当前胰头癌外科治疗的几个热点问题

近年来胰头癌的外科治疗进步显著,表现在手术切除率较前有了显著提高,围手术期病死率及各种合并症的发生率显著下降.对涉及治疗理念如手术适应证、切除范围、外科治疗的局限性及多学科综合治疗等诸方面,认识上更趋理性.但由于中远期生存率无显著改善,在不断尝试多种辅助手段治疗效果的同时,亦不断有热点问题出现,特别是在循证医学原则的指导下,面临对既往经验性的结论予以重新评价的必要性,特别是需要设计开展符合循证原则的前瞻性研究,以在涉及胰头癌诸多治疗方式的选择上更为规范,进而提高其治疗效果.     

Vagotomy in the surgical treatment of pyloroduodenal ulcers

The results of organ-preserving operations in 243 patients with peptic ulcer of the pyloric part of the stomach and duodenum are analysed; 88% of patients were operated on in the occurrence of life-threatening complications of the disease. The main type of surgical operation was selective proximal vagotomy which was isolated only in 44 cases. The immediate and late sequela of the operations were evaluated by means of the aspiration-titration method of studying acid production, pH-metry, roentgenoscopy, electrogastrography, and esophagogastroscopy. The late results of the vagotomy were studied during prolonged continuous medical observation of the patients. A socioeconomic impact of SPV is shown. The results of organ-preserving operation were excellent in 84.4%, satisfactory in 10.5%, and poor in 5.1% of patients according to Visick's classification.     

Minimally-invasive surgical treatment of perforated gastroduodenal ulcers

The results of treatment of 249 patients aged 15 to 78 years with perforated gastroduodenal ulcers were analyzed. The study group consisted of 128 patients in whom video-laparoscopic procedure was used for suturing of ulcer, control group -- of 107 patients treated conventionally. Conversion of laparoscopic procedure to open surgery was in 14 cases. It is demonstrated that the intensity of pain syndrome, hospital stay and the number of postoperative complications in the study group were less that in the control group. Indications and contraindications for video-laparoscopic method in these patients were formulated.     

Minimal resections in surgical treatment of perforative duodenal ulcers

289 patients were operated on the reason of perforative duodenal ulcer. Omental tamponade of the ulcer after Oppel-Policarpov was performed in 260 (90%) cases; traditional ulcer closure with omental support - in 13 (4,5%); excision of the ulcer?- in 4 (1,4%); truncal vagotomy and pyloroplasty - in 9 (3,1%) and gastric resection was performed in 3 (1%) patients. After 277 operations "of minimal volume" major complications were registered in 21 (7,6%) patients with lethal outcomes in 9 cases. All patients received adequate antiulcer drug treatment. Follow-up results, obtained in 153 patients, demonstrated good results of the operation and nonrecurrent course in 133 (86,9%) cases. The omental tamponade of the ulcer after Oppel-Policarpov proved to be the method of choice in treatment of the perforative duodenal ulcer. Early beginning of antiulcer conservative treatment after the operation provide excellent results and stable recovery.     

The surgical treatment of malignant stomach ulcers]

The authors analyse the specific features of the clinical picture, diagnosis, pathomorphological changes and surgical treatment in 52 patients with gastric ulcer which underwent malignant degeneration. It is noted that malignancy occurs most frequently in close vicinity to the ulcerative defect and rarely in the mucosa beyond the ulcer. The morphostructural reorganizations are determined to a certain degree by the peculiarities of extension of the tumor along the mucosa and the organ as a whole. The authors discuss the principles of the choice of the method for treatment according to the findings of pathomorphological examination of biopsy material and the results of emergency intraoperative examination. Even if the merest suspicion of malignancy of the ulcer arises, the operation should be conducted with observance of all oncological principles. Postoperative mortality was 3.8%, complications occurred in 7.7% of cases. Five-year survival was 84.6% in the absence of metastases and the presence of carcinoma cells within the limits of the mucosa and 12.5% among cases in which metastases were found during the operation. Attention is drawn to the principles of regular medical surveillance over patients receiving nonoperative treatment for gastric ulcer.     

Pylorus-sparing gastric resection in the surgical treatment of mediogastric ulcers

Pylorus-preserving resections of the stomach were fulfilled in 118 patients with type I ulcers. The detected drop of the acid production in the stomach with ulcers of such localization was considered to be an indication to the removal of not more than 1/2 of the stomach. A necessary condition of pyloropreserving resection is the leaving of the pylorus zone not more than 2-3 cm. Two patients died (one from peritonitis and one from pulmonary insufficiency), 5 patients had disturbed evacuatory function of the stomach related with anastomosis. Long-term results were followed-up in 113 patients. All the patients returned to their normal activity, the pain syndrome disappeared, the dumping syndrome was absent. Complete inhibition of free hydrochloric acid was noted. There were no recurrences.     

Procedural problems in the surgical treatment of gastroduodenal ulcers]

Data concerning 175 cases operated upon for gastroduodenal ulcer are set forth in the article. Much importance is attached to a thorough mobilization of the duodenum, treatment of its stump, gastroenterostomy on the shortest afferent loop and to a broad use of suturing apparatuses and of caprone as a suture material, as well. Mortality constituted 1.1%.     

Late results of surgical treatment of perforated pyloroduodenal ulcers

The results of treatment of 171 patient operated on for perforative pyloroduodenal ulcer in follow-up of up to 12 years are analysed. After closure of a perforative ulcer, the bad result was noted in 51.6% of the patients. The performance of the different types of vagotomy contributed to stable recovery in 88.3% of the patients.