【正文】 lity as an indication for surgical intervention has markedly diminished and now accounts for only less than 5% of patients who undergo all types of ulcer operations Intractable ulcer prolonged, severe symptoms inadequately relieved by medicine loss of sleep, work and ine perating ulcer Callous ulcer postbulbar ulcer bined ulcer(DU+GU) DU Operations for DU Aims: to decrease acid with ulcer excision and a drainage procedure DU Operations 1) Gastrectomy (1) Partial (PG) (G. resection) (2) Subtotal (STG) (3) Total (TG) 2) Vagotomy (1) Truncal (TV) (2) Selective (SV) (3) Highly Selective (HSV) 3) Drainage (1) Pyloroplasty (PP) (2) Gastrojejunostomy (GJ) DU 1) Subtotal gastrectomy 2) Vagotomy amp。 drainage 3) Vagotomy amp。 antrectomy 4) Parietal cell vagotomy 5) Gastrojejunostomy DU 1. Subtotal Gastrectomy 1st successful gastric resection , 1881 Theodor Billroth from Vienna Popular in China for PU DU 1. Subtotal Gastrectomy DU 1. Subtotal Gastrectomy DU 1. Subtotal Gastrectomy DU gastric ramnant efferent loop duodenal stump afferent loop 1. Subtotal Gastrectomy DU Antecolic anastomosis retrocolic anastomosis Mechanism of gastrectomy 1) removing the gastrinsecreting antrum 2) removing majority of the body 3) excluding the ulcerbearing area 4) resection of ulcer itself(excision) 5) alkalinating effect DU 1) Subtotal gastrectomy 2) Vagotomy amp。 drainage 3) Vagotomy amp。 antrectomy 4) Parietal cell vagotomy 5) Gastrojejunostomy DU and drainage Vagotomy 1) Truncal vagotomy 2) Selective vagotomy Drainage procedure 1) Pyloroplasty (USA) 2) Gastrojejunostomy (UK) DU DU 2) Vagotomy amp。 drainage DU DU pyloroplasty HeineckeMikulicz pyloroplasty Finney pyloroplasty Excision pyloroplasty Posterior gastroenterostomy Anterior juxtapyloric gastroenterostomy Pyloric dilation by gastrotomy DU 1) Subtotal gastrectomy 2) Vagotomy amp。 drainage 3) Vagotomy amp。 antrectomy 4) Parietal cell vagotomy 5) Gastrojejunostomy 3) Vagotomy amp。 antrectomy DU 3) Vagotomy amp。 antrectomy objective: ↓incidence of recurrence rate of recurrence lowest other plication more DU 1) Subtotal gastrectomy 2) Vagotomy amp。 drainage 3) Vagotomy amp。 antrectomy 4) Parietal cell vagotomy 5) Gastrojejunostomy cell vagotomy (PCV) Proximal gastric vagotomy (PGV) Highlyselective vagotomy (HSV) Superselective vagotomy (SSV) First PGV by Johston, 1969 Gastric emptying: not influenced Drainage procedure: unnecessary DU 4. Parietal cell vagotomy (PCV) a low incidence of postop. symptoms a higher ulcer recurrence rate a timeconsuming and technically difficult op. skill and experience of the surgeon DU 5. Gastroenterostomy (Gastrojejunostomy First op. for PU Widely used :1890s1920s Gradully discarded since then DU Gastric Ulcer Gastric Ulcer Peak incidence: aged 40~50 years 95% on the lesser curvature 60% 6cm of the pylorus Similar to DU in many ways symptoms plications GU Symptoms and signs Epigastric pain less relief by food or antacids tends to appear earlier after eating More mon: Vomiting Anorexia厭食 Aggravation by eating Clinical Findings GU Laboratory Findings GU acpanied by DU: hypersecretion BAO amp。 MAO: low or normal Achlorhydria:酸缺乏 malignant GU (5%) DU with GU: benign ulcer GU Xray Finding Ulcer on the lesser curvature Suggestions of malignanacy (in the absence of a tumor mass, just a crater) 1) deepest peration not beyond the expected border of the gastric wall 2) prominent rim (rolled up) 3) diameter 2cm GU GU GU GCa Gastroscopy and Biopsy Performed routinely A rolledup margin: malignant ulcer