胃十二指肠疾病双语教学课件

THEDISEASEOFSTOMACHANDDUODENUM

胃十二指肠疾病

THEDISEASEOFSTOMACHANDDUO1OutlineSURGICALTREATMENTOFPEPTICULCERCOMPLICATIONSOFPEPTICULCERSTOMACHCANCEROutlineSURGICALTREATMENTOFP2SURGICALTREATMENTOFPEPTICULCER

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

History

FiberopticEndoscopyRadiologyDiagnosis7十二指肠球部前壁可见一圆形疡，大小约0.6cm×0.7cm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0.6cm×0.7cm溃8十二指肠球部前壁可见一大小约1.0cm×1.2cm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1.0cm×1.2cm溃疡，溃疡9胃十二指肠疾病双语教学课件10DuodenalUlcerDuodenalUlcer11DuodenalUlcerSurgicalindicationInefficacyofmedicaltreatment

（intractableulcer,

telephium顽固性溃疡）seriouscomplication

（hemorrhage,perforation,cicatricialPyloricObstruction）

DuodenalUlcerSurgicalindicat12IntractableulcerIntractability

islooselydefinedasfailureofanulcertohealafteraninitialtrialof8to12weeksoftherapyorifpatientsrelapseaftertherapyhasbeendiscontinued.

----SabistonTextbookofSurgery,18thedIntractableulcerIntractabilit13GastricUlcerClinicalfeatureNoregularityofgatricpain1/2-1hafteringestion，postprandialdiscomfortIngestionoffoodandantacidscannotrelievepain,orexacerbationoneatingGastricUlcerClinicalfeature14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1.0cm×1.2cm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胃角中央可见一1.5cm×1.8cm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。胃角中央可见一1.5cm×1.8cm圆形深溃疡,内附较厚的黄16GastricUlcerGastricUlcer17胃十二指肠疾病双语教学课件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胃十二指肠疾病双语教学课件23胃十二指肠疾病双语教学课件24CLINICALMANIFESTATIONANDDIAGNOSISUlcerhistory10%negtiveSevereepigastricandlatergeneralizeabdominalpain。（Thepatientcantypicallyrecalltheexacttimeofonsetofabdominalpain）NauseaandvomitingToxicSymptom:fever，WBC↑，lowbloodpreasure。CLINICALMANIFESTATIONANDDIA25CLINICALMANIFESTATIONANDDIAGNOSISsupination仰卧andliesstillBoardlikerigidityoftheabdominalmusculature，boardlikeventer板状腹Decreasedbowelsounds80%casesshowfreeairunderthediaphram，eroperitoneum气腹症CLINICALMANIFESTATIONANDDIA26DIAGNOSISHistoryPhysicalexaminationX-rayDiagnosticabdominalparacentesis

notclear,foodresidue,yellowishDIAGNOSISHistory27DifferentialDiagnosisAcutePancreatitisAcuteCholecystitisAcuteAppendicitisPerforationOfGastricCancerDifferentialDiagnosisAcutePa28ManagementNonoperativemanagementindication：Mildclinicalmanifestation,limitedperitonitisPerforationonemptystomachRuleouttelephium顽固性溃疡,hemorrhage,obstructionandcancerationHardtotoleratesurgicalprocedureManagementNonoperativemanagem29Perforationrepair

PatchingtheperforatedulcerIndicationsbadgeneralcondition;>12h，sinceperforate;severeinflamationinabdominalcavitySurgicaltreatmentPerforationrepairSurgicaltr30SurgicaltreatmentRadicalSurgery

subtotalgastricresectionpatchingmethods+highlyselectivevagotomyIndicationsgoodgeneralcondition，<12h,sinceperforate;mildinflamationinabdominalcavity，hadhistoryofperforation,hemorrhage,obstructionpriortothisperforationsuspectcancerationSurgicaltreatmentRadicalSurg31PerforationrepairPerforationrepair32PerforationrepairPerforationrepair33Hemorrhageofgastroduodenalulcer-----TheleadingcauseofdeathduetopepticulcerHemorrhageofgastroduodenalu34HemorrhageofgastroduodenalulcerpathologyTheerotionofbasevessalinulcer.Commoninlessergastriccurvatureorposteriorwallofduodenum.Hemorrhageofgastroduodenalu35ClinicalManifestationAndDiagnosisHaematemesisandmelenaBloodloss>400ml,pale,drymouth,quickpules>800ml，shockAbdominalphysicalsignisnotobviousClinicalManifestationAndDia36DifferentialDiagnosisEsophagealVaricesBleeding胃底食管静脉曲张破裂出血AcuteHemobilia胆道出血GastricCancerBleedingStressUlcerationBleeding应激性溃疡出血DifferentialDiagnosisEsophage37therapeuticprincipleHemostasis止血SupplementBloodVolumePreventRecurrence.therapeuticprinciple38SurgicalindicationMassivehemorrhage,acutebloodlossresultinsyncope晕厥。600-800mlbloodtransfusionin6-8h，unstablebloodpresure.Haveanotherhemorrhagehistory.Duringtheperiodofantiulcerdrugtherapy.Togetherwithperforateandcicatricialpyloric

obstructionpatientover60yearsoldorwitharteriosclerosis.SurgicalindicationMassivehem39Surgicaltreatment：SubtotalgastrectomyLigationofthebleedingvesselwithintheulcerbase＋vagotomy＋pyloroplasty幽门成形术SimpleligationofthebleedingvesselSurgicaltreatment：40CicatricialPyloricObstructionCicatricialPyloricObstructio41EtiologyAndPathologySpasticity痉挛性（reflectivity反射性）Edematous水肿性（inflammation）Cicatricle瘢痕性（oraccompanywithspasticityandedematous）Oftenoccurinpatientwithduodenalulcer.Longcourseofdisease:EtiologyAndPathologySpastici42clinicalmanifestationanddiagnosisClinicalManifestationAbdominaldistention,tovomitindigestivefoodwithoutbile.malnutritionsplashingsound振水音（+）DiagnosishistoryX-ray:bariumretention>24hclinicalmanifestationanddia43DifferentialDiagnosisPylorospasmandoedemacausedbyactiveulcerobstructioninducedbyGastriccancerObstructioninferiortoduodenalbulb

gastroscope,X-rayDifferentialDiagnosisPylorosp44TreatmentPreoperativepreparation

gastrointestinaldecompression胃肠减压gastriclavage洗胃3-7days

tocorrectWater-ElectrolyteandacidbasebalancedisorderSurgicalprocedure

subtotalgastrectomy

vagotomy+antrectomy胃窦切除术

stomach-jejunumanastomosis胃空肠吻合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超选择性迷走神经切断术

Highlyselectivevagotomy超选择性迷走神经切断术

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输入段梗阻anastomoticstomaobstruction

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

postoperativecomplicationsof68postoperativecomplicationsofvagotomyEsophagusperforationLessergastriccurvaturenecrosisDysphagia吞咽困难DelayedgastricemptyingPostvagotomydiarrheaIncompletevagaltransectionpostoperativecomplicationsof69GASTRICCANCER

(CANCEROFSTOMACH)GASTRICCANCER

(CANCEROFSTOM70GrossPathologyEarlygastriccancer

diseaseinvolvingonlythemucosaorsubmucosa

AdvancedgastriccancerinvasionofthemuscularisorbeyondGrossPathology71EarlygastriccancerⅠ型隆起型Ⅱa型隆起表浅型Ⅱb型平坦表浅型Ⅱc型表浅凹陷型Ⅲ型凹陷型Ⅱ型表浅型EarlygastriccancerⅠ型隆起型Ⅱ72Borrmann’sclassificationBorrmann’spathologicclassificationofgastriccancerbasedongrossappearanceBorrmann’sclassificationBorrm73methodsofextension1，spreadwithinthegastricwall2，lymphaticmetastasis23grouplymphnodessupraclavicularlymphnodes左锁骨上淋巴结3，bloodspread：hepaticmetastasis4，implantationmetastasis种植转移5，ovariesmetastasis卵巢转移6，gastricmicrometastasis微转移methodsofextension1，spreadw74胃十二指肠疾病双语教学课件75TNMStagingClassificationforCarcinomaoftheStomach(AJCCSixthEdition,2002)TNMStagingClassificationfor76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78N1：1－6lymphnodesmetastasisN1：1－6lymphnodesmetastasis79N2：7－15lymphnodesmetastasisN2：7－15lymphnodesmetastasis80N3：>16lymphnodesmetastasisN3：>16lymphnodesmetastasis81胃十二指肠疾病双语教学课件82TNM分期N0N1N2N3T1ⅠAⅠBⅡⅣT2ⅠBⅡⅢAⅣT3ⅡⅢAⅢBⅣT4ⅢAⅣⅣH1P1CY1M1ⅣⅣⅣTNM分期N0N1N2N3T1ⅠAⅠBⅡⅣT2ⅠBⅡⅢAⅣT83NstageoftheJGCA(JapaneseGastricCancerAssociation)classification(thethirteenthedition)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(Japanese84ClinicalmanifestationSign:nocharacteristicsymptomEpigastricsymptomNauseaandvomiting

haematemesisandmelenaphysicalsign：nospecialfindingsinearlycasesEpigastrictenderness,mass,weightlossVirchow’ssentinelnode(supraclsvicularnodeontheleft)ClinicalmanifestationSign:no85DiagnosticmethodsGastroscopyX-RaysDiagnosticmethodsGastroscopy86胃体部可见约3.0cm×5.0cm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3.0cm×5.0cm范围内多发性大小不等的不规87胃角部可见一2.5cm×2.8cm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。胃角部可见一2.5cm×2.8cm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90Gastriccarcinoma（infiltratingtype）Gastriccarcinoma（infiltrating91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

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胃十二指肠疾病

THEDISEASEOFSTOMACHANDDUO98OutlineSURGICALTREATMENTOFPEPTICULCERCOMPLICATIONSOFPEPTICULCERSTOMACHCANCEROutlineSURGICALTREATMENTOFP99SURGICALTREATMENTOFPEPTICULCER

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

History

FiberopticEndoscopyRadiologyDiagnosis104十二指肠球部前壁可见一圆形疡，大小约0.6cm×0.7cm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0.6cm×0.7cm溃105十二指肠球部前壁可见一大小约1.0cm×1.2cm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1.0cm×1.2cm溃疡，溃疡106胃十二指肠疾病双语教学课件107DuodenalUlcerDuodenalUlcer108DuodenalUlcerSurgicalindicationInefficacyofmedicaltreatment

（intractableulcer,

telephium顽固性溃疡）seriouscomplication

（hemorrhage,perforation,cicatricialPyloricObstruction）

DuodenalUlcerSurgicalindicat109IntractableulcerIntractability

islooselydefinedasfailureofanulcertohealafteraninitialtrialof8to12weeksoftherapyorifpatientsrelapseaftertherapyhasbeendiscontinued.

----SabistonTextbookofSurgery,18thedIntractableulcerIntractabilit110GastricUlcerClinicalfeatureNoregularityofgatricpain1/2-1hafteringestion，postprandialdiscomfortIngestionoffoodandantacidscannotrelievepain,orexacerbationoneatingGastricUlcerClinicalfeature111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1.0cm×1.2cm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112胃角中央可见一1.5cm×1.8cm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。胃角中央可见一1.5cm×1.8cm圆形深溃疡,内附较厚的黄113GastricUlcerGastricUlcer114胃十二指肠疾病双语教学课件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胃十二指肠疾病双语教学课件120胃十二指肠疾病双语教学课件121CLINICALMANIFESTATIONANDDIAGNOSISUlcerhistory10%negtiveSevereepigastricandlatergeneralizeabdominalpain。（Thepatientcantypicallyrecalltheexacttimeofonsetofabdominalpain）NauseaandvomitingToxicSymptom:fever，WBC↑，lowbloodpreasure。CLINICALMANIFESTATIONANDDIA122CLINICALMANIFESTATIONANDDIAGNOSISsupination仰卧andliesstillBoardlikerigidityoftheabdominalmusculature，boardlikeventer板状腹Decreasedbowelsounds80%casesshowfreeairunderthediaphram，eroperitoneum气腹症CLINICALMANIFESTATIONANDDIA123DIAGNOSISHistoryPhysicalexaminationX-rayDiagnosticabdominalparacentesis

notclear,foodresidue,yellowishDIAGNOSISHistory124DifferentialDiagnosisAcutePancreatitisAcuteCholecystitisAcuteAppendicitisPerforationOfGastricCancerDifferentialDiagnosisAcutePa125ManagementNonoperativemanagementindication：Mildclinicalmanifestation,limitedperitonitisPerforationonemptystomachRuleouttelephium顽固性溃疡,hemorrhage,obstructionandcancerationHardtotoleratesurgicalprocedureManagementNonoperativemanagem126Perforationrepair

PatchingtheperforatedulcerIndicationsbadgeneralcondition;>12h，sinceperforate;severeinflamationinabdominalcavitySurgicaltreatmentPerforationrepairSurgicaltr127SurgicaltreatmentRadicalSurgery

subtotalgastricresectionpatchingmethods+highlyselectivevagotomyIndicationsgoodgeneralcondition，<12h,sinceperforate;mildinflamationinabdominalcavity，hadhistoryofperforation,hemorrhage,obstructionpriortothisperforationsuspectcancerationSurgicaltreatmentRadicalSurg128PerforationrepairPerforationrepair129PerforationrepairPerforationrepair130Hemorrhageofgastroduodenalulcer-----TheleadingcauseofdeathduetopepticulcerHemorrhageofgastroduodenalu131HemorrhageofgastroduodenalulcerpathologyTheerotionofbasevessalinulcer.Commoninlessergastriccurvatureorposteriorwallofduodenum.Hemorrhageofgastroduodenalu132ClinicalManifestationAndDiagnosisHaematemesisandmelenaBloodloss>400ml,pale,drymouth,quickpules>800ml，shockAbdominalphysicalsignisnotobviousClinicalManifestationAndDia133DifferentialDiagnosisEsophagealVaricesBleeding胃底食管静脉曲张破裂出血AcuteHemobilia胆道出血GastricCancerBleedingStressUlcerationBleeding应激性溃疡出血DifferentialDiagnosisEsophage134therapeuticprincipleHemostasis止血SupplementBloodVolumePreventRecurrence.therapeuticprinciple135SurgicalindicationMassivehemorrhage,acutebloodlossresultinsyncope晕厥。600-800mlbloodtransfusionin6-8h，unstablebloodpresure.Haveanotherhemorrhagehistory.Duringtheperiodofantiulcerdrugtherapy.Togetherwithperforateandcicatricialpyloric

obstructionpatientover60yearsoldorwitharteriosclerosis.SurgicalindicationMassivehem136Surgicaltreatment：SubtotalgastrectomyLigationofthebleedingvesselwithintheulcerbase＋vagotomy＋pyloroplasty幽门成形术SimpleligationofthebleedingvesselSurgicaltreatment：137CicatricialPyloricObstructionCicatricialPyloricObstructio138EtiologyAndPathologySpasticity痉挛性（reflectivity反射性）Edematous水肿性（inflammation）Cicatricle瘢痕性（oraccompanywithspasticityandedematous）Oftenoccurinpatientwithduodenalulcer.Longcourseofdisease:EtiologyAndPathologySpastici139clinicalmanifestationanddiagnosisClinicalManifestationAbdominaldistention,tovomitindigestivefoodwithoutbile.malnutritionsplashingsound振水音（+）DiagnosishistoryX-ray:bariumretention>24hclinicalmanifestationanddia140DifferentialDiagnosisPylorospasmandoedemacausedbyactiveulcerobstructioninducedbyGastriccancerObstructioninferiortoduodenalbulb

gastroscope,X-rayDifferentialDiagnosisPylorosp141TreatmentPreoperativepreparation

gastrointestinaldecompression胃肠减压gastriclavage洗胃3-7days

tocorrectWater-ElectrolyteandacidbasebalancedisorderSurgicalprocedure

subtotalgastrectomy

vagotomy+antrectomy胃窦切除术

stomach-jejunumanastomosis胃空肠吻合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超选择性迷走神经切断术

Highlyselectivevagotomy超选择性迷走神经切断术

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