2020肝内胆管结石课件

Accordingtotheassessmentrequirementsofpartyconductandcleangovernment,combinedwiththefiveregulationsandfivenewrequirementsofstate-ownedEnterpriseleaders'integrityandself-discipline肝内胆管结石邓丹东2015.07.02Accordingtotheassessmentrequirementsofpartyconductandcleangovernment,combinedwiththefiveregulationsandfivenewrequirementsofstate-ownedEnterpriseleaders'integrityandself-discipline肝内胆管结石定义定义病因、病理临床表现分型诊断治疗肝内胆管结石又称肝胆管结石，是原发性胆管结石的一部分，指左右肝管汇合部以上结石，可广泛分布肝内胆管系统，也可分布在某一区域的肝叶和肝段胆管内，但以左肝外叶和右肝后叶为多见。这与此处胆管弯曲度大而引流不畅有关。多为胆色素结石。肝内胆管结石常合并肝外胆管结石，其症状也常由肝外胆管结石引起。定义Accordingtotheassessmentrequirementsofpartyconductandcleangovernment,combinedwiththefiveregulationsandfivenewrequirementsofstate-ownedEnterpriseleaders'integrityandself-discipline肝内胆管结石的病因和基本病理改变定义病因、病理临床表现分型诊断治疗•肝胆管结石的形成与以下因素有关•1.胆道慢性炎症、细菌感染、胆道蛔虫•2.胆汁淤滞、营养不良•胆管内慢性炎症是结石形成的重要因素•胆汁淤滞是结石形成的必要条件病因、病理Accordingtotheassessmentrequirementsofpartyconductandcleangovernment,combinedwiththefiveregulationsandfivenewrequirementsofstate-ownedEnterpriseleaders'integrityandself-discipline•肝胆管结石的形成与以下因素有关•1.胆道慢性炎症细菌感染胆道蛔虫•2.胆汁淤滞营养不良•胆管内慢性炎症是结石形成的重要因素•胆汁淤滞是结石形成的必要条件肝内胆管结石的病因和基本病理改变1.结石呈肝内节段性分布肝部分切除术治疗肝胆管结石的理论依据病理特征2.并存肝胆管狭窄结石形成和复发的基本病理因素影响手术治疗效果的重要因素病理特征右肝萎缩左肝增生左肝萎缩右肝增生对正确判断病变部位具有重要指导意义3.肝脏萎缩—增大复合征病理特征Accordingtotheassessmentrequirementsofpartyconductandcleangovernment,combinedwiththefiveregulationsandfivenewrequirementsofstate-ownedEnterpriseleaders'integrityandself-discipline静止型：病人无明显症状或症状轻微，仅有上腹隐痛不适，常在体检时才被发现梗阻型：表现为间歇性黄疸、肝区和胸腹部持续性疼痛不适、消化功能减退等胆道梗阻的症状，双侧肝胆管结石伴有肝胆管狭窄时可呈持续性黄疸胆管炎型：表现为反复发作的急性化脓性胆管炎。急性发作时出现阵发性上腹绞痛或持续胀痛、寒战高热、黄疸肝内胆管结石的临床表现定义病因、病理临床表现分型诊断治疗Accordingtotheassessmentrequirementsofpartyconductandcleangovernment,combinedwiththefiveregulationsandfivenewrequirementsofstate-ownedEnterpriseleaders'integrityandself-discipline•根据结石在肝内的分布、相应肝管及肝脏的病损程度分为三型：•Ⅰ型：即局限型•结石局限于某一肝段或亚肝段,•受累肝脏及胆管病变轻微.•临床表现多属于静止型肝内胆管结石的分型定义病因、病理临床表现分型诊断治疗Accordingtotheassessmentrequirementsofpartyconductandcleangovernment,combinedwiththefiveregulationsandfivenewrequirementsofstate-ownedEnterpriseleaders'integrityandself-discipline•Ⅱ型：即区域型结石沿肝内胆管树呈区域性分布，充满一个或几个肝段，常合并病变区段肝管的狭窄及受累肝段的萎缩。临床表现可为梗阻型或胆管炎型定义病因、病理临床表现分型诊断治疗肝内胆管结石的分型Accordingtotheassessmentrequirementsofpartyconductandcleangovernment,combinedwiththefiveregulationsandfivenewrequirementsofstate-ownedEnterpriseleaders'integrityandself-discipline•Ⅲ型：即弥漫型结石遍布双侧肝叶胆管内定义病因、病理临床表现分型诊断治疗肝内胆管结石的分型Accordingtotheassessmentrequirementsofpartyconductandcleangovernment,combinedwiththefiveregulationsandfivenewrequirementsofstate-ownedEnterpriseleaders'integrityandself-discipline术前应明确结石分布情况,胆管系统病变,肝实质的病变B超是首选检查方法，可作为临床诊断的线索，但不能作为外科手术的依据。在决定行外科手术治疗前需要作其他影像学检查CT可全面显示结石分布、胆管系统扩张、肝脏实质病变，与B超联合应用，一般提供可靠的依据MRI+MRCP可全面显示结石的分布、肝实质的病变、胆管狭窄及扩张，是无创性胆道影像诊断方法，兼具断层扫描及胆道成像的优点定义病因、病理临床表现分型诊断治疗肝内胆管结石的诊断Accordingtotheassessmentrequirementsofpartyconductandcleangovernment,combinedwiththefiveregulationsandfivenewrequirementsofstate-ownedEnterpriseleaders'integrityandself-discipline胆道直接显像（ERCP、PTC及胆道引流管造影），为有创检查，可清晰显示“胆管树”影像，有诱发急性胆管炎的危险当前,肝胆管结石的术前诊断应以B超、CT和/或MRCP为主，ERCP和/或PTC等侵入性直接胆道影像检查已非必须定义病因、病理临床表现分型诊断治疗肝内胆管结石的诊断←ERCPPTC→Accordingtotheassessmentrequirementsofpartyconductandcleangovernment,combinedwiththefiveregulationsandfivenewrequirementsofstate-ownedEnterpriseleaders'integrityandself-discipline肝内胆管结石的治疗定义病因、病理临床表现分型诊断治疗外科治疗原则去除病灶取尽结石矫正狭窄通畅胆流防治复发个体化的治疗方案Accordingtotheassessmentrequirementsofpartyconductandcleangovernment,combinedwiththefiveregulationsandfivenewrequirementsofstate-ownedEnterpriseleaders'integrityandself-discipline肝内胆管结石的手术方法1.肝胆管切开取石术(最基本的方法)2.肝部分切除术3.肝门部胆管狭窄修复重建术4.胆肠吻合术常需多术式联用Ø单纯胆道取石引流手术多用于急症和重症病例，旨在暂时通畅胆流、控制胆道感染、改善肝功能以挽救病人生命或为二期确定性手术做准备Ø只有对受累的肝管及肝脏病变轻微、取尽结石后肝内外无残留病灶、胆管无狭窄的I型病例，单独肝胆管切开取石有可能作为确定性手术方式Ø充分切开肝门部胆管狭窄必要时切开二级肝管可在直视下取除主要肝管的结石，结合胆道镜明视下取石，能有效地清除肝管内结石，显著降低结石残留率肝胆管切开取石术肝胆管切开取石术肝外胆管联合肝胆管切开取石法肝胆管切开取石术肝切除后经肝断面胆管取石法肝部分切除术切除病变肝段以最大限度地清除含有结石、狭窄及扩张胆管的病灶，是治疗肝内胆管结石的最有效手段早期（即肝脏病变轻微时）：多采用以取石为主的疗，术中运用胆道镜技术尽量取尽结石；后期（肝纤维化并萎缩时）：则多以肝切除为重点；终末期（合并重度胆汁性肝硬变、门静脉高压等）：则最好的治疗为肝移植术。Accordingtotheassessmentrequirementsofpartyconductandcleangovernment,combinedwiththefiveregulationsandfivenewrequirementsofstate-ownedEnterpriseleaders'integrityandself-discipline肝内胆管结石的外科治疗Accordingtotheassessmentrequirementsofpartyconductandcleangovernment,combinedwiththefiveregulationsandfivenewrequirementsofstate-ownedEnterpriseleaders'integrityandself-discipline肝内胆管结石的外科治疗Accordingtotheassessmentrequirementsofpartyconductandcleangovernment,combinedwiththefiveregulationsandfivenewrequirementsofstate-ownedEnterpriseleaders'integrityandself-discipline结石位置:左半肝结石，胆总管结石。病变特点:左外叶萎缩，左肝内胆管扩张。手术方式:左半肝切除,胆总管切开取石。肝内胆管结石手术病例问题与思考一、如何重建胆道？结石取净或明确有残留但术中条件无法取净，Oddi括约肌功能良好者可行T管外引流；而肝内结石取净、Oddi括约肌无功能，或肝门区胆管受损无法重建或者局部合并癌变者，应在完整切除病变后行Roux-Y内引流术。Oddi括约肌功能未完全丧失，例如镜下可见微弱而缓慢的收缩，以及肝内结石未取净但前次手术已行内引流者如何处理。二、如何防止术后结石复发？生活环境、饮水条件、有无肠道和胆道蛔虫史以及饮食中脂肪的含量都是相关的影响因素Accordingtotheassessmentrequirementsofpartyconductandcleangovernment,combinedwiththefiveregulationsandfivenewrequirementsofstate-ownedEnterpriseleade