Removing the superior vena cava for lung cancer

Resection of the superior vena cava in lung cancer is performed with the right-sided location of the tumor, most often, with its localization in the upper lobe. The lesion of the superior vena cava can be caused both by the germination of its primary tumor, and, which is observed more often, by metastases to paravenous lymph nodes. At the same time, as a rule, there is extensive metastasis to the lymph nodes of the mediastinum, multiple blastomatous lesions of various extrapulmonary anatomical structures and organs of the thoracic cavity.

In the clinic, resection of the superior vena cava was performed in 51 patients, which accounted for 12.0% among patients who underwent resection of the vascular-atrial type and 8.4% among all operated on patients who underwent combined operations.

The establishment of a tumor lesion of the superior vena cava is often crucial in determining the operability of the patient. In such a situation, it is necessary to solve the problem: abandon the operation or undertake resection of the superior vena cava. The initial period of the clinic in such cases was looking for a way out in a wide resection of the superior vena cava, and using vascular prostheses for plastic surgery. The unsatisfactory results obtained in this case determined the need to search for new technical approaches. The experience of the clinic in this direction, the analysis of failures of surgical treatment allow a more restrained approach to the use of vascular prostheses and the use of reconstructive interventions on the superior vena cava with their help.

The study of the nature and characteristics of paracancic inflammatory changes associated with the development of a tumor and its lymph node metastases showed that in most patients with an expected widespread lesion of the superior vena cava tumor, true germination is much smaller in length. Detailed dissection of the vein wall can most often be distinguished from

paracrocranial changes in the surrounding tissues, to clarify and localize the border of tumor growth. Reliable and accurate information about the true germination of the vessel wall by a tumor can be obtained by intracardiac finger revision of the right atrium and vena cava.

With limited germination of the tumor in the wall of the superior vena cava, if it does not cause significant narrowing and central hemodynamic disturbances, it is possible to perform marginal resection of the vessel using hardware mechanical or manual suture.

In cases where it is impossible to perform marginal resection, it is advisable to resect a portion of the vessel wall with subsequent plastic repair of the resulting defect. The clinic uses plastic with an autopericardium using an internal shunt of the superior vena cava.

Performing resection of the wall of the superior vena cava is preceded by her intracardiac digital revision through access in the ear of the right atrium according to the technique developed in the clinic. After the end of the revision, a venous shunt is inserted through the same access into the right atrium and then into the superior vena cava before its bifurcation. The purse-string suture, placed on the ear auricle, is tightened, above and below the site of the intended resection of the vessel wall, turnstiles are tightened and tightened (Fig. 43). Then proceed to resection of the affected area of ​​the superior vena cava and plastic surgery of the resulting defect by the autopericardium section using a manual vascular suture. After its completion, the turnstiles are dismissed and the tightness of the seams is checked. This stage of surgical intervention is completed by removing a shunt from the superior vena cava and right atrium and suturing the ear with a double suture. In total, resection of the area of ​​the superior vena cava with plasty with its autopericardium was performed in 12 patients.

The analysis of the clinical observations available at our disposal allows us to conclude that it is possible to establish the true dimensions of the tumor lesion of the superior vena cava only in the process of careful detailed preparation of the vessel wall and the use of special methods of intraoperative revision. Only such an approach allows to reasonably solve the issue of indications for its resection. The indication for resection of the superior vena cava with its subsequent grafting is the presence of vessel invasion by a tumor, the dimensions of which do not exceed one third of its circumference and 2– cm in length. The larger size of the tumor lesion, as a rule, testifies to the neglect of the blastomatous process and the extensive multiple lesions of other anatomical structures and organs of the thoracic cavity, cast doubt on the oncological validity of the surgical procedure and significantly increase its risk.

Blastomatous lesion of the pulmonary artery and the need to perform its resection equally often occur in both right- and left-sided thoracotomies, mostly with tumor localization in the upper lobes of the lungs. Germination of a pulmonary artery by a tumor indicates neglect of the blastomatous process and is almost always accompanied by multiple lesions of various extrapulmonary structures and organs of the thoracic cavity.

A pulmonary artery resection in the clinic was undertaken in 40 patients, which was 6.4% among all operated patients undergoing combined operations and 9.2% among patients who underwent vascular-atrial resection. At the same time, more than half of the patients, 14 out of 24, with lesions of the left lung, had marginal resections of the pulmonary artery stem.

The most difficult and crucial stage in the implementation of the resection of the pulmonary artery, which was already mentioned earlier, is its isolation and evaluation of the indications for the intervention. Unlike vessels of the great circle of blood circulation,

pulmonary arteries have a number of features that make manipulations with them a very responsible and dangerous stage of surgery. This is, above all, the fragility of the pulmonary arteries, the walls of which contain a very small amount of elastic fibers. Damage to the arterial wall as a result of its rupture is always associated with the risk of its spreading to the pulmonary artery stem and the development of massive, sometimes fatal bleeding. Bleeding from a vessel directly flowing into the heart leads to severe cardiac hemodynamic disturbances much faster with the development of acute coronary insufficiency and cardiac arrest than with equally abundant bleeding from peripheral vessels. With the defeat of a pulmonary tumor tissue, the risk of damage to the vessel increases sharply.

When resection of the pulmonary artery in the immediate vicinity of the common trunk or with a portion of its side wall, both the mechanical hardware suture and the flashing of the artery wall with a manual vascular suture are used. A prerequisite before performing a resection of the pulmonary artery is a preliminary temporary clamping of the vessel at the site of the intended resection in order to determine the patency of the common trunk of the pulmonary artery.

Extremely unfavorable factor significantly affecting the determination of the patient’s operability is the detection of tumor lesion of the aortic wall during surgery. It occurs mainly in the left-sided localization of the primary lung tumor. Germination by the tumor tissue of the ascending part of the aorta in cancer of the right lung is much less common and, in our opinion, is a sign of the patient’s inoperability. The clinic has no experience with such operations.

The resection of the aorta wall section was performed only with left-sided thoracotomy, almost equally often when the primary tumor is located in both the upper and lower lobes of the lung. At the same time, tumor lesions of various extrapulmonary anatomical structures and organs of the thoracic cavity were predominantly multiple. Aortic resection in the clinic was performed in 34 patients, which accounted for 5.6% of the total number of patients, and 8% of the number of patients who underwent resection of the vascular-atrial type.

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