外科学胆道疾病(中英文).ppt

Carcinoma of Bile Duct Signs 肝肿大、触痛 脾肿大、腹水——门静脉受侵犯 胆囊肿大——胆囊管开口以下 Clinical Presentation Physical examination. Lab examinations AKP、SGPT、BIL升高、CA19-9、CA125、CEA升高 BUS、CT、MRI、PTC、ERCP MRCP Carcinoma of Bile Duct Treatment 手术治疗 上段胆管癌：切除后行胆肠吻合术切除范围：肝外胆管、胆囊及胆囊管、肝十二指肠韧带内脂肪及淋巴结，（部分肝脏）。 中段胆管癌：切除后行胆肠吻合术 下段胆管癌：胰十二指肠切除术 Carcinoma of Bile Duct 姑息治疗 梗阻以上胆管-空肠Roux-en-Y吻合 置管胆肠转流术 通过肿瘤置支撑管引流术 经PTC、ERCP置入内支架 放疗和化疗: 疗效不佳 本节重点内容 胆囊息肉的手术指征 胆囊癌、胆管癌的临床诊断 ANATOMY Extrahepatic Biliary Tract 左右肝管 The left and right hepatic ducts左：2.5-4cm, 右：1-3cm 肝总管 The common hepatic duct长：2-4cm, 直径：0.4-0.6cm副肝管： 与肝动脉、门静脉前后、分叉关系。 ANATOMY 胆管、门静脉和肝动脉的关系 ANATOMY Extrahepatic Biliary Tract 胆总管（The common bile duct）长：7-9cm，直径：0.6-0.8cm，1cm病理分段：十二指肠上段、后段、胰腺段、十二指 肠壁内段 胆囊（The gallbladder）分底、体、颈三部（fundus, body, and neck）。 胆囊管 （The cystic duct） * * * * * * * * * Figure 50-6 Triangular phase diagram with axes plotted in percent cholesterol, lecithin (phospholipid), and the bile salt, sodium taurocholate. Below the solid line, cholesterol is maintained in solution in micelles. Above the solid line, bile is supersaturated with cholesterol and precipitation of cholesterol crystals can occur. Ch, cholesterol. (From Donovan JM, Carey MC: Separation and quantitation of cholesterol carriers in bile. Hepatology 12:94S, 1990.) * Pigment stone * * Figure 50-10 Trocar placement for laparoscopic cholecystectomy. The laparoscope is placed through a 10-mm port just above the umbilicus. Additional ports are placed in the epigastrium, and subcostally in the midclavicular and near the anterior axillary lines. (From Cameron JC: Atlas of Surgery, Vol. 2. Philadelphia, BC Decker, 1994.) * Figure 50-11 A, The gallbladder is retracted cephalad using the grasper on the gallbladder fundus and laterally at the infundibulum. The peritoneum overlying the gallbladder infundibulum and neck and the cystic duct is divided bluntly exposing the cystic duct. B, Once the gallbladder cystic duct junction has