Download - vie biliari in oncologia
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La patologia ostruttiva biliare oncologica
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K colecisti
K papilla di Vater
K cefalopancreatico
Tumore di Klatskin
K coledoco
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CHI SONO GLI SPECIALISTI COINVOLTI ?
CHIRURGO
RADIOLOGO INTERVENTISTA
ENDOSCOPISTA
GASTROENTEROLOGO
RADIOLOGO
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Segmentazione epatica
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DORSAL SECTOR OF THE LIVER
7
8 4
9
9
1
I
II
IIIIV
V
VI
VII
VIII
IX SEGMENT IX
- C. Couinaud, Chirurgie 1998 -
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Anatomia normale in AP e LL
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19% 11%
1,6 % 0,6 %
5,8 %
62%
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Colangio TC
meglumine iotroxateBiliscopin
100 mL, 50 mg I/mL in 500 mL fis.
SE: 88%SP: 94%
SE: 88-95%SP: 89-96%
Colangio-RM / ERCP
Hashimoto M et al., Radiographics 2008Persson A et al, BJR 2005
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COLANGIO RM
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VOLUMETRIA LOBO SINISTROLOBO SINISTRO PRE-EMBOLIZZAZIONE
Embolizzazione portale pre chirurgia
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EMBOLIZZAZIONE SEGMENTI S5, S6, S7, S8
con GLUBRAN-2
Rami anteromediali
Rami posterolaterali
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VOLUMETRIA LOBO SINISTROLOBO SINISTRO POST-EMBOLIZZAZIONE
AUMENTO VOLUMELOBO SINISTRO:
24,5 %
DOPO1 MESE
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Intraepatico (6%)
Periilare (67%)
(27%)
Procedura percutanea
Procedura endoscopica
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Colangiocarcinoma dell’ilo epatico o tumore di Klatskin
Tipo I: >2 cm dalla confluenza dei dotti epatici
Tipo II: < 2 cm dalla confluenza dei dotti epatici
Tipo III: a livello della confluenza dei dotti epatici
Tipo IV: interessamento della porzione prossimale di entrambi i dotti epatici
Classificazione di Bismuth e Corlette
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INDICI DI NON RESECABILITA’
Infiltrazione del tronco principale della vena porta (o sue branche) o dell’arteria epatica (o sue branche)
Diffusione bilaterale ai dotti di II ordine
Presenza di lesioni neoplastiche multifocali bilaterali
Presenza di metastasi a distanza
Associazione di infiltrazione dei vasi di un emifegato con interessamento delle VB di II ordine dell’emifegato opposto
Colangiocarcinoma dell’ilo epatico o tumore di Klatskin
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Tecnica percutanea
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Accesso dx
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Accesso dx con doppio ago
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Accesso sn ecoguidato
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Accesso sn ecoguidato
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L’introduttore
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drenaggio biliareinterno-esterno
drenaggio biliareesterno
Tecnica percutanea
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Il drenaggio biliare
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PTCDRENAGGIO BILIARE
ESTERNO
BILIOPLASTICADRENAGGIO BILIAREINTERNO-ESTERNO
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DRENAGGIO BILIARE
BRIDGE PER INTERVENTO CHIRURGICO ?
TRATTAMENTO PALLIATIVO CON ENDOPROTESI METALLICA
Tramite per BIOPSIA
TRATTAMENTO PALLIATIVO CON ENDOPROTESI PLASTICA
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DRENAGGIO BILIARE
BRIDGE PER INTERVENTO CHIRURGICO ?
TRATTAMENTO PALLIATIVO CON ENDOPROTESI PLASTICA
TRATTAMENTO PALLIATIVO CON ENDOPROTESI METALLICA
Tramite per BIOPSIA
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DRENAGGIO BILIARE
BRIDGE PER INTERVENTO CHIRURGICO ?
TRATTAMENTO PALLIATIVO CON ENDOPROTESI PLASTICA
TRATTAMENTO PALLIATIVO CON ENDOPROTESI METALLICA
Tramite per BIOPSIA
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DRENAGGIO BILIARE
BRIDGE PER INTERVENTO CHIRURGICO ?
TRATTAMENTO PALLIATIVO CON ENDOPROTESI METALLICA
Tramite per BIOPSIA
TRATTAMENTO PALLIATIVO CON ENDOPROTESI PLASTICA
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Trattamento palliativo conendoprotesi plastica
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DRENAGGIO BILIARE
BRIDGE PER INTERVENTO CHIRURGICO ?
TRATTAMENTO PALLIATIVO CON ENDOPROTESI PLASTICA
TRATTAMENTO PALLIATIVO CON ENDOPROTESI METALLICA
Tramite per BIOPSIA
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Trattamento palliativo con endoprotesi metallica
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Trattamento palliativo con endoprotesi metallica ricoperta
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Trattamento palliativo con endoprotesi metallica ricoperta
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Trattamento in combinata
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Trattamento in combinata
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Trattamento in combinata
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Trattamento in combinata
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Trattamento in combinata
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Trattamento in combinata
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Trattamento in combinata
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Trattamento in combinata
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Complicanze
Fistola bilio-cutanea Fistola bilio-venosa
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Complicanze
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FLOWCHART DIAGNOSTICO-TERAPEUTICA DELL’ITTERO OSTRUTTIVO ONCOLOGICO
ITTERO OSTRUTTIVO
INDAGINI CLINICO –STRUMENTALI(ES. LABORAT.- ECOGRAFIA – ANGIO TC – COLANGIO RM)
ECO ENDOSCOPIA – BIOPSIA ENDOSCOPICA
E’ OPERABILE?
NOSI
CHIRURGIA DOVE È LOCALIZZATA LA LESIONE?
VB “BASSE”
ERCP
VB “ALTE”
PTC-PTBD
EMB. VP
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GRAZIE PER L’ATTENZIONE