1、AcidGastric Mucosal BarrierNonsteroidal Antiinflammatory Drugs（NSAIDs）AlcohalGastric StasisHelicobacter Pylori, HPCigarette SmokingDuodenal Ulcervagus nerveoversecretion of acidGastric UlcerDisruption of gastric mucosal barrier 2,Gastric stasishunger painnight painDiagnosisHistory Fiberoptic Endosco
2、py Radiology十二指肠球部前壁可见一圆形疡，大小约0.6cm0.7cm溃疡，基底覆黄厚坏死苔，周边充血水肿 十二指肠球部前壁可见一大小约1.0cm1.2cm溃疡，溃疡表面覆盖黄白色坏死苔，周边充血水肿。 Inefficacy of medical treatment intractable ulcer, telephium （hemorrhage, perforation, cicatricial Pyloric Obstruction ）Sabiston Textbook of Surgery, 18th edNo regularity of gatric pain1/2-1h a
3、fter ingestion，postprandial discomfortIngestion of food and antacids can not relieve pain ,or exacerbation on eating 男，48岁。上腹痛。幽门可见，类圆形，呈开放状态，粘膜充血水肿，可见大小约1.0cm1.2cm溃疡，溃疡表面覆盖黄白色坏死苔，周边充血水肿，色泽红。 胃角中央可见一1.5cm1.8cm圆形深溃疡,内附较厚的黄色坏死苔,周边充血水肿；经两次病理活检,确诊为良性溃疡。type 1 （60%）： have low-to-normal acid output. betwe
4、en the fundic and antral type 2（15%）： located in the body of the stomach in combination with a duodenal ulcer. associated with excess acid secretion.Type 3 （20%）：are prepyloric ulcers and are associated with hypersecretion of gastric acid. Type 4 （10%）：occur high on the lesser urvature near the GE j
5、unction. are not associated with excessive acid secretion.（ulcers on the greater curvature of the stomach, 5% ）Acute Perforation of Gastroduodenal Ulcer90% of perforated duodenal ulcers occur in the anterior duodenal bulb. 60% of gastric ulcers are located in the lesser curvature.chemical peritoniti
6、s bacterial peritonitisCLINICAL MANIFESTATION AND DIAGNOSISUlcer history 10% negtiveSevere epigastric and later generalize abdominal pain。（Nausea and vomitingToxic Symptom: fever，WBC，low blood preasure。CLINICAL MANIFESTATION AND DIAGNOSISsupination仰卧 and lies stillBoardlike rigidity of the abdominal
7、 musculature，boardlike venter 板状腹Decreased bowel sounds80% cases show free air under the diaphram，eroperitoneum气腹症 not clear, food residue, yellowishDifferential Diagnosis1Acute Pancreatitis1Acute Cholecystitis1Acute Appendicitis 1Perforation Of Gastric Cancer indicationMild clinical manifestation,
8、limited peritonitisPerforation on empty stomachRule out telephium顽固性溃疡, hemorrhage, obstruction and cancerationHard to tolerate surgical procedureThe erotion of base vessal in ulcer.Common in lesser gastric curvature or posterior wall of duodenumClinical Manifestation And DiagnosisHaematemesis and m
9、elenaBlood loss 400ml, pale, dry mouth, quick pules 800ml，shockAbdominal physical sign is not obviousDifferential DiagnosisEsophageal Varices BleedingAcute HemobiliaStress Ulceration Bleedingtherapeutic principleHemostasis Subtotal gastrectomy幽门成形术Cicatricial Pyloric ObstructionSpasticityEdematousCi
10、catricleclinical manifestation and diagnosisClinical Manifestationsplashing soundDiagnosisDifferential Diagnosis gastrointestinal decompression胃肠减压 gastric lavage洗胃 3-7days to correct Water-Electrolyte and acid base balance disorder subtotal gastrectomy vagotomy + antrectomy胃窦切除术胃窦切除术stomach-jejunum
11、 anastomosisBillroth I Simple, to fit physiological function；reduce refluxing of bile and pancreatic juice；Insufficient gastrectomy.Hemigastrectomy with Billroth 1 (gastroduodenal) anastomosis. (From Dempsey D, Pathak A: Antrectomy. Operative Techniques in General Surgery 5:86100, 2003.)Billroth II
12、sufficient gastrectomy, complicated more postoperative complicationBillroth II operation and some of its modifications. parietal cell or highly selective vagotomy Figure 45-12 A to E, Heineke-Mikulicz pyloroplasty. (AE, From Soreide JA, Soreide A: Pyloroplasty. Operative Techniques in General Surger
13、y 5:6572, 2003.)Surgical Treatment Recommendations for Complications Related to Peptic Ulcer Disease Duodenal UlcerIntractable: parietal cell vagotomy Bleeding: truncal vagotomy with pyloroplasty and oversewing of bleeding vessel Perforation: patch closure with treatment of H. pylori with or without
14、 parietal cell vagotomy Obstruction: rule out malignancy and parietal cell vagotomy with gastrojejunostomy Sabiston Textbook of Surgery, 18th edSurgical Treatment Recommendations for Complications Related to Peptic Ulcer DiseaseGastric Ulcer Intractable: Type I: distal gastrectomy with Billroth I Ty
15、pe II or III: distal gastrectomy with truncal vagotomyBleeding Type I: distal gastrectomy with Billroth I Type II or III: distal gastrectomy with truncal vagotomy Perforated Type I, stable: distal gastrectomy with Billroth I Type I, unstable: biopsy, patch, and treatment for H. pylori Type II or III
16、: patch closure with treatment of H. pylori Sabiston Textbook of Surgery, 18th edSurgical Treatment Recommendations for Complications Related to Peptic Ulcer DiseaseGastric UlcerObstruction: rule out malignancy and antrectomy with vagotomy.Type IV: depends on ulcer size, distance from the gastroesop
17、hageal junction, and degree of surrounding inflammation. Giant gastric ulcers: distal gastrectomy, with vagotomy reserved for type II and III gastric ulcers. Sabiston Textbook of Surgery, 18th edOperations for high-lying ulcers near the gastroesophageal junction (type IV) POSTOPERATIVE COMPLICATIONS
18、 OF SUBTOTAL GASTRECTOMYPOSTOPERATIVE COMPLICATIONSpostoperative complicationspostoperative complications of subtotal gastrectomypostoperative complications of subtotal gastrectomypostoperative complications of subtotal gastrectomyEarly Dumping Syndrome：Late Dumping Syndrome:postoperative complicati
19、ons of subtotal gastrectomyAlkaline Reflux Gastritispatients Roux-en-Y anastomosis postoperative complications of vagotomyEarly gastric cancer disease involving only the mucosa or submucosa Advanced gastric cancer invasion of the muscularis or beyondEarly gastric cancer型型 隆起型隆起型a型型隆起表浅型隆起表浅型b型型平坦表浅型
20、平坦表浅型 c型型表浅凹陷型表浅凹陷型型型 凹陷型凹陷型型型表浅型表浅型Borrmanns pathologic classification of gastric cancer based on gross appearance1，spread within the gastric wall 2，lymphatic metastasis 23 group lymph nodes supraclavicular lymph nodes左锁骨上淋巴结3，blood spread ：hepatic metastasis4，implantation metastasis种植转移5，ovaries m
21、etastasis卵巢转移6，gastric micrometastasis微转移N1：16 lymph nodes metastasisN2：715 lymph nodes metastasisN3：16 lymph nodes metastasisN N0 0N N1 1N N2 2N N3 3T T1 1A AB BT T2 2B BA AT T3 3A AB BT T4 4A AH H1 1 P P1 1 CY CY1 1 M M1 1N stage of the JGCA ( Japanese Gastric Cancer Association) classification (t
22、he thirteenth edition)肿瘤部位N1N2N3L/LD3,4d,5,61,7,8a,9,11p,12a,14v4sb,8p,12b/p,13,16a2/b1LM/M/ML1,3,4sb,4d,5,67,8a,9,11p,12a2,4sa,8p,10,11d,12b/p,13,14v,16a2/b1MU/UM1,2,3,4sa,4sb,4d,5,67,8a,9,10,11p,11d,12a8p,12b/p,14v,16a2/b1，19，20U1,2,3,4sa,4sb4d,7,8a,9,10,11p,11d5,6,8p,12a,12b/p,16a2/b1，19，20LMU/MU
23、L/MLU/UML1,2,3,4sa,4sb,4d,5,67,8a,9,10,11p,11d,12a,14v8p,12b/p,13,16a2/b1，19，20characteristic symptom Epigastric symptom Nausea and vomiting haematemesis and melenaphysical sign Epigastric tenderness, mass, weight loss Virchows sentinel node (supraclsvicular node on the left)胃体部可见约3.0cm5.0cm范围内多发性大小不等的不规则结节隆起，伴有糜烂，病理粘液附着，基底坚硬如石。 胃角部可见一2.5cm2.8cm圆形深溃疡,内附的黄色坏死苔,周边糜烂浸润，脆易出血，基底僵硬，蠕动缺失。 infiltrating typeRadiotherapyImmunotherapyThe Traditional Chinese MedicineGene Therapy
