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1、超聲引導下經(jīng)皮肝穿刺膽道引流PercutaneousTranshepaticCholangiographyandDrainage夏喜剛楊志奇孫振綱申報科室：肝膽外科2012年12月12日Purpose當膽道因結石或腫瘤造成阻塞，膽汁無法引流到十二指腸，為避免膽汁滯留而造成感染，必須將膽汁引流。經(jīng)皮穿肝膽道引流術即在超音波或X光透視下，在上腹經(jīng)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。Anatomy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)Diameterofcommo
2、nbileductNormalpatient----lessthan4mm.Obstructivejaundice---greaterthan11mm.Highlysuspicious---between7to11mm.Gallbladder底部（fundus）體部（body）頸部（neck）GallbladderwallthicknessNormaldistendedGB------1-2mmasingleechogeniclayerPhysiologicallycontractedGB3-4mmPathology阻塞性黃疸原因：良性結石膽管炎或術后造成的狹窄膽道出血惡性CBDt
3、umorPancreaticheadcaAmpularvatercaHCC(tumorthrombus)ChiefcomplainYellowishskinTeacolorurineClaycolorstoolSkinitchingLabdataTotalbilirubinAlkaline-PWBCIndication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Contraindication凝血功能不佳腹水廣泛轉移性肝腫瘤造成阻塞性黃疸癌末病人PreparationVisitingpatientan
4、dchecklab.Data.Reviewpreviousradiologicalexamination.Antibioticprophylaxis(IV).Analgesic/sedativepremedicationNPO4~6hoursMaterialsN/SXylocaineAIC造影劑chibaneedleTelfon-needle/sheath6#cruiserPTCD包GuildeWireConnectingtubeTie橡皮管引流袋Pre-PTCDimagingstudyChestfilmPlainKUBSonographyComputedtomographyERC
5、PMRCPMethods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Procedure超音波定位plainfilm消毒局部麻醉Procedure穿刺達定位后拔內針打造影劑找膽道抽Bile放GuideWire打造影劑做膽道造影放pig-tail引流袋固定PostprocedurecareBedrestCheckBpandvitalsignWoundcareRecordbiledrainedamountRecordbilecolorchangeCheckserumbilirubinComplicationsBleedingSepsisBileleakage,bileper
6、itonitisHepaticarterialinjuryPneumothorax,biliarypleuralfistulaDeathPTCD的優(yōu)缺點優(yōu)點易執(zhí)行取結石缺點疼痛出血、感染ThankYouforYourAttention!
