外科学课件：胃十二指肠外科疾病(英文版)-.ppt

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

2、e Posterior branch Celiac branch Crow footR.VagusL.VagusVagal innervation of the stomachR.VagusVagal innervation of the stomachGastric MorphologyCELLSLOCATIONFUNCTIONParietal BodySecretion of acid and intrinsic factorMucusBody,Antrum MucusChiefBodyPepsinGAntrumGastrinDBody,antrumSomatostatinGastric

3、Cell Types,Location,and FuctionC Shaped Length:Gross Anatomy of the DuodenumPART 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 response 3.Increased gastrin le

4、vels with a resultant increase in acid secretionPathogenesisA: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 Drugs4.Mucosal injury Mucus-bicarbonate layer Surface e

5、pithelial cells Blood flow to mucosaPathogenesisA:Balance is gotten between protective and hostile factorsB:Balance is broken between protective and hostile factors Clinical PresentationGastric ulcer Made worse by eatingDuodenal Ulcer Possibly worse at night Occurs 1-3 hours postprandialEpigastric p

6、ain Heartburn Belching Bloated feeling NauseaOther symptomsDifferential DiagnosisNeoplasm of the stomachPancreatitisPancreatic cancerDiverticulitisNonulcer dyspepsia(also called functional dyspepsia)CholecystitisGastritis Complications of Peptic Ulceri)Perforation&Penetrationinto pancreas,liver and

7、retroperitoneal space ii)Pyloric Obstruction iii)HemorrhageAcute Perforation A,Penetration of a gastric ulcer;B,Cross sectional view of stomach wall and pancreas A,Endoscopic view;B,cross-section HemorrhagePyloric Obstruction1.Symptoms need to be relieved 2.The ulcer needs to be healed 3.Recurrence

8、must be prevented The clinician has three major goals when faced with a patient with ulcer disease:TherapySurgical indications for Peptic UlcerFour classic indications Intractability Hemorrhage Perforation&Penetration Obstruction Other indications Stress ulcer Pancreatogenic ulcerOne goal of ulcer s

9、urgery is to prevent gastric acid secretionSurgical Procedures for Peptic Ulceri)Gastrectomyii)Truncal vagotomyiii)Selective vagotomyiv)Highly selective vagotomyDistal Gastrectomy with Billroth I AnastomosisDistal gastrectomy with Billroth II anastomosisDistal gastrectomy with Roux-en-Y anastomosisB

10、illroth II operation and some of its modificationsV.Eiselsberg Gastrojejunostomy 1,Truncal Vagotomy 2,Selective Vagotomy 12Highly Selective VagotomySurgical Procedures for Peptic UlcerDrainage procedure in association with vagotomyPostgastrectomy SyndromesDumping SyndromeEarly DumpingMetabolic Distu

11、rbancesAnemiadeficiency in iron impairment in vitamin B12 metabolismImpaired absorption of fatdeficiencies in calciumOsteoporosis and osteomalacia Dumping SyndromeEarly DumpingMetabolic DisturbancesLate DumpingPostgastrectomy SyndromesRelated to Gastric ReconstructionAfferent Loop SyndromeEfferent L

12、oop ObstructionAlkaline Reflux GastritisGastric AtonyCauses of afferent loop syndromePostgastrectomy SyndromesPostvagotomy DiarrheaPostvagotomy SyndromesPostvagotomy DiarrheaPostvagotomy Gastric AtonyIncomplete Vagal TransectionSevere Complications of Peptic Ulceri)Acute Perforationii)Massive Hemorr

13、hageiii)Cicatricial Pyloric stenosisDiagnosis and Treatment for Acute PerforationClinical Presentation of Acute Perforation Initial sudden onset of severe abdominal pain SyndromesPhysical signsi)Abdominal tenderness ii)Abdominal rebound tendernessiii)Tabulate venteriv)Bowel sounds absentFree airX-ra

14、yCT scanFree airInvestigationsInfected asctiesBile ascitesDiagnostice peritoneocentesisBUSAsctiesInvestigationsImmediate difinitive surgery:i)A chronic ulcer history;ii)Bleeding and/or obstrction;iii)Without preoperative risk for immediate difinitive surgeryStandard treatmentSimple omental patch clo

15、sure:lifesaving operationSurgical Management for PerforationSurgical Management for PerforationRepair of peptic ulcer perforationLaparoscopic SurgeryNon-operative Management for PerforationSelective treatment i)Intravenous flluids,ii)Nasogastric suction,iii)Broad spectrum antibioticNo clinical impro

16、vement after 12h,required an operationCarefully selected paitents:i)Age 70 years old ii)Perforation 24 hours iii)Haemodynamically stable iv)Can be closely monitoredClinical presention i)Hematemesis ii)Melena or hematochezia iii)Shock(Hemodynamic instability:hypotension with systolic blood pressure 1

17、000ml/24h,a high transfusion requirementAge 60yRebleeding after stabilization of recent massive hemorrhage Co-exist with acute perforation or cicatricial pyloric obstructionBleeding during anti-ulcer therapySurgical procedures for massive bleedingi)Gastrectomy(involving ulcer lesion)iii)Bancroft plu

18、s 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：projectile vomiting

19、,devoid of any bile.Severe Complication:Cicatricial Pyloric ObstructionCicatricial Pyloric ObstructionClinical Features(2)Physical examination wasting,dehydration peristalsis,splash-like sound Laboratory features Metabolic alkalosisInvestigationsCicatricial Pyloric ObstructionCicatricial Pyloric Obs

20、tructionSurgical procedures for Cicatricial Pyloric Obstruction1,Gastrectomy2,Drainage procedure in association with truncal vagotomy3,Gastrojejunostomy 1.Clinical features and management of the severe complications of peptic ulcer 2.Operative indications for peptic ulcer3.Differential diagnosis of

21、upper digestive tract hemorrhageQUESTIONSPART I Anatomy PART II Peptic Ulcer Disease PART III NeoplasmsPART III Neoplasm 1.Gastric carcinoma 2.Gastrointestinal stromal tumor 3.Gastric lymphoma 4.Duodenal carcinomaEpidemiologyThe fourth most common cancer worldwide,however,stomach cancer remains the

22、second most common cause of death from cancer Higher rates in Eastern Asia,South America,Eastern EuropeLower rates in Western Europe and the United States.Gastric carcinoma Nutritional Low fat or protein consumption Salted meat or fish High nitrate consumption High complex carbohydrate consumptionCa

23、usesCauses 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 classCausesi)Early gastric cancer(EGC)Gastric cancer confined

24、to the mucosa or submucosa,regardless of the presence or absence of lymph node metastasisPathology ii)Advanced gastric cancer(AGC)Cancer cells infiltrate the proprial muscle layer or serosa EGCPathology I:protrudedIIa:superficially elevatedIIc:superficially depressedIIb:superficially flatIII:excavat

25、edEGC:Endoscopic imagesType IIIType IType IIPathology Borrmanns pathologic classification of gastric cancer based on gross appearanceAGC:Borrmanns classificationLinitis plasticaPhotomicrographs of Gastric CarcinomaH&E,400H&E,25Arrows on signet ring cellsT stage T stage are defined by depth of penetr

26、ation into the gastric wallLamina propriaT1aT1bT4aT4bT3Subserosal connective tissueT1bT1aT4aT4bN StagingMetastesis Direct invasion Lyphmatic metastesis Hematogenous metastasis Seeding metastasis Clinical Presentationi)Lacks specific symptoms early:vague epigastric discomfort indigestion.ii)Epigastri

27、c pain is constant,nonradiating,and unrelieved by food ingestion.iii)Advanced disease may present with weight loss,anorexia,fatigue,or vomiting.iv)Symptoms often reflect the site of origin of the tumor.Proximal tumors involving the gastroesophageal junction often present with dysphagia,whereas dista

28、l antral tumors may present as gastric outlet obstruction.v)Hematemesis,anemic.vi)Presenting as large bowel obstruction.Physical signs i)a palpable abdominal mass,ii)a palpable supraclavicular(Virchows)or periumbilical(Sister Mary Josephs)lymph node,ii)peritoneal metastasis palpable by rectal examin

29、ation(Blummers shelf),iii)a palpable ovarian mass(Krukenbergs tumor).iv)as the disease progresses,jaundice,ascites,and cachexia.Endoscopy MSCT(multiple detector-row spiral CT)BUS&EUS Double-contrast radiography MRI DL(diagnostic laparoscopy)PET-CTInvestigationsEndoscopy Carcinoma in situAdvanced car

30、cinomaNicheDouble-Contrast Barium Upper GI RadiographyEUSEUSTTNCT scan TNH1T4N2M1CT scan MRI TTLaparoscopyAbdominal metastasisBUSleftrightrightPET/CTT3N2Principles of radical operation for gastric canceri)Negative marginii)Extent of lymph node dissectioniii)Enbloc resectioniv)M0Surgical Treatment fo

31、r Gastric CancerTreatment for Gastric CancerSurgery Endoscopic mucosal resection(EMR)Endoscopic submucosal dissection(ESD)Laparoscopic Surgery Open SurgeryChemotherapyChemoradiotherapyTarget therapyEMR for Earlier gastric cancer(EGC)Criteria for EMRNCCN 2013 V2:1.Tis or T1a 2.Well or moderately diff

32、erentiated histology3.Tumors less than 15mm in size4.Absence of ulceration and no evidence of invasive findingCriteria for EMRAbsolute indication(EMR/ESD):Differentiated adenocarcinomaT1adiameter is 2 cmwithout ulcer finding(UL-)Japanese Gastric Cancer AssociationExpanded indication(ESD):Tumors clin

33、ically diagnosed as T1a and:(a)Differentiated,UL(-),but 2 cm(b)Differentiated-type,UL(+),and 3 cm(c)Undifferentiated-type,UL(-),and 2cmEMREMREMR1.Difficult to resect large than 20mm tumor in size2.Difficult to resect ulcerative lesions Limitation of EMR techniquesESD has been developedESD for EGCESD

34、ESDLaparoscopic Resection 1)A suitable procedure for ECG;2)The efficacy and safety of this approach for advanc gastric carcinoma requires further investigationOpen Surgery for Advanced Gastric Cancer1.A suitable procedure for ACG2.R0 resection3.R1 resection4.R2 resection Principles of radical operat

35、ion for gastric cancerGastrectomy with regional 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 nodesGastrectomy with D2 lymphadenectomy is the standard treatment for curable gastric cancer in eastern Asia Ga

36、strectomy and D2 lymphadenectomy for advanced gastric carcinomaGastrectomyLymphadenectomyAnastomosisSubtotal gastrectomyRoux-en-Y anastomosis Billroth II anastomosisTotal gastrectomyLeft gastric AHepatic ASplenic ANo.11 LNAdjuvant Therapy ChemotherapyRadiation TherapyTargeted TherapyECF:Epirubicin,C

37、isplatin,5-FuFOLFOX:Oxaliplatin,5-Fu,CFSOX:S-1,OxaliplatinXELOX:Capecitabin,OxaliplatinDCF:Docetaxel,Cisplatin,5-FuChemotherapyPreoperative Chemotherapy Postoperative ChemotherapyAfter 3 courses of preoperative chemotherapyPreoperative chemotherapyLiver after ChemotherapyOur experienceLaser recannul

38、ization and endoscopic dilation with or without stent placementPalliative TreatmentSurgical palliation Resection or bypass alone or in conjunction with percutaneous,endoscopic,or radiotherapy techniquesNonoperative therapies H.pylori infection and gastric carcinoma Cyclooxygenase-2 Activation and ga

39、stric carcinomaMini-invasive operationSentinel node Neoadjunctive chemotherapyMicrometastasis Individualized treatmentMolecular Targeted TherapiesCutting edge:gastric carcinoma Targeted TherapiesAngiogenesis inhibitorBevacizumab（FDA approved）Proteasome inhibitor PS2341，bortezomib（FDA approved）Growth

40、 factor receptor(EGFR),HER receptors inhibitorCetuximabEMD72000，matuzumabGefitinibErlotinibTrastuzumabCyclin-dependent kinase inhibitor(CDKI)Flavop iridolGastrointestinal stromal tumor(GIST)Mesenchymal neoplasms Located primarily in the GI tract,omentum and mesentery 0.2%of all GI tumors 80%of GI sa

41、rcomas 80%90%stain positive for KIT or PDGFREpidemiologyAmerica:1020/1000,000 per yearEurope:6.614.5/1000,000 per yearHighest incidence among group aged 5065 yearsSimilar male/female incidence,although some reports suggest higher incidence in men GIST locationCausePresentationAbdominal pain,about 50

42、70%GI bleeding,about 50%Nausea and vomitingWeight lossPalpable tumor massesAnemiaInvestigationsEndoscopic Ultrasound(US)Computed Tomography(CT)Magnetic Resonance Imaging(MRI)18F-FDG Positive Emission Tomography(PET)Dynamic Contrast-Enhanced Ultrasonography(DCE-US)Biopsy Risks:GISTs may be soft and f

43、ragile 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 metastasisInvestigationsEUS-FNACore BiopsyImmunohistochemistry CD117 95%(+)CD117 95%(+)DOG-

44、1 DOG-1 98%(+)98%(+)CD34 CD34 70%70%80%80%(+)(+)SMA SMA 40%(+)40%(+)S-100 S-100 (-)(-)PKCPKCCarbonic anhydrase-II Genetic testingD842VSurgery Principles for Primary TumorsIndication if 2 cm R0 resection1-2 cm clear marginNo lymph node metastases in primary tumorsLesions 2 cm could be followed(often

45、by endoscopy)rather than resectedOperation Complete macroscopic resection with microscopically negative margins over the organ of origin(R0 resection)Extensive resections may be necessary Total gastrectomy Pancreaticoduodenectomy(Whipple procedure)Abdominoperineal resection(APR)Resection of adjacent

46、 organs maybe necessary Lymphadenectomy not indicated Through abdominal explorationRisk Stratification(2008 Joensuu)Risk CategoryTumro size（cm）Mitotic Index（/50HPFs）Primary tumor siteVery low risk5Gastric10AnyAnyAny10Any5.05Any2.15.05Nongastric5.110.05NongastricPostoperation therapy 1.Imatinib(First

47、 line)Indication?Duration?Drug resistance?2.Sunitinib(Second line)Gastric lymphoma The most common site in the gastrointestinal system.Less than 15%of gastric malignancies and 2%of lymphomas.Peak incidence in the 6th and 7th decades(male:female=2:1)EpidemiologyPresentation Vague symptoms Epigastric pain Early satiety Fatigue AnemiaInvestigationEndoscopyEUSCTBiopsyTreatment Surgery (controversial)Chemotherapy(5%perforation)Radiation(stricture,enteritis,secondary tumor formation)Individualized