1、Purposev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。經皮穿肝膽道引流術即在超音波或X光透視下，在上腹經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肝細胞分泌膽汁微膽管微膽管膽小管膽小管膽管膽管左右肝管左右肝管總肝管總肝管膽囊管膽囊管總膽管總膽管胰管胰管肝胰壺腹肝胰壺腹開口於十開口於十二指腸乳頭二指腸乳頭(歐迪氏括約歐迪氏括約肌肌)Diameter of common bile ductvNormal patient-less than 4 mm.vObstructive ja
2、undice-greater than 11 mm.vHighly suspicious-between 7 to 11 mm.vBut if C/P greater than 1-significant of obstructive jaundiceGallbladderv底部（fundus）v體部（body）v頸部（neck）Gallbladder wall thicknessvNormal distended GB-1-2 mm a single echogenic layervPhysiologically contracted GB 3-4 mmPathology 阻塞性黃疸阻塞性黃
3、疸原因：原因：良性良性v結石結石v膽管炎或術後造成的膽管炎或術後造成的狹窄狹窄v膽道出血膽道出血惡性vCBD tumorvPancreatic head cavAmpular vater cavHCC(tumor thrombus)Chief complainvYellowish skinvTea color urinevClay color stoolvSkin itchingLab datavTotal bilirubin vAlkaline-PvWBCIndicationv因結石或腫瘤引起的膽道阻塞。v外傷或開刀引起的膽道挫傷及膽汁外漏。v放置金屬支架之前置步驟。v膽管內置放射線治療之前
4、置步驟。v外科取石Contraindicationv凝血功能不佳v腹水v廣泛轉移性肝腫瘤造成阻塞性黃膽v癌末病人PreparationvVisiting patient and check lab.Data.vReview previous radiological examination.vAntibiotic prophylaxis(IV).vpermitvAnalgesic/sedative premedicationvNPO 46 hoursMaterialsvN/SXylocaineAIC對比劑vchiba needleTelfon-needle/sheath6#cruiservPT
5、CD包Guilde WireConnecting tubevDilatorPig-tailPTCSvTie橡皮管小腿尿袋Pre-PTCD imaging studyvChest filmvPlain KUBvSonographyvComputed tomographyvERCPvMRCPMethodsv穿刺右葉肝內膽管穿刺右葉肝內膽管v穿刺左葉肝內膽管穿刺左葉肝內膽管v穿刺膽囊方法穿刺膽囊方法 v內留置管引流法內留置管引流法 vSkinvPleuravPeritoneumvLiver capsulevBile ductProcedurev超音波定位vplain filmv消毒v局部麻醉v穿刺v
6、達定位後拔內針v打顯影劑找膽道v抽Bilev放Guide Wirev打顯影劑做膽道攝影v放pig-tailv引流袋固定Post procedure carevBed restvCheck Bp and vital signvWound carevRecord bile drained amountvRecord bile color changevCheck serum bilirubin ComplicationsvBleedingvSepsisvBile leakage,bile peritonitisvHepatic arterial injuryvPneumothorax,biliary pleural fistulavDeathPTCD的優缺點優點v易執行v取結石缺點v疼痛v出血、感染Casev69歲 女性 Pancreatic ca.v71歲 男性v79歲 女性 PTGBDv56歲 女性Referencesv醫用解剖學(劉紹東等人編譯)v膽道結石症之介入性放射檢查(姜仁惠)v台北榮民總醫院放射線部。放射診療訓練暨 作業手冊 vhttp:/.twvhttp:/.tw/38806.htmThank You for Your Attention!
