胃十二指肠疾病双语教学.pptx

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 ULCEREtiologyAcidGastricMucosalBarrierNonsteroidalAntiinflammatoryDrugs（NSAIDs）AlcohalGastricStasisHelicobacterPylori,HPCigaretteSmokingDifference Between Gastric And Duodenal UlcerDuodenalUlcervagusnerve-oversecretionofacidGastricUlcer1,Disruptionofgastricmucosalbarrier2,GastricstasisDuodenal UlcerClinicalfeatureburning，stabbing,orgnawingepigastricpain.34hoursafteringestionhungerpainandnightpainIngestionoffoodandantacidsoftenrelievepainDiagnosisHistoryFiberoptic 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 （intractable ulcer,telephium 顽固性溃疡顽固性溃疡）serious complication （hemorrhage,perforation,cicatricial Pyloric Obstruction）IntractableulcerIntractability islooselydefinedasfailureofanulcertohealafteraninitialtrialof8to12weeksoftherapyorifpatientsrelapseaftertherapyhasbeendiscontinued.-SabistonTextbookofSurgery,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。胃角中央可见一1.5cm1.8cm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,确诊为良性溃疡。Gastric UlcerTypesOfGastricUlcertype1（60%）：havelow-to-normalacidoutput.betweenthefundicandantraltype2（15%）：locatedinthebodyofthestomachincombinationwithaduodenalulcer.associatedwithexcessacidsecretion.Type3（20%）：areprepyloriculcersandareassociatedwithhypersecretionofgastricacid.Type4（10%）：occurhighonthelesserurvatureneartheGEjunction.arenotassociatedwithexcessiveacidsecretion.（ulcersonthegreatercurvatureofthestomach,5%）Gastric UlcerSurgical indication hemorhage,perforation,obstuction,intractability,need to rule out the possibility of carcinomaAcutePerforationofGastroduodenalUlcerpathology90%ofperforatedduodenalulcersoccurintheanteriorduodenalbulb.60%ofgastriculcersarelocatedinthelessercurvature.chemicalperitonitis6-8h bacterialperitonitisCLINICALMANIFESTATIONANDDIAGNOSISUlcerhistory10%negtiveSevereepigastricandlatergeneralizeabdominalpain。（Thepatientcantypicallyrecalltheexacttimeofonsetofabdominalpain）NauseaandvomitingToxicSymptom:fever，WBC，lowbloodpreasure。CLINICALMANIFESTATIONANDDIAGNOSISsupination仰卧andliesstillBoardlikerigidityoftheabdominalmusculature，boardlikeventer板状腹Decreasedbowelsounds80%casesshowfreeairunderthediaphram，eroperitoneum气腹症DIAGNOSISHistoryPhysicalexaminationX-rayDiagnosticabdominalparacentesisnotclear,foodresidue,yellowishDifferentialDiagnosis1Acute Pancreatitis1Acute Cholecystitis1Acute Appendicitis 1Perforation Of Gastric Cancer ManagementNonoperative managementindication：Mildclinicalmanifestation,limitedperitonitisPerforationonemptystomachRuleouttelephium顽固性溃疡,hemorrhage,obstructionandcancerationHardtotoleratesurgicalprocedurePerforation repair Patching the perforated ulcerIndicationsbad general condition;12h，since perforate;severe inflamation in abdominal cavitySurgical treatmentSurgical 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,quick pules 800ml，shockAbdominal physical sign is not obviousDifferentialDiagnosisEsophagealVaricesBleeding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therapeuticprincipleHemostasis止血SupplementBloodVolumePreventRecurrence.Surgical indicationMassive hemorrhage,acute 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 antiulcer drug therapy.During the period of antiulcer drug therapy.Together with perforate and cicatricial pyloricTogether with perforate and cicatricial pyloricobstructionobstructionpatient over 60 years old or with patient over 60 years old or with arteriosclerosis.arteriosclerosis.Surgicaltreatment：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）Often occur in patient with duodenal ulcer.Long course of disease:clinical manifestation and diagnosisClinical ManifestationAbdominal distention,to vomit indigestive food Abdominal distention,to vomit indigestive food without bile.without bile.malnutritionmalnutritionsplashing sound振水音（振水音（振水音（振水音（+）DiagnosishistoryhistoryX-ray:barium retention24hX-ray:barium retention24hDifferentialDiagnosisPylorospasm and oedema caused by active ulcerobstruction induced by Gastric cancer Obstruction inferior to duodenal bulb gastroscope,X-rayTreatmentPreoperative preparationPreoperative preparation gastrointestinal decompression胃肠减压 gastric lavage洗胃 3-7days to correct Water-Electrolyte and acid base balance disorderSurgical procedureSurgical procedure subtotal gastrectomy vagotomy+antrectomy胃窦切除术胃窦切除术 stomach-jejunumanastomosis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.Itisusuallyreservedforpatientswithunderlyingmalignanciesorpatientswhohavedevelopedrecurrentulcerationsfollowingtruncalvagotomyandantrectomy.SUBTOTAL GASTRECTOMYBillroth I anastomosisSimple,to fit physiological function；reduce refluxing of bile and pancreatic juice；Insufficient gastrectomy.HemigastrectomywithBillroth1(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 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-Mikulicz pyloroplasty.(AE,From Soreide JA,Soreide A:Pyloroplasty.Operative Techniques in General Surgery 5:6572,2003.)Surgical Treatment Recommendations for Complications Related to Peptic Ulcer DiseaseDuodenal UlcerIntractable:parietalcellvagotomyBleeding:truncalvagotomywithpyloroplastyandoversewingofbleedingvesselPerforation:patchclosurewithtreatmentofH.pyloriwithorwithoutparietalcellvagotomyObstruction:ruleoutmalignancyandparietalcellvagotomywithgastrojejunostomy-SabistonTextbookofSurgery,18-SabistonTextbookofSurgery,18thedSurgical Treatment Recommendations for Complications Related to Peptic Ulcer DiseaseGastric UlcerIntractable:TypeI:distalgastrectomywithBillrothITypeIIorIII:distalgastrectomywithtruncalvagotomyBleedingTypeI:distalgastrectomywithBillrothI TypeIIorIII:distalgastrectomywithtruncalvagotomyPerforated TypeI,stable:distalgastrectomywithBillrothI TypeI,unstable:biopsy,patch,andtreatmentforH.pylori TypeIIorIII:patchclosurewithtreatmentofH.pylori-SabistonTextbookofSurgery,18-SabistonTextbookofSurgery,18thedSurgical Treatment Recommendations for Complications Related to Peptic Ulcer DiseaseGastric UlcerObstruction:ruleoutmalignancyandantrectomywithvagotomy.TypeIV:dependsonulcersize,distancefromthegastroesophagealjunction,anddegreeofsurroundinginflammation.Giantgastriculcers:distalgastrectomy,withvagotomyreservedfortypeIIandIIIgastriculcers.-SabistonTextbookofSurgery,18-SabistonTextbookofSurgery,18thedOperationsforhigh-lyingulcersnearthegastroesophagealjunction(typeIV)POSTOPERATIVECOMPLICATIONSOFSUBTOTALGASTRECTOMYPOSTOPERATIVECOMPLICATIONS（1）postoperative 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 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 Syndrome：occurswithin20to30minutesfollowingingestionofaoccurswithin20to30minutesfollowingingestionofamealandisaccompaniedbybothgastrointestinalandmealandisaccompaniedbybothgastrointestinalandcardiovascularsymptomscardiovascularsymptomsitismorecommonafterpartialgastrectomywiththeitismorecommonafterpartialgastrectomywiththeBillrothIIreconstructionBillrothIIreconstructionLate Dumping Syndrome:appears2to3hoursafteramealappears2to3hoursafterameal、HypoglycemiasyndromHypoglycemiasyndrompostoperativecomplicationsofsubtotalgastrectomyAlkaline Reflux Gastritissevereepigastricabdominalpainaccompaniedsevereepigastricabdominalpainaccompaniedbybiliousvomitingandweightlossbybiliousvomitingandweightlossusuallynotrelievedbyfoodorantacidsusuallynotrelievedbyfoodorantacidspatients withintractablesymptoms-withintractablesymptoms-Roux-en-Y anastomosis postoperativecomplicationsofvagotomyEsophagusperforationLessergastriccurvaturenecrosisDysphagia吞咽困难DelayedgastricemptyingPostvagotomydiarrheaIncompletevagaltransectionGASTRIC CANCER(CANCER OF STOMACH)GrossPathologyEarly gastric cancerdisease involving only the 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，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 micrometastasis微转移TNM Staging Classification for Carcinoma of the Stomach(AJCC Sixth Edition,2002)N1：16lymphnodesmetastasisN2：715lymphnodesmetastasisN3：16lymphnodesmetastasisTNM分期分期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,8p,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:nocharacteristicsymptom:nocharacteristicsymptomEpigastricsymptomNauseaandvomitinghaematemesis and melenaphysicalsign：nospecialfindingsinearlycasesnospecialfindingsinearlycasesEpigastrictenderness,mass,weightlossVirchowssentinelnode(supraclsvicularnodeontheleft)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。第二站组。第二站淋巴结：淋巴结：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。新辅助化疗及辅助化疗方案选择新辅助化疗及辅助化疗方案选择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