THEDISEASEOFSTOMACHANDDUODENUM

胃十二指腸疾病

THEDISEASEOFSTOMACHANDDUO1OutlineSURGICALTREATMENTOFPEPTICULCERCOMPLICATIONSOFPEPTICULCERSTOMACHCANCEROutlineSURGICALTREATMENTOFP2SURGICALTREATMENTOFPEPTICULCER

SURGICALTREATMENTOFPEPTICU3EtiologyAcidGastricMucosalBarrierNonsteroidalAntiinflammatoryDrugs（NSAIDs）AlcohalGastricStasisHelicobacterPylori,HPCigaretteSmokingEtiologyAcid4DifferenceBetweenGastricAndDuodenalUlcerDuodenalUlcervagusnerve------oversecretionofacidGastricUlcer1,Disruptionofgastricmucosalbarrier2,GastricstasisDifferenceBetweenGastricAnd5DuodenalUlcerClinicalfeatureburning，stabbing,orgnawingepigastricpain.3－4hoursafteringestionhungerpainandnightpainIngestionoffoodandantacidsoftenrelievepainDuodenalUlcerClinicalfeature6Diagnosis

History

FiberopticEndoscopyRadiologyDiagnosis7十二指腸球部前壁可見(jiàn)一圓形瘍，大小約0.6cm×0.7cm潰瘍，基底覆黃厚壞死苔，周邊充血水腫十二指腸球部前壁可見(jiàn)一圓形瘍，大小約0.6cm×0.7cm潰8十二指腸球部前壁可見(jiàn)一大小約1.0cm×1.2cm潰瘍，潰瘍表面覆蓋黃白色壞死苔，周邊充血水腫。十二指腸球部前壁可見(jiàn)一大小約1.0cm×1.2cm潰瘍，潰瘍9胃十二指腸疾病雙語(yǔ)教學(xué)課件10DuodenalUlcerDuodenalUlcer11DuodenalUlcerSurgicalindicationInefficacyofmedicaltreatment

（intractableulcer,

telephium頑固性潰瘍）seriouscomplication

（hemorrhage,perforation,cicatricialPyloricObstruction）

DuodenalUlcerSurgicalindicat12IntractableulcerIntractability

islooselydefinedasfailureofanulcertohealafteraninitialtrialof8to12weeksoftherapyorifpatientsrelapseaftertherapyhasbeendiscontinued.

----SabistonTextbookofSurgery,18thedIntractableulcerIntractabilit13GastricUlcerClinicalfeatureNoregularityofgatricpain1/2-1hafteringestion，postprandialdiscomfortIngestionoffoodandantacidscannotrelievepain,orexacerbationoneatingGastricUlcerClinicalfeature14男，48歲。上腹痛。

幽門(mén)可見(jiàn)，類圓形，呈開(kāi)放狀態(tài)，粘膜充血水腫，可見(jiàn)大小約1.0cm×1.2cm潰瘍，潰瘍表面覆蓋黃白色壞死苔，周邊充血水腫，色澤紅。男，48歲。上腹痛。

幽門(mén)可見(jiàn)，類圓形，呈開(kāi)放狀態(tài)，粘膜充血15胃角中央可見(jiàn)一1.5cm×1.8cm圓形深潰瘍,內(nèi)附較厚的黃色壞死苔,周邊充血水腫；經(jīng)兩次病理活檢,確診為良性潰瘍。胃角中央可見(jiàn)一1.5cm×1.8cm圓形深潰瘍,內(nèi)附較厚的黃16GastricUlcerGastricUlcer17胃十二指腸疾病雙語(yǔ)教學(xué)課件18TypesOfGastricUlcertype1

（60%）：havelow-to-normalacidoutput.betweenthefundicandantraltype2（15%）：locatedinthebodyofthestomachincombinationwithaduodenalulcer.associatedwithexcessacidsecretion.Type3

（20%）：areprepyloriculcersandareassociatedwithhypersecretionofgastricacid.Type4

（10%）：occurhighonthelesserurvatureneartheGEjunction.arenotassociatedwithexcessiveacidsecretion.（ulcersonthegreatercurvatureofthestomach,5%）TypesOfGastricUlcertype1（19GastricUlcerSurgicalindication

hemorhage,perforation,obstuction,intractability,needtoruleoutthepossibilityofcarcinomaGastricUlcerSurgicalindicati20AcutePerforationofGastroduodenalUlcerAcutePerforationofGastroduo21pathology90%ofperforatedduodenalulcersoccurintheanteriorduodenalbulb.60%ofgastriculcersarelocatedinthelessercurvature.chemicalperitonitis6-8hbacterialperitonitispathology90%ofperforatedduo22胃十二指腸疾病雙語(yǔ)教學(xué)課件23胃十二指腸疾病雙語(yǔ)教學(xué)課件24CLINICALMANIFESTATIONANDDIAGNOSISUlcerhistory10%negtiveSevereepigastricandlatergeneralizeabdominalpain。（Thepatientcantypicallyrecalltheexacttimeofonsetofabdominalpain）NauseaandvomitingToxicSymptom:fever，WBC↑，lowbloodpreasure。CLINICALMANIFESTATIONANDDIA25CLINICALMANIFESTATIONANDDIAGNOSISsupination仰臥andliesstillBoardlikerigidityoftheabdominalmusculature，boardlikeventer板狀腹Decreasedbowelsounds80%casesshowfreeairunderthediaphram，eroperitoneum氣腹癥CLINICALMANIFESTATIONANDDIA26DIAGNOSISHistoryPhysicalexaminationX-rayDiagnosticabdominalparacentesis

notclear,foodresidue,yellowishDIAGNOSISHistory27DifferentialDiagnosisAcutePancreatitisAcuteCholecystitisAcuteAppendicitisPerforationOfGastricCancerDifferentialDiagnosisAcutePa28ManagementNonoperativemanagementindication：Mildclinicalmanifestation,limitedperitonitisPerforationonemptystomachRuleouttelephium頑固性潰瘍,hemorrhage,obstructionandcancerationHardtotoleratesurgicalprocedureManagementNonoperativemanagem29Perforationrepair

PatchingtheperforatedulcerIndicationsbadgeneralcondition;>12h，sinceperforate;severeinflamationinabdominalcavitySurgicaltreatmentPerforationrepairSurgicaltr30SurgicaltreatmentRadicalSurgery

subtotalgastricresectionpatchingmethods+highlyselectivevagotomyIndicationsgoodgeneralcondition，<12h,sinceperforate;mildinflamationinabdominalcavity，hadhistoryofperforation,hemorrhage,obstructionpriortothisperforationsuspectcancerationSurgicaltreatmentRadicalSurg31PerforationrepairPerforationrepair32PerforationrepairPerforationrepair33Hemorrhageofgastroduodenalulcer-----TheleadingcauseofdeathduetopepticulcerHemorrhageofgastroduodenalu34HemorrhageofgastroduodenalulcerpathologyTheerotionofbasevessalinulcer.Commoninlessergastriccurvatureorposteriorwallofduodenum.Hemorrhageofgastroduodenalu35ClinicalManifestationAndDiagnosisHaematemesisandmelenaBloodloss>400ml,pale,drymouth,quickpules>800ml，shockAbdominalphysicalsignisnotobviousClinicalManifestationAndDia36DifferentialDiagnosisEsophagealVaricesBleeding胃底食管靜脈曲張破裂出血AcuteHemobilia膽道出血GastricCancerBleedingStressUlcerationBleeding應(yīng)激性潰瘍出血DifferentialDiagnosisEsophage37therapeuticprincipleHemostasis止血SupplementBloodVolumePreventRecurrence.therapeuticprinciple38SurgicalindicationMassivehemorrhage,acutebloodlossresultinsyncope暈厥。600-800mlbloodtransfusionin6-8h，unstablebloodpresure.Haveanotherhemorrhagehistory.Duringtheperiodofantiulcerdrugtherapy.Togetherwithperforateandcicatricialpyloric

obstructionpatientover60yearsoldorwitharteriosclerosis.SurgicalindicationMassivehem39Surgicaltreatment：SubtotalgastrectomyLigationofthebleedingvesselwithintheulcerbase＋vagotomy＋pyloroplasty幽門(mén)成形術(shù)SimpleligationofthebleedingvesselSurgicaltreatment：40CicatricialPyloricObstructionCicatricialPyloricObstructio41EtiologyAndPathologySpasticity痙攣性（reflectivity反射性）Edematous水腫性（inflammation）Cicatricle瘢痕性（oraccompanywithspasticityandedematous）Oftenoccurinpatientwithduodenalulcer.Longcourseofdisease:EtiologyAndPathologySpastici42clinicalmanifestationanddiagnosisClinicalManifestationAbdominaldistention,tovomitindigestivefoodwithoutbile.malnutritionsplashingsound振水音（+）DiagnosishistoryX-ray:bariumretention>24hclinicalmanifestationanddia43DifferentialDiagnosisPylorospasmandoedemacausedbyactiveulcerobstructioninducedbyGastriccancerObstructioninferiortoduodenalbulb

gastroscope,X-rayDifferentialDiagnosisPylorosp44TreatmentPreoperativepreparation

gastrointestinaldecompression胃腸減壓gastriclavage洗胃3-7days

tocorrectWater-ElectrolyteandacidbasebalancedisorderSurgicalprocedure

subtotalgastrectomy

vagotomy+antrectomy胃竇切除術(shù)

stomach-jejunumanastomosis胃空腸吻合TreatmentPreoperativepreparat45SurgicalProceduresforPepticUlcerDiseaseSurgicalProceduresforPeptic46SUBTOTALGASTRECTOMYSubtotalgastrectomyisrarelyperformedfortreatmentofpatientswithpepticulcerdisease.Itisusuallyreservedforpatientswithunderlyingmalignanciesorpatientswhohavedevelopedrecurrentulcerationsfollowingtruncalvagotomyandantrectomy.SUBTOTALGASTRECTOMYSubtotalg47SUBTOTALGASTRECTOMYBillrothIanastomosisSimple,tofitphysiologicalfunction；reducerefluxingofbileandpancreaticjuice；Insufficientgastrectomy.SUBTOTALGASTRECTOMYBillrothI48HemigastrectomywithBillroth1(gastroduodenal)anastomosis.(FromDempseyD,PathakA:Antrectomy.OperativeTechniquesinGeneralSurgery5:86–100,2003.)HemigastrectomywithBillroth49SUBTOTALGASTRECTOMYBillrothIIanastomosissufficientgastrectomy,complicatedmorepostoperativecomplicationSUBTOTALGASTRECTOMYBillroth50BillrothIIoperationandsomeofitsmodifications.BillrothIIoperationandsome51Roux-en-Y

gastro-jejunumanastomosisRoux-en-Ygastro-jejunumanas52VagotomyVagotomydecreasespeakacidoutputbyapproximately50%,whereasvagotomyplusantrectomy,whichremovesthegastrin-secretingportionofthestomach,decreasespeakacidoutputbyapproximately85%.VagotomyVagotomydecreasespea53

54parietalcellorhighlyselectivevagotomyparietalcellorhighlyselect55超選擇性迷走神經(jīng)切斷術(shù)

Highlyselectivevagotomy超選擇性迷走神經(jīng)切斷術(shù)

Highlyselectivev56Figure45-12AtoE,Heineke-Mikuliczpyloroplasty.(A–E,FromSoreideJA,SoreideA:Pyloroplasty.OperativeTechniquesinGeneralSurgery5:65–72,2003.)Figure45-12AtoE,Heineke-M57SurgicalTreatmentRecommendationsforComplicationsRelatedtoPepticUlcerDisease

DuodenalUlcerIntractable:parietalcellvagotomy

Bleeding:truncalvagotomywithpyloroplastyandoversewingofbleedingvessel

Perforation:patchclosurewithtreatmentofH.pyloriwithorwithoutparietalcellvagotomy

Obstruction:ruleoutmalignancyandparietalcellvagotomywithgastrojejunostomy----SabistonTextbookofSurgery,18thedSurgicalTreatmentRecommendat58SurgicalTreatmentRecommendationsforComplicationsRelatedtoPepticUlcerDiseaseGastricUlcer

Intractable:

?TypeI:distalgastrectomywithBillrothI

?

TypeIIorIII:distalgastrectomywithtruncalvagotomyBleeding

?

TypeI:distalgastrectomywithBillrothI

?

TypeIIorIII:distalgastrectomywithtruncalvagotomy

Perforated

?

TypeI,stable:distalgastrectomywithBillrothI

?

TypeI,unstable:biopsy,patch,andtreatmentforH.pylori

?

TypeIIorIII:patchclosurewithtreatmentofH.pylori

----SabistonTextbookofSurgery,18thedSurgicalTreatmentRecommendat59SurgicalTreatmentRecommendationsforComplicationsRelatedtoPepticUlcerDiseaseGastricUlcerObstruction:ruleoutmalignancyandantrectomywithvagotomy.TypeIV:dependsonulcersize,distancefromthegastroesophagealjunction,anddegreeofsurroundinginflammation.

Giantgastriculcers:distalgastrectomy,withvagotomyreservedfortypeIIandIIIgastriculcers.----SabistonTextbookofSurgery,18thedSurgicalTreatmentRecommendat60Operationsforhigh-lyingulcersnearthegastroesophagealjunction(typeIV)

Operationsforhigh-lyingulce61POSTOPERATIVECOMPLICATIONSOF

SUBTOTALGASTRECTOMYPOSTOPERATIVECOMPLICATIONSOF62POSTOPERATIVECOMPLICATIONS（1）postoperativegastrichemorrhage

<24h----uncertainhemostasisinoperation

>4-6，anastomoticstomableedingPOSTOPERATIVECOMPLICATIONS（1）63postoperativecomplications（2）duodenalstumpruptureOftenin1-2

daysafteroperation。

<48

resutureduodenalstumpandmakeduodenaldrainage.

>48

abdominalcavitydrainage。postoperativecomplications（2）64postoperativecomplicationsofsubtotalgastrectomy（3）gastrointestinalanastomoticstomaruptureorfistula

rare

5-7

afteroperation

postoperativecomplicationsof65postoperativecomplicationsofsubtotalgastrectomy（4）postoperativeobstructionAFFERENTLOOPSYNDROMEorafferentloopobstruction輸入段梗阻anastomoticstomaobstruction

GastroparesisorDelayedGastricEmptying(DGE)EFFERENTLOOPOBSTRUCTIONpostoperativecomplicationsof66postoperativecomplicationsofsubtotalgastrectomyEarlyDumpingSyndrome：occurswithin20to30minutesfollowingingestionofamealandisaccompaniedbybothgastrointestinalandcardiovascularsymptomsitismorecommonafterpartialgastrectomywiththeBillrothIIreconstructionLateDumpingSyndrome:appears2to3hoursafterameal、Hypoglycemiasyndrompostoperativecomplicationsof67postoperativecomplicationsofsubtotalgastrectomyAlkalineRefluxGastritissevereepigastricabdominalpainaccompaniedbybiliousvomitingandweightlossusuallynotrelievedbyfoodorantacidspatientswithintractablesymptoms-----Roux-en-Yanastomosis

postoperativecomplicationsof68postoperativecomplicationsofvagotomyEsophagusperforationLessergastriccurvaturenecrosisDysphagia吞咽困難DelayedgastricemptyingPostvagotomydiarrheaIncompletevagaltransectionpostoperativecomplicationsof69GASTRICCANCER

(CANCEROFSTOMACH)GASTRICCANCER

(CANCEROFSTOM70GrossPathologyEarlygastriccancer

diseaseinvolvingonlythemucosaorsubmucosa

AdvancedgastriccancerinvasionofthemuscularisorbeyondGrossPathology71EarlygastriccancerⅠ型隆起型Ⅱa型隆起表淺型Ⅱb型平坦表淺型Ⅱc型表淺凹陷型Ⅲ型凹陷型Ⅱ型表淺型EarlygastriccancerⅠ型隆起型Ⅱ72Borrmann’sclassificationBorrmann’spathologicclassificationofgastriccancerbasedongrossappearanceBorrmann’sclassificationBorrm73methodsofextension1，spreadwithinthegastricwall2，lymphaticmetastasis23grouplymphnodessupraclavicularlymphnodes左鎖骨上淋巴結(jié)3，bloodspread：hepaticmetastasis4，implantationmetastasis種植轉(zhuǎn)移5，ovariesmetastasis卵巢轉(zhuǎn)移6，gastricmicrometastasis微轉(zhuǎn)移methodsofextension1，spreadw74胃十二指腸疾病雙語(yǔ)教學(xué)課件75TNMStagingClassificationforCarcinomaoftheStomach(AJCCSixthEdition,2002)TNMStagingClassificationfor76胃十二指腸疾病雙語(yǔ)教學(xué)課件77胃十二指腸疾病雙語(yǔ)教學(xué)課件78N1：1－6lymphnodesmetastasisN1：1－6lymphnodesmetastasis79N2：7－15lymphnodesmetastasisN2：7－15lymphnodesmetastasis80N3：>16lymphnodesmetastasisN3：>16lymphnodesmetastasis81胃十二指腸疾病雙語(yǔ)教學(xué)課件82TNM分期N0N1N2N3T1ⅠAⅠBⅡⅣT2ⅠBⅡⅢAⅣT3ⅡⅢAⅢBⅣT4ⅢAⅣⅣH1P1CY1M1ⅣⅣⅣTNM分期N0N1N2N3T1ⅠAⅠBⅡⅣT2ⅠBⅡⅢAⅣT83NstageoftheJGCA(JapaneseGastricCancerAssociation)classification(thethirteenthedition)腫瘤部位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/b1，19，20NstageoftheJGCA(Japanese84ClinicalmanifestationSign:nocharacteristicsymptomEpigastricsymptomNauseaandvomiting

haematemesisandmelenaphysicalsign：nospecialfindingsinearlycasesEpigastrictenderness,mass,weightlossVirchow’ssentinelnode(supraclsvicularnodeontheleft)ClinicalmanifestationSign:no85DiagnosticmethodsGastroscopyX-RaysDiagnosticmethodsGastroscopy86胃體部可見(jiàn)約3.0cm×5.0cm范圍內(nèi)多發(fā)性大小不等的不規(guī)則結(jié)節(jié)隆起，伴有糜爛，病理粘液附著，基底堅(jiān)硬如石。胃體部可見(jiàn)約3.0cm×5.0cm范圍內(nèi)多發(fā)性大小不等的不規(guī)87胃角部可見(jiàn)一2.5cm×2.8cm圓形深潰瘍,內(nèi)附的黃色壞死苔,周邊糜爛浸潤(rùn)，脆易出血，基底僵硬，蠕動(dòng)缺失。胃角部可見(jiàn)一2.5cm×2.8cm圓形深潰瘍,內(nèi)附的黃色壞死88胃癌（潰瘍型）胃癌（潰瘍型）89胃十二指腸疾病雙語(yǔ)教學(xué)課件90Gastriccarcinoma（infiltratingtype）Gastriccarcinoma（infiltrating91治療胃癌根治術(shù)要求：充分切除原發(fā)癌灶徹底廓清胃周圍淋巴結(jié)完全消滅腹腔游離癌細(xì)胞和微小轉(zhuǎn)移灶治療胃癌根治術(shù)要求：92標(biāo)準(zhǔn)胃癌根治術(shù)范圍:切除大小網(wǎng)膜、橫結(jié)腸系膜前葉、胰腺被膜；清掃第一站淋巴結(jié)：3、4d、5、6組。第二站淋巴結(jié)：1、7、8a、9、11p、12a、14v組切除3-4cm十二指腸、上切緣距癌邊緣5cm以上。標(biāo)準(zhǔn)胃癌根治術(shù)范圍:93胃十二指腸疾病雙語(yǔ)教學(xué)課件94新輔助化療及輔助化療方案選擇

FOLFOX7方案（首選）：

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5-FU2400mg/m2共計(jì)240ml5ml/h持續(xù)泵入48h

生理鹽水新輔助化療及輔助化療方案選擇FOLFOX7方案（首選）：95RadiotherapyImmunotherapyTheTraditionalChineseMedicineGeneTherapyRadiotherapy96ThankYou!ThankYou!97THEDISEASEOFSTOMACHANDDUODENUM

胃十二指腸疾病

THEDISEASEOFSTOMACHANDDUO98OutlineSURGICALTREATMENTOFPEPTICULCERCOMPLICATIONSOFPEPTICULCERSTOMACHCANCEROutlineSURGICALTREATMENTOFP99SURGICALTREATMENTOFPEPTICULCER

SURGICALTREATMENTOFPEPTICU100EtiologyAcidGastricMucosalBarrierNonsteroidalAntiinflammatoryDrugs（NSAIDs）AlcohalGastricStasisHelicobacterPylori,HPCigaretteSmokingEtiologyAcid101DifferenceBetweenGastricAndDuodenalUlcerDuodenalUlcervagusnerve------oversecretionofacidGastricUlcer1,Disruptionofgastricmucosalbarrier2,GastricstasisDifferenceBetweenGastricAnd102DuodenalUlcerClinicalfeatureburning，stabbing,orgnawingepigastricpain.3－4hoursafteringestionhungerpainandnightpainIngestionoffoodandantacidsoftenrelievepainDuodenalUlcerClinicalfeature103Diagnosis

History

FiberopticEndoscopyRadiologyDiagnosis104十二指腸球部前壁可見(jiàn)一圓形瘍，大小約0.6cm×0.7cm潰瘍，基底覆黃厚壞死苔，周邊充血水腫十二指腸球部前壁可見(jiàn)一圓形瘍，大小約0.6cm×0.7cm潰105十二指腸球部前壁可見(jiàn)一大小約1.0cm×1.2cm潰瘍，潰瘍表面覆蓋黃白色壞死苔，周邊充血水腫。十二指腸球部前壁可見(jiàn)一大小約1.0cm×1.2cm潰瘍，潰瘍106胃十二指腸疾病雙語(yǔ)教學(xué)課件107DuodenalUlcerDuodenalUlcer108DuodenalUlcerSurgicalindicationInefficacyofmedicaltreatment

（intractableulcer,

telephium頑固性潰瘍）seriouscomplication

（hemorrhage,perforation,cicatricialPyloricObstruction）

DuodenalUlcerSurgicalindicat109IntractableulcerIntractability

islooselydefinedasfailureofanulcertohealafteraninitialtrialof8to12weeksoftherapyorifpatientsrelapseaftertherapyhasbeendiscontinued.

----SabistonTextbookofSurgery,18thedIntractableulcerIntractabilit110GastricUlcerClinicalfeatureNoregularityofgatricpain1/2-1hafteringestion，postprandialdiscomfortIngestionoffoodandantacidscannotrelievepain,orexacerbationoneatingGastricUlcerClinicalfeature111男，48歲。上腹痛。

幽門(mén)可見(jiàn)，類圓形，呈開(kāi)放狀態(tài)，粘膜充血水腫，可見(jiàn)大小約1.0cm×1.2cm潰瘍，潰瘍表面覆蓋黃白色壞死苔，周邊充血水腫，色澤紅。男，48歲。上腹痛。

幽門(mén)可見(jiàn)，類圓形，呈開(kāi)放狀態(tài)，粘膜充血112胃角中央可見(jiàn)一1.5cm×1.8cm圓形深潰瘍,內(nèi)附較厚的黃色壞死苔,周邊充血水腫；經(jīng)兩次病理活檢,確診為良性潰瘍。胃角中央可見(jiàn)一1.5cm×1.8cm圓形深潰瘍,內(nèi)附較厚的黃113GastricUlcerGastricUlcer114胃十二指腸疾病雙語(yǔ)教學(xué)課件115TypesOfGastricUlcertype1

（60%）：havelow-to-normalacidoutput.betweenthefundicandantraltype2（15%）：locatedinthebodyofthestomachincombinationwithaduodenalulcer.associatedwithexcessacidsecretion.Type3

（20%）：areprepyloriculcersandareassociatedwithhypersecretionofgastricacid.Type4

（10%）：occurhighonthelesserurvatureneartheGEjunction.arenotassociatedwithexcessiveacidsecretion.（ulcersonthegreatercurvatureofthestomach,5%）TypesOfGastricUlcertype1（116GastricUlcerSurgicalindication

hemorhage,perforation,obstuction,intractability,needtoruleoutthepossibilityofcarcinomaGastricUlcerSurgicalindicati117AcutePerforationofGastroduodenalUlcerAcutePerforationofGastroduo118pathology90%ofperforatedduodenalulcersoccurintheanteriorduodenalbulb.60%ofgastriculcersarelocatedinthelessercurvature.chemicalperitonitis6-8hbacterialperitonitispathology90%ofperforatedduo119胃十二指腸疾病雙語(yǔ)教學(xué)課件120胃十二指腸疾病雙語(yǔ)教學(xué)課件121CLINICALMANIFESTATIONANDDIAGNOSISUlcerhistory10%negtiveSevereepigastricandlatergeneralizeabdominalpain。（Thepatientcantypicallyrecalltheexacttimeofonsetofabdominalpain）NauseaandvomitingToxicSymptom:fever，WBC↑，lowbloodpreasure。CLINICALMANIFESTATIONANDDIA122CLINICALMANIFESTATIONANDDIAGNOSISsupination仰臥andliesstillBoardlikerigidityoftheabdominalmusculature，boardlikeventer板狀腹Decreasedbowelsounds80%casesshowfreeairunderthediaphram，eroperitoneum氣腹癥CLINICALMANIFESTATIONANDDIA123DIAGNOSISHistoryPhysicalexaminationX-rayDiagnosticabdominalparacentesis

notclear,foodresidue,yellowishDIAGNOSISHistory124DifferentialDiagnosisAcutePancreatitisAcuteCholecystitisAcuteAppendicitisPerforationOfGastricCancerDifferentialDiagnosisAcutePa125ManagementNonoperativemanagementindication：Mildclinicalmanifestation,limitedperitonitisPerforationonemptystomachRuleouttelephium頑固性潰瘍,hemorrhage,obstructionandcancerationHardtotoleratesurgicalprocedureManagementNonoperativemanagem126Perforationrepair

PatchingtheperforatedulcerIndicationsbadgeneralcondition;>12h，sinceperforate;severeinflamationinabdominalcavitySurgicaltreatmentPerforationrepairSurgicaltr127SurgicaltreatmentRadicalSurgery

subtotalgastricresectionpatchingmethods+highlyselectivevagotomyIndicationsgoodgeneralcondition，<12h,sinceperforate;mildinflamationinabdominalcavity，hadhistoryofperforation,hemorrhage,obstructionpriortothisperforationsuspectcancerationSurgicaltreatmentRadicalSurg128PerforationrepairPerforationrepair129PerforationrepairPerforationrepair130Hemorrhageofgastroduodenalulcer-----TheleadingcauseofdeathduetopepticulcerHemorrhageofgastroduodenalu131HemorrhageofgastroduodenalulcerpathologyTheerotionofbasevessalinulcer.Commoninlessergastriccurvatureorposteriorwallofduodenum.Hemorrhageofgastroduodenalu132ClinicalManifestationAndDiagnosisHaematemesisandmelenaBloodloss>400ml,pale,drymouth,quickpules>800ml，shockAbdominalphysicalsignisnotobviousClinicalManifestationAndDia133DifferentialDiagnosisEsophagealVaricesBleeding胃底食管靜脈曲張破裂出血AcuteHemobilia膽道出血GastricCancerBleedingStressUlcerationBleeding應(yīng)激性潰瘍出血DifferentialDiagnosisEsophage134therapeuticprincipleHemostasis止血SupplementBloodVolumePreventRecurrence.therapeuticprinciple135SurgicalindicationMassivehemorrhage,acutebloodlossresultinsyncope暈厥。600-800mlbloodtransfusionin6-8h，unstablebloodpresure.Haveanotherhemorrhagehistory.Duringtheperiodofantiulcerdrugtherapy.Togetherwithperforateandcicatricialpyloric

obstructionpatientover60yearsoldorwitharteriosclerosis.SurgicalindicationMassivehem136Surgicaltreatment：SubtotalgastrectomyLigationofthebleedingvesselwithintheulcerbase＋vagotomy＋pyloroplasty幽門(mén)成形術(shù)SimpleligationofthebleedingvesselSurgicaltreatment：137CicatricialPyloricObstructionCicatricialPyloricObstructio138EtiologyAndPathologySpasticity痙攣性（reflectivity反射性）Edematous水腫性（inflammation）Cicatricle瘢痕性（oraccompanywithspasticityandedematous）Oftenoccurinpatientwithduodenalulcer.Longcourseofdisease:EtiologyAndPathologySpastici139clinicalmanifestationanddiagnosisClinicalManifestationAbdominaldistention,tovomitindigestivefoodwithoutbile.malnutritionsplashingsound振水音（+）DiagnosishistoryX-ray:bariumretention>24hclinicalmanifestationanddia140DifferentialDiagnosisPylorospasmandoedemacausedbyactiveulcerobstructioninducedbyGastriccancerObstructioninferiortoduodenalbulb

gastroscope,X-rayDifferentialDiagnosisPylorosp141TreatmentPreoperativepreparation

gastrointestinaldecompression胃腸減壓gastriclavage洗胃3-7days

tocorrectWater-ElectrolyteandacidbasebalancedisorderSurgicalprocedure

subtotalgastrectomy

vagotomy+antrectomy胃竇切除術(shù)

stomach-jejunumanastomosis胃空腸吻合TreatmentPreoperativepreparat142SurgicalProceduresforPepticUlcerDiseaseSurgicalProceduresforPeptic143SUBTOTALGASTRECTOMYSubtotalgastrectomyisrarelyperformedfortreatmentofpatientswithpepticulcerdisease.Itisusuallyreservedforpatientswithunderlyingmalignanciesorpatientswhohavedevelopedrecurrentulcerationsfollowingtruncalvagotomyandantrectomy.SUBTOTALGASTRECTOMYSubtotalg144SUBTOTALGASTRECTOMYBillrothIanastomosisSimple,tofitphysiologicalfunction；reducerefluxingofbileandpancreaticjuice；Insufficientgastrectomy.SUBTOTALGASTRECTOMYBillrothI145HemigastrectomywithBillroth1(gastroduodenal)anastomosis.(FromDempseyD,PathakA:Antrectomy.OperativeTechniquesinGeneralSurgery5:86–100,2003.)HemigastrectomywithBillroth146SUBTOTALGASTRECTOMYBillrothIIanastomosissufficientgastrectomy,complicatedmorepostoperativecomplicationSUBTOTALGASTRECTOMYBillroth147BillrothIIoperationandsomeofitsmodifications.BillrothIIoperationandsome148Roux-en-Y

gastro-jejunumanastomosisRoux-en-Ygastro-jejunumanas149VagotomyVagotomydecreasespeakacidoutputbyapproximately50%,whereasvagotomyplusantrectomy,whichremovesthegastrin-secretingportionofthestomach,decreasespeakacidoutputbyapproximately85%.VagotomyVagotomydecreasespea150

151parietalcellorhighlyselectivevagotomyparietalcellorhighlyselect152超選擇性迷走神經(jīng)切斷術(shù)

Highlyselectivevagotomy超選擇性迷走神經(jīng)切斷術(shù)

Highlyselectivev153Figure45-12AtoE,Heineke-Mikuliczpyloroplasty.(A–E,FromSoreideJA,SoreideA:Pyloroplasty.OperativeTechniquesinGeneralSurgery5:65–72,2003.)Figure45-12AtoE,Heineke-M154SurgicalTreatmentRecommendationsforComplicationsRelatedtoPepticUlcerDisease

DuodenalUlcerIntractable:parietalcellvagotomy

Bleeding:truncalvagotomywithpyloroplastyandoversewingofbleedingvessel

Perforation:patchclosurewithtreatmentofH.pyloriwithorwithoutparietalcellvagotomy

Obstruction:ruleoutmalignancyandparietalcellvagotomywithgastrojejunostomy----SabistonTextbookofSurgery,18thedSurgicalTreatmentRecommendat155SurgicalTreatmentRecommendationsforComplicationsRelatedtoPepticUlcerDiseaseGastricUlcer

Intractable:

?TypeI:distalgastrectomywithBillrothI

?

TypeIIorIII:distalgastrectomywithtruncalvagotomyBleeding

?

TypeI:distalgastrectomywithBillrothI

?

TypeIIorIII:distalgastrectomywithtruncalvagotomy

Perforated

?

TypeI,stable:distalgastrectomywithBillrothI

?

TypeI,unstable:biopsy,patch,andtreatmentforH.pylori

?

TypeIIorIII:patchclosurewithtreatmentofH.pylori

----SabistonTextbookofSurgery,18thedSurgicalTreatmentRecommendat156SurgicalTreatmentRecommendationsforComplicationsRelatedtoPepticUlcerDiseaseG