Training material VI
Treatment of cardiac cancer
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。
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。
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).
- 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.