胆道疾病双语课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,第四十四章 胆道疾病,Diseases of the,Biliary Tract,胆道疾病,(P559),.,1,Diseases of the Biliary Tract,ANATOMY,Intrahepatic Biliary Tract,Extrahepatic Biliary Tract,The gallbladder,Oddis sphincter,.,2,ANATOMYIntrahepatic Biliary Tr,ANATOMY,Intrahepatic Biliary Tract,毛细,胆管,小叶间胆管,肝段,胆管,肝叶,胆管,左右,肝管,三级 二级 一级,.,3,ANATOMYIntrahepatic Biliary T,Anatomy of the Biliary System,and its Relationship to Surrounding Structures,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：,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,胆管、门静脉和肝动脉的关系,.,4,Anatomy of the Biliary System,Anatomy of the Biliary System,and its Relationship to Surrounding Structures,胆囊,（,The gallbladder,）分底、体、颈三部（,fundus, body, and neck,）。,胆囊管,（,The cystic duct,）,Sheath of Glisson,Pouch of Hartmann,Valves of Heister,Triangle of Calot,Papilla of Vater,Sphincter of Oddi,.,5,Anatomy of the Biliary System,ANATOMY,Artery,术中注意：胆囊,A,、胆管,A,走行与分布,Vein,Lymph,肿瘤转移,Nerve,胆心反射,.,6,ANATOMYArtery术中注意：胆囊A、胆管A走行与分,Biliary Physiology,胆汁的分泌、成分和功能,：分泌：肝细胞、胆管细胞,量,?,成分：,97%,为水，胆汁酸、胆盐、胆固醇、卵磷脂,(phospholipid),功能：,?,800-1200ml/,日,乳化脂肪、抑制细菌、刺激肠蠕动、中和胃酸。,.,7,Biliary Physiology胆汁的分泌、成分和功能：,Biliary Physiology,Regulation of bile secretion,促胰液素、,CCK,：胃酸、脂肪、蛋白质的刺激。,Metabolism of bile,：,胆固醇的溶解：,胆盐、磷酯酰胆碱,微胶粒,(micelles),胆固醇磷脂泡：磷酯,+,胆固醇,胆盐池的稳定：,肠肝循环,.,8,Biliary PhysiologyRegulation o,肠肝循环,.,9,肠肝循环.9,Admirand and Small Triangle,.,10,Admirand and Small Triangle.10,Biliary Physiology,Metabolism of bilirubin,胆红素的溶解：,胆红素,+,葡萄糖醛酸,结合胆红素,肝脏代谢异常胆道细菌感染,.,11,Biliary PhysiologyMetabolism o,.,12,.12,Biliary Physiology,Physiological function of bile duct-,regulation of bile discharge,1.18kPa,0.98kPa,3.83kPa,0.79kPa,1.18kPa,.,13,Biliary PhysiologyPhysiologica,Biliary Physiology,Physiological function of gall bladder,Concentration and storage of bile,Discharge bile,Secretion,.,14,Biliary PhysiologyPhysiologica,解剖生理概要重点内容,胆管、门静脉和肝动脉的关系,胆总管,:,直径：,0.6-0.8cm,，,1cm,病理,Triangle of Calot,胆汁的功能：,胆固醇、胆红素的溶解,.,15,解剖生理概要重点内容胆管、门静脉和肝动脉的关系.15,Diagnostic Approaches,US,：,B-type Ultrasonography,首选,Diagnosis of gallstone,：强回声光团,+,声影,Differentiation of joundic,：,胆管扩张,Detection of gallbladder function,Other biliary illness,Intraoperative US,：干扰小,.,16,Diagnostic ApproachesUS：B-type,胆石超声图像,.,17,胆石超声图像.17,.,18,.18,Diagnostic Approaches,Conventional Radiology,KUB film,：,钙化结石,15%,，瓷化胆囊，胆道积气,Oral cholecystography,：,功能测定、充盈缺损,Veinal cholangiography,：,胆管显影,.,19,Diagnostic ApproachesConventio,Diagnostic Approaches,Special Radiology,PTC,：,黄疸鉴别、,PTCD,ERCP,：,乳头部病变、定性诊断、造影,CT,、,MRI,（,MRCP,）,Intra- or postoprative cholangiography,.,20,Diagnostic ApproachesSpecial R,PTC,影像,.,21,PTC影像.21,.,22,.22,.,23,.23,.,24,.24,.,25,.25,.,26,.26,.,27,.27,.,28,.28,Diagnostic Approaches,Endoscopic,Examinations,胆道镜检查术中、术后,诊断、治疗,十二指肠引流,.,29,Diagnostic ApproachesEndoscopi,.,30,.30,.,31,.31,本节重点内容,胆道疾病的首选检查方法,BUS,、,CT,、,PTC,、,PTCD,、,ERCP,、,MRI,、,MRCP,.,32,本节重点内容胆道疾病的首选检查方法.32,Liu Bin,Surgeon in Chief and Vice-Chairman,Division of General Surgery,胆石病,Cholelithiasis,.,33,Liu Bin胆石病 Cholelithiasis.33,胆石病,Cholelithiasis,常见病、多发病,结石分类,胆固醇结石,(Cholesterol Gallstones),：,80%,位于胆囊,胆色素结石,(Pigment Gallstones),：主要发生于胆管,混合性结石,：胆囊,60%,、胆管,40%,.,34,胆石病 Cholelithiasis常见病、多发病.34,胆石分类,.,35,胆石分类.35,.,36,.36,.,37,.37,.,38,.38,胆囊结石,C,holecystolithiasis,、,Gall stone,结石性质,发病年龄、性别,(4F: Forty, Female, Fatty, Fertility),发病机制：,胆汁胆固醇过饱和,促成核因子：均相成核、异相成核,胆囊功能,.,39,胆囊结石Cholecystolithiasis、Gall,胆囊结石,C,holecystolithiasis,、,Gall stone,Clinical presentations,：,静止性结石,（,silent stone , asymptomatic ),有症状性结石,胃肠道症状,胆绞痛,Mirrizi syndrome,胆囊积液,其他：继发性胆管结石、胰腺炎、胆石性肠梗阻、癌变。,.,40,胆囊结石Cholecystolithiasis、Gall,胆囊结石,Cholecystolithiasis,、,Gall stone,Diagnosis,病史体征,影像学确诊,:,首选,BUS,诊断率,96%,以上强回声光团,+,声影,+,移动性,.,CT,、,MRI,、胆囊造影,.,41,胆囊结石Cholecystolithiasis、Gall,.,42,.42,胆囊结石,Cholecystolithiasis,、,Gall stone,Treatment,首选胆囊切除,指征：有症状、有并发症,无症状者，可观察，其手术指征为：,胆囊无功能、结石较大、老年人心肺功能不良、合并糖尿病,.,43,胆囊结石Cholecystolithiasis、Gall,胆囊结石,Cholecystolithiasis,、,Gall stone,Treatment,手术方法,开腹手术,(Open Cholecystectomy),腹腔镜手术,(Laparoscopic cholecystectomy),胆管探查指征,术前术中发现胆管结石或其他病变,有黄疸或胆管炎、胰腺炎表现,胆管扩张,1.0cm,非手术治疗：碎石、溶石、排石。,.,44,胆囊结石Cholecystolithiasis、Gall,胆囊切除术,.,45,胆囊切除术.45,.,46,.46,Laparoscopic Cholecystectomy,.,47,Laparoscopic Cholecystectomy.4,Laparoscopic Cholecystectomy,.,48,Laparoscopic Cholecystectomy.4,.,49,.49,.,50,.50,.,51,.51,胆管结石,Choledocholithiasis,原发性：胆色素或混合性结石,继发性：胆固醇结石,肝外胆管结石：,CBD,远端,肝内胆管结石：左外叶、右后叶多见,.,52,胆管结石Choledocholithiasis 原发性：,肝外胆管结石,Pathology,：,梗阻,+,感染,胆管梗阻：不全性、完全性近端扩张、壁增厚、胆汁淤滞,继发感染：组织充血、水肿、化脓、糜烂、溃破，脓毒症,肝细胞坏死、胆源性肝脓肿、胆汁性肝硬化,胆源性胰腺炎,.,53,肝外胆管结石Pathology：梗阻+感染.53,肝外胆管结石,Clinical presentations,Charcot,三联症,（,Clinical triad of Charcot,）,腹痛：,部位、性质,寒战高热：,黄疸：,间歇性、波动性影响因素：梗阻程度、感染、有无胆囊,体征：胆囊肿大、腹膜刺激征,.,54,肝外胆管结石Clinical presentations.5,肝外胆管结石,Lab examinations,：,WBC,、,Bilirubin,、,SGPT,、,AKP,Radiology Findings,：,BUS,首选,CT,、,MRI,PTC,ERCP,.,55,肝外胆管结石Lab examinations：.55,.,56,.56,.,57,.57,肝外胆管结石,Diagnosis,Charcot,三联症,+,影像学检查,Differentiation,壶腹癌和胰头癌,肾绞痛,肠绞痛,.,58,肝外胆管结石Diagnosis.58,肝外胆管结石,Management,手术治疗为主,手术原则,取尽结石,解除梗阻,去除病灶,通畅引流,.,59,肝外胆管结石Management .59,肝外胆管结石,-,手术方法,CBD,切开取石,+T,管引流术,适应症：胆管无狭窄,术中检查：造影、,BUS,、胆道镜,术后注意事项,妥善固定,引流通畅,拔管指征,：时间、临床症状、引流情况、造影、夹管试验,.,60,肝外胆管结石-手术方法CBD切开取石+T管引流术.60,T,型管、,Y,型管,.,61,T 型管、Y型管.61,肝外胆管结石,-,手术方法,胆肠吻合术,适应症：,CBD,扩张、远端狭窄、泥沙样结石不易取尽,Roux-en-Y,吻合术（,+,抗返流措施）,CBD,十二指肠吻合术,.,62,肝外胆管结石-手术方法胆肠吻合术.62,肝外胆管结石,-,手术方法,Oddi,括约肌成型术,：,CBD,扩张轻,经内镜下括约肌切开取石术：,.,63,肝外胆管结石-手术方法Oddi 括约肌成型术：CBD扩张轻,肝内胆管结石,Hepatolithiasis,Etiology,感染、胆汁淤滞、胆道蛔虫,Pathology,部位：左叶、右后叶多见,肝内胆管狭窄、狭窄近端扩张,胆管炎：慢性增生、肉芽肿、化脓性,肝胆管癌,.,64,肝内胆管结石Hepatolithiasis Etiolog,.,65,.65,.,66,.66,肝内胆管结石,Hepatolithiasis,Clinical presentations,合并肝外胆管结石表现,无症状或肝区不适,AOSC,、黄疸不显,胆源性肝脓肿,胆管支气管瘘,胆汁性肝硬化、胆管癌,.,67,肝内胆管结石HepatolithiasisClinical,肝内胆管结石,Hepatolithiasis,Diagnosis,BUS,CT,PTC,特征,狭窄、扩张、结石影,部分胆管不显影,.,68,肝内胆管结石HepatolithiasisDiagnosi,.,69,.69,.,70,.70,.,71,.71,肝内胆管结石,Hepatolithiasis,Management,：,手术为主,原则：,取尽结石、解除梗阻、去除病灶、通畅引流,高位胆管切开及取石术,胆肠内引流术,肝叶切除术,中西结合治疗,残石的处理：胆道镜、激光、微爆破、溶石,.,72,肝内胆管结石 HepatolithiasisManagem,本节重点内容,胆石分类及部位,胆囊结石的临床表现、典型表现,胆囊结石手术指征及胆总管探查指征,肝外胆管结石的典型表现：,Charcot,三联症,肝内外胆管结石的手术原则及方法、适应症,T,型管的观察及拔除指征。,.,73,本节重点内容胆石分类及部位.73,胆道感染,Infection of biliary tract,Liu Bin,Division of HPB Surgery,.,74,胆道感染Infection of biliary trac,胆道感染,Infection of biliary tract,胆囊炎,Cholecystitis,、胆管炎,Cholangitis,急性、亚急性、慢性，常与胆石合并存在、互为因果,急性胆囊炎,Cholecystitis,Acute calculous cholecystitis 95%,Acute acalculous cholecystitis 5%,.,75,胆道感染Infection of biliary trac,Acute Calculous Cholecystitis,Etiology,胆囊管,梗阻,、结石损伤、胆盐刺激,细菌,感染,：,G,-,、厌氧菌,Pathology,急性单纯性胆囊炎,急性化脓性胆囊炎,坏疽性胆囊炎,胆囊穿孔,并发胆管炎、胰腺炎、消化道内瘘、胆石性肠梗阻,.,76,Acute Calculous Cholecystitis,Acute Calculous Cholecystitis,Clinical presentations,女性多见,典型表现,：,疼痛：突发性、诱因、阵发性,-,持续性、放射性痛、夜间痛,寒战高热,（黄疸）,体征：腹膜刺激征、,Murphy sign(+),、肿大的胆囊,.,77,Acute Calculous CholecystitisC,Acute Calculous Cholecystitis,Laboratory examination,WBC,、,SGPT,、,AKP,、,Bilirubin,、,amylase,Radiological examination,BUS:,胆囊增大、壁增厚（双边、夹层）胆囊内结石光团,CT,、,MRI,.,78,Acute Calculous CholecystitisL,.,79,.79,Acute Calculous Cholecystitis,Diagnosis and differentiation,胃十二指肠穿孔,急性胰腺炎,高位阑尾炎,肝脓肿,结肠肝曲癌,右侧肺炎、胸膜炎,.,80,Acute Calculous CholecystitisD,Acute Calculous Cholecystitis,Treatment,非手术治疗,禁食,输液、纠正水、电解质及酸碱平衡,抗生素：广谱、联合,解痉止痛：,并存病处理、术前准备,.,81,Acute Calculous CholecystitisT,Acute Calculous Cholecystitis,Operative treatment,时机：,发病,72,小时内,非手术治疗无效且病情恶化,有并发症：胆囊穿孔、弥漫性腹膜炎、化脓性胆管炎、急性坏死性胰腺炎,手术方法,：,胆囊切除、胆囊造口,手术指征：局部、全身情况、术者技术,.,82,Acute Calculous CholecystitisO,Acute Acalculus Cholecystitis,Incidence,:,4-8%,Etiology,严重创伤、烧伤、手术后：低血压,危重病人：脓毒症,长时间的,TPN,：,CCK,下降，胆汁淤积,Pathology,同结石性胆囊炎，坏死、穿孔率高,.,83,Acute Acalculus CholecystitisI,Acute Acalculus Cholecystitis,Clinical manifestations,男：女,=1.5,：,1,表现同结石性胆囊炎,易被原发病掩盖，提高认识和警惕,Management,一经诊断、早期手术：切除或造口,难以耐受手术者：经皮穿刺引流,病情较轻者：严密观察下非手术治疗,.,84,Acute Acalculus CholecystitisC,Chronic cholecystitis,Etiology,急性胆囊炎的结果,结石的反复刺激,Pathology,炎性细胞浸润,纤维组织增生,增厚、萎缩、瘢痕,.,85,Chronic cholecystitisEtiology.,Chronic cholecystitis,Clinical presentations,不典型,胆绞痛史,消化道症状,右上腹和肩背部隐痛,Signs:,胆囊区轻压痛,.,86,Chronic cholecystitisClinical,Chronic cholecystitis,Diagnosis,BUS:,胆囊缩小、壁增厚，排空功能减退或消失。胆囊内结石。,口服胆囊造影：显影差、收缩功能降低,Differentiations,胃十二指肠溃疡,胃炎,肝病,.,87,Chronic cholecystitisDiagnosis,Acute Obstructive Suppurative Cholangitis, AOSC,Acute Cholangitis of Severe Type,，,ACST,Etiology,最常见原因：胆管结石，,76-88.5%,胆管狭窄，,8.7-11%,胆管、壶腹部肿瘤,原发性硬化性胆管炎,胆肠吻合术后、经,T,管造影、,PTC,术后,.,88,Acute Obstructive Suppurative,Acute Obstructive Suppurative Cholangitis, AOSC,Pathology,基本病理改变,：,胆道梗阻,+,胆管内化脓性感染,胆管,：,内压升高、胆管扩张、管壁增厚、炎性细胞浸润、糜烂、溃疡,肝脏,：,充血肿大、细胞肿胀变性、淤胆、肝细胞坏死、多发性肝脓肿,全身,性化脓性感染、多器官功能损害,胆血反流：胆内压,1.96kPa(20cmH,2,O),.,89,Acute Obstructive Suppurative,Acute Obstructive Suppurative Cholangitis, AOSC,Clinical presentations,Reynolds,五联症,：,Charcot,三联症,+,休克、中枢神经系统受抑制表现,畏寒、发热,：,39-40C,或以上,疼痛,：,依梗阻部位而异,黄疸,：,肝内胆管一侧梗阻可不出现,神经系统症状,：,淡漠、嗜睡、神智不清、昏迷,休克,：,.,90,Acute Obstructive Suppurative,Acute Obstructive Suppurative Cholangitis, AOSC,Clinical presentations,T39-40 C,、,P120,次,/,分、,BP,下降,腹膜刺激征、肝肿大、压痛,WBC2010,9,/L,、,PL,降低、,PT,延长、肝肾功能损害、体液失衡,BUS,：梗阻部位、性质,CT,、,MRI,（,MRCP,）,.,91,Acute Obstructive Suppurative,Acute Obstructive Suppurative Cholangitis, AOSC,Treatment,原则：,紧急手术解除胆道梗阻并引流、及早而有效地降低胆管内压力,非手术治疗,：,治疗手段（观察,6h),及术前准备,抗生素：足量、有效、广谱,纠正水、电解质紊乱,纠正休克、低氧血症,对症治疗,.,92,Acute Obstructive Suppurative,Acute Obstructive Suppurative Cholangitis, AOSC,Treatment,手术治疗,：,简单、有效,胆总管切开减压、,T,管引流,肝脓肿处理,单纯胆囊造口不宜采用,非手术方法置减压引流,PTCD,ERCP-ENBD,（,endoscopic nasobiliary drainage),.,93,Acute Obstructive Suppurative,.,94,.94,本节重点内容,急性胆囊炎的诊断及鉴别诊断,急性胆囊炎的手术时机及方法选择,AOSC,的典型表现及治疗原则,.,95,本节重点内容急性胆囊炎的诊断及鉴别诊断.95,Biliary ascariasis,多发于青少年和儿童,农村多见,Etiology and pathology,蛔虫喜碱厌酸，胃肠功能紊乱时上行,钻孔习性,机械刺激,-,胆绞痛、胰腺炎,细菌逆行感染,细菌残骸,-,胆结石,.,96,Biliary ascariasis多发于青少年和儿童.96,Biliary ascariasis,Clinical manifestations,突发性、剑突下、阵发性、钻顶样、剧烈绞痛，右肩部放射痛,可突然缓解、间歇期正常,（胆管炎表现）,体征轻微,BUS,：平行强光带。,ERCP,：,.,97,Biliary ascariasisClinical man,Biliary ascariasis,Diagnosis,特点：症状与体征不相称,+ BUS,.,98,Biliary ascariasisDiagnosis.98,Biliary ascariasis,Treatment,非手术疗法：,解痉止痛,利胆驱蛔：乌梅汤、食醋、,30%,硫酸镁 驱虫剂：驱蛔灵、左旋咪唑 消炎利胆：,抗感染,内镜治疗,.,99,Biliary ascariasisTreatment.99,Biliary ascariasis,Treatment,手术治疗,手术指征,积极治疗,3-5,天无缓解,蛔虫较多或合并结石,进入胆囊,合并严重并发症,手术方式：,CBD,切开取虫,+T,管引流,.,100,Biliary ascariasisTreatment.10,胆道肿瘤,Tumor of biliary tract,胆囊息肉样病变,(polypoid lesions of gallbladder)-,微小隆起性病变,肿瘤性：腺瘤、腺癌，其他少见,非肿瘤性；炎性、胆固醇性、腺肌性增生,诊断：,BUS,手术指征：疑为恶性或有明显临床症状,.,101,胆道肿瘤Tumor of biliary tract胆囊息,胆道肿瘤,Tumor of biliary tract,Differentiation of benign and malignant tumor,良性 恶性,大小 小于,1cm,大于,1cm,增长速度 慢 快,数目 多发 单发,形状 乳头状、蒂细长 不规则、基底宽,BUS,强回声 低回声,.,102,胆道肿瘤Tumor of biliary tract.10,.,103,.103,胆固醇息肉,声像图特征为：,1,，呈球形、桑葚状或乳头状，有蒂或基底较窄；,2,，一般多发，可见于胆囊任何部位；,3,，体积小，通常内径小于,10mm,，,4,，多为强回声表现，不随体位而移动。,.,104,胆固醇息肉声像图特征为：1，呈球形、桑葚状或乳头状，有蒂或基,.,105,.105,.,106,.106,.,107,.107,胆囊腺肌瘤样增生（,adenomyomatous hyperplasia,）,胆囊粘膜上皮及其平滑肌层增生，肌肉间可见多数由柱状细胞构成的大小腺腔，细胞无异型性。,HE100,.,108,胆囊腺肌瘤样增生（adenomyomatous hyperp,Carcinoma of Gallbladder,胆道系统常见的恶性肿瘤，占肝外胆道癌的,25%,，胆囊切除的,1%,左右,女性多见，男：女,=1:1.98,发病高峰年龄,60-70,岁,Etiology,70-98%,合并胆囊结石,腺瘤恶变,腺肌性增生、黄色肉芽肿性胆囊炎、瓷化胆囊,.,109,Carcinoma of Gallbladder胆道系统常见,Carcinoma of Gallbladder,Pathology,体、底部多见,80%,为腺癌，其他：未分化癌、鳞状细胞癌、混合性癌,转移途径：,淋巴、静脉、种植、神经、胆管,.,110,Carcinoma of GallbladderPathol,Carcinoma of Gallbladder,Classification,Nevin,分期,I,期： 粘膜内原位癌,II,期： 侵犯粘膜和肌层,III,期： 侵犯胆囊壁全层,IV,期： 侵犯胆囊壁全层并周围淋巴结转移,V,期： 侵犯肝和（或）转移至其他脏器,.,111,Carcinoma of GallbladderClassi,Carcinoma of Gallbladder,Classification of UICC,I,期： 侵犯粘膜或肌层（,T,1,N,0,M,0,）,II,期： 侵犯囊壁全层（,T,2,N,0,M,0,）,III,期： 侵犯肝,2cm,（,T,4,N,0,M,0,，,T,X,N,1,M,0,）,IVB,期：远处淋巴或脏器转移（,T,X,N,2,M,0,，,T,X,N,0,M,1,）,.,112,Carcinoma of GallbladderClassi,Stage,T,N,M,Stage 0,Tis,N0,M0,Stage I,T1,N0,M0,Stage II,T2,N0,M0,Stage III,T1T2T3T3,N1N1N0N1,M0M0M0M0,Stage IVa,T4T4,N0N1,M0M0,Stage IVb,Any TAny T,N2Any N,M0M1,.,113,.113,Carcinoma of Gallbladder,Clinical presentations and classification,早期：非浸润期，未穿透胆囊壁,无特殊症状,中期：早期浸润，侵犯浆膜或胆囊床可发生淋巴结转移,腹痛或放射痛,晚期：晚期浸润，广泛转移,腹痛、黄疸、腹部包块、腹水,.,114,Carcinoma of GallbladderClinic,Carcinoma of Gallbladder,Lab examinations,CEA,、,CA-19-9,、,CA-125,可阳性，无特异性,Radiological examination,BUS,、,CT,：胆囊壁不均匀增厚，腔内不均质肿块，肝转移、淋巴转移征象,.,115,Carcinoma of GallbladderLab ex,胆囊癌（结节型）。,CT,增强扫描示腔内明显强化的肿瘤结节。,胆囊癌（厚壁型）。,CT,增强示胆囊壁广泛不规则增厚。,.,116,胆囊癌（结节型）。CT增强扫描示腔内明显强化的肿瘤结节。胆囊,胆囊癌超声图像,.,117,.,118,.118,.,119,.,120,.120,胆囊癌（肿块型）。,胆囊内不规则肿块，邻近肝脏受累。,.,121,胆囊癌（肿块型）。胆囊内不规则肿块，邻近肝脏受累。.121,Carcinoma of Gallbladder,Treatment,手术为主，方法根据病期,单纯胆囊切除术：,Nevin I,期、,UICC I,期,胆囊癌根治术：,Nevin II,、,III,、,IV,期、,UICC I,期局部肝切除,+,淋巴清扫,扩大根治术：肝切除、胰十二指肠切除门静脉切除重建,姑息性手术：晚期伴有黄疸者,.,122,Carcinoma of GallbladderTreatm,Carcinoma of Gallbladder,Prognosis,生存期：多数,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,）,.,143,ANATOMYExtrahepatic Biliary Tr,