What is combined gastric cancer obstruction
Pyloric obstruction and cardia obstruction are both the most frequent complications of progressive gastric cancer. Infiltration of cancer around the pylorus or pancreatic area develops, resulting in obstruction due to stiffness of the gastric wall and narrowing of the lumen. Progressive gastric cancer with extensive involvement of gastric body may also show similar manifestation of pyloric obstruction due to stiffness of gastric wall, obstruction of peristalsis and obstruction of emptying.
Clinical manifestations of gastric cancer and obstruction
Obstruction of food passage is the most important manifestation.
Progressive dysphagia is the main symptom of pancreatic and peripancreatic cancer. Malnutrition, emaciation, anemia and other wasting manifestations are the accompanying symptoms. In some cases, if the abdominal wall is relaxed in a sitting position and deep breathing is performed, the mass hidden in the deep surface of the costal arch can be palpated.
Postprandial epigastric fullness and vomiting of large amounts of fermented food from other meals or overnight are the main symptoms of pyloric and peripyloric carcinoma, and they worsen day by day, accompanied by malnutrition and systemic wasting. Gastric pattern and gastric peristaltic waves are mostly seen, and masses can be palpated in the upper abdomen.
Diagnosis of gastric cancer and obstruction
The diagnosis of gastric cancer with obstruction mainly includes the following three points.
1. Based on the typical symptoms of progressively worsening dysphagia or vomiting in the history of gastric cancer, combined with the masses that may be palpated, the diagnosis is mostly not difficult.
2. Gastrointestinal imaging can show luminal narrowing of cardia or pylorus, shadow of mass, slow emptying and luminal storage performance. 3. Endoscopy can visualize the size, shape and boundary of gastric cancer foci as well as take tissues for pathological diagnosis, and can provide the peri-focal mucosal involvement, which is beneficial to the choice of operation. Before endoscopic examination, the stomach should be thoroughly lavaged before endoscopic examination.
Treatment of gastric cancer with obstruction
Gastric cancer patients with pyloric obstruction have food retention and fermentation in the stomach, electrolyte disorders, hypoproteinemia, low gastric acidity and increased gastric flora. Before surgery, attention should be paid to the correction of water-electrolyte imbalance, protein supplementation, thorough gastric lavage and the application of antibiotics are all necessary.
1. Surgical treatment.
Surgical treatment is currently the most important measure for the treatment of pyloric and cardia obstruction. The ideal surgery is radical gastrectomy to remove the primary focus, contour the surrounding lymph nodes, eliminate the possible metastatic tissues or lesions, and reconstruct the digestive tract. Recently, the authors have performed radical resection of gastric cancer and duodenectomy in 6 cases of gastric sinus cancer with pyloric obstruction and pancreatic head or duodenal involvement, and achieved good recent results, but it should be used with caution in elderly patients.
For those who have lost the time of radical resection but the primary foci can still be resected, non-radical gastrectomy should be strived to reconstruct the digestive tract, which can relieve the obstruction, eliminate the concern of gastric cancer perforation and bleeding, and improve the immune function of the body.
For cases of pyloric obstruction of gastric cancer with fixed primary foci that cannot be removed, gastrojejunostomy is feasible, or gastric cancer isolation (transection of the stomach about 5 cm from the cancer margin and closure of the lateral cut end of the pylorus. In cases of unresectable pancreatic obstruction, a gastrojejunostomy (diversion) between the esophagus and stomach or jejunum is feasible to reconstruct the digestive tract, relieve obstruction and maintain nutrition.
For total gastric cancer with obstruction, jejunostomy is feasible, and food can be instilled through the sputum-forming port. According to the physical condition of gastric cancer patients, chemotherapy and Chinese herbal medicine treatment should be supplemented appropriately.
2. Endoscopic treatment.
Laser optical fiber, microwave radiation antenna and high-frequency electrocautery apparatus for treatment are inserted through the endoscopic clamp channel to target the lesion under direct vision of endoscopy, and perform cautery, coagulation and resection to enlarge the lumen of the obstructed area and relieve the obstruction.
For cases with severe lumen obstruction, long lesions and heavy stenosis, where neither surgery nor endoscopic laser, microwave or high-frequency electrotherapy is difficult, endoscopic placement of nasal feeding tube can be used to send the tube to the distal side of the stenosis for nasal feeding diet.
Endoscopic treatment is a new treatment measure in recent years, which is simple and practical.
3. Chemotherapy and radiotherapy.
Chemotherapy alone is extremely ineffective for those whose gastric cancer has become obstructed and should not be used. Chemotherapy is mostly used as an adjuvant therapy after surgery. During surgery, intravenous and intraperitoneal chemotherapeutic drugs, such as 5-fluorouracil, mitomycin, cisplatin, etc., can be used for those with better general condition to reduce intraoperative dissemination of cancer cells. After surgery, for those with good general condition and immune function, if radical resection has been performed, single drug chemotherapy can be used; for those with non-radical resection or primary foci not removed, combination chemotherapy with two or more drugs is mostly used. Those with poor general condition and low immune function after surgery should use chemotherapy with caution to avoid counterproductive effect.
Gastric cancer is mostly adenocarcinoma, which is poorly sensitive to radiotherapy, and there are many important organs adjacent to the stomach, so radiotherapy is limited. Therefore, radiotherapy is limited. Generally, radiotherapy is not used as a single treatment, but only as one of the comprehensive treatment measures, together with surgery, to improve the efficacy of surgery.
For gastric cancer with pyloric obstruction, if the tumor is not larger than 6 cm (maximum not more than 10 cm) and it is estimated that it can be resected, preoperative radiotherapy can be used to reduce the tumor size and the proliferation function of tumor cells, so as to reduce intraoperative dissemination; for resected sinus or body cancer foci, intraoperative high-dose irradiation can be performed to eliminate residual cancer foci and subclinical foci and control intraoperative metastatic dissemination of tumor cells; postoperatively, because of the patient’s weakness, radiotherapy is not used. Only for residual foci marked intraoperatively and undifferentiated carcinoma with sensitive histology, postoperative radiotherapy can be considered.