肝胆管结石诊断和治疗.ppt

胆囊腺瘤01癌变率6%~36%。临床表现与慢性胆囊炎相似。确诊即行胆囊切除术，尤其腺瘤5mm，或为广基者。注意检查手术标本的病理（术中冰冻），癌变者按照胆囊癌处理。01胆囊癌病因：和胆囊结石有关。病理：多发于胆囊体部、底部腺癌（80％）、鳞状细胞癌（3％）、混合性癌（1％）淋巴结转移和肝脏侵犯常见临床表现右上腹痛：67.7%右上腹块：42.5%黄疸：40.9%其他：纳差、消瘦；腹水、恶液质；上消化道出血USCT：伴肝转移或其他器官转移06：Ⅲ+胆囊管淋巴结转移05：胆囊壁三层结构受侵犯04：侵犯黏膜和肌层03：局限于黏膜02Nevin分期01可根据分期及淋巴结侵犯情况决定：01~Ⅱ期：单纯胆囊切除或加胆囊床切除02期：标准根治切除03~Ⅴ期：扩大根治术04（PD、半肝或中肝切除、右05三叶切除）06争取Ro根治切除07治疗logo治疗姑息性治疗胆道内引流术：胆管空肠RouX-en-Y或袢式吻合经圆韧带旁左肝管切开，胆肠吻合术胆道外引流术：胃肠吻合术：解除胃肠道梗阻总5年生存率约5%~12%中山大学一附院3年生存率为8.7%根治性切除者3年生存率达27.2%日本Tsukada:（1996年）根治性切除术5年生存率达33%（35/106）预后胆管癌1有关疾病胆管结石原发性硬化性胆管炎先天性胆管扩张其他：中华支睾吸虫感染2HepatitisBvirus(HBV)isoneofthemostinfectious,mostcommonandmostimportantvirusesintheworld--hepatitisBvirusisestimatedtobe100timesmoreinfectiousthanHIV,thevirusthatcausesAIDS.Globally,hepatitisBvirushasbeenestimatedtoinfectmorethan2billionpeople--approximatelyathirdoftheworld’spopulation. tmax=timeafterdosingtoachievepeakserumconcentration Cmax=maximumserumconcentrationLamivudineiswellabsorbedfromthegastrointestinaltract,andtheoralbioavailabilityoflamivudineinadultsisnormallybetween80%and85%.Allformulations(tablets,capsules,andsolution)showsimilarbioavailability.Followingoraladministration,themeantime(tmax)tothemaximumserumconcentrations(Cmax)isabout1hour.Cmaxforlamivudine100mgdailyisintheorderof1.1-1.5μg/mL. JohnsonMA,MooreKHP,YuenGJ,ByeA,PakesGE.Clinicalpharmacokineticsoflamivudine.ClinPharmacokinet1999;36(1):41-66. ZeffixProductMonograph.GlaxoWellcome.Aftersingleandrepeateddoses,lamivudinedisplayedlinear,consistentpharmacokineticsTheAUCandCmaxwerelinearwithincreasingdosesupto600mg.Clearanceinthepresenceoffood,renalclearance,andtimeafterdosetoreachpeakserumconcentrations(Tmax)wereindependentofthedose.Thepha