Training material VII
Treatment of recurrent ulcer after subtotal gastrectomy
多发性溃疡的发生机制目前尚不完全明了，但有以下几种原因可促使溃疡复发。
一、与手术有关的因素
1、输入袢过长: 约占复发性溃疡病因的3%左右，一般要求应在屈氏韧带下 6-10cm 最为合适。
2、胃切除过少: 一般认为切除过少，不能切去足够的壁细胞，因此，切除胃约在 75% 的组织实属必要。
3、胃窦粘膜存留: 复发性溃疡中有 9% 的病人有胃窦粘膜存留，如第一次手术时剩下 l cm 的胃窦粘膜都有可能发生溃疡复发。
4、由于不适当的选用 Roux-y 吻合，或空肠近袢间侧侧吻合，分流了胃肠吻合区中和酸的胰液和胆汁，增加了溃疡复发机会。
5、用不吸收的丝线缝合吻合口，轻者可致炎症，重者可能溃疡或形成吻合口糜烂。
6、手术中引起胃肠粘膜的损伤，或剪除胃肠粘膜过多。
7、碱性返流性胃炎，由于胆汁返流入胃，致胃酸分泌增加，损害胃粘膜屏障，胆盐与胆酸在胃内亦可破坏溶酶体膜，导致溃疡发生。
The mechanism of multiple ulcerations is currently not fully understood, but there are several reasons why they may recur.
- factors related to surgery:
- Excessive length of afferent loop: it accounts for about 3% of the causes of recurrent ulcer. The general requirement is that 6-10cm below the ligament of Treitz is the most appropriate.
- Too little gastrectomy: It is generally considered that the resection is too little to remove enough parietal cells. Therefore, it is necessary to remove about 75% of the stomach tissue.
- Preservation of gastric antrum mucosa: The gastric antrum mucosa is preserved in 9% of patients with recurrent ulcer. For example, the gastric antrum mucosa with the thickness of l cm left during the first operation may have ulcer recurrence.
- Roux-y anastomosis or lateral jejunal anastomosis between proximal loops is inappropriately selected, which shunts the neutralized pancreatic fluid and bile in the gastrointestinal anastomosis area and increases the chance of ulcer recurrence.
- The anastomosis shall be sutured with non-absorbable silk thread. In mild cases, the anastomosis may be inflamed, while in severe cases, the anastomosis may be ulcerated or eroded.
- cause damage to the gastrointestinal mucosa in the operation, or cut off too much gastrointestinal mucosa.
- alkaline reflux gastritis, due to bile reflux into the stomach, increase gastric acid secretion, damage the gastric mucosal barrier, bile salts and cholic acid in the stomach can also destroy the lysosomal membrane, leading to the occurrence of ulcers.
- Gastric antrum G cell proliferation.
- Gastric seminoma or pancreatic ulcer syndrome accounts for about 1.8% of recurrent ulcers.
- Ulcer drugs, such as salicylate type, indomethacin, baotaisong, corticosteroids, reserpine, etc. may lead to ulcer recurrence.
Surgical treatment of recurrent ulceration after subtotal gastrectomy:
The recurrence of ulcer is a fundamental failure of the previous operation, so great caution should be exercised during the reoperation to avoid further failure. First of all, the diagnosis should be clear, to better understand the previous operation, carefully observe the recent x-ray barium meal film, pay special attention to whether the residual stomach is too much, followed by gastroscopy, to determine the diagnosis and the location of the lesion, and pathological diagnosis, all these are very important, and also make sure to rule out the possibility of gastric cancer.
About the principle of reoperation:
The principle of retaking the surgery is to correct the defects of the first surgery. During the surgery, we should first explore whether the stomach is left uncut too much, whether the afferent loop is too long, and whether there is gastric antrum left. We should carefully explore the pancreas to exclude pancreatic ulcer and choose different surgery methods according to different situations. For pancreatic ulcer, the surgical methods include simple tumor resection and total gastrectomy. However, in most cases, the tumor is not easy to be found due to its small size, or it is difficult to remove the multiple affected parts, so total gastrectomy is the best policy. After total gastrectomy, the tumor loses its target organ and will most likely degenerate.
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
