The Lewis Operation in the System of Esophageal Cancer Treatment

The research is dedicated to the analysis and improvement of the Lewis operation as a key surgical method for treating cancer of the thoracic esophagus. The work examines the evolution of principles of cancer surgery, the technique of performing esophagectomy with the transposition of a gastric transplant into the right pleural cavity, and a comprehensive assessment of intra- and postoperative complications, motor-evacuation disorders, and late functional results. Special attention is given to substantiating the indications for the operation, ensuring oncological radicality of lymphadenectomy, and optimizing technical techniques aimed at increasing patient survival and quality of life.

The dissertation contains scientific novelty in considering the surgical, oncological, and functional aspects of the Lewis operation as a whole, starting from the justification of the technique and ending with the late results. The practical value of the work lies in substantiating the indications for the operation and implementing improved technical techniques that allow reducing the frequency of complications and mortality, as well as increasing 5-year survival and ensuring a good quality of life for patients.

Relevance of the topic. Treatment of esophageal cancer represents a complex surgical and oncological problem, remaining especially relevant for the regions of the Volga-Caspian basin of Russia (Astrakhan Oblast, Kalmykia) and Kazakhstan (Atyrau Oblast), where the morbidity rate reaches 17.3 per 100 OO population [8,20,33,42,82,69].

The main method of radical treatment for patients with esophageal cancer is surgical intervention, requiring a high level of surgical technique and anesthesia support and characterized by a complex recovery period.

For cancer of the thoracic esophagus, the majority of surgical centers both in Russia and abroad consider esophagectomy with one-time esophagoplasty using a gastric transplant as the method of choice [20, 24, 26, 37, 46, 50, 56, 57, 61, 70, 73, 91, 94, 103, 108, 111, 114, 115, 125, 130, 156, 172, 185, 198] . Over the past decades, the technique of these interventions has been substantially improved, and the number of complications and mortality has decreased by 2–3 times.

According to the opinion of most authors, the basic principles regarding these operations are as follows:

• such interventions should be performed in specialized departments;

• the reliability of anastomosis should not contradict oncological radicality (i.e., the volume of esophagectomy should be total or subtotal);

• the operation must be accompanied by celiac, mediastinal, and cervical lymphadenectomy [19, 25, 26, 29, 46, 56, 60, 62, 67, 76, 85, 98, 103, 108, 112, 127, 149, 156, 157, 169, 184, 193, 208] . It should be noted that there are certain disagreements among authors regarding the choice of a rational surgical approach, i.e., between supporters of transthoracic and cervico-abdominal esophagectomy. Thus, Prof. A.F. Chernousov with co-authors (1990, 1997, 2003), who have been working for many years on improving cervico-abdominal esophagectomy with plasticization of a narrow gastric stem and have achieved a reduction in mortality in these operations to 1.4%, propose to expand the indications for their use (including, for advanced cancer). A number of authors question the expediency of performing such a type of intervention in oncological patients. Academician M.I. Davydov (1993, 2006), Prof. P. Lozack'h (1992, 1997), are supporters of intrathoracic esophagoplasty, mortality in which, according to their data, ranges from 1.5% to 4.7%. In their opinion, only this type of intervention can ensure the radicality of resection and lymphadenectomy at stage III of the tumor.

First performed in 1946 by English surgeon I. Lewis and improved over the second half of the 20th century by European surgeons, the transthoracic esophagectomy with transposition of the stomach into the right pleural cavity has occupied one of the main places in modern esophageal surgery.

With the development of esophageal surgery, anesthesiology, and oncology, the central aspects of studying this intervention have shifted from preventing esophagogastric anastomotic insufficiency and postoperative pneumonias to 5-year survival with ensuring "digestive comfort" - i.e., they have passed the path from postoperative complications of the Lewis operation to its rehabilitation aspects, a number of which require additional study. The question of the influence of the shape and size of the transplant on the safety of the early postoperative period and quality of life in the late terms remains unresolved. There is no unified concept regarding the patterns of development of motor-evacuation disorders of the transposed stomach, the occurrence of gastroparesis, dumping syndrome, reflux esophagitis [9, 31, 32, 52, 54, 74, 78, 83, 92, 93, 126, 133, 136, 148, 179, 202, 207] - in the available literature, a comprehensive clinical and morphofunctional assessment of the state of the gastric transplant in the Lewis operation is absent. The opinion on the expediency of unloading the intrathoracic stomach using pyloromyotomy remains contradictory [104, 152, 153, 161, 163, 169]. The acid-producing function and microbial colonization of the gastric transplant have not been studied in terms of their influence on the occurrence of anastomositis, gastritis, erosions, and ulcers. In addition, to this day, the role of preoperative and postoperative radiation and chemotherapy in this category of patients is evaluated ambiguously.

Thus, the experience accumulated in this complex section of surgery and oncology determines the necessity of conducting a scientifically grounded comprehensive assessment of the surgical, oncological, functional, and rehabilitation aspects of the Lewis operation in the modern system of treatment for patients with esophageal cancer.

Goal of the research:

Improvement of the early and late results of surgical treatment for patients with esophageal cancer by refining the methodological and technical aspects of the Lewis operation.

Tasks of the research:

1. Determine the indications and assess the oncological adequacy of the Lewis operation at various stages of cancer of the thoracic esophagus.

2. Provide a characterization of the most significant intra- and postoperative complications of the Lewis operation and evaluate the tactical and technical possibilities of their prevention.

3. Study the dynamics of early motor-evacuation disorders developing in the Lewis operation.

4. Assess the significance of various manifestations of "diseased operated esophagus" in the Lewis operation and study its late functional results.

5. Conduct an assessment of the late results of the applied methods in surgical and combined treatment of esophageal cancer, studying survival and quality of life.

Scientific novelty

• For the first time, the surgical, oncological, and functional aspects of the Lewis operation in the system of treatment for patients with esophageal cancer are considered as a whole, starting from the justification of the technique and ending with the late functional results.

• Scientific justification is provided for the improvement of technical techniques of esophagectomy with one-time gastric plasty, aimed at preventing motor-evacuation functional disorders and diseases of the artificial esophagus.

• The advantages of using a "tubulized" stomach as a gastric transplant in combination with pyloromyotomy are demonstrated.

Practical value of the work

A substantiated choice of indications for the Lewis operation in patients with cancer of the thoracic esophagus and its performance based on the universal principles of surgical oncology, using a number of improved technical techniques, allow reducing the frequency of esophagogastric anastomotic insufficiency from 8% to 3.2%, postoperative mortality from 12.9% to 6.3%, increasing 5-year survival by 18.1%, and ensuring a good quality of life in 86% of patients.

Main provisions submitted for defense:

• The application of the Lewis operation technique in cancer of the thoracic esophagus stage III allows performing a two-zone lymphadenectomy with the formation of a reliable esophagogastric anastomosis and ensures good immediate and late functional results.

• Intrathoracic esophagoplasty with a "tubulized" stomach, supplemented by partial pyloromyotomy, has advantages in terms of preventing motor-evacuation functional disorders.

• During the formation of the gastric transplant when the tumor is localized in the lower thoracic esophagus, resection of the cardia and subcardia with a small curvature of the stomach is indicated.

Implementation of the results of the work into practice

The results of the work have been implemented in the surgical thoracic departments of the Alexandro-Mariinsky Regional Clinical Hospital and the Regional Oncological Dispensary of Astrakhan. The materials of the work are used in the training of students, clinical residents, and cadets of the postgraduate education faculty of AGMA.

Review of the work

The main provisions of the dissertation were reported at the Russian scientific-practical conference "Thoracic Oncology" (Krasnodar, 2004), a meeting of the Astrakhan Regional Scientific Society of Surgeons (2005), the final scientific session of the Astrakhan Medical Academy (2005), at the All-Russian Conference of Surgeons in Astrakhan (2006), a congress of surgeons of the Southern Federal District (Rostov-on-Don, 2007), at an interdepartmental meeting of departments of general, hospital, faculty surgery, oncology, surgical diseases with an endoscopy course, postgraduate education faculty, and the department of surgical diseases of the pediatric faculty (2007).

Publications

15 scientific works have been published on the topic of the dissertation, including in the journal "Thoracic and Cardiovascular Surgery" - 3, in "Kazan Medical Journal" - 1.

Volume and structure of the work

The dissertation is presented on 124 pages of computer text, consisting of an introduction, a literature review, two sections of own research, conclusion, conclusions, and practical recommendations. The work contains 24 tables, illustrated with 16 figures and copies of X-rayograms, extracts from two case histories.