超声引导下经皮肝穿刺胆道引流.ppt

超声引导下经皮肝穿刺胆道引流PercutaneousTranshepaticCholangiographyandDrainage,夏喜刚杨志奇孙振纲,申报科室：肝胆外科,2012年12月12日,Purpose,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,肝细胞分泌胆汁微胆管胆小管胆管左右肝管总肝管胆囊管总胆管胰管肝胰壺腹開口於十二指腸乳頭(歐迪氏括約肌),Diameterofcommonbileduct,Normalpatient-lessthan4mm.Obstructivejaundice-greaterthan11mm.Highlysuspicious-between7to11mm.,Gallbladder,底部（fundus）体部（body）颈部（neck）,Gallbladderwallthickness,NormaldistendedGB-1-2mmasingleechogeniclayerPhysiologicallycontractedGB3-4mm,Pathology,阻塞性黃疸原因：良性结石胆管炎或术后造成的狭窄胆道出血,恶性CBDtumorPancreaticheadcaAmpularvatercaHCC(tumorthrombus),ChiefcomplainYellowishskinTeacolorurineClaycolorstoolSkinitching,LabdataTotalbilirubinAlkaline-PWBC,Indication,因结石或肿瘤引起的胆道阻塞。外傷或开刀引起的胆道挫傷及胆汁外漏。放置金属支架之前置步骤。胆管內置放射线治疗之前置步骤。外科取石,Contraindication,凝血功能不佳腹水广泛转移性肝肿瘤造成阻塞性黄疸癌末病人,Preparation,Visitingpatientandchecklab.Data.Reviewpreviousradiologicalexamination.Antibioticprophylaxis(IV).Analgesic/sedativepremedicationNPO46hours,Materials,N/S,Xylocaine,AIC,造影剂,chibaneedle,Telfon-needle/sheath,6#cruiser,PTCD包,GuildeWire,Connectingtube,Tie,橡皮管,引流袋,Pre-PTCDimagingstudy,ChestfilmPlainKUBSonographyComputedtomographyERCPMRCP,Methods,穿刺右叶肝內胆管穿刺左葉肝內胆管穿刺胆囊方法內留置管引流法,Procedure,超音波定位plainfilm消毒局部麻醉,Procedure,穿刺达定位后拔內针打造影剂找胆道抽Bile放GuideWire,打造影剂做胆道造影放pig-tail引流袋固定,Postprocedurecare,BedrestCheckBpandvitalsignWoundcareRecordbiledrainedamountRecordbilecolorchangeCheckserumbilirubin,Complications,BleedingSepsisBileleakage,bileperitonitisHepaticarterialinjuryPneumothorax,biliarypleuralfistulaDeath,PTCD的优缺点,优点易执行取结石缺点疼痛出血、感染,ThankYouforYourAttention!,