腹腔镜胃癌D2根治术后迟发性大出血的临床分析及防治策略

发布时间：2018-05-11 02:09

本文选题：腹腔镜 + 胃癌D2根治术　；参考：《山东大学》2017年硕士论文

【摘要】：研究背景和意义:胃癌根治手术因涉及器官较多、步骤复杂,规范开展有一定难度,术后不可避免的会出现一些并发症。出血即是胃癌根治手术后最常见的并发症之一,部分病人甚至因出血量较大导致严重的后果。其中一部分病人出血表现为迟发性出血,此类病人病情进展迅速,处理困难,往往诊断不及时或处理不当,死亡率较高。近年来,腹腔镜胃癌手术因视野清晰、创伤较小、恢复迅速等特点越来越受到普外科医师的关注,其临床解剖、手术入路、手术技术、流程及电能量设备均有了很大进步,但因操作有其独特特点,迟发性出血也是该类手术所面临的重要问题。因此,总结腹腔镜胃癌术后迟发性大出血的常见原因进而分析其危险因素、总结防治策略是非常必要的。方法:收集来自山东大学附属省立医院胃肠外科2013年6月至2016年6月所施行的421例腹腔镜胃癌D2根治手术的病人临床信息,按照所设定的出血患者认定标准,共筛选出手术后发生迟发性大出血的病例12例,回顾性分析腹腔镜胃癌D2根治手术后大出血患者的病例信息,根据其辅助检查、治疗方案及治疗转归探讨其发生的可能原因及防治方法。结果:12例腹腔镜辅助胃癌D2根治手术后发生的迟发性大出血患者中,穿刺器孔导致的出血1例,腹腔内的出血共8例,吻合口所致的出血3例。腹腔内的出血可分为早发性的出血及迟发发生的出血两种,前者多为手术过程中血管处理技术不当所致,后者多为手术后吻合口或残端漏所致的血管假性动脉瘤破裂所致。治疗方式有保守治疗(3/12)、手术治疗(3/12)、内镜(1/12)或血管介入治疗(5/12)。腹腔内迟发性大出血因出血量大、病情恶化迅速治疗困难,若处理不当或不及时容易导致失血性休克甚至死亡,DSA可快速显影,TAE可有效止血,二者结合是最佳的处理方法。结论:1、腹腔镜辅助胃癌D2根治术后出血是其重要并发症,主要包括穿刺孔出血、腹腔内血管出血、吻合口出血,不同类型的诱发因素有差别,应注意分析并预防。2、穿刺孔出血多为腹壁动脉损伤所致,光源引导下穿刺和确切的全层关闭是预防关键。3、腹腔内出血分为早发性出血和迟发性出血。早发性出血多为术中血管处理技术不当所致;迟发性出血多为腹腔内血管假性动脉瘤破裂所致,其病情进展迅速,死亡率高。DSA可快速显影,TAE可有效止血,二者结合是最佳的处理方法。4、随着吻合技术和吻合器械的进步,吻合口出血的发生率已经明显降低。熟悉掌握腹腔镜下的吻合特点,规范操作非常重要;对于吻合口应激性溃疡出血,因腹腔镜胃癌手术创伤小,机体应激反应小,术后常规应用质子泵抑制剂可降低应激性溃疡出血的机率。
[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.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R735.2

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