醫(yī)學(xué)課件：肝臟外科-(英文版)

1、 Surgical Diseases of the Liver Surgical Diseases of the LOutlines of todays contents Surgical diseases of the liver 1. Classification 2. Surgical anatomy 3. Liver abscess bacterial abscess 4. Tumor of the liver HCCOutlines of todays contents1.ClassificationtraumaticInfectious：Bacterial AbscessTumor

2、ous: Hepatocellular Carcinomamalformedothers： Intrahepatic calculous parasitic1.Classificationtraumatic 2. Surgical Anatomy of the liver 2. Surgical Anatomy of the Liver lies in the right upper quadrant of abdomen. The largest gland, weighs 1500g in adult.Falciform ligament Coronary ligamentTriangul

3、ar ligamentGallbladderLigamentum teres hepaticusDiaphragmLiver lies in the right upper Three sets of ligamentsFalciform ligamentAnterior and posterior right and left coronary ligaments, fused to form right and left triangular ligaments at the both endings3. Gastrohepatic and hepatoduodenal ligaments

4、Four lobes1. Right lobe2. Left lobe3. Quadrate lobe4. Caudate lobeThree sets of ligaments French segmental systemCouinaud nomenclature system 8 segments: hepatic venous drainage and portal vein system distribution 4 in the right (segments 5-8) 3 in the left (segments 2-4) 1 caudate (segment 1) Frenc

5、h segmental system醫(yī)學(xué)課件：肝臟外科-(英文版)第一肝門(The first porta hepatis)肝動(dòng)脈（Hepatic artery）門靜脈（Portal vein）肝總管（Common hepatic bile duct）第一肝門(The first porta hepatis)醫(yī)學(xué)課件：肝臟外科-(英文版)第二肝門 The second porta hepatis第二肝門 The second porta hepatis第二肝門(The Second Porta Hepatis)第二肝門(The Second Porta Hepatis)第三肝門 The thi

6、rd porta hepatisShort hepatic veinsOpenings of short hepatic veins entering inferior vena cava第三肝門 The third porta hepatisS第三肝門 (the third porta hepatis ) 第三肝門 (the third porta hepatis醫(yī)學(xué)課件：肝臟外科-(英文版)Liver FunctionsBile formation： 6001000ml/day/adultMetabolism of carbohydrate, lipid, protein and vita

7、min: glycogen; fat-soluble vitamin A,D,E,K Coagulation:fibrinogen;coagulation factors; ProthrombinMetabolism of Drugs and Toxins: oxidation, reduction and hydrolysisImmunologic FunctionRegulation of the systemic circulationLiver FunctionsBile formation：Liver Blood flow70% to 75% of total hepatic blo

8、od flow comes from the portal vein, while the remainder comes from the hepatic artery.However, 40%60% oxygen supply comes from hepatic artery Liver Blood flow3. Liver AbscessLiver abscess may be bacterial, parasitic, or fungal in origin.Bacterial abscess the most commonAmebic abscess next to the mos

9、t common3. Liver AbscessLiver abs Bacterial liver abscess Bacterial liEtiology : Biliary tract Hepatic artery Portal vein Lymphatic system injury醫(yī)學(xué)課件：肝臟外科-(英文版)Biliary Infections Abdominal infections Generalized sepsisempyema of the gallbladder appendicitis pneumonitisprotracted cholangitis divertic

10、ulitis endocarditis biliary tractportal veinhepatic arteryLiver AbscessBiliary Infections Clinical features Chill , hyperthermia :3940 oC Hepatalgia: persistent pain Hepatomegaly WBC B-type ultrasound:2cm,96% CT scan: positive rate 90% X-ray: elevated hemidiaphragm, blunt costophrenic angle, intrahe

11、patic air-fluid level Clinical featuresDiagnosis and Treatment Correct diagnosis of pyogenic versus amebic abscess is very important, because the treatments are radically different.Diagnosis and TreatmentDifferential diagnosis between bacterial abscess and amebic abscess History : abdominal infectio

12、ns; diarrhea Abscess:multiple ; single Symptom: fever and chill; fever without chill Blood test and culture:serologic test positive ; negative Stool test Pus Diagnostic therapy: antibiotic, amebicideDifferential diagnosis between Therapy for bacterial liver abscess Supportive treatment Antibiotics P

13、ercutaneous catheterization and drainage Open drainage Transabdominal drainage Extra-peritoneal drainage Therapy for bacterial liveAmebic abscessNon-operativeExcept: rupture and secondary infectionAmebic abscesspercutaneous drainagepercutaneous drainage4. Tumor of the liver4. Tumor of the liverClass

14、ificationBenign tumorsMalignant tumorsClassificationBenign tumorsBenign TumorsCavernous HemangiomaAdenomaFocal nodular hyperplasiaLipomaTeratomaLeiomyoma Benign TumorsCavernous HemanMalignant TumorsPrimary liver cancerSecondary (metastatic) liver cancerMalignant TumorsPrimary Liver cancer (PLC)Hepat

15、ocellular carcinoma (HCC, 9095% 0f PLC)CholangiocarcinomaHepatocellular- cholangiocellular carcinoma (combined type) Cellular types:Primary Liver cancer (PLC)HepHepatocellular Carcinoma (HCC ) Hepatocellular Carcinoma Prevalence of HCCAge-Standardized Liver Cancer Incidence Rates Among Males Jemal A

16、, et al. CA Cancer J Clin 2002 fifth most common cancer in men and eighth in women third leading cause of cancer death in men and the sixth among women China accounts for over 55% of the totalPrevalence of HCCAge-Standardi hepatitis virus B or C cirrhosis aflatoxin Etiology EtiologyHepatitis B Virus

17、70%80% of HCC patients, HBV carrier in Asia and Africa21% of HCC patients, HBV infection in USAHepatitis B Virus70%80% of HCHepatitis CHCV infection presents in 51% of the patients with HCC in Japan. 26% with HBV infection in the same countryHepatitis CHCV infection preseCoexistence of Cirrhosis and

18、 HCC68%74% UK70% Japan80%86.5% ChinaCoexistence of Cirrhosis and H Clinical features1. Hepatalgia:upper abdominal pain, tenderness2. General and digestive: weakness,anorexia,malaise, weight loss3. Hepatomegaly: abdominal mass(14%),4. Jaundice(24%) Clinical feature DiagnosisSpecific marker:AFP(-fetal

19、 protein) elevation, or =400ug/LRadioimmunoassay: positivity 6993%30% negativeMild elevation : acute hepatitis,chronic liver diseaseMarkedly increase: teratocarcinoma,yolk sac tumor, rarely metastastic tumor from pancreas or stomach Diagnosis B-type ultrasound: 2cm; 84%CT scan (computed tomography):

20、 1 cm; 90%Hypoechoic lesion HypoechoicMRI (magnetic resonance imaging), sensitivity 95%Radioisotope scanning: 99mTc red hepatic single-photon emission computed tomography, SPECT 3cm; 8590%X-rayNeedle biopsy: guided by ultrasoundLaparoscopy: over 70% of liver surface direct assessment of abdominal sp

21、read醫(yī)學(xué)課件：肝臟外科-(英文版)Treatment of HCCTreatment of HCC treatment options for HCC1. Hepatic resection the most effective 2. Chemoembolization3. Chemotherapy4. Cryosurgery5. Radiofrequency Ablation6. Radiation Therapy7. Percutaneous Ethanol Injection8. Liver Transplantation Hepatic ResectionAt present, r

22、esection is the only therapy that substantially prolongs survival .Resection has often resulted in cure , particularly in the absence of cirrhosis. Hepatic ResectionAt present, *Selection of suitable patients who could tolerate a hepatic resection.The patients are required to meet the following crit

23、eria:Serum albumin 3.5gm/dlProthrombin time 3 secondsAST normalSerum total bilirubin normalICG retention(at 15 min.) 15%Without ascitesNontumorous liver parenchyma 50%*Selection of suitable patienCase 1Case 1Hepatic resectionHepatic resection Transarterial chemoembolization,TACEEmbolization is the p

24、rocess of injecting a foreign substance (iodized oil) into the tumor to stop the blood flow. The lack of blood deprives the tumor of needed oxygen and nutrients and eventually causes cells to die. Embolization iCase 2Case 2 Regional chemotherapy Systemic chemotherapy response rate less than 25% Chemotherapy Regional chemotherapyCRegional drug deliver