Laws H L, McKernan J B
Department of Surgery, Carraway Methodist Medical Center, Birmingham, Alabama.
Ann Surg. 1993 May;217(5):548-55; discussion 555-6. doi: 10.1097/00000658-199305010-00016.
This article reviews the authors' experience with endoscopic management of duodenal ulcer and ulcers occurring after a previous drainage procedure.
Patients with complications of duodenal ulcer and ulcers occurring after a previous drainage procedure still require surgical management. Virtually all operations for duodenal ulcer include some form of vagotomy. American surgeons in academic centers prefer highly selective vagotomy in suitable candidates. Video-directed laparoscopic and thoracoscopic operations have been done for all complications of duodenal ulcer except for acute hemorrhage.
The authors have performed laparoscopic operation on eight patients with intractable chronic duodenal ulcer, seven patients with gastroesophageal reflux disease combined with duodenal ulcer, one patient with chronic duodenal ulcer and gastric outlet obstruction, and one patient with acute perforation. Operations performed included omentopexy, anterior seromyotomy plus post truncal vagotomy, and highly selective vagotomy. Seven patients had a simultaneous Nissen fundoplication; and the patient with obstruction underwent concomitant pyloroplasty and vagotomy. Six patients with intestinal ulcers occurring after a previous drainage procedure were treated with thoracoscopic vagotomy. Techniques used are shown.
There has been one recurrent ulcer in the laparoscopic group after anterior seromyotomy plus posterior truncal vagotomy. The patient treated by omentopexy for duodenal perforation recovered gastrointestinal function promptly with no further difficulty, but eventually died of primary medical disease. Patients undergoing thoracoscopic vagotomy have all become asymptomatic. Postoperative hospital stay after highly selective vagotomy, anterior seromyotomy plus posterior truncal vagotomy, or thoracoscopic vagotomy was 1-5 days.
Laparoscopic management of duodenal ulcers is feasible. Larger numbers of patients with longer follow-up are essential. Ulcers occurring after a drainage procedure deserve thoracoscopic vagotomy.
本文回顾作者在内镜治疗十二指肠溃疡及既往引流术后发生的溃疡方面的经验。
十二指肠溃疡并发症患者及既往引流术后发生溃疡的患者仍需手术治疗。几乎所有十二指肠溃疡手术都包括某种形式的迷走神经切断术。学术中心的美国外科医生在合适的患者中更倾向于高选择性迷走神经切断术。除急性出血外，已对十二指肠溃疡的所有并发症进行了视频引导下的腹腔镜和胸腔镜手术。
作者对8例顽固性慢性十二指肠溃疡患者、7例胃食管反流病合并十二指肠溃疡患者、1例慢性十二指肠溃疡合并胃出口梗阻患者及1例急性穿孔患者进行了腹腔镜手术。实施的手术包括网膜固定术、前壁浆膜切开术加迷走神经干后切断术以及高选择性迷走神经切断术。7例患者同时行了nissen胃底折叠术；梗阻患者同时行了幽门成形术和迷走神经切断术。6例既往引流术后发生肠溃疡的患者接受了胸腔镜迷走神经切断术。展示了所采用的技术。
腹腔镜组在前壁浆膜切开术加迷走神经干后切断术后出现1例复发性溃疡。因十二指肠穿孔接受网膜固定术治疗的患者胃肠功能迅速恢复，未再出现问题，但最终死于原发性内科疾病。接受胸腔镜迷走神经切断术的患者均无症状。高选择性迷走神经切断术、前壁浆膜切开术加迷走神经干后切断术或胸腔镜迷走神经切断术后的住院时间为1 - 5天。
腹腔镜治疗十二指肠溃疡是可行的。需要更多患者并进行更长时间的随访。引流术后发生的溃疡值得行胸腔镜迷走神经切断术。
