November 16, 2006课件.ppt

November 16, 2006 Joint Medicine-Surgery Conference 精品文档 Learning Objectives Evaluation and management of the patient with a gallbladder mass Peri-operative management of the patient with a recent coronary stent Peri-operative management of the patient with a recent NSTEMI 精品文档 Case The patient is a 51 year old Bangladeshi woman with a history of type 2 diabetes on oral agents and stable angina April 8, 2006: presented to Bellevue with a NSTEMI, peak troponin 0.45 mg/dl. Cardiac cath revealed severe obstructions of the proximal and mid LAD which were both successfully stented with drug- eluting sirolimus/Cypher stents April 25: Pt electively underwent a staged intervention of a severe RCA lesion with a Cypher stent 精品文档 Case May 20: Pt presented with acute pancreatitis. Amylase 1409, lipase 9896 AST 627, ALT 422, AlkP 166, Tbil 1.3, Dbil 0.8 Imaging was perfomed 精品文档 Gallbladder MassPresentation Often presents with typical biliary symptoms Biliary colic Acute cholecystitis Obstructive jaundice Incidental finding on imaging 1 cm is an often-used cutoff for intervention Asymmetrical GB wall thickening Role of doppler imaging 精品文档 Gallbladder MassDifferential Diagnosis Gallstones Gallbladder polyp Mucosal lesion Cholesterol “polyp” Adenomyomatosis Adenocarcinoma Metastatic cancer Melanoma most common Cholangiocarcinoma 精品文档 Gallbladder MassRisk Factors for Cancer Gallstones Present in 74-92% if patients with cancer Single large stone Porcelain gallbladder Chronic cholecystitits Premalignant epithelial changes Biliary Salmonella typhi infection Biliary adenomas Choledochal cysts /ctarc/ct186a2.jpg 精品文档 Adenocarcinoma of Gallbladder Rapidly fatal disease Resection only hope for cure Liver resection if T2-T4 30-40% candidates for resection 5 year survival: 5-10% overall 38% if resected 85-100% for T1 30-40% for T2 (80 to 90% with radical resection in highly selected patients) T and N status predict survival R0 resection predicts survival Fong, et al. Annals