胃十二指肠疾病双语教学课件

,单击此处编辑母版标题样式,#,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,THE DISEASE OF STOMACH AND DUODENUM,胃十二指肠疾病,THE DISEASE OF STOMACH AND DUO,1,Outline,SURGICAL TREATMENT OF PEPTIC ULCER,COMPLICATIONS OF PEPTIC ULCER,STOMACH CANCER,OutlineSURGICAL TREATMENT OF P,2,SURGICAL TREATMENT OF PEPTIC ULCER,SURGICAL TREATMENT OF PEPTIC U,3,Etiology,Acid,Gastric Mucosal Barrier,Nonsteroidal Antiinflammatory Drugs,（,NSAIDs,）,Alcohal,Gastric Stasis,Helicobacter Pylori, HP,Cigarette Smoking,EtiologyAcid,4,Difference Between Gastric And Duodenal Ulcer,Duodenal Ulcer,vagus nerve - oversecretion of acid,Gastric Ulcer,1,Disruption of gastric mucosal barrier,2,Gastric stasis,Difference Between Gastric And,5,Duodenal Ulcer,Clinical feature,burning,，,stabbing, or gnawing epigastric pain. 3,4 hours after ingestion,hunger pain and night pain,Ingestion of food and antacids often relieve pain,Duodenal UlcerClinical feature,6,Diagnosis,History,Fiberoptic Endoscopy,Radiology,Diagnosis,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,8,十二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,胃十二指肠疾病双语教学课件,10,Duodenal Ulcer,Duodenal Ulcer,11,Duodenal Ulcer,Surgical indication,Inefficacy of medical treatment,（,intractable ulcer,telephium,顽固性溃疡,）,serious complication,（,hemorrhage, perforation, cicatricial Pyloric Obstruction,）,Duodenal UlcerSurgical indicat,12,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 Textbook of Surgery, 18,th,ed,Intractable ulcerIntractabilit,13,Gastric Ulcer,Clinical feature,No regularity of gatric pain,1/2-1h after ingestion,，,postprandial discomfort,Ingestion of food and antacids can not relieve pain ,or exacerbation on eating,Gastric UlcerClinical feature,14,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,15,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,16,Gastric Ulcer,Gastric Ulcer,17,胃十二指肠疾病双语教学课件,18,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 prepyloric 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%,）,Types Of Gastric Ulcertype 1 （,19,Gastric Ulcer,Surgical indication,hemorhage,perforation,obstuction,intractability,need to rule out the possibility of carcinoma,Gastric UlcerSurgical indicati,20,Acute Perforation of Gastroduodenal Ulcer,Acute Perforation of Gastroduo,21,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 peritonitis,pathology90% of perforated duo,22,胃十二指肠疾病双语教学课件,23,胃十二指肠疾病双语教学课件,24,CLINICAL MANIFESTATION AND DIAGNOSIS,Ulcer history 10% negtive,Severe epigastric and later generalize abdominal pain,。（,The patient can typically recall the exact time of onset of abdominal pain,）,Nausea and vomiting,Toxic Symptom: fever,，,WBC,，,low blood preasure,。,CLINICAL MANIFESTATION AND DIA,25,CLINICAL MANIFESTATION AND DIAGNOSIS,supination,仰卧,and lies still,Boardlike rigidity of the abdominal musculature,，,boardlike venter,板状腹,Decreased bowel sounds,80% cases show free air under the diaphram,，,eroperitoneum,气腹症,CLINICAL MANIFESTATION AND DIA,26,DIAGNOSIS,History,Physical examination,X-ray,Diagnostic abdominal paracentesis,not clear, food residue, yellowish,DIAGNOSISHistory,27,Differential Diagnosis,Acute Pancreatitis,Acute Cholecystitis,Acute Appendicitis,Perforation Of Gastric Cancer,Differential DiagnosisAcute Pa,28,Management,Nonoperative management,indication,：,Mild clinical manifestation, limited peritonitis,Perforation on empty stomach,Rule out telephium,顽固性溃疡, hemorrhage, obstruction and canceration,Hard to tolerate surgical procedure,ManagementNonoperative managem,29,Perforation repair,Patching the perforated ulcer,Indications,bad general condition;,12h,，,since perforate;,severe inflamation in abdominal cavity,Surgical treatment,Perforation repair Surgical tr,30,Surgical treatment,Radical Surgery,subtotal gastric resection,patching methods+ highly selective vagotomy,Indications,good general condition,，,400ml, pale, dry mouth,quick pules,800ml,，,shock,Abdominal physical sign is not obvious,Clinical Manifestation And Dia,36,Differential Diagnosis,Esophageal Varices Bleeding,胃底食管静脉曲张破裂出血,Acute Hemobilia,胆道出血,Gastric Cancer Bleeding,Stress Ulceration Bleeding,应激性溃疡出血,Differential DiagnosisEsophage,37,therapeutic principle,Hemostasis,止血,Supplement Blood Volume,Prevent Recurrence.,therapeutic principle,38,Surgical indication,Massive hemorrhage, acute blood loss result in syncope,晕厥。,600-800ml blood transfusion in 6-8h,，,unstable blood presure.,Have another hemorrhage history.,During the period of antiulcer drug therapy.,Together with perforate and cicatricial pyloric,obstruction,patient over 60 years old or with arteriosclerosis.,Surgical indicationMassive hem,39,Surgical treatment,：,Subtotal gastrectomy,Ligation of the bleeding vessel within the ulcer base,vagotomy,pyloroplasty,幽门成形术,Simple ligation of the bleeding vessel,Surgical treatment：,40,Cicatricial Pyloric Obstruction,Cicatricial Pyloric Obstructio,41,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.,Long course of disease:,Etiology And PathologySpastici,42,clinical manifestation and diagnosis,Clinical Manifestation,Abdominal distention, to vomit indigestive food without bile.,malnutrition,splashing sound,振水音（,+,）,Diagnosis,history,X-ray: barium retention24h,clinical manifestation and dia,43,Differential Diagnosis,Pylorospasm and oedema caused by active ulcer,obstruction induced by Gastric cancer,Obstruction inferior to duodenal bulb,gastroscope, X-ray,Differential DiagnosisPylorosp,44,Treatment,Preoperative preparation,gastrointestinal decompression,胃肠减压,gastric lavage,洗胃,3-7days,to correct Water-Electrolyte and,acid base balance,disorder,Surgical procedure,subtotal gastrectomy, vagotomy,+,antrectomy,胃窦切除术,stomach-,jejunum anastomosis,胃空肠吻合,TreatmentPreoperative preparat,45,Surgical Procedures for Peptic Ulcer Disease,Surgical Procedures for Peptic,46,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 ulcerations following truncal vagotomy and antrectomy.,SUBTOTAL GASTRECTOMYSubtotal g,47,SUBTOTAL GASTRECTOMY,Billroth I,anastomosis,Simple, to fit physiological function,；,reduce refluxing of bile and pancreatic juice,；,Insufficient gastrectomy.,SUBTOTAL GASTRECTOMYBillroth I,48,Hemigastrectomy with Billroth 1 (gastroduodenal) anastomosis.,(From Dempsey D, Pathak A: Antrectomy. Operative Techniques in General Surgery 5:86100, 2003.),Hemigastrectomy with Billroth,49,SUBTOTAL GASTRECTOMY,Billroth II,anastomosis,sufficient gastrectomy, complicated,more postoperative complication,SUBTOTAL GASTRECTOMYBillroth,50,Billroth II operation and some of its modifications.,Billroth II operation and some,51,Roux-en-Y,gastro-jejunum anastomosis,Roux-en-Y gastro-jejunum anas,52,Vagotomy,Vagotomy decreases peak 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%.,VagotomyVagotomy decreases pea,53,54,parietal cell or highly selective vagotomy,parietal cell or highly select,55,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Highly selective v,56,Figure 45-12 A to E, Heineke-Mikulicz pyloroplasty.,(AE, From Soreide JA, Soreide A: Pyloroplasty. Operative Techniques in General Surgery 5:6572, 2003.),Figure 45-12 A to E, Heineke-M,57,Surgical Treatment Recommendations for Complications Related to Peptic Ulcer Disease,Duodenal Ulcer,Intractable:,parietal cell vagotomy,Bleeding:,truncal vagotomy with pyloroplasty and oversewing 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, 18,th,ed,Surgical Treatment Recommendat,58,Surgical Treatment Recommendations for Complications Related to Peptic Ulcer Disease,Gastric Ulcer,Intractable:,Type I: distal gastrectomy with Billroth I,Type II or III: distal gastrectomy with truncal vagotomy,Bleeding,Type I: distal gastrectomy with Billroth I,Type II or III: distal gastrectomy with truncal vagotomy Perforated,Type I, stable: distal gastrectomy 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, 18,th,ed,Surgical Treatment Recommendat,59,Surgical Treatment Recommendations for Complications Related to Peptic Ulcer Disease,Gastric Ulcer,Obstruction:,rule out malignancy 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, 18,th,ed,Surgical Treatment Recommendat,60,Operations for high-lying ulcers near,the gastroesophageal junction (type IV),Operations for high-lying ulce,61,POSTOPERATIVE COMPLICATIONS OF SUBTOTAL GASTRECTOMY,POSTOPERATIVE COMPLICATIONS OF,62,POSTOPERATIVE COMPLICATIONS,（,1,）,postoperative gastric hemorrhage,4-6,，,anastomotic stoma bleeding,POSTOPERATIVE COMPLICATIONS（1）,63,postoperative complications,（,2,）,duodenal stump rupture,Often in 1-2,days after operation,。,48,abdominal cavity drainage,。,postoperative complications（2）,64,postoperative,complications of subtotal gastrectomy,（,3,）,gastrointestinal anastomotic stoma rupture or fistula,rare,5-7,after operation,postoperative complications of,65,postoperative,complications of subtotal gastrectomy,（,4,）,postoperative obstruction,AFFERENT LOOP SYNDROME or afferent loop obstruction,输入段梗阻,anastomotic stoma obstruction,Gastroparesis or Delayed Gastric Emptying(DGE),EFFERENT LOOP OBSTRUCTION,postoperative complications of,66,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 cardiovascular symptoms,it is more common after partial gastrectomy with the Billroth II reconstruction,Late Dumping Syndrome:,appears 2 to 3 hours after a meal,、,Hypoglycemia syndrom,postoperative complications of,67,postoperative,complications of subtotal gastrectomy,Alkaline Reflux Gastritis,severe epigastric abdominal pain accompanied by bilious vomiting and weight loss,usually not relieved by food or antacids,patients,with intractable symptoms -,Roux-en-Y,anastomosis,postoperative complications of,68,postoperative,complications of vagotomy,Esophagus perforation,Lesser gastric curvature necrosis,Dysphagia,吞咽困难,Delayed gastric emptying,Postvagotomy diarrhea,Incomplete vagal transection,postoperative complications of,69,GASTRIC CANCER(CANCER OF STOMACH),GASTRIC CANCER(CANCER OF STOM,70,Gross Pathology,Early gastric cancer,disease involving only the mucosa or submucosa,Advanced gastric cancer,invasion of the muscularis or beyond,Gross Pathology,71,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,Early gastric cancer型 隆起型,72,Borrmanns classification,Borrmanns pathologic classification of gastric cancer based on gross appearance,Borrmanns classificationBorrm,73,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 metastasis,4,，,implantation metastasis,种植转移,5,，,ovaries metastasis,卵巢转移,6,，,gastric micrometastasis,微转移,methods of extension1，spread w,74,胃十二指肠疾病双语教学课件,75,TNM Staging Classification for Carcinoma of the Stomach (AJCC Sixth Edition, 2002),TNM Staging Classification for,76,胃十二指肠疾病双语教学课件,77,胃十二指肠疾病双语教学课件,78,N1,：,1,6 lymph nodes metastasis,N1：16 lymph nodes metastasis,79,N2,：,7,15 lymph nodes metastasis,N2：715 lymph nodes metastasis,80,N3,：,16 lymph nodes metastasis,N3：16 lymph nodes metastasis,81,胃十二指肠疾病双语教学课件,82,TNM,分期,N,0,N,1,N,2,N,3,T,1,A,B,T,2,B,A,T,3,A,B,T,4,A,H,1,P,1,CY,1,M,1,TNM分期N0N1N2N3T1ABT2BAT,83,N stage of the JGCA ( Japanese Gastric Cancer Association),classification (the thirteenth edition),肿瘤部位,N1,N2,N3,L/LD,3,4d,5,6,1,7,8a,9,11p,12a,14v,4sb,8p,12b/p,13,16a2/b1,LM/M/ML,1,3,4sb,4d,5,6,7,8a,9,11p,12a,2,4sa,8p,10,11d,12b/p,13,14v,16a2/b1,MU/UM,1,2,3,4sa,4sb,4d,5,6,7,8a,9,10,11p,11d,12a,8p,12b/p,14v,16a2/b1,，,19,，,20,U,1,2,3,4sa,4sb,4d,7,8a,9,10,11p,11d,5,6,8p,12a,12b/p,16a2/b1,，,19,，,20,LMU/MUL,/MLU/UML,1,2,3,4sa,4sb,4d,5,6,7,8a,9,10,11p,11d,12a,14v,8p,12b/p,13,16a2/b1,，,19,，,20,N stage of the JGCA ( Japanese,84,Clinical manifestation,Sign,: no characteristic symptom,Epigastric symptom,Nausea and vomiting,haematemesis and melena,physical sign,：,no special findings in early cases,Epigastric tenderness, mass, weight loss,Virchows sentinel node (supraclsvicular node on the left),Clinical manifestationSign: no,85,Diagnostic methods,Gastroscopy,X-Rays,Diagnostic methodsGastroscopy,86,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,87,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,88,胃癌（溃疡型）,胃癌（溃疡型）,89,胃十二指肠疾病双语教学课件,90,Gastric carcinoma,（,infiltrating type,）,Gastric carcinoma（infiltrating,91,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：,92,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。,标准胃癌根治术范围:,93,胃十二指肠疾病双语教学课件,94,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/m2,5%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,新辅助化疗及辅助化疗方案选择 FOLFOX7方案（首选）：,95,Radiotherapy,Immunotherapy,The Traditional Chinese Medicine,Gene Therapy,Radiotherapy,96,Thank You!,Thank You!,97,