食管癌根治术护理查房医学PPT课件.ppt

1、1组织学分类组织学分类解剖解剖护理问题护理问题临床表现临床表现诊断诊断治疗治疗主要手术步骤主要手术步骤洗手护士配合要点洗手护士配合要点巡回护士配合要点巡回护士配合要点护理措施护理措施2解剖解剖前后扁窄的肌性管道上端：C6下缘续咽；下端：T11左侧与胃连 接；3生理狭窄生理狭窄食管入口处食管入口处气管分叉处气管分叉处膈肌裂孔处膈肌裂孔处4颈段颈段（5cm 5cm）食管入口食管入口-胸骨切迹胸骨切迹胸段胸段（18cm18cm）胸骨切迹胸骨切迹-膈裂孔处膈裂孔处上胸段上胸段：胸骨切迹：胸骨切迹-主主动脉弓上缘动脉弓上缘中胸段中胸段：主动脉上缘：主动脉上缘-肺下静脉肺下静脉下胸段下胸段：肺下静脉：肺下

2、静脉-膈膈裂孔裂孔腹段腹段（2cm2cm）膈裂孔膈裂孔-贲门贲门 食管分段食管分段5上段上段食管入口食管入口-主动脉弓上主动脉弓上缘缘 中段中段 主动脉弓上缘主动脉弓上缘-肺下静肺下静脉脉 下段下段 肺下静脉肺下静脉-贲门贲门临床分段临床分段67发生于食管粘膜上皮的消发生于食管粘膜上皮的消化道恶性肿瘤化道恶性肿瘤男性多于女性男性多于女性我国食道癌发病率居世界我国食道癌发病率居世界之首，占各部位死亡率的之首，占各部位死亡率的第二位第二位5070岁最多见岁最多见食管癌食管癌8化学性病因：亚硝胺化学性病因：亚硝胺生物性病因：真菌生物性病因：真菌微量元素缺乏：钼、铁、锌、氟、硒微量元素缺乏：钼、铁、锌

3、、氟、硒缺乏维生素：缺乏维生素：A A、B B2 2、C C及动物蛋白、新鲜蔬菜、水果摄及动物蛋白、新鲜蔬菜、水果摄入不入不 足足遗传易感性遗传易感性食管癌前病变：食管慢性炎症、上皮不典型增生、贲门食管癌前病变：食管慢性炎症、上皮不典型增生、贲门失弛缓症、疤痕狭窄等失弛缓症、疤痕狭窄等不良的嗜好及饮食习惯：酒、烟、茶，粗、热、硬、快不良的嗜好及饮食习惯：酒、烟、茶，粗、热、硬、快及蹲食等习惯及蹲食等习惯粘膜上皮损伤粘膜上皮损伤修复修复损伤损伤细胞增生活跃细胞增生活跃癌变癌变9病理分型病理分型鳞状细胞癌鳞状细胞癌腺癌腺癌腺角化癌腺角化癌小细胞未分化癌小细胞未分化癌9.50%9.50%55.80%

4、55.80%34.70%34.70%0%0%20%20%40%40%60%60%80%80%上段上段中段中段下段下段10临床分型临床分型50-60%50-60%15-20%15-20%10%10%5-10%5-10%髓质型髓质型蕈伞型蕈伞型溃疡型溃疡型缩窄型缩窄型11髓质型髓质型蕈伞型蕈伞型溃疡型溃疡型缩窄型缩窄型临床分型临床分型12分期分期长度长度 范围范围转移转移O O不定不定限于粘膜层限于粘膜层无无早期早期 3 3cmcm侵及粘膜下层侵及粘膜下层无无3-5cm3-5cm侵及部分肌层侵及部分肌层无无中期中期 5cm5cm侵及全肌层或外侵侵及全肌层或外侵局部淋巴转移局部淋巴转移晚期晚期 5c

5、m5cm明显外侵明显外侵远处淋巴结远处淋巴结或血性转移或血性转移临床病理分期临床病理分期13TXTX：原发肿瘤不能测定：原发肿瘤不能测定T1T1：肿瘤侵及粘膜固有：肿瘤侵及粘膜固有层或粘膜下层层或粘膜下层 T2T2：肿瘤侵及肌层：肿瘤侵及肌层 T3T3：肿瘤侵及食管纤维：肿瘤侵及食管纤维膜膜 T4T4：肿瘤侵及邻近器官：肿瘤侵及邻近器官 Nx:Nx:区域内淋巴结不区域内淋巴结不 能测定能测定 N0N0：无远处转移：无远处转移 N1N1：区域淋巴结转移：区域淋巴结转移 Mx:Mx:远处转移不能测定远处转移不能测定 M0M0：无远处转移：无远处转移 M1M1：有远处转移：有远处转移 1415临床表

6、现临床表现1.1.侵犯穿孔：疼痛、呛咳、呕血侵犯穿孔：疼痛、呛咳、呕血 2.2.神经受累：声音嘶哑神经受累：声音嘶哑 3.3.恶病质：消瘦、贫血、低蛋白恶病质：消瘦、贫血、低蛋白 4.4.远处转移：锁骨上淋巴结、肝脏远处转移：锁骨上淋巴结、肝脏16诊断诊断病史：进行性吞咽困难病史：进行性吞咽困难X X线食管钡餐检查线食管钡餐检查食管镜检查食管镜检查食管脱落细胞拉网检查食管脱落细胞拉网检查CTCT检查检查超声内镜检查超声内镜检查17治疗治疗手术治疗手术治疗 -根治性手术根治性手术 -姑息性手术姑息性手术内镜下治疗内镜下治疗 -食管扩张，食管支架食管扩张，食管支架 -内镜下电灼切除、内镜下电灼切除

7、、光动力疗法等光动力疗法等化疗：化疗：5-Fu5-Fu和顺铂为主和顺铂为主放疗：外放射为主放疗：外放射为主以手术为主的综合治疗以手术为主的综合治疗18早期食管癌早期食管癌中期（中期（）颈段颈段3cm3cm胸上段胸上段4cm4cm胸下段胸下段5cm5cm全身情况好者全身情况好者中期（中期（）病变在病变在5cm5cm以上以上无明显远处转移无明显远处转移术前放化疗与手术综合术前放化疗与手术综合放射复发，无远处转移，全身情况良好者放射复发，无远处转移，全身情况良好者 19病变侵犯范围大病变侵犯范围大有远处转移有远处转移 全身情况差，呈恶病质全身情况差，呈恶病质20手术疗法手术疗法左进胸左进胸右进胸：管

8、状胃右进胸：管状胃三切口三切口21手术疗法手术疗法22Convert PowerPoint to flash for web sharing.Post your slide show on Myspace and blog.Convert PowerPoint to video or burn to DVD.Present your slide show on TV to share with family.Add flash-based quizzes and demos to slide show to interact with your audience.23Convert Power

9、Point to flash for web sharing.Post your slide show on Myspace and blog.Convert PowerPoint to video or burn to DVD.Present your slide show on TV to share with family.Add flash-based quizzes and demos to slide show to interact with your audience.24Convert PowerPoint to flash for web sharing.Post your

10、 slide show on Myspace and blog.Convert PowerPoint to video or burn to DVD.Present your slide show on TV to share with family.Add flash-based quizzes and demos to slide show to interact with your audience.25Convert PowerPoint to flash for web sharing.Post your slide show on Myspace and blog.Convert

11、PowerPoint to video or burn to DVD.Present your slide show on TV to share with family.Add flash-based quizzes and demos to slide show to interact with your audience.26Convert PowerPoint to flash for web sharing.Post your slide show on Myspace and blog.Convert PowerPoint to video or burn to DVD.Prese

12、nt your slide show on TV to share with family.Add flash-based quizzes and demos to slide show to interact with your audience.27Convert PowerPoint to flash for web sharing.Post your slide show on Myspace and blog.Convert PowerPoint to video or burn to DVD.Present your slide show on TV to share with f

13、amily.Add flash-based quizzes and demos to slide show to interact with your audience.28Convert PowerPoint to flash for web sharing.Post your slide show on Myspace and blog.Convert PowerPoint to video or burn to DVD.Present your slide show on TV to share with family.Add flash-based quizzes and demos

14、to slide show to interact with your audience.29Convert PowerPoint to flash for web sharing.Post your slide show on Myspace and blog.Convert PowerPoint to video or burn to DVD.Present your slide show on TV to share with family.Add flash-based quizzes and demos to slide show to interact with your audi

15、ence.30Convert PowerPoint to flash for web sharing.Post your slide show on Myspace and blog.Convert PowerPoint to video or burn to DVD.Present your slide show on TV to share with family.Add flash-based quizzes and demos to slide show to interact with your audience.31Convert PowerPoint to flash for w

16、eb sharing.Post your slide show on Myspace and blog.Convert PowerPoint to video or burn to DVD.Present your slide show on TV to share with family.Add flash-based quizzes and demos to slide show to interact with your audience.32Convert PowerPoint to flash for web sharing.Post your slide show on Myspa

17、ce and blog.Convert PowerPoint to video or burn to DVD.Present your slide show on TV to share with family.Add flash-based quizzes and demos to slide show to interact with your audience.33Convert PowerPoint to flash for web sharing.Post your slide show on Myspace and blog.Convert PowerPoint to video

18、or burn to DVD.Present your slide show on TV to share with family.Add flash-based quizzes and demos to slide show to interact with your audience.34Convert PowerPoint to flash for web sharing.Post your slide show on Myspace and blog.Convert PowerPoint to video or burn to DVD.Present your slide show o

19、n TV to share with family.Add flash-based quizzes and demos to slide show to interact with your audience.35Convert PowerPoint to flash for web sharing.Post your slide show on Myspace and blog.Convert PowerPoint to video or burn to DVD.Present your slide show on TV to share with family.Add flash-base

20、d quizzes and demos to slide show to interact with your audience.36Convert PowerPoint to flash for web sharing.Post your slide show on Myspace and blog.Convert PowerPoint to video or burn to DVD.Present your slide show on TV to share with family.Add flash-based quizzes and demos to slide show to int

21、eract with your audience.37Convert PowerPoint to flash for web sharing.Post your slide show on Myspace and blog.Convert PowerPoint to video or burn to DVD.Present your slide show on TV to share with family.Add flash-based quizzes and demos to slide show to interact with your audience.38Convert Power

22、Point to flash for web sharing.Post your slide show on Myspace and blog.Convert PowerPoint to video or burn to DVD.Present your slide show on TV to share with family.Add flash-based quizzes and demos to slide show to interact with your audience.39Convert PowerPoint to flash for web sharing.Post your

23、 slide show on Myspace and blog.Convert PowerPoint to video or burn to DVD.Present your slide show on TV to share with family.Add flash-based quizzes and demos to slide show to interact with your audience.40Convert PowerPoint to flash for web sharing.Post your slide show on Myspace and blog.Convert

24、PowerPoint to video or burn to DVD.Present your slide show on TV to share with family.Add flash-based quizzes and demos to slide show to interact with your audience.41Convert PowerPoint to flash for web sharing.Post your slide show on Myspace and blog.Convert PowerPoint to video or burn to DVD.Prese

25、nt your slide show on TV to share with family.Add flash-based quizzes and demos to slide show to interact with your audience.42Convert PowerPoint to flash for web sharing.Post your slide show on Myspace and blog.Convert PowerPoint to video or burn to DVD.Present your slide show on TV to share with f

26、amily.Add flash-based quizzes and demos to slide show to interact with your audience.43Convert PowerPoint to flash for web sharing.Post your slide show on Myspace and blog.Convert PowerPoint to video or burn to DVD.Present your slide show on TV to share with family.Add flash-based quizzes and demos

27、to slide show to interact with your audience.44Convert PowerPoint to flash for web sharing.Post your slide show on Myspace and blog.Convert PowerPoint to video or burn to DVD.Present your slide show on TV to share with family.Add flash-based quizzes and demos to slide show to interact with your audi

28、ence.45Convert PowerPoint to flash for web sharing.Post your slide show on Myspace and blog.Convert PowerPoint to video or burn to DVD.Present your slide show on TV to share with family.Add flash-based quizzes and demos to slide show to interact with your audience.461 1、肿瘤切除率：对奇静脉和主动脉弓水平有外侵的肿瘤，、肿瘤切除

29、率：对奇静脉和主动脉弓水平有外侵的肿瘤，右进胸切除机率较高右进胸切除机率较高2 2、手术创伤：右进胸增加了腹部切口但有利于对腹腔淋巴结、手术创伤：右进胸增加了腹部切口但有利于对腹腔淋巴结 的清扫；左进胸不需加腹部切口，但切开膈肌的清扫；左进胸不需加腹部切口，但切开膈肌 对呼吸功能有一定损害，亦不利于对腹腔淋巴对呼吸功能有一定损害，亦不利于对腹腔淋巴 结的清扫结的清扫3 3、淋巴清扫：右进胸对胸段食管显露好，便于食管旁淋巴结、淋巴清扫：右进胸对胸段食管显露好，便于食管旁淋巴结 的清扫的清扫左、右进胸比较左、右进胸比较47全胃全胃管状胃管状胃48胃短动脉胃短动脉胃左动脉胃左动脉胃右动脉胃右动脉胃网

30、膜右动脉胃网膜右动脉淋巴结淋巴结49胃左动脉胃左动脉胃右动脉胃右动脉胃短动脉胃短动脉胃网膜左动胃网膜左动脉脉胃网膜右动胃网膜右动脉脉50管状胃：以胃底最高点处小弯侧管状胃：以胃底最高点处小弯侧1-2cm1-2cm作为起点，于胃右动脉作为起点，于胃右动脉近幽门侧近幽门侧2-3cm2-3cm分支处切断胃右动静脉及所属小网膜所有组织，分支处切断胃右动静脉及所属小网膜所有组织，以该点作为以该点作为“管状胃管状胃”裁制的终点，以直线切割缝合器切除裁制的终点，以直线切割缝合器切除至少至少1/31/3的胃组织，仅保留胃大弯部制成的胃组织，仅保留胃大弯部制成“管状胃管状胃”，管状胃，管状胃外径约外径约4-6c

31、m4-6cm为宜为宜511 1、可以有效延长胃的长度，消除吻合、可以有效延长胃的长度，消除吻合后吻合口张力后吻合口张力2 2、管状胃上窄下宽，形态上更接近原、管状胃上窄下宽，形态上更接近原食管及胃食管及胃3 3、管状胃易置于食管床，其扩张程度、管状胃易置于食管床，其扩张程度较小，对心肺压迫较轻较小，对心肺压迫较轻4 4、管状胃在胃血供不变的情况下切除、管状胃在胃血供不变的情况下切除胃小弯侧和贲门，使原来供应该区域的胃小弯侧和贲门，使原来供应该区域的血液重新分配，使残胃血供更为丰富，血液重新分配，使残胃血供更为丰富，有利于吻合口愈合有利于吻合口愈合5 5、减少胃泌酸组织，使胃泌素水平下、减少胃泌

32、酸组织，使胃泌素水平下降，术后反流少，反流性食管炎发生率降，术后反流少，反流性食管炎发生率降低，应激性溃疡发生率低降低，应激性溃疡发生率低6 6、管状胃切除贲门、胃小弯及所属淋、管状胃切除贲门、胃小弯及所属淋巴结，可减少术后癌肿复发率巴结，可减少术后癌肿复发率成本高成本高521、平卧位：腹部胃游离、淋巴结清扫及管状胃成形2、左侧卧位：食管游离、淋巴结清扫剑突水平与腋中线交界处1cm小切口：观察镜腋前线第4肋间或第5肋间3cm小切口：主操作孔腋后线第6肋间1cm切口：次孔3、吻合：于主操作孔内吻合 颈段：左胸锁乳突肌前缘切口分离拿出食管近断端，将管状胃经右胸食管床拉至颈部行胃-食管吻合53术前访

33、视术前访视器械器械准备齐全准备齐全超声刀的正确安装、使超声刀的正确安装、使用用术中无菌操作术中无菌操作熟练配合，节省手术时熟练配合，节省手术时间，减少并发症的发生间，减少并发症的发生54术前访视术前访视器械性能的检查、准备器械性能的检查、准备配合麻醉师实施麻醉配合麻醉师实施麻醉正确安放手术体位正确安放手术体位正确连接腔镜器械，调正确连接腔镜器械，调节参数节参数术中加强观察术中加强观察患者的保温患者的保温标本的正确处理标本的正确处理妥善固定引流管妥善固定引流管55恐惧、焦虑：与环境改变，对手术的担忧有关恐惧、焦虑：与环境改变，对手术的担忧有关有皮肤完整性受损的危险：与手术时间长及有皮肤完整性受损

34、的危险：与手术时间长及 体体位摆放有关位摆放有关疼痛：与手术切口有关疼痛：与手术切口有关有灼伤的危险：与电外科仪器的使用有关有灼伤的危险：与电外科仪器的使用有关有低体温的危险：与手术暴露有关有低体温的危险：与手术暴露有关56有体液不足的危险：与切口暴露与输液不足有体液不足的危险：与切口暴露与输液不足 有关有关有感染的危险：与手术切口、抵抗力下降、有感染的危险：与手术切口、抵抗力下降、留置导尿有关留置导尿有关潜在并发症：出血；肿瘤细胞种植转移；乳糜胸；吻合口潜在并发症：出血；肿瘤细胞种植转移；乳糜胸；吻合口瘘瘘57术前访视，介绍手术室环境，耐心解答病人提出的问题术前访视，介绍手术室环境，耐心解答

35、病人提出的问题介绍医生资质，介绍成功病例介绍医生资质，介绍成功病例病人进入手术室后热情接待病人，多与病人交流，尽量满病人进入手术室后热情接待病人，多与病人交流，尽量满足病人的要求足病人的要求58正确安置体位，骨突处安置软垫正确安置体位，骨突处安置软垫术中加强观察术中加强观察避免皮肤接触潮湿、金属物品避免皮肤接触潮湿、金属物品59术前做好解释安慰工作，告诉病人疼痛与精神心理因素的术前做好解释安慰工作，告诉病人疼痛与精神心理因素的关系关系协助麻醉师实施麻醉协助麻醉师实施麻醉教会病人转移疼痛的方法教会病人转移疼痛的方法术后连接好镇痛泵，并教会其正确使用术后连接好镇痛泵，并教会其正确使用导尿管、引流管

36、固定好，防止牵拉引起的疼痛导尿管、引流管固定好，防止牵拉引起的疼痛注意切口敷料干燥，避免感染加重疼痛注意切口敷料干燥，避免感染加重疼痛60术前检查仪器的性能，保证术前检查仪器的性能，保证其完好其完好正确安放负极板，保证电流正确安放负极板，保证电流回路的通畅回路的通畅避免病人肢体接触金属避免病人肢体接触金属术中加强巡视术中加强巡视不盲目加大电刀功率不盲目加大电刀功率手术结束后，检查病人皮肤，手术结束后，检查病人皮肤，做出正确评估做出正确评估61术前安放好手术体位后，注意病术前安放好手术体位后，注意病人保暖人保暖术中熟练配合，尽量减少手术时术中熟练配合，尽量减少手术时间间冲洗液温度控制于冲洗液温度

37、控制于4040 4242输液适当加温输液适当加温术中加强观察和监测术中加强观察和监测适当使用加温装置，如变温毯等适当使用加温装置，如变温毯等62熟练配合，减少手术时间熟练配合，减少手术时间术中加强观察，评估尿量，及时补液术中加强观察，评估尿量，及时补液正确的输血与输液正确的输血与输液配合止血配合止血63术前术前30min30min应用抗生素，超过应用抗生素，超过3h3h加用抗生素加用抗生素术中严格控制参观人数术中严格控制参观人数术中严格各项无菌操作术中严格各项无菌操作固定好导尿管和引流管，防止逆流固定好导尿管和引流管，防止逆流保持引流通畅保持引流通畅保持敷料干燥，防止感染保持敷料干燥，防止感染64正确配合，及时止血正确配合，及时止血及时输血、输液及时输血、输液加强无瘤操作加强无瘤操作65预预防防开展卫生宣教开展卫生宣教开展普查普治开展普查普治早期诊断及处理早期诊断及处理严密随访高危人群严密随访高危人群6667