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------1-2mmasingleechogeniclayerPhysiologicallycontractedGB3-4mmPathology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CBDtumorPancreaticheadcaAmpularvatercaHCC(tumorthrombus)ChiefcomplainYellowishskinTeacolorurineClaycolorstoolSkinitchingLabdataTotalbilirubinAlkaline-PWBCIndication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/sedativepremedicationNPO4~6hoursMaterialsN/S•Xylocaine•AIC•造影剂chibaneedle•Telfon-needle/sheath•6#cruiserPTCD包GuildeWireConnectingtubeTie橡皮管引流袋Pre-PTCDimagingstudyChestfilmPlainKUBSonographyComputedtomographyERCPMRCPMethods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BedrestCheckBpandvitalsignWoundcareRecordbiledrainedamountRecordbilecolorchangeCheckserumbilirubinComplicationsBleedingSepsisBileleakage,bileperitonitisHepaticarterialinjuryPneumothorax,biliarypleuralfistulaDeathPTCD的优缺点优点易执行取结石缺点疼痛出血、感染ThankYouforYourAttention!