1、超声引导下经皮肝穿刺超声引导下经皮肝穿刺胆道引流胆道引流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。超声引导下经皮肝穿刺胆道引流2 Anatomy 超声引导下经皮肝穿刺胆道引流3超声引导下经皮肝穿刺胆道引流4超声引导下经皮肝穿刺胆道引流5胆汁的流向胆汁的流向肝肝细胞细胞分泌分泌胆汁胆汁微微胆管胆管胆胆小管小管胆胆管管左右肝管左右肝管总总肝管肝管胆囊胆囊管管总胆总胆管管胰管胰管肝胰壺腹肝胰壺腹開口於十開口於十二指腸
2、乳頭二指腸乳頭(歐迪氏括約歐迪氏括約肌肌)超声引导下经皮肝穿刺胆道引流6Diameter of common bile ductlNormal patient-less than 4 mm.lObstructive jaundice-greater than 11 mm.lHighly suspicious-between 7 to 11 mm.超声引导下经皮肝穿刺胆道引流7Gallbladderl底部（fundus）l体部（body）l颈部（neck）超声引导下经皮肝穿刺胆道引流8Gallbladder wall thicknesslNormal distended GB-1-2 mm a
3、single echogenic layerlPhysiologically contracted GB 3-4 mm超声引导下经皮肝穿刺胆道引流9Pathology 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)超声引导下经皮肝穿刺胆道引流10Chief complainlYellowish skinlTea color urinelClay color stoollSkin itching
4、Lab datalTotal bilirubin lAlkaline-PlWBC超声引导下经皮肝穿刺胆道引流11Indicationl因结石或肿瘤引起的胆道阻塞。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外科取石超声引导下经皮肝穿刺胆道引流12Contraindicationl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癌末病人超声引导下经皮肝穿刺胆道引流13PreparationlVisiting patient and check lab.Data.lReview previous radiological examinati
5、on.lAntibiotic prophylaxis(IV).lAnalgesic/sedative premedicationlNPO 46 hours超声引导下经皮肝穿刺胆道引流14MaterialslN/SXylocaineAIC造影剂超声引导下经皮肝穿刺胆道引流15lPTCD包Guilde WireConnecting tube超声引导下经皮肝穿刺胆道引流17超声引导下经皮肝穿刺胆道引流18lTie橡皮管引流袋超声引导下经皮肝穿刺胆道引流19Pre-PTCD imaging studylChest filmlPlain KUBlSonographylComputed tomograph
6、ylERCPlMRCP超声引导下经皮肝穿刺胆道引流20Methodsl穿刺右穿刺右叶肝內胆管叶肝內胆管l穿刺左葉肝內胆管穿刺左葉肝內胆管l穿刺胆囊方法穿刺胆囊方法 l內留置管引流法內留置管引流法 超声引导下经皮肝穿刺胆道引流21Procedurel超音波定位lplain filml消毒l局部麻醉超声引导下经皮肝穿刺胆道引流22Procedure超声引导下经皮肝穿刺胆道引流23l穿刺l达定位后拔內针l打造影剂找胆道l抽Bilel放Guide Wire超声引导下经皮肝穿刺胆道引流24l打造影剂做胆道造影l放pig-taill引流袋固定超声引导下经皮肝穿刺胆道引流25Post procedure c
7、arelBed restlCheck Bp and vital signlWound carelRecord bile drained amountlRecord bile color changelCheck serum bilirubin 超声引导下经皮肝穿刺胆道引流26ComplicationslBleedinglSepsislBile leakage,bile peritonitislHepatic arterial injurylPneumothorax,biliary pleural fistulalDeath超声引导下经皮肝穿刺胆道引流27PTCD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、感染超声引导下经皮肝穿刺胆道引流28Thank You for Your Attention!超声引导下经皮肝穿刺胆道引流29
