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胰十二指肠或中段胰腺切除后胰腺残端-消化道的重建方式主要包括胰肠吻合和胰胃吻合两大类。两种吻合方式在围手术期并发症尤其是胰瘘发生率方面差异无统计学意义,胰胃吻合对胰腺远期内外分泌功能的影响尚不明了。对有望获得长期生存,或已经有胰腺内外分泌功能不全的病人,为避免远期的进一步损害,选择胰肠吻合较合理;而对于中段胰腺切除或胰管内乳头状黏液性肿瘤(IPMNs)的病人,可考虑胰胃吻合。总之,选择何种重建方式应综合考虑术者的操作习惯、手术方式、原发疾病的性质、胰腺的质地和内外分泌功能状态等诸多因素。     

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溃疡病的发病率在高峰时期曾高达人群的 1 0 % ,但近30年来不断下降 ,尤以十二指肠溃疡 (ＤＵ)最为明显 ,致使与胃溃疡 (ＧＵ)之比由原来 1 0∶1降至 <2∶1。有人将发病率陡降归功于Ｈ2 受体拮抗剂高疗效的结果 ,但流行病学调查表明早在此类药物问世的十几年前 ,ＤＵ的发病率已开始下降。近年应用的Ｈ2 受体拮抗剂及质子泵抑制剂治疗ＤＵ的疗效甚佳 ,但停药后 1年复发率却高达 5 0 %～ 80 % ,需要再治或长期半量维持。而且 5 %～ 1 0 %的病例无论何种药物均不能使溃疡愈合 ,成为难治性溃疡 (ｒｅｆｒａｃｔｏｒｙｕｌｃｅｒ)。因此目前ＤＵ…     

原发性十二指肠肿瘤手术的术式选择

原发性十二指肠肿瘤(primarytumorsoftheduodenum,PTD)是指原发于十二指肠各段的肿瘤,包括原发性十二指肠良性肿瘤(primarybenigntumoroftheduodemm,PBTD)和原发性十二指肠恶性肿瘤(pri-marymalignanttumoroftheduodemum,PMTD)。以往的文献报道PTD比较少见,约占小肠肿瘤的9%～29%犤1犦。PTD以恶性病变为多,PMTD发生率为0.35‰,占全消化道恶性肿瘤的0.3%～0.4%,占小肠恶性肿瘤的25.0%～54.5%犤1-4犦;PBTD占十二指肠肿瘤的9%～25%犤5,6犦。我院近15年间收治PTD44例,恶性病变占86.4%(38/44),良性病变占13.6%(6/44)。近年来随着纤维…     

根治性胰头十二指肠切除术在胃下部癌中的应用

报告12例胃下部癌行根治性胰头十二指肠切除术(RPD),取得了满意的临床效果。认为胃下部癌侵及胰头和(或)十二指肠者为绝对适应证。而N3( )者为相对适应证,第16组淋巴结转移者应放弃RPD。淋巴结的清除范围达D_3即可。适应证的选择应从严掌握,须结合病人的年龄、一般状况、重要脏器功能及经济条件等因素综合考虑。对胃癌侵及胰腺和淋巴结转移的判定应慎重,必要时需行冰冻活检。并对该手术的有关问题进行讨论。     

胃幽门窦癌浸润胰头联合胰十二指肠切除43例临床分析

目的探讨胃幽门窦癌浸润胰头时的手术方法。方法回顾性分析1984年6月至2004年6月收治的采用胰十二指肠切除术(PD)治疗的胃癌侵及胰头43例临床资料。结果无手术死亡。19例根治手术中联合胰十二指肠切除术15例,胰头局部切除4例;姑息切除17例;探查及胃空肠吻合7例。术后并发症发生率:PD术后为33%(5/15),胰头部分切除为25%(1/4),姑息切除为18%(3/17),探查活检为14%(1/7)。组间差异无显著性意义(P>0·05)。随访:中位生存时间PD为26个月(12~156个月),胰头部分切除为23个月(14~73个月),姑息切除为8个月(3~37个月),探查及胃空肠吻合为3个月(1·5~9·0个月)。联合PD和胰头部分切除的生存期明显长于姑息切除和探查及胃空肠吻合组(P<0·01)。结论胃幽门窦癌联合PD或胰头局部切除能够提高病人的生存期,手术指征选择恰当和肿瘤的彻底根治是取得良好临床效果的关键。     

Whipple术中应用改良式胃造瘘术的临床研究

目的探讨Whipple术中应用改良式胃造瘘术的临床意义。方法总结2004年11月至2006年12月收治的36例Whipple术中行改良式胃造瘘术加空肠造瘘术（治疗组）患者的临床资料,并与24例同期Whipple术中行传统胃造瘘术加空肠造瘘术（对照1组）及22例同期行Whipple术加空肠造瘘术（对照2组）的患者进行对照研究。对3组患者的手术时间,术后开始行肠内营养时间,术后留置鼻胃引流管时间以及术后胃瘫、胰瘘、胆瘘、腹腔感染等并发症的发生率进行统计学分析。结果治疗组及对照2组术后胃瘫发生率明显低于对照1组（P〈0．05）;治疗组术后留置鼻胃引流管时间明显短于对照2组（P〈0．01）;3组的手术时间、术后开始行肠内营养时间、胰瘘、胆瘘及腹腔感染发生率的差异无统计学意义（P〉0．05）。结论Whipple术中行改良式胃造瘘术安全、可靠,可以明显缩短术后鼻胃引流管留置时间;与传统胃造瘘方法相比,可明显降低术后胃瘫的发生率。     

胃下部癌行根治性胰头十二指肠切除术10例报告

胃下部癌行根治性胰头十二指肠切除术１０例报告沈阳军区总医院普外科（１１００１５）张雪峰宗修锟曲化远陈源光王希泽我科自１９８４年６月至１９９５年６月共选择１０例胃下部癌侵及胰头和（或）十二指肠者行根治性胰头十二指肠切除术（ｐａｎｃｒｅｔｏｄｕｏｄｅｎｅ...     

预防胰十二指肠切除术后胰瘘的临床研究

目的：改进胰肠吻合技术并探讨预防胰瘘的术式。方法：16例胰头癌根治切除术后，改进消化道重建方法，术后经胆道T管逆行造影，观察胰肠吻合肠襻的影像特征。结果：16例无胰瘘并发症。术后T管造影显示，快速注药可见胰肠吻合肠襻及吻合口显影。结论：改进胰肠吻合的缝合技巧及减轻胰肠吻合肠襻张力的术式有助于预防胰瘘。     

胰头癌的生物学特性及术式选择

胰腺癌的发病率逐渐增加 ,且死亡率居高不下 ,已成为危及人类生命的主要恶性肿瘤之一。由于胰腺位置深在 ,肿瘤早期缺乏特异性症状 ,难以早期诊断。目前 ,我国到医院就诊的胰腺癌患者多为进展期肿瘤。据中华医学会胰腺外科学组对1990～ 1995年全国 2 0家医院的统计资料 ,5 9.6%的患者就诊时肿瘤大于 5ｃｍ ,70 %以上的肿瘤伴有胰周组织、器官的浸润、转移。根治性手术切除率为 18.6%。其中 ,胰头癌占全部肿瘤的 80 %以上。多种因素影响着胰头癌患者的术后疗效 ,这些因素又多与肿瘤特有的生物学特性相关。了解胰头癌的生物学特性及复发、转移…     

胃癌胰十二指肠区转移的外科治疗

为探讨胃癌侵犯邻近器官或术后复发转移行扩大切除术的远期效果，我们对5例病人行合并胰十二指肠切除3例，合并胰体尾部切除2例，其他合并肝部分切除，横结肠部分切除，右半结肠切除各1例。结果无手术死亡，病人存活6个月至1年8个月。认为胃癌转移或复发癌行扩大切除是可行的。     

Choice of surgical treatment method for peptic ulcer of operated stomach

The analysis of immediate and long-term results of surgical treatment in 98 patients with peptic ulcer of operated stomach is presented. The choice of surgical method was determined by the disease cause. Reconstructive stomach resection by Bilrot-II in Roux modification was operation of choice in peptic ulcer with non-hormonal factors of ulcerogenesis. When hormonal cause of ulcerogenesis was suspected, even in unknown origin of hypergastrinemia, the extirpation of gastric stump is indicated. Trunkal vagotomy can be performed as an additional surgical method only. Favorable surgical outcomes were seen in 90 (91.8%) patients. Long-term results from 2 to 15 years were studied in 74 (82.2%) patients. They were recognized as good in 48 (53.3%) patients, as satisfactory--in 12 (13.3%). The recurrence of the disease was seen in 4 (4.4%) patients. 10 patients died due to causes not associated with stomach diseases.     

Operation-sequel carcinoma of the stomach. Experimental studies of surgical techniques with or without resection

Several etiopathogenetic factors responsible for carcinogenesis in the operated stomach have been proposed in the literature, but exact proof is still lacking. An experimental assay was planned to determine the pathogenetic roles of surgical trauma, of duodenogastric reflux, and of carcinogen application and its effects. Five different techniques of gastric surgery were performed on a collective of 466 Wistar rats: Billroth I resection, Billroth II resection, Billroth II plus gastroenterostomy with Roux-en-Y technique, Billroth II plus Braun's anastomosis, and gastroenterostomy without resection. Forty-two animals were left unoperated as controls. The appropriate date for autopsy was determined by general clinical observation and random endoscopic and radiologic examinations, and eventually fixed on the 56th postoperative week. Carcinomas developing in the resected stomach were found in animals with and without carcinogen exposure. The actual rate of carcinoma incidence was strongly dependent on the surgical procedure chosen for the respective group. The lowest carcinoma incidence (0%) was found in gastroenterostomy without Roux-en-Y anastomosis, the highest rate (70% without carcinogen, 50% with carcinogen application) in gastroenterostomy alone. Tumor development was found to be connected with alterations of the physiological environment induced by the surgical intervention; a direct association between duodenogastric reflux and tumorigenesis can be postulated. The results of the present study are interpreted with an emphasis on reflux-preventing techniques for gastric surgery that should be included in clinical routine.

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Résumé On trouve dans la littérature diverses hypothèses étiopathogéniques sur le développement d'un cancer dans l'estomac opéré. Mais il n'existe actuellement aucune preuve. Nous avons développé un modèle expérimental pour étudier le rÔle pathogène du traumatisme chirurgical, du reflux duodénogastrique, de l'application de carcinogènes.Cinq types d'interventions ont été réalisés chez 466 rats Wistar: résection type Billroth I, résection type Billroth II, Billroth II avec gastro-entérostomie en Roux-Y, Billroth II avec anastomose type Braun, gastro-entérostomie sans résection gastrique. Les témoins étaient 42 animaux non opérés. La date d'autopsie a été fixée, par l'observation clinique et par des examens endoscopiques et radiologiques faits au hasard, à la 56è semaine postopératoire.Des cancers se sont développés après résection gastrique chez les animaux soumis ou non aux carcinogènes. La fréquence des cancers dépend étroitement de l'opération subie: elle est minimale (0%) après gastro-entérostomie en Roux-Y et maximale (70% avec carcinogène, 50% sans carcinogène) après gastro-entérostomie sans résection gastrique.Le développement des tumeurs est en relation avec les perturbations physiologiques produites par l'intervention, parmi lesquelles le reflux duodénogastrique paraÎt Être le facteur le plus important. Les résultats de cette étude suggèrent que la chirurgie gastrique devrait, en routine, éviter le reflux.

     

Outcome of surgical treatment for patients with scirrhous carcinoma of the stomach

BACKGROUND: Postoperative survival in patients with scirrhous gastric carcinoma is poorer than that in patients with other gastric carcinomas. METHODS: We retrospectively examined outcome in patients with scirrhous gastric carcinoma who underwent gastrectomy to determine how to increase postoperative survival. Postoperative survival in patients with scirrhous gastric carcinoma was compared with that in patients having other gastric cancers overall and by disease stage. Prognostic factors were examined for all patients including those with stage III disease. RESULTS: By multivariate analysis, disease stage, patient age, and scirrhous carcinoma were significant prognostic factors. Five-year survival in patients with stage III scirrhous carcinoma was significantly worse than those with other stage III gastric carcinomas. Extent of lymphadenectomy was one of the variables influencing survival in patients with stage III scirrhous carcinoma. CONCLUSIONS: Gastrectomy with extended lymphadenectomy should be performed to maximize survival in patients with stage III scirrhous gastric carcinoma.     

Local failure after definitive radiation or surgical therapy for carcinoma of the prostate and options for prevention and therapy

The incidence of local failure and its relation to distant failure following definitive therapy of carcinoma of the prostate is discussed. Local failure may arise from incomplete resection, tumor spillage, clones of radioresistant cells, development of new tumors in an organ left in situ, or inadequate treatment portals. The authors review the various measures used as prophylaxis or treatment of local failure in relation to clinical and pathologic stage.     

Aggressive resection of the airway invaded by thyroid carcinoma

BACKGROUND: The aim of this study was to investigate the hypothesis that outcome following concomitant airway resection is superior to that after shaving of the tumour in patients with airway invasion of thyroid carcinoma. METHODS: The records of 34 patients with thyroid cancer with airway invasion were reviewed retrospectively. In addition to total thyroidectomy, airway resection was performed in 18 patients (group 1), whereas the tumour was shaved away from the airway in the other 16 patients (group 2). 131I was used as postoperative adjuvant therapy in all patients. Metastasis and recurrence of the primary lesion were determined by 131I whole-body scans, serum thyroglobulin levels, and computed tomography or ultrasonography of the neck. RESULTS: In group 1, two anastomotic dehiscences resulted in one death. Patients in group 2 had a higher rate of local recurrence (relative risk 8.0, P = 0.013) and earlier recurrence (mean(s.e.m.) 2.6(0.8) versus 7.0(1.1) years; P = 0.026) than those in group 1. Median survival was 5.8 and 4.3 years in the 18 patients of group 1 and 16 patients of group 2 (P = 0.259), and the respective 5-year survival rates were 88 and 84 per cent (P = 0.783). CONCLUSION: Aggressive airway resection can minimize local recurrence of thyroid carcinoma with airway invasion.     

胰头癌的术式选择

胰腺癌的发病率呈上升趋势,近30年来发病率上升3～7倍。胰腺癌可发生于胰腺的任何部位,胰头癌约占2／3。我院360例胰腺癌中胰头癌占75％。中国抗癌协会胰腺癌专业委员会报道胰腺癌2340例,胰头癌占70％。郑树森等2003年报道胰腺癌216例,胰头癌占70．2％。由于胰腺癌多发生于胰头部,临床研究亦多为胰头癌的诊断与治疗。     

Palliative surgical therapy of incurable esophagus cancer by stomach bypass and endotube

Palliative treatment plays an important role in the management of esophageal carcinoma. On the whole there are more than 50% of the patients where the tumour is already inoperable at the time of diagnosis. From 1977 to 1983 we treated a total of 132 patients affected with esophageal carcinoma. It was only in 44 patients that the tumour could be resected. In 26 cases the approach was thoraco-abdominal, in 18 patients thoracotomy was unnecessary. Only palliative measures were possible for the rest. In recent years we have favoured gastric bypass or endoscopically and radiologically guided intubation for palliative treatment of esophageal carcinomas. In 17 patients a Celestin tube was placed surgically. During the last 2 years we exclusively inserted the tube endoscopically using the Nottingham introducer (n = 32). According to our results the best palliative treatment could be achieved by gastric bypass, restoring normal swallowing. Only 1 of 16 patients died postoperatively. Endoscopic insertion of an esophageal tube should be considered as a second choice treatment. A review of our mortality statistics and complication rate suggest that the Celestin tube should rather not be introduced by open surgery. Radiological and endoscopic investigation preoperatively is strictly advised. Furthermore, the indication for a Celestin tube depends on the localisation of the obstruction. In our view, the commercially available tubes (Medoc, Medinex Ltd.) supplied in 3 standard lengths are perfectly satisfying.