What is Cardia
Cardia occurs in malignant tumors of the gastric cardia. Cardia is in the strict sense refers to the area where the cardia gland, visual observation is difficult to judge the scope of the region, especially pathological state, this region is often damaged, difficult to judge. Therefore, most clinical surgeon stomach the esophageal junction Ministry upper and lower range of about 2cm called cardiac region. 1998 International Gastric Cancer Association (Intemational Gastric Carcinoma Association, IG-CA) and the International esophageal disease the Society (Intcrnalional Society for Disease of the Esophagus, IS-DE) United cardia made tomorrow
Symptoms of Cardia
Progressive dysphagia symptoms mainly of the cardia, the cardia of symptoms and may have vomiting, pain, weight loss and other manifestations.
(1) The general classification
1) early cardia eye typing:
① depressed: mucosal lesion depression, erosion, occasionally visible superficial ulceration is not obvious and normal tissue boundaries.
(2) elevated type: lesion mucosa slightly irregular uplift the cardia performance surface is rough, granular, touch the hard occasional formation of nodules or polypoid projections.
③ flat: lesion except for slightly rough, usually naked eye no abnormal findings slice lesion thickness similar to normal mucosa, the nature and location of the lesions, can only be confirmed under the microscope.
2), advanced cardiac naked eye typing:
① the cauliflower type: the tumor was nodular, cauliflower-like or polypoid, protruding into the lumen, often the edge of the rules, moth-eaten occasionally ulceration.
(2) the ulcers Type: tumor diameter is generally less than 5cm in, deep in the ulcer, clear boundary from the high.
③ infiltrating ulcer type: tumor ulceration with unclear boundaries surrounding mucosa, the cardia symptoms showed infiltrative growth. Wide range of infiltration, generally more than 5cm in diameter.
④ infiltrative type: cancer to diffuse infiltration cardia District stomach wall layer, leading to the obvious thickening of the stomach wall, visible on the surface erosion, usually no ulcer formation, or only superficial ulceration.
(2) The type of organization
① cardia adenocarcinoma: gastric adenocarcinoma of the cardia adenocarcinoma and other parts of the same, and varying degrees of differentiation from well-differentiated to poorly differentiated adenocarcinoma. The majority of which highly differentiated adenocarcinoma, glandular structure, cells with low columnar or cuboidal nuclear neat, and often accompanied by mucus secretion and mucus adenocarcinoma. Cardia in patients with common part of the region for well-differentiated adenocarcinoma, while other regions are manifested as mucinous adenocarcinoma. Some mucus secretion much like form mucus Lake. Scattered smaller nuclear stained cells, forming small glandular Cancer pulp filled with mucus, while nuclear diffuse infiltration into the side of a crescent-signet ring cell carcinoma. Mucus histochemical staining, some mucus was neutral, and some acidic sulfate mucus positive.
② squamous cell carcinoma of the cardia: cardia squamous cell carcinoma is very rare, and the need to exclude esophageal squamous cell carcinoma cardia violated wall itself but not squamous cell boundary line following your door population at occurrence of squamous cell carcinoma can be identified only fresh primary in the cardia squamous cell carcinoma, and its source may be congenital esophageal squamous remnants.
③ cardia carcinoid: cardia carcinoid is rare, but has also been reported, probably from the gastric mucosa of Kult-Chitsky cells, such cells increased in intestinal metaplasia time, small cells, round or polygonal form solid clumps or cords. Cancer the argyrophilic rather than pro-silver, occasionally forming glandular-like structure and intracellular mucus droplets. The carcinoid slower growth, infiltration and shallow, hair, Feng transfer. Carcinoid tumor may be any kind of endocrine cells of the gastric mucosa occurred. Variety of secretory products, such as 5-HT, epinephrine, norepinephrine, VIP, PP and Peptide YY such.
(4) atypical carcinoid: a significant endocrine differentiation characteristics (morphology on cell morphology and beam-like, flower ring structure; and ultrastructural observation be seen how the amount of high-density core particles endocrine; Immunohistochemical examination showed neural enolase positive), but the morphology was atypical. The cardia prognosis is worse than ordinary (typical) carcinoid than adenocarcinoma good. Some atypical carcinoid associated adenocarcinoma.
⑤ cardia lymphoma: seldom see.
⑥ cardia undifferentiated carcinoma: rare cancer is small, mostly round, irregular or elongated, less cytoplasm, similar to the oat cell carcinoma of the lung.
What Causes Cardia
Tests and Diagnosis for Cardia
(A) a history of collecting points
Varying degrees and types of swallowing symptoms. The cardia cancer diagnosis including swallowing, choking feeling, pain when swallowing, chest pain swelling, nausea discomfort and foreign body sensation in swallowing. At the same time, there may be abdominal discomfort, vomiting and weight loss.
2 of the above symptoms occur gradually increased over the course of the evolution.
The cardia check supraclavicular lymph nodes, hoarseness, cough, and hemoptysis phenomenon, severe jaundice, ascites, coma may be associated with.
Cardia cancer patients with a history of chronic cough, constipation, chest and abdomen surgery, trauma history and family history.
(B) physical examination points
1. General development, nutrition, body weight, mental, blood pressure and pulse.
Local cardia early local signs obvious in patients with advanced palpable left abdominal mass. Note mass texture, size, activity.
3. Systemic check-
The cardia of systemic physical examination of the more important. ① left supraclavicular lymph node enlargement, systemic subcutaneous whether there nodule. Whether ② abdominal palpable mass, jaundice, ascites, bloody ascites, palpable rectal examination. (3) whether the senile chronic bronchitis and emphysema signs, with or without signs of circulatory system.
(3) Auxiliary Checkpoints
1. Laboratory examination (1) Urine routine: Early no obvious abnormalities, anemia, leukocytosis performance advanced with obstruction symptoms get worse and distant metastases occurred. ② blood biochemistry: disorders of water, electrolyte and acid-base balance.
2.X-ray examination of the chest and abdominal plain film observed such as the lungs, heart, diaphragm, mediastinal, and to observe the size and shape of the stomach bubble, with or without soft tissue mass observed cardiac region.
3. Cardia balloon cytology cell samples taken off direct smear by Air Papanicolaou staining, the Census and found that one of the important methods of cardia cancer diagnosis. Positioning of early lesions can be segmented pull the network to determine.
(D) further inspection items
Esophagogastric barium swallow
The barium swallow esophagogastric contrast to show the extent of the tumor. Cardia early symptoms of mucosal changes of normal morphology, advanced performance filling defect, stricture and obstruction Kanying and cardia.
CT examination can clearly show whether the cardia cardia zone wall thickening, luminal mass range, mass violations of the gastric fundus, the cardia cancer examination revealed carcinoid tumor of the size, location, and violations of the scope of the stomach, cancer outward expansion of the degree of infringement, invasion and adjacent organs. And lymph node enlargement. Estimated surgical resection may provide a reference.
Endoscopy for cardiac cancer diagnosis is very important. In addition to determining the lesions can also understand the scope of the lesion, the degree of lumen blockage and fixed with the surrounding tissue. But the rate of misdiagnosis early cardia. O.5% methylene blue or l% indigocarmine and conduct certain dyeing auxiliary role.
Endoscopic Ultrasonography Endoscopic ultrasonography (EUS) cardia preoperative clinical treatment choice, the determination of the surgical approach and prognostic assessment with the reference value of the diagnosis of the cardia.
5. Magnetic resonance imaging (MRI) MRI found some difficulties early cardia, except cardia general for infringement or determine lymph node metastasis.
6.PET check in tracking distant metastasis and lymph node metastasis, PET is superior to general cardia cancer diagnosis, but PET can not determine the thickness of the tumor invasion.
. Achalasia patients younger and more common in women. Although dysphagia, but non-sexual, emotional changes and intermittent, longer duration, progress has been slow. X-ray examination showed a narrow esophagus great expansion of the funnel-shaped barium through the cardia stricture may be due to the injection of atropine or inhaled amyl nitrate release.
Esophageal diverticulum often dysphagia, chest pain and other symptoms, but there is little difficulty in swallowing barium meal examination, cardia is not difficult to identify.
3. Esophagus or cardia common benign tumor of esophageal leiomyoma. Longer duration, mild symptoms. X-ray examination semilunar notch, endoscopic examination showed a smooth surface of the tumor, mucous membranes without damage.
4 external pressure esophageal obstruction esophageal due to ectopic organs and mediastinal primary or metastatic tumor compression caused dysphagia. External pressure dysphagia saw the shift esophageal mucosa destruction. Except malignancy symptoms and the rapid development of the external pressure, the the other esophageal pressure caused dysphagia slow progress.
Esophagitis of the disease clinical manifestations may be similar with early esophageal cancer, cytology See esophageal epithelial cell of moderate hyperplasia or inflammation change.
6. The functional dysphagia such cardia patient complained often esophageal foreign body sensation, blocking flu, poor swallowing, or dysphagia, such as myasthenia gravis patients can have this performance, there is no positive findings of esophagoscopy and cytology. No abnormal esophageal barium swallow.
Benign esophageal strictures are often the sequelae of the esophagus burns or chemical burns, can be traced to swallow a history of strong acids or bases. This scar stenosis may be cancerous.
Treatments of Cardia
(A) The principle of treatment
Cardia treatment options based on the history of the lesion, the tumor extended range and patients general condition. The main principles of treatment based on a comprehensive treatment of the surgical treatment, the cardia cancer treatment including radiotherapy, chemotherapy, Chinese medicine treatment, immunotherapy and laser, stenting, etc.. It should be the preferred surgical treatment, GCA is not sensitive to radiotherapy, should choose surgical resection is appropriate.
(B) the preoperative preparation
Strengthen nutrition, given the high-fat, high-protein diet. Correcting water, electrolyte and acid-base balance disorders.
Help cardia cancer patients to increase activity levels in order to enhance the physical, exercises in bed to urinate and effective cough. Recent acute respiratory infection shall be subject to a formal anti-inflammatory treatment.
3. Strengthen brush our teeth, to pay attention to oral health.
4. Obstruction severe cases, three days before the surgery, the evening before going to sleep with catheter flushing esophagus.
5, one day before surgery to prepare the skin.
6. Evening before surgery enema given sleeping pills. Surgery on the morning of indwelling stomach tube, the preoperative injection drug.
7 Prepare colon colon preparation should be carried out on behalf of the esophagus, the cardia cancer treatment: three days before surgery to a semi-liquid diet, the preoperative liquid food. Surgery three days before the date of oral streptomycin 0.5 g metronidazole 0.4g, 3 times a day, while giving the Vit K. Ready to gut a fast method for: Preoperative l day liquid food, night and day of surgery morning Cleaner enema 1, one day before the afternoon l, 3,5,7 o'clock each serving neomycin 1g and Metronidazole 0.4g.
Control of other complicating diseases, such as coronary heart disease, hypertension, bradycardia.
1. Surgical treatment
(1) The indications for surgery: where the tumor Ⅲ of the following, no distant metastasis or other contraindications, surgery should be carried out
(2) the timing of surgery: gastric cardia deadline surgery, patients after diagnosis; should actively preoperative ready as soon as the surgery.
(3) surgical approach: cardia surgical approach used transthoracic incision through the abdomen and the chest and abdomen.
① simple the transthoracic approach applies to early or localized gastric cardia. 7th rib bed or 7th intercostal into the chest. Exposed esophagectomy length, sweeping intrathoracic metastatic lymph nodes, anastomosis convenient advantages, the traditional cardia approach.
⑦ simple transabdominal approach applies to early or localized gastric cardia, or the elderly and the poor cardiopulmonary function cardia cancer patients. With less wound bleeding, less pain, shorter hospital stay, etc.. But anastomosis difficult, intrathoracic lymph node metastases are not easily removed, the shortcomings of the cutting edge residual cancer tissue.
③ thoracoabdominal approach applies to infiltrating gastric cardia. This approach is good exposure. The abdominal incision plus sternum and epigastric middle of the 1/3 of the incision, the the epigastric middle of plus first 7 intercostal or 6th intercostal chest and abdomen incision, cut off the costal arch, cut the diaphragm, damage may be used.
④ by thoracic and abdominal incision: In theory, it is necessary to overcome the abdominal cavity of the transthoracic cleaning is not thorough shortcomings and overcome a the transabdominal chest cleaning thorough shortcomings diaphragmatic costal arch integrity, to maintain good respiratory function. But the trauma is a major drawback.
⑤ by the neck abdomen (esophagus the turn dial off) incision: When cardia cancer, esophageal cancer occur at the same time, early esophageal cancer without lymph node metastasis, cardia infringement stomach nor too big, adopted by the neck abdomen (esophagus cardia cancer treatment varus written off).
⑥ after laparoscopic surgery or assisted small incision, less trauma, there are certain difficulties but the operation requires a certain amount of equipment, the cost is higher.
In short, the choice of the cut should be to get the best exposure, minimal damage to the guidelines. And depending on the circumstances and the flexibility to choose, but also with the habits of the surgeon.
(4) surgical methods: cardia cancer surgery can be divided into proximal gastrectomy surgery, total gastrectomy and gastric cardia combined organ resection.
① transthoracic proximal gastrectomy, the esophagus - stomach intrathoracic anastomosis: cardia (0, Ⅰ, Ⅱ period and part of stage Ⅲ) no significant peritoneal metastases, X-ray imaging, CT examination, B-ultrasound lesions violations of not more than the lesser curvature of the stomach, soft tissue shadow cardia cancer surgery, should also be considered.
The first step, the free inferior pulmonary ligament pulmonary upward traction. The longitudinal cut mediastinal pleura, free of the lower esophagus and cuffs stretch, the esophageal bed hemostasis gauze pad. Esophageal probing whether the infringement, esophagus paraneoplastic whether there subcarinal lymph node metastasis.
The second step, open the diaphragm, exploration cardia tumors foreign invasion, whether lymph node metastasis, lymph node metastasis, and the planting of exploratory abdominal and chest.
The third step, each dealing with the short gastric blood vessels and the left gastric artery. The stomach completely free to decide resection. In general, the cutting edge of the stomach and esophagus should be away from cancer more than 5cm. If the cancer has violated the tail of the pancreas, splenic and hepatic left lobe removed together with a piece or part of the organ, diaphragmatic resection line around the diaphragmatic hiatus diaphragmatic invasion. Line abdominal lymph node dissection.
The fourth step, the treatment of gastric cardia can be used intrathoracic esophagus - stomach anterior wall anastomosis and esophagus - stomach wall anastomosis anastomosis of the stomach and esophagus.
② total gastrectomy jejunal behalf of stomach surgery: apply to the cardia involving the gastric body, extensive peritoneal metastases. Cardia cancer has not yet invaded the whole stomach, but already pyloric lymph node metastasis, and still capable of radical surgery. Leather-like stomach hemorrhage, obstruction of advanced cardiac Although there is no cure is possible to improve the symptoms, but should line total gastrectomy.
A first step, to free the lower esophagus and the diaphragmatic hiatus. Then free the stomach, left gastric artery and liver and stomach ligament ligation, then a free distal stomach. Lift the omentum, gastrocolic ligament, cut along the transverse colon free to flip up the stomach, transverse colon was pulled down, separation, ligation and cut off the right gastroepiploic artery. In the left edge of the hepatoduodenal ligament, cut hepatogastric the ligament to be after the separation of the right gastric artery ligation and cutting. Complete ionizing stomach.
The second step, in the the pyloric remote 2cm at cutting the duodenum. Stump closed, lined embedded near the omentum coverage.
The third step is to cut the Treitz ligament, the jejunum mentioned pleural. Lines at 30cm from the Treitz ligament jejunal esophageal end side anastomosis. Cardia cancer after surgery in the plane of the duodenum, jejunum song line jejunum proximal segment and the the jejunum distal end of side-to-side anastomosis.
The fourth step, as empty mesenteric shorter length, the jejunal loop mention with esophageal difficult, can be used esophagus - Roux-en-Y anastomosis.
③ the cardia the United exenteration: cardia cancer lymph node metastasis applies to direct invasion of adjacent organs, but the the cardia joint organ resection can achieve radical effect.
Radical resection of the cardia cancer, the most common organ resection distal pancreatectomy and splenectomy. Include resection of the diaphragm, transverse colon, liver and other organs.
④ palliative surgery: palliative surgery, such as bypass surgical explants plastic tube, and in recent years has been the basic need. Memory alloy stent clinical application, gastrostomy or jejunostomy applications to reduce the serious obstruction, and only when the tumor is small resection, the patient agreed, to Caixing gastrostomy or jejunostomy.
[Postoperative observation and treatment]
2 after 24 to 48 hours of closed beta blood pressure, pulse, respiration and ECG, oxygen saturation monitoring.
Continuous decompression, postoperative recovery of bowel movement can unplug the gastric tube, a small amount of liquid diet gastric tube after removal.
Closed thoracic drainage, the daily records cited traffic, 48 hours after surgery chest radiographs, chest no obvious the effusion plot gas drainage tubes were removed in.
5 record intake and output.
6. Encourage patients to cough, early activities, given aerosol inhalation, 3 times a day.
7 given antibiotics and vitamins, the necessary energy and liquid supplement.
(B) observation and treatment of complications
1. Anastomotic fistula anastomotic leakage is the responsibility doors cancer after high mortality complications. Can occur early cardia cancer after 2 to 3 days; mid-occur in 1 to 2 weeks after the operation; the late fistula occurred after two weeks after surgery. Anastomotic leak can cause local inflammation and systemic symptoms, digestive juices and can lead to substantial loss of lead water and electrolyte metabolism disorders, acid-base balance, and renal failure. Available through the postoperative clinical and X-ray findings. Thoracentesis, swallowing contrast agent diagnosis. Early and mid-anastomotic fistula as conditions allow, cardia cancer treatment should line thoracotomy, give again anastomosis or repair. The late anastomotic fistula may be given anti-infection, drainage, maintenance of nutrition and correcting water, electrolyte imbalance and other conservative treatment.
2. Empyema empyema caused by non-anastomotic fistula. More performance for 1 to 2 days after removal of the drainage tube, elevated body temperature, shortness of breath, difficulty in breathing. X-ray and thoracentesis can assist in the diagnosis. Confirmed empyema after oral administration of methylene blue except anastomotic leakage. In addition to general supportive therapy after the occurrence of empyema, closed drainage should be early line, continuous drainage and promote lung expansion to latch the abscess. Limitations empyema as the abscess is small, feasible intermittent puncture pus, well feasible drug rinse Vomica processing.
3 chylothorax, surgical causing the thoracic duct injury causes chylous fluid into the chest, is more common. Can be expressed as chylous fluid caused by the chest compression symptoms and a large number of chylous fluid loss caused symptoms. The chylous fluid occurred early can be support for conservative treatment, such as conservative treatment is invalid or chylous fluid loss is greater than 1000 ~~ 1500ml / d, the treatment of gastric cardia should again surgical ligation of the thoracic duct.
Diaphragmatic hernia multi bowel or mesenteric hernia into the chest as the main performance, intestinal obstruction. X-ray examination intrathoracic plane of single or most sizes of liquid to gas, or "empty circle" (ie the bowel loops shadow). Once diagnosed postoperative diaphragmatic hernia repair surgery immediately.
5. Gastroesophageal reflux gastric cardia resection gastroesophageal reflux is a very common phenomenon. Supine or right lateral position, a digestive juice into the mouth. The diagnosis depends endoscopy. May be given a semi-recumbent sleep, and promote the treatment of gastric motility, mucosal coverage and antacid drugs.
【Therapeutic evaluation and treatment]
Clear effect of cardia cancer surgery, Ellis reported Ⅰ, Ⅱ five-year survival rate of 36.6%, the Ⅲ five-year survival rate of 22.5%. Ⅳ of survival does not exceed 1 year. Reported for 1, 3, 5, 10-year survival rates were 66.95%, 30.0%, 19.5% and 10.3%, respectively. Was visible early detection, early surgical treatment is very important in the treatment of gastric cardia.