超声引导下经皮肝穿刺胆道引流 Percutaneous Transhepatic Cholangiography and Drainage,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),Diameter of common bile duct,Normal patient - less than 4 mm. Obstructive jaundice - greater than 11 mm. Highly suspicious - between 7 to 11 mm.,Gallbladder,底部（fundus）体部（body）颈部（neck）,Gallbladder wall thickness,Normal distended GB-1-2 mm a single echogenic layerPhysiologically contracted GB 3-4 mm,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 CBD tumor Pancreatic head ca Ampular vater ca HCC (tumor thrombus),Chief complainYellowish skin Tea color urine Clay color stool Skin itching,Lab dataTotal bilirubin Alkaline-P WBC,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,Visiting patient and check lab. Data. Review previous radiological examination. Antibiotic prophylaxis (IV). Analgesic / sedative premedication NPO 46 hours,Materials,N/S,Xylocaine,AIC,造影剂,chiba needle,Telfon-needle/sheath,6#cruiser,PTCD包,Guilde Wire,Connecting tube,Tie,橡皮管,引流袋,Pre-PTCD imaging study,Chest film Plain KUB Sonography Computed tomography ERCP MRCP,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plain film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Guide Wire,打造影剂做胆道造影 放pig-tail 引流袋固定,Post procedure care,Bed rest Check Bp and vital sign Wound care Record bile drained amount Record bile color change Check serum bilirubin,Complications,Bleeding Sepsis Bile leakage, bile peritonitis Hepatic arterial injury Pneumothorax, biliary pleural fistula Death,PTCD的优缺点,优点 易执行 取结石缺点 疼痛 出血、感染,Thank You for Your Attention!,