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Medicine Lecture Notes
【立委按】老爸的医学生涯电子版另开辟【教育园地】专栏，整理刊载老爸医学生涯中所做的医学讲座、代表性手术记录以及对后生传帮带方面的资料。相信这些资料对于同行和后学自有其参考价值。在老爸一路向上的医学生涯中，职称上最高的一级当然是主任医师的评定。材料中，五例四类手术例案是九四年申报主任医师的必备附件之一。当然，申报成功还要加上省级至全国核心期刊发表论文五篇以上、专业英文笔试合格、医学教学能力（例如下面的医学讲座）及临床领导经验等综合考核评价。
[Editor’s Comment] Dad's electronic version of his medical career has a separate column entitled [Education Garden], which collates and publishes medical lectures given by Dad in his medical career, records of representative surgeries and information on mentoring epigenetic patients. I believe these materials have their own reference value for peers and postgraduates. In dad all the way up in the medical career, title on the highest level, of course, is the chief physician evaluation. Among the materials, five cases with four types of operations were one of the necessary accessories for reporting to the chief physician in 1994. Of course, the success of the application also requires the comprehensive assessment and evaluation of more than five papers published in provincial to national core journals, qualified professional English written examination, medical teaching ability (such as the following medical lectures) and clinical leadership experience.
1. Yellow resistance related clinical problems
1 Jaundice–syndrome. Pre-liver (hemolytic), hepatocellular, and post-liver (obstructive). mixed type
2 Yellow resistance-intrahepatic capillary duct–small bile duct–hepatobiliary duct–common hepatic duct–common bile duct … obstruction.
3 Internal medicine jaundice—surgical jaundice: internal and external hepatic obstruction. (15%-20% difficult to identify)
4 Diagnostic procedures and methods of yellow resistance: clinical, laboratory tests, X-ray, B-US, CT, MRI, PTC, ERCP, radionuclide (isotope iodine 131, De99) imaging, selective angiography ... liver biopsy, laparotomy ...
5 Three elements of diagnosis—yellow stalk or not–location and degree of obstruction–cause of obstruction.
6 the characteristics of surgical jaundice: (1) Biliary colic (Charcot triad, Ranold pentalogy); Painless progressive jaundice is often suggestive of cancer. (2) Physical examination: The right upper abdomen or the whole abdomen shows peritoneal irritation sign and swollen gallbladder. (3) Laboratory tests: bilirubin +85.5umol/L and direct/total bilirubin > 35% or "biliary enzyme separation", AKP↑ and urine bilirubin+and urobilinogen-. (4) Common causes: cholelithiasis, biliary parasites, bile duct stenosis, cancer, inflammation and pancreatic cancer, inflammation, hilar metastatic cancer, Mirizzi snidrome (5) Internal medicine jaundice that needs to be excluded—for example, viral hepatitis, drug-induced liver damage, idiopathic jaundice of pregnancy, sclerosing cholangitis ...
7 Surgical jaundice treatment: strive for early surgery.
8 For preoperative jaundice reduction (especially malignant terrigenous jaundice—liver and kidney, coagulation function, gastric mucosa damage, and immunologic hypofunction, with blood bilirubin of 170umol/L). Methods: (1) External drainage technique —— PTCD, U-tube, cholecystostomy, choledochostomy. (2) Internal drainage technique—biliary and intestinal drainage.
9 Surgeries
9.1 Stone removal+external and internal drainage (T-tube drainage, pelvic biliary-intestinal drainage, Roux-Y, diseased hepatectomy ...)
9.2 Pancreas cancer resection: Whipple and Child surgery
1、阻黄的有关临床问题 (讲稿提要)
1 黄疸 —— 症候群。肝前 (溶血性)、肝细胞性、肝后性 (梗阻性)。混合型
2 阻黄 —— 肝内毛细胆管 – 小胆管 – 肝胆管 – 肝总管 – 胆总管 … 梗阻。
3 内科黄疸 —— 外科黄疽: 肝内、外梗阻。(15%-20%难以鉴别)
4 阻黄的诊断程序和方法: 临床、化验、X线、B-US、CT、MRI、PTC、ERCP、核素 (同位素碘131、得99) 显象、选择性动脉造影 … 肝活检、剖腹探查…
5 诊断三要素 —— 梗黄与否 – 梗阻部位、程度 – 梗阻原因。
6 外科黄疸的特点:
(1) 胆绞痛 (Charcot三联征、Ranold五联征); 无痛性进行性黄疸常提示癌症。
(2) 查体: 右上腹或全腹呈腹膜刺激征、肿大的胆囊。
(3) 化验: 胆红素+85.5umol/L 且直接/总胆红素 >35%或“胆酶分离”、 AKP↑、尿胆红素 +、尿胆原 -。
(4) 常见原因: 胆石症、胆道寄生虫、胆管狭窄、癌、炎症及胰癌、炎、肝门转移癌、Mirizzi Snydrome
(5) 需除外内科黄疸 —— 如: 病毒性肝炎、药物性肝损害、妊娠特发性黄疸、硬化性胆管炎 ……
7 外科黄疸的治疗: 力争早期手术。
8 关于术前减黄问题 (尤其恶性梗黄 —— 肝肾、凝血机能、胃粘膜损害及免疫功能低下等，血胆红素在170umol/L)。方法: (1) 外引流技术 —— PTCD、U管、胆囊造口、胆总管造口术。(2) 内引流技术 —— 胆肠内引流。
9 手术
9.1 取石术+外、内引流术 (T管引流、盆式胆肠内引流、Roux-Y、
病肝切除…)
9.2 胰癌切除: Whipple、Child手术2. Complications of most gastric resection
1 Recent complications
1.1 intraoperative injuries: common bile duct, pancreas, and middle colon artery.
1.2 Postoperative gastric bleeding
1.2.1 Recent—incomplete hemostasis, and open ulceration.
1.2.2 7–10 days after surgery (secondary hemorrhage)–most cases can be self-stopped.
1.3 Leak of duodenal stump (Billroth-II type): (1) poor suture, (2) obstruction of jejunal afferent loop, (3) local poor blood supply.
1.4 3-4% anastomotic emptying disorders
1.4.1 Full anastomosis.
1.4.2 Output loop.
1.5 Input loop syndrome (Formula B-II)
1.5.1 Chronic simple partial obstruction (technical factor) —— Braun anastomosis, Roux-Y anastomosis (30-40Cm).
1.5.2 Causes of acute strangulation complete obstruction (excluding pancreatitis): (1) Input/output junction (high pressure—necrotic perforation), (2) Input loop is too long—internal hernia. Treatment: emergency operation.
1.6 Surgical exploration of output loop obstruction (barium meal examination). Causes: retrocolonic—mesangial foramen narrowing, anterior to the colon—internal hernia.
1.7 Postoperative acute pancreatitis 1% (abdominal amylase—diagnosis). Causes: trauma, sphincter of Oddi spasm, afferent loop obstruction, decreased postoperative protease inhibitor secretion. Treatment: Surgical drainage.
2 Long-term complications
2.1 causes and mechanisms of "dumping" syndrome: ① high pressure in the small intestine—intestinal distension—intestinal hormones such as 5-hydroxytryptamine—accelerated peristalsis and vasodilation—decreased blood volume, k ↑– gravity pulling the residual stomach—stimulating visceral nerves—epigastric and cardiovascular symptoms. Treatment: Surgery to avoid small residual stomach, large anastomosis, diet, posture adjustment, drugs: antihistamine or anti-acetylcholine, anti-spasm and sedatives or anti-5- hydroxytryptamine and other drugs, surgery: aims to reduce the speed of food directly into the jejunum (narrow the anastomosis, change B-11 to B-I type, gastroduodenal jejunal interposition.
2.2 Hypoglycemia syndrome: mechanistic food-rapid-small intestine-blood glucose-insulin-blood glucose treatment: slight food intake.
2.3 Mechanism of basic reflux gastritis: it is caused by the difference in PH of the gastrointestinal tract. The procedure was chan to Roux-Y or plus Braun for that purpose of reducing reflux of intestinal fluid to the stomach.
2.4 Loss of function of pylorus in food mass ileus—coarse fiber, ropy—simple obstruction of small intestine.
2.5 Anemia
2.5.1 Iron deficiency-caused by low acid in the stomach, iron supplement.
2.5.2 Giant cell sex—lack of internal factors, V-B12, folic acid, liver preparations.
2.6 Malnutrition is generally normal.
2.7 Surgical failure of an anastomotic ulcer (Zollinger-Elison syndrome).
1999-5-8 wuhu changhang hospital
2、胃大部分切除的并发症 (讲稿摘要)
1 近期并发症
1.1 术中损伤: 胆总管、胰腺、结肠中动脉。
1.2 术后胃出血
1.2.1 近期 —— 止血不彻底、溃疡旷置。
1.2.2 术后7~10天 (继发性出血) —— 多可自止。
1.3 十二指肠残端漏 (Billroth-Ⅱ式): (1) 缝合不佳,(2) 空肠输入袢梗阻，(3) 局部血供不良。
1.4 吻合口排空障碍 3-4%
1.4.1 全吻合口。
1.4.2 输出袢。
1.5 输入袢综合征 (B-Ⅱ式)
1.5.1 慢性单纯性部分梗阻 (技术因素) —— Braun式吻合、Roux-Y 式吻合(30-40Cm)。
1.5.2 急性绞窄性完全性梗阻 (剔除胰腺炎) 原因: (1) 输入、出交叉 (压力过高—— 坏死穿孔)，(2) 输入袢过长 —— 内疝，治疗: 急症手术。
1.6 输出袢梗阻 (钡餐检查) 手术探查。原因: 结肠后 —— 系膜孔缩窄、结肠前 —— 内疝。
1.7 术后急性胰腺炎1% (腹液淀粉酶 —— 诊断)。原因: 创伤、Oddi 括约肌痉挛、输入袢梗阻、术后抑蛋白酶分泌减少。治疗: 手术引流。
2 远期并发症
2.1 “倾倒”综合征 原因和机理: ① 小肠内高压 —— 肠管膨胀 —— 5-羟色胺等肠道激素 —— 蠕动增快和血管扩张 —— 血容量降低，K↑ —— &重力牵拉残胃 —— 刺激内脏神经 —— 上腹和心血管症状。治疗: 手术避免残胃过小、吻合口过大，饮食、体位调节，药物: 抗组织胺或抗乙酰胆碱、抗痉挛和镇静剂或抗5-羟色胺等药物，手术: 旨在减少食物直接进入空肠的速度 (缩小吻合口、改B-11为B-I式、胃十二指肠空肠间置。
2.2 低血糖综合征：机理食物 —— 快速 —— 小肠 —— 血糖↓ —— 胰岛素↓ —— 血糖↓ 治疗: 稍进食物。
2.3 碱性返流性胃炎 机理: 胃肠PH差异致使。改手术为Roux-Y或加 Braun，目在减少肠液向胃返流。
2.4 食物团肠梗阻 幽门失功能 —— 粗纤维、粘稠 —— 小肠单纯梗阻。
2.5 贫血
2.5.1 缺铁性 —— 胃内低酸致使，补铁。
2.5.2 巨细胞性 —— 内因子缺乏，V-B12、叶酸、肝制剂。
2.6 营养不良 一般还正常。
2.7吻合口溃疡 手术失败 (胃切除不足，Zollinger-Elison syndrome)。
1999-5-8芜湖长航医院
3. Large intestinal cancer
1 Colon and rectum anatomy: The colon is 150Cm in length and can be divided into cecum, ascending colon, transverse colon, descending colon and sigmoid colon. The rectum was about 12.5Cm long, connected with the anal canal (3–4 cm) under the sigmoid colon, and the retroperitoneal fold was 7.5Cm away from the anal margin.
2 Anatomical and physiological characteristics of colon and rectum: (1) The blood supply is that the terminal artery is poorer than the small intestine; (2) The intestinal wall is thin; (3) There are many enteric bacteria's, with high infection; (4) Absorbing water makes the feces form.
3 Once the colorectal cancer is definitely diagnosed, surgical treatment should be performed as soon as possible. Of course, comprehensive treatment should also be considered. Colorectal cancer has liver metastasis, but if the primary cancer and mesangial lymph node metastasis can still be completely removed, and the metastatic lesions touched in the liver are single, and it is not difficult to locally resect the site, the primary cancer can also be resected and the intrahepatic metastatic lesions can be resected at the same time, which can result in a long-term remission for some patients and a survival period of 5 years or more for a few patients. Cancer at the junction of straight and B accounts for 60% of all colorectal cancers.
4 Operating technical principles of radical resection of colorectal cancer: in order to prevent hematogenous dissemination and local planting of cancer cells during the operation as much as possible, the operation on cancer should be light and squeezing should be avoided; Before free cancer, the pathways of cancer cell intestinal implantation and hematogenous metastasis were blocked first.
5 Intestinal preparation before surgery: Preoperative preparation of the colon (intestine) is an important measure to reduce intraoperative pollution, prevent postoperative infection of the abdominal cavity and incision, and ensure good healing of the anastomosis. The purpose of intestinal preparation is to empty the feces in the colon without flatulence, and the number of intestinal bacteria will be reduced. Bowel preparation method: The colon is cleaned during the operation by regulating diet, taking laxative and cleaning the bowel.
- Total fluid was administered three days before surgery, and Folium sennae 30g was orally administered. Fluid was infused for three times a day, 1500-2000ml per day. Or 25 grams of magnesium sulfate one day before surgery, twice a day.
- Three days before surgery, metronidazole 0.5 was given orally four times per day and norfloxacin 0.2 was given four times per day.
- Clean enema (soapy water) one night before operation, and clean water enema again the next morning.
6 Colonic surgery includes right hemicolectomy, transverse colectomy, left hemicolectomy and sigmoidectomy; Rectal resection includes anterior rectal resection (Dixon's technique), pullout resection (Bacon's technique), abdominoperineal resection (Miles's technique), and retrosacral approach (Klarsks's technique).
7 Surgical procedures:
- The bowel was ligated with a cloth tape, including the marginal vessels, at 10cm each from the proximal and distal sides of the margin of the cancer to block the bowel
- The arteries and veins that were ready to be cut were exposed at the root of mesangium. They were ligated and cut separately. From then on, the mesangium was gradually cut to the intestinal part that was to be cut. (Digital pressure test can be performed before cutting to visually preserve intestinal blood supply)
- Free the intestinal segment including cancer and resect it.
- After intestinal anastomosis, the operation area was rinsed with sterile distilled water in order to destroy the exfoliated cancer cells.
8 Postoperative complications:
- If the course of the disease is long and there are symptoms of incomplete obstruction, the intestinal preparation may not meet the requirements, and once the abdominal cavity is polluted during the operation, it will cause abdominal infection.
- Due to intestinal wall edema and different degrees of intestinal dilatation, anastomotic leakage or anastomotic stenosis caused by large anastomotic tension is easy to occur after colorectal resection.
- colorectal resection, abdominal itching, easy to cause abdominal bowel adhesion.
- During the operation, it is easy to bleeding or cause accidental injury of other organs, such as ureter, duodenum, pancreas, and inferior vena cava.
- Abdominal incision is large, and incision infection is easy to occur.
9 Post-operative treatment:
- Pay attention to blood pressure, pulse and respiration within 48 hours after operation.
- pay attention to intra-abdominal hemorrhage and wound bleeding.
- Remove the catheter after 48 hours of retention after operation.
- pay attention to the supplement of liquid, nutrition and electrolyte every day.
- a large number of broad-spectrum antibiotics.
April 8, 2005 Li Mingjie Yu Changhang Hospital
3、大肠癌
1 结、直肠解剖:
结肠长度150Cm，可分盲肠、升结肠、横结肠、降结肠、和乙状结肠; 直肠长约12.5Cm, 上接乙状结肠下连肛管 (肛管 3-4Cm)，其腹膜反折部距肛缘7.5Cm。
2 结、直肠解剖、生理特点: (1) 血供为终末动脉较小肠差，(2) 肠壁薄，(3) 肠内细菌多，感染性高，(4) 吸收水份使粪成形。
3 结、直肠癌一旦明确诊断后应尽早地施行手术治疗，当然，还应考虑综合性治疗。
结、直肠癌虽已有肝转移，但如原发癌及系膜淋巴结转移癌尚可完全切除，而肝内触及的转移灶为单个, 且其所在部位做局部切除困难不大时，也可以切除原发癌的同时，将肝内转移灶切除，部分病人可因此而获得较长时间的缓解，少数病人尚可有5年或更长的生存期。
直、乙交界处癌占全部大肠癌的60%。
4 结、直肠癌根治术的操作技术原则: 为了尽可能防止术中癌细胞的血行播散和局部种植，对癌肿的操作要轻，避免挤压; 游离癌肿前，先阻断癌细胞肠腔内种植和血行转移的途径。
5 手术前的肠道准备:
结肠的术前准备 (肠道) 是减轻术中污染，预防术后腹腔和切口感染，以及保证吻合口良好愈合的重要措施。肠道准备的目的是使结肠内粪便排空，无胀气，肠道细菌数量随之减少。
肠道准备方法:
主要是通过调节饮食，服用泻剂及清洁肠道，达到手术时结肠“清洁”的目的。
(1) 术前三天进全流质，同时口服番泻叶30克冲服，三次/日，每天补液1500-2000ml。或术前1天服硫酸镁 25 克，二次/日。
(2) 术前三天口服灭滴灵 0.5，四次/日，加氟哌酸 0.2，四次/日。
(3) 术前一天晚上清洁灌肠 (肥皂水)，次日晨再行清水灌肠。
6 结肠手术分右半结肠切除、横结肠切除、左半结肠切除、乙状结肠切除; 直肠切除分为直肠前切除 (Dixon术式)、拉出切除 (Bacon术式)、腹会阴联合切除 (Miles术式)、经骶后入路 (Klarsks术式) 等…….
7 手术步聚:
(1) 在距癌肿缘远近侧各10cm处，将肠管包括边缘血管在内，以布带扎紧以阻断肠
(2) 在系膜根部显露准备切断的动静脉，分别结扎，切断，自此开始逐步切断系膜至拟切断的肠管部。(切断前可指压试行，以视保留肠管血运)
(3) 游离包括癌肿在内的肠段，予以切除。
(4) 肠吻合完毕后，用无菌蒸馏水冲洗手术区，以期能破坏脱落的癌细胞。
8 术后并发症:
(1) 若病程长，有不全梗阻症状，肠道准备工作可能达不到应有的要求，术中一旦腹腔受到污染后，会引起腹腔感染。
(2) 由于肠壁水肿，又有不同程度肠管扩张，结、直肠切除后，吻合易发生吻合口瘘或因吻合口张力大引起吻合口狭窄。
(3) 结、直肠切除，腹腔搔扰性大，易引起腹腔肠管的粘连。
(4) 术中易出血或引起其他脏器的误伤如输尿管、十二指肠、胰腺、下腔静脉等。
(5) 腹部切口大，易发生切口感染。
9 术后处理:
(1) 术后48小时内注意血压、脉搏、呼吸。
(2) 注意腹腔内出血和伤口出血。
(3) 术后保留导尿48小时后拔除。
(4) 每天注意液体、营养和电解质的补充。
(5) 大量应用广谱抗菌素。
April 8, 2005 李名杰于长航医院
4. Umbilical disease
1 Umbilical embryology - body pedicle: umbilical artery-lateral umbilical ligament (2); Umbilical vein-umbilical intermediate ligament (1); Vitelline canal; Urachal.
2 IgY duct deformity
2.1 Complete patent of vitelline duct — vitelline duct fistula (navel-gut fistula).
2.2 Partial patent yolk sac
2.2.1 Umbilical region — umbilical sinus
2.2.2 Middle part — yolk sac cyst
2.2.3 Bowel — Meckel diverticulum
2.3 Umbilical mucosal residue — umbilical cord (umbilical polyp)
2.4 Residues of vitelline tubule and its vascular fibrotic zona — umbilical enterozona
3 Urachal malformation
3.1 Urachal fistula-patent
3.2 Partial Closure
3.2.1 Umbilical region — urachal sinus
3.2.2 Middle part - urachal cyst
3.2.3 Bladder region-bladder diverticulum
4 Vascular malformations — persistent vitelline canal, urachal and umbilical blood vessels
5 Diseases of navel itself — umbilical hernia, omphalocele, infection, endometriosis, epithelial neoplasm, etc
4、脐部疾病 (讲稿提要)
1 脐部胚胎学 —— 体蒂: 脐动脉-脐外侧韧带(2); 脐静脉-脐中间韧带(1); 卵黄管; 脐尿管。
2卵黄管畸形
2.1 卵黄管完全未闭 —— 卵黄管瘘 (脐肠瘘)。
2.2 卵黄管部分未闭
2.2.1 脐部 —— 脐窦
2.2.2 中间部 —— 卵黄管囊肿
2.2.3 肠部 —— 麦克耳憩室 (Meckel diverticulum)
2.3 脐部粘膜残余 —— 脐茸 (脐息肉)
2.4 卵黄管及其血管纤维化索带残留 —— 脐肠索带
3脐尿管畸形
3.1 脐尿管瘘 —— 未闭
3.2 部分未闭
3.2.1 脐部 —— 脐尿管窦
3.2.2 中间部 —— 脐尿管囊肿
3.2.3 膀胱部 —— 膀胱憩室
4 血管畸形 —— 永存的卵黄管、脐尿管及脐部的血管
5 脐本身疾患 —— 脐疝、脐膨出、感染、子宫内膜异位症、上皮赘生物等
5. Congenital biliary malformations
1 Congenital biliary atresia (divided into six types)
bilioenteral drainage (50 cases +44 cases only, omitted)
2 Congenital choledochal cyst
2.1 Etiology:
2.1.1 Abnormal development of autonomic nerves in the terminal wall of common bile duct (similar to the etiology of Hirschsprung's disease)
2.1.2 Development disorder of common bile duct itself — weak duct wall (similar to the cause of congenital primary hydronephrosis)
2.1.3 Viral infection - obstruction/weak wall - dilatation-cyst
2.2 Pathology:
2.2.1 Extrahepatic (majority): cystic dilatation of common bile duct, diverticulum
2.2.2 Intra-hepatic (Caroli's cyst)
2.2.3 Mixed type (rare)
2.3 Symptom: three major symptoms (usually appear when the patient is three years old, but usually sees doctors later); abdominal pain 60%, lump 90%, jaundice 70%, fever 30%, pale feces, gallbladder pigment urine, intussusception perforation peritonitis and abnormal liver function.
2.4 Diagnosis: (i) three major Intermittent symptoms, (ii) ultrasonic diagnosis, (iii) abdominal X-ray or barium meal examination cholangiography. (iv) cyst puncture.
2.5 Treatment:
2.5.1 Cystectomy — Roux-Y cholangioenterostomy (difficult and with high mortality).
2.5.2 Cyst – duodenal anastomosis (easy and effective): low position, large incision (6Cm), and mucosa aligned suture.
2.5.3 Cyst - jejunal Roux-Y anastomosis.
2.5.4 External drainage of cysts (emergency transition).
2.5.5 Treatment of intrahepatic cyst: hepatectomy
3 Congenital gallbladder malformation
3.1 Abnormal number
3.1.1 Absence of gallbladder – 0.07% – predisposing to bile duct stones.
3.1.2 Double gall bladders – 0.025% of the double gall bladders are more prone to lithiasis and inflammation.
3.2 Location abnormality
3.2.1 intrahepatic gallbladder – 10% more children, with gradual emigration later on.
3.2.2 Left subtalar gallbladder
3.2.3 Right retrohepatic gallbladder
3.3 Morphological abnormalities
3.3.1 Biliary gall bladder – mediastinal membrane in the gall bladder.
3.3.2 bilobar gallbladder – bottom separation.
3.3.3 Leg sac diverticulum
3.3.4 gourd-shaped gallbladder
4 Abnormal adhesion — free gallbladder.
5 Abnormal tissue structure — ectopic tissue: pancreas and gastric mucosa.
This article was originally published in Proceedings of Wuhu Annual Surgical Conference,1996；28-30 Changhang Hospital, Li Mingjie
from 外科截瘫14例手术分析
