經(jīng)皮穿肝膽道引流術percutaneoustranshepatic

1、經(jīng)皮穿肝膽道引流術Percutaneous Transhepatic Cholangiography and Drainage,Purpose,當膽道因結石或腫瘤造成阻塞，膽汁無法流到十二指腸，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的膽管或膽囊，來達到引流膽汁的目的 。,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→

2、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 --- between 7 to 11 mm.But if C/P greater than 1

3、--- significant of obstructive jaundice,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

4、原因：良性結石膽管炎或術後造成的狹窄膽道出血,惡性CBD tumorPancreatic head caAmpular vater caHCC (tumor thrombus),Chief complainYellowish skinTea color urineClay color stoolSkin itching,Lab dataTotal bilirubin Alkaline-PWBC,Ind

5、ication,因結石或腫瘤引起的膽道阻塞。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移性肝腫瘤造成阻塞性黃膽癌末病人,Preparation,Visiting patient and check lab. Data.Review previous radiological examination.Anti

6、biotic prophylaxis (IV).permitAnalgesic / sedative premedicationNPO 4~6 hours,Materials,N/S,Xylocaine,AIC,對比劑,chiba needle,Telfon-needle/sheath,,6#cruiser,PTCD包,Guilde Wire,,Connecting tube,Dilator,Pig-tail,PTCS,Tie,橡

7、皮管,小腿尿袋,Pre-PTCD imaging study,Chest filmPlain KUBSonographyComputed tomographyERCPMRCP,Methods,穿刺右葉肝內膽管穿刺左葉肝內膽管穿刺膽囊方法 內留置管引流法,SkinPleuraPeritoneumLiver capsuleBile duct,Procedure,超音波定位plain film消毒局部

8、麻醉,穿刺達定位後拔內針打顯影劑找膽道抽Bile放Guide Wire,打顯影劑做膽道攝影放pig-tail引流袋固定,Post procedure care,Bed restCheck Bp and vital signWound careRecord bile drained amountRecord bile color changeCheck serum bilirubin,Complications,Bl

9、eedingSepsisBile leakage, bile peritonitisHepatic arterial injuryPneumothorax, biliary pleural fistulaDeath,PTCD的優(yōu)缺點,優(yōu)點易執(zhí)行取結石缺點疼痛出血、感染,Case,69歲 女性 Pancreatic ca.,71歲 男性,79歲 女性 PTGBD,56歲 女性,References,醫(yī)用解剖學 (劉