T管放置的改进的.pptVIP

胆道探查后T管放置的改进 北京医院普外科肝胆组 陈剑 Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd. T管留置的价值和历史沿革 1889年Kehr首创T管引流,沿用至今100余年已经成为胆道探查手术之常规 有利于减轻术后胆道压力,可降低因反复探查乳头开口水肿,胆汁引流不畅而致的胆道压力增高,降低胆瘘发生率 支架作用,可防术后胆道狭窄 为后续的胆道镜治疗建立出入口 Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd. Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd. T管留置后的弊端 病人活动不便,痛苦大,经济负担大 术后住院时间长,一般在2-3周，床位周转慢 胆汁丢失,水电解质代谢和消化功能异常,影响病人术后康复 术中(尤腹腔镜下)置管操作困难 T管相关并发症 Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd. T管相关并发症1 2001.1.-12.25,共135篇有关T管的报道,47篇题目是关于T管并发症的,占34.8%.1974-2002.12共880篇/172篇 胆瘘/胆汁性腹膜炎: (占并发症报道文章数的80%以上)可发生于带管和拔管时。原因有 拔除Ｔ管时：拔除过早/瘘道形成不牢(T管材质和透明质酸钠)／操作粗暴／放置不当（缝合／双臂过长） 带管时：活动时不慎／腹胀／咳嗽/缝合固定不仔细 Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd. T管相关并发症2 十二指肠瘘 胆道感染和T管周围感染 T管断裂残留于胆管内—成石核心/梗阻/感染/肝硬化 T管滑脱 胆道梗阻 T管置入假道 狭窄/息肉:30例连续术后胆道镜观察,2例出现上方狭窄,4例瘘道开口有息肉样增生物 Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd. T管滑脱后插管造影 Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd. T管上臂过长 Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd. Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd. 解决之道 不放置T管 改变探查入路 胆囊管入路 微切开入路 一期(直接)缝合 其他管道替换 支架管胆管内置 鼻胆管引流 术前PTCD EST 逆行经肝胆管引流 经胆囊管引流 Evaluation only. Created with Aspose.Slides for .NET 3.5 Client Profile 5.2.0.0. Copyright 2004-2011 Aspose Pty Ltd. 胆囊管入路 报道，约1/3病人可获得成功（1991年,Lennert 1023例胆道镜协助的胆道探查） 我院试行20例（1996-1998.12），均在肉眼认为胆囊管增粗的情况下进行，成功14例。 缺点：受胆囊管内径、螺旋瓣及汇入角影响，操作相当困难，手术时间长。 评价：少数自然条件好的病人可取。一般无明显胆