Zhu Yanjun, Department of Thoracic Surgery, Air Force General Hospital Which hospital is authoritative for minimally invasive surgical treatment of lung cancer Zhu Yanjun, Department of Thoracic Surgery, Air Force General Hospital
Cardia cancer is an adenocarcinoma that occurs in the cardia of the stomach, which is about 2cm below the esophagogastric junction line. It is a special type of gastric cancer and should be distinguished from cancer of the lower esophagus. However, it is different from other parts of gastric cancer and has its own anatomical-histological characteristics and clinical manifestations, unique diagnostic and therapeutic methods and poorer surgical treatment results.
The incidence of pancreatic cancer is also very high in the high incidence area of esophageal cancer in China.
1 Pathogenesis: general typology
1.1 Progressive stage: Gastrointestinal tumor staging generally follows Borrman staging, whose basic classification is myxoid, ulcer type I, ulcer type II and infiltrative type.
Accordingly, our authors have classified 4 types of cardia cancer. (4) Infiltrative type: the tumor is infiltrating and growing in the wall of cardia, the involved area is uniformly thickened, without boundary with the surrounding tissues, and the surrounding mucosa is often contracted radially.
1.11 The general staging is related to the histologic type. Type 1 and 2 are more frequently associated with highly differentiated adenocarcinoma and mucinous adenocarcinoma. The infiltrative ulcerative type has a greater proportion of hypofractionated adenocarcinoma and mucinous adenocarcinoma. The infiltrative type is mostly hypofractionated diffuse adenocarcinoma or mucinous adenocarcinoma. The prognosis of surgical treatment is best for the augmented type, second for the limited ulcerated type, worse for the infiltrating ulcerated type, and worst for the infiltrating type.
1.12 There are two main histological types of pancreatic adenocarcinoma: adenocarcinoma and mucinous adenocarcinoma with significant mucus secretion. These two types are divided into three subtypes: highly differentiated, poorly differentiated and diffuse according to the degree of differentiation. The degree of differentiation is closely related to the prognosis of surgery. In addition to adenocarcinoma and mucinous adenocarcinoma, there are some other rare histological types of cardia cancer, such as adenosquamous carcinoma, undifferentiated carcinoma, carcinoid tumor and carcinosarcoma.
1.2 Early stage: The general morphology of early cardia cancer is similar to that of early cancers in other parts of the stomach and esophagus. It can be simply divided into three types: ① depressed type: the mucosa of the cancerous part is irregularly and mildly depressed, a few of them are shallow ulcers, which are not clearly demarcated from the surrounding normal mucosa and often poorly differentiated microscopically; ② elevated type: the mucosa of the cancerous part is thickened and rough, slightly elevated, and part of it appears as plaques, nodules or polyps, with highly differentiated adenocarcinoma accounting for most of them; ③ occult type: the mucosa of the lesion is slightly dark in color and slightly coarse in texture, but there are no obvious changes in general. It is the earliest of the three types and is diagnosed only after histological examination.
1 Symptoms
1.1 Symptoms and signs: The initial symptoms appear in two ways. If it occurs in the lower esophagus, the already narrow cardia will be even narrower, so it is easy to develop symptoms similar to those of esophageal cancer; if it occurs in the body of the stomach or on the head side of the stomach, there are generally no conscious symptoms at the initial stage, so it is also difficult to diagnose. There is a strange sensation when passing food, severe pain, a little obstruction, and slight heartburn. The above symptoms are felt when swallowing, and when swallowing hard food, it feels like a “thud” falling directly into the stomach, especially when drinking hot or cold liquids, with the first bite being the most pronounced. In the case of cancer, these symptoms, once present, are always present. As for non-cancerous patients with similar symptoms, these symptoms will come and go without any regularity, and the severity of the symptoms will vary.
1.2 Another initial symptom of cardia cancer is upper gastrointestinal bleeding, which is manifested as vomiting blood or tarry stools. Depending on the severity of the bleeding, it may be accompanied by shock or severe anemia. The incidence of this condition is about 5% of patients. Due to the lack of obstructive symptoms, such patients are easily misdiagnosed as bleeding peptic ulcers and are operated on by an abdominal surgeon, who can only confirm the diagnosis intraoperatively. It is also because most of these patients are operated in an emergency and are not adequately prepared in all aspects that they have a higher incidence of surgical complications and mortality and poor outcomes.
1.3 Initial symptoms: ①Posterior sternal distension or mild pain. This symptom does not occur continuously, but intermittently or is aggravated after exertion and during rapid feeding; ② foreign body sensation during swallowing food. During swallowing, food (especially dry and hard food) passing through the lesion area (the lesion is small) may produce a foreign body sensation, often fixed in one area, and some patients describe a feeling of never-ending swallowing. It is easy to be neglected by patients because the symptoms are mild and occur intermittently; ③ swallowing stagnation or stuttering sensation, i.e., the patient seems to have a momentary stagnation and stuttering sensation in a certain area when swallowing food. Patients complain of a kind of stuffy phenomenon in the front of the chest, which seems to be blocked by an object and makes the chest feel constricted, especially when swallowing food, but it does not affect normal life and work; 5. This is often the early symptom of cardia cancer.
1.4 Intermediate symptoms: between early symptoms and advanced symptoms, with progressive development. There are moderate cachexia, anemia, edema, general failure, metastasis of important organs such as liver, lung, brain and metastasis of abdominal cavity and pelvis, causing pelvic blood, ascites sue bloody ascites, liver failure, coma, gastrointestinal obstruction, etc.
1.5 Symptoms in the deterioration period: anemia, low plasma protein, wasting and even dehydration are seen in patients in the middle and late stages. The presence of abdominal masses, hepatomegaly, ascites signs, and pelvic masses (anal examination) are all signs of unsuitability for surgery. In advanced cases, in addition to difficulty in swallowing, there may be persistent pain in the upper abdomen and lower back, indicating that the cancer has involved the pancreas and other retroperitoneal tissues, which is a contraindication to surgery. Besides the symptoms of esophageal cancer, there are all the symptoms of gastric cancer as follows: ① swallowing disorder (also when drinking water); ② heaviness in the upper abdomen; ③ pain in the stomach; ④ nausea and vomiting; ⑤ people gradually lose weight.
The harm of cardia cancer disease
Some information shows that the mortality rate of pancreatic cancer accounts for about 12% of the total mortality rate. In Henan’s Hebi suburbs, Linzhou City and other areas with high incidence of esophageal cancer, the death caused by pancreatic cancer reaches 20% of the total causes of death of residents. In China, the mortality and incidence rate of pancreatic cancer is among the top among all kinds of malignant tumors, the following is the detailed introduction of pancreatic cancer hazards.
1.Invasion of tracheobronchus by pancreatic cancer: esophageal respiratory fistula is most common; it causes cough, dyspnea, fever, hemoptysis and pulmonary infection and other respiratory symptoms, which may develop into pneumonia or abscess.
2.Intra-thoracic nerve invasion of cardia cancer: it can cause persistent chest and back pain, hoarseness, hiccups and other manifestations, which may be the earliest manifested symptoms, suggesting that radical surgery cannot be performed.
3.Other symptoms caused by local invasion and compression of tumor: spontaneous rupture and bleeding of tumor, tumor necrosis and perforation, formation of sinus tract from esophagus to mediastinum, which may lead to mediastinal abscess. It can also directly invade the organs around the mediastinum.
4.Gastrointestinal tract dysfunction in early postoperative period due to vagus nerve severance: diarrhea often occurs after the patient starts to eat, and individual patients with severe diarrhea can mostly also cause dehydration and electrolyte disturbance.
5.Pseudomembranous enteritis: It is a hazard of pancreatic cancer. After the onset, patients often have high fever, abdominal pain and severe diarrhea.
Diagnosis and differentiation Editor 1 Medical and technical examination
1.1 Laboratory examination: cytological examination, also known as pullnet cytological examination, can improve the detection rate for those who have repeatedly failed to detect lesions with barium meal fluoroscopy and fiberscopy or have suspicious lesions but cannot confirm the diagnosis, and pullnet cytological examination can provide a good basis for diagnosis.
Cardia cancer
1.2 X-ray barium meal imaging: early stage shows subtle mucosal changes, and ulcerative niche shadow as well as not very obvious filling defect can be found. The X-ray observation of advanced cardia cancer is very clear, including soft tissue shadow, ulcer, filling defect, mucosal destruction, niche shadow, invasion of lower esophagus, distorted and narrowed cardia channel, and infiltration of the gastric wall with small and large curved gastric body in the fundus, and reduction of gastric volume. Fiberoptic gastroscopy combined with brush cytology and biopsy pathology must be performed in early barium X-ray imaging to confirm the diagnosis well.
1.3 Endoscopy: fiberoptic esophagoscopy or gastroscopy can be used as an important examination method to diagnose pancreatic cancer. It can understand the diagnosis of lesion occurrence, length, esophageal stricture degree, etc. If cardia cancer is not clearly diagnosed, endoscopic review should be done within a short period of time.
1.4 B ultrasound examination: It can reveal the location, shape, size, relationship with surrounding tissues and the depth of cancer infiltration into esophagus and whether the nearby lymph nodes are enlarged, which can help the early diagnosis of cardia and esophageal cancer.
1.5 CT examination: It can understand the relationship between cardia and esophagus and surrounding organs. It can show the invasion, size and location of tumor, thickening of esophageal wall, expansion of upper esophagus, lymph nodes and metastasis of distant organs. It is helpful for the diagnosis and differential diagnosis of pancreatic cancer and esophageal cancer.
2 Easily misdiagnosed diseases
2.1 Cardia achalasia: The patient is young, has a long history of dysphagia, but still maintains moderate health. x-ray esophagogram shows symmetrical smooth funnel-shaped stenosis above the cardia, and its proximal segment of esophagus is highly dilated.
2.2 Lower esophagitis: often accompanied by hiatal hernia and gastric reflux, the patient has a long history of “heartburn” and acid reflux, is short and fat, and the inflammation is long enough to cause scar stenosis and dysphagia. The diagnosis can be confirmed by repeated multi-point biopsies if the results are always negative.
2.3 Peptic ulcer: Upper abdominal discomfort, mild post-food fullness, dyspepsia, or vague pain in the heart fossa are easily confused with cardia cancer. And it is difficult to distinguish bleeding peptic ulcer from bleeding pancreatic cancer, and the diagnosis rate of gastroscopic biopsy is higher.
The differential diagnosis of cardia cancer includes cardia spasm (cardia achalasia), stenosis due to chronic inflammation of the lower esophagus, and peptic ulcer in the cardia. Cases of cardia spasm are clinically characterized by young age, long history of disease, and long history of dysphagia, but still maintain moderate health. x-ray esophagogram reveals symmetrical smooth funnel-shaped stenosis above the cardia and its highly dilated proximal segment of the esophagus.
Disease treatment
I. Surgical treatment
1. Indications for surgery: So far, surgery is recognized as the treatment of choice for cardia cancer. Due to its histology of adenocarcinoma or mucinous adenocarcinoma, radiation therapy is almost ineffective and chemotherapy has little effect. Indications for surgery for pancreatic cancer.
①Confirmed diagnosis by X-ray, cytology and endoscopy.
②Excluding lymph nodes, liver, adrenal gland, omentum, peritoneum and pelvic metastasis without ascites by ultrasonography, abdominal CT scan or laparoscopy.
③General condition is moderate or above, without major cardiopulmonary or other organ comorbidities.
Cardia cancer
2. Surgical route and method: A standard open incision is made in the left posterior lateral chest, through the 7th rib bed or intercostal area, and then a radial incision is made at the top of the left diaphragm with the esophagus as the axis to open the abdomen. With this approach, the cardia area is well exposed and sufficient for subtotal gastrectomy and lymph node dissection of the perigastric and left gastric vessels. If the scope of resection needs to be extended to perform total gastric resection or combined resection of the spleen and part of the pancreas, the incision can be extended forward and down to the upper abdominal wall, and the left costal cartilage arch of the diaphragm and abdominal wall muscles can be cut, which can be easily turned into a combined thoracoabdominal incision to fully expose the upper abdomen.
In patients with low cardiopulmonary reserve and advanced age, a cervico-abdominal two-incision non-opening esophageal inversion and partial gastrectomy with esophagogastric neck anastomosis can be used. The esophageal probe is sent to the neck through the opening of the fundus or abdominal segment of the esophagus after the lesion can be resected by opening the abdomen first. The free stomach is routinely excised partially, and the large curve is cut into a tube and lifted into the neck via the esophageal bed to anastomose with the esophagus. The disadvantage of this procedure is that the extent of gastrectomy is limited, which can lead to residual cancer with unclean lateral gastric margins. When there is inflammation in the mediastinum in the past, such as lymphatic tuberculosis and adhesions occur, it will make it difficult to turn and pull out, and it will not pull out or tear the tracheobronchial membrane, and in the latter case, it is necessary to open the chest immediately for repair.
For patients with cardiopulmonary insufficiency, there is another surgical route, which is a combined median sternotomy and median epigastric incision. This kind of incision is limited to reveal the posterior mediastinum, and an esophagogastric mechanical anastomosis can be used to ensure the quality of the anastomosis.
The commonly used surgical approach is subtotal proximal gastrectomy. It is indicated when the tumor in the cardia is small in size and the invasion along the lesser curvature does not exceed 1/3 of its full length. The operation is as follows: the left posterior external 7th rib bed or intercostal opening is performed to explore the lower esophagus, then the diaphragm is incised and the abdomen is explored to the left front with the fissure as the axis. Gauze pads are used to open the body and tail of the pancreas, reveal the left gastric vessels and their nearby lymph nodes, carefully clear the lymph nodes, ligate and cut the left gastric vessels, sever the hepatogastric ligament, completely free the proximal stomach, and cut the gastric tube on the side of the greater curvature. The gastric tube was rotated 90° clockwise and then anastomosed with the lower esophageal stump end-to-end, the inner layer was sutured with a full layer of nodes, and the outer layer was wrapped around the anastomosis about 2 cm with an upward sleeve of gastric pulp muscle layer, like a telescope. Before anastomosis, in order to prevent the mucosa of the gastric orifice from being too long and turning out to cover the muscle layer side to affect the anastomosis operation, the muscle layer of the gastric tube mouth can be circumferentially cut first, at which time the loose mucosa is exposed like a sleeve due to the retraction of the distal muscle layer. At this time, the mucosa of the gastric tube mouth is exactly level with the muscle layer, and the field of view is very clear during anastomosis, which helps to close the anastomosis.
If the tumor infiltrates more than half of the length of the gastric lesser curvature, total gastrectomy should be performed, and the blood supply of all 5 groups of stomach should be severed. The simplest is an end-to-end esophagojejunal anastomosis, a lateral jejunojejunal anastomosis, or a Roux-Y end-to-end esophagojejunal anastomosis, and an end-to-end jejunojejunal anastomosis. The authors believe that the former operation is simpler and the jejunal blood flow is better preserved than the latter.
If the tumor has invaded the gastrosplenic ligament or pancreatic tail, splenectomy and pancreatic tail can be performed at the same time of subtotal or total gastrectomy. It is better to cover the pancreatic duct with large omentum to prevent pancreatic fistula.
3. Near and long-term outcome of surgical treatment: The surgical outcome of cardia cancer is worse than that of esophageal cancer. The resection rate of the three major groups in China is 73.7% to 82.1%, and the resection mortality rate is 1.7% to 2.4%. The 5-year survival rate of the three major groups ranged from 19.0% to 24.0%, and the 10-year survival rate ranged from 8.6% to 14.3%.
The main factors affecting the long-term survival of cardia cancer are the presence or absence of lymph node metastasis, whether the tumor infiltrates the plasma membrane and the nature of resection (radical or palliative). The international TNM staging of pancreatic cancer is also an effective indicator to predict patient’s regression because it integrates the first two variables.
4. Residual gastric cardia cancer: There are increasing reports of cancer occurring in the residual gastric capsule after partial gastrectomy of the distal side. Its incidence is 0.55% to 8.9%, of which those occurring in the cardia account for 16.4% to 58.5% of all.
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