经皮穿肝胆道引流术PercutaneousTranshepatic课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,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。,Purpose當膽道因結石或腫瘤造成阻塞，膽汁無法流到十二指,Anatomy,Anatomy,经皮穿肝胆道引流术PercutaneousTranshepatic课件,经皮穿肝胆道引流术PercutaneousTranshepatic课件,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,),膽汁的流向肝細胞分泌膽汁,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-significant of obstructive jaundice,Diameter of common bile ductNo,Gallbladder,底部（,fundus,）,體部（,body,）,頸部（,neck,）,Gallbladder,Gallbladder wall thickness,Normal distended GB-1-2 mm a single echogenic layer,Physiologically contracted GB 3-4 mm,Gallbladder wall thicknessNorm,Pathology,阻塞性黃疸,原因：,良性,結石,膽管炎或術後造成的狹窄,膽道出血,惡性,CBD tumor,Pancreatic head ca,Ampular vater ca,HCC(tumor thrombus),Pathology,Chief complain,Yellowish skin,Tea color urine,Clay color stool,Skin itching,Lab data,Total bilirubin,Alkaline-P,WBC,Chief complainLab data,Indication,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,Indication因結石或腫瘤引起的膽道阻塞。,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,Contraindication凝血功能不佳,Preparation,Visiting patient and check lab.Data.,Review previous radiological examination.,Antibiotic prophylaxis(IV).,permit,Analgesic/sedative premedication,NPO 46 hours,PreparationVisiting patient an,Materials,N/S,Xylocaine,AIC,對比劑,MaterialsN/SXylocaineAIC對比劑,chiba needle,Telfon-needle/sheath,6#cruiser,chiba needleTelfon-needle/shea,PTCD,包,Guilde Wire,Connecting tube,PTCD包Guilde WireConnecting tub,Dilator,Pig-tail,PTCS,DilatorPig-tailPTCS,Tie,橡皮管,小腿尿袋,Tie橡皮管小腿尿袋,Pre-PTCD imaging study,Chest film,Plain KUB,Sonography,Computed tomography,ERCP,MRCP,Pre-PTCD imaging studyChest fi,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,Methods穿刺右葉肝內膽管,Skin,Pleura,Peritoneum,Liver capsule,Bile duct,Skin,Procedure,超音波定位,plain film,消毒,局部麻醉,Procedure超音波定位,穿刺,達定位後拔內針,打顯影劑找膽道,抽,Bile,放,Guide Wire,穿刺,打顯影劑做膽道攝影,放,pig-tail,引流袋固定,打顯影劑做膽道攝影,Post procedure care,Bed rest,Check Bp and vital sign,Wound care,Record bile drained amount,Record bile color change,Check serum bilirubin,Post procedure careBed rest,Complications,Bleeding,Sepsis,Bile leakage,bile peritonitis,Hepatic arterial injury,Pneumothorax,biliary pleural fistula,Death,ComplicationsBleeding,PTCD,的優缺點,優點,易執行,取結石,缺點,疼痛,出血、感染,PTCD的優缺點優點,Case,69,歲 女性,Pancreatic ca.,Case69歲 女性 Pancreatic ca.,经皮穿肝胆道引流术PercutaneousTranshepatic课件,经皮穿肝胆道引流术PercutaneousTranshepatic课件,71,歲 男性,71歲 男性,经皮穿肝胆道引流术PercutaneousTranshepatic课件,79,歲 女性,PTGBD,79歲 女性 PTGBD,56,歲 女性,56歲 女性,经皮穿肝胆道引流术PercutaneousTranshepatic课件,References,醫用解剖學,(,劉紹東等人編譯,),膽道結石症之介入性放射檢查,(,姜仁惠,),台北榮民總醫院放射線部。放射診療訓練暨,作業手冊,http:/.tw,http:/.tw/38806.htm,References醫用解剖學(劉紹東等人編譯),Thank You for Your Attention!,Thank You for Your Attention!,