胃十二指肠疾病优秀PPT.ppt

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1、THE DISEASE OF STOMACH AND DUODENUM胃十二指肠疾病胃十二指肠疾病OutlineSURGICAL TREATMENT OF PEPTIC ULCERSURGICAL TREATMENT OF PEPTIC ULCERCOMPLICATIONS OF PEPTIC ULCERCOMPLICATIONS OF PEPTIC ULCERSTOMACH CANCERSTOMACH CANCERSURGICAL TREATMENT OF PEPTIC ULCEREtiologyAcidGastricMucosalBarrierNonsteroidalAntiinflamm

2、atoryDrugs（NSAIDs）AlcohalGastricStasisHelicobacterPylori,HPCigaretteSmokingDifference Between Gastric And Duodenal UlcerDuodenalUlcervagusnerve-oversecretionofacidGastricUlcer1,Disruptionofgastricmucosalbarrier2,GastricstasisDuodenal UlcerClinicalfeatureburning，stabbing,orgnawingepigastricpain.34hou

3、rsafteringestionhungerpainandnightpainIngestionoffoodandantacidsoftenrelievepainDiagnosisHistoryFiberoptic 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 UlcerDuodenal UlcerSurgical indicationInefficacy of medical treatment （i

4、ntractable ulcer,telephium 顽固性溃疡顽固性溃疡）serious complication （hemorrhage,perforation,cicatricial Pyloric Obstruction）IntractableulcerIntractability islooselydefinedasfailureofanulcertohealafteraninitialtrialof8to12weeksoftherapyorifpatientsrelapseaftertherapyhasbeendiscontinued.-SabistonTextbookofSurg

5、ery,18thedGastric UlcerClinical featureNoregularityofgatricpain1/2-1hafteringestion，postprandialdiscomfortIngestionoffoodandantacidscannotrelievepain,orexacerbationoneating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。胃角中心可见一1.5cm1.8cm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

6、溃疡。Gastric UlcerTypesOfGastricUlcertype1（60%）：havelow-to-normalacidoutput.betweenthefundicandantraltype2（15%）：locatedinthebodyofthestomachincombinationwithaduodenalulcer.associatedwithexcessacidsecretion.Type3（20%）：areprepyloriculcersandareassociatedwithhypersecretionofgastricacid.Type4（10%）：occurhi

7、ghonthelesserurvatureneartheGEjunction.arenotassociatedwithexcessiveacidsecretion.（ulcersonthegreatercurvatureofthestomach,5%）Gastric UlcerSurgical indication hemorhage,perforation,obstuction,intractability,need to rule out the possibility of carcinomaAcutePerforationofGastroduodenalUlcerpathology90

8、%ofperforatedduodenalulcersoccurintheanteriorduodenalbulb.60%ofgastriculcersarelocatedinthelessercurvature.chemicalperitonitis6-8h bacterialperitonitisCLINICALMANIFESTATIONANDDIAGNOSISCLINICALMANIFESTATIONANDDIAGNOSISUlcerhistory10%negtiveSevereepigastricandlatergeneralizeabdominalpain。（Thepatientca

9、ntypicallyrecalltheexacttimeofonsetofabdominalpain）NauseaandvomitingToxicSymptom:fever，WBC，lowbloodpreasure。CLINICALMANIFESTATIONANDDIAGNOSISCLINICALMANIFESTATIONANDDIAGNOSISsupination仰卧andliesstillBoardlikerigidityoftheabdominalmusculature，boardlikeventer板状腹Decreasedbowelsounds80%casesshowfreeairun

10、derthediaphram，eroperitoneum气腹症DIAGNOSISHistoryPhysicalexaminationX-rayDiagnosticabdominalparacentesisnotclear,foodresidue,yellowishDifferentialDiagnosis1Acute Pancreatitis1Acute Cholecystitis1Acute Appendicitis 1Perforation Of Gastric Cancer ManagementNonoperative managementindication：Mildclinicalm

11、anifestation,limitedperitonitisPerforationonemptystomachRuleouttelephium顽固性溃疡,hemorrhage,obstructionandcancerationHardtotoleratesurgicalprocedurePerforation repair Patching the perforated ulcerIndicationsbad general condition;12h，since perforate;severe inflamation in abdominal cavitySurgical treatme

12、ntSurgical treatmentRadical SurgeryRadical Surgery subtotal gastric resectionsubtotal gastric resection patching methods+highly selective vagotomy patching methods+highly selective vagotomyIndicationsIndicationsgood general conditiongood general condition，12h,since perforate;400ml,pale,dry mouth,qui

13、ck pules 800ml，shockAbdominal physical sign is not obviousDifferentialDiagnosisEsophagealVaricesBleeding胃底食管静脉曲张裂开出血AcuteHemobilia胆道出血GastricCancerBleedingStressUlcerationBleeding应激性溃疡出血therapeuticprincipleHemostasis止血SupplementBloodVolumePreventRecurrence.Surgical indicationMassive hemorrhage,acute

14、 blood loss result Massive hemorrhage,acute blood loss result in syncopein syncope晕厥。晕厥。晕厥。晕厥。600-800ml blood transfusion in 6-8h600-800ml blood transfusion in 6-8h，unstable blood presure.unstable blood presure.Have another hemorrhage history.Have another hemorrhage history.During the period of anti

15、ulcer drug therapy.During the period of antiulcer drug therapy.Together with perforate and cicatricial pyloricTogether with perforate and cicatricial pyloric obstructionobstructionpatient over 60 years old or with patient over 60 years old or with arteriosclerosis.arteriosclerosis.Surgicaltreatment：

16、SubtotalgastrectomyLigationofthebleedingvesselwithintheulcerbasevagotomypyloroplasty幽门成形术SimpleligationofthebleedingvesselCicatricialPyloricObstructionEtiologyAndPathologySpasticity痉挛性（痉挛性（reflectivity反射性）反射性）Edematous水肿性（水肿性（inflammation）Cicatricle瘢痕性（瘢痕性（or accompany with spasticity and edematous）

17、Often occur in patient with duodenal ulcer.Long course of disease:clinical manifestation and diagnosisClinical ManifestationClinical ManifestationAbdominal distention,to vomit indigestive food Abdominal distention,to vomit indigestive food without bile.without bile.malnutritionmalnutritionsplashing

18、sound振水音（振水音（振水音（振水音（+）DiagnosisDiagnosishistoryhistoryX-ray:barium retention24hX-ray:barium retention24hDifferentialDiagnosisPylorospasm and oedema caused by active ulcerobstruction induced by Gastric cancer Obstruction inferior to duodenal bulb gastroscope,X-rayTreatmentPreoperative preparationPre

19、operative preparation gastrointestinal decompression gastrointestinal decompression胃肠减压胃肠减压 gastric lavagegastric lavage洗胃洗胃 3-7days3-7days to correct Water-Electrolyte and to correct Water-Electrolyte and acid base balance disorderdisorderSurgical procedureSurgical procedure subtotal gastrectomy su

20、btotal gastrectomy vagotomy vagotomy+antrectomy胃窦切除术胃窦切除术胃窦切除术胃窦切除术 stomach-stomach-jejunumanastomosisjejunumanastomosis胃空肠吻胃空肠吻胃空肠吻胃空肠吻合合合合Surgical Procedures for Peptic Ulcer DiseaseSUBTOTAL GASTRECTOMYSubtotalgastrectomyisrarelyperformedfortreatmentofpatientswithpepticulcerdisease.Itisusuallyrese

21、rvedforpatientswithunderlyingmalignanciesorpatientswhohavedevelopedrecurrentulcerationsfollowingtruncalvagotomyandantrectomy.SUBTOTAL GASTRECTOMYBillroth I anastomosisSimple,to fit physiological function；reduce refluxing of bile and pancreatic juice；Insufficient gastrectomy.HemigastrectomywithBillro

22、th1(gastroduodenal)anastomosis.(From Dempsey D,Pathak A:Antrectomy.Operative Techniques in General Surgery 5:86100,2003.)SUBTOTAL GASTRECTOMYBillroth II anastomosissufficient gastrectomy,complicated more postoperative complicationBillrothIIoperationandsomeofitsmodifications.Roux-en-Y gastro-jejunum

23、anastomosisVagotomyVagotomydecreasespeakacidoutputbyapproximately50%,whereasvagotomyplusantrectomy,whichremovesthegastrin-secretingportionofthestomach,decreasespeakacidoutputbyapproximately85%.parietalcellorhighlyselectivevagotomy超选择性迷走神经切断术Highly selective vagotomyFigure 45-12 A to E,Heineke-Mikuli

24、cz pyloroplasty.(AE,From Soreide JA,Soreide A:Pyloroplasty.Operative Techniques in General Surgery 5:6572,2003.)Surgical Treatment Recommendations for Surgical Treatment Recommendations for Complications Related to Peptic Ulcer DiseaseComplications Related to Peptic Ulcer Disease Duodenal UlcerIntra

25、ctable:Intractable:parietalcellvagotomyparietalcellvagotomyBleeding:Bleeding:truncalvagotomywithpyloroplastytruncalvagotomywithpyloroplastyandoversewingofbleedingvesselandoversewingofbleedingvesselPerforation:Perforation:patchclosurewithtreatmentofpatchclosurewithtreatmentofH.H.pyloripyloriwithorwit

26、houtparietalcellvagotomywithorwithoutparietalcellvagotomyObstruction:Obstruction:ruleoutmalignancyandparietalruleoutmalignancyandparietalcellvagotomywithgastrojejunostomycellvagotomywithgastrojejunostomy-SabistonTextbookofSurgery,18SabistonTextbookofSurgery,18ththededSurgical Treatment Recommendatio

27、ns for Surgical Treatment Recommendations for Complications Related to Peptic Ulcer DiseaseComplications Related to Peptic Ulcer DiseaseGastric UlcerGastric Ulcer Intractable:Intractable:TypeI:distalgastrectomywithBillrothITypeI:distalgastrectomywithBillrothI TypeIIorIII:distalgastrectomywithtruncal

28、vagotomyTypeIIorIII:distalgastrectomywithtruncalvagotomyBleedingBleeding TypeI:distalgastrectomywithBillrothITypeI:distalgastrectomywithBillrothI TypeIIorIII:distalgastrectomywithtruncalvagotomyTypeIIorIII:distalgastrectomywithtruncalvagotomyPerforatedPerforated TypeI,stable:distalgastrectomywithBil

29、lrothITypeI,stable:distalgastrectomywithBillrothI TypeI,unstable:biopsy,patch,andtreatmentforTypeI,unstable:biopsy,patch,andtreatmentforH.H.pyloripylori TypeIIorIII:patchclosurewithtreatmentofTypeIIorIII:patchclosurewithtreatmentofH.pyloriH.pylori-SabistonTextbookofSurgery,18SabistonTextbookofSurger

30、y,18ththededSurgical Treatment Recommendations for Surgical Treatment Recommendations for Complications Related to Peptic Ulcer DiseaseComplications Related to Peptic Ulcer DiseaseGastric UlcerGastric UlcerObstruction:Obstruction:ruleoutmalignancyandantrectomyruleoutmalignancyandantrectomywithvagoto

31、my.withvagotomy.TypeIV:TypeIV:dependsonulcersize,distancefromdependsonulcersize,distancefromthegastroesophagealjunction,anddegreeofthegastroesophagealjunction,anddegreeofsurroundinginflammation.surroundinginflammation.Giantgastriculcers:Giantgastriculcers:distalgastrectomy,withdistalgastrectomy,with

32、vagotomyreservedfortypeIIandIIIgastricvagotomyreservedfortypeIIandIIIgastriculcers.ulcers.-SabistonTextbookofSurgery,18SabistonTextbookofSurgery,18ththededOperationsforhigh-lyingulcersnearthegastroesophagealjunction(typeIV)POSTOPERATIVECOMPLICATIONSOFSUBTOTALGASTRECTOMYPOSTOPERATIVECOMPLICATIONS（1）p

33、ostoperative gastric hemorrhage 4-6，anastomoticstomableedingpostoperativecomplications（2）duodenalstumpruptureOften in 1-2 days after operation。48 abdominal cavity drainage。postoperativecomplicationsofsubtotalgastrectomy（3）gastrointestinal anastomotic stoma rupture or fistula rare 5-7 after operation

34、 postoperativecomplicationsofsubtotalgastrectomy（4）postoperative obstructionAFFERENT LOOP SYNDROME or afferent loop obstruction输入段梗阻输入段梗阻 anastomotic stoma obstruction Gastroparesis or Delayed Gastric Emptying(DGE)EFFERENT LOOP OBSTRUCTIONpostoperativecomplicationsofsubtotalgastrectomyEarly Dumping

35、SyndromeEarly Dumping Syndrome：occurswithin20to30minutesfollowingingestionofaoccurswithin20to30minutesfollowingingestionofamealandisaccompaniedbybothgastrointestinalandmealandisaccompaniedbybothgastrointestinalandcardiovascularsymptomscardiovascularsymptomsitismorecommonafterpartialgastrectomywithth

36、eitismorecommonafterpartialgastrectomywiththeBillrothIIreconstructionBillrothIIreconstructionLate Dumping Syndrome:Late Dumping Syndrome:appears2to3hoursafteramealappears2to3hoursafterameal、HypoglycemiasyndromHypoglycemiasyndrompostoperativecomplicationsofsubtotalgastrectomyAlkaline Reflux Gastritis

37、Alkaline Reflux Gastritissevereepigastricabdominalpainaccompaniedsevereepigastricabdominalpainaccompaniedbybiliousvomitingandweightlossbybiliousvomitingandweightlossusuallynotrelievedbyfoodorantacidsusuallynotrelievedbyfoodorantacidspatients patients withintractablesymptoms-withintractablesymptoms-R

38、oux-en-Y Roux-en-Y anastomosisanastomosis postoperativecomplicationsofvagotomyEsophagusperforationLessergastriccurvaturenecrosisDysphagia吞咽困难DelayedgastricemptyingPostvagotomydiarrheaIncompletevagaltransectionGASTRIC CANCER(CANCER OF STOMACH)GrossPathologyEarly gastric cancerdisease involving only t

39、he mucosa or submucosaAdvanced gastric cancer invasion of the muscularis or beyondEarly gastric cancer型型 隆起型隆起型a型型隆起表浅型隆起表浅型b型型平坦表浅型平坦表浅型 c型型表浅凹陷型表浅凹陷型型型 凹陷型凹陷型型型表浅型表浅型BorrmannsclassificationBorrmanns pathologic classification of gastric cancer based on gross appearancemethodsofextension1 1，spread w

40、ithin the gastric wall spread within the gastric wall 2 2，lymphatic metastasislymphatic metastasis 23 group lymph nodes 23 group lymph nodes supraclavicular lymph nodes supraclavicular lymph nodes左锁骨上淋巴结左锁骨上淋巴结3 3，blood spread blood spread：hepatic metastasishepatic metastasis4 4，implantation metasta

41、sisimplantation metastasis种植转移种植转移5 5，ovaries metastasisovaries metastasis卵巢转移卵巢转移6 6，gastric micrometastasisgastric micrometastasis微转移微转移TNM Staging Classification for Carcinoma of the Stomach(AJCC Sixth Edition,2002)N1：16lymphnodesmetastasisN2：715lymphnodesmetastasisN3：16lymphnodesmetastasisTNM分期分

42、期N N0 0N N1 1N N2 2N N3 3T T1 1A AB BT T2 2B BA AT T3 3A AB BT T4 4A AH H1 1 P P1 1 CY CY1 1 M M1 1N stage of the JGCA(Japanese Gastric Cancer Association)classification(the thirteenth edition)肿瘤部位N1N2N3L/LD3,4d,5,61,7,8a,9,11p,12a,14v4sb,8p,12b/p,13,16a2/b1LM/M/ML1,3,4sb,4d,5,67,8a,9,11p,12a2,4sa,8

43、p,10,11d,12b/p,13,14v,16a2/b1MU/UM1,2,3,4sa,4sb,4d,5,67,8a,9,10,11p,11d,12a8p,12b/p,14v,16a2/b1，19，20U1,2,3,4sa,4sb4d,7,8a,9,10,11p,11d5,6,8p,12a,12b/p,16a2/b1，19，20LMU/MUL/MLU/UML1,2,3,4sa,4sb,4d,5,67,8a,9,10,11p,11d,12a,14v8p,12b/p,13,16a2/b1，19，20ClinicalmanifestationSignSign:no:nocharacteristics

44、ymptomcharacteristicsymptomEpigastricsymptomEpigastricsymptomNauseaandvomitingNauseaandvomitinghaematemesis and melenahaematemesis and melenaphysicalsignphysicalsign：nospecialfindingsinearlycasesnospecialfindingsinearlycasesEpigastrictenderness,mass,weightlossEpigastrictenderness,mass,weightlossVirc

45、howssentinelnode(supraclsvicularnodeVirchowssentinelnode(supraclsvicularnodeontheleft)ontheleft)DiagnosticmethodsGastroscopyX-Rays胃体部可见约3.0cm5.0cm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）胃癌（溃疡型）Gastric carcinoma（infiltratingtype）治 疗胃癌根治术要求：充分切

46、除原发癌灶彻底廓清胃四周淋巴结完全歼灭腹腔游离癌细胞和微小转移灶标准胃癌根治术标准胃癌根治术范围范围:切除大小网膜、切除大小网膜、横结肠系膜前叶、横结肠系膜前叶、胰腺被膜；胰腺被膜；清扫第一站淋巴清扫第一站淋巴结：结：3 3、4d4d、5 5、6 6组。其次站淋组。其次站淋巴结：巴结：1 1、7 7、8a8a、9 9、11p11p、12a12a、14v14v组组切除切除3-4cm3-4cm十二十二指肠、上切缘距指肠、上切缘距癌边缘癌边缘5cm5cm以上。以上。新协助化疗及协助化疗方案选择新协助化疗及协助化疗方案选择 FOLFOX7方案（首选）：方案（首选）：5%GS250mlivgttd12h5%GS250mlivgttd12h奥沙利铂奥沙利铂130mg/m2130mg/m25%GS250mlivgttd12h5%GS250mlivgttd12h甲酰四氢叶酸甲酰四氢叶酸 400mg/m2400mg/m2 5-FU2400mg/m25-FU2400mg/m2共计共计240ml5ml/h240ml5ml/h持续泵入持续泵入 48h48h 生理盐水生理盐水RadiotherapyImmunotherapyTheTraditionalChineseMedicineGeneTherapy