Enhanced combined resections of the mediastinal-esophageal type include extensive subtotal resections of the mediastinal pleura, usually with resection of fragments of the large nerve trunks of the mediastinum (diaphragmatic, vagus nerves), esophagus.
Among the 605 combined operations, resection of this type was performed in the clinic in 230 cases, which was 38%. Only in 67 (29.1%) patients with resection
were single. In the majority, 163 patients (70.9%), they were multiple in nature and, as a rule, were combined, that is, they included several resections of various types. Of the 230 patients who underwent mediastinal-esophageal type resections, 209 (90.9%) had pneumonectomies and 21 (9.1%) had partial lung resections.
Extensive resections of the mediastinal pleura with areas of the mediastinal nerve trunks are the most common type of resection of the mediastinal-esophageal type.
Indications for resection of the mediastinal pleura with fragments of the phrenic and vagus nerves occur during central tumor localization in the lung, especially during paravasal and peribronchial growth, metastasis to the root and prepericardial groups of lymph nodes, and during the transition of the tumor process to the diaphragm in front of the lung root, the diaphragm of the lymph nodes passes. and behind, vagus nerves. In case of left-sided tumor localization in cases of metastases in the aortic window lymph nodes, the recurrent laryngeal nerve is often involved in the tumor process . If, during surgery, mediastinal lymphadenectomy is not possible to isolate it from the tumor tissue, it is resected.
After completion of the operation, there remains a significant defect in the mediastinal pleura, which, if possible, should be closed with a parietal pleura flap on a broad base, located at the spine. This is necessary for the separation of the pleural cavity and shelter bronchus stump in the mediastinum.
Resection of the wall section of the esophagus with its tumor lesion is performed much less frequently. In the clinic, it was performed on 58 patients, which amounted to 9.6% in relation to the total number of all patients undergoing combined operations and 25.2% of the number of patients who underwent resection of the mediastinal-esophageal type.
Indications for resection of the esophagus wall section can occur during operations on both sides. At the same time, tumor germination in the esophagus wall is observed mainly at the border of the upper and middle third, as well as the middle third of the esophagus, which corresponds to the level of the fourth to seventh thoracic vertebrae. The defeat of the lower third of the thoracic esophagus is much less common.
Resection of the muscular layer of the esophagus wall is carried out in the absence of tumor germination in its lumen. The length of such resections can reach 7 – cm in length and up to half the circumference of the esophagus. The resulting defect is easily closed knotted seams. The peculiarities of the blood supply to the various layers of the esophagus wall determine, with an intact mucosa, good healing of such extensive defects of its muscular part. If suturing the muscle wall of the esophagus wall causes a significant narrowing of its lumen, then it can be not sutured, and the resulting defect can be closed with a parietal or mediastinal pleura flap on the pedicle.
In cases when, during resection of the muscular membrane of the esophageal wall, its lumen is opened, the resulting defect must be sutured in layers by double-row interrupted sutures. Suturing only the mucous membrane, as a rule, leads to the development of insolvency seams.