【正文】 Ultrasound CT TNM stage T: depth of invasion N: lymph node metastasis M: distant metastasis Treatment Surgical treatment: main Radical resection Palliative operation Adjuvant therapy chemotherapy Radical Resection The extent of lymphadenectomy D1, D2, D3, D4 Resection of different lymph node station 。 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。 antrectomy 4) Parietal cell vagotomy 5) Gastrojejunostomy 3) Vagotomy amp。 drainage 3) Vagotomy amp。Diseases of the Stomach and Duodenum Dept. of Gastrointestinal Surgery First Affiliated Hospital Sun Yatsen University Surgical treatment for peptic ulcer “If there is no acid, peptic ulceration cannot occur.” In fact, peptic ulcers may occur anywhere where pepsin and acid occur together . They may occur in the esophagus, the duodenum, the stomach itself, the jejunum after surgical construction of a gastrojejunostomy, or in the Meckel’s diverticulum . Peptic Ulcer Disease Duodenal ulcer(DU) Gastric ulcer(GU) The causes, Clinical features, and prognosis of DU and GU are different. DU and GU ?Etiology ? acid ? Nerval and humoral secretion ? mucosal defences ? mucosal barrier prevent antidromic diffuse ? Pylori infection ? impair mucosal defences PU is caused by an imbalance between secretion of acid and pepsin, and breakdown of mucosal defence. An acid environment and reduced mucosal defences provide ideal circumstances for pepsin to cause mucosal ulceration. Etiology and Pathogenesis DU or overexcitment of vagus nerve number of parietal cells quick gastric emptying GU retention of duodenal juice of parietal cells Etiology and Pathogenesis Overexcitement of vagus nerveDU Breakdown of mucosal defencesGU Helicobactor Pylori infectionBoth Incidence M?F： Men are affected 3 times as often as women. DU ?GU： DU is 10 times more mon than GU in the young pts. But in the older age groups the frequency is about equal. In general terms, the ulcerative process can lead to 4 types of disability: ?Pain: most mon ?Bleeding ?Perforation ?Obstruction Chief cellpepsinogen Cardiac gland area mucous secreting cell Parietal cellacid oxyntic gland area parietal 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。 drainage 3) Vagotomy