胃镜联合腹腔镜胃浆肌层切开缝合加病灶热凝固法治疗Dieulafoy溃疡的体会

The experience of the combined therapy of Dieulafoy ulcer using endoscope and laparoscope to incise and suture gastric seromuscular layer and exerting the thermal coagulation to the focus

目的：探讨内镜联合腹腔镜胃浆肌层切开再缝合加病灶热凝固治疗Dieulafoy溃疡的可行性。方法：术中为6例胃前壁Dieulafoy溃疡患者进行胃镜定位,腹腔镜下在溃疡两侧做尖端向胃小弯的V形切口,切开胃浆肌层,阻断溃疡的血液供应,胃镜检查溃疡无出血后再缝合浆肌层切口。经胃镜对溃疡面进行高频电热凝固,电凝时电流输出功率选择40 W,先除去溃疡面附着的血栓,暴露整个溃疡面,如无出血则电凝病灶,电凝范围超出溃疡边缘2 mm,如溃疡继续出血,则行楔形切除。结果：5例完成手术,1例患者胃窦前壁溃疡继续出血,改行楔形切除术。手术时间平均（50.83±7.31）min;手术出血量平均（7.5±2.5）ml;术后胃肠功能恢复时间平均（15.0±6.19）h;平均住院（5.67±0.75）d。术后患者均恢复顺利,痊愈出院。随访1~2年,无消化道出血症状,镜检无溃疡复发。结论：胃浆肌层切开再缝合加病灶热凝固操作简单,适于胃前壁Dieulafoy溃疡的治疗。

Objective： To study the feasibility of the combined therapy of Dieulafoy ulcer,which uses endoscope and laparoscope to incise and suture gastric seromuscular layer and the thermal coagulation to the focus. Methods： In 6 Dieulafoy ulcer cases,endoscope was used to locate the focus on gastric front wall,and laparoscope was used to make V incision to the ulcer that the tip oriented the lesser curvature of the stomach. Then the gastric seromuscular layer was cut open,the blood supply of the ulcer was blocked. The ulcer was checked by gastroscopy,and the incision was sutured after no hemorrhage was found in the check. High-frequency electric thermal coagulation was given to the surface of ulcer by endoscope. 40 W power output of current was selected in electrocoagulation. The adhering thrombus was removed first to expose the surface of ulcer. After that if no hemorrhage was found,electrocoagulation was exerted to the focus. The range exceeded 2 mm to the margin of ulcer. If hemorrhage was found,wedge excision was performed. Results： Five operations were completed,hemorrhage at front wall of gastric antrum was found in 1 case and then wedge excision was made. The average duration of operation was（ 50. 83 ± 7. 31） min,and the amount of bleeding was（ 7. 5 ± 2. 5） ml. After operations,time of recovery of gastrointestinal function was（ 15. 0 ± 6. 19） h. The average length of hospital stay was（ 5. 67 ± 0. 75） d. All patients were cured and in good recovery. In 1-2 years after operations,no alimentary tract hemorrhage or relapse of ulcer were found in endoscopic check in followup visits. Conclusions： Method of incision and suture gastric seromuscular layer and the thermal coagulation is simple to operate,appropriate for the treatment of Dieulafoy ulcer on gastric front wall.