Clinical and Functional Substantiation of Economical and Bronchoplastic Lung Operations in Elderly and Senile Patients

The dissertation is devoted to the substantiation of the application of economical and bronchoplastic lung resections in elderly and senile patients with limited functional reserves. The work examines the diagnostics of functional disorders of the cardiovascular and respiratory systems, as well as the influence of comorbidity on the rate and character of postoperative complications. The study aims to identify the criteria that determine the course of the early postoperative period and the long-term results of surgical treatment of lung neoplasms. Particular attention is given to the comparative evaluation of the immediate and long-term results of standard and organ-preserving operations using the EORTC QLQ-C30-LC13 quality of life questionnaire. The data obtained make it possible to recommend economical and bronchoplastic resections as a promising method of treatment for this category of patients.

RELEVANCE OF THE PROBLEM

In connection with the increase in the overall life expectancy of the population, the number of elderly and senile patients with lung neoplasms has grown. Providing surgical care to this category of patients is a complex task, since the presence of comorbidity and low functional parameters worsens the treatment prognosis. Diagnostics of the severity and character of functional disorders resulting from the underlying and concomitant pathology, as well as age-related changes in organs and systems, make it possible to determine the tactics of surgical treatment and to predict intraoperative and postoperative complications. The dependence of the complication rate on the age of patients has been noted by many authors [Trakhtenberg A.Kh. et al., 1998; Santambrolio L. et al., 1996; Van Meerbeeck J.P. et al., 2002; Cook D.J., Rooke G.A., 2003]. However, age itself does not influence the outcome of treatment; a higher probability of complications is associated with the character of concomitant diseases. Age-related changes occurring in the respiratory system are characterized by changes in the bony structures and muscular mass of the chest, airways, lung parenchyma, and the vascular system of the pulmonary circulation, and also affect the complication rate.

The aspiration to preserve functionally adequate lung tissue in elderly and senile patients has led to the application of economical atypical resections and segmentectomies in early stages of lung cancer [Kotlyarov E.V. et al., 1990; Biryukov Yu.V. et al., 1991; Dobrovol'skii S.R. et al., 1991; Dominioni L. et al., 2000; Smythe W.R., 2001; Yamamoto K. et al., 2003]. The radical nature of atypical resections is questioned by many authors [Korolev B.A. et al., 1982; Pirogov A.I. et al., 1986]. Kharchenko V.P. et al. (1998) consider typical segmentectomy with removal of regional lymph nodes of the lobe and lung root followed by a course of radiation therapy as an alternative to atypical resection. According to the author, the five-year survival after such combined treatment amounted to 70.5%.

D.J. Sugarbaker et al. (2000) carried out an analysis of survival in early stages of lung cancer. The results indicate that the rate of recurrences and metastases was higher after segmental resections. In the second group of 244 patients, the results of segmental resections at stage IA were worse than the results of lobectomy at stage IB.

The aspiration toward organ-preserving operations in central lung tumors has led to the rapid development of bronchoplastic surgery for lung cancer [Petrovskii B.V., Perel'man M.I. et al., 1978; Chissov V.I., Trakhtenberg A.Kh. et al., 1990; Kharchenko V.P. et al., 1994; Mathisen D.J., Grillo H.C., 1991; Watanabe Y. et al., 2000]. The main significance of bronchial resection consists in the fact that it allows expanding the indications for lobectomy and performing it in cases where partial lung removal is impossible or non-radical without reconstruction of the airways. According to data of many authors, lobectomy with resection and plasty of the bronchi is not inferior to pneumonectomy in terms of radical nature [Petrovskii B.V., Perel'man M.I. et al., 1978; Chissov V.I., Trakhtenberg A.Kh. et al., 1990; Kharchenko V.P. et al., 1994; Bisenkov L.N. et al., 1998].

Much attention is paid to the surgical treatment of lung cancer in elderly and senile patients, since lung cancer is predominantly a disease of elderly age. Given the age-related changes in the bronchopulmonary system and concomitant diseases, this category of patients demonstrates a high rate of intraoperative and postoperative complications, higher mortality, and a worse prognosis. Adamyan A.A. et al. (1985) consider chronic ischemic heart disease, external respiratory function insufficiency, and the duration and extent of the operation to be the most important risk factors for complications after lung operations. According to Sokolov E.A. (1979), postoperative complications in elderly patients occur in 45.9% of cases, the main ones being tracheobronchial obstructions, pneumonias, cardiac rhythm disturbances, and pulmonary-cardiac insufficiency. Postoperative mortality amounts to 8.1% and increases with age. Similar data are presented by Shulutko M.L. et al. (1986).

Thorough preoperative preparation, correction of pathological changes in vital organs and systems, and reduction of the extent of surgical intervention constitute the main methods of decreasing postoperative complications and mortality. Thus, the development of new algorithms for determining the functional status and reserves of vital organs and systems of a patient appears highly relevant.

OBJECTIVE OF THE STUDY

The objective of the present study is to improve the immediate and long-term results of surgical treatment of lung cancer in elderly and senile patients with limited functional reserves.

TASKS OF THE STUDY

1. To determine the specific features of the influence of reduced functional reserves of the cardiovascular and respiratory systems and concomitant diseases in elderly and senile patients on the rate and character of postoperative complications depending on the extent of the performed operation.

2. To identify the most significant criteria influencing the course of the early postoperative period, mortality, and long-term results of surgical treatment of patients with lung neoplasms.

3. To substantiate the expediency of economical and bronchoplastic lung resections in elderly and senile patients, especially in cases of reduced functional reserves.

4. To compare the immediate and long-term results of surgical treatment of lung cancer after standard operations in the general group of patients and after economical and bronchoplastic lung resections.

MAIN PROPOSITIONS DEFENDED

1. The most severe early postoperative complications in elderly and senile patients, both with reduced parameters of the circulatory system and with respiratory system disorders, are complications of the cardiovascular system.

2. The most unfavorable prognostic factors influencing the results of surgical treatment of lung cancer are pulmonary arterial hypertension and obstructive disorders of the ventilatory function of the lungs.

3. A promising method of surgical treatment of lung cancer in elderly and senile patients with limited functional reserves is the performance of economical lung resections. These operations do not contradict the principles of oncological radicalism, since they are performed with observance of the broncho-, angio-, and lymphoarchitectonics of the lung.

4. The early and long-term results after economical and bronchoplastic lung resections are better than after standard surgical interventions, due to the preservation of functionally adequate lung tissue.

SCIENTIFIC NOVELTY

For the first time in clinical practice, an analysis of early postoperative complications by categories has been carried out depending on the functional state of a given system.

For the first time in clinical practice, a comparative analysis has been performed and reliable differences have been established in the long-term results of surgical treatment of lung cancer according to the assessment of the quality of life using the questionnaire of the European Organisation for Research and Treatment of Cancer EORTC QLQ-C30-LC13 in patients after standard interventions and in patients with limited functional reserves after economical lung resections.

PRACTICAL SIGNIFICANCE

The possibility of predicting and preventing early postoperative complications has been determined depending on the results of preoperative examination of the patient (reduced parameters of the respiratory and circulatory systems).

The wide application of economical and bronchoplastic lung resections made it possible to improve the early and long-term results of treatment of patients with a low functional status.

IMPLEMENTATION OF STUDY RESULTS

The results and proposals of the completed work have been implemented in the practice of the thoracic department of the Saratov Regional Clinical Hospital and are also used in the educational process of the departments of surgery of the Faculty of Advanced Training and Professional Retraining of Specialists, faculty surgery of the therapeutic faculty, and operative surgery and topographic anatomy of the Saratov State Medical University.

APPROBATION OF THE WORK

The main propositions and fragments of the work were reported at:

- the jubilee conference dedicated to the 80th anniversary of the birth of Professor K.I. Myshkin (Saratov, 2001);

- the third Russian Scientific Forum "Surgery 2001" (Moscow, 2001);

- the regional scientific-practical conference of surgical profile physicians of the Kabardino-Balkarian Republic (Nal'chik, 2002);

- the conference of young scientists of the Saratov State Medical University (Saratov, 2004);

- the meeting of the scientific-practical society of surgeons of the city of Saratov, 2006.

PUBLICATIONS

Five printed works have been published on the topic of the dissertation. Two certificates for rationalization proposals No. 2639 of 18.02.05 and No. 2657 of 01.06.05 have been obtained.

STRUCTURE AND VOLUME OF THE DISSERTATION

The dissertation consists of an introduction, a literature review, three chapters of original research, a conclusion, findings, practical recommendations, and a bibliographic list.