外科學(xué)：胃十二指腸外科疾病(英文版)完整版

DiseasesoftheStomachandDuodenumPARTIAnatomyPARTIIPepticUlcerDiseasePARTIIINeoplasmsGrossAnatomy:DivisionsofthestomachBloodsupplytothestomachandduodenumLymphaticdrainageofthestomachNerveofthestomachLeftvagusnerveAnteriorbranchesHepaticbranchesRightvagusnervePosteriorbranchCeliacbranchCrowfootcrowfootR.VagusL.VagusVagalinnervationofthestomachR.VagusVagalinnervationofthestomachGastricMorphologyCELLSLOCATIONFUNCTIONParietalBodySecretionofacidandintrinsicfactorMucusBody,AntrumMucusChiefBodyPepsinGAntrumGastrinDBody,antrumSomatostatinGastricCellTypes,Location,andFuction

CShapedLength:12fingers’breadthabout25cminadultD1SuperiorpartD2DescendingpartD3HorizontalpartD4AscendingpartGrossAnatomyoftheDuodenumPARTIAnatomyPARTIIPepticUlcerDiseasePARTIIINeoplasms1.HelicobacterpyloriInfection

1.

Productionoftoxicproductstocauselocaltissueinjury

2.

Inductionofalocalmucosalimmuneresponse

3.

IncreasedgastrinlevelswitharesultantincreaseinacidsecretionPathogenesisA:H.pyloriresidentonthegastricepithelium;B:Electronmicrograph2.Hypersecretionofgastricacid

“Noacid,noulcer”nowextendsto“ifacid,whyulcer”3.NonsteroidalAnti-inflammatoryDrugs4.MucosalinjuryMucus-bicarbonatelayerSurfaceepithelialcellsBloodflowtomucosaPathogenesisA:BalanceisgottenbetweenprotectiveandhostilefactorsB:BalanceisbrokenbetweenprotectiveandhostilefactorsClinicalPresentationGastriculcer

MadeworsebyeatingDuodenalUlcer

PossiblyworseatnightOccurs1-3hourspostprandialEpigastricpainHeartburnBelchingBloatedfeelingNauseaOthersymptomsDifferentialDiagnosisNeoplasmofthestomachPancreatitisPancreaticcancerDiverticulitisNonulcerdyspepsia(alsocalledfunctionaldyspepsia)CholecystitisGastritisComplicationsofPepticUlceri)Perforation&Penetration—intopancreas,liverandretroperitonealspaceii)PyloricObstructioniii)HemorrhageAcutePerforationA,Penetrationofagastriculcer;B,CrosssectionalviewofstomachwallandpancreasA,Endoscopicview;B,cross-sectionHemorrhagePyloricObstruction1.

Symptomsneedtoberelieved2.

Theulcerneedstobehealed3.

RecurrencemustbepreventedTheclinicianhasthreemajorgoalswhenfacedwithapatientwithulcerdisease:TherapySurgicalindicationsforPepticUlcerFourclassicindications

IntractabilityHemorrhagePerforation&PenetrationObstruction

Otherindications

StressulcerPancreatogeniculcerOnegoalofulcersurgeryistopreventgastricacidsecretionSurgicalProceduresforPepticUlcerGastrectomyTruncalvagotomySelectivevagotomyHighlyselectivevagotomyDistalGastrectomywithBillrothIAnastomosisDistalgastrectomywithBillrothIIanastomosisDistalgastrectomywithRoux-en-YanastomosisBillrothIIoperationandsomeofitsmodificationsV.EiselsbergGastrojejunostomy

1,TruncalVagotomy2,SelectiveVagotomy12HighlySelectiveVagotomySurgicalProceduresforPepticUlcerDrainageprocedureinassociationwithvagotomyPostgastrectomySyndromesDumpingSyndromeEarlyDumpingMetabolicDisturbancesAnemiadeficiencyinironimpairmentinvitaminB12metabolismImpairedabsorptionoffatdeficienciesincalciumOsteoporosisandosteomalaciaDumpingSyndromeEarlyDumpingMetabolicDisturbancesLateDumpingPostgastrectomySyndromesRelatedtoGastricReconstructionAfferentLoopSyndromeEfferentLoopObstructionAlkalineRefluxGastritisGastricAtonyCausesofafferentloopsyndromePostgastrectomySyndromesPostvagotomyDiarrheaPostvagotomySyndromesPostvagotomyDiarrheaPostvagotomyGastricAtonyIncompleteVagalTransectionSevereComplicationsofPepticUlceri)AcutePerforationii)MassiveHemorrhageiii)CicatricialPyloricstenosisDiagnosisandTreatmentforAcutePerforationClinicalPresentationofAcutePerforation

InitialsuddenonsetofsevereabdominalpainSyndromesPhysicalsignsi)Abdominaltendernessii)Abdominalreboundtendernessiii)Tabulateventeriv)BowelsoundsabsentFreeairX-rayCTscanFreeairInvestigationsInfectedascties

BileascitesDiagnosticeperitoneocentesisBUSAsctiesInvestigationsImmediatedifinitivesurgery:

i)Achroniculcerhistory;ii)Bleedingand/orobstrction;iii)WithoutpreoperativeriskforimmediatedifinitivesurgeryStandardtreatmentSimpleomentalpatchclosure:lifesavingoperationSurgicalManagementforPerforationSurgicalManagementforPerforationRepairofpepticulcerperforationLaparoscopicSurgeryNon-operativeManagementforPerforationSelectivetreatment

i)Intravenousflluids,ii)Nasogastricsuction,iii)BroadspectrumantibioticNoclinicalimprovementafter12h,requiredanoperationCarefullyselectedpaitents:

i)Age<70yearsoldii)Perforation<24hoursiii)Haemodynamicallystableiv)CanbecloselymonitoredClinicalpresention

i)Hematemesisii)Melenaorhematocheziaiii)Shock(Hemodynamicinstability:hypotensionwithsystolicbloodpressure<90mmHg)iv)AnemiaSevereComplication:

MassiveHemorrhageMassivehemorrhageEndoscopicimageABDigitalsubtractionangiography(DSA)NonoperativemanagementforMassiveHemorrhagei)Intravenousfluids(anitshocktherapy)ii)Nasogastricsuctioniii)Antiacid:protonpumpinhibitoriv)SomatostatinTherapeuticendoscopyInterventionalembolizationEndoscopiclasercoagulationEndoscopicsalineinjectionEndoscopichemostasiausingTitaniumClipVascularembolizationunderDSAIndicationsofOperativemanagementShockimmdeiatelyFailureofnonoperativemanagementBleeding>1000ml/24h,ahightransfusionrequirementAge>60yRebleedingafterstabilizationofrecentmassivehemorrhage

Co-existwithacuteperforationorcicatricialpyloricobstructionBleedingduringanti-ulcertherapySurgicalproceduresformassivebleedingi)Gastrectomy(involvingulcerlesion)iii)Bancroftplusarterysutures(gastroduodenalarteryorleftgastricartery)ii)Sewinghomeostasis+DrainageprocedureinassociationwithtruncalselectivevagotomyClinicalFeatures(1)HistoryofpreviouspepticulcersVomitting

volume：1000~2000mltime:recogniyablefood>8hpostprandialfeatures：projectilevomiting,devoidofanybile.SevereComplication:

Cicatricial

PyloricObstructionCicatricial

PyloricObstructionClinicalFeatures(2)

Physicalexamination

wasting,dehydrationperistalsis,splash-likesound

Laboratoryfeatures

MetabolicalkalosisBariumX-ray

aswollenstomachandnarrowedpylorusEndoscopy

cannotpassthroughthepylorusInvestigationsCicatricialPyloricObstructionCicatricialPyloricObstructionSurgicalproceduresforCicatricialPyloricObstruction1,Gastrectomy2,Drainageprocedureinassociationwithtruncalvagotomy3,Gastrojejunostomy

ClinicalfeaturesandmanagementoftheseverecomplicationsofpepticulcerOperativeindicationsforpepticulcerDifferentialdiagnosisofupperdigestivetracthemorrhageQUESTIONSPARTIAnatomyPARTIIPepticUlcerDiseasePARTIIINeoplasmsPARTIIINeoplasm1.Gastriccarcinoma2.Gastrointestinalstromaltumor3.Gastriclymphoma4.DuodenalcarcinomaEpidemiologyThefourth

mostcommoncancerworldwide,however,stomachcancerremainsthesecondmostcommoncauseofdeathfromcancerHigherratesinEasternAsia,SouthAmerica,EasternEuropeLowerratesinWesternEuropeandtheUnitedStates.GastriccarcinomaNutritional

LowfatorproteinconsumptionSaltedmeatorfishHighnitrateconsumptionHighcomplexcarbohydrateconsumptionCausesCausesEnvironmental

Poorfoodpreparation(smoked,salted)LackofrefrigerationPoordrinkingwaterSmokingMedical

PriorgastricsurgeryH.pyloriinfectionGastricatrophyandgastritisAdenomatouspolypsOther

MalegenderLowsocialclassCausesi)Earlygastriccancer(EGC)Gastriccancerconfinedtothemucosaorsubmucosa,regardlessofthepresenceorabsenceoflymphnodemetastasisPathologyii)Advancedgastriccancer(AGC)Cancercellsinfiltratetheproprialmusclelayerorserosa

EGCPathologyI:protrudedIIa:superficiallyelevatedIIc:superficiallydepressedIIb:superficiallyflatIII:excavatedEGC:EndoscopicimagesTypeIIITypeITypeIIPathologyBorrmann's

pathologicclassificationofgastriccancerbasedongrossappearanceAGC:Borrmann’sclassificationLinitisplasticaPhotomicrographsofGastricCarcinomaH&E,×400H&E,×25ArrowsonsignetringcellsTstageTstagearedefinedbydepthofpenetrationintothegastricwallLaminapropriaT1aT1bT4aT4bT3SubserosalconnectivetissueT1bT1aT4aT4bNStagingMetastesisDirectinvasionLyphmaticmetastesisHematogenousmetastasisSeedingmetastasisClinicalPresentationLacksspecificsymptomsearly:vagueepigastricdiscomfortindigestion.Epigastricpainisconstant,nonradiating,andunrelievedbyfoodingestion.Advanceddiseasemaypresentwithweightloss,anorexia,fatigue,orvomiting.Symptomsoftenreflectthesiteoforiginofthetumor.Proximaltumorsinvolvingthegastroesophagealjunctionoftenpresentwithdysphagia,whereasdistalantraltumorsmaypresentasgastricoutletobstruction.Hematemesis,anemic.Presentingaslargebowelobstruction.Physicalsignsi)apalpableabdominalmass,ii)apalpablesupraclavicular(Virchow's)orperiumbilical(SisterMaryJoseph's)lymphnode,ii)peritonealmetastasispalpablebyrectalexamination(Blummer'sshelf),iii)apalpableovarianmass(Krukenberg'stumor).iv)asthediseaseprogresses,jaundice,ascites,andcachexia.EndoscopyM－SCT(multipledetector-rowspiralCT)BUS&EUSDouble-contrastradiographyMRIDL(diagnosticlaparoscopy)PET-CTInvestigationsEndoscopyCarcinomainsituAdvancedcarcinomaNicheDouble-ContrastBariumUpperGIRadiographyEUSEUSTTNCTscan

ABCTNH1T4N2M1CTscan

MRITTLaparoscopyAbdominalmetastasisBUSleftrightLivermetastasisKrukenberg’stumorrightPET/CTT3N2Principlesofradicaloperationforgastriccanceri)Negativemarginii)Extentoflymphnodedissectioniii)Enblocresectioniv)M0SurgicalTreatmentforGastricCancerTreatmentforGastricCancerSurgeryEndoscopicmucosalresection(EMR)Endoscopicsubmucosaldissection(ESD)LaparoscopicSurgeryOpenSurgeryChemotherapyChemoradiotherapyTargettherapyEMRforEarliergastriccancer(EGC)CriteriaforEMRNCCN2013V2:1.TisorT1a2.Wellormoderatelydifferentiatedhistology3.Tumorslessthan15mminsize4.AbsenceofulcerationandnoevidenceofinvasivefindingCriteriaforEMRAbsoluteindication(EMR/ESD):DifferentiatedadenocarcinomaT1adiameteris≤2cmwithoutulcerfinding(UL-)JapaneseGastricCancerAssociationExpandedindication(ESD):TumorsclinicallydiagnosedasT1aand:(a)Differentiated,UL(-),but

>2cm(b)Differentiated-type,UL(+),and≤3cm(c)Undifferentiated-type,UL(-),and≤2cmEMREMREMR1.Difficulttoresectlargethan20mmtumorinsize2.DifficulttoresectulcerativelesionsLimitationofEMRtechniquesESDhasbeendevelopedESDforEGCESDESDLaparoscopicResection1)AsuitableprocedureforECG;2)TheefficacyandsafetyofthisapproachforadvancgastriccarcinomarequiresfurtherinvestigationOpenSurgeryforAdvancedGastricCancer1.AsuitableprocedureforACG2.R0resection3.R1resection4.R2resection

PrinciplesofradicaloperationforgastriccancerGastrectomywithregionallymphatics:perigastriclymphnodes(D1)andthosealongthenamedvesselsoftheceliacaxis(D2),withagoalofexamining15orgreaterlymphnodesGastrectomywithD2lymphadenectomyisthestandardtreatment

forcurablegastriccancerineasternAsia

GastrectomyandD2lymphadenectomyforadvancedgastriccarcinomaGastrectomyLymphadenectomyAnastomosisSubtotalgastrectomyRoux-en-YanastomosisBillrothIIanastomosisTotalgastrectomyLeftgastricAHepaticASplenicANo.11LNPORTALVEINAdjuvantTherapyChemotherapyRadiationTherapyTargetedTherapyECF:Epirubicin,Cisplatin,5-FuFOLFOX:Oxaliplatin,5-Fu,CFSOX:S-1,OxaliplatinXELOX:Capecitabin,OxaliplatinDCF:Docetaxel,Cisplatin,5-Fu……ChemotherapyPreoperativeChemotherapy

PostoperativeChemotherapyAfter3coursesofpreoperative

chemotherapyPreoperativechemotherapyLiverafterChemotherapyOurexperienceLaserrecannulizationandendoscopicdilationwithorwithoutstentplacementPalliativeTreatmentSurgicalpalliation

Resectionorbypassaloneorinconjunctionwithpercutaneous,endoscopic,orradiotherapytechniquesNonoperativetherapiesH.pyloriinfectionandgastriccarcinoma

Cyclooxygenase-2ActivationandgastriccarcinomaMini-invasiveoperationSentinelnodeNeoadjunctivechemotherapyMicrometastasis

IndividualizedtreatmentMolecularTargetedTherapiesCuttingedge:gastriccarcinoma

TargetedTherapiesAngiogenesisinhibitorBevacizumab（FDAapproved）ProteasomeinhibitorPS2341，bortezomib（FDAapproved）Growthfactorreceptor(EGFR),HERreceptorsinhibitorCetuximabEMD72000，matuzumabGefitinibErlotinibTrastuzumabCyclin-dependentkinaseinhibitor(CDKI)FlavopiridolGastrointestinalstromaltumor(GIST)MesenchymalneoplasmsLocatedprimarilyintheGItract,omentumandmesentery0.2%ofallGItumors80%ofGIsarcomas80%~90%stainpositiveforKITorPDGFREpidemiologyAmerica:10~20/1000,000peryearEurope:6.6~14.5/1000,000peryearHighestincidenceamonggroupaged50–65yearsSimilarmale/femaleincidence,althoughsomereportssuggesthigherincidenceinmenGISTlocationCausePresentationAbdominalpain,about50–70%GIbleeding,about50%NauseaandvomitingWeightlossPalpabletumormassesAnemiaInvestigationsEndoscopicUltrasound(US)ComputedTomography(CT)MagneticResonanceImaging(MRI)18F-FDGPositiveEmissionTomography(PET)DynamicContrast-EnhancedUltrasonography(DCE-US)BiopsyRisks:GISTsmaybesoftandfragileBiopsymaycausehemorrhageandincreasetheriskoftumordisseminationBiopsyisnecessaryif:Suspectinganothercancersuchaslymphoma

orgermcelltumorsConsideringneoadjuvanttherapyConfirmingmetastasisInvest