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1、THE DISEASE OF STOMACH AND DUODENUM胃十二指肠疾病,Outline,SURGICAL TREATMENT OF PEPTIC ULCERCOMPLICATIONS OF PEPTIC ULCERSTOMACH CANCER,SURGICAL TREATMENT OF PEPTIC ULCER,Etiology,AcidGastric Mucosal BarrierNonsteroidal Antiinflammatory Drugs（NSAIDs）AlcohalGastric StasisHelicobacter Pylori, HPCigarette Smo
2、king,Difference Between Gastric And Duodenal Ulcer,Duodenal Ulcer vagus nerve - oversecretion of acidGastric Ulcer 1,Disruption of gastric mucosal barrier 2,Gastric stasis,Duodenal Ulcer,Clinical featureburning，stabbing, or gnawing epigastric pain. 34 hours after ingestionhunger pain and night painI
3、ngestion of food and antacids often relieve pain,Diagnosis History Fiberoptic Endoscopy Radiology,十二指肠球部前壁可见一圆形疡，大小约0.6cm0.7cm溃疡，基底覆黄厚坏死苔，周边充血水肿,十二指肠球部前壁可见一大小约1.0cm1.2cm溃疡，溃疡表面覆盖黄白色坏死苔，周边充血水肿。,Duodenal Ulcer,Duodenal Ulcer,Surgical indicationInefficacy of medical treatment （ intractable ulcer, telep
4、hium 顽固性溃疡）serious complication （hemorrhage, perforation, cicatricial Pyloric Obstruction ）,Intractable ulcer,Intractability is loosely defined as failure of an ulcer to heal after an initial trial of 8 to 12 weeks of therapy or if patients relapse after therapy has been discontinued. -Sabiston Text
5、book of Surgery, 18th ed,Gastric Ulcer,Clinical featureNo regularity of gatric pain1/2-1h after ingestion，postprandial discomfortIngestion of food and antacids can not relieve pain ,or exacerbation on eating,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1.0cm1.2cm溃疡，溃疡表面覆盖黄白色坏死苔，周边充血水肿，色泽红。,胃角中央可见一1.5cm1.8cm
6、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。,Gastric Ulcer,Types Of Gastric Ulcer,type 1 （60%）： have low-to-normal acid output. between the fundic and antral type 2（15%）： located in the body of the stomach in combination with a duodenal ulcer. associated with excess acid secretion.Type 3 （20%）：are prepy
7、loric ulcers and are associated with hypersecretion of gastric acid. Type 4 （10%）：occur high on the lesser urvature near the GE junction. are not associated with excessive acid secretion.（ulcers on the greater curvature of the stomach, 5% ）,Gastric Ulcer,Surgical indication hemorhage, perforation, o
8、bstuction, intractability, need to rule out the possibility of carcinoma,Acute Perforation of Gastroduodenal Ulcer,pathology,90% of perforated duodenal ulcers occur in the anterior duodenal bulb. 60% of gastric ulcers are located in the lesser curvature.chemical peritonitis 6-8h bacterial peritoniti
9、s,CLINICAL MANIFESTATION AND DIAGNOSIS,Ulcer history 10% negtiveSevere epigastric and later generalize abdominal pain。（The patient can typically recall the exact time of onset of abdominal pain ）Nausea and vomitingToxic Symptom: fever，WBC，low blood preasure。,CLINICAL MANIFESTATION AND DIAGNOSIS,supi
10、nation仰卧 and lies stillBoardlike rigidity of the abdominal musculature，boardlike venter 板状腹Decreased bowel sounds80% cases show free air under the diaphram，eroperitoneum气腹症,DIAGNOSIS,HistoryPhysical examinationX-rayDiagnostic abdominal paracentesis not clear, food residue, yellowish,Differential Dia
11、gnosis,Acute PancreatitisAcute CholecystitisAcute Appendicitis Perforation Of Gastric Cancer,Management,Nonoperative managementindication：Mild clinical manifestation, limited peritonitisPerforation on empty stomachRule out telephium顽固性溃疡, hemorrhage, obstruction and cancerationHard to tolerate surgi
12、cal procedure,Perforation repair Patching the perforated ulcerIndicationsbad general condition; 12h，since perforate; severe inflamation in abdominal cavity,Surgical treatment,Surgical treatment,Radical Surgery subtotal gastric resection patching methods+ highly selective vagotomyIndicationsgood gene
13、ral condition，12h, since perforate;mild inflamation in abdominal cavity，had history of perforation, hemorrhage, obstruction prior to this perforation suspect canceration,Perforation repair,Perforation repair,Hemorrhage of gastroduodenal ulcer-The leading cause of death due to peptic ulcer,Hemorrhage
14、 of gastroduodenal ulcer,pathologyThe erotion of base vessal in ulcer.Common in lesser gastric curvature or posterior wall of duodenum.,Clinical Manifestation And Diagnosis,Haematemesis and melenaBlood loss 400ml, pale, dry mouth, quick pules 800ml，shockAbdominal physical sign is not obvious,Differe
15、ntial Diagnosis,Esophageal Varices Bleeding胃底食管静脉曲张破裂出血Acute Hemobilia胆道出血Gastric Cancer BleedingStress Ulceration Bleeding应激性溃疡出血,therapeutic principle,Hemostasis止血Supplement Blood VolumePrevent Recurrence.,Surgical indication,Massive hemorrhage, acute blood loss result in syncope晕厥。600-800ml blood
16、 transfusion in 6-8h，unstable blood presure.Have another hemorrhage history.During the period of antiulcer drug therapy.Together with perforate and cicatricial pyloric obstructionpatient over 60 years old or with arteriosclerosis.,Surgical treatment：Subtotal gastrectomyLigation of the bleeding vesse
17、l within the ulcer basevagotomypyloroplasty幽门成形术Simple ligation of the bleeding vessel,Cicatricial Pyloric Obstruction,Etiology And Pathology,Spasticity痉挛性（reflectivity反射性）Edematous水肿性（inflammation）Cicatricle瘢痕性（or accompany with spasticity and edematous）Often occur in patient with duodenal ulcer.Lo
18、ng course of disease:,clinical manifestation and diagnosis,Clinical ManifestationAbdominal distention, to vomit indigestive food without bile.malnutritionsplashing sound振水音（+）DiagnosishistoryX-ray: barium retention24h,Differential Diagnosis,Pylorospasm and oedema caused by active ulcerobstruction in
19、duced by Gastric cancer Obstruction inferior to duodenal bulb gastroscope, X-ray,Treatment,Preoperative preparation gastrointestinal decompression胃肠减压gastric lavage洗胃 3-7days to correct Water-Electrolyte and acid base balance disorderSurgical procedure subtotal gastrectomy vagotomy + antrectomy胃窦切除术
20、 stomach-jejunum anastomosis胃空肠吻合,Surgical Procedures for Peptic Ulcer Disease,SUBTOTAL GASTRECTOMY,Subtotal gastrectomy is rarely performed for treatment of patients with peptic ulcer disease. It is usually reserved for patients with underlying malignancies or patients who have developed recurrent
21、ulcerations following truncal vagotomy and antrectomy.,SUBTOTAL GASTRECTOMY,Billroth I anastomosisSimple, to fit physiological function；reduce refluxing of bile and pancreatic juice；Insufficient gastrectomy.,Hemigastrectomy with Billroth 1 (gastroduodenal) anastomosis. (From Dempsey D, Pathak A: Ant
22、rectomy. Operative Techniques in General Surgery 5:86100, 2003.),SUBTOTAL GASTRECTOMY,Billroth II anastomosissufficient gastrectomy, complicated more postoperative complication,Billroth II operation and some of its modifications.,Roux-en-Y gastro-jejunum anastomosis,Vagotomy,Vagotomy decreases peak
23、acid output by approximately 50%, whereas vagotomy plus antrectomy, which removes the gastrin-secreting portion of the stomach, decreases peak acid output by approximately 85%.,parietal cell or highly selective vagotomy,超选择性迷走神经切断术Highly selective vagotomy,Figure 45-12 A to E, Heineke-Mikulicz pylor
24、oplasty. (AE, From Soreide JA, Soreide A: Pyloroplasty. Operative Techniques in General Surgery 5:6572, 2003.),Surgical Treatment Recommendations for Complications Related to Peptic Ulcer Disease,Duodenal UlcerIntractable: parietal cell vagotomy Bleeding: truncal vagotomy with pyloroplasty and overs
25、ewing of bleeding vessel Perforation: patch closure with treatment of H. pylori with or without parietal cell vagotomy Obstruction: rule out malignancy and parietal cell vagotomy with gastrojejunostomy -Sabiston Textbook of Surgery, 18th ed,Surgical Treatment Recommendations for Complications Relate
26、d to Peptic Ulcer Disease,Gastric Ulcer Intractable: Type I: distal gastrectomy with Billroth IType II or III: distal gastrectomy with truncal vagotomyBleedingType I: distal gastrectomy with Billroth I Type II or III: distal gastrectomy with truncal vagotomy Perforated Type I, stable: distal gastrec
27、tomy with Billroth I Type I, unstable: biopsy, patch, and treatment for H. pylori Type II or III: patch closure with treatment of H. pylori -Sabiston Textbook of Surgery, 18th ed,Surgical Treatment Recommendations for Complications Related to Peptic Ulcer Disease,Gastric UlcerObstruction: rule out m
28、alignancy and antrectomy with vagotomy.Type IV: depends on ulcer size, distance from the gastroesophageal junction, and degree of surrounding inflammation. Giant gastric ulcers: distal gastrectomy, with vagotomy reserved for type II and III gastric ulcers. -Sabiston Textbook of Surgery, 18th ed,Oper
29、ations for high-lying ulcers near the gastroesophageal junction (type IV),POSTOPERATIVE COMPLICATIONS OF SUBTOTAL GASTRECTOMY,POSTOPERATIVE COMPLICATIONS,（1）postoperative gastric hemorrhage 4-6，anastomotic stoma bleeding,postoperative complications,（2） duodenal stump ruptureOften in 1-2 days after o
30、peration。 48 abdominal cavity drainage。,postoperative complications of subtotal gastrectomy,（3） gastrointestinal anastomotic stoma rupture or fistula rare 5-7 after operation,postoperative complications of subtotal gastrectomy,（4） postoperative obstructionAFFERENT LOOP SYNDROME or afferent loop obst
31、ruction输入段梗阻 anastomotic stoma obstruction Gastroparesis or Delayed Gastric Emptying(DGE) EFFERENT LOOP OBSTRUCTION,postoperative complications of subtotal gastrectomy,Early Dumping Syndrome：occurs within 20 to 30 minutes following ingestion of a meal and is accompanied by both gastrointestinal and
32、cardiovascular symptomsit is more common after partial gastrectomy with the Billroth II reconstructionLate Dumping Syndrome:appears 2 to 3 hours after a meal、Hypoglycemia syndrom,postoperative complications of subtotal gastrectomy,Alkaline Reflux Gastritissevere epigastric abdominal pain accompanied
33、 by bilious vomiting and weight lossusually not relieved by food or antacidspatients with intractable symptoms -Roux-en-Y anastomosis,postoperative complications of vagotomy,Esophagus perforationLesser gastric curvature necrosisDysphagia吞咽困难Delayed gastric emptyingPostvagotomy diarrheaIncomplete vag
34、al transection,GASTRIC CANCER(CANCER OF STOMACH),Gross Pathology,Early gastric cancer disease involving only the mucosa or submucosa Advanced gastric cancer invasion of the muscularis or beyond,Early gastric cancer,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,Borrmanns classification,Borrmanns pathologic
35、 classification of gastric cancer based on gross appearance,methods of extension,1，spread within the gastric wall 2，lymphatic metastasis 23 group lymph nodes supraclavicular lymph nodes左锁骨上淋巴结3，blood spread ：hepatic metastasis4，implantation metastasis种植转移5，ovaries metastasis卵巢转移6，gastric micrometast
36、asis微转移,TNM Staging Classification for Carcinoma of the Stomach (AJCC Sixth Edition, 2002),N1：16 lymph nodes metastasis,N2：715 lymph nodes metastasis,N3：16 lymph nodes metastasis,TNM分期,N stage of the JGCA ( Japanese Gastric Cancer Association) classification (the thirteenth edition),Clinical manifes
37、tation,Sign: no characteristic symptom Epigastric symptom Nausea and vomiting haematemesis and melenaphysical sign：no special findings in early cases Epigastric tenderness, mass, weight loss Virchows sentinel node (supraclsvicular node on the left),Diagnostic methods,GastroscopyX-Rays,胃体部可见约3.0cm5.0
38、cm范围内多发性大小不等的不规则结节隆起，伴有糜烂，病理粘液附着，基底坚硬如石。,胃角部可见一2.5cm2.8cm圆形深溃疡,内附的黄色坏死苔,周边糜烂浸润，脆易出血，基底僵硬，蠕动缺失。,胃癌（溃疡型）,Gastric carcinoma（infiltrating type）,治 疗,胃癌根治术要求：充分切除原发癌灶彻底廓清胃周围淋巴结完全消灭腹腔游离癌细胞和微小转移灶,标准胃癌根治术范围: 切除大小网膜、横结肠系膜前叶、胰腺被膜；清扫第一站淋巴结：3、4d、5、6组。第二站淋巴结：1、7、8a、9、11p、12a、14v组切除3-4cm十二指肠、上切缘距癌边缘5cm以上。,新辅助化疗及辅助化疗方案选择,FOLFOX7方案（首选）： 5%GS 250ml ivgtt d1 2h奥沙利铂130mg/m25%GS 250ml ivgtt d1 2h甲酰四氢叶酸 400mg/m2 5-FU 2400mg/m2 共计240ml 5ml/h 持续泵入 48h 生理盐水,RadiotherapyImmunotherapyThe Traditional Chinese MedicineGene Therapy,Thank You!,
