1、阑 尾 炎 （APPENDICITIS） 浙江大学医学院附属第一医院普外科浙江大学医学院附属第一医院普外科 沈沈 岩岩 急性阑尾炎急性阑尾炎 急性阑尾炎是最常见的急腹症急性阑尾炎是最常见的急腹症 18861886年年FitsFits首次命名阑尾炎首次命名阑尾炎 18891889年年McBurneyMcBurney提出外科手术治疗观点提出外科手术治疗观点 患者，女，患者，女，2323岁岁 转移性右下腹痛转移性右下腹痛1 1天天 体格检查：急性病面容，痛苦貌。体格检查：急性病面容，痛苦貌。 腹平软，右下腹麦氏点明显压痛，腹平软，右下腹麦氏点明显压痛， 反跳痛，无肌紧张。反跳痛，无肌紧张。 辅助检查
2、：辅助检查： WBC 12.3X109/LWBC 12.3X109/L，N N 90%90% 首先考虑何种疾病？首先考虑何种疾病？ 需要和哪些疾病鉴别？需要和哪些疾病鉴别？ 如果出现肌紧张，说明什么问题？如果出现肌紧张，说明什么问题？ 阑尾位于何处？何谓麦氏点？阑尾位于何处？何谓麦氏点？ 要不要做手术？要不要做手术？ 如何非手术治疗？如何非手术治疗？ 何时应考虑手术何时应考虑手术 ？ QUESTIONS DIAGNOSIS MANAGEMENT ANATOMY 61:69. Epidemiology Jemal A, Bray F, Center MM, et al. Global cance
3、r statistics. CA Cancer J Clin 2011; 61:69. Risk Factors 1. Nutrition Low fat or protein consumption Salted meat or fish High nitrate consumption High complex-carbohydrate consumption 2. Environment Poor food preparation (smoked, salted) Lack of refrigeration Poor drinking water (well water) Smoking
4、 3.Social Low socioeconomic status (except in Japan) Risk Factors 4.Medical Prior gastric surgery Helicobacter pylori infection Gastric atrophy and gastritis Adenomatous polyps Pernicious anemia Male gender Etiological Factors (Risk Factors) Pathology 1.Early gastric cancer (EGC) Gastric cancer conf
5、ined to the mucosa or submucosa, regardless of the presence or absence of lymph node metastasis 2. Advanced gastric cancer (AGC) Cancer cells infiltrate the proprial muscle layer or serosa EGC Pathology I: protruded IIa: superficially elevated IIc: superficially depressed IIb: superficially flat III
6、: excavated EGC: Endoscopic images Type I Type II Type III Pathology Borrmanns classification of gastric cancer based on gross appearance AGC: Borrmanns classification Linitis plastica T stage are defined by depth of penetration into the gastric wall Lamina propria T1a T1b T4a T4b T3 Subserosal conn
7、ective tissue T1b T1a T4a T4b T stage Grouping of Regional Lymph Nodes (Groups 1-3) by Location of Primary Tumor According to the Japanese Classification of Gastric Carcinoma N stage Metastesis Direct invasion Lyphmatic metastesis Hematogenous metastasis Seeding metastasis Clinical Presentation 1. V
8、ague epigastric discomfort 2. Epigastric pain 3.Weight loss, anorexia, fatigue, or vomiting 4. Hematemesis, anemic Physical signs 1. A palpable abdominal mass 2. A palpable supraclavicular lymph node 3. A palpable mass by rectal examination 4. A palpable ovarian mass (Krukenbergs tumor) Examination
9、Endoscopy M-SCT (multiple detector-row spiral CT) MRI BUS B: Electron micrograph 2. Hypersecretion of gastric acid No acid, no ulcer now extends to if acid, why ulcer 3.Nonsteroidal Anti-inflammatory Drugs 4.Mucosal injury Mucus-bicarbonate layer Surface epithelial cells Blood flow to mucosa Pathoge
10、nesis A: Balance is gotten between protective and hostile factors B: Balance is broken between protective and hostile factors Clinical Presentation Gastric ulcer Made worse by eating Duodenal Ulcer Possibly worse at night Occurs 1-3 hours postprandial Epigastric pain Heartburn Belching Bloated feeli
11、ng Nausea Other symptoms Differential Diagnosis Neoplasm of the stomach Pancreatitis Pancreatic cancer Diverticulitis Nonulcer dyspepsia (also called functional dyspepsia) Cholecystitis Gastritis Complications of Peptic Ulcer i) Perforation B, Cross sectional view of stomach wall and pancreas A, End
12、oscopic view; B, cross-section Hemorrhage Pyloric Obstruction 1. Symptoms need to be relieved 2. The ulcer needs to be healed 3. Recurrence must be prevented The clinician has three major goals when faced with a patient with ulcer disease: Therapy Surgical indications for Peptic Ulcer Four classic i
13、ndications Intractability Hemorrhage Perforation ii) Bleeding and/or obstrction; iii) Without preoperative risk for immediate difinitive surgery Standard treatment Simple omental patch closure: lifesaving operation Surgical Management for Perforation Surgical Management for Perforation Repair of pep
14、tic ulcer perforation Laparoscopic Surgery Non-operative Management for Perforation Selective treatment i) Intravenous flluids, ii) Nasogastric suction, iii) Broad spectrum antibiotic No clinical improvement after 12h, required an operation Carefully selected paitents: i) Age 70 years old ii) Perfor
15、ation 24 hours iii) Haemodynamically stable iv) Can be closely monitored Clinical presention i) Hematemesis ii) Melena or hematochezia iii) Shock (Hemodynamic instability: hypotension with systolic blood pressure 1000ml/24h, a high transfusion requirement Age 60y Rebleeding after stabilization of re
16、cent massive hemorrhage Co-exist with acute perforation or cicatricial pyloric obstruction Bleeding during anti-ulcer therapy Surgical procedures for massive bleeding i) Gastrectomy (involving ulcer lesion ) iii) Bancroft plus artery sutures (gastroduodenal artery or left gastric artery) ii) Sewing
17、homeostasis +Drainage procedure in association with truncal selective vagotomy Clinical Features(1) History of previous peptic ulcers Vomitting volume： 10002000ml time: recogniyable food 8h post prandial features：projectile vomiting, devoid of any bile. Severe Complication : Cicatricial Pyloric Obst
18、ruction Cicatricial Pyloric Obstruction Clinical Features(2) Physical examination wasting, dehydration peristalsis, splash-like sound Laboratory features Metabolic alkalosis Barium X-ray a swollen stomach and narrowed pylorus Endoscopy can not pass through the pylorus Investigations Cicatricial Pylo
19、ric Obstruction Cicatricial Pyloric Obstruction Surgical procedures for Cicatricial Pyloric Obstruction 1, Gastrectomy 2, Drainage procedure in association with truncal vagotomy 3, Gastrojejunostomy 1.Clinical features and management of the severe complications of peptic ulcer 2.Operative indication
20、s for peptic ulcer 3.Differential diagnosis of upper digestive tract hemorrhage QUESTIONS PART I Anatomy PART II Peptic Ulcer Disease PART III Neoplasms PART III Neoplasm 1. Gastric carcinoma 2. Gastrointestinal stromal tumor 3. Gastric lymphoma 4. Duodenal carcinoma Epidemiology The fourth most com
21、mon cancer worldwide, however, stomach cancer remains the second most common cause of death from cancer Higher rates in Eastern Asia, South America, Eastern Europe Lower rates in Western Europe and the United States. Gastric carcinoma Nutritional Low fat or protein consumption Salted meat or fish Hi
22、gh nitrate consumption High complex carbohydrate consumption Causes Causes Environmental Poor food preparation (smoked, salted) Lack of refrigeration Poor drinking water Smoking Medical Prior gastric surgery H. pylori infection Gastric atrophy and gastritis Adenomatous polyps Other Male gender Low s
23、ocial class Causes i) Early gastric cancer(EGC) Gastric cancer confined to the mucosa or submucosa, regardless of the presence or absence of lymph node metastasis Pathology ii) Advanced gastric cancer(AGC) Cancer cells infiltrate the proprial muscle layer or serosa EGC Pathology I: protruded IIa: su
24、perficially elevated IIc: superficially depressed IIb: superficially flat III: excavated EGC:Endoscopic images Type III Type I Type II Pathology Borrmanns pathologic classification of gastric cancer based on gross appearance AGC:Borrmanns classification Linitis plastica Photomicrographs of Gastric C
25、arcinoma H 2) The efficacy and safety of this approach for advanc gastric carcinoma requires further investigation Open Surgery for Advanced Gastric Cancer 1. A suitable procedure for ACG 2. R0 resection 3. R1 resection 4. R2 resection Principles of radical operation for gastric cancer Gastrectomy w
26、ith regional lymphatics: perigastric lymph nodes(D1) and those along the named vessels of the celiac axis (D2), with a goal of examining 15 or greater lymph nodes Gastrectomy with D2 lymphadenectomy is the standard treatment for curable gastric cancer in eastern Asia Gastrectomy and D2 lymphadenecto
27、my for advanced gastric carcinoma Gastrectomy Lymphadenectomy Anastomosis Subtotal gastrectomy Roux-en-Y anastomosis Billroth II anastomosis Total gastrectomy Left gastric A Hepatic A Splenic A No.11 LN PORTAL VEIN Adjuvant Therapy Chemotherapy Radiation Therapy Targeted Therapy ECF: Epirubicin , Ci
28、splatin, 5-Fu FOLFOX: Oxaliplatin, 5-Fu, CF SOX: S-1, Oxaliplatin XELOX: Capecitabin, Oxaliplatin DCF: Docetaxel, Cisplatin, 5-Fu Chemotherapy Preoperative Chemotherapy Postoperative Chemotherapy After 3 courses of preoperative chemotherapy Preoperative chemotherapy Liver after Chemotherapy Our expe
29、rience Laser recannulization and endoscopic dilation with or without stent placement Palliative Treatment Surgical palliation Resection or bypass alone or in conjunction with percutaneous, endoscopic, or radiotherapy techniques Nonoperative therapies H. pylori infection and gastric carcinoma Cycloox
30、ygenase-2 Activation and gastric carcinoma Mini-invasive operation Sentinel node Neoadjunctive chemotherapy Micrometastasis Individualized treatment Molecular Targeted Therapies Cutting edge: gastric carcinoma Targeted Therapies Angiogenesis inhibitor Bevacizumab （FDA approved） Proteasome inhibitor
31、PS2341 ，bortezomib （ FDA approved） Growth factor receptor (EGFR), HER receptors inhibitor Cetuximab EMD72000 ，matuzumab Gefitinib Erlotinib Trastuzumab Cyclin-dependent kinase inhibitor (CDKI) Flavop iridol Gastrointestinal stromal tumor (GIST) Mesenchymal neoplasms Located primarily in the GI tract
32、, omentum and mesentery 0.2% of all GI tumors 80% of GI sarcomas 80%90% stain positive for KIT or PDGFR Epidemiology America: 1020 /1000,000 per year Europe: 6.614.5 /1000,000 per year Highest incidence among group aged 5065 years Similar male/female incidence, although some reports suggest higher i
33、ncidence in men GIST location 29.20% 0.80% 4.90% 4% 61.10% Esophagus Stomach Small bowel Colon E-GIST Cause Presentation Abdominal pain, about 5070% GI bleeding, about 50% Nausea and vomiting Weight loss Palpable tumor masses Anemia Investigations Endoscopic Ultrasound (US) Computed Tomography (CT)
34、Magnetic Resonance Imaging (MRI) 18F-FDG Positive Emission Tomography (PET) Dynamic Contrast-Enhanced Ultrasonography (DCE-US) Biopsy Risks: GISTs may be soft and fragile Biopsy may cause hemorrhage and increase the risk of tumor dissemination Biopsy is necessary if: Suspecting another cancer such a
35、s lymphoma or germ cell tumors Considering neoadjuvant therapy Confirming metastasis Investigations EUS-FNA Core Biopsy Immunohistochemistry CD117 95%(+)CD117 95%(+) DOGDOG- -1 1 98%(+)98%(+) CD34 CD34 70%70%80%(+)80%(+) SMA SMA 40%(+)40%(+) S S- -100 100 ( (- -) ) PKCPKC Carbonic anhydrase-II Genet
36、ic testing D842V Surgery Principles for Primary Tumors Indication if 2 cm R0 resection 1-2 cm clear margin No lymph node metastases in primary tumors Lesions 2 cm could be followed (often by endoscopy) rather than resected Operation Complete macroscopic resection with microscopically negative margin
37、s over the organ of origin (R0 resection) Extensive resections may be necessary Total gastrectomy Pancreaticoduodenectomy (Whipple procedure) Abdominoperineal resection (APR) Resection of adjacent organs maybe necessary Lymphadenectomy not indicated Through abdominal exploration Risk Stratification
38、(2008 Joensuu) Risk Category Tumro size （cm） Mitotic Index （/50HPFs） Primary tumor site Very low risk 5 Gastric 10 Any Any Any 10 Any 5.0 5 Any 2.15.0 5 Nongastric 5.110.0 5 Nongastric Postoperation therapy 1. Imatinib ( First line) Indication? Duration? Drug resistance? 2. Sunitinib( Second line) G
39、astric lymphoma The most common site in the gastrointestinal system. Less than 15% of gastric malignancies and 2% of lymphomas. Peak incidence in the 6th and 7th decades (male : female = 2:1) Epidemiology Presentation Vague symptoms Epigastric pain Early satiety Fatigue Anemia Investigation Endoscop
40、y EUS CT Biopsy Treatment Surgery (controversial) Chemotherapy (5% perforation) Radiation (stricture, enteritis, secondary tumor formation) Individualized The West Lake, Hangzhou, China 胰胰 腺腺 疾疾 病病 浙江大学医学院 附属第一医院肝胆胰外科 吴 健 胰腺的解剖和生理概要胰腺的解剖和生理概要 胰腺长胰腺长15-20cm，宽，宽3-4cm，厚，厚1.5-2.5cm 分头、颈、体、尾四部分头、颈、体、尾四部
41、横卧于横卧于1-2腰椎腰椎 前方，胰头右侧前方，胰头右侧 被十二指肠包绕被十二指肠包绕 胰尾与脾门相邻胰尾与脾门相邻 前面有胃、胃结前面有胃、胃结 肠韧带和横结肠肠韧带和横结肠 及其系膜及其系膜 胰腺的毗邻胰腺的毗邻 胰腺的血流供应胰腺的血流供应 胰头：胃十二指肠动脉的胰十二指肠上动脉胰头：胃十二指肠动脉的胰十二指肠上动脉 和肠系膜上动脉的胰十二指肠下动脉和肠系膜上动脉的胰十二指肠下动脉 胰体尾：脾动脉发出的胰大动脉、胰尾动脉胰体尾：脾动脉发出的胰大动脉、胰尾动脉 以及胰背动脉及其分支胰横动脉以及胰背动脉及其分支胰横动脉 静脉：汇入脾静脉、肠系膜上静脉和门静脉静脉：汇入脾静脉、肠系膜上静脉和门
42、静脉 胰腺的淋巴引流胰腺的淋巴引流 胰头注入胰十二指肠上、下淋巴结胰头注入胰十二指肠上、下淋巴结 胰体注入胰上淋巴结和胰下淋巴结胰体注入胰上淋巴结和胰下淋巴结 胰尾注入脾门淋巴结胰尾注入脾门淋巴结 最后注入腹腔淋巴结和肠系膜上淋巴结最后注入腹腔淋巴结和肠系膜上淋巴结 共同通道共同通道 胰腺生理概要胰腺生理概要 外分泌：胰液。由腺泡细胞和导管细胞产生，外分泌：胰液。由腺泡细胞和导管细胞产生， 主要成分为碳酸氢盐和消化酶主要成分为碳酸氢盐和消化酶 内分泌：内分泌： A细胞：胰高血糖素细胞：胰高血糖素 B细胞：胰岛素细胞：胰岛素 D细胞细胞 ：生长抑素：生长抑素 G细胞细胞 ：胃泌素：胃泌素 急性胰
43、腺炎急性胰腺炎 慢性胰腺炎慢性胰腺炎 胰腺癌胰腺癌 壶腹周围癌壶腹周围癌 胰腺内分泌肿瘤胰腺内分泌肿瘤 急性胰腺炎急性胰腺炎 外科常见的急腹症外科常见的急腹症 胰腺局部炎症病变胰腺局部炎症病变 全身性疾病全身性疾病 病病 因因 梗阻因素梗阻因素 过量饮酒过量饮酒 暴饮暴食暴饮暴食 高脂血症高脂血症 高钙血症高钙血症 创伤创伤 胰腺缺血胰腺缺血 其它其它 发病机制发病机制 胆汁、十二指肠液返流，胰管压力增高胆汁、十二指肠液返流，胰管压力增高 胰液外溢胰液外溢,胰酶激活胰酶激活 胰蛋白酶原胰蛋白酶原 弹性蛋白酶弹性蛋白酶 破坏血管壁和胰腺导管破坏血管壁和胰腺导管 磷脂酶磷脂酶A 破坏细胞膜和线粒体
44、膜破坏细胞膜和线粒体膜 饮酒饮酒 胰液分泌增加胰液分泌增加 增加增加Oddi括约肌的阻力括约肌的阻力 自由脂肪酸增高自由脂肪酸增高 氧自由基损伤氧自由基损伤 病理分类和临床分型病理分类和临床分型 病理分类病理分类 急性水肿性胰腺炎急性水肿性胰腺炎 急性出血坏死性胰腺炎急性出血坏死性胰腺炎(Acute hemorrhgic and necrotic pancreatitis AHNP) 临床分型临床分型 轻型急性胰腺炎轻型急性胰腺炎 重症急性胰腺炎重症急性胰腺炎(Severe Acute pancreatitis SAP) 暴发性急性胰腺炎暴发性急性胰腺炎 临床表现临床表现 腹痛腹痛 恶心呕吐恶
45、心呕吐 腹胀腹胀 腹膜炎体征腹膜炎体征 其它：发热，黄疸，其它：发热，黄疸， Gray-Turner 征征,Cullen征征 重型急性胰腺炎的特殊临床表现重型急性胰腺炎的特殊临床表现 实验室检查实验室检查 血、尿淀粉酶测定血、尿淀粉酶测定 脂肪酶、血常规、肝功能、血糖、血脂肪酶、血常规、肝功能、血糖、血 气分析、血钙、气分析、血钙、DIC全套全套 腹腔穿刺腹腔穿刺 影像学检查影像学检查 B 超超 CT ERCP MRCP 腹部平片腹部平片 * * * * 胰腺坏死胰腺坏死 无菌性胰腺坏死无菌性胰腺坏死 感染性胰腺坏死感染性胰腺坏死 胰腺假性囊肿胰腺假性囊肿 胰腺脓肿胰腺脓肿 局部并发症局部并发
46、症 急性胰腺假性囊肿急性胰腺假性囊肿 指急性胰腺炎后形成的有纤维组织 或肉芽囊壁包裹的胰液积聚。急性 胰腺炎患者的假性囊肿少数可通过 触诊发现，多数通过影像学检查确 定诊断。常呈圆形或椭圆形，囊壁 清晰。 SAP临床诊断与分级标准临床诊断与分级标准 急性胰腺炎伴有器官功能障碍急性胰腺炎伴有器官功能障碍，或出现坏死或出现坏死、脓肿或假性脓肿或假性 囊肿等局部并发症者囊肿等局部并发症者，或两者兼有或两者兼有。 临床表现临床表现 腹部体征：明显压痛腹部体征：明显压痛、反跳痛反跳痛、肌紧张肌紧张、腹胀腹胀、肠鸣音消失肠鸣音消失 腹部包块腹部包块、GreyTurner征征、Cullen征征 器官功能障碍器官功能障碍 难复性休克难复性休克（扩容后休克不好转扩容后休克不好转） CT检查示胰腺肿大检查示胰腺肿大，质不均质不均，胰外有浸润胰外有浸润 多器官功能衰竭多器官功能衰竭 心功能：脉搏细速、休克表现心功能：脉搏细速、休克表现 肺功能：肺功能：PaO211.1mmol/L 凝血系统功能：凝血系统功能：
