Training material VI
Treatment of cardiac cancer
胃癌在临床上一旦确诊，应考虑尽快地施行手术治疗，但术后还应结合病人的实际情况，采取综合性治疗如化疗、中医中药治疗、免疫治疗等。
胃体癌、胃底癌、贲门癌或全胃癌的癌肿应施行全胃切除术，在临床上根据手术切除的彻底性分为根治性全胃切除术及姑息性全胃切除术。另外根据是否同时切除其他脏器，又可分为单纯性胃切除术和联合脏器切除术两种。全胃切除术的切除范围通常包括全胃，十二指肠球部食管下端的一部分、大网膜、小网膜及胃脾韧带，并在根部结扎，切断胃的所属血管，以清除胃周围转移淋巴结，这就是单纯性全胃切除术。有时脾门及胰腺上缘有转移的淋巴结，需同时将脾及胰尾切除，也有时癌侵及了横结肠或肝左叶，需将部分横结肠或肝左叶一并切除，这就是联合切除术。
是否需作全胃切除术，术前有时难以决定，往往需在剖腹后，根据病变部位，癌肿扩散程度及机体状况等方面来判断。其原因是，凡用胃大部分切除术不能根治，而只有切除全胃才能根治的胃癌才考虑全胃切除术。要慎重选择全胃切除术的适应症，尽量少采用姑息性全胃切除术，尤其是姑息性联合切除术，以免带来不良后果。
手术原则是: 操作时应从周边向中心进行，并在根部结扎，切断胃的所属血管，切断端距癌瘤边缘要有一定的安全距离 (一般在5cm)，操作中用纱布包裹肿瘤井保护腹腔，以做到清除胃周围转移淋巴结，并防止癌细胞扩散。
全胃切除术消化道重建有以下几种方法 (略)。
术后井发症;
1、吻合口瘘：是全胃切除术后最重要并发症，多在术后 5-7 天，即开始进食时出现，如体温上升，脉搏增快，烦躁不安并有腹痛及恶心等症状时，应想到吻合口瘘的可能。一旦确诊应行腹腔引流，同时作空肠造瘘补给营养，加大抗菌素应用。
2、膈下感染: 由于创伤大，腹腔有时受到污染后而出现感染，一般在术后一周后有持续体温升高，血象高，有呃逆现象，往往通过X线摄片或 BUS 检查而定诊断。
3、腹泻：多发生在老年病人，常为消化不良性稀便，病人很快消瘦，主要是由于老年病人消化能力减低，加之全胃切除以后，消化与吸收的机能更加减退，食物刺激小肠使其蠕动增强所致。
4、反流性食管炎: 是一个晚期并发症，主要表现为胸骨后烧灼样疼痛、呃逆、向口腔反流苦水，给予稀盐酸合剂，症状可缓解。
5、营养障碍：主要表现为逐步消瘦及贫血，全胃切除后食物不能充分与胆汁、胰液混合，而且迅速进入空肠，影响消化与吸收。
6、吻合口狭窄: 主要是在吻合时，吻合口内翻过多所致，或因疤痕收缩而引起，或因吻合口过小等均可发生。一旦发生后，可行扩张术或再次手术。
Once gastric cancer is clinically diagnosed, surgical treatment should be considered as soon as possible, but combined with the actual situation of patients after surgery, comprehensive treatments such as chemotherapy, traditional Chinese medicine treatment, immune treatment, etc. should be taken.
Total gastrectomy should be performed for cancers of gastric body cancer, gastric fundus cancer, cardiac cancer or whole gastric cancer. According to the completeness of surgical resection, total gastrectomy is divided into radical gastrectomy and palliative total gastrectomy clinically. In addition, according to whether other organs are resected at the same time, the disease can be divided into simple gastrectomy and combined organ resection. Total gastrectomy usually covers the whole stomach, part of the lower esophagus of the duodenal bulb, the greater omentum, the lesser omentum, and the gastric and splenic ligaments, and ligation is performed at the root to cut off the blood vessels belonging to the stomach in order to remove the metastatic lymph nodes around the stomach. This is pure total gastrectomy.
Sometimes there are metastatic lymph nodes at the splenic hilus and superior margin of pancreas, and the spleen and pancreatic tail need to be removed at the same time. Sometimes the cancer invades the transverse colon or left lobe of liver, and part of the transverse colon or left lobe of liver needs to be removed together. This is called combined resection. Whether total gastrectomy is required is sometimes difficult to determine preoperatively, and often depends on the site of the lesion, the extent of tumor spread, and the body condition after laparotomy. The reason for this is that total gastrectomy is considered for gastric cancer which cannot be cured by most gastrectomy, but only by resection of the whole stomach. The indications of total gastrectomy should be carefully selected, and palliative total gastrectomy, especially palliative combined gastrectomy, should be avoided as much as possible to avoid adverse consequences.
The principle of surgery:
the operation should be performed from the periphery to the center, and ligation should be performed at the root. The blood vessel of the stomach should be cut off, and the cut end should be a certain safe distance (generally 5cm) from the edge of the tumor. The abdominal cavity should be protected by wrapping the tumor well with gauze during the operation, so as to clear the metastatic lymph nodes around the stomach and prevent the spread of cancer cells. There are several methods for digestive tract reconstruction after total gastrectomy (omitted).
Postoperative diseases:
- Anastomotic fistula: It is the most important complication after total gastrectomy. It usually occurs 5 to 7 days after surgery, when food is eaten. For example, when the body temperature rises, the pulse increases, the patient is agitated, and there are symptoms such as abdominal pain and nausea, the possibility of anastomotic fistula should be considered. Once diagnosed, abdominal drainage should be performed, together with jejunostomy for nutritional supplement and increased application of antibiotics.
- Hypophragmatic infection: Due to large trauma, the abdominal cavity is sometimes infected due to contamination. Generally, the patient has a continuous increase in body temperature, high hemogram, and hiccup after one week after surgery, which is often diagnosed through X-ray film or BUS examination.
- Diarrhea: It mostly occurs in the elderly patients, often causing indigestion and loose stool. The patients soon lose weight, mainly due to the reduced digestive ability of the elderly patients. In addition, after the total gastrectomy, the digestive and absorption functions are further reduced, and food stimulates the small intestine to enhance its peristalsis.
- Reflux esophagitis: It is a late complication mainly manifested as post-sternal burning-like pain, hiccup, and bitter water regurgitating into the mouth. The symptoms can be relieved after administration of dilute hydrochloric acid mixture.
- Nutrition disorder: It is mainly characterized by progressive emaciation and anemia. After total gastrectomy, food cannot be fully mixed with bile and pancreatic juice, and quickly enters the jejunum, thus affecting digestion and absorption.
- Anastomotic stenosis: It is mainly caused by excessive turnover in the anastomosis during anastomosis, or caused by scar contraction, or due to excessively small anastomosis. Once it has occurred, dilatation or reoperation may be performed.
This article was originally published in Proceedings of Wuhu Annual Surgical Conference,1996；28-30 Changhang Hospital, Li Mingjie
from 外科截瘫14例手术分析
