Germination of the tumor into the diaphragm, as a rule, is not considered a contraindication to performing lung resection unless the organs of the subphrenic space are involved in the tumor process. The high elasticity of the diaphragm makes it possible to resect it significantly up to 10– cm. It is better to perform a dissection of the diaphragm and the resection of the affected area at the final stage of the operation. Only in some cases, if there is a suspicion of the possibility of damage to the abdominal organs, is a pre-performed diaphragmotomy and a revision of the subphrenic space is performed.
Thus, intraoperative diagnosis from the point of view of technical capabilities and the validity of the surgical intervention, carried out in the early stages of lung cancer, sometimes in minutes, with a common tumor process, requires a lot of experience and high surgical skills from the surgeon. Taking the final decision on the implementation of the intended scope of the operation, he must fully understand the nature and extent of the tumor lesion, be sure of the technical possibilities of the implementation, as a last resort, of palliative intervention.
Given the difficulty of determining the operability of patients with advanced stages of the disease, the final decision of which in some cases is possible only in the process of intraoperative diagnosis, the question naturally arises about the competence to perform a test thoracotomy, its effect on the fate of operated patients.
In contrast to the diagnostic thoracotomy, undertaken for the final diagnosis of the underlying disease (Trakhtenberg A.Kh., 1987) and being a casuistic rarity in surgery of advanced stages of lung cancer, trial thoracotomy is a relatively frequent type of surgical intervention. Of the 2524 lung cancer patients operated on at the clinic in 1960–19, it was performed in 281 patients (11.1%). It should be noted that the frequency of trial thoracotomy at various periods of work remained almost unchanged. So, in the I period it was 11.8%, in the II — 10.5% and in the III – 10.9% of the total number of surgical interventions performed in the clinic for lung cancer.
To assess the impact of the trial thoracotomy on the fate of the operated patients, we studied the immediate and long-term results of this operation, performed in the second period of the clinic. Of the 726 patients operated on for lung cancer during this period, a test thoracotomy was performed in 76 (10.5%) patients. Of these, 72 (94.7%) were men and 4 (5.3%) women. The average age of patients was 53.6 ± 0.46 years (M ± m), V = 7.64%. According to a retrospective analysis of the results of pre- and postoperative diagnostics, an operational revision, autopsies, 21 patients had stage IV disease, 55 – III B. According to the histological structure, differentiated forms of squamous cell carcinoma prevailed — 64 (84.2%) patients, 1 patient had adenocarcinoma, and 11 (14.5%) had various forms
poorly differentiated lung cancer. Intraoperative revision to establish the operability of the patient included partial or complete separation of the lung from adhesions, mediastino- and pericardotomy in 64 (84.8%), diaphragmotomy in 9 (11.8%), in 3 (3.9%) patients intracardiac revision of the right atrium and vena cava. The operative blood loss was 0.75 ± 0.048 l, V = 8.72%. The reasons for the inoperability were the spread of the tumor to extrapulmonary structures and organs of the thoracic cavity in 55 (70.5%) patients. Of these, 14 have germination of the trunk of the pulmonary artery, 15 are hollow veins, 11 are aortic, 8 are trachea,
7 —heart. 15 patients were diagnosed with pleuroma carcinomatosis, in 6 patients metastasis to the liver. In the postoperative period, 7 patients died (9.2%). Of these, 3 died from the progression of the underlying disease, 4 patients from various purulent-infectious complications that developed in the postoperative period. Of these, the immediate cause of death in 2 patients was pulmonary embolism, in 2 patients progressive cardiopulmonary insufficiency was progressive. All patients died in the long-term postoperative period — 5– day. The average life expectancy after surgery was 13.7 ± 4.9 days,
V = 95.2%. The fate of 65 out of 69 discharged patients (94.2%) was studied. The vast majority of patients died during the first year after surgery. Only two patients survived this period. The maximum lifespan was 14 months. The average life expectancy of patients after trial thoracotomy, discharged from the clinic, was 7.5 ± 0.34 months, V = 36.9%.
Thus, a trial thoracotomy is a complex and traumatic surgical intervention, accompanied by significant blood loss and relatively high postoperative mortality. However, a comparison of the life expectancy of patients who underwent trial thoracotomy with the average life expectancy of 50 patients who for various reasons were denied surgical intervention showed that the operation in patients who successfully underwent the postoperative period and were discharged from the clinic did not reduce the life expectancy compared with patients control group. Thus, the average life expectancy of 50 non-operated patients was 8.3 ± 0.47 months, V = 40.1% (t = 1.4, p> 0.05).
Considering that in some cases the intraoperative revision is the only way to finally decide on the true extent and nature of the local prevalence of the tumor process and assess the patient’s operability, we believe that performing a test thoracotomy today is, although necessary, but quite justifiable for diagnosing prevalence lung cancer in advanced stages of the disease.