncture biopsy, it is impossible to take a histological examination from the submucosal layer. At the same time, in-traoperatively, all patients underwent an urgent histological examination, the result of which was a leiomyoma. Only using the whole complex of examinations, it is possible to determine the extent of surgical intervention in the future.
Based on the data obtained, benign NSF of the UPDT in the absence of clinical manifestations, malignant nature of the disease, the absence of functional disorders can operate with tumor size in the esophagus from 2 cm in diameter, in the stomach - from 1 cm in diameter. Given the difficulty of pre-operative diagnosis, a tactic is possible in agreement with the patient: videotho-rascopic or videolaparoscopic resection of the wall with a tumor with visual signs of benign neoplasm.
Results and discussion
A significant number of patients with NSF of the esophagus (14 patients, 73.7 (51.2-88.2)%) underwent a VTS resection of the esophagus wall with a tumor. It is important to know that the technical difficulties were with finding new lesions less than 1.5 cm in diameter. In the early postoperative period, 6 patients had complications (5 people - pneumonia, 1 person - pneumothorax). After carrying out antibacterial therapy and puncturing the pleural cavity according to Bulau (in a patient with a strained pneumothorax), the patients' condition returned to normal.
A significant number of patients with gastric NSF were exposed to VLS resection of the stomach wall with a tumor (51 people, 87.9 (77.1-94.0)%). A patient with GIST of duodenum (3 cm in diameter, the border of the horizontal and descending branch of the duodenum) underwent video-assisted excision of the anterior wall of the duodenum with the tumor.
When comparing the duration of surgical intervention from "open" access (comparison group) and using mini-invasive technologies (main group), statistically significant differences were revealed. Thus, video endosurgical operations are characterized by a greater average time of surgery, but less intensity of pain syndrome and length of hospitalization of patients. In both groups there were no complications.
In this study, the quality of life of patients with NSF of the UPDT was studied for the first time after surgical treatment with the use of minimal invasive video endosurgical technologies by questionnaire (SF-36) and data of special methods of UPDT research. The conducted analysis of the questionnaire research showed that after the surgical intervention, the quality of life indicators was significantly higher in comparison with the baseline data, in particular, in those patients who had a clinic before surgery associated with a tumor of the esophagus, stomach or duodenum.
When comparing the data obtained, it can be concluded that there are significant differences (P <0.05) between the groups of patients with GIST of UPDT, operated from open access and using minimal invasive technologies in terms of indices - pain intensity, role functioning, conditioned by emotional state of patient, mental health of pa-
tients. Patients with GIST of UPDT, operated with the help of minimal invasive technologies, have slightly better indicators on the quality of life based on the results of the questionnaire.
Conclusion
The most sensitive method (100%) of preop-erative studies was endoscopic ultrasonography of UPDT. However, this study does not allow to accurately differentiate between leiomyoma and GIST. The lowest sensitivity from all preoperative methods of examination was X-rays of the esophagus, stomach and duodenum (78.51%), since tumors less than 1 cm in diameter were not radioliologi-cally detected.
The sensitivity of immunohistochemistry compared with other methods for the accurate differential diagnosis of leiomyoma and GIST is 100%.
It should be noted that all patients with GIST of the esophagus, stomach and duodenum with an "open" and mini-invasive operation, as well as patients from the dynamic observation group and patients operated with benign NSF of the UPDT corresponded by sex, age, average tumor size, clinical picture. Thus, in these patients, there were no statistically significant differences in these factors.
Considering the improvement of technological solutions and the development of new technologies, the structure of early postoperative complications has changed significantly. All the patients examined in the remote postoperative period had no functional disorders of the esophagus, stomach and duodenum. This is due to the preservation during the operative intervention of adequate innervation and blood supply. In all patients having Helicobacter pillory in the long-term postoperative period, eradication therapy was performed.
Investigating remote results of patients with benign NSF and GIST of UPDT, we note that all patients had 1-, 2-, 3-, 5-year survival.
Working out the immediate and long-term results of video endosurgical treatment of patients, the NSF of the UPDT revealed an exception of relapse of the main pathology. There was a small number of postoperative disorders in the study of the functional state of the previously involved hollow organ. When comparing the data, a high quality of life of patients was found. Data of surgical interventions show high efficiency of the developed methods of endosurgical treatment.
References
1.Vorobyev G.I. Basics of Coloproctology. Moscow; 2006. 349.
2. Polkowski M, Butruk E. Submucosal lesions. Gastrointest Endosc Clin N Am. 2005; 15: 33—54.
3. Starkov Yu.G., Solodinina E.N., Novozhilova A.V. Submucosal neoplasms of the gastrointestinal tract in endoscopic practice. Clinical endoscopy. 2010; 2: 30-38.
4. Hwang JH, Kimmey MB. The incidental upper gastrointestinal subepithelial mass. Gastroenterology. 2004; 126: 301-307.
5. Ando N, Goto H, Niwa Y, et al. The diagnosis of GI stromal tumors with EUSguided fine needle aspiration with immunohistochemical analysis. Gastrointest Endosc. 2002; 55: 37—43.
6. Bucber P, Villiger P, Egger J-F, et al. Management of gastrointestinal stromal tumors: from diagnosis to treatment. Swiss med wkly. 2004; 134: 145—153.
7. Fletcher CD, Berman JJ, Corless C, et al. Diagnosis of gastrointestinal stromal tumors: A consensus approach. Hum Patol. 2002; 33: 459—465.
8. Nesje LB, Laerum OD, Svanes K, Odegaard S. Subepithelial masses of the gastrointestinal tract evaluated by endoscopic ultrasonography. Eur J Ultrasound. 2002; 15: 45—54.
9. Greenson JK. Gastrointestinal stromal tumors and other mesenchymal lesions of the gut. Mod Pathol. 2003; 16(4): 366—375.
10. Starkov Yu.G., Solodinina E.N., Novozhilo-va A.V. Submucosal formation of the gastrointestinal tract in endoscopic practice. Surgery. 2010; 2: 51-59.
11. Seremetis MG, Lyons WS, de Guzman VC, Ir JW. Peabody Leiomiomata of the oesophagus an analysis of 838 cases. Cancer. 1976; 38: 2166.
12. Demetri GD, Mehren M, Antonescu CR, et al. NCCN Task Force report: update on the management of patients with gastrointestinal stromal tumors. J Nat Compr Canc Netw. 2010; 8(2): 1-41.
13. Hirota S, Isozaki K, Moriyama Y. et al. Gain-of-function mutations of c-kit in human gastrointestinal stromal tumors. Science. 1998; 279: 577-580.
14. Ghanem N, Altehoefer C, Furtwangler A, et al. Computed tomography in gastrointestinal stromal tumors. Eur Radiol. 2003; 13: 1669-1678.
Contacts
Corresponding author: Gankov Viktor Anato-lievich, Doctor of Medical Sciences, Professor of the Department of General Surgery, Operative Surgery and Topographic Anatomy, Altai State Medical University, Barnaul. 656050, Barnaul, ul. Malakhova, 53. Tel.: (3852) 403854. Email: [email protected]
Maslikova Svetlana Anatolyevna, Assistant
of the Department of General Surgery, Operative
Surgery and Topographic Anatomy, Altai State
Medical University, Barnaul.
656050, Barnaul, ul. Malakhova, 53.
Tel.: (3852) 403854.
Email: [email protected]
Lazarev Alexander Fedorovich, Doctor of Medical Sciences, Professor, Head of the Department of Oncology, Radiation Therapy and Radiation Diagnostics, Altai State Medical University, Barnaul. 656045, Barnaul, Zmeinogorsky Trakt, 110. Tel.: (3852) 632620. Email: [email protected]
Oskretkov Vladimir Ivanovich, Doctor of Medical Sciences, Professor of the Department of General Surgery, Operative Surgery and Topographic Anatomy, Altai State Medical University, Barnaul. 656050, Barnaul, ul. Malakhova, 53. Tel.: (3852) 403854. Email: [email protected]
