浅谈大肠手术跟造口.pptx

浅谈大肠手术跟造口

名词释义?Stomy:做造口的这个”术式”?Stoma:指“造口”本身

Stom的a种类T-loopcolostomaEnd-colostomaDoublebarrelcolostomaIleostoma

T-loopcolostoma

End-colostoma

Doublebarrelcolostoma

Loopileostoma

IleostomaColostoma分泌量多,液体状,bile色 700-800mL/day,动辄破1000以上 容易电解质不平衡分泌量很少,已经是粪便 更换次数少,比较好照顾 越近端则粪便越液状,越远端则粪便越固体状Decompression效果差 因为有ileo-cecalvalve 术后保护吻合口多Decompression效果好手术较简单 小肠在腹腔中是浮动的手术较困难 大肠相对比较固定,且很涨的时候手术不易Loopileostomavs.Loopcolostoma

为什么要有stoma?Afraidofleakage!!!!!

oximalDistal

考虑需要stom的a因素?还是一样,怕leak!!!?术前colo因n阻塞而非常涨?病人太多内科的co-morbidity?Livercirrhosis?ESRD(End-stagerenaldisease)?年纪太大?Anastomosis太低?低位直肠癌?术前,术中或者术后生命征象不稳…

常见的大肠术式

Righthemi-colectomy血流很丰富,几乎不需要术后造口保护

Lefthemi-colectomy左侧大肠血流较差,有时需术后造口

LAR需要造口的机会较多SigmoidLAR(lowanteriorresection)

APR(abdomino-perinealresection)APR为永久之造口

造口可以是永久,也可以是暂时的Hartmann’sprocedure

观念No.1End-colostom跟aLoopcolostomatake-dow的n方式有什么不同?

T-loopcolostoma

Hartmann’sprocedure

观念No.2Coloncancer完全阻塞治疗的方式

Coloncancerwithtotalobstruction3stagestreatmentVS.2stagestreatment

3stagestreatment?1stoperation?Decompressivecolostomy 10-14dayslater…?2ndoperation?CurativerresectionLaparoscopicoropen?Lefthemi-colectomy?Sigmoidcolectomy?LAR3monthslater…?3rdoperation?Colo-stomatakedownTumrSto

2stagesoperation?1st+2ndoperation?OPENcurativeresection+intra-OPcolonirrigation?因为病人肚子很涨，再加上术中洗肠子清理粪便，通常也只能open手术?Needdivertingcolostomatoprotectanastomosisfromleakage3monthslater…?Colostomatakedown?3rdoperation

Alternative2stagesoperation?1stoperation?Decompressivecolostomy?10-14daysinterval?FFPtransfusion?Parenteralnutritionsupport?Stomadecompression?2nd+3rdoperation?Curativeresection+colostomatakedwon?因为已经有了colostomafordecompression，肠子已经不涨，可以好好的colonpreparation?可以LAPAROSCOPICapproach?此时takedown手术后的leak机率已经降低10-14dayslater…

Case

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