胃十二指肠疾病(双语教学).ppt

THEDISEASEOFSTOMACHANDDUODENUM胃十二指肠疾病 1 Outline SURGICALTREATMENTOFPEPTICULCERCOMPLICATIONSOFPEPTICULCERSTOMACHCANCER 2 SURGICALTREATMENTOFPEPTICULCER 3 Etiology AcidGastricMucosalBarrierNonsteroidalAntiinflammatoryDrugs NSAIDs AlcohalGastricStasisHelicobacterPylori HPCigaretteSmoking 4 DifferenceBetweenGastricAndDuodenalUlcer DuodenalUlcervagusnerve oversecretionofacidGastricUlcer1 Disruptionofgastricmucosalbarrier2 Gastricstasis 5 DuodenalUlcer Clinicalfeatureburning stabbing orgnawingepigastricpain 3 4hoursafteringestionhungerpainandnightpainIngestionoffoodandantacidsoftenrelievepain 6 DiagnosisHistoryFiberopticEndoscopyRadiology 7 十二指肠球部前壁可见一圆形疡 大小约0 6cm 0 7cm溃疡 基底覆黄厚坏死苔 周边充血水肿 8 十二指肠球部前壁可见一大小约1 0cm 1 2cm溃疡 溃疡表面覆盖黄白色坏死苔 周边充血水肿 9 10 DuodenalUlcer 11 DuodenalUlcer SurgicalindicationInefficacyofmedicaltreatment intractableulcer telephium顽固性溃疡 seriouscomplication hemorrhage perforation cicatricialPyloricObstruction 12 Intractableulcer Intractabilityislooselydefinedasfailureofanulcertohealafteraninitialtrialof8to12weeksoftherapyorifpatientsrelapseaftertherapyhasbeendiscontinued SabistonTextbookofSurgery 18thed 13 GastricUlcer ClinicalfeatureNoregularityofgatricpain1 2 1hafteringestion postprandialdiscomfortIngestionoffoodandantacidscannotrelievepain orexacerbationoneating 14 男 48岁 上腹痛 幽门可见 类圆形 呈开放状态 粘膜充血水肿 可见大小约1 0cm 1 2cm溃疡 溃疡表面覆盖黄白色坏死苔 周边充血水肿 色泽红 15 胃角中央可见一1 5cm 1 8cm圆形深溃疡 内附较厚的黄色坏死苔 周边充血水肿 经两次病理活检 确诊为良性溃疡 16 GastricUlcer 17 18 TypesOfGastricUlcer type1 60 havelow to normalacidoutput betweenthefundicandantraltype2 15 locatedinthebodyofthestomachincombinationwithaduodenalulcer associatedwithexcessacidsecretion Type3 20 areprepyloriculcersandareassociatedwithhypersecretionofgastricacid Type4 10 occurhighonthelesserurvatureneartheGEjunction arenotassociatedwithexcessiveacidsecretion ulcersonthegreatercurvatureofthestomach 5 19 GastricUlcer Surgicalindicationhemorhage perforation obstuction intractability needtoruleoutthepossibilityofcarcinoma 20 AcutePerforationofGastroduodenalUlcer 21 pathology 90 ofperforatedduodenalulcersoccurintheanteriorduodenalbulb 60 ofgastriculcersarelocatedinthelessercurvature chemicalperitonitis6 8hbacterialperitonitis 22 23 24 CLINICALMANIFESTATIONANDDIAGNOSIS Ulcerhistory10 negtiveSevereepigastricandlatergeneralizeabdominalpain Thepatientcantypicallyrecalltheexacttimeofonsetofabdominalpain NauseaandvomitingToxicSymptom fever WBC lowbloodpreasure 25 CLINICALMANIFESTATIONANDDIAGNOSIS supination仰卧andliesstillBoardlikerigidityoftheabdominalmusculature boardlikeventer板状腹Decreasedbowelsounds80 casesshowfreeairunderthediaphram eroperitoneum气腹症 26 DIAGNOSIS HistoryPhysicalexaminationX rayDiagnosticabdominalparacentesisnotclear foodresidue yellowish 27 DifferentialDiagnosis AcutePancreatitisAcuteCholecystitisAcuteAppendicitisPerforationOfGastricCancer 28 Management Nonoperativemanagementindication Mildclinicalmanifestation limitedperitonitisPerforationonemptystomachRuleouttelephium顽固性溃疡 hemorrhage obstructionandcancerationHardtotoleratesurgicalprocedure 29 PerforationrepairPatchingtheperforatedulcerIndicationsbadgeneralcondition 12h sinceperforate severeinflamationinabdominalcavity Surgicaltreatment 30 Surgicaltreatment RadicalSurgerysubtotalgastricresectionpatchingmethods highlyselectivevagotomyIndicationsgoodgeneralcondition 12h sinceperforate mildinflamationinabdominalcavity hadhistoryofperforation hemorrhage obstructionpriortothisperforationsuspectcanceration 31 Perforationrepair 32 Perforationrepair 33 Hemorrhageofgastroduodenalulcer Theleadingcauseofdeathduetopepticulcer 34 Hemorrhageofgastroduodenalulcer pathologyTheerotionofbasevessalinulcer Commoninlessergastriccurvatureorposteriorwallofduodenum 35 ClinicalManifestationAndDiagnosis HaematemesisandmelenaBloodloss 400ml pale drymouth quickpules 800ml shockAbdominalphysicalsignisnotobvious 36 DifferentialDiagnosis EsophagealVaricesBleeding胃底食管静脉曲张破裂出血AcuteHemobilia胆道出血GastricCancerBleedingStressUlcerationBleeding应激性溃疡出血 37 therapeuticprinciple Hemostasis止血SupplementBloodVolumePreventRecurrence 38 Surgicalindication Massivehemorrhage acutebloodlossresultinsyncope晕厥 600 800mlbloodtransfusionin6 8h unstablebloodpresure Haveanotherhemorrhagehistory Duringtheperiodofantiulcerdrugtherapy Togetherwithperforateandcicatricialpyloricobstructionpatientover60yearsoldorwitharteriosclerosis 39 Surgicaltreatment SubtotalgastrectomyLigationofthebleedingvesselwithintheulcerbase vagotomy pyloroplasty幽门成形术Simpleligationofthebleedingvessel 40 CicatricialPyloricObstruction 41 EtiologyAndPathology Spasticity痉挛性 reflectivity反射性 Edematous水肿性 inflammation Cicatricle瘢痕性 oraccompanywithspasticityandedematous Oftenoccurinpatientwithduodenalulcer Longcourseofdisease 42 clinicalmanifestationanddiagnosis ClinicalManifestationAbdominaldistention tovomitindigestivefoodwithoutbile malnutritionsplashingsound振水音 DiagnosishistoryX ray bariumretention 24h 43 DifferentialDiagnosis PylorospasmandoedemacausedbyactiveulcerobstructioninducedbyGastriccancerObstructioninferiortoduodenalbulbgastroscope X ray 44 Treatment Preoperativepreparation gastrointestinaldecompression胃肠减压gastriclavage洗胃3 7days tocorrectWater ElectrolyteandacidbasebalancedisorderSurgicalprocedure subtotalgastrectomy vagotomy antrectomy胃窦切除术 stomach jejunumanastomosis胃空肠吻合 45 SurgicalProceduresforPepticUlcerDisease 46 SUBTOTALGASTRECTOMY Subtotalgastrectomyisrarelyperformedfortreatmentofpatientswithpepticulcerdisease Itisusuallyreservedforpatientswithunderlyingmalignanciesorpatientswhohavedevelopedrecurrentulcerationsfollowingtruncalvagotomyandantrectomy 47 SUBTOTALGASTRECTOMY BillrothIanastomosisSimple tofitphysiologicalfunction reducerefluxingofbileandpancreaticjuice Insufficientgastrectomy 48 HemigastrectomywithBillroth1 gastroduodenal anastomosis FromDempseyD PathakA Antrectomy OperativeTechniquesinGeneralSurgery5 86 100 2003 49 SUBTOTALGASTRECTOMY BillrothIIanastomosissufficientgastrectomy complicatedmorepostoperativecomplication 50 BillrothIIoperationandsomeofitsmodifications 51 Roux en Ygastro jejunumanastomosis 52 Vagotomy Vagotomydecreasespeakacidoutputbyapproximately50 whereasvagotomyplusantrectomy whichremovesthegastrin secretingportionofthestomach decreasespeakacidoutputbyapproximately85 53 54 parietalcellorhighlyselectivevagotomy 55 超选择性迷走神经切断术Highlyselectivevagotomy 56 Figure45 12AtoE Heineke Mikuliczpyloroplasty A E FromSoreideJA SoreideA Pyloroplasty OperativeTechniquesinGeneralSurgery5 65 72 2003 57 SurgicalTreatmentRecommendationsforComplicationsRelatedtoPepticUlcerDisease DuodenalUlcerIntractable parietalcellvagotomyBleeding truncalvagotomywithpyloroplastyandoversewingofbleedingvesselPerforation patchclosurewithtreatmentofH pyloriwithorwithoutparietalcellvagotomyObstruction ruleoutmalignancyandparietalcellvagotomywithgastrojejunostomy SabistonTextbookofSurgery 18thed 58 SurgicalTreatmentRecommendationsforComplicationsRelatedtoPepticUlcerDisease GastricUlcerIntractable TypeI distalgastrectomywithBillrothI TypeIIorIII distalgastrectomywithtruncalvagotomyBleeding TypeI distalgastrectomywithBillrothI TypeIIorIII distalgastrectomywithtruncalvagotomyPerforated TypeI stable distalgastrectomywithBillrothI TypeI unstable biopsy patch andtreatmentforH pylori TypeIIorIII patchclosurewithtreatmentofH pylori SabistonTextbookofSurgery 18thed 59 SurgicalTreatmentRecommendationsforComplicationsRelatedtoPepticUlcerDisease GastricUlcerObstruction ruleoutmalignancyandantrectomywithvagotomy TypeIV dependsonulcersize distancefromthegastroesophagealjunction anddegreeofsurroundinginflammation Giantgastriculcers distalgastrectomy withvagotomyreservedfortypeIIandIIIgastriculcers SabistonTextbookofSurgery 18thed 60 Operationsforhigh lyingulcersnearthegastroesophagealjunction typeIV 61 POSTOPERATIVECOMPLICATIONSOFSUBTOTALGASTRECTOMY 62 POSTOPERATIVECOMPLICATIONS 1 postoperativegastrichemorrhage4 6 anastomoticstomableeding 63 postoperativecomplications 2 duodenalstumpruptureOftenin1 2daysafteroperation 48abdominalcavitydrainage 64 postoperativecomplicationsofsubtotalgastrectomy 3 gastrointestinalanastomoticstomaruptureorfistularare5 7afteroperation 65 postoperativecomplicationsofsubtotalgastrectomy 4 postoperativeobstruction AFFERENTLOOPSYNDROMEorafferentloopobstruction输入段梗阻 anastomoticstomaobstructionGastroparesisorDelayedGastricEmptying DGE EFFERENTLOOPOBSTRUCTION 66 postoperativecomplicationsofsubtotalgastrectomy EarlyDumpingSyndrome occurswithin20to30minutesfollowingingestionofamealandisaccompaniedbybothgastrointestinalandcardiovascularsymptomsitismorecommonafterpartialgastrectomywiththeBillrothIIreconstructionLateDumpingSyndrome appears2to3hoursafterameal Hypoglycemiasyndrom 67 postoperativecomplicationsofsubtotalgastrectomy AlkalineRefluxGastritissevereepigastricabdominalpainaccompaniedbybiliousvomitingandweightlossusuallynotrelievedbyfoodorantacidspatientswithintractablesymptoms Roux en Yanastomosis 68 postoperativecomplicationsofvagotomy EsophagusperforationLessergastriccurvaturenecrosisDysphagia吞咽困难DelayedgastricemptyingPostvagotomydiarrheaIncompletevagaltransection 69 GASTRICCANCER CANCEROFSTOMACH 70 GrossPathology EarlygastriccancerdiseaseinvolvingonlythemucosaorsubmucosaAdvancedgastriccancerinvasionofthemuscularisorbeyond 71 Earlygastriccancer 型隆起型 a型隆起表浅型 b型平坦表浅型 c型表浅凹陷型 型凹陷型 型表浅型 72 Borrmann sclassification Borrmann spathologicclassificationofgastriccancerbasedongrossappearance 73 methodsofextension 1 spreadwithinthegastricwall2 lymphaticmetastasis23grouplymphnodessupraclavicularlymphnodes左锁骨上淋巴结3 bloodspread hepaticmetastasis4 implantationmetastasis种植转移5 ovariesmetastasis卵巢转移6 gastricmicrometastasis微转移 74 75 TNMStagingClas