1、超声引导下经皮肝穿刺胆道引流 Percutaneous Transhepatic Cholangiography and Drainage夏喜刚 杨志奇 孙振纲申报科室：肝胆外科2012年12月12日Purposel当胆道因结石或肿瘤造成阻塞，胆汁无法引流到十二指肠，为避免胆汁滞留而造成感染，必須將胆汁引流。经皮穿肝胆道引流术即在超音波或X光透視下，在上腹经过皮肤及肝脏放置一条引流管到肝內的胆管或胆囊，来达到引流胆汁的目的。Anatomy 胆汁的流向胆汁的流向肝肝细胞分泌胆汁细胞分泌胆汁微胆管微胆管胆小管胆小管胆管胆管左右肝管左右肝管总肝管总肝管胆囊管胆囊管总胆管总胆管胰管胰管肝胰壺腹肝胰壺腹
2、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 ductlNormal patient-less than 4 mm.lObstructive jaundice-greater than 11 mm.lHighly suspicious-between 7 to 11 mm.Gallbladderl底部（fundus）l体部（body）l颈部（neck）Gallbladder wall thicknesslNormal distended GB-1-2 mm a single echogenic layerlPhysiologic
3、ally contracted GB 3-4 mmPathology 阻塞性黃疸阻塞性黃疸原因：原因：良性良性l结石结石l胆管炎或术后造成的胆管炎或术后造成的狭窄狭窄l胆道出血胆道出血恶性lCBD tumorlPancreatic head calAmpular vater calHCC(tumor thrombus)Chief complainlYellowish skinlTea color urinelClay color stoollSkin itchingLab datalTotal bilirubin lAlkaline-PlWBCIndicationl因结石或肿瘤引起的胆道阻塞。
4、l外傷或开刀引起的胆道挫傷及胆汁外漏。l放置金属支架之前置步骤。l胆管內置放射线治疗之前置步骤。l外科取石Contraindicationl凝血功能不佳l腹水l广泛转移性肝肿瘤造成阻塞性黄疸l癌末病人PreparationlVisiting patient and check lab.Data.lReview previous radiological examination.lAntibiotic prophylaxis(IV).lAnalgesic/sedative premedicationlNPO 46 hoursMaterialslN/SXylocaineAIC造影剂lchiba n
5、eedleTelfon-needle/sheath6#cruiserlPTCD包Guilde WireConnecting tubelTie橡皮管引流袋Pre-PTCD imaging studylChest filmlPlain KUBlSonographylComputed tomographylERCPlMRCPMethodsl穿刺右穿刺右叶肝內胆管叶肝內胆管l穿刺左葉肝內穿刺左葉肝內胆管胆管l穿刺穿刺胆囊方法胆囊方法 l內留置管引流法內留置管引流法 Procedurel超音波定位lplain filml消毒l局部麻醉Procedurel穿刺l达定位后拔內针l打造影剂找胆道l抽Bilel
6、放Guide Wirel打造影剂做胆道造影l放pig-taill引流袋固定Post procedure carelBed restlCheck Bp and vital signlWound carelRecord bile drained amountlRecord bile color changelCheck serum bilirubin ComplicationslBleedinglSepsislBile leakage,bile peritonitislHepatic arterial injurylPneumothorax,biliary pleural fistulalDeathPTCD的的优缺点优缺点优点l易执行l取结石缺点l疼痛l出血、感染Thank You for Your Attention!
