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Curs 10 Patologia chirurgicala a cailor biliare II

Tumori veziculareTumori benigne (rare): - polipi - adenoame ( elemente papilare) - Hplaz. adenomatoas (adenomiomatoz) - fibroame - lipoame - leiomioameTumori maligne (carcinoame)

Tumori veziculare benigneSimptom: proprie rar i nespecific (litiaz?)Diagn: VBRx (lacun), eco (ecogenit fix fr umbr) Evol: de regul lent, dar 20% din adenoame cancereTratam: VBect indicat n: - polipi >1cm(inciden cancer >) - polipi cu litiaz - polipi clar simptomatici Polipii 0,5cm sunt monitorizai eco la 3 luni Tumori veziculare maligne4% din cancere, loc 5/cancere digestive: - 85% au litiaz VB - maxim ntre 50-70 ani - sex ratio f:b = 4:1Morfopat: adenok-90%(schir-65%,papilifer, mucipar), k epidermoid, k anaplazic, sarcom

Clinic: 5% diagn preoper, simpt de mprumut: - durere epigastru-hipoc dr - greuri/vrsturi - icter - mas palpabil n hipoc dr

Tumori veziculare maligne - diagnParaclinic: modif bio nespecificterCA 19-9

Stadiu TNM: T 1a muc, 1b musc T 2-tot peretele, 32cm de perete, 4 >... N 1-gg cistic, periCBP, hil hepatic N 2-gg peripc, dd, celiaci, mezent sup M 1-metastazeProgn: suprav la 5 ani 5-15%

Tumori veziculare maligne TratamentChir: 95% diagnostic cu ocazia VBect VBect + rez pat hep + gg pediculari paliativ pt icter (derivaii, stent CBP)Adjuvant: - RxRp (uneori Rxsens, poate remite icterul) - ChRp (10% ameliorri tempor) Icterul mecanic= sdr.manif.prin color.galben a tegum., muc.i umorilor det.de BR>2.5mg dat. obstruciei biliare, beneficiind de Rp chir.

Clasificare ictere: - prehepatice (hemolitice) - hepatice (hepato-celulare) - posthepatice (obstructive=mecanice=chirurgicale)Clasificare ontogenetic: - congenitale (Hb-patii, def.enzim, malformaii CB) - dobndite (alte hemolize, hepatite, obstr.nonmalf.)

Etiologia icterului mecanicCauze congenitale: - agenezia/atrezia cilor biliare - malformaii ectaziante intra/extrahepatice - colestaza benign recurent

Cauze dobndite: - mecanice (trauma, litiaz, parazii, compresii extrins) - inflamatorii (stenoze, colangite, ulcer, pancreatite, gg) - tumorale (papiloame, cancere hep/CBP/pancr/dd) - iatrogene (stenoze/ligaturi CBP, corpi strini, oddite)Patogenia icterului mecanicPoziia obstacolului n raport cu peretele CB: - endoluminal - parietal - extrinsec

Poziia anatomic a obstacolului: - intrahepatic - hilar - pedicular (hepatic comun, coledoc Sdd/retroddpc) - oddian

Diagnosticul icterului mecanic

Clinic: debut, evoluie, asocieri (prurit, febr)Sindr: icter, Hcolal, dispep, neo,alerg, -vitam.AKBio: BR, UBG, FA, enz, HLG, mark T&imunoRx: hipoc.dr, tranzitBa, colangioR...Alte imag: eco(Doppler, 3D/4D, elasto), CT, RMN (ficat, colangio) , scint (hep99mTc, cole131I)Endo: EDS, CPRE, CBPscopieTestRp Kohler (TP=N/adm p/ent K n icter obstr)Dg IO: viz/palp/instr, puncii, bio, Rx, eco

Diagnostic diferenial icter mecanic

Alte ictere: - hemol (Hb, sc+urin HCr, BRi+UBG >, hepatic N) - hepatocelulare(hep>,sc N+urin HCr, pb hep, Kohler-)

icter - color galben tegum (caroten, hemocr...) - scaune decolor (steatoree, Ba) - Urin Hcrom (deshidr, Hb/Mburie, melanurie, ocronoz, hematurie nalt, ingestie AF, SSz, Rf, Nf) Icter mecanic: ComplicaiiAle afect cauzale - peritonite/fistule biliare, ileus - abcese hep, pancreatite - fenom alergice, metaInflecioase - angiocolita - colecistita acutToxice - ciroza biliar sec - intox SNC (icter nuclear)Disfuncionale - steatoree - sngerri prelg - dureri osoase - prurit

Icter mecanic: AtitudineObiective chir: - decomprimare biliar (suprimare/ocolire obst, evac ext) - reintroducerea bilei n circuitul digestiv (implicit/supr obst)

Pregtire: perf, vitam (A,D,E, K), AB, Rp asoc, diet

Supr obst: CBP-litotomie, sf-tomie, rez segm; Forare obst (mpingere calcul, foraj transT/stent, dilat-tutorizare stenoz)

Derivaii bil: ext, biliodig (VB/CBP/CBIHG/D/JsauJY)

&: - VBect - cura KHH (parazit+Lagrot/KHdigestA/hepatect regl) - rezecii G de excludere, deriv G i pancreatice...Laparotomie exploratorie

Litiaza CBP

Etiopat: c.veziculari (c.sec.=colest) naturaliz, c.primitivi CBP (pigmentariCa), c.din CBIH 10-20% din cei VBect pt lit.VB au i lit.CBP

HP: rar unici (=prim.), frecv.multipli mpietruire, oval/faet.sunt pasabili (3-5mm) sau nu (>5mm), se bloch. n pct.critic Baraya sau n papil (5%)

Clinic: icter (33-70%), durere (>80%) febr

Ff.clin: clasic, intrapapilar, VBit ac.sec, cu pancreatit, cu angiocolit, dureroas pur, febril pseudopaludic, dispeptic, caectizant, ...mut

Litiaza CBP: diagnostic

Bio: L, VSH, fbgen, colestaza (mai ales FA)

Rx: cc. Rxopaci, colangioTPH

Imag: eco, CT, RMN(colangio), colescint Tc99m

Endo: papila, CPRE, CBPscopie

IO: palpare pedicul, colangioIO, eco, instrum/CBP, CBPscopieCnd?: - lit.VBveche, c., s.Courvoisier-Terrier

Paraclinic: colestaz; eco, CT, colangioRMN, colangioRx TPH, CPRE, coledoscopie retrograd

Dg stadial (TNM): T1 (perete: 1a=muc,1b=musc), T2 (adv), T3 (organe v.) No (fr adenopatie), N1 (adenopatie regional) Mo (fr meta), M1 (cu meta) Stadiu I T1N0, II T2N0, III T1-2N1, IVa T3NM0, IVb TNM1

Tumori CBP: tratament

Medical &: AB, analg, reechilibr.(H+E+M), vit.K

Decompr.bil.min.inv (percutan, retrograd transT)

Chirurgical:Paliativ (anastomoze bilio-digestive, drenaj biliar extern)

Radical prox: rezecie hilar+HJ(Y)A n placa hilar

Radical mediu: rezecie CBP+HCA/HJ(Y)A

Radical distal: CBP-duodenopancreatect.cefalic+...A

Prognostic: suprav.medie e de 2-8luni/paliativ, 2 ani/radical; la 5 ani suprav.