胃十二指肠疾病双语教学课件

THE DISEASE OF STOMACH AND DUODENUM胃十二指肠疾病胃十二指肠疾病THEDISEASEOFSTOMACHANDDUO1 1OutlineSURGICAL TREATMENT OF PEPTIC ULCERSURGICAL TREATMENT OF PEPTIC ULCERCOMPLICATIONS OF PEPTIC ULCERCOMPLICATIONS OF PEPTIC ULCERSTOMACH CANCERSTOMACH CANCEROutlineSURGICALTREATMENTOFP2 2SURGICAL TREATMENT OF PEPTIC ULCERSURGICALTREATMENTOFPEPTICU3 3EtiologyAcidGastricMucosalBarrierNonsteroidalAntiinflammatoryDrugs（NSAIDs）AlcohalGastricStasisHelicobacterPylori,HPCigaretteSmokingEtiologyAcid4 4Difference Between Gastric And Duodenal UlcerDuodenalUlcervagusnerve-oversecretionofacidGastricUlcer1,Disruptionofgastricmucosalbarrier2,GastricstasisDifferenceBetweenGastricAnd5 5Duodenal UlcerClinicalfeatureburning，stabbing,orgnawingepigastricpain.34hoursafteringestionhungerpainandnightpainIngestionoffoodandantacidsoftenrelievepainDuodenalUlcerClinicalfeature6 6DiagnosisHistoryFiberoptic Endoscopy RadiologyDiagnosis7 7十二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圆形疡，大小约0.6cm0.7cm溃8 8十二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。十二指肠球部前壁可见一大小约1.0cm1.2cm溃疡，溃疡9 9胃十二指肠疾病双语教学课件1010Duodenal UlcerDuodenalUlcer1111Duodenal 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）DuodenalUlcerSurgicalindicat1212IntractableulcerIntractability islooselydefinedasfailureofanulcertohealafteraninitialtrialof8to12weeksoftherapyorifpatientsrelapseaftertherapyhasbeendiscontinued.-SabistonTextbookofSurgery,18thedIntractableulcerIntractabilit1313Gastric UlcerClinical featureNoregularityofgatricpain1/2-1hafteringestion，postprandialdiscomfortIngestionoffoodandantacidscannotrelievepain,orexacerbationoneatingGastricUlcerClinicalfeature1414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。男，48岁。上腹痛。幽门可见，类圆形，呈开放状态，粘膜充血1515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。胃角中央可见一1.5cm1.8cm圆形深溃疡,内附较厚的黄1616Gastric UlcerGastricUlcer1717胃十二指肠疾病双语教学课件1818TypesOfGastricUlcertype1（60%）：havelow-to-normalacidoutput.betweenthefundicandantraltype2（15%）：locatedinthebodyofthestomachincombinationwithaduodenalulcer.associatedwithexcessacidsecretion.Type3（20%）：areprepyloriculcersandareassociatedwithhypersecretionofgastricacid.Type4（10%）：occurhighonthelesserurvatureneartheGEjunction.arenotassociatedwithexcessiveacidsecretion.（ulcersonthegreatercurvatureofthestomach,5%）TypesOfGastricUlcertype1（1919Gastric UlcerSurgical indication hemorhage,perforation,obstuction,intractability,need to rule out the possibility of carcinomaGastricUlcerSurgicalindicati2020AcutePerforationofGastroduodenalUlcerAcutePerforationofGastroduo2121pathology90%ofperforatedduodenalulcersoccurintheanteriorduodenalbulb.60%ofgastriculcersarelocatedinthelessercurvature.chemicalperitonitis6-8h bacterialperitonitispathology90%ofperforatedduo2222胃十二指肠疾病双语教学课件2323胃十二指肠疾病双语教学课件2424CLINICALMANIFESTATIONANDDIAGNOSISUlcerhistory10%negtiveSevereepigastricandlatergeneralizeabdominalpain。（Thepatientcantypicallyrecalltheexacttimeofonsetofabdominalpain）NauseaandvomitingToxicSymptom:fever，WBC，lowbloodpreasure。CLINICALMANIFESTATIONANDDIA2525CLINICALMANIFESTATIONANDDIAGNOSISsupination仰卧andliesstillBoardlikerigidityoftheabdominalmusculature，boardlikeventer板状腹Decreasedbowelsounds80%casesshowfreeairunderthediaphram，eroperitoneum气腹症CLINICALMANIFESTATIONANDDIA2626DIAGNOSISHistoryPhysicalexaminationX-rayDiagnosticabdominalparacentesisnotclear,foodresidue,yellowishDIAGNOSISHistory2727DifferentialDiagnosis1Acute Pancreatitis1Acute Cholecystitis1Acute Appendicitis 1Perforation Of Gastric Cancer DifferentialDiagnosisAcutePa2828ManagementNonoperative managementindication：Mildclinicalmanifestation,limitedperitonitisPerforationonemptystomachRuleouttelephium顽固性溃疡,hemorrhage,obstructionandcancerationHardtotoleratesurgicalprocedureManagementNonoperativemanagem2929Perforation repair Patching the perforated ulcerIndicationsbad general condition;12h，since perforate;severe inflamation in abdominal cavitySurgical treatmentPerforationrepairSurgicaltr3030Surgical 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 obviousClinicalManifestationAndDia3636DifferentialDiagnosisEsophagealVaricesBleeding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DifferentialDiagnosisEsophage3737therapeuticprincipleHemostasis止血SupplementBloodVolumePreventRecurrence.therapeuticprinciple3838Surgical 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.SurgicalindicationMassivehem3939Surgicaltreatment：SubtotalgastrectomyLigationofthebleedingvesselwithintheulcerbasevagotomypyloroplasty幽门成形术SimpleligationofthebleedingvesselSurgicaltreatment：4040CicatricialPyloricObstructionCicatricialPyloricObstructio4141EtiologyAndPathologySpasticity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:EtiologyAndPathologySpastici4242clinical 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 retention24hclinicalmanifestationanddia4343DifferentialDiagnosisPylorospasm and oedema caused by active ulcerobstruction induced by Gastric cancer Obstruction inferior to duodenal bulb gastroscope,X-rayDifferentialDiagnosisPylorosp4444TreatmentPreoperative 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TreatmentPreoperativepreparat4545Surgical Procedures for Peptic Ulcer DiseaseSurgicalProceduresforPeptic4646SUBTOTAL GASTRECTOMYSubtotalgastrectomyisrarelyperformedfortreatmentofpatientswithpepticulcerdisease.Itisusuallyreservedforpatientswithunderlyingmalignanciesorpatientswhohavedevelopedrecurrentulcerationsfollowingtruncalvagotomyandantrectomy.SUBTOTALGASTRECTOMYSubtotalg4747SUBTOTAL GASTRECTOMYBillroth I anastomosisSimple,to fit physiological function；reduce refluxing of bile and pancreatic juice；Insufficient gastrectomy.SUBTOTALGASTRECTOMYBillrothI4848HemigastrectomywithBillroth1(gastroduodenal)anastomosis.(From Dempsey D,Pathak A:Antrectomy.Operative Techniques in General Surgery 5:86100,2003.)HemigastrectomywithBillroth4949SUBTOTAL GASTRECTOMYBillroth II anastomosissufficient gastrectomy,complicated more postoperative complicationSUBTOTALGASTRECTOMYBillroth5050BillrothIIoperationandsomeofitsmodifications.BillrothIIoperationandsome5151Roux-en-Y gastro-jejunum anastomosisRoux-en-Ygastro-jejunumanas5252VagotomyVagotomydecreasespeakacidoutputbyapproximately50%,whereasvagotomyplusantrectomy,whichremovesthegastrin-secretingportionofthestomach,decreasespeakacidoutputbyapproximately85%.VagotomyVagotomydecreasespea53535454parietalcellorhighlyselectivevagotomyparietalcellorhighlyselect5555超选择性迷走神经切断术Highly selective vagotomy超选择性迷走神经切断术Highlyselectivev5656Figure 45-12 A to E,Heineke-Mikulicz pyloroplasty.(AE,From Soreide JA,Soreide A:Pyloroplasty.Operative Techniques in General Surgery 5:6572,2003.)Figure45-12AtoE,Heineke-M5757Surgical Treatment Recommendations for Complications Related to Peptic Ulcer DiseaseDuodenal UlcerIntractable:parietalcellvagotomyBleeding:truncalvagotomywithpyloroplastyandoversewingofbleedingvesselPerforation:patchclosurewithtreatmentofH.pyloriwithorwithoutparietalcellvagotomyObstruction:ruleoutmalignancyandparietalcellvagotomywithgastrojejunostomy-SabistonTextbookofSurgery,18-SabistonTextbookofSurgery,18thedSurgicalTreatmentRecommendat5858Surgical 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,18thedSurgicalTreatmentRecommendat5959Surgical Treatment Recommendations for Complications Related to Peptic Ulcer DiseaseGastric UlcerObstruction:ruleoutmalignancyandantrectomywithvagotomy.TypeIV:dependsonulcersize,distancefromthegastroesophagealjunction,anddegreeofsurroundinginflammation.Giantgastriculcers:distalgastrectomy,withvagotomyreservedfortypeIIandIIIgastriculcers.-SabistonTextbookofSurgery,18-SabistonTextbookofSurgery,18thedSurgicalTreatmentRecommendat6060Operationsforhigh-lyingulcersnearthegastroesophagealjunction(typeIV)Operationsforhigh-lyingulce6161POSTOPERATIVECOMPLICATIONSOFSUBTOTALGASTRECTOMYPOSTOPERATIVECOMPLICATIONSOF6262POSTOPERATIVECOMPLICATIONS（1）postoperative gastric hemorrhage 4-6，anastomoticstomableedingPOSTOPERATIVECOMPLICATIONS（1）6363postoperativecomplications（2）duodenalstumpruptureOften in 1-2 days after operation。48 abdominal cavity drainage。postoperativecomplications（2）6464postoperativecomplicationsofsubtotalgastrectomy（3）gastrointestinal anastomotic stoma rupture or fistula rare 5-7 after operation postoperativecomplicationsof6565postoperativecomplicationsofsubtotalgastrectomy（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 OBSTRUCTIONpostoperativecomplicationsof6666postoperativecomplicationsofsubtotalgastrectomyEarly Dumping Syndrome：occurswithin20to30minutesfollowingingestionofaoccurswithin20to30minutesfollowingingestionofamealandisaccompaniedbybothgastrointestinalandmealandisaccompaniedbybothgastrointestinalandcardiovascularsymptomscardiovascularsymptomsitismorecommonafterpartialgastrectomywiththeitismorecommonafterpartialgastrectomywiththeBillrothIIreconstructionBillrothIIreconstructionLate Dumping Syndrome:appears2to3hoursafteramealappears2to3hoursafterameal、HypoglycemiasyndromHypoglycemiasyndrompostoperativecomplicationsof6767postoperativecomplicationsofsubtotalgastrectomyAlkaline Reflux Gastritissevereepigastricabdominalpainaccompaniedsevereepigastricabdominalpainaccompaniedbybiliousvomitingandweightlossbybiliousvomitingandweightlossusuallynotrelievedbyfoodorantacidsusuallynotrelievedbyfoodorantacidspatients withintractablesymptoms-withintractablesymptoms-Roux-en-Y anastomosis postoperativecomplicationsof6868postoperativecomplicationsofvagotomyEsophagusperforationLessergastriccurvaturenecrosisDysphagia吞咽困难DelayedgastricemptyingPostvagotomydiarrheaIncompletevagaltransectionpostoperativecomplicationsof6969GASTRIC CANCER(CANCER OF STOMACH)GASTRICCANCER(CANCEROFSTOM7070GrossPathologyEarly gastric cancerdisease involving only the mucosa or submucosaAdvanced gastric cancer invasion of the muscularis or beyondGrossPathology7171Early 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Earlygastriccancer型隆起型7272BorrmannsclassificationBorrmanns pathologic classification of gastric cancer based on gross appearanceBorrmannsclassificationBorrm7373methodsofextension1，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methodsofextension1，spreadw7474胃十二指肠疾病双语教学课件7575TNM Staging Classification for Carcinoma of the Stomach(AJCC Sixth Edition,2002)TNMStagingClassificationfor7676胃十二指肠疾病双语教学课件7777胃十二指肠疾病双语教学课件7878N1：16lymphnodesmetastasisN1：16lymphnodesmetastasis7979N2：715lymphnodesmetastasisN2：715lymphnodesmetastasis8080N3：16lymphnodesmetastasisN3：16lymphnodesmetastasis8181胃十二指肠疾病双语教学课件8282TNM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 1TNM分期N0N1N2N3T1ABT2BAT8383N 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/b1，19，20NstageoftheJGCA(Japanese8484ClinicalmanifestationSignSign:nocharacteristicsymptom:nocharacteristicsymptomEpigastricsymptomNauseaandvomitinghaematemesis and melenaphysicalsign：nospecialfindingsinearlycasesnospecialfindingsinearlycasesEpigastrictenderness,mass,weightlossVirchowssentinelnode(supraclsvicularnodeontheleft)ClinicalmanifestationSign:no8585DiagnosticmethodsGastroscopyX-RaysDiagnosticmethodsGastroscopy8686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。胃体部可见约3.0cm5.0cm范围内多发性大小不等的不规8787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。胃角部可见一2.5cm2.8cm圆形深溃疡,内附的黄色坏死8888胃癌（溃疡型）胃癌（溃疡型）胃癌（溃疡型）8989胃十二指肠疾病双语教学课件9090Gastric carcinoma（infiltratingtype）Gastriccarcinoma（infiltrating9191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治疗胃癌根治术要求：9292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。标准胃癌根治术范围:9393胃十二指肠疾病双语教学课件9494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 生理盐水生理盐水新辅助化疗及辅助化疗方案选择FOLFOX7方案（首选）：9595RadiotherapyImmunotherapyTheTraditionalChineseMedicineGeneTherapyRadiotherapy9696ThankYou!9797