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胡迪醫學 Hudi Medical Science

胡迪醫學

SADI-S術后袖管狀胃縫釘線上瘺的處理方法

瀏覽量:1305 / 發布時間:2021-11-24

胡迪主任給大家介紹一種新型減重手術,

手術名為腹腔鏡袖式胃切除術

加單吻合口十二指腸回腸吻合術( SADI-S)。

這個手術的具體細節,

胡迪主任會在近期發布的

《減重手術方式演變簡史》中細說。

歡迎各位到時候收閱。


今天介紹SADI-S手術的一個常見并發癥,

袖式胃切除縫釘線上瘺及其處理方法。

SADI-S術后最常見瘺發生的部位

自從臨床上引入了SADI-S手術以來,

袖管狀胃縫釘線上,

是十二指腸轉流手術后

瘺發生最常見部位。

根據報道,其發病率為1%到4%。

在過去的5到10年里,

隨著外科醫生在單純腔鏡

袖式胃切除手術方面經驗的增加,

并發癥發病率有所下降。


瘺發生的最常見部位

在袖管胃上三分之一地方,

由于袖管胃縮窄或狹窄,

導致胃內爆破壓升高,

在靠近食管胃結合部附近的

袖管胃縫釘線上,因這里相對比較薄弱,

容易發生破裂而形成瘺。

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圖上顯示胃底切割線交叉處是瘺發生部位,

圖片來自互聯網,版權歸原著者,

僅供學習和交流之用,不是商業推廣之用

瘺的處理方法

在沒有明顯阻塞的情況下,

早期緊急處理方法就是

再次手術手工縫合或再次用吻合器吻合,

沖洗受影響的區域。

如果早期污染不嚴重,

緊急處理得當,

能很快地完全愈合。


如果是慢性瘺管形成或

術后后期出現瘺,

情況就會復雜很多。

瘺一發生就需要營養支持和給予抗生素,

并輔以充分的引流。


引流通??梢酝ㄟ^外科手術或

介入放射學的幫助下進行。

但最近的研究表明,

內鏡技術也能實現充分引流。

如內鏡傷口負壓清理術或

內鏡造口術。


然而,最重要、最佳治療是

尋找和緩解梗阻點,

梗阻通常發生胃切跡呈角的地方。

通過放置內鏡支架可以解決部分病情,

但在一些謹慎的病例中,

最終可能需要手術切除和Roux-en-Y重建。

Leaks from Sleeve Gastrectomy

A leak from the SG portion of the procedure has historically been the most common area for a leak after a duodenal switch. The incidence has been reported as 1 to 4 percent, depending on the study evaluated. Over the last 5 to 10 years, the incidence has dropped as surgeon experience has increased in performing the SG as a stand-alone procedure. The most common area for a leak is in the upper one-third of the sleeve due to narrowing or stricture of the sleeve at the incisura angularis (Figure 2). This will cause an increase in pressure in the sleeve with a blowout at the upper portion of the staple line near the gastroesophageal junction since this is the weakest point in the sleeve. The treatment of a sleeve leak in the acute setting without a significant obstruction involves a washout of the affected area with resuturing or restapling of the sleeve. Many of these can heal completely if addressed early enough with minimal contamination. In the chronic setting or with a chronic fistula, it gets a bit more complicated. Nutritional support and antibiotics are required initially, combined with adequate drainage. Drains can usually be placed via a surgical approach or with the aid of interventional radiology, but recent studies have shown that drainage can also be facilitated with endoscopic techniques, such as an endoscopic wound vac or endoscopic septotomy. The most important aspect though for definitive treatment is to look for and relieve the obstructive point, which is usually at the angularis. This can be done with placement of an endoscopic stent, but in reticent cases, eventual surgical resection and Roux-en-Y reconstruction might be required.

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