Cardia cancer is a more common tumor of the gastrointestinal tract, which is an adenocarcinoma of the combined esophagus and stomach with the center of the tumor located within 5 cm of the proximal and distal part of the cardia. The lymph node metastasis rate of cardia cancer is as high as 57% to 88%, and cardia cancer mostly metastasizes to intra-abdominal and intrathoracic lymph nodes. The main route of abdominal lymph node metastasis is along the lymphatic vessels of the gastric lesser curvature, which can metastasize to any group of lymph nodes of the stomach; the rate of intrathoracic lymph node metastasis is about 20%.
Surgical treatment is the first choice, and the objectives of surgical treatment are: 1. to remove the tumor and prevent or relieve the stenosis and obstruction of the cardia to prolong the patient’s life; 2. to ensure that no cancer tissue remains in the esophagus and gastric incision margin after resection of the primary tumor as far as possible to reduce the recurrence rate; 3. to thoroughly clear the suspected drainage area or local lymph nodes.
Studies have shown that the resection of the lower esophagus and the length of its resection is one of the important aspects affecting the surgical effect in cardia resection. The length of the surgical margin from the upper and lower edges of the tumor reaches or exceeds 5 cm, and more extensive clearance of lymph nodes in the tumor drainage area can improve the 5-year survival rate of patients.
The common surgical approaches are: 1. through the left posterior lateral thoracic incision , incising the diaphragm; 2. through the left combined thoracoabdominal incision, incising the diaphragm; 3. through the abdomen.
Combined with the characteristics of lymph node metastasis of cardia cancer, I think the combined left thoracoabdominal incision is the better surgical approach, which can be used for all types of cardia cancer. A posterior lateral incision through the left chest can be used for type I patients, which can meet the requirements of complete lymph node dissection in the thoracic cavity, but it is more difficult to operate on the abdominal cavity, and also requires higher lung function and more obvious postoperative pain. Transabdominal surgery is often insufficient for the resection of the upper margin of the tumor and is prone to postoperative recurrence, so it is only used for early type III patients and for palliative surgical treatment in patients who cannot tolerate open thoracic surgery or cannot be cured with obvious obstructive symptoms.