Drainage of the common bile duct or gallbladder

The biliary drainage method is divided into external drainage, internal and external drainage and internal drainage. It is often used in patients with obstructive jaundice. The first two methods are the simplest and are suitable for patients with short-term application and internal drainage failure. At present, the interventional biliary drainage method commonly used at home and abroad is the expansion and support of the bile duct by the metal stent, promoting the normal excretion of bile and reducing the symptoms of jaundice in patients. Biliary stent drainage can improve the survival of patients and prolong the length of life. Treatment of diseases: iatrogenic bile duct injury, traumatic bile duct injury, surgical procedure 1. Treatment of puncture points 2. In addition to the first ultrasound in the cholangiography, the cholangiography should be performed before the X-ray guidance. Use a Chiba needle to spur horizontally to the right edge of the 11th thoracic vertebra to stop at 2 cm. Under the xiphoid approach, the right oblique slant is directed to the area, and the depth of the needle should be between 8 and 10 cm. The diluted contrast agent was pumped with a 5 ml syringe, and the needle was withdrawn while injecting until the bile duct was developed. The mark of development is a continuous development of a pipe and a slow flow to form a dendritic pipe. Continue to add lO ~ 20ml contrast agent to the main bile duct development. If the hepatic vein is stabbed, the contrast agent is quickly evacuated to the second hepatic hilum, suggesting that the puncture level is on the dorsal side. If the hepatic artery and portal vein are stabbed, it shows that the contrast agent flows faster into the liver and disappears, suggesting that the hepatic duct is in the vicinity, and the puncture layer can be slightly biased to the dorsal or ventral side. Extrahepatic and subcapsular puncture showed an increase in strip or flaky density. Hepatic parenchyma or intratumoral puncture can show small lumps and diffuse slowly. It should be noted that the contrast agent should not be injected too much into the bile duct to prevent the bile duct pressure from suddenly increasing, so that the infected bile is retrograde into the blood and causes bacteremia. If the dose is not enough to confirm the diagnosis, the drainage tube can be implanted first, and then the cholangiography should be performed after 24 hours of drainage. 3. Bile tube puncture has a one-step puncture method and a two-step puncture method. A two-step puncture method is usually used: after the cholangiography, the Chiba needle is withdrawn, the bile duct site to be puncture is selected, and the puncture is re-pierced with a trocar. The operator holds the needle in the left hand and tightens the needle core in the right hand to prevent it from retreating into the needle sleeve. After entering the subcutaneous tissue, the patient holds his breath, quickly penetrates the liver capsule, then adjusts the direction and horizontal plane, and punctures the branch of the developed bile duct. It is advisable to choose bile duct branches in order to facilitate subsequent operations. Generally, when the bile duct is inserted, the wall of the tube is first compressed and flattened. Exit the needle core, slowly retreat the needle sleeve, observe whether there is bile outflow, and send the guide wire once the bile flows smoothly. If the blood flows out, wait for it to see if it will flow out of the bile, or if the blood is mixed with bile (the bile is often thicker or thicker, or it is dripped on a clean gauze, and a clear yellow band can be displayed around). Otherwise, continue to withdraw the outer cannula, generally require the casing to not withdraw from the liver capsule, so as to avoid multiple damage of the liver capsule, resulting in bleeding. Sometimes the bile is too viscous and not easy to flow out, and it can be observed by injecting a contrast agent. Advantages of this method: When the second trocar puncture is performed, according to the condition of bile duct development, the branches and parts of the bile duct which are beneficial for subsequent operations such as bile duct intubation can be selected. Disadvantages: When trocar puncture, it is sometimes difficult to succeed once, and the liver damage is relatively large. One-step puncture method: if equipped with a micro-guide wire, it can be sent along the Chiba needle, and then the needle is withdrawn; if it is a PTCD set, it can be directly fed into the trocar along the Chiba needle. The damage of this method is relatively small and the operation is relatively simple. If the bile duct site is not satisfied due to puncture, it is sometimes difficult to complete the subsequent bile duct intubation and other operations, and a second puncture is still required. 4. After successful bile duct intubation, the soft guide wire is sent first, and the bile duct is made as far as possible. If possible, or if you need internal and external drainage, you can enter the duodenum through the narrow area, and you can push the outer casing deep along the guide wire. After the guide wire was withdrawn, part of the bile was released and a small amount of contrast agent was injected for further observation. The position of the tube end and the bile duct condition were clearly defined. Replace the super-hard guide wire, and use a dilator to expand the puncture channel and then implant the drainage tube. Simple external drainage can be placed at the proximal end of the stenosis with a pigtail catheter. Internal and external drainage is performed with a multi-lateral internal and external drainage tube, the distal end is placed in the duodenum, and the proximal end is placed in the dilated bile duct. The side hole should not be placed in the liver parenchyma and outside the liver capsule, otherwise it may cause bleeding. , bile abdominal cavity leakage and catheter blockage. If the obstruction plane is high, the left and right hepatic ducts are involved in the hilar region, and the guidewire cannot enter the common bile duct through the stenotic end after repeated attempts. The drainage tube can be placed in the larger branch of the left and right hepatic ducts or ride across two Branch. In order to improve the drainage effect, the left and right bile duct drainage can be performed simultaneously through the xiphoid process and the right iliac midline approach. After the drainage tube is implanted, it is observed whether the bile can flow smoothly and bile properties. If the bile is difficult to flow out, adjust the position of the tube end under fluoroscopy and inject the contrast agent to see if it is inside the bile duct. The catheter can be injected into the catheter to allow the bile to flow out by itself, and if necessary, a little suction. 5. The external fixation of the drainage tube is feasible until the bile is smoothly discharged. First gently tighten the catheter retaining wire and tighten the interface screw or retainer. Cut off the excess fixing line, otherwise the line can cut the catheter interface. In the past, local skin suture fixation was often used. This method has a high local infection and decoupling rate, and is not used now. The catheter can be clamped with a dedicated catheter holder to attach the holder to the skin. The patient may be allowed to shower, but a thicker, stiffer catheter is not suitable for this method. complication 1. Bile duct hemorrhage: mainly related to the number of punctures, operation time and inappropriate equipment. For example, cancer in the hilar region is likely to cause bleeding during puncture. After the success of PTCD, a small amount of bloody bile is more common. 2. Bile leakage: can leak into the abdominal cavity or leak out of the abdominal wall through the puncture point. Clinically, about 3.5% to 10% of biliary peritonitis can occur. Generally, as time goes by, the appearance of the leak can be eliminated by itself, and very little special treatment is required. The main reasons for the leakage of bile are: 1 the enlarged channel is thicker than the drainage catheter. 2 The drainage tube is not deep enough, and some of the side holes leak in the liver parenchyma and even outside the liver. 3 drainage tube drainage is not smooth. It is feasible to use drainage tube angiography to clarify the cause and do targeted treatment. 3. Retrograde bile duct infection: including the original septic cholangitis angiography caused by excessive biliary pressure, infected bile human blood, the formation of sepsis sepsis and delayed retrograde bile duct infection. 4. Excessive bile secretion: normal bile secretion is about 600ml per day, such as higher than 1500ml, called bile secretion, the maximum daily outflow can reach 3000ml.