total gastrectomy

The upper gastric cancer is closer to the esophagus. For example, the upper edge of the early gastric cancer tumor should be within 2cm from the esophagus, the invasive gastric cancer should be within 6cm, and the localized gastric cancer should be within 4cm. Intravenous infusion during the fasting period, supplemented with glucose solution, normal saline, vitamin B and C, potassium chloride, etc., can also be given intravenous fat emulsion, complex amino acid solution, intravenous high nutrient treatment. Treatment of diseases: gastric cancer in the elderly Indication Total gastrectomy is used for patients with gastric cancer that are located in the corpus. Contraindications In the advanced stage of gastric cancer, there are very poor physical metastases in other organs. Preoperative preparation 1. Correct water, electrolyte, acid-base balance disorder before surgery. Combined with anemia, preoperative blood transfusion corrected. 2. For those who have been violated by the transverse colon, preoperative bowel preparations such as oral enteric bactericidal drugs, cleansing enema, etc. are required. 3. Preoperative systemic use of antibiotics, usually started 3 days before surgery. 4. Prepare blood and prepare skin. 5. Insert the stomach tube. Surgical procedure 1. Incision: Incision in the upper abdomen, up to 2~3cm on the xiphoid process, bypassing the umbilicus to the umbilicus 2~3cm, and removing the xiphoid process to reveal the esophagus. 2. Exploration: The intra-abdominal exploration was performed centering on the infiltration of the primary gastric cancer. First explore the presence or absence of liver metastasis and peritoneal and omental metastasis. Then gently spread the transverse colon to explore the extent of invasion of gastric cancer. If the cancer has invaded the serosa, it should be covered with gauze to prevent the cancer cells from falling out during surgery. Then turn the transverse colon up to observe the deep intestine cavity for cancer infiltration, explore the duodenal jejunum, explore the para-aortic lymph nodes, and explore the presence or absence of metastatic nodules in the Douglas fossa. Put back the transverse colon, pull the hook to open the left edge of the incision, extend the left hand into the spleen, and put the spleen into the front with the palm of your hand. Place two large yarn mats behind the spleen to make the spleen, pancreas and stomach close to the center of the abdomen. 3. Peeling of the right side of the omentum and the head of the pancreas: the omentum extends to the right to cover the colonic hepatic flexure, sometimes adhering to the abdominal wall. The omentum was sequentially peeled off from the colon, duodenum, and pancreatic head. Push the colon downwards to reveal the full length of the duodenum. Kocher free, cut the right anterior fascia, peel off the duodenum, further dissipate the posterior part of the pancreas, retract the pancreatic duodenum forward, continue to the left, reveal the inferior vena cava From the surface of the inferior vena cava to the surface of the left renal vein, if possible, then to the left to the left side of the abdominal aorta to the left. 4. Excision of the greater omentum: the transverse colon is pulled downward, the omentum is pulled up and flattened, and the omentum is peeled off from the transverse colon with an electric knife or a knife, and the omentum is peeled off together with the anterior lobe of the transverse mesentery. During the exfoliation, it can be shown that the middle cerebral artery travels to the root of the back of the pancreas, while the venous vein of the colon travels to the venous trunk of the stomach (Henle dry). Peeling the greater omentum and the transverse colitis of the transverse mesenteric to the lower edge of the pancreas, and separating it from the right vein of the gastric retina to the front of the pancreatic head to the venous stem of the stomach and colon, further showing the superior mesenteric vein and superior mesenteric artery, where the mesentery is carefully removed. Lymph nodes. 5. Clear the pyloric lymph nodes: Cut the right venous root of the gastric retina at the stem of Henle to remove the fatty lymphoid tissue. The posterior lobe of the greater omentum moves to the pancreatic capsule at the lower edge of the pancreas. After careful separation of the adhesion of the lower edge of the pancreas, the pancreatic capsule is peeled off to the upper edge of the pancreas, left to the tail of the pancreas, right to the duodenum, and the stomach is revealed. The duodenal artery cuts the right gastric artery at the root and clears the pyloric lymph nodes. 6. Peeling on the left side of the omentum: the left side of the omentum is the gastric collateral ligament, which is separated from the anterior leaf of the transverse mesentery, so that only the omentum can be removed without removing the anterior leaf of the transverse mesentery. . The left side of the omentum was peeled off from the transverse spleen and the spleen to the right, and the spleen colon ligament was cut off, and the right side of the omentum was peeled off. 7. Clear the liver and duodenal ligament (I): Cut the serosa in front of the liver and duodenal ligament near the hepatic hilum and peel off. First, the left hepatic artery was found, and the left hepatic artery was dissected to the junction with the right hepatic artery, and the intra-ligamental lymph node between the place and the common bile duct was removed. Continue to peel off the duodenum, reveal the right gastric artery, cut the right gastric artery at the root, and clear the upper pyloric lymph node. Continue to dissipate to the duodenal wall and cut the duodenum 2 cm away from the pylorus. The left hepatic artery is pulled to the right and peeled to the deep side at the left edge to reveal the left edge of the portal vein, and the lymph nodes after the ligament are carefully peeled off. 8. Cleaning around the common hepatic artery: the liver and stomach ligaments are cut along the liver margin, and the left hepatic artery is peeled off to the hepatic artery, and then the left common hepatic artery is removed to the left hepatic duodenal ligament. The lymph nodes were cleared to the left side, and the pyloric lymph nodes and the anterior pancreatic capsule that were peeled off from the large curved side were also peeled upward to the front of the common hepatic artery and peeled to the left. The common hepatic artery is lifted with a strap to completely remove the surrounding fatty lymph node tissue. 9. Clean the hepatoduodenal ligament (II): Peel off the right edge of the hepatoduodenal ligament, carefully separate the common bile duct and portal vein, and remove the para-biliary lymph nodes. Turn the pancreatic head duodenum to the left and continue to clear the lymph nodes behind the pancreas. The two sets of lymph nodes are connected and move to the left after removal. 10. Dissection of the right side of the abdominal aorta: dissection along the anterior direction of the inferior vena cava, revealing the left renal vein. The inferior vena cava is pulled to the right under the left renal vein, and the adipose lymphoid tissue between the aorta and the abdominal aorta is removed and cleared to the beginning of the inferior mesenteric artery. The hepatoduodenal ligament was pulled to the left side, and the right foot of the diaphragm was exposed to the posterior wall of the abdomen. The left renal vein is pulled to the caudal side with a cloth belt, and the left renal artery on the dorsal side can be seen to clear the fatty lymphoid tissue here. Go up to the posterior lymph nodes of the common hepatic artery. 11. Sweep around the celiac artery: pull the stomach down, continue to peel around the common hepatic artery to the periphery of the celiac artery, fully expose the right foot of the diaphragm, and remove the fat lymphatic tissue along the nerve fibers of the celiac ganglion. 12. Severing of the left gastric artery: Continue to peel off the root of the common hepatic artery, find the root of the left gastric artery to the left, cut off at the root, and clear the lymph nodes. The adipose tissue between the root and the splenic artery is further removed. 13. Freeness of the spleen and the tail of the pancreas: Cut the peritoneum outside the spleen and let the spleen free. Then cut the anterior leaf of the left renal fascia, and release the tail of the pancreas and the spleen, and turn it to the right. Touch the left renal hilum, reveal the upper edge of the left renal vein, clear the adipose lymphoid tissue between it and the left renal artery, and remove the left lymph node of the abdominal aorta. 14. Spleen lymph node dissection: the spleen is placed in the center of the surgical field, and the root of the left ventricle of the gastric retina is ligated at the root, and then the spleen and stomach ligament and the short gastric artery are cut upward, the spleen is revealed, and the splenic lymph node is probed. If there is metastasis of the splenic lymph nodes, the spleen should be removed. 15. Spleen the lymph nodes of the splenic artery: the free pancreatic capsule along the right side is turned up to the upper edge of the spleen and the pancreas to reveal the splenic artery. The lymphatic tissue surrounding the splenic artery trunk was removed from the outside to the inside, the posterior gastric artery was cut, and the root was swept inward to the root of the splenic artery. 16. Freeness of the posterior wall of the proximal stomach: Turn the free stomach upside down to see the gastric and ligament ligaments between the posterior wall of the stomach and the upper edge of the pancreas and the posterior wall of the abdomen. From the free celiac artery to the left to the left peritoneum to the right side of the cardia, and then cut the gastric pancreatic ligament, so that the posterior wall of the stomach completely free, revealing the posterior wall of the esophagus and esophageal hiatus muscle bundle, sweeping the diaphragmatic lymph nodes. 17. Freeness in front of the lower part of the esophagus: The stomach is placed back in place and pulled back and down to reveal the lower part of the esophagus. Cut the peritoneum in front of the esophageal hiatus to expose the esophagus and the hole. Cut the left and right vagus nerve trunks and clean the right lymph nodes and diaphragmatic lymph nodes in the lower part of the esophagus. Carefully cut the peritoneum of the left edge of the esophageal hiatus, expose the left inferior phrenic artery, and cut the ligation. Further reveal the left edge of the esophageal hiatus and the left temporal muscle, and clean the left lymph node and the transverse lymph node of the esophagus. 18. Cut the esophagus: Cut the esophagus 3 cm above the cardia. If the tumor invades the esophagus, the esophagus should be cut 3 cm above the upper edge of the tumor. A large right-angle pliers is placed at the place where the esophagus is to be cut, and a large right-angle pliers is placed underneath, and the two pliers are cut off and the specimen is removed. If the instrument is used for anastomosis, the upper right angle clamp is clamped 2 to 3 cm above the esophagus to be cut. 19. Digestive tract reconstruction: Roux-en-Y esophageal jejunal anastomosis is usually used, which is easy and safe to operate and has fewer complications. The duodenum ends are sutured in two layers. The jejunum was cut 15 to 20 cm away from the Treiz ligament, and the distal jejunum of the transverse collateral was removed through the avascular region of the transverse mesenteric. The end of the esophagus jejunum anastomosis was performed by anastomosis or hand-slit method. end. Then, the proximal jejunum and the end of the jejunum were anastomosed 40 cm from the anastomosis of the esophageal jejunum. Because of the frequent occurrence of nutritional metabolic disorders after total gastrectomy, in order to improve the quality of life of patients, in recent years, it is generally advocated for esophageal jejunal pouch anastomosis or jejunal anastomosis. The former mainly includes P-type anastomosis and Hunt anastomosis. The P-type anastomosis is an anastomosis of the esophageal jejunum 10~15cm from the upper end of the upper jejunum, and then the end of the jejunum is anastomosed to form a P-shape. . The Hunt's anastomosis method is to end the end of the esophageal jejunum anastomosis about 10 cm from the jejunal stump, suture the jejunal stump, and then align with the upper jejunum to form a jejunal pouch. The jejunum is anastomosed to the end of the duodenum and the jejunum is placed between the esophagus and the jejunum. A 30cm long vascular jejunum was taken from the Treiz ligament 15~20cm, and it was pulled through the avascular angioplasty area of the transverse mesorectum. The proximal end of the peristaltic direction was anastomosed with the end of the esophagus. The distal end and the duodenum end. Anastomosis, and then end-to-end anastomosis of the distal end of the jejunum. 20. Place the drainage, close the abdomen in the esophageal jejunal anastomosis, and place a silicone drainage tube from the left abdomen. Place a silicone drainage tube at the position of the small omentum sac from the right abdomen. The abdominal wall incision was sutured layer by layer. complication (1) Recurrent ulcers. (2) symptoms of dumping syndrome such as abdominal discomfort, palpitation, dizziness, sweating, weakness, nausea, and diarrhea after eating. (3) Bile reflux gastritis. (4) Anemia and nutritional disorders. (5) Cancer recurrence or metastasis. If the above complications occur, non-surgical treatment can be alleviated or eliminated. Gastric cancer patients need to be treated with chemotherapy before and after surgery to improve the curative effect.

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