鼻胆管引流治疗拔除T管后胆漏28例护理体会

拔除T管后出现胆漏持久不愈是胆道外科比较少见的术后并发症之一,通常在内科非手术、窦道口再置引流管等无效后采取手术探查处理。但再次手术常给患者心理和经济带来很大的负担。鼻胆管引流（Endoscopic nasobiliary drainage,ENBD）治疗拔除T管后出现胆漏具有创伤小、恢复快、并发症少,避免再次手术,减少患者的心理和经济负担等优点。总结2000年9月-2007年5月28例拔T管后并发胆漏的患者行ENBD治疗中的护理体会。     

1例医源性胆管损伤致反复高热患者的护理

1病例介绍 患者,男,38岁,因胆囊结石行开腹胆囊切除术,术后患者出现反复寒战、高热,体温在39℃-40℃之间,每次给予抗炎,对症治疗后均缓解。1年前患者突然寒战,高热收住院,经86天的治疗与护理,患者未再出现发热出院。由于该患者属医源性胆管损伤形成肝管后支狭窄而造成反复发热,我们根据患者的病情特点,进行了如下护理:     

胆囊术后胆漏致腹腔巨大积液介入治疗1例

患者，男，50岁，因右上腹疼痛20d，加重2d伴黄疸，2006—03在外院行胆囊切除术，术中见胆囊水肿张力大，部分坏疽，内见一枚结石。术后第6天出现腹痛、腹胀，第8天腹痛、腹胀加重并出现腹膜刺激症状，第10天行B超检查提示：腹腔有大量液性暗区。行左下腹穿刺抽出胆汁样液8ml,考虑有胆漏并胆汁性腹膜炎。行剖腹探查，腹腔内抽吸出胆汁样液量约2500ml，未发现明显胆漏部位。[第一段]     

医源性肝外胆管损伤的防治

１９７５年以来，我们治疗了１６例肝外胆管损伤，其中本院发生４例，占同期手术的０．１％。临床资料发生于胆囊切除术１４例，胃手术２例。损伤类型为胆总管横断、肝总管和／或胆总管部分切除、肝外胆管完全切除、胆总管贯穿伤。９例术中当即处理，４例３天内处理，３例...     

医源性肝外胆管损伤的防治体会

医源性肝外胆管损伤的防治体会刘连义医源性肝外胆管损伤最常见于胃、十二指肠溃疡行胃大部切除术及胆囊炎、胆石症行胆囊切除术中。此类手术较规范，多数难度不大，但由于种种原因，潜在并发症较多。一旦发生胆管损伤，往往病情凶险，处理很棘手，甚至导致多次手术，后遗...     

超声介入治疗1例婴儿腹腔囊肿

1 病历简介 孕妇,32岁.孕2产1,孕35周.超声检查: 胎儿头、颈及脊柱正常.双顶径86mm,股骨长67mm,胎心率142次/min.胃泡及膀胱存在.胎儿左上腹腔内腹主动脉前方见囊腔,壁较厚不光滑,透声尚好,囊腔大小48mm×43 mm(图1).囊腔与所见内脏无关,未见有蠕动征象,羊水适量.超声诊断:(1)晚期妊娠,单活胎;(2)胎儿腹腔内囊肿(肠系膜囊肿可能性大).建议行超声引导下胎儿腹腔囊肿穿刺引流术.家属不接受,3d后催产一活女婴,腹部彩色多普勒超声示: 腹腔囊肿,大小约47mm×44mm,其内充满细密点状及间隔带状回声(图2).     

腹腔镜胆囊切除术致肝外胆管损伤的护理

肝外胆管损伤是腹腔镜胆囊切除术（LC）常见且最严重的并发症之一，术中未能及时发现会导致术后黄疸、胆汁性腹膜炎，继而发展为化脓性腹膜炎。如重建手术失当，则常导致胆管狭窄，复发胆管炎，造成终身残疾，甚至死亡。LC初期阶段，此并发症的发生率较高。我院从1991年9月-2005年10月行12000例，其中肝外胆管损伤8例，经治疗8例均治愈。     

鼻胆管引流治疗T管拔除后胆漏8例

1临床资料 1．1对象本组男5例,女3例;年龄32．67岁,平均52岁;均按常规行开腹胆囊切除、胆总管探查、T管引流术,术后根据各自病情拔管时间为4—8周,8例胆漏患者中,常规拔除T管出现胆漏7例,拔T管后经窦道纤维胆道镜取残余结石时窦道破裂出现胆漏1例,均为经保守治疗无效,窦道内置入导尿管局部引流胆汁效果不佳或失败。     

肝门胆管癌介入治疗的疗效比较

近年来,我国胆管癌的发病率呈上升趋势.外科根治性切除仍然为其首选的治疗方式.根据Bismuth和Corlette分类法,Ⅰ、Ⅱ、Ⅲ及Ⅳ型胆管癌的切除率分别为100%、100%、47%、15.18%[1].Ⅲ和Ⅳ型肝门部胆管癌的切除率明显偏低,而胆管癌死亡的主要原因是胆道长期梗阻导致的肝肾功能进行性损害、胆道感染、肝脓肿等并发症.控制肿瘤的生长、维持胆道通畅成了Ⅲ及Ⅳ型肝门部胆管癌姑息性治疗的关键.     

Acetic acid sclerotherapy for treatment of a biliary leak from an isolated bile duct after hepatic surgery

Bile duct leakage from the main biliary tree is not uncommon after hepatic surgery. In this case, successful percutaneous treatment was performed for bile leakage from an isolated bile duct after left hemihepatectomy in a 48-year-old woman who underwent surgery for biliary cystadenocarcinoma and developed a biloma at the left subphrenic space. Diagnostic procedures revealed that the right posterior segmental bile duct drained aberrantly into the left bile duct, which remained undrained after resection and led to biloma formation. Ablation of the isolated bile duct was performed with acetic acid, resulting in avoidance of repeated operation and other complications.     

超声引导下行PTCS微创胆管取石的临床应用

难取性胆管结石指单用十二指肠镜难以取出的胆管结石,包括肝内胆管结石（含左右肝管结石）、结石直径大于20mm的多发胆总管结石及肝总管结石。我院自2005年6月以来应用超声介入经皮经肝纤维胆道镜（percutaneous transhepatic cholangioscopy,PTCS）微创治疗难取性胆管结石患者42例,疗效满意,现报告如下。     

Obstruction of the left hepatic duct: diagnosis and treatment by selective fine-needle cholangiography and percutaneous biliary drainage

Obstruction of the left hepatic duct due to periportal pathologic conditions was identified by fine-needle transhepatic cholangiography in 28 patients. Selective cholangiography of the left duct was performed in 30 instances and subsequent selective left-sided catheter decompression was carried out in 23 cases. Techniques for selective puncture and drainage of the left duct required procedure modifications to accommodate the specific anatomic and pathologic features of the obstructed left duct system. Ultrasonography was indispensable as an aid to delineation of the left duct anatomy for directing needle puncture. Accurate documentation and successful catheter drainage of left duct obstruction are important contributions to the total management of patients with high biliary obstruction.     

"囊腔穿刺闭式引流"术治疗肺腔包虫病的手术配合

肺包虫病是西藏畜牧区常见寄生虫病。对于该病的外科治疗目前尚无最佳治疗方法〔1〕。我院外科1990年1月~2006年1月间共收治25例孤立性、单房型肺包虫病,均采用在体外X线引导下行“囊腔穿刺闭式引流”术治疗,其疗效较临床上常用的“开胸内囊摘除”术式更佳。现就其手术配合体会     

肝癌介入治疗后并发急性上消化道出血的原因分析及治疗措施

目的 探讨肝癌介入治疗后并发急性上消化道大出血的原因及治疗措施。方法 分析1124例肝癌介入治疗后出现14例此类并发症的发生原因和治疗过程。12例经肝动脉注入化疗药并碘油化疗药乳剂(10ml～30m1)栓塞治疗，2例行单纯灌注化疗。结果 14例均在介入术后24h内出现上消化道大出血。经内科治疗后止血，无一例死亡。结论 碘油逆流入门静脉引起门静脉高压或加重原有门静脉高压是出血的主要原因，药物降低门静脉压和止血是治疗该症的有效方法。     

新型冠状病毒肺炎期间介入手术患者整体护理策略

目的探讨新型冠状病毒肺炎(新冠肺炎)期间介入手术患者的整体护理策略。方法选取浙江大学医学院附属第一医院肝胆胰介入中心新冠肺炎疫情期间行TACE治疗的32例患者为研究对象,综合采用院前筛查、病区管理、术前评估、术中防护、术后指导等一系列针对性护理策略,观察患者TACE成功率、患者就医满意度及新冠肺炎的防控成功率。结果 32例TACE治疗患者均顺利接受了TACE治疗,治疗成功率达100%,患者住院期间对医护人员的满意度达100%,且所有患者均顺利出院,患者和工作人员均未感染新冠肺炎。结论在科学防控的基础上通过有序实施整体护理和病房、介入手术室的疫情防控与管理,让患者得到了及时必要的诊疗及康复,确保了患者和医务人员安全,做到了防疫与治疗统筹兼顾。     

不同方法治疗脊柱骨折伴硬脊膜损伤术后脑脊液漏的疗效比较

目的 比较体位调节伤口加压包扎、经皮蛛网膜下置管脑脊液引流和术区持续引流至切口愈合时拔管缝合管口治疗脊柱骨折伴硬脊膜损伤术后脑脊液漏的疗效. 方法 选择2005年6月-2010年6月行脊柱骨折伴硬脊膜损伤手术后出现脑脊液漏的64例患者.采用体位调节伤口加压包扎治疗21例(A组),经皮蛛网膜下置管脑脊液引流治疗21例(B组),术区持续引流至切口愈合时拔管缝合管口治疗22例(C组),观察3组切口脑脊液漏消失和切口愈合时间及脑脊液漏初次治疗成功率和相关并发症发生率. 结果 A组脑脊液漏消失时间为(19.0±3.9)d,切口愈合时间为(25.0±4.6)d;13例Ⅰ期治疗切口愈合;8例初期治疗失败,6例出现并发症,经相关治疗后痊愈.B组脑脊液漏消失时间为(3.0±1.0)d,切口愈合时间为(16.0 ±2.6)d;15例Ⅰ期治疗成功;6例初期治疗失败,行后续治疗愈合,无并发症发生.C组无脑脊液漏,切口Ⅰ期愈合时间为(13.0±1.0)d;均Ⅰ期治疗成功,无并发症发生;切口愈合时间短于A、B组两组(P＜0.05),Ⅰ期治疗成功率高于A、B组两组(P＜0.05). 结论 术区持续引流至切口愈合时拔管缝合管口治疗脊柱骨折伴硬脊膜损伤术后脑脊液漏切口愈合好,脑脊液漏初次治疗成功率高,并发症少,是一种较好的治疗方法.     

Contrast-enhanced MRI combined with MR cholangiopancreatography for the evaluation of patients with biliary strictures: differentiation of malignant from benign bile duct strictures

PURPOSE: To determine imaging criteria for the combined use of contrast-enhanced (CE)-MRI and MR cholangiopancreatography (MRCP) to differentiate malignant from benign biliary strictures. MATERIALS AND METHODS: A total of 44 patients with biliary stricture who had undergone unenhanced, MRCP, and dynamic MRI were identified from radiological and surgical databases. Two radiologists analyzed MR features for asymmetry, luminal irregularity, abrupt narrowing, outer margin, signal intensity (SI) on T2-weighted (T2W) images, and hyperenhancement relative to liver parenchyma during portal phase. The wall thickness and length of the narrowed segment were measured. MR findings relevant as predictors were identified using a Chi-square or Fisher's exact test and the odds ratio (OR). RESULTS: The presence of hyperenhancement relative to liver parenchyma, length > 12 mm, wall thickness > 3 mm, indistinct outer margin, luminal irregularity, and asymmetry of strictured bile duct were significant factors for malignancy (P < 0.05). Malignant strictures were significantly thicker (5.0 +/- 2.0 mm) and longer (27.0 +/- 13.6 mm) than benign strictures. When any three or more of these six criteria were used in combination, we could identify 100% of malignant strictures and 87.0% of benign strictures. CONCLUSION: The combined use of CE-MRI and MRCP helped to define the criteria for differentiating malignant from benign biliary strictures in our data.