1、經皮穿肝膽道引流術Percutaneous Transhepatic Cholangiography and Drainage,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 。,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),Diameter of common bile duct,Normal patient - less than
2、 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,Gallbladder,底部（fundus）體部（body）頸部（neck）,Gallbladder wall thickness,Normal distended GB-1-2 mm a single echogenic layerPhysiologically contracted GB 3-
3、4 mm,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 tumorPancreatic head caAmpular vater caHCC (tumor thrombus),Chief complainYellowish skinTea color urineClay color stoolSkin itching,Lab dataTotal bilirubin Alkaline-PWBC,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,Contra
4、indication,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,Preparation,Visiting patient and check lab. Data.Review previous radiological examination.Antibiotic prophylaxis (IV).permitAnalgesic / sedative premedicationNPO 46 hours,Materials,N/S,Xylocaine,AIC,對比劑,chiba needle,Telfon-needle/sheath,6#cruiser,PTCD包,Guilde W
5、ire,Connecting tube,Dilator,Pig-tail,PTCS,Tie,橡皮管,小腿尿袋,Pre-PTCD imaging study,Chest filmPlain KUBSonographyComputed tomographyERCPMRCP,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,SkinPleuraPeritoneumLiver capsuleBile duct,Procedure,超音波定位plain film消毒局部麻醉,穿刺達定位後拔內針打顯影劑找膽道抽Bile放Guide Wire,打顯影劑做膽道攝影放pig-tail
6、引流袋固定,Post procedure care,Bed restCheck Bp and vital signWound careRecord bile drained amountRecord bile color changeCheck serum bilirubin,Complications,BleedingSepsisBile leakage, bile peritonitisHepatic arterial injuryPneumothorax, biliary pleural fistulaDeath,PTCD的優缺點,優點易執行取結石缺點疼痛出血、感染,Case,69歲 女性 Pancreatic ca.,71歲 男性,79歲 女性 PTGBD,56歲 女性,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:/.twhttp:/.tw/38806.htm,Thank You for Your Attention!,
