介入放射学：第二章 经皮穿刺引流术

经皮穿刺引流术SchoolofOphthalmology&OptometryWenzhouMedicalCollege简述人体管道、体腔或器官组织内的病理性积液、血肿、脓肿或胆汁、胰液、尿液等体液郁积达到一定容量时，就会出现临床症状，甚至危及生命。WenzhouMedicalCollege应用对象全身各部位的脓肿、囊肿、浆膜腔积液、胆道或泌尿道梗阻、颅内血肿WenzhouMedicalCollege目的1.诊断：细胞学、细菌学、生化检测2.治疗：局部抗炎、引流、减压、消炎、囊肿灭能SchoolofOphthalmology&OptometryWenzhouMedicalCollege

器材与操作技术WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege通常由穿刺针、微导丝、交换导管组成。多数包装在一起。微穿刺系统SchoolofOphthalmology&OptometryWenzhouMedicalCollege微导丝普通导丝超滑导丝CopeMandril导丝Lunderquist导丝WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege引流导管直径多为7-14F，8-10F最常用，进入引流区的一段有多个侧孔。头端弯曲或膨大。SchoolofOphthalmology&OptometryWenzhouMedicalCollege内外引流管主要用于胆道的内外引流。SchoolofOphthalmology&OptometryWenzhouMedicalCollege内外引流导管WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege

粗针套管针WenzhouMedicalCollege细针套合穿刺针SchoolofOphthalmology&OptometryWenzhouMedicalCollege固定器械

丝线胶布固定盘：是解决长期固定引流管的较好器械之一。WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege操作方法Seldinger法套管法WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollegeSeldinger法WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollegeSeldinger法术前准备设备及器材准备患者准备：签字、皮试、化验，术前禁食2-4小时，术前30分钟肌注镇静药穿刺及引流通道设计WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege穿刺及引流通道设计穿刺途径尽量避开占位性病变、生理管腔和邻近脏器必须影像学导向，定好进针方向及深度皮肤上做好标记浅吸气后屏气，穿刺到位后平静呼吸。脓肿穿刺选择的引流通道应包含1cm以上的脓肿壁与脏器表面之间的正常组织，并且引流途径最短。SchoolofOphthalmology&OptometryWenzhouMedicalCollege操作方法SchoolofOphthalmology&OptometryWenzhouMedicalCollege注意事项引流管侧孔段应尽量置于引流区的最低处冲洗引流管需慎重，应避免加压冲洗避免牵拉引流管，以防脱出如缝线失去固定作用，应重新设法固定导管(如改用固定盘)WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege套管法WenzhouMedicalCollege套管法使用套管针在影像学导引下一次性完成穿刺和引流操作。术前准备：同Seldinger法。操作方法注意事项穿刺针道较粗，不宜反复穿刺；穿刺进程中，令患者浅吸气后屏气。套管法1套管法2SchoolofOphthalmology&OptometryWenzhouMedicalCollege适应症和禁忌症适应症：正常人体管道阻塞体腔内由于病理原因引起脏器功能受损或毒性物质不能排出实质脏器内的积液或积脓引起症状者SchoolofOphthalmology&OptometryWenzhouMedicalCollege禁忌症：严重的心、肺、肾功能不全凝血机制异常SchoolofOphthalmology&OptometryWenzhouMedicalCollege不良反应及并发症脏器损伤感染出血引流管阻塞及脱位SchoolofOphthalmology&OptometryWenzhouMedicalCollegeWenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollegeWenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege胆道梗阻SchoolofOphthalmology&OptometryWenzhouMedicalCollege胆道梗阻

阻塞按部位分成

肝外机械性梗阻结石肿瘤淋巴结压迫肝内非机械性梗阻肝炎病毒感染所致的毛细胆管型肝炎原发性胆汁性肝硬化引起阻塞性黄疸临床症状巩膜与皮肤黄染，明显搔痒实验室检查血胆红素升高，以直接胆红素为主WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollegeWenzhouMedicalCollege术前减压提高手术成功率并减少术后严重并发症，降低术后死亡率永久性姑息性治疗胆肠吻合口狭窄无法手术切除的肿瘤引起的胆道狭窄胆道梗阻导致的败血症

适应症SchoolofOphthalmology&OptometryWenzhouMedicalCollege禁忌证

凝血功能障碍大量腹水脓毒血症及败血症是相对禁忌症WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege外引流操作方法

WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege注意事项

术前抗炎、支持、对症治疗如左右肝管均梗阻，最好分别穿刺插管引流，或对最大的分支作引流一旦引流管脱出，立即重放监测生命体征和症状变化，记录每天引流胆汁量，定期检测胆红素及电解质WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege经皮经肝胆道内

——外引流术WenzhouMedicalCollege在外引流术的基础上，用较长引流管使胆汁经引流管同时既作体外引流又可引入胆总管下端或十二指肠，称为胆道内-外引流术

SchoolofOphthalmology&OptometryWenzhouMedicalCollege优点可防止胆汁过多丢失引起的消化不良和电解质紊乱保留外引流通道可以方便引流管的定期冲洗防止侧孔堵塞，便于胆道造影复查为下一步的胆道球囊扩张术及支架植入术打下基础WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollegeWenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollegeWenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege并发症

胆汁瘘胆道出血胆管感染引流管脱位或闭塞

WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege疗效评价

可以提高患者生活质量。术后生存期取决于引起胆道梗阻的原发性病灶。WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollegeWenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege泌尿道梗阻

WenzhouMedicalCollege儿童以畸形多见；成人常为结石、创伤、炎症、结核、肿瘤(肿瘤压迫或放射治疗后疤痕收缩)；妇女可能与盆腔内疾病有关；老年男性与前列腺肥大有关。

SchoolofOphthalmology&OptometryWenzhouMedicalCollege介入放射学治疗手段经皮穿刺肾盂造瘘术；取石、扩张成形术、支架术等。WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege用于诊断

(1)明确诊断尿路梗阻的部位及原因

(2)顺行输尿管灌注造影鉴别梗阻性与非梗阻性尿路扩张。

(3)肾盂输尿管刷片活检。用于治疗

解除尿路梗阻所致的肾盂肾盏和上段输尿管扩张；输尿管瘘者作上段尿分流；扩张狭窄的输尿管或灌注药物；引流后作其它腔内介入治疗，如取石、活检或肾镜检查等。WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege禁忌证：出血性或凝血障碍性疾病。严重高血压，为相对禁忌证，药物降压后仍可作造瘘术。穿刺道局部感染者。

WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege操作方法

Seldinger法Cope法WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege并发症常见并发症有：尿瘘、疼痛、出血、感染与毒血症、肾周围脓肿、尿囊肿、导管阻塞等。WenzhouMedicalCollege解除梗阻后肾功能恢复情况一般认为,1周以内的完全性梗阻解除后,肾功能可完全恢复;完全性梗阻2周,在解除梗阻后3~4月,仅能恢复70%;4周以上者,恢复至30%;8周以上者几乎完全丧失。SchoolofOphthalmology&OptometryWenzhouMedicalCollege肾囊性病变多囊肾(polycysticrenaldisease)单纯性肾囊肿(simplerenalcyst)介入治疗以穿刺引流术为主WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege适应证：大囊肿压迫肾动脉；压迫尿路；囊肿感染等。禁忌证：不能纠正的出血体质。WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege注意事项必须无菌操作刺入囊腔后，将套管推进达囊肿最低处将全部囊液作离心沉淀后检验，明确病变性质多囊肾的抽吸应选最大的囊腔，并尽量争取一针能同时通过几个囊腔，先抽吸离皮肤穿刺点最远的，最后抽吸距皮肤最近的囊液WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege经皮穿刺肾囊肿抽吸术SchoolofOphthalmology&OptometryWenzhouMedicalCollege经皮穿刺肾囊肿抽吸术SchoolofOphthalmology&OptometryWenzhouMedicalCollege肝脓肿症状乏力、发热与腹痛为主，其次为盗汗、消瘦、厌食、恶心与腹泻等，表现常不典型体征有肝肿大、发热与右上腹痛WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege穿刺置管引流术适应证：已有液化区的肝内脓肿禁忌证：凝血功能异常者、有腹水者WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege操作方法Seldinger法套管法WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege注意事项

套管法穿刺要求穿刺一次成功要选择带外鞘引流导管针多发性或分隔多房性肝脓肿需要多管引流反复冲洗脓腔。拔管前影像复查。WenzhouMedicalCollegeSchoolofOphthalmology&OptometryWenzhouMedicalCollege注意事项引流管置入后避免加压冲洗一般留管10天左右，拔管之前应再作脓腔造影或其它影像学检查证实脓腔缩小消失，即可拔管WenzhouMedicalCollegeSchoolofOphthalmology&