Percutaneous transhepatic biliary drainage (PTCD) uses a special puncture needle to percutaneously penetrate the intrahepatic bile duct under the guidance of Rapid imaging was performed, and biliary drainage was performed through the contrast tube. It is an important treatment technology in current biliary surgery and has been widely used in clinical practice.
This method is a minimally invasive treatment, but complications such as bile leakage, bleeding, and biliary infection may occur. The coagulation function should be checked and vitamin K should be injected for 2-3 days before surgery, and antibiotics should be used if necessary. It has become a common method for current biliary tract treatment.
1. Clinical significance:
1. PTCD can reduce stress, reduce jaundice, relieve symptoms, improve general condition, conduct elective surgery, increase surgical safety, reduce complications, and reduce mortality rate. It is especially suitable for elderly patients, those with frailty, poor general condition, insufficiency of important organs and severe shock.
2. It can be flushed through the drainage tube, antibiotics can be instilled, and multiple angiograms can be performed.
3. Through an indwelling catheter, compound tangerine oil emulsion can be infused for stone dissolving treatment. Chemotherapy, radiotherapy, cytological examination, and transsinus cholecystoscopy can also be used to remove stones.
2. Indications:
1. For malignant biliary obstruction caused by advanced tumors, palliative biliary drainage is performed.
2. Preoperative preparation for patients with severe jaundice (including benign and malignant lesions).
3. For acute biliary tract infection, such as acute obstructive suppurative cholangitis, emergency biliary decompression and drainage should be performed to convert emergency surgery into elective surgery.
4. Benign biliary stricture, after multiple biliary repairs, biliary reconstruction and biliary-enteric anastomotic stenosis.
5. Chemotherapy, radiotherapy, litholysis, cytological examination, and percutaneous fiberoptic choledochoscopy to remove stones through drainage tubes.
3. Contraindications:
1. Those who are allergic to iodine, have severe coagulation disorders, severe heart, liver, and kidney failure and large amounts of ascites.
2. The intrahepatic bile duct is divided into multiple cavities by the tumor and cannot drain the entire bile duct system.
3. Ultrasound examination confirmed that there was a large fluid level in the liver and the Casoni test was positive. Hepatic echinococcosis was suspected.
4. Surgical steps:
1. Preoperative preparation, puncture method and PTC.
2. Use a 22-gauge fine needle for PTC angiography to determine the location and nature of the lesion.
3. Based on the angiography results, select a thick, straight, horizontal bile duct for internal drainage and intubation.
4. Make a puncture point from the 8th to 9th intercostal space on the right midaxillary line. After local anesthesia, use a sharp knife to poke a small opening in the skin. Instruct the patient to pause breathing, and quickly insert the needle into the pre-selected bile duct under TV monitoring. When there is a sense of breakthrough into the bile duct, pull out the needle core, insert the guide wire after the bile flows out smoothly, and continuously rotate and change the direction to make the guide wire The wire enters the distal bile duct or duodenum through the obstructed end or stenotic segment, withdraws the puncture needle, uses a dilation tube to dilate the channel, and then passes the multi-side hole catheter along with the guide wire through the obstructed end or stenotic segment so that the side holes of the catheter are located in the obstruction The catheter is fixed above and below the end or the narrowed segment. After the bile flows smoothly from the catheter, a contrast agent is injected and a film is taken.
5. After one week of drainage, perform another angiography to observe the catheter position and drainage effect.
5. Precautions during the operation:
1. To ensure successful intubation, the needle tail of the puncture needle can be tilted 10° to 15° cephalad to allow the needle tip to enter the bile duct The back is slightly tilted downward to facilitate the guidewire to go down smoothly along the bile duct and enter the narrow distal end or duodenum. If the guidewire enters parallel or the needle tip is upward, the guidewire will easily hit the opposite side tube wall and curl or the guidewire will be upward and can Enter the left hepatic duct.
2. Although PTC shows biliary obstruction, sometimes the guidewire can still enter the duodenum through the obstructed end. If the catheter cannot pass through the obstruction, proximal drainage can be performed for 5 to 7 days to allow the biliary tract to enter the duodenum. After the inflammatory edema caused by the infection subsides, the guidewire and catheter are inserted to the distal end of the obstruction.
3. The drainage catheter should be prevented from falling off and being blocked. Flush with 5 to 10 ml of normal saline 1 to 2 times a day, and replace the catheter every 3 days. If there is fever after long-term catheter placement, it means that the catheter is clogged or displaced and the catheter needs to be replaced. Generally, after 10 to 14 days of drainage, a granulation channel larger than the catheter has been formed in the liver parenchyma. If the catheter falls off, the catheter can be reinserted within 24 hours under the guidance of a guidewire.
4. There are four situations of tube detachment: ① After surgery, the diaphragm and liver move up and down with breathing, so the drainage tube cannot be completely left in the bile duct cavity, showing that the drainage tube is not smooth; ② Tube prolapse Liver parenchyma; ③The tube protrudes into the abdominal cavity; ④It is not firmly fixed or is accidentally pulled out by the patient. To prevent decannulation, try to insert the cannula 3 to 4 cm deep into the bile duct during catheter placement. When there is no guidewire to penetrate the bile duct, do not rush to insert the cannula straight into the bile duct. Therefore, if the bile duct is blocked by stones or the angle is small, the cannula may enter the liver parenchyma along the original needle tract. After the contrast agent is injected, the bile duct will expand and thicken compared with before puncture, the stones will loosen, and the angle will increase. Then slowly insert the cannula. Easy to penetrate deep into the bile duct cavity.
6. Preoperative care:
1. Psychological care, patiently provide psychological counseling to patients and their families, explain the purpose, significance, and methods of PTCD puncture, and introduce the same type of care Cases that have improved or been successfully cured. Enhance patients' confidence in overcoming the disease.
2. Understand the patient’s condition before surgery and propose nursing measures for predictive nursing issues. For example, if the liver function is poor and there is a tendency for bleeding, cooperate with the doctor to use hemostatic drugs and take care of the liver. If the infection is serious, antibiotics should be used and the patient should be advised to rest.
3. Inform the patient of the operation time and instruct the patient to fast and drink before the operation.
7. Postoperative care:
1. You need to stay in bed for 24 hours after the operation, and monitor vital signs every 2 hours for one day.
2. Properly fix the PTCD drainage tube and observe the color, nature and amount of the drainage fluid. Keep the PTCD tube drainage smoothly to prevent pressure and falling off. Change the drainage bag twice a week and pay attention to sterility to prevent retrograde infection. .
3. Observe abdominal signs, observe whether there are progressively enlarging masses in the upper abdomen and peritoneal irritation, and report to the doctor for treatment in a timely manner.
4. Use antibiotics, hemostatic drugs and vitamin K for transfusion as directed by the doctor, and pay attention to electrolyte balance and nutritional supplement.
5. If the patient is discharged from the hospital with a PTCD tube, teach the patient and his family how to care for the tube and what precautions should be taken, especially to keep the tube fixed and the drainage smooth. If any discomfort occurs, return to the hospital immediately for treatment.
8. Instructions for discharge with a tube:
1. Instruct the patient and family members to observe whether the amount and color of bile are abnormal after the patient is discharged from the hospital with a tube. Normal bile is brown-yellow, and infectious bile is black-green. Normally, the drainage volume is >200ml in 24 hours. If no bile is extracted, the amount of bile extracted is too little, bloody bile and other abnormalities, medical staff should be reported in time.
2. Avoid fatigue, move appropriately, and turn over. Use safety pins to secure the hem of your top while standing. Avoid twisting, bending, and detachment.
3. Regularly review blood biochemical indicators. If abdominal pain, chills, high fever, jaundice, etc. occur, you should seek medical treatment in time to identify whether there is a biliary infection as soon as possible and perform tube adjustment or tube replacement.
4. Replace the drainage bag regularly, and protect the drainage tube for those with permanent drainage. Replace the drainage tube every 3 to 6 months.
5. People with biliary stent implantation should avoid eating high-fiber foods, such as bamboo shoots, corn, etc., to prevent the stent lumen from clogging.
6. Regular outpatient follow-up.