超聲引導下經(jīng)皮肝穿刺膽道引流

1、超聲引導下經(jīng)皮肝穿刺膽道引流 Percutaneous Transhepatic Cholangiography and Drainage,夏喜剛 楊志奇 孫振綱,申報科室：肝膽外科,2012年12月12日,Purpose,當膽道因結(jié)石或腫瘤造成阻塞，膽汁無法引流到十二指腸，為避免膽汁滯留而造成感染，必須將膽汁引流。經(jīng)皮穿肝膽道引流術即在超音波或X光透視下，在上腹經(jīng)過皮膚及肝臟放置一條引流管到肝內(nèi)的膽管或膽囊，來達到引流膽

2、汁的目的 。,Anatomy,膽汁的流向,肝細胞分泌膽汁→微膽管→膽小管→膽管→左右肝管→總肝管→膽囊管→總膽管→胰管→肝胰壺腹→開口於十二指腸乳頭(歐迪氏括約肌),Diameter of common bile duct,Normal patient ---- less than 4 mm.Obstructive jaundice --- greater than 11 mm.Highly suspicious ---

3、 between 7 to 11 mm.,Gallbladder,底部（fundus）體部（body）頸部（neck）,Gallbladder wall thickness,Normal distended GB------1-2 mm a single echogenic layerPhysiologically contracted GB 3-4 mm,Pathology,阻塞性黃疸原因：良性結(jié)石膽管炎或術后造成

4、的狹窄膽道出血,惡性CBD tumorPancreatic head caAmpular vater caHCC (tumor thrombus),Chief complainYellowish skinTea color urineClay color stoolSkin itching,Lab dataTotal bilirubin Alkaline-PWBC,Indication,因結(jié)石或腫瘤引起的膽道

5、阻塞。外傷或開刀引起的膽道挫傷及膽汁外漏。放置金屬支架之前置步驟。膽管內(nèi)置放射線治療之前置步驟。外科取石,Contraindication,凝血功能不佳腹水廣泛轉(zhuǎn)移性肝腫瘤造成阻塞性黃疸癌末病人,Preparation,Visiting patient and check lab. Data.Review previous radiological examination.Antibiotic prophylaxis

6、(IV).Analgesic / sedative premedicationNPO 4~6 hours,Materials,N/S,Xylocaine,AIC,造影劑,chiba needle,Telfon-needle/sheath,,6#cruiser,PTCD包,Guilde Wire,,Connecting tube,Tie,橡皮管,引流袋,Pre-PTCD imaging study,Chest filmPlain K

7、UBSonographyComputed tomographyERCPMRCP,Methods,穿刺右葉肝內(nèi)膽管穿刺左葉肝內(nèi)膽管穿刺膽囊方法 內(nèi)留置管引流法,Procedure,超音波定位plain film消毒局部麻醉,Procedure,穿刺達定位后拔內(nèi)針打造影劑找膽道抽Bile放Guide Wire,打造影劑做膽道造影放pig-tail引流袋固定,Post procedure care,

8、Bed restCheck Bp and vital signWound careRecord bile drained amountRecord bile color changeCheck serum bilirubin,Complications,BleedingSepsisBile leakage, bile peritonitisHepatic arterial injuryPneumothorax, bil