介入放射學(xué)：第二章 經(jīng)皮穿刺引流術(shù)

經(jīng)皮穿刺引流術(shù)SchoolofOphthalmology&OptometryWenzhouMedicalCollege簡(jiǎn)述人體管道、體腔或器官組織內(nèi)的病理性積液、血腫、膿腫或膽汁、胰液、尿液等體液郁積達(dá)到一定容量時(shí)，就會(huì)出現(xiàn)臨床癥狀，甚至危及生命。WenzhouMedicalCollege應(yīng)用對(duì)象全身各部位的膿腫、囊腫、漿膜腔積液、膽道或泌尿道梗阻、顱內(nèi)血腫WenzhouMedicalCollege目的1.診斷：細(xì)胞學(xué)、細(xì)菌學(xué)、生化檢測(cè)2.治療：局部抗炎、引流、減壓、消炎、囊腫滅能SchoolofOphthalmology&OptometryWenzhouMedicalCollege

器材與操作技術(shù)WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege通常由穿刺針、微導(dǎo)絲、交換導(dǎo)管組成。多數(shù)包裝在一起。微穿刺系統(tǒng)SchoolofOphthalmology&OptometryWenzhouMedicalCollege微導(dǎo)絲普通導(dǎo)絲超滑導(dǎo)絲CopeMandril導(dǎo)絲Lunderquist導(dǎo)絲WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege引流導(dǎo)管直徑多為7-14F，8-10F最常用，進(jìn)入引流區(qū)的一段有多個(gè)側(cè)孔。頭端彎曲或膨大。SchoolofOphthalmology&OptometryWenzhouMedicalCollege內(nèi)外引流管主要用于膽道的內(nèi)外引流。SchoolofOphthalmology&OptometryWenzhouMedicalCollege內(nèi)外引流導(dǎo)管WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege

粗針套管針WenzhouMedicalCollege細(xì)針套合穿刺針SchoolofOphthalmology&OptometryWenzhouMedicalCollege固定器械

絲線膠布固定盤(pán)：是解決長(zhǎng)期固定引流管的較好器械之一。WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege操作方法Seldinger法套管法WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollegeSeldinger法WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollegeSeldinger法術(shù)前準(zhǔn)備設(shè)備及器材準(zhǔn)備患者準(zhǔn)備：簽字、皮試、化驗(yàn)，術(shù)前禁食2-4小時(shí)，術(shù)前30分鐘肌注鎮(zhèn)靜藥穿刺及引流通道設(shè)計(jì)WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege穿刺及引流通道設(shè)計(jì)穿刺途徑盡量避開(kāi)占位性病變、生理管腔和鄰近臟器必須影像學(xué)導(dǎo)向，定好進(jìn)針?lè)较蚣吧疃绕つw上做好標(biāo)記淺吸氣后屏氣，穿刺到位后平靜呼吸。膿腫穿刺選擇的引流通道應(yīng)包含1cm以上的膿腫壁與臟器表面之間的正常組織，并且引流途徑最短。SchoolofOphthalmology&OptometryWenzhouMedicalCollege操作方法SchoolofOphthalmology&OptometryWenzhouMedicalCollege注意事項(xiàng)引流管側(cè)孔段應(yīng)盡量置于引流區(qū)的最低處沖洗引流管需慎重，應(yīng)避免加壓沖洗避免牽拉引流管，以防脫出如縫線失去固定作用，應(yīng)重新設(shè)法固定導(dǎo)管(如改用固定盤(pán))WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege套管法WenzhouMedicalCollege套管法使用套管針在影像學(xué)導(dǎo)引下一次性完成穿刺和引流操作。術(shù)前準(zhǔn)備：同Seldinger法。操作方法注意事項(xiàng)穿刺針道較粗，不宜反復(fù)穿刺；穿刺進(jìn)程中，令患者淺吸氣后屏氣。套管法1套管法2SchoolofOphthalmology&OptometryWenzhouMedicalCollege適應(yīng)癥和禁忌癥適應(yīng)癥：正常人體管道阻塞體腔內(nèi)由于病理原因引起臟器功能受損或毒性物質(zhì)不能排出實(shí)質(zhì)臟器內(nèi)的積液或積膿引起癥狀者SchoolofOphthalmology&OptometryWenzhouMedicalCollege禁忌癥：嚴(yán)重的心、肺、腎功能不全凝血機(jī)制異常SchoolofOphthalmology&OptometryWenzhouMedicalCollege不良反應(yīng)及并發(fā)癥臟器損傷感染出血引流管阻塞及脫位SchoolofOphthalmology&OptometryWenzhouMedicalCollegeWenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollegeWenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege膽道梗阻SchoolofOphthalmology&OptometryWenzhouMedicalCollege膽道梗阻

阻塞按部位分成

肝外機(jī)械性梗阻結(jié)石腫瘤淋巴結(jié)壓迫肝內(nèi)非機(jī)械性梗阻肝炎病毒感染所致的毛細(xì)膽管型肝炎原發(fā)性膽汁性肝硬化引起阻塞性黃疸臨床癥狀鞏膜與皮膚黃染，明顯搔癢實(shí)驗(yàn)室檢查血膽紅素升高，以直接膽紅素為主WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollegeWenzhouMedicalCollege術(shù)前減壓提高手術(shù)成功率并減少術(shù)后嚴(yán)重并發(fā)癥，降低術(shù)后死亡率永久性姑息性治療膽腸吻合口狹窄無(wú)法手術(shù)切除的腫瘤引起的膽道狹窄膽道梗阻導(dǎo)致的敗血癥

適應(yīng)癥SchoolofOphthalmology&OptometryWenzhouMedicalCollege禁忌證

凝血功能障礙大量腹水膿毒血癥及敗血癥是相對(duì)禁忌癥WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege外引流操作方法

WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege注意事項(xiàng)

術(shù)前抗炎、支持、對(duì)癥治療如左右肝管均梗阻，最好分別穿刺插管引流，或?qū)ψ畲蟮姆种ё饕饕坏┮鞴苊摮?，立即重放監(jiān)測(cè)生命體征和癥狀變化，記錄每天引流膽汁量，定期檢測(cè)膽紅素及電解質(zhì)WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege經(jīng)皮經(jīng)肝膽道內(nèi)

——外引流術(shù)WenzhouMedicalCollege在外引流術(shù)的基礎(chǔ)上，用較長(zhǎng)引流管使膽汁經(jīng)引流管同時(shí)既作體外引流又可引入膽總管下端或十二指腸，稱為膽道內(nèi)-外引流術(shù)

SchoolofOphthalmology&OptometryWenzhouMedicalCollege優(yōu)點(diǎn)可防止膽汁過(guò)多丟失引起的消化不良和電解質(zhì)紊亂保留外引流通道可以方便引流管的定期沖洗防止側(cè)孔堵塞，便于膽道造影復(fù)查為下一步的膽道球囊擴(kuò)張術(shù)及支架植入術(shù)打下基礎(chǔ)WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollegeWenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollegeWenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege并發(fā)癥

膽汁瘺膽道出血膽管感染引流管脫位或閉塞

WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege療效評(píng)價(jià)

可以提高患者生活質(zhì)量。術(shù)后生存期取決于引起膽道梗阻的原發(fā)性病灶。WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollegeWenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege泌尿道梗阻

WenzhouMedicalCollege兒童以畸形多見(jiàn)；成人常為結(jié)石、創(chuàng)傷、炎癥、結(jié)核、腫瘤(腫瘤壓迫或放射治療后疤痕收縮)；婦女可能與盆腔內(nèi)疾病有關(guān)；老年男性與前列腺肥大有關(guān)。

SchoolofOphthalmology&OptometryWenzhouMedicalCollege介入放射學(xué)治療手段經(jīng)皮穿刺腎盂造瘺術(shù)；取石、擴(kuò)張成形術(shù)、支架術(shù)等。WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege用于診斷

(1)明確診斷尿路梗阻的部位及原因

(2)順行輸尿管灌注造影鑒別梗阻性與非梗阻性尿路擴(kuò)張。

(3)腎盂輸尿管刷片活檢。用于治療

解除尿路梗阻所致的腎盂腎盞和上段輸尿管擴(kuò)張；輸尿管瘺者作上段尿分流；擴(kuò)張狹窄的輸尿管或灌注藥物；引流后作其它腔內(nèi)介入治療，如取石、活檢或腎鏡檢查等。WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege禁忌證：出血性或凝血障礙性疾病。嚴(yán)重高血壓，為相對(duì)禁忌證，藥物降壓后仍可作造瘺術(shù)。穿刺道局部感染者。

WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege操作方法

Seldinger法Cope法WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege并發(fā)癥常見(jiàn)并發(fā)癥有：尿瘺、疼痛、出血、感染與毒血癥、腎周圍膿腫、尿囊腫、導(dǎo)管阻塞等。WenzhouMedicalCollege解除梗阻后腎功能恢復(fù)情況一般認(rèn)為,1周以內(nèi)的完全性梗阻解除后,腎功能可完全恢復(fù);完全性梗阻2周,在解除梗阻后3~4月,僅能恢復(fù)70%;4周以上者,恢復(fù)至30%;8周以上者幾乎完全喪失。SchoolofOphthalmology&OptometryWenzhouMedicalCollege腎囊性病變多囊腎(polycysticrenaldisease)單純性腎囊腫(simplerenalcyst)介入治療以穿刺引流術(shù)為主WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege適應(yīng)證：大囊腫壓迫腎動(dòng)脈；壓迫尿路；囊腫感染等。禁忌證：不能糾正的出血體質(zhì)。WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege注意事項(xiàng)必須無(wú)菌操作刺入囊腔后，將套管推進(jìn)達(dá)囊腫最低處將全部囊液作離心沉淀后檢驗(yàn)，明確病變性質(zhì)多囊腎的抽吸應(yīng)選最大的囊腔，并盡量爭(zhēng)取一針能同時(shí)通過(guò)幾個(gè)囊腔，先抽吸離皮膚穿刺點(diǎn)最遠(yuǎn)的，最后抽吸距皮膚最近的囊液WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege經(jīng)皮穿刺腎囊腫抽吸術(shù)SchoolofOphthalmology&OptometryWenzhouMedicalCollege經(jīng)皮穿刺腎囊腫抽吸術(shù)SchoolofOphthalmology&OptometryWenzhouMedicalCollege肝膿腫癥狀乏力、發(fā)熱與腹痛為主，其次為盜汗、消瘦、厭食、惡心與腹瀉等，表現(xiàn)常不典型體征有肝腫大、發(fā)熱與右上腹痛WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege穿刺置管引流術(shù)適應(yīng)證：已有液化區(qū)的肝內(nèi)膿腫禁忌證：凝血功能異常者、有腹水者WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege操作方法Seldinger法套管法WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege注意事項(xiàng)

套管法穿刺要求穿刺一次成功要選擇帶外鞘引流導(dǎo)管針多發(fā)性或分隔多房性肝膿腫需要多管引流反復(fù)沖洗膿腔。拔管前影像復(fù)查。WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege注意事項(xiàng)引流管置入后避免加壓沖洗一般留管10天左右，拔管之前應(yīng)再作膿腔造影或其它影像學(xué)檢查證實(shí)膿腔縮小消失，即可拔管WenzhouMedicalCollegeSchoolofOphthalmology&