Bancroft术式治疗十二指肠球部溃疡伴胃流出道梗阻5例临床诊治分析.pdf

Chin J Hemorh.2023;33(2)178基金项目：国家自然科学基金资助项目(82073180)，江苏省青年医学人才(QNRC2016732)，苏州市“姑苏卫生人才”计划青年拔尖人才(2018-057)，姑苏卫生人才培养项目(GSWS2019028)，苏州市科技计划(SLC201906)收稿日期：2023-01-10 作者简介：白燕金(1997),男,江苏常州人,硕士研究生在读,研究方向:胃肠外科的基础与临床。通讯作者：李 瑶，E-mail：doi:10.3969/j.issn.1009-881X.2023.02.003Bancroft术式治疗十二指肠球部溃疡伴胃流出道梗阻5 例临床诊治分析白燕金1，阮小康1，汪盛嘉1，吴林伟1，王 进2，张 喆2，赵 鑫1，李 瑶3（1.苏州大学附属第一医院普外科，江苏 苏州 215006；2.苏州大学附属独墅湖医院普外科，江苏 苏州 215123；3.苏州大学附属第一医院消化内科，江苏 苏州 215006）摘要：目的 探讨Bancroft术式在治疗十二指肠球部消化性溃疡致胃流出道梗阻病人中的优势，以提高该病的治疗效果。方法 回顾性分析苏州大学附属第一医院2014年4月2020年9月行Bancroft术治疗的十二指肠球部良性溃疡致胃流出道梗阻患者的临床资料。分析Bancroft术式治疗该病的优点以及国内外的相关经验。结果 5 例行Bancroft术式的病人均于术后710 d出院，在院期间未见相关并发症发生，1 例病人在出院2 周后出现胃窦残端关闭端外瘘，经保守治疗2 个月后，再次入院行二次手术治愈出院。5 例病人出院1 个月后复查时体重均明显上升，无再次出现消化道梗阻。结论 Bancroft术式治疗十二指肠球部消化性溃疡致胃流出道梗阻具有其明显的优势。关键词：消化性溃疡病；十二指肠溃疡；胃出口梗阻；Bancroft中图分类号：R656.62 文献标识码：A 文章编号：1009-881X(2023)02-0178-04Clinical Diagnosis and Treatment of 5 Cases of Duodenal Ulcer with Gastric Outflow Tract Obstruction by Bancroft OperationBAI Yan-jin1,RUAN Xiao-kang1,WANG Sheng-jia1,WU Lin-wei1,WANG Jin2,ZHANG Zhe2,ZHAO Xin1,LI Yao3(1.Department of General Surgery,First Affiliated Hospital of Soochow University,Suzhou,Jiangsu,215006,China;2.Department of General Surgery,Dushuhu Hospital Affiliated to Soochow University,Suzhou,Jiangsu,215123,China;3.Department of Gastroenterology,First Affiliated Hospital of Soochow University,Suzhou,Jiangsu,215006,China)Abstract：Objective To explore the advantages of Bancroft operation in treating patients with gastric outflow obstruction caused by duodenal bulb peptic ulcer,in order to improve the treatment effect of this disease.Methods Clinical data of patients with gastric outflow tract obstruction caused by benign duodenal ulcer who underwent Bancroft surgery in the First Affiliated Hospital of Soochow University from April 2014 to September 2020 were retrospective analyzed,to study the advantages of Bancroft surgery in treating this disease and the relevant experience at home and abroad.Results Five patients who underwent the Bancroft operation were discharged from the hospital 7-10 days after surgery,and no related complications occurred during the hospital period.One patient developed an external fistula at the closed end of the gastric antrum 2 weeks after discharge.After conservative treatment for 2 months,they were re-admitted for a second surgery and discharged.Five patients showed a significant increase in weight during follow-up one month after discharge,with no recurrence 中国血液流变学杂志.2023;33(2)179of gastrointestinal obstruction.Conclusion Bancroft operation has obvious advantages in treating gastric outflow tract obstruction caused by duodenal bulb peptic ulcer.Key words：peptic ulcer;duodenal ulcer;gastric outflow tract obstruction;Bancroft十二指肠溃疡致胃流出道梗阻是消化性溃疡病的常见并发症之一，发生率为2%4%1，由于质子泵抑制剂及H2受体拮抗剂的广泛使用，胃及十二指肠溃疡一般在早期就得到控制2，少数病人可能因未正规内科治疗或药物控制不佳导致溃疡反复发作，进而致使瘢痕形成，造成胃流出道梗阻，该病确诊后需行手术治疗。本研究回顾性分析了苏州大学附属第一医院2014年2020年因十二指肠溃疡致胃流出道梗阻，内科治疗无效后行Bancroft术式治疗的5 例患者，探讨Bancroft术式治疗该病的优势以及国内外的相关经验。1 资料与方法1.1 一般资料 苏州大学附属第一医院2014年4月2020年9月收治的十二指肠溃疡致胃流出道梗阻患者行Bancroft术式治疗的5 例病例，其中男4 例，女1 例，年龄2151 岁。1.2 诊断 根据患者的症状、体征、影像学表现为主要诊断标准，主要临床表现为：1.上腹部胀痛不适，呕吐隔夜宿食且呕吐物不含胆汁，有腐败酸臭味，呕吐后腹胀减轻；2.上腹部可见胃肠型、蠕动波，部分病人可闻及“振水声”；3.消瘦。消化道碘剂或钡剂造影显示造影剂潴留明显增多，胃体、胃窦部黏膜可见增粗，扭曲，造影剂无法通过或仅有极少量通过幽门进入十二指肠（图1）。胃镜提示胃窦黏膜充血水肿，红白相间，幽门变形，十二指肠球部可见凹陷性溃疡，边缘黏膜充血水肿，球部变形狭窄，胃镜无法通过（图2）。图1 上消化道钡剂造影显示胃出口梗阻Fig.1 Upper gastrointestinal barium contrast imaging showing gastric outlet obstruction 图2 胃镜显示胃流出道梗阻Fig.2 Gastroscopy showing obstruction of gastric effluent tract1.3 治疗方法1.3.1 术前营养支持治疗：对于术前营养状况较差的病人，即血清白蛋白低于30 g/L，前白蛋白低于100 mg/L者，术前经胃镜或透视介入手段穿过流出道梗阻部位置入空肠内营养管，给予肠内营养混悬液制剂行肠内营养支持，同时给予静脉全合一补液行肠外营养支持。行上述围手术期营养治疗12 周，并静脉输注人血白蛋白，其目的为改善患者的营养状态，纠正水电解质失衡，以达到术后快速康复和减少术后并发症的目的。1.3.2 手术方式：步骤1：在幽门近侧34 cm处断胃，在幽门远侧上一肠钳，暂时阻断血流，在无血情况下剥离胃窦部黏膜。步骤2：在幽门黏膜根部之远侧，以可吸收缝线线交叉缝合二针，然后剪除幽门黏膜，去除止血钳，电凝或结扎止血。步骤3：紧靠黏膜残端，在左右二角的幽门肌层，各做一半荷包缝合，中间可吸收倒刺缝线连续缝合数针关闭。步骤4：减去多余的幽门浆肌层袖，可吸收倒刺缝线连续缝合数针关闭，前后壁贴紧，不留死腔，游离缘不必内翻，但用大网膜覆盖之（图3，图4）。步骤5：残胃与距屈氏韧带20 cm空肠行侧侧吻合术（即B-式重建），再加Brauns吻合术。2 结果5 例病人均在术后23 d有肛门排气，由术后禁食逐渐过渡到流质饮食和半流质饮食，术后Chin J Hemorh.2023;33(2)180710 d顺利出院。1 例病人出院后2 周出现胃窦残端关闭口瘘，经右上腹引流管拔除后的腹壁伤口流出黄绿色液体。经该腹壁瘘管插入细引流管引流等保守治疗2 个月后，予以拔除引流管，仍有液体引出，行二次手术开腹探查，证实为胃窦残端瘘，予以倒刺线连续缝合关闭残端瘘口，术后1 周治愈出院。余4 例病人均无并发症，术后随访复查2 年均未再发生消化道梗阻，体重增长510 kg，营养指标均较术前明显改善。3 讨论胃流出道梗阻是十二指肠溃疡的常见并发症之一，一般认为溃疡的病因为幽门螺杆菌（Hp）感染或非甾体抗炎药物的使用，其中Hp在胃窦黏膜中的患病率81.5%，目前Hp易感个体的机制尚不明确3，也有报道提到大部分需手术治疗的病例中Hp感染率并不高4。溃疡反复发作，炎症修复导致局部纤维瘢痕形成，导致胃流出道梗阻。胃流出道梗阻主要临床表现为消瘦，腹痛，进食后腹胀或只能进食流质食物，顽固性呕吐，早期病人可无症状或只是轻微腹胀。在先前的治疗中，由于缺乏对Hp的认识和有效的抑制胃酸药物，该疾病的患病率及复发率都较高5，现因内镜技术的发展、Hp的发现及质子泵抑制剂的广泛使用，消化性溃疡病的发病率已明显降低。继而，由其所致的胃流出道梗阻发病率也明显降低。病理生理学上，幽门通道狭窄导致淤滞，其升高的胃pH值导致明显的胃泌素释放和过量的酸产生。严重的胃胀进一步增加了胃泌素的释放。这种组合加剧了持续的酸生产，导致“恶性循环”6。目前，对于胃流出道梗阻主要的治疗方法包括抑酸治疗，内镜下治疗，外科治疗，其中内镜下治疗主要包括内镜下球囊扩张（endoscopic balloon dilatation,EBD）、放置自膨胀支架，手术治疗包括高选择性迷走神经切开术联合某种形式的幽门成形术、躯干迷走神经切开术联合胃肠切开术或躯干迷走神经切开术联合椎体切除术等。曾有报告7指出，单纯的抗Hp治疗治愈了胃出口梗阻，但缺少大型的实验数据支持，在可选择的情况下，综合考虑患者的收益及风险，EBD自1982年被第一次实施以来一直是胃流出道梗阻的首选8，所以目前对于抗Hp治疗无效的病人通常使用的治疗方案为EBD及抑酸联合治疗，EBD对67%83%的病人在短期内有良好的疗效9-15。但EBD也有其自身缺点，包括远期复发率高，穿孔率高，手术率高，对于内镜下治疗胃出口梗阻仍缺乏相应的指南指导，相关适应证需要严格把握。有一定的机率存在不适宜用于内镜治疗的病人接受了内镜治疗，导致了不良预后的发生。相对而言，虽然与内镜治疗相比，外科手术治疗伤害较大，费用较高，但其仍是一种重要的治疗方式，且是内镜治疗失败后首选的治疗方式，对于十二指肠或胃窦残端的处置将是本文讨论的重点，也是目前临床上存在争议之处。大部分的主刀医师选择行远端胃大部切除B-式消化道重建，其优点主要为：(1)切除了溃疡病灶本身，治疗彻底；(2)切除了溃疡的好发部位；(3)切除了大部分胃体，减少了胃酸的分泌；(4)切除了G细胞主要分布的胃窦部，减少了胃泌素的分泌。但是该术式治疗本病的缺点也非常明显，即因溃疡反复炎症发作导致十二指肠球部瘢痕形成，手术切除十二指肠球部时解剖层次图3 完整剥离胃窦黏膜Fig.3 Complete dissection of gastric antral mucosa 图4 关闭远端胃并做加强缝合Fig.4 Closing the distal stomach and performing enhanced sutures中国血液流变学杂志.2023;33(2)181不清，组织不易分离，容易造成医源性误损伤，如十二指肠球后端的胆总管以及胰腺组织等。甚至有些病例因炎症时间较长，瘢痕组织浸润生长，与周围组织器官紧密粘连，缺乏解剖间隙，造成十二指肠球部固定，无法切除。给外科治疗带来很大困难和潜在的手术风险。然而，相较于远端胃大部切除，Bancroft有其明显的优点：(1)免于对十二指肠球部瘢痕组织的分离，因而避免了误损伤，降低了手术难度和手术风险。(2)该术式剥除了残留的胃窦部黏膜，减少了幽门腺的胃酸分泌，其手术效果与切除病灶无异16。对于部分年轻病人或对于部分一般状况较差的病人，考虑良性病变所致胃流出道梗阻无需类似于恶性病灶必须保证切缘阴性，使用该术式可尽可能保留较多的正常胃组织，可最大程度保留胃的储存功能。(3)少数病人为十二指肠溃疡穿孔术后再发狭窄，考虑到其解剖层次已存在变异，为了降低术后残端瘘的发生率，可考虑行Bancroft术式。另一方面，对于胃流出道梗阻的病人，由于严重的呕吐，导致大量消化液丢失，营养摄入减少，机体处于长期负氮平衡状态，故常表现为明显的消瘦17，血清白蛋白及前白蛋白等营养指标显著降低，有研究18表明白蛋白及前白蛋白水平与术后出现如吻合口瘘等相关并发症密切相关。因此，术前营养支持至关重要，且有研究19表明肠内营养支持在术后胃肠功能恢复、降低手术并发症、降低死亡率等方面均较肠外营养更好。我们的处理经验是，对于胃流出道梗阻的病例，大多数的梗阻部位可以允许营养管通过，经鼻饲营养管行肠内营养联合肠外营养支持12 周，可显著改善患者的营养状态，为术后恢复创造良好条件。尽管随着内镜技术的发展，相较于外科手术的高风险、高花费，越来越多的病人开始尝试内镜下治疗，但内镜下支架技术的长期疗效还有待考证，外科手术的远期复发率因病灶的去除或改道而明显低于支架技术。综上，若消化性溃疡病致胃流出道梗阻，手术治疗仍然是有效且确切的一种方式，对于十二指肠周围瘢痕增生的处置，Bancroft术式简单易行，安全性高，疗效可靠，是手术方式的较佳选择。参考文献1 陈可,朱文成,沈元娜,等.内镜下球囊扩张术治疗十二指肠瘢痕狭窄疗效分析J.中国内镜杂志,2007,13(11):1222-1223.2 Yuan Y,Padol IT,Hunt RH.Peptic ulcer disease 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