超聲引導(dǎo)經(jīng)皮經(jīng)肝支架置入在膽道惡性梗阻中的應(yīng)用

1、超聲引導(dǎo)經(jīng)皮經(jīng)肝支架置入在膽道惡性梗阻中的應(yīng)用         08-07-21 14:30:00     編輯：studa20           作者：汪濤 田伏洲 蔡忠紅 湯禮軍 李旭 陳濤 石力【摘要】  目的 探討超聲引導(dǎo)經(jīng)皮經(jīng)肝支架置入技術(shù)在膽道惡性梗阻中的治療意義。方法 16例惡性膽道梗阻患者，采用B超引導(dǎo)經(jīng)皮經(jīng)肝膽管穿刺置管外引流，并膽道造影后行金屬支

2、架置入。結(jié)果 膽道支架置入成功率100%，2例術(shù)后分別出現(xiàn)膽道及腹腔內(nèi)出血，保守治療控制。術(shù)后14周黃疸消除率87.5%。最短生存時(shí)間2個(gè)月，最長(zhǎng)18個(gè)月，中位生存時(shí)間6.8個(gè)月。6例隨訪期間出現(xiàn)膽道再梗阻，其中3例經(jīng)B超引導(dǎo)經(jīng)皮經(jīng)肝膽道(PTCD)外引流+膽道沖洗再通，另3例因腫瘤長(zhǎng)入，長(zhǎng)期PTCD外引流。結(jié)論 (1)膽道金屬支架減黃效果確切，并能原位恢復(fù)膽道的生理連續(xù)性；(2)超聲介導(dǎo)技術(shù)可提高膽道金屬支架置入成功率；(3)充分有效的膽汁外引流能減少支架置入的相關(guān)并發(fā)癥，也為膽道再梗阻提出了解決的途徑。 【關(guān)鍵詞】  膽道梗阻 支架置入 經(jīng)皮經(jīng)肝 超聲引導(dǎo)  

3、     【Abstract】  Objective  To explore the effect of percutaneous transhepatic metallic stent placement (PTMSP) on patients with malignant biliary obstruction (MBO) under ultrasonic guidance (UG). MethodsThe clinical data of 16 patients with MBO were analyzed retrospect

4、ively. All the patients underwent percutaneous transhepatic cholangial drainage (PTCD) under UG, and PTMSP was then performed according to cholangiograpy. Results  The successful rate of PTMSP was 100%. Biliary hemorrhage occured in 1 case and abdominal cavity hemorrhage in another after stent

5、placement, but both patients were cured by preservative therapy. Jaundice disappeared in 14 cases (87.5%) within postoperative 4 weeks. The survival time was 2-18 months (average 6.8 months). Biliary reobstruction was found in 6 cases during the followup period, the bile duct was reopened in three o

6、f them with the management of PTCD and bile duct flush, and the other 3 cases accepted longterm PTCD. Conclusions  PTMSP is an ideal palliative therapy under ultrasonic guidance for malignant biliary obstruction and effective PTCD can reduce the relevant complications of PTMSP and offer a manag

7、ement for biliary reobstruction.    【Key words】  Biliary obstruction; Stent placement; Percutaneous transhepatic; Ultrasonic guidance    姑息性膽道內(nèi)引流是治療膽道惡性梗阻的重要手段，可消除黃疸、控制感染、保護(hù)肝臟功能和改善癥狀。與傳統(tǒng)外科手術(shù)行膽腸吻合相比較，通過介入技術(shù)放置膽道支架不僅能有效引流膽汁，更兼有微創(chuàng)、痛苦少、并發(fā)癥低和住院時(shí)間短等特點(diǎn)，且能實(shí)現(xiàn)在原位恢復(fù)膽道的生理連續(xù)性。我們

8、近年對(duì)16例膽道惡性梗阻患者實(shí)施了B超引導(dǎo)的經(jīng)皮經(jīng)肝金屬支架置入術(shù)，報(bào)告如下。    1  資料和方法    1.1  臨床資料    多種惡性腫瘤導(dǎo)致膽道梗阻患者16例，男性12例，女性4例，年齡2678歲，臨床上均有不同程度的皮膚、鞏膜黃染及肝功異常，血清總膽紅素明顯升高(104.2583 mol/L)。按梗阻部位：高位梗阻(左右肝管匯合平面及以上)2例，其中肝癌、膽囊癌各1例；中位梗阻(肝總管至膽總管中段平面)2例，其中肝癌、胰腺癌各1例；低位梗阻(膽總管下段及以下)12例。本組

9、患者伴有膽道感染6例，陶土便7例，凝血功能異常8例。    1.2  儀器及材料    日本Aloka SSD680EX彩超機(jī)，探頭頻率3.5 MHz，MP2411B穿刺架。6F多孔導(dǎo)管(帶針芯)，Arrow金屬引導(dǎo)絲，COOK自膨式鎳鈦合金膽道金屬支架(ZIV78086.0)，0.035超滑導(dǎo)絲及球囊擴(kuò)張管。500 mA放射機(jī)(3200HGDAR299,SHIMADZU)。    1.3  方法     2  結(jié)果 

10、0;  2.1  B超引導(dǎo)經(jīng)皮經(jīng)肝支架置入    本組膽道支架置入成功率100%。9例經(jīng)右前支擴(kuò)張膽管穿刺建立經(jīng)皮經(jīng)肝通道，7例經(jīng)左外下支膽管穿刺建立經(jīng)皮經(jīng)肝通道，隨后置入膽道支架。其中1例膽囊癌致肝門膽管梗阻，行右肝膽道支架置入并超聲介導(dǎo)左肝內(nèi)膽管PTCD外引流；1例肝癌壓迫右肝管行右肝管支架置入；另14例中低位膽道梗阻患者膽道金屬支架釋放遵循如下原則：支架中點(diǎn)與狹窄中點(diǎn)重合，支架應(yīng)跨越狹窄兩端1.0 cm以上，胰頭及壺腹腫瘤患者支架置于十二指腸內(nèi)長(zhǎng)度23 cm。    2.2  并發(fā)癥    1例支架置入術(shù)后出現(xiàn)膽道出血，表現(xiàn)為PTCD管血性膽汁流出。經(jīng)膽道持續(xù)滴注冰鹽水、去甲腎上腺素和凝血酶混合液，3 d后出血停止，造影示支架通暢，拔除PTCD管。另1例于支架置入后6 h出現(xiàn)血壓下降、脈搏增快和血紅蛋白下降，B超檢查及診斷性腹腔穿刺結(jié)果顯示腹腔內(nèi)出血。其原因可能與術(shù)前血小板減少、凝血功能障礙及機(jī)械性創(chuàng)傷等有關(guān)，經(jīng)保守治療，5 d后病情穩(wěn)定，11 d后平穩(wěn)出院。本組無膽道感染、膽漏、膽道及十二指腸穿孔發(fā)生。  &#