腹腔镜胃大部切除术的操作技巧

腹腔镜胃大部切除术的操作技巧上海长海医院腹腔镜诊疗中心（２００４３３）郑成竹，沈炎明，仇明，柯重伟，华积德我院从１９９３年５月至１９９４年５月共施行腹腔镜胃大部切除术１０例。１例行腹腔镜辅助下Ｂ－Ｉ式吻合，其余９例行全腹腔镜下Ｂ－Ⅱ式结肠前吻合。本文...     

胃类癌的诊断与治疗

目的 探讨胃类癌的临床、病理及影响预后因素。方法 １９６８年１月至１９９３年１月天津医科大学附属肿瘤医院收治胃炎类癌２３例，占同期胃肿瘤的０．３６％（２２／６０９８），所有病例均经手术切除，对患者进行随访，并评价其治疗效果、临床进程和随访结果报告。结果 胃类癌以上腹痛（７７．３％），呕血和（或）黑便（５４．５％）为主要临床表现。胃远端大部治切除术１１例，大部切除７例，近端胃大部切除２例，全胃切除２     

胃大部切除术并发胰瘘2例

胃大部切除术并发胰瘘２例山东省莒南县人民医院（２７６６００）田兆快例１．男，３２岁。因溃疡病再穿孔急症手术。术中见十二指肠胃大弯侧穿孔，直径１ｃｍ，有４ｃｍ×５ｃｍ球部瘢痕，后壁穿至胰腺。行胃大部切除Ｂ－Ⅱ式胃肠吻合，溃疡瘢痕行锐性分离。因十二指肠残...     

残胃贲门癌外科治疗体会

对１０例残胃贲门癌的外科治疗进行回顾性分析。首次胃大部切除术后至残胃贲门癌确诊时间为２－２９年。术式包括残胃全切除并食管空肠Ｒｏｕｘ－ｙ吻合５例、残胃部分切除并食管胃管吻合５例。结果：术后存活３年以上者占４０％，２例存活已８年。资料显示：（１）首次胃大部切除术后１０年为残胃癌发病高峰期。残胃癌发生似匀首次术式有关，以ＢｉｌｌｒｏｔｈⅡ式发病率高且发病间期较短；（２）合并肺转移者若有切除可能市应列为手术禁忌；（３）腹部入路有诸多优点，用残胄胃管重建消化道是可行的，且能简化手术。     

腹腔镜手术中恶性肿瘤的漏诊与发现

１９９２年５月～１９９６年８月，行２２种腹腔镜手术５２２例，３例漏诊并存的恶性肿瘤（０．５７％）。３例平均延误时间为１．２７个月，平均年龄５９．７岁，分别为阑尾周围脓肿漏诊乙状结肠癌、胆囊结石漏诊胰头癌、胆囊积脓伴结石漏诊胃底癌，仅１例得到根治切除。另１例（０．１９％）２３岁女性，开腹阑尾切除术后出现肠梗阻，误为粘连性肠梗阻，腹腔镜手术中明确为横结肠癌。强调术者重视此问题并注意分析不典型的症状体征，术中仔细探查，主张术中超声检查。     

残胃贲门癌的外科治疗

本院自１９８０年８月至２００１年２月，共收治残胃贲门癌５例，占同期收治贲门癌的０．８％。现报告如下。临床资料１．一般资料：本组均为男性；年龄５０～６７岁；病程１～８月。胃大部切除，距贲门癌发病的时间为１．２～１０年，平均５．８４年。４例因胃十二指肠溃疡出血急诊行胃大部切除术，术式BillrothⅡ式结肠前胃空肠吻合，贲门肿块大小１～６cm，平均２．９cm，伴左肝转移性结节１例，术后病理均为腺癌。２．手术方式：全部经左胸腹联合切口切除贲门癌，食管残余胃底荷包式吻合２例，全胃切除加左肝转移性结节切除并食管空肠R…     

腹腔镜胆囊切除中胆管损伤分析

腹腔镜胆囊切除中胆管损伤分析李德宁阎玉矿周兆棠段君英１９９３年６月至１９９７年６月我院行腹腔镜下胆囊切除术（ＬＣ）８５６例，其中发生胆管损伤（ＢＤＩ）５例（０．５８％）。现就损伤的原因和防治体会报告如下：临床资料本组５例均系慢性结石性胆囊炎。男１例，...     

腹腔镜手术在胃十二指肠溃疡外科治疗中的应用

腹腔镜手术在胃十二指肠溃疡外科治疗中的应用第二军医大学长海医院（上海，２００４３３）沈炎明仇明郑成竹目前用于治疗胃十二指肠溃疡的腹腔镜手术主要有３种：（１）胃大部切除术；（２）高选迷切术；（３）溃疡穿孔修补术。我院自１９９２年１２月至１９９７年５月共...     

胃大部切除术后黄疸三例教训分析

胃大部切除术后黄疸三例教训分析马克华我院近２０年来共行胃大部切除术４１６例，其中术后出现黄疸３例，约占０．７２％。现报告如下。例１：男，４９岁。因十二指肠球部溃疡行胃大部切除术（毕Ⅱ式）。术中见溃疡与周围粘连较严重。分离粘连，切除溃疡，术后第２天出现...     

胃大部切除术后吻合口溃疡穿孔

胃大部切除术后吻合口溃疡穿孔王永乾，尉婉贞，牛文玲本院曾治疗胃大部切除术后吻合口溃疡穿孔７例。男４例，女３例，年龄２７岁至４０岁５例，４０岁至６５岁２例。术中发现５例为Ｂ－Ⅱ式，２例为Ｂ－Ⅰ式。吻合口溃疡穿孔距切除术后最长时间６年，最短时间４５天。存...     

Completely laparoscopic total and partial gastrectomy for benign and malignant diseases: a single institute's prospective analysis

BACKGROUND: Laparoscopic surgery for gastrointestinal benign disease has gained worldwide acceptance; totally laparoscopic surgery for malignant diseases remains controversial. The purposes of this study were to examine prospectively our experience with laparoscopic gastric resections, to evaluate the surgical outcomes, and to discuss the role of these procedures in the treatment of benign and malignant diseases of the stomach. To the best of our knowledge, this is the largest prospective study of totally laparoscopic total and partial gastrectomies in Western countries. STUDY DESIGN: Thirty-three patients who underwent totally laparoscopic gastric resection between April 1995 and January 2004 were studied prospectively. Eight patients underwent laparoscopic total gastrectomy and 25 patients had laparoscopic partial gastrectomy. There were 21 women and 12 men with a mean age of 71 +/- 10 years. RESULTS: Twenty-one patients (63.6%) were operated on for malignant diseases and 12 patients (36.4%) had benign lesions. Conversion to laparotomy was not required in any case. Mean operative time was 138 +/- 40 minutes and mean blood loss was 58 +/- 85 mL. There were no major intraoperative complications except for one splenectomy, and there were no perioperative deaths. Two postoperative complications occurred; one patient developed an intraperitoneal abscess with a small duodenal fistula after total gastrectomy and was treated by peritoneal lavage and drain placement. The other patient developed delayed gastric emptying after subtotal gastrectomy and was managed conservatively. Mean ambulation time and mean hospital stay were 2.3 +/- 0.7 days and 14.6 +/- 5 days, respectively. All resected margins were tumor free. The mean number of retrieved lymph nodes for the malignant lesions was 22 +/- 12 (range 10 to 53). CONCLUSIONS: This prospective trial demonstrated that totally laparoscopic total and partial gastric resections had good results and were feasible and safe procedures. In addition, we concluded that the totally laparoscopic approach for early and advanced gastric cancer can obtain adequate margins and follow oncologic principles.     

Cholelithiasis after gastric surgery--possibilities and limits of laparoscopic approach

An increased incidence of cholelithiasis has been widely reported after gastric surgery. In the early phase of patient selection, previous gastric surgery has been considered a relative contraindication to laparoscopic cholecystectomy. Between 1999-2003, in our clinic, laparoscopic cholecystectomy was attempted on 3145 patients. Of these patients, 37 patients had gallstone, which occurred several years (mean 17.9 years) after gastric surgery for peptic ulcer (34 cases), gastric cancer (1 case) and hiatal hernia (2 cases). Surgical procedures that had been performed included Billroth I gastrectomy (14 cases), Billroth II gastrectomy (15 cases), truncal vagotomy and piloroplasty (6 cases), and Nissen (2 cases). On this group there were 19 chronic cholecystites, 17 acute cholecystites and one cholesterolosis with gallbladder polyps. One patient was diagnosed with gallstone in common bile duct, successfully removed preoperatively after endoscopic sphincterotomy. The laparoscopic approach was possible in 26 cases. The technical difficulty after Cuschieri was level III--26 patients and level IV--11 patients (reconversion). The mean operative time was 75 minutes. The postoperative evolution of the patients was good in 36 cases. One case had a biliary fistula. The mean postoperative hospital stay was 3.6 days for laparoscopic cholecystectomy and 9 days after conversion. The postoperative adhesions determine the main technical difficulty, but it proved to be a relative contraindication for laparoscopic cholecystectomy for gallstones after gastric surgery. Clear visualization of anatomic structures and landmarks, and scrupulous hemostasis are needed to perform a safe laparoscopic cholecystectomy in these patients.     

毕Ⅱ+Braun吻合与毕Ⅱ式吻合在腹腔镜远端胃癌根治术中的疗效对比研究

目的:对比分析毕Ⅱ式+Braun吻合与单纯毕Ⅱ式吻合在腹腔镜远端胃癌根治术中的安全性及有效性,探讨毕Ⅱ+Braun吻合在胃癌根治术中的优势.方法:回顾分析2015年12月至2018年12月74例行腹腔镜远端胃癌根治术患者的临床资料,其中35例行毕Ⅱ+Braun吻合(毕Ⅱ+Braun组),39例行毕Ⅱ式吻合(毕Ⅱ组).对...     

Pylorus and antroseromuscular flap-preserving gastrectomy--a new type of reconstruction after subtotal gastrectomy for treatment of gastroduodenal ulcer: clinical and experimental study

To avoid motility disturbances after Billroth gastrectomy, the authors designed pylorus and antroseromuscular flap-preserving subtotal gastrectomy (PAFPG). Results showed that gastric motility and emptying time of dogs after PAFPG were close to normal. PAFPG was applied to 125 consecutive patients with gastroduodenal ulcers (gastric ulcer, 15 patients; duodenal ulcer, 94 patients; and combined ulcers, 16 patients) confirmed by barium examination and fibro-gastroendoscopy. All patients recovered smoothly, none of them had postoperative complication. Gastric acid output reduction rates were as follows: basal acid output, 85.05% +/- 8.13%; maximal acid output, 81.76% +/- 10.85%; peak acid output, 81.42% +/- 10.15%. The incidence of postoperative enterogastric reflux (endoscopically) and the concentration of cholic acids in gastric juice were significantly lower in patients after PAFPG than after Billroth I or II gastrectomy. Results suggest that PAFPG reduced gastric acid outputs definitely and overcame adverse motility consequences after Billroth I or II gastrectomy desirably.     

胃癌BillrothⅡ式胃切除术对合并2型糖尿病患者的治疗价值

目的探讨胃癌BillrothⅡ式胃切除术对合并2型糖尿病患者糖代谢的影响。方法回顾性观察7例体重指数（BMl）〈35kg／m^2合并2型糖尿病的病人因胃癌接受Billroth Ⅱ式胃切除手术前后血糖控制情况以及糖尿病治疗的变化。结果7例均成功完成了根治性BillrothⅡ式胃切除术，4例行腹腔镜手术，3例行开腹手术。术后未发生严重并发症。术前空腹血糖（FPG）6．6～9．0mmol／L，平均8．1mmol／L；糖化血红蛋白（HbAlc）6．8％～9．5％，平均7．8％。术后1～8个月复查FPG4．8～7．9mmol／L，平均6．4mmol／L；HbAlc5．5％～7．2％，平均6．3％。据美国糖尿病协会（ADA）糖尿病疗效判断标准，4例治愈，3例改善。结论胃癌BillrothⅡ式胃切除术可治疗胃癌患者合并的2型糖尿病。     

Laparoscopic cholecystectomy and choledocholithotomy in patients with a previous gastrectomy

BACKGROUND:

An increased incidence of cholelithiasis has been widely reported after truncal vagotomy and after gastric resection. In the early phase of patient selection, previous gastrectomy has been considered a relative contraindication to laparoscopic cholecystectomy (LC). In this study, we examined the management of LC in patients with previous gastrectomy.

STUDY DESIGN:

LC was attempted on 1,260 consecutive patients. Of these patients, 29 had a previous gastrectomy. Surgical procedures that had been performed included Billroth I gastrectomies (15), Billroth II gastrectomies (10), and total gastrectomies (4). There were 23 cases of cholelithiasis, 4 chronic cholecystitis, 2 gallbladder polyps, 1 porcelain gallbladder, and 1 gallbladder cancer. Nine patients were diagnosed with stones in their common bile duct or common hepatic duct.

RESULTS:

Preoperatively, seven of nine patients with common bile duct stones were subjected to endoscopic sphincterotomy, and the stones were removed successfully from five of these patients. In the remaining two patients, common bile duct stones were removed by laparoscopic choledocholithotomy by choledochotomy. The LC was completed in 26 patients (90%) who had undergone previous gastrectomy. In 449 patients who had previous abdominal surgery without a gastrectomy, only 4 patients (0.9%) required open surgery. In contrast, three patients (10%) with previous gastrectomy required open surgery. No major complications were recorded in this study series, and no residual or retained stones were seen during a followup period of 3 months.

CONCLUSIONS:

Clear visualization of anatomic structures and landmarks, and scrupulous hemostasis are needed to perform a safe LC in these patients. We conclude that in our study patients, a previous gastrectomy is considered an indication for LC and laparoscopic choledochotomy.     

胃三角吻合术与Billroth I吻合术在腹腔镜远端胃癌根治术中的短期疗效比较

目的：比较胃三角吻合术与Billroth I吻合术在腹腔镜远端胃癌根治术中短期疗效。 方法：选取解放军总医院2009—2013年间37例行腹腔镜远端胃癌根治术的早期胃癌患者资料,其中14例行胃三角吻合术（三角吻合组）,23例行Billroth I吻合术（Billroth I吻合组）,比较两组术中及术后的相关指标。 结果：与Billroth I吻合组比较,三角吻合组手术时间延长,但术中出血量降低,止痛泵使用时间、术后排气时间、拆线时间均缩短,差异均有统计学意义（均P<0.05）;两组住院时间方面差异无统计学意义（P>0.05）。术后病理显示,三角吻合组近、远端切缘距肿瘤的平均距离均明显大于Billroth I吻合组（均P<0.05）。两组术后并发症与不良反应发生率差异无统计学意义（P>0.05）。 结论：三角吻合能一定程度减少腹腔镜远端胃癌根治术患者的创伤、疼痛,降低腔镜下操作难度及感染的风险,加速患者胃肠道功能恢复。

     

Indication for and outcome of laparoscopy-assisted Billroth I gastrectomy

BACKGROUND: Since 1991, laparoscopy-assisted Billroth I gastrectomy has been used for patients with early gastric cancer. The aim of this study was to clarify the outcome of 40 patients who underwent this operation and to examine the indications based on a retrospective histological study of 248 resected cases of early gastric cancer. METHODS: Operating time, blood loss, length of skin incision, and postoperative hospital stay and complications were examined using the operation records and medical charts. The presence or absence of lymph node metastasis, tumour size, site, gross type, histological type, depth of invasion, presence or absence of ulceration, and status of lymph node metastasis were investigated in 248 early gastric cancers. RESULTS: The mean operating time was 3 h and 48 min and the mean length of skin incision was 5.8 cm. Although one patient who had suffered from chronic bronchitis developed pneumonia and wound dehiscence, no other patients had a postoperative complication. The mean hospital stay after operation was 16 days and all patients were alive without recurrence at a median follow-up of 21 months. The incidence of lymph node metastasis in early gastric cancer was 2 per cent (three of 130) in mucosal cancers and 14 per cent (17 of 118) in submucosal cancers. These lesions could have been completely resected by laparoscopy-assisted gastrectomy. CONCLUSION: All 40 patients were treated successfully by laparoscopy-assisted Billroth I gastrectomy without significant complications and with no recurrences to date. Pathological study of conventionally resected stomach and lymph nodes confirmed that laparoscopy-assisted Billroth I gastrectomy would be a safe and useful operation for most early gastric cancers.     

Early international results of laparoscopic gastrectomies

Background: The first totally laparoscopic Billroth II gastrectomy was performed in 1992. To date, laparoscopic gastrectomy has been performed by a small number of surgeons around the world and the laparoscopic approach has been extended to Billroth I and total gastrectomy. The aim of this study is to review the state of laparoscopically performed gastrectomies in the international scene. Methods: Questionnaires were prepared and sent to every surgeon in the world known by the authors or their contacts to have performed a laparoscopic gastrectomy. A questionnaire survey was started in July 1994 and completed by November 1994. Data collected included age, sex, type of gastric resection, technique of reconstruction after resection, average duration of surgery, time to liquid and solid intake, postoperative hospital stay, complications, and opinions of the surgeons. Results: Sixteen surgeons contributed to this study. A total number of 118 cases of laparoscopic gastrectomies, comprising Billroth I (11), Billroth II (87), vagotomy and antrectomy (10), and total gastrectomy (10) had been performed. The indications were gastric and/or duodenal ulcers and benign and malignant gastric tumors. Conclusions: Laparoscopic gastrectomy was found to be superior to the open technique by 10 of 16 surgeons because of faster recovery, less pain, and better cosmesis. The procedure was an expensive and long operation according to four. Two surgeons were uncertain of any benefit because of limited experience. Received: 7 August 1996/Accepted: 28 October 1996