超声引导下经皮经肝穿刺胆管置管引流的技术应用

目的；探讨超声引导下经皮经肝穿刺胆管置管引流术的技术应用及临床价值。方法：对1999年5月-2005年3月187例（237例次）超声引导下经皮经肝穿刺胆管置管引流术进行回顾性总结。结果：1次穿刺胆管成功率高达96．2％，2次穿刺胆管成功率100％；穿刺并首次置管成功率90．7％，再次置管成功率99．6％；仅1例经3次置管成功。并发症主要为胆汁带血，发生率7．6％。结论：超声引导下经皮经肝穿刺胆管准确安全，置管简便有效，作为多种晚期肿瘤的姑息性治疗方法厦梗阻性黄疸伴严重感染的一项有效治疗措施，常为临床首选。     

PTBD技术在胆系疾病中的应用

目的 评价经皮肝胆道引流术(PTBD)在胆系疾病中的应用价值。方法 对13例不能手术的胆道梗阻患者行PTBD术，其中肝门部胆管阻塞4例，胆总管下段梗阻9例。结果 13例共行15例次PTBD，11例(13例次)置管引流成功，手术成功率86．6％(13／15)，成功置管的13例次中1次穿刺成功率84．6％(11／13)。成功手术的11例患者术后1周黄疸明显减退者8例(72．7％)，血浆胆红素下降至5g／L以下，2例血浆胆红素较术前有下降，但仍高于5g／L(2．5％)，1例无明显减退。结论 PTBD能有效地降低不能手术治疗的胆系阻塞患者的血浆胆红素，已被临床证实为阻塞性黄疸患者术前减轻黄疸与姑息性治疗的有效方法。     

Percutaneous biliary drainage in acute suppurative cholangitis

One hundred and sixteen percutaneous drainage procedures of the biliary system were performed in a 2-year period. Eight of 9 acutely ill patients with the diagnosis of acute suppurative cholangitis were successfully treated nonoperatively. They represented 26% of all patients with benign or postsurgical obstruction referred for biliary decompression. Conversely, acute suppurative cholangitis only occurred in 2.3% of patients with underlying malignant disease. These observations are considered most relevant in predicting the purulent nature of the disease, with further implications for patient management. Early recognition and prompt decompression of the biliary system are mandatory, along with the appropriate antibiotic coverage. Our experience compares favorably with surgical results and the procedure is proposed as the method of choice for the initial treatment of acute suppurative cholangitis.     

Technique for replacement of accidentally removed percutaneous biliary drainage catheter

A simple technique for replacement of accidentally removed percutaneous transhepatic biliary drainage catheters is described. It requires no special catheters or wires and can be performed with material generally available in any angiographic suite.     

Percutaneous management of benign biliary disease

Thiry-two patients had percutaneous drainage for benign disease of the biliary system, and in 81% of the patients the catheter could be removed. The patients' conditions were of 3 types: choledocholithiasis, biliary strictures, and primary sclerosing cholangitis. Fourteen patients had balloon dilatation of strictures in the biliary tract. As in malignant disease, many patients may be managed entirely by percutaneous methods and surgery avoided, but the results with percutaneous drainage are more gratifying.     

梗阻性黄疸患者MRCP及肝胆断层MR检查对于PTC及PTBD指导作用的分析

目的比较MRCP与PTC在梗阻性黄疸的诊断过程中的优缺点,探讨MRCP对PTC和PTBD治疗的指导作用.方法 15例梗阻性黄疸患者分别进行MRCP和PTC检查,并行PTBD介入治疗,分析图像,对两种检查方法的定位、定性诊断的正确率和对胆道显示的情况进行比较.结果 MRCP与PTC的定位诊断和定性诊断的正确率分别为:PTC 100%和80%;MRCP 100%和93%.MRCP与PTC相比在梗阻性黄疸患者中能够更好地显示肝内外胆道的情况.与MRCP检查同时进行的横断面和冠状断层图像可以准确显示胆道管腔以外的病变.在MRCP指导下,PTBD介入治疗留置引流管单纯外引流6例,内外引流9例.引流效果满意,没有严重并发症发生.结论梗阻性黄疸患者的MRCP及肝胆断层MRI检查,可以较PTC提供更多的诊断信息,并对PTBD提供有力的指导作用,减少并发症,提高手术成功率.     

PTCD及支架植入术治疗高龄恶性梗阻性黄疸的护理

近年来,恶性梗阻性黄疸发病率越来越高,年龄越来越高龄化。晚期恶性阻塞性黄疸患者由于病变范围大、病史时间长、年龄大、体质差等原因,不能耐受手术或外科手术切除率低。经皮肝穿胆道引流术（PTCD）及支架植入术的介入方法以其操作简便、创伤小、并发症少及成功率高等已经成为临床治疗高龄恶性梗阻性黄疸的常用方法。本文旨在探讨PTCD及支架植入术在介入治疗高龄恶性梗阻性黄疸围手术期相关并发症的防治与护理。     

DSA下经皮肝穿刺胆管引流及胆管支架置入术的护理体会

目的 探讨经皮经肝穿刺胆管引流(PTCD)及胆管支架置入术的护理.方法 对36例行PTCD配合胆管支架置入术患者做好术前准备、术中配合及针对性护理.结果 36例患者均成功进行了PTCD及胆管支架置入术,无护理并发症发生;术后1周复查血胆红素明显下降,皮肤瘙痒消失.结论 认真细致的术前及术中护理,是保证患者顺利度过手术期并达到预期治疗效果的有力保障.     

Portal vein embolization in the treatment of portal vein bleeding after percutaneous transhepatic biliary drainage: A case report and literature review

Percutaneous transhepatic biliary drainage (PTBD) is an effective treatment for benign and malignant obstructive jaundice. Major bleeding complications occur in approximately 2–3% of patients after PTBD, which can result in death. A case involving a 63-year-old male with malignant obstructive jaundice, who experienced severe bleeding after PTBD, is reported. Emergency digital subtraction angiography, celiac trunk artery and superior mesenteric artery angiography were performed; however, no signs of arterial bleeding were found. To identify etiology, portal venography was performed under ultrasound guidance and portal vein bleeding was diagnosed. Ultimately, selective portal vein embolization successfully stopped the bleeding.     

Ultrasound and fluoroscopy guided percutaneous transhepatic biliary drainage in patients with nondilated bile ducts

Background  The purpose of this study is to demonstrate the feasibility, safety, and success of percutaneous transhepatic biliary drainage (PTBD) using a combination of ultrasound and fluoroscopy guidance in patients with nondilated bile ducts. Methods  Between January 2005 and July 2007, 50 patients with nondilated bile ducts underwent ultrasound-and-fluoroscopy guided PTBD. The underlying disease processes were divided into biliary obstruction (n = 38) and bile leakage (n = 12). We used ultrasound guidance when puncturing a bile duct and during cholangiography. We punctured along the course of the targeted bile duct or portal vein when the bile duct was not visualized, which we termed the “parallel technique.” This method made it possible for us to cannulate the peripheral bile duct successfully, even when its course was not visualized well by sonography. We then installed a drainage catheter under fluoroscopy guidance. The technical success and complications of the procedure were evaluated. Results  Neither significant complications nor technical failures were observed. There were only four minor complications: transient hemobilia (n = 3) and fever (n = 1). Conclusions  Ultrasound-and-fluoroscopy guided PTBD in patients with nondilated bile ducts is a safe, feasible, and efficient procedure for the palliation of biliary obstruction and leakage.     

PTBD治疗肝内胆管微扩张型梗阻性黄疸

目的探讨超声实时引导结合X线透视下,经皮肝胆管穿刺置管引流术（PTBD）治疗肝内胆管微扩张型梗阻性黄疸的操作技术及其临床应用价值。方法回顾性分析9例肝内胆管微扩张型梗阻性黄疸患者的临床资料,6例行右肝胆管PTBD,3例行左肝胆管PTBD。结果胆管穿刺置管成功率100％,术后短暂性发热1例、一过性血性胆汁1例,未出现腹腔出血及胆汁性腹膜炎等严重并发症,术后一周胆红素平均下降（75．4±29．6）μmol／L。引流时间10d～5个月。结论超声引导结合X线透视下PTBD治疗肝内胆管微扩张型梗阻性黄疸是安全可行的。     

内镜逆行胰胆管造影术与经皮肝穿刺胆道引流术治疗肝外胆管梗阻性黄疸的对比研究

目的探讨内镜逆行胰胆管造影术(ERCP)与经皮肝穿刺胆道引流术(PTCD)在治疗良、恶性肝外胆管梗阻性黄疸方面各自的优劣。方法回顾性分析2013年5月至2014年7月期间兰州大学第二医院普外四科收治的肝外胆管梗阻性黄疸患者并分别采用ERCP与PTCD治疗的临床资料,比较2种方法的手术成功率、5 d血清胆红素下降水平及术后常见并发症的发生率等。结果与PTCD相比,ERCP在治疗良性肝外胆管梗阻性黄疸时,术后5 d血清总胆红素水平下降速度较快[(94.9±11.58)μmol/L vs.(84.3±15.50)μmol/L,t=2.946,P=0.005],术后并发症发生率较低(3.3%vs.21.4%,χ2=4.469,P=0.035),但手术成功率(96.7%vs.92.9%,χ2=0.429,P=0.513)二者无统计学差异。在治疗恶性肝外胆管梗阻性黄疸时,两种方法术后常见并发症的发生率(9.5%vs.18.5%,χ2=0.767,P=0.381)虽无明显差异,但相比ERCP,在手术成功率(95.2%vs.70.4%,χ2=4.795,P=0.029)和术后5 d血清总胆红素水平下降速度[(206.3±13.26)μmol/L vs.(186.8±20.59)μmol/L,t=-2.516,P=0.015]方面PTCD组效果较为显著。结论对于良性肝外胆管梗阻性黄疸患者ERCP不仅具有创伤小、并发症少、起效快、疗效好的优点,而且可以从根本上解除梗阻;而对于恶性肝外胆管梗阻性黄疸,由于PTCD手术成功率高,可以有效缓解梗阻症状,快速降低血清胆红素水平,改善肝功能,提高患者生活质量,因此成为首选方法。     

Hypercarbia during tracheostomy: a comparison of percutaneous endoscopic, percutaneous Doppler, and standard surgical tracheostomy

Objective: Tracheostomy is one of the most commonly performed surgical procedures in the critical care setting. The early use of tracheostomy as a method of primary airway management has been proposed as a means to decrease pulmonary morbidity and to shorten the number of ventilator, intensive care unit, and hospital days. We set out to (1) determine whether hypercarbia occurs during tracheostomy of the critically ill patient and (2) determine the extent to which the partial pressure of carbon dioxide in arterial blood (PaCO₂) rises during percutaneous endoscopic, percutaneous Doppler, and standard surgical tracheostomy. Design: Prospective, open clinical trial. Setting: Surgical intensive care unit and operating room in teaching hospitals. Patients: During mechanical ventilation, patients underwent either percutaneous endoscopic (PET), percutaneous Doppler (PDT), or standard surgical tracheostomy (ST), based on surgeon preference. Arterial blood gas readings were obtained approximately every 4 min throughout each procedure. Measurements and results: All tracheostomies were successfully performed. No serious complications (including hypoxia) occurred during the study. Significant (p < 0.05 vs PDT and ST) hypercarbia (maximum Δ PaCO₂ 24 ± 3 mmHg) and acidosis (maximum Δ pH – 0.16 ± 0.02) developed during PET. The changes in PaCO₂ and pH during PDT (maximum Δ PaCO₂ 8 ± 2 mmHg; maximum Δ pH – 0.07 ± 0.02) and ST (maximum Δ PaCO₂ 3 ± 1 mmHg; maximum ΔpH – 0.04 ± 0.01) were markedly less pronounced. Conclusions: Continuous bronchoscopy during percutaneous tracheostomy contributes significantly to early hypoventilation, hypercarbia, and respiratory acidosis during the procedure. Percutaneous tracheostomy, when performed using the Doppler ultrasound method to position the endotracheal tube, significantly reduces CO₂ retention when compared to PET. Because of a possible rise in intracranial pressure, the potential for hypercarbia should be considered when choosing the method of tracheostomy in the critically ill and/or head-injured patient, where hypercarbia may be detrimental. If PET is to be performed, steps to minimize occult hypercarbia, such as using the smallest bronchoscope available, minimizing suctioning during bronchoscopy, and minimizing the length of time the bronchoscope is in the endotracheal tube, should be undertaken. Received: 7 October 1996 Accepted: 6 March 1997     

Catheter dislodgement of percutaneous transhepatic biliary drainage: identification of role of puncture sites and catheter sheath

Background: To identify the appropriate puncture points in the bile duct to avoid catheter dislodgement. Methods: Percutaneous transhepatic biliary drainage catheters (n = 300) were placed in 242 patients. The frequency of dislodgement (complete dislodgement or bending of the catheter) was prospectively investigated. The puncture site of the bile duct was classified on the ultrasonographic findings as follows: Main-B3, main branch of the lateral inferior segment; peripheral-B3, peripheral branch of the lateral inferior segment; B2, lateral superior segment; left hepatic duct, proximal portion of the left hepatic duct; B8, anterior superior segment; B5, anterior inferior segment; B5 + 8, main bile duct of the anterior segment; B6, bile duct of posterior inferior segment; and right hepatic duct, proximal portion of the right hepatic duct. Results: When a catheter without an outer sheath was used, catheter dislodgement in peripheral-B3 (2/11, 18%) was more common than in main-B3 (0/32, 0%; p < 0.05). In B5, catheter dislodgement (6/12, 50%) was more frequent than in B8 (3/20, 15%; p < 0.05) and in B6 (0/14, 0%; p < 0.005). When a catheter with an outer sheath was used, catheter dislodgement (2/207, 1%) was rare. Conclusion: Drainage from B5 and peripheral-B3 is associated with a high risk of dislodgement of the catheter. A catheter with an outer sheath was useful to prevent catheter dislodgement. RID=" ID=" <E5>Correspondence to:</E5> K. Tamada Received: 8 February 2000/Accepted: 8 March 2000     

胆管双支架置入操作技巧及价值

目的通过比较单支架、双支架及金属支架之间在胆道恶性梗阻引流减黄的效果,探讨双支架置入操作技巧与价值。方法88例患者根据显影情况分为3组,其中双支架治疗26例,单支架治疗35例,金属支架治疗27例。分别比较3组支架放置前后血清总胆红素和直接胆红素的变化情况、操作成功率、早期并发症。结果支架放置前后,3组患者总胆红素和直接胆红素均有所下降,其中以双支架组和金属支架组下降明显,2组间差异不显著(P>0.05);单支架放置组胆红素下降最少,明显低于前2组(P<0.05)。操作成功率双支架放置低于单支架和金属支架(P<0.05)。早期并发症3组间均无明显差异(P>0.05)。结论双支架引流疗效可靠,值得在临床上推广。     

经皮经肝胆管引流术与内镜逆行胰胆管造影对接术治疗梗阻性黄疸的围手术期护理

目的探讨对经皮经肝胆管引流术（PTBD）与内镜逆行胰胆管造影（ERCP）对接术治疗梗阻性黄疸术围手术期的护理,总结其临床护理特点。方法采用围手术期的护理程序对行ERCP失败后,实施PTBD与ERCP对接胆道支架植入术的17例梗阻性黄疸患者进行护理总结。结果本调查中17例PTBD与ERCP对接治疗恶性梗阻性黄疸均获得成功,无护理并发症出现。结论PTBD与ERCP对接术是治疗ERCP失败的梗阻性黄疸的一种新方法,具有良好的临床应用价值,因此总结该项技术的围手术期的护理要点,对于协助此类患者平稳过渡手术时期有着至关重要的作用。     

肝内胆管结石并胆管狭窄的手术治疗63例分析

目的 探讨肝内胆管结石并狭窄的手术治疗方法及其效果。方法 回顾性总结了2002年7月～2004年1月间63例肝内胆管结石并胆管狭窄的外科手术治疗资料。结果 该组63例中行肝叶切除49例，胆总管切开取石 T管引流37例，胆肠吻合 肝叶切除或胆总管取石28例。肝门部肝胆管狭窄整形19例。术后残留结石41例，术后经胆道镜取石32例。有9例术后常有上腹隐痛或发烧。结论 对肝内胆管多发结石，尤其是胆道狭窄病变的患者，应用肝叶切除并内引流术是一种有效的治疗手段。     

肝胆管结石腹腔镜微创治疗探讨

目的探讨腹腔镜胆总管切开联合纤维胆道镜探查取石T管引流或一期缝合治疗肝胆管结石的经验。方法运用腹腔镜瘦纤维胆道镜对126例肝胆管结石患者进行腹腔镜下胆总管切开瘦胆道镜探查取石术、T管引流或一期缝合。结果126例手术均获成功，无中转开腹，无死亡病例，无近期严重并发症。住院时间明显缩短，而手术时间与开腹手术相似。部分病例随访半年以上未见远期并发症。结论腹腔镜胆总管切开联合纤维胆道镜探查取石、T管引流或一期缝合是安全有效的，具有创伤小、恢复快、住院时间短等优点，是治疗肝胆管结石的有效方法。     

术后胆漏和继发胆管狭窄的内镜治疗

胆漏和继发胆管狭窄是严重的外科并发症，传统的治疗方法是再次开腹手术，但再手术并发症多，死亡率高。而内镜胆管造影不仅可明确诊断，且内镜下治疗具有安全、疗效肯定、创伤小和并发症少等优点，可作为大多数胆漏和胆管狭窄患者首选治疗方法。     

Retrospective analysis of T-lymphocyte subsets and cytokines in malignant obstructive jaundice before and after external and internal biliary drainage

ObjectiveTo study changes in T lymphocyte subsets, cytokines, and liver enzymes in patients with malignant obstructive jaundice (MOJ) before and after external biliary drainage (percutaneous transhepatic cholangiography drainage, PTCD) and internal biliary drainage (percutaneous transhepatic insertion of biliary stents, PTIBS).MethodsMOJ patients undergoing PTCD (n = 44) and PTIBS (n = 38) at our hospital were enrolled in the study from January 2017 until December 2019. Peripheral blood total bilirubin (TBIL), direct bilirubin (DBIL), aspartate aminotransferase (AST), alanine aminotransferase (ALT), CD3⁺%, CD4⁺%, CD4⁺/CD8⁺ ratio, interleukin (IL)-2, IL-6, and tumor necrosis factor (TNF)-α were measured before and 1 week after biliary drainage.ResultsThere was no significant difference in any parameter between the two groups before biliary drainage. TBIL, DBIL, AST and ALT following PTCD were significantly lower than before PTCD. By contrast, CD3⁺%, CD4⁺%, CD4⁺/CD8⁺ ratio, IL-2, IL-6 and TNF-α showed no significant difference before and 1 week after PTCD. TBIL, DBIL, AST, ALT, IL-6 and TNF-α were significantly lower following PTIBS than before PTIBS. CD3⁺%, CD4⁺%, CD4⁺/CD8⁺ ratio and IL-2 were significantly higher following PTIBS than before PTIBS.ConclusionBoth PTCD and PTIBS were effective for treatment of MOJ, but PTIBS was more beneficial for recovery of immune function.