外科學(xué)教學(xué)課件：胃十二指腸外科疾病

1、Diseases of the Stomach and Duodenum PART I Anatomy PART II Peptic Ulcer Disease PART III Neoplasms Gross Anatomy: Divisions of the stomach Blood supply to the stomach and duodenum Lymphatic drainage of the stomach Nerve of the stomach Left vagus nerve Anterior branches Hepatic branches Right vagus

2、nerve Posterior branch Celiac branch Crow foot R. Vagus L. Vagus Vagal innervation of the stomach R.Vagus Vagal innervation of the stomach Gastric Morphology CELLSLOCATIONFUNCTION Parietal Body Secretion of acid and intrinsic factor MucusBody, Antrum Mucus ChiefBodyPepsin GAntrumGastrin DBody, antru

3、mSomatostatin Gastric Cell Types, Location, and Fuction C Shaped Length: Gross Anatomy of the Duodenum PART I Anatomy PART II Peptic Ulcer Disease PART III Neoplasms 1. Helicobacter pylori Infection 1. Production of toxic products to cause local tissue injury 2. Induction of a local mucosal immune r

4、esponse 3. Increased gastrin levels with a resultant increase in acid secretion Pathogenesis A: H. pylori resident on the gastric epithelium; B: Electron micrograph 2. Hypersecretion of gastric acid “No acid, no ulcer” now extends to “if acid, why ulcer” 3.Nonsteroidal Anti-inflammatory Drugs 4.Muco

5、sal injury Mucus-bicarbonate layer Surface epithelial cells Blood flow to mucosa Pathogenesis A: Balance is gotten between protective and hostile factors B: Balance is broken between protective and hostile factors Clinical Presentation Gastric ulcer Made worse by eating Duodenal Ulcer Possibly worse

6、 at night Occurs 1-3 hours postprandial Epigastric pain Heartburn Belching Bloated feeling Nausea Other symptoms Differential Diagnosis Neoplasm of the stomach Pancreatitis Pancreatic cancer Diverticulitis Nonulcer dyspepsia (also called functional dyspepsia) Cholecystitis Gastritis Complications of

7、 Peptic Ulcer i) Perforation B, Cross sectional view of stomach wall and pancreas A, Endoscopic view; B, cross-section Hemorrhage Pyloric Obstruction 1. Symptoms need to be relieved 2. The ulcer needs to be healed 3. Recurrence must be prevented The clinician has three major goals when faced with a

8、patient with ulcer disease: Therapy Surgical indications for Peptic Ulcer Four classic indications Intractability Hemorrhage Perforation ii) Bleeding and/or obstrction; iii) Without preoperative risk for immediate difinitive surgery Standard treatment Simple omental patch closure: lifesaving operati

9、on Surgical Management for Perforation Surgical Management for Perforation Repair of peptic ulcer perforation Laparoscopic Surgery Non-operative Management for Perforation Selective treatment i) Intravenous flluids, ii) Nasogastric suction, iii) Broad spectrum antibiotic No clinical improvement afte

10、r 12h, required an operation Carefully selected paitents: i) Age 70 years old ii) Perforation 24 hours iii) Haemodynamically stable iv) Can be closely monitored Clinical presention i) Hematemesis ii) Melena or hematochezia iii) Shock (Hemodynamic instability: hypotension with systolic blood pressure

11、 1000ml/24h, a high transfusion requirement Age 60y Rebleeding after stabilization of recent massive hemorrhage Co-exist with acute perforation or cicatricial pyloric obstruction Bleeding during anti-ulcer therapy Surgical procedures for massive bleeding i) Gastrectomy (involving ulcer lesion ) iii)

12、 Bancroft plus artery sutures (gastroduodenal artery or left gastric artery) ii) Sewing homeostasis +Drainage procedure in association with truncal selective vagotomy Clinical Features(1) History of previous peptic ulcers Vomitting volume： 10002000ml time: recogniyable food 8h post prandial features

13、：projectile vomiting, devoid of any bile. Severe Complication : Cicatricial Pyloric Obstruction Cicatricial Pyloric Obstruction Clinical Features(2) Physical examination wasting, dehydration peristalsis, splash-like sound Laboratory features Metabolic alkalosis Investigations Cicatricial Pyloric Obs

14、truction Cicatricial Pyloric Obstruction Surgical procedures for Cicatricial Pyloric Obstruction 1, Gastrectomy 2, Drainage procedure in association with truncal vagotomy 3, Gastrojejunostomy 1.Clinical features and management of the severe complications of peptic ulcer 2.Operative indications for p

15、eptic ulcer 3.Differential diagnosis of upper digestive tract hemorrhage QUESTIONS PART I Anatomy PART II Peptic Ulcer Disease PART III Neoplasms PART III Neoplasm 1. Gastric carcinoma 2. Gastrointestinal stromal tumor 3. Gastric lymphoma 4. Duodenal carcinoma Epidemiology The fourth most common can

16、cer worldwide, however, stomach cancer remains the second most common cause of death from cancer Higher rates in Eastern Asia, South America, Eastern Europe Lower rates in Western Europe and the United States. Gastric carcinoma Nutritional Low fat or protein consumption Salted meat or fish High nitr

17、ate consumption High complex carbohydrate consumption Causes Causes Environmental Poor food preparation (smoked, salted) Lack of refrigeration Poor drinking water Smoking Medical Prior gastric surgery H. pylori infection Gastric atrophy and gastritis Adenomatous polyps Other Male gender Low social c

18、lass Causes i) Early gastric cancer(EGC) Gastric cancer confined to the mucosa or submucosa, regardless of the presence or absence of lymph node metastasis Pathology ii) Advanced gastric cancer(AGC) Cancer cells infiltrate the proprial muscle layer or serosa EGC Pathology I: protruded IIa: superfici

19、ally elevated IIc: superficially depressed IIb: superficially flat III: excavated EGC:Endoscopic images Type III Type I Type II Pathology Borrmanns pathologic classification of gastric cancer based on gross appearance AGC:Borrmanns classification Linitis plastica Photomicrographs of Gastric Carcinom

20、a H 2) The efficacy and safety of this approach for advanc gastric carcinoma requires further investigation Open Surgery for Advanced Gastric Cancer 1. A suitable procedure for ACG 2. R0 resection 3. R1 resection 4. R2 resection Principles of radical operation for gastric cancer Gastrectomy with reg

21、ional lymphatics: perigastric lymph nodes(D1) and those along the named vessels of the celiac axis (D2), with a goal of examining 15 or greater lymph nodes Gastrectomy with D2 lymphadenectomy is the standard treatment for curable gastric cancer in eastern Asia Gastrectomy and D2 lymphadenectomy for

22、advanced gastric carcinoma Gastrectomy Lymphadenectomy Anastomosis Subtotal gastrectomy Roux-en-Y anastomosis Billroth II anastomosis Total gastrectomy Left gastric A Hepatic A Splenic A No.11 LN Adjuvant Therapy Chemotherapy Radiation Therapy Targeted Therapy ECF: Epirubicin , Cisplatin, 5-Fu FOLFO

23、X: Oxaliplatin, 5-Fu, CF SOX: S-1, Oxaliplatin XELOX: Capecitabin, Oxaliplatin DCF: Docetaxel, Cisplatin, 5-Fu Chemotherapy Preoperative Chemotherapy Postoperative Chemotherapy After 3 courses of preoperative chemotherapy Preoperative chemotherapy Liver after Chemotherapy Our experience Laser recann

24、ulization and endoscopic dilation with or without stent placement Palliative Treatment Surgical palliation Resection or bypass alone or in conjunction with percutaneous, endoscopic, or radiotherapy techniques Nonoperative therapies H. pylori infection and gastric carcinoma Cyclooxygenase-2 Activatio

25、n and gastric carcinoma Mini-invasive operation Sentinel node Neoadjunctive chemotherapy Micrometastasis Individualized treatment Molecular Targeted Therapies Cutting edge: gastric carcinoma Targeted Therapies Angiogenesis inhibitorBevacizumab （FDA approved） Proteasome inhibitor PS2341 ，bortezomib （

26、 FDA approved） Growth factor receptor (EGFR), HER receptors inhibitor Cetuximab EMD72000 ，matuzumab Gefitinib Erlotinib Trastuzumab Cyclin-dependent kinase inhibitor (CDKI) Flavop iridol Gastrointestinal stromal tumor (GIST) Mesenchymal neoplasms Located primarily in the GI tract, omentum and mesent

27、ery 0.2% of all GI tumors 80% of GI sarcomas 80%90% stain positive for KIT or PDGFR Epidemiology America: 1020 /1000,000 per year Europe: 6.614.5 /1000,000 per year Highest incidence among group aged 5065 years Similar male/female incidence, although some reports suggest higher incidence in men GIST

28、 location Cause Presentation Abdominal pain, about 5070% GI bleeding, about 50% Nausea and vomiting Weight loss Palpable tumor masses Anemia Investigations Endoscopic Ultrasound (US) Computed Tomography (CT) Magnetic Resonance Imaging (MRI) 18F-FDG Positive Emission Tomography (PET) Dynamic Contrast

29、-Enhanced Ultrasonography (DCE-US) Biopsy Risks: GISTs may be soft and fragile Biopsy may cause hemorrhage and increase the risk of tumor dissemination Biopsy is necessary if: Suspecting another cancer such as lymphoma or germ cell tumors Considering neoadjuvant therapy Confirming metastasis Investi

30、gations EUS-FNA Core Biopsy Immunohistochemistry CD117 95%(+)CD117 95%(+) DOG-1 DOG-1 98%(+)98%(+) CD34 CD34 70%70%80%80%(+)(+) SMA SMA 40%(+)40%(+) S-100 S-100 (-)(-) PKCPKC Carbonic anhydrase-II Genetic testing D842V Surgery Principles for Primary Tumors Indication if 2 cm R0 resection 1-2 cm clear margin No lymph node metastases in primary tumors Lesions 2 cm could be followed (often by endoscopy) rather than resected Operation Complete macroscopic resection with microscopically negative margins over the organ of origin (R0 resection) Exte