全胃切除治疗胃恶性肿瘤(例44附报告)

本文报告华西医大普外科1981～1989.2月间作了全胃切除的胃恶性肿瘤44例,手术死亡率2.27％,近期并发症31.8％,主要为胸部并发症,吻合口漏只1例。对远期生存者作了消化吸收功能研究,多数病人代胃空物功能良好。本文讨论了①全胃切除的指征;②如何降低手术死亡率及远期并发症;③推荐Roux-n-y,P型空肠袢代胃术或P型空肠袢间置代胃术,两者均为合理的消化道重建方式。     

胃癌行全胃切除P型空肠间置原位代胃术33例分析

目的探讨胃癌行全胃切除术P型空肠间置原位代胃术的效果。方法对33例符合全胃切除的患者,施行了全胃切除P型空肠间置原位代胃术。结果无手术死亡,无切口,腹腔感染及吻合口瘘。发生反流性食管炎1例,对症治疗缓解。33例均于术后0.5a内3次钡餐检查,P型胃充盈及排空顺利。术后6个月和1a患者饮食量、体重均恢复到接近术前水平。1、3、5a存活率分别为85.5%、59%和22%。结论全胃切除P型空肠间置原位代胃术,符合解剖生理规律,并发症少,代胃效果满意。     

同时发现的食管、胃重复癌的外科治疗

目的：探讨同时发现的食管、胃重复癌的外科诊断、治疗方法及效果.方法：1985年1月至2006年12月我科共收治同时发现的食管、胃重复癌10例,男7 例,女3例,平均年龄58.9岁.全组均行手术治疗,成功完成同期食管次全切除并全胃切除、空肠“P”袢代胃、结肠代食管重建消化道5例,食管癌切除并胃部分切除,残胃代食管重建消化道4例,二期食管次全切除并全胃切除,空肠“P”袢代胃、结肠代食管重建消化道1例.结果：术后发生颈部吻合口瘘1例,经保守治愈.切口感染1例,二期缝合后愈合.全组无死亡病例.随访8例,1、3、5年生存率分别为100%、37.5%、25%.结论：同时发现的食管、胃重复癌根据具体情况选择不同的手术方式可取得与单纯的食管癌手术同样的疗效.     

全胃切除P袢空肠代胃术后的滴饲护理

P 袢空肠代胃、食管空肠吻合术是全胃切除,重建消化道的一种新术式,也是恢复正常消化功能,维持病人生命的一种重要手段。鉴于食管在解剖上仅有一层纵行平滑肌、含弹性纤维较多、外层又无浆膜覆盖,若术后近期内饮食不当,则有发生吻合口瘘的危险。为了防止发生这一严重并发症及有利于病人的营养支持,我们对13例 P 袢空肠代胃术后病人的饮食     

全胃切除超膈顶食管空肠机械吻合临床研究（附102例对比分析）

目的探讨贲门癌和胃上部癌切除术后消化道重建方式。方法全胃切除术后其中60例（本组）采用超膈顶食管空肠机械吻合，42例（对照组）采用膈顶食管空肠端侧手工缝合，同时行空肠袢Brow吻合。结果本组60例，全部治愈，无吻合口瘘，随诊2-27a健存者无吻合口狭窄及返流性食管炎。对照组42例，术后发生并发症5例，死亡2例，两组差别显著，P〈0．01。结论贲门癌及胃上部癌行全胃切除，采用超膈顶食管空肠机械吻合能有效预防术后并发症，提高近期治愈率及远期生活质量。     

吻合器在胃肠道吻合术中的应用

目的 探讨吻合器在胃肠道重建中的应用价值。方法 回顾性总结2000年1月～2005年12月我院实施吻合器行胃肠道吻合96例病例的经验。对于胃底贲门癌切除，胃食管吻合可以经腹实施。低位直肠切除，通过吻合器行结直肠吻合，尽可能保留肛门。结果 胃底贲门切除30例，经腹用吻合器行食管胃端侧吻合。胃大部切除29例，行胃空肠侧侧吻合。大肠切除37例，其中直肠切除28例，行结直肠端侧或端端吻合。术后采发生吻合口出血、狭窄和吻合瘘等并发症。结论 应用吻合器行胃肠切除后消化道重建，操作方便，安全可靠，省时，创伤小，避免开胸；对低位直肠切除可提高保留肛门的机率。     

我院胃手术后病人的饮食护理

胃的手术包括全胃切除术、胃大部切除术、胃部分切除术、胃空肠吻合术等,胃肠吻合又分毕氏Ⅰ式和毕氏Ⅱ式,全胃切除后则多为食管空肠吻合即空肠袢代胃术.     

我院胃手术后病人的饮食护理

胃的手术包括全胃切除术、胃大部切除术、胃部分切除术、胃空肠吻合术等，胃肠吻合又分毕氏Ⅰ式和毕氏Ⅱ式，全胃切除后则多为食管空肠吻合即空肠袢代胃术。在临床工作中，胃手术后往往因进饮进食不合理或饮食不节引起呕吐、上腹部憋胀、倾倒综合征、吻合口出血、吻合口瘘等并发症，给病人带来了不应有痛苦。为了减少胃手术后并发症的发生，使病人顺利度过术后恢复期，促进病人康复，正确合理的饮食护理在整个治疗和康复过程中起着非常重要的作用。现就胃手术后，针对不同术式，怎样做好饮食护理等问题介绍如下。     

管型吻合器在上消化道重建中的应用(附89例报告)

目的　探讨应用管型吻合器重建消化道的效果。方法　行全胃或胃大部切除后 ,在预定两吻合口之间切开近端空肠 ,置入吻合器行空肠侧侧、食管 空肠或残胃 空肠一次性吻合 ,缝合缩窄切口部肠管。结果　术后未见吻合口瘘、狭窄、出血、排空障碍等并发症 ,随访 3～ 6个月 ,无食管或残胃区疼痛 ,无呕吐等。结论　此法操作简单易掌握 ,行食管空肠吻合时更显其优点 ,保证了空肠的连续性 ,缝扎缩窄空肠可阻止十二指肠液向上逆流 ,达到Roux en Y式效应。     

全胃切除两种代胃术式的临床比较

目的：探讨更加符合生理学要求的全胃切除消化道重建术式。方法：将33例行消化道重建的胃近侧部癌患者分为两组。A组（n=16）行“P”袢＋Roux-en-y间置代胃术；B组（n=17）行空肠原位间置代胃术。术后随访12个月，比较两组患者的血红蛋白、血浆蛋白及体重变化；了解“代胃”排空及反流情况。结果：两组血浆蛋白与体重下降数值比较，差异有统计学意义（P〈0．05，P〈0．01），B组的血液营养学指标及体重增长指标优于A组。“代胃”排空时间A组平均25min，B组平均30min两组均无胆汁反流及倾倒综合征。结论：食管空肠原位间置代胃术是胃近侧部癌全胃切除术后消化道重建的一种较合理术式。     

全胃切除术后两种常用消化道重建方式的比较

目的探讨全胃切除术合理的消化道重建方式。方法回顾分析我院1999—2008年所开展全胃切除手术病例,选择其中最常采用的P袢空肠Roux—en—Y重建术和功能性空肠间置吻合术,对其手术难度、术后病人的并发症及营养差异进行比较。结果两种手术方法手术难度、术后并发症相差不太。P袢空肠Roux—en—Y重建术后早期适应性较好;功能性空肠间置吻合术后病人后期营养优于前者。结论全胃切除后,P袢Roux—en—Y吻合术和功能性空肠间置吻合术在改善患者术后症状和生活质量等方面是比较理想的重建术式,但功能性空肠间置吻合术是一种更符合生理,更能解决全胃切除后病人发生营养障碍的术式。     

Circular staplers in esophagojejunal and esophagogastric anastomoses

A report on 100 consecutive esophagoenteric anastomoses (EEA stapler) following total (esophagojejunostomy) or proximal gastrectomy (esophagogastrostomy) is presented. The following intraoperative problems occurred: insufficiency of the purse string suture [4], lumen of the esophagus too small [1], rupture of the esophageal wall [4], incomplete rings [4]. Fatal postoperative complications included two cases of insufficiency of the esophagojejunostomy, whilst the remaining six postoperative deaths were not linked to the use of the stapler (operative mortality 8%). Follow-up showed no recurrence at the stapler line, but two anastomotic strictures occurred. The EEA stapler is a helpful instrument to reduce leakage at the esophagoenteric anastomosis and, hence operative mortality after total and proximal gastrectomy.     

Proximal gastrectomy and jejunal pouch interposition: radiographic evaluation of postoperative findings

BACKGROUND: We assessed the postoperative findings of proximal gastrectomy and jejunal pouch interposition with contrast radiography. METHODS: Eleven patients with proximal gastrectomy and jejunal pouch interposition for proximal gastric carcinoma underwent contrast radiography. We evaluated the radiographic findings of the remnant stomach and interposed jejunal pouch. RESULTS: The interposed jejunal pouch showed good expansion, and the motility of the remnant gastric antrum was normal in all patients. One patient had significant lumenal narrowing of the esophageal pouch anastomotic site. Leak at the anastomotic site was not found. Reflux into the esophagus from the pouch was observed in two patients. Gastric emptying time was considerably delayed in two patients. CONCLUSION: Follow-up upper gastrointestinal series of the proximal gastrectomy and jejunal pouch interposition showed different postoperative findings. Awareness of the normal and abnormal findings is essential in the accurate postoperative evaluation of these patients.     

保留胃窦的间置空肠双通道术式在食管胃结合部癌根治术中的应用探讨

目的探讨保留胃窦的间置空肠双通道术式在食管胃结合部癌(AEG)根治术中的临床应用价值。方法对66例SiewertⅡ、Ⅲ型食管胃结合部癌,分别采取保留胃窦的间置空肠双通道术式(28例)和全胃切除Roux-en-Y空肠食管吻合术式(38例),回顾性分析对比两组手术患者在手术时间、出血量、术后肠功能恢复时间以及术后并发症发生率等方面有无差异。结果保留胃窦的间置空肠双通道术式组,与全胃切除Roux-en-Y空肠食管吻合术组对比,除在术后肛门排气时间和进食流质时间两个方面略有差异外,无论在手术时间、术中出血量、住院时间以及术后早期并发症的发生率均无明显差异。此外,保留胃窦的间置空肠双通道术式组在术后的反流性食管炎发生也要低于全胃切除Roux-en-Y空肠食管吻合术组。随访6¹8个月,患者近期生活质量满意。结论保留胃窦的间置空肠双通道术式,因残胃有一定储袋作用,且进食具备双通道路径,能较好地预防反流性食管炎和倾倒综合征。同时,保留了十二指肠路径,能有效刺激胆汁分泌,降低胆结石的发生率。此外,此术式清扫、切除范围合理,手术创伤相对较小,是SiewertⅡ、Ⅲ型AEG根治术较理想的消化道重建方式之一。     

D2 gastrectomy -- a safe operation in experienced hands

In the contemporary practice, surgery is the only potentially curative treatment available for gastric cancer. However, there is no consensus on the extent of surgical resection. Advantages of D2 gastrectomy in terms of morbidity, mortality, local recurrence and survival are confirmed in Japanese as well as some European trials. In our hospital, all patients with operable gastric cancer are treated with D2 gastrectomy along with splenectomy and distal pancreatectomy followed by jejunal pouch reconstruction. The study was undertaken to evaluate our practice in terms of postoperative morbidity and mortality. All the patients who had total gastrectomy for gastric carcinoma from January 1995 to December 2000 were included in the study. During this 6-year period, 33 patients underwent potentially curative D2 gastrectomy. Postoperative morbidity and mortality were 18 and 9%, respectively. There were no anastomotic leaks. Three (9%) patients developed dysphasia, of which two (6%) had anastomotic stricture requiring dilatation. We feel D2 gastrectomy with splenectomy and distal pancreatectomy when performed electively is a safe procedure in experienced hands. Oesophago-jejunal anastomosis can be safely performed using circular stapler.     

改良下鼻甲成形术治疗慢性肥厚性鼻炎的临床研究

目的探讨改良下鼻甲成形术治疗慢性肥厚性鼻炎患者的临床疗效及手术技巧。方法 76例不伴有显著黏膜肥厚的慢性肥厚性鼻炎患者随机分组,38例行鼻内镜改良下鼻甲成形术(A组),38例行下鼻甲骨折外移术(B组),比较两组治疗下鼻甲肥大的疗效。结果两组组内术前与术后比较,鼻阻力值及VAS评分均显著降低(P<0.05);两组间术前与术后1个月时鼻阻力及VAS评分比较差异无统计学意义(P>0.05),而术后1年时差异有统计学意义(P<0.05);A组组内比较术后近、远期疗效差异无统计学意义(P>0.05),B组组内比较术后近、远期疗效差异有统计学意义(P<0.05)。结论改良下鼻甲成形术是改善不伴有显著黏膜肥厚的慢性肥厚性鼻炎患者鼻塞的有效方法,近、远期疗效都比较理想,值得临床推广。     

Robot-assisted total remnant gastrectomy for interposed jejunal pouch dysfunction 25 years after proximal gastrectomy for gastric cancer: A case report

Proximal gastrectomy (PG) in combination with jejunal pouch interposition is a technique aimed at improving the postoperative dietary outcomes; however, some cases are reported to require surgical intervention owing to difficulty of food intake caused by pouch dysfunction. Herein, we present a case of robot-assisted surgery for interposed jejunal pouch (IJP) dysfunction in a 79-year-old male, occurring 25 years after the initial PG for gastric cancer. The patient had chronic anorexia for 2 years and was treated with medications and dietary guidance; however, 3 months prior to admission his quality of life had reduced, owing to worsening symptoms. The patient was diagnosed with pouch dysfunction due to extremely dilated IJP identified using computed tomography and underwent robot-assisted total remnant gastrectomy (RATRG) with IJP resection. After an uneventful course of intraoperative and postoperative treatment, he was discharged with sufficient food intake on postoperative day 9. RATRG can, thus, be considered in patients with IJP dysfunction after PG.     

腹腔镜全胃切除术后不同消化道重建方式对胃癌患者胆囊收缩功能及术后并发症的影响

目的观察腹腔镜全胃切除术后采取不同消化道重建方式对胃癌患者胆囊收缩功能、术后并发症情况的影响。方法选取我院行腹腔镜全胃切除术治疗的胃癌患者98例,利用随机数字表法分为两组各49例,A组采取功能性空肠间置代胃重建术(FJI),B组采取Roux-en-Y重建术,比较两组手术指标、手术前后营养代谢情况体质量指数(BMI)、血红蛋白(Hb)、总蛋白(TP)、预后营养指数(PIN)、胆囊收缩功能胆囊容积、胆囊排空率、胆囊收缩素(CCK)水平、胃肠功能(代胃肠管最大径值与管内钡剂停留时长)及术后并发症情况等。结果两组患者手术重建时间与术中出血量比较差异无统计学意义(P>0.05);A组术后6个月BMI、Hb、TP、PIN均显著高于B组;术后胆囊容积、CCK水平低于B组,胆囊排空率高于B组;术后6个月代胃肠管最大径值大于B组,管内钡剂停留时间长于B组;术后R-S综合征与倾倒综合征发生率明显低于B组,差异均有统计学意义(P<0.05)。结论胃癌患者腹腔镜全胃切除术后采取FJI更益于胆囊收缩功能恢复,可更好促进机体营养代谢,提高消化吸收功能,降低术后并发症风险。     

游离空肠移植重建下咽及颈段食管的临床分析

目的探讨游离空肠修复下咽及颈段食管肿瘤切除术后组织缺损的方法和疗效。方法回顾性分析采用游离空肠重建下咽颈段食管7例,为下咽癌侵及颈段食管,均行全喉、下咽及颈段食管切除。术前均行x线食管造影及胃镜检查,了解病变范围,术后复查x线食管造影。术后均补充放疗。随访7个月～24个月。结果本组7例患者移植游离空肠全部成活。1例于术后13d发现咽瘘,经换药、抗炎等处理后18d痊愈。1例患者于术后95d无明确诱因出现上消化道大出血死亡。1例患者术后5个月出现进食困难,发现胸段食管癌,放弃治疗于术后11个月死亡。5例患者随访至今游离空肠均成活良好,无吻合口狭窄及进食困难。结论以游离空肠修复下咽及颈段食管部位肿瘤切除术所致缺损,并发症较少,成功率高,恢复消化道的连续性安全可靠。