Cardia Dysphagia [Concept 】 Cardia dysphagia is a condition in which there is no peristaltic movement of the esophagus during swallowing, and the cardia sphincter muscle does not relax properly, making it difficult to swallow food. It is mostly seen in the age of 20-50 years old, and is slightly more common in women. Etiology and Pathology 】 It is generally believed that this disease is caused by the degeneration, reduction or absence of ganglion in the muscle layer of the esophagus, and the loss of the normal driving force of the esophagus. The lower esophageal sphincter and cardia can not be relaxed, resulting in food retention in the esophagus. In the long run, the esophagus will be dilated, hypertrophied, elongated and flexed, and the food will be stagnated, which will chronically stimulate the esophageal mucosa, resulting in congestion, inflammation, and even ulceration. A few may become cancerous. Surgery, Chaohu Second People’s Hospital, Ren Jungen 【 Clinical manifestations 】 1. Difficulty in swallowing, feeling of heaviness or obstruction behind the sternum. 2. Difficulty in swallowing may be severe or mild, often accompanied by regurgitation and vomiting of undigested food. 3. Weight loss and anemia. 4. Specialized examination, there may be no positive signs, combined with respiratory complications, there are corresponding signs. Diagnostic points 】 1, according to the clinical history and barium meal examination shows the esophagus dilatation and enlargement, the lower end of the bird’s beak-like features can be confirmed the diagnosis. 2. Esophagoscopy can exclude cancer. Differential diagnosis 】 1.Tumor of esophagus; 2.Esophagitis. Principles of treatment 】 1, non-surgical treatment: for the short duration of the disease and mild: (1) diet: small meals, chewing, avoiding stimulating diet; (2) symptomatic treatment: sedation, antispasmodic; (3) dilatation therapy: probe strip dilatation, balloon dilatation. 2.Surgical treatment: (1) lower esophageal cardia myotomy (transabdominal, transthoracic or thoracoscopic); (2) lower esophageal cardia myotomy plus anti-reflux surgery, suitable for duodenogastric reflux or high gastric acid; (3) cardia and lower esophageal resection, esophagogastric anastomosis, suitable for esophageal over-expansion, myofibrous proliferation of the muscle layer is severe, or recurrence of the myotomy after the procedure. Esophageal hiatal hernia and reflux esophagitis 【 Clinical features 】 1, heartburn, acidity, retrosternal pain, dysphagia and dysphagia; 2, epigastric discomfort, tightness; 3, advanced malnutrition, vomiting blood and aspiration pneumonia. Auxiliary examination 】 (1) X-ray barium meal imaging and film; (2) esophagoscopy; (3) esophageal manometry and PH monitoring. Diagnostic points 】 According to the clinical features, barium meal examination, esophagoscopy, combined with the results of esophageal manometry and PH measurement, the diagnosis of esophageal hiatal hernia and reflux esophagitis can be clearly defined, and the two may coexist or occur separately. Differential diagnosis 】 1, coronary heart disease. Peptic ulcer. Peptic ulcer. 3. Cardia bradycardia. 4. Esophageal tumor. Treatment principle 】 1, non-surgical treatment: (1) low-fat diet: small meals, avoid tobacco, alcohol, coffee, weight loss; (2) 2~3h before bedtime should not eat, sleep with the head of the bed elevated 15~20cm; (3) the use of acidulants, morpholine, cisapride. (2) surgical treatment: (1) operation: anti-reflux surgery; (2) indications for surgery: ① gastro-esophageal reflux complications, such as bleeding, stenosis, ulcers, pulmonary complications, etc.; ② ineffective medication for a long time without symptomatic relief; ③ infants and children with reflux complications; ④ no matter whether there are no symptoms of the type II (para-esophageal hernia) esophageal hiatal hernia; ⑤ Barrett’s esophagus; ⑤ the esophageal hernia; (4) the esophageal hernia; (5) the esophageal hernia; (5) the esophageal hernia. ⑤ Barrett’s esophagus; ⑥ Combined with other lesions in the upper abdomen. (3) Resection of cardia and lower esophagus and esophagogastric anastomosis are suitable for those with excessive enlargement of the esophagus, severe myofibrous hyperplasia or recurrence after myotomy. Therapeutic Criteria 】 1. Cure: symptoms disappear, and no reflux, can participate in normal work and social activities; 2. Improvement: symptoms are reduced, occasional dysphagia and acid reflux, or burning pain behind the sternum, but can participate in general work and social activities; 3. Ineffective: symptoms are the same as the previous one, affecting the life and work. Benign esophageal tumors 【Clinical features 】 1, benign esophageal tumors can be divided into intraluminal (polyps and papillomas), submucosal (hemangiomas and granular cell myoblastomas) and intermural type according to the source of tissue occurrence. Esophageal smooth muscle tumor accounts for about 3/4~4/5; 2. Symptoms and signs mainly depend on the anatomical location and size of the tumor. Larger tumors can block the esophageal lumen to different degrees, resulting in symptoms such as difficulty in swallowing, vomiting and weight loss. Auxiliary examination 】 (1) X-ray barium meal imaging and film; (2) esophagoscopy, if the mucosa is normal, biopsy should not be performed so as not to affect the future surgical removal. Diagnostic points 】 X-ray esophagography showed that the lesion was a smooth filling defect with no destruction of the mucosa. Esophagoscopy shows that the extra-luminal mass squeezes the esophageal wall, but the esophageal mucosa is normal and intact. Differential diagnosis 】 1. Mediastinal tumor. Normal left main bronchus and aortic arch produce esophageal pressure marks. Esophageal cancer. Treatment principle 】 1. Mucosal tumors should be surgically resected. 2. 2. Extramucosal tumors, such as esophageal smooth muscle tumor, can be removed by TV thoracoscopy or thoracotomy. 3.Giant benign esophageal tumors with large mucosal involvement and muscle layer degeneration should be partially resected and reconstructed. Esophageal Cancer 【 Clinical manifestations 】 1. Early stage of esophageal cancer is choking sensation, burning sensation behind the sternum and foreign body sensation in the esophagus; 2. Typical symptoms are progressive dysphagia; 3. Vomiting, persistent chest and back pain, hoarseness. 4. In the late stage, there is emaciation, significant weight loss, anemia, and enlarged supraclavicular lymph nodes. 5. Involvement of the recurrent laryngeal nerve may result in vocal cord paralysis; involvement of the cervical sympathetic nerves may result in Horner’s syndrome. (2) Thoracic segment: it is divided into upper, middle and lower segments. Upper thoracic segment – from the upper thoracic opening to the plane of the tracheal bifurcation; middle thoracic segment – from the plane of the tracheal bifurcation to the upper half of the full length of the cardia; lower thoracic segment – from the plane of the tracheal bifurcation to the lower half of the full length of the cardia. Middle thoracic segment – from the plane of tracheal bifurcation to the upper half of the total length of cardia; lower thoracic segment – from the plane of tracheal bifurcation to the lower half of the total length of cardia. Esophageal cancer in the middle thoracic segment is more common, followed by the lower segment and less common in the upper segment. Early stage esophageal cancer is mostly confined to the surface of mucosa (carcinoma in situ), and no obvious mass is seen. Naked eye shows congestion, erosion, plaque or papilla. 3. According to the pathological pattern, it can be divided into four types: medullary type, mycotic umbrella type, ulcerative type and narrowing type. 4. Histologic typing: (1) Squamous cell carcinoma: the most common one. (2) Adenocarcinoma: less common, can be divided into simple adenocarcinoma, adenosquamous carcinoma, mucoepidermoid carcinoma and adenoid cystic carcinoma. (3) Undifferentiated carcinoma: less common, but highly malignant. The majority of upper and middle esophageal carcinomas are squamous cell carcinomas, while the majority of lower esophageal carcinomas are adenocarcinomas. Spreading and metastasis of esophageal cancer: (1) Spreading within the esophageal wall: The cancerous transformation of the underlying cells of the epithelium next to the esophageal cancer or the formation of carcinoma in situ is one of the ways of surface spreading of the cancerous tumors. Cancer cells often do not infiltrate the lymphatic vessels in the submucosal layer of the lamina propria of the esophagus. (2) Direct infiltration of neighboring organs, upper esophageal cancer can invade larynx, trachea and soft tissues of neck, and even invade bronchus, forming broncho-esophageal fistula; it can also invade thoracic duct, odd vein, pulmonary hilar and lung tissues, and part of it can invade aorta to form esophageal-aortic fistula, which can lead to haemorrhage and cause faraway. Lower esophageal cancer can often involve cardia and pericardium. (3) Lymphatic metastasis is relatively common, accounting for about 2/3 of the cases. Middle esophageal cancer often metastasizes to paraesophageal or hilar lymph nodes, and may also metastasize to lymph nodes in the neck, around the cardia, and next to the left gastric artery. Lower esophageal cancer can often metastasize to paraesophageal lymph nodes, paracentral lymph nodes, paracentral lymph nodes of the left gastric artery and abdominal cavity, and occasionally to the upper mediastinum and cervical lymph nodes. Lymphatic metastases are to the septum, abdomen, trachea and paratrachea, hilar and parabronchial. (4) Hematogenous metastasis is most common in patients with advanced disease. The most common metastasis to the liver (about 1/4) and lungs (about 1/5), other organs in order of bone, kidney, adrenal gland, pleura, omentum, pancreas, heart, lung, thyroid and brain. Auxiliary examination 】 (1) X-ray barium meal fluoroscopy and radiographs, radiographs should include the entire length of the esophagus and stomach; early visible: esophageal mucosal folds are disorganized, rough, or interrupted. Small filling defects. Restricted wall stiffness with interrupted peristalsis. Small niche shadows. In the middle and late stages, there are obvious irregular stenosis and filling defects, and the wall is stiff. (2) Esophageal and gastroscopic examination, cytologic biopsy. Diagnostic points 】 1, early diagnosis based on clinical manifestations, X-ray barium meal and esophagoscopy cytology and other comprehensive analysis; 2, in the late stage is mainly based on X-ray esophagography and typical clinical symptoms to confirm the diagnosis, may not be esophagoscopy and cytological examination. Differential diagnosis 】 1. Esophagitis. Benign esophageal tumors, such as esophageal smooth muscle tumor. Cardia dystrophy. Benign esophageal stenosis. Principles of Treatment 】 1. Non-surgical treatment: (1) metal stent placement in the esophagus, applicable to patients with esophageal cancer below the thoracic segment that cannot be or is inconvenient to be surgically resected or is complicated by esophageal-tracheal (or bronchial) fistulae; (2) radiotherapy, mainly used for cervical esophageal cancer, adjuvant radiotherapy before or after surgical treatment, and esophageal cancer that cannot be surgically resected. (2) Radiotherapy is mainly used for patients with cervical esophageal cancer, adjuvant radiotherapy before or after surgical treatment, and patients who cannot be surgically resected. (1) For patients with stage 0, I, II, and part of stage III lesions, surgical treatment should be pursued when the general condition of the patient permits. (2) For patients with stage III esophageal cancer of upper thoracic segment, and with a better general condition, the comprehensive treatment of preoperative radiotherapy and surgical resection should be adopted. (3) Contraindications for surgery: ① Clinical and X-ray images show that the tumor is extensive or invades adjacent vital organs, such as trachea, lung, mediastinum or heart, and cannot be surgically resected; ② There are signs of distant metastasis, such as bone, liver, lung, abdominal bloody ascites, or metastasis to other parts; ③ There is serious cardiopulmonary insufficiency, which cannot afford the surgery; ④ There is serious malignant disease. Surgical methods for esophageal cancer 】 1. Radical esophageal cancer, pancreatic cancer resection and esophageal reconstruction are the preferred surgical methods, and the stomach should be used as far as possible to reconstruct the esophagus, and esophagogastric anastomosis should be carried out in the neck or the chest. 2. Early-stage esophageal cancer can be treated without opening the chest, and the esophagus should be bluntly stripped or internally reversed through the cervical and abdominal incision, and then the esophagogastric anastomosis should be carried out in the neck. Reduction surgery, such as endoluminal metal stent placement, gastrostomy, etc., is suitable for advanced esophageal cancer and cardia cancer that cannot undergo radical surgery and has obvious obstruction of food intake.