腔镜胃内建腔处理急性胃十二指肠大出血的临床应用及分析

发布时间：2018-08-04 21:24

【摘要】：上消化道大出血是指屈氏韧带以上的消化道在较短的时间内失血量1000ml或20%循环血容量,是临床较为常见的一种危重急症,死亡率可高达40%。其中胃、十二指肠出血占50-60%。由于设备检查的局限性,仍有约5%的消化道出血原因不明。随着药物、内镜及介入等内科综合治疗方法的不断进步和规范,非手术疗法对于大多数上消化道出血是有效的,然而对于一些内科治疗效果不佳,尤其是原因不明确的上消化道大出血,仍是临床上的一大难题。对于上消化道大出血,若经内科积极处理,仍无法控制症状时,需积极手术治疗,外科手术治疗也许是患者的最后一个希望。随着腹部微创技术的蓬勃发展,腹腔镜技术在胃肠外科的应用也越来越广泛。对于消化道大出血的患者,如何尽快的找到出血点进行止血,如何减少手术创伤,如何减少术后并发症,改善术后恢复情况。许多学者对腹腔镜技术在这类患者中的应用进行了相关探讨。无论动物实验研究及临床医疗实践均说明腹腔镜胃腔内手术是可行的,是可以应用于临床的。但仍存在许多问题,需进一步探讨。研究目的探讨腔镜胃内建腔处理急性胃十二指肠大出血的可行性及安全性,总结手术相关经验。研究方法回顾性收集2012年-2016年间胃十二指肠大出血病例共27例,其中采用传统方法处理消化道出血的病例共15例,男13例,女2例,年龄21-88岁;十二指肠球部出血8例,其中血管畸形3例,溃疡出血6例;胃内出血7例,其中胃溃疡出血4例,胃恶性肿瘤2例(术后常规病检结果明确),贲门粘膜撕裂综合症1例。采用本研究方法处理消化道出血的病例共12例,男8例,女4例,年龄23-68岁;十二指肠球部出血4例,其中血管畸形2例,溃疡出血2例;胃内出血8例,其中胃底静脉曲张破裂1例,贲门撕裂综合症3例,间质瘤血管破裂1例,胃窦部溃疡出血1例,胃底血管破裂出血2例。本研究采用胃内置入腔镜或联合胃镜建腔探查胃十二指肠并在胃腔内进行病灶处理,只需在胃壁上做1-3个5mm孔,使用腔镜器械完成腔内冲洗、显露病灶、病灶止血等操作,并与传统的方法在患者手术时间、术后留置胃管时间、进食时间、制酸药物使用、术后镇痛药物使用、住院时间及术后近期再发出血情况进行比较。结果腔镜组在手术时间、术后拔管时间、术后进食时间、制酸药物使用、住院时间方面均优于开放组,差异有统计学意义(P0.05,见表4.2);两组在术后严重并发症比较中腔镜组优于开放组,差异有统计学意义(P=0.00010.05,见表4.3)。两组在术后使用镇痛药物治疗比较中,腔镜组优于开放组,尽管得出P=0.0070.05,存在差异,有统计学意义,但需要考虑患者个体的主观因素及手术方式的差别,本文未再做这方面的进一步分析,今后在临床中可做进一步探讨、分析。结论本方法明显减小了患者的手术损伤,减少了手术时间,术后止血效果可靠。这项集诊断与治疗于一体的技术为处理急性胃十二指肠大出血找到一个新的方法,有希望得到进一步推广应用。目前主要问题是临床上的经验仍少,仍需在临床应用中进一步探索、完善。
[Abstract]:Large hemorrhage of upper gastrointestinal tract refers to the loss of blood volume 1000ml or 20% circulatory blood volume over a short period of time in the digestive tract of the flexor ligaments. It is a most common critical emergency in the clinic. The mortality rate can be as high as 40%. of the stomach, and duodenal hemorrhage accounts for the limitation of the equipment examination, and there are still about 5% of the causes of digestive tract bleeding. The continuous progress and standardization of the comprehensive treatment of medicine, endoscopy and intervention, nonsurgical treatment is effective for most upper gastrointestinal bleeding. However, some internal medical treatment results are not good, especially the large hemorrhage of upper gastrointestinal tract, which is unclear, is still a major problem in the clinical. Active treatment, still unable to control the symptoms, the need for active surgery, surgical treatment may be the last hope of the patient. With the vigorous development of the abdominal minimally invasive technology, the application of laparoscopic technology in the gastrointestinal surgery is becoming more and more widespread. For patients with large gastrointestinal bleeding, how to find bleeding spots as soon as possible to stop bleeding, how to reduce Few surgical trauma, how to reduce postoperative complications and improve postoperative recovery. Many scholars have discussed the application of laparoscopy in these patients. Both animal experiments and clinical practice indicate that laparoscopic intragastric surgery is feasible and can be applied to the clinic. However, there are still many problems that need to be advanced. The purpose of this study is to explore the feasibility and safety of endoscopic endagastric cavity treatment for acute gastroduodenal hemorrhage, and summarize the experience. A retrospective study of 27 cases of large gastroduodenal hemorrhage in -2016 in 2012, of which 15 cases of gastrointestinal bleeding were treated by traditional methods, 13 men and 2 women. 21-88 years of age and 8 cases of duodenal hemorrhage, including 3 cases of vascular malformation, 6 cases of ulcer bleeding, 7 cases of intragastric hemorrhage, 4 cases of gastric ulcer bleeding, 2 cases of gastric malignant tumor (clear postoperative routine examination results) and 1 cases of gastric cardia tear syndrome, 12 cases of gastrointestinal bleeding were used in this study, 8 men, 4 cases, age 23-68. 4 cases of duodenal hemorrhage, including 2 cases of vascular malformation, 2 cases of ulcer bleeding, 8 cases of intragastric bleeding, 1 cases of rupture of gastric fundus varicosity, 3 cases of cardia tear syndrome, 1 cases of vascular rupture of stromal tumor, 1 cases of gastric antral ulcer bleeding, 2 cases of gastric fundus vascular rupture and hemorrhage, were used in this study to explore the stomach ten with endoscopy or combined gastroscope building cavity exploration of the stomach ten The two finger intestines were treated in the stomach cavity. Only 1-3 5mm holes were done on the stomach wall, the endoscopic instruments were used to complete the cavity irrigation, the focus of the lesion and the hemostasis of the lesion, and the traditional methods in the patient's operation time, the time of gastric tube retention, the time of eating, the use of acid medicine, the use of postoperative analgesic drugs, the time of hospitalization and postoperative close. Results the time of recurrent bleeding was compared. Results the endoscopic group was better than the open group in the operation time, the time of extubation, the time of eating, the use of acid, the time of hospitalization, and the difference was statistically significant (P0.05, see table 4.2). The two groups were better than the open group in the comparison of postoperative severe complications (P=0.00010 .05, see table 4.3). The two groups in the postoperative use of analgesic drugs in comparison, endoscopic group is better than the open group, although the difference, there are differences, there is statistical significance, but need to consider the subjective factors of the individual and the difference in the mode of operation, this article does not do further analysis in this respect, further discussion in the future in clinical. Conclusion this method obviously reduces the surgical injury of the patients, reduces the operation time and the effect of postoperative hemostasis reliable. This technique of diagnosis and treatment in one is a new method for the treatment of acute gastroduodenal hemorrhage, and it is hopeful to be further applied. The main problem before the eyes is that the clinical experience is still few and still need to be found. Further exploration and improvement in clinical application.
【学位授予单位】：宁波大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R656.6

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