本文選題：腹腔鏡 + 胃癌D2根治術(shù)�。� 參考：《山東大學(xué)》2017年碩士論文

【摘要】：研究背景和意義:胃癌根治手術(shù)因涉及器官較多、步驟復(fù)雜,規(guī)范開展有一定難度,術(shù)后不可避免的會(huì)出現(xiàn)一些并發(fā)癥。出血即是胃癌根治手術(shù)后最常見的并發(fā)癥之一,部分病人甚至因出血量較大導(dǎo)致嚴(yán)重的后果。其中一部分病人出血表現(xiàn)為遲發(fā)性出血,此類病人病情進(jìn)展迅速,處理困難,往往診斷不及時(shí)或處理不當(dāng),死亡率較高。近年來,腹腔鏡胃癌手術(shù)因視野清晰、創(chuàng)傷較小、恢復(fù)迅速等特點(diǎn)越來越受到普外科醫(yī)師的關(guān)注,其臨床解剖、手術(shù)入路、手術(shù)技術(shù)、流程及電能量設(shè)備均有了很大進(jìn)步,但因操作有其獨(dú)特特點(diǎn),遲發(fā)性出血也是該類手術(shù)所面臨的重要問題。因此,總結(jié)腹腔鏡胃癌術(shù)后遲發(fā)性大出血的常見原因進(jìn)而分析其危險(xiǎn)因素、總結(jié)防治策略是非常必要的。方法:收集來自山東大學(xué)附屬省立醫(yī)院胃腸外科2013年6月至2016年6月所施行的421例腹腔鏡胃癌D2根治手術(shù)的病人臨床信息,按照所設(shè)定的出血患者認(rèn)定標(biāo)準(zhǔn),共篩選出手術(shù)后發(fā)生遲發(fā)性大出血的病例12例,回顧性分析腹腔鏡胃癌D2根治手術(shù)后大出血患者的病例信息,根據(jù)其輔助檢查、治療方案及治療轉(zhuǎn)歸探討其發(fā)生的可能原因及防治方法。結(jié)果:12例腹腔鏡輔助胃癌D2根治手術(shù)后發(fā)生的遲發(fā)性大出血患者中,穿刺器孔導(dǎo)致的出血1例,腹腔內(nèi)的出血共8例,吻合口所致的出血3例。腹腔內(nèi)的出血可分為早發(fā)性的出血及遲發(fā)發(fā)生的出血兩種,前者多為手術(shù)過程中血管處理技術(shù)不當(dāng)所致,后者多為手術(shù)后吻合口或殘端漏所致的血管假性動(dòng)脈瘤破裂所致。治療方式有保守治療(3/12)、手術(shù)治療(3/12)、內(nèi)鏡(1/12)或血管介入治療(5/12)。腹腔內(nèi)遲發(fā)性大出血因出血量大、病情惡化迅速治療困難,若處理不當(dāng)或不及時(shí)容易導(dǎo)致失血性休克甚至死亡,DSA可快速顯影,TAE可有效止血,二者結(jié)合是最佳的處理方法。結(jié)論:1、腹腔鏡輔助胃癌D2根治術(shù)后出血是其重要并發(fā)癥,主要包括穿刺孔出血、腹腔內(nèi)血管出血、吻合口出血,不同類型的誘發(fā)因素有差別,應(yīng)注意分析并預(yù)防。2、穿刺孔出血多為腹壁動(dòng)脈損傷所致,光源引導(dǎo)下穿刺和確切的全層關(guān)閉是預(yù)防關(guān)鍵。3、腹腔內(nèi)出血分為早發(fā)性出血和遲發(fā)性出血。早發(fā)性出血多為術(shù)中血管處理技術(shù)不當(dāng)所致;遲發(fā)性出血多為腹腔內(nèi)血管假性動(dòng)脈瘤破裂所致,其病情進(jìn)展迅速,死亡率高。DSA可快速顯影,TAE可有效止血,二者結(jié)合是最佳的處理方法。4、隨著吻合技術(shù)和吻合器械的進(jìn)步,吻合口出血的發(fā)生率已經(jīng)明顯降低。熟悉掌握腹腔鏡下的吻合特點(diǎn),規(guī)范操作非常重要;對(duì)于吻合口應(yīng)激性潰瘍出血,因腹腔鏡胃癌手術(shù)創(chuàng)傷小,機(jī)體應(yīng)激反應(yīng)小,術(shù)后常規(guī)應(yīng)用質(zhì)子泵抑制劑可降低應(yīng)激性潰瘍出血的機(jī)率。
[Abstract]:Background and significance: radical resection of gastric cancer involves more organs, complicated steps, and it is difficult to carry out standardization. Some complications will inevitably occur after operation. Bleeding is one of the most common complications after radical operation of gastric cancer. Some of the patients presented with delayed bleeding. These patients developed rapidly and were difficult to deal with. They were often not diagnosed in time or improperly treated, and the mortality rate was high. In recent years, laparoscopic gastric cancer surgery has attracted more and more attention of general surgeons because of its clear visual field, less trauma and rapid recovery. Its clinical anatomy, surgical approach, surgical techniques, processes and electrical energy equipment have made great progress. But because the operation has its unique characteristics, delayed hemorrhage is also an important problem in this kind of surgery. Therefore, it is necessary to summarize the common causes of delayed massive hemorrhage after laparoscopic gastric cancer operation and analyze its risk factors. Methods: the clinical information of 421 patients undergoing laparoscopic D2 radical gastric cancer surgery from June 2013 to June 2016 in the provincial hospital affiliated to Shandong University was collected. A total of 12 patients with delayed massive hemorrhage after operation were selected. The case information of patients with massive hemorrhage after laparoscopic D2 radical operation for gastric cancer was retrospectively analyzed. To explore the possible causes and prevention methods of treatment and outcome. Results among 12 cases of delayed massive hemorrhage after laparoscopic assisted D2 radical resection of gastric cancer, 1 case was caused by puncture hole, 8 cases by intraperitoneal hemorrhage, and 3 cases by anastomotic stoma. Intraperitoneal hemorrhage can be divided into early bleeding and late bleeding. The former is mainly caused by improper vascular management during operation, and the latter is caused by rupture of vascular pseudoaneurysm caused by anastomotic stoma or stump leakage after operation. The treatments include conservative treatment, surgical treatment, surgery, endoscopic surgery, or vascular interventional therapy, or 5 / 12 / 12, or 5 / 12 / 12 / 12 / 12, or 5 / 12 / 12 / 12, respectively, of conservative treatment, surgical treatment and endoscopy. Due to the large amount of bleeding in abdominal cavity, it is difficult to treat the disease rapidly. If the treatment is improper or not easy to lead to hemorrhagic shock or even death, DSA can quickly develop Tae to stop bleeding effectively. The combination of the two is the best treatment method. Conclusion the major complications of laparoscopic assisted D2 radical gastrectomy for gastric cancer include puncture hole hemorrhage, intraperitoneal vascular hemorrhage, anastomotic bleeding, and different types of inducing factors. It should be paid attention to analyze and prevent. The bleeding of puncture foramen is mostly caused by the injury of abdominal wall artery. The key of prevention is guided by light source puncture and exact whole layer closure. Intraperitoneal hemorrhage can be divided into early hemorrhage and late hemorrhage. Premature hemorrhage was caused by improper technique of intraoperative vascular management, delayed hemorrhage was caused by rupture of pseudoaneurysm in abdominal cavity, and the disease progressed rapidly. The mortality rate was high. DSA could quickly develop Tae to stop bleeding effectively. The combination of the two is the best treatment method. With the progress of anastomosis technique and anastomotic instruments, the incidence of anastomotic haemorrhage has been significantly reduced. Familiar with the characteristics of laparoscopic anastomosis, standard operation is very important. For anastomotic stress ulcer bleeding, laparoscopic gastric cancer surgery has less trauma and less body stress response. Postoperative routine use of proton pump inhibitors can reduce the risk of stress ulcer bleeding.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R735.2

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