覆膜金属支架治疗CDF幻灯
手术讲解模板：胸主动脉覆膜支架腔内隔绝术66页PPT
•
27、法律如果不讲道理，即使延续时 间再长 ，也还 是没有 制约力 的。— —爱·科 克
•
28、好法律是由坏风俗创造出来的。 ——马 克罗维 乌斯
•
29、在一切能够接受法律支配的人类 的状态 中，哪 里没有 法律， 那里就 没有自 由。— —洛克
•
30、风俗可以造就法律，也可以废除 法律。 ——塞·约翰逊
内隔绝术
6、最大的骄傲于最大的自卑都表示心灵的最软弱无力。——斯宾诺莎 7、自知之明是最难得的知识。——西班牙 8、勇气通往天堂，怯懦通往地狱。——塞内加 9、有时候读书是一种巧妙地避开思考的方法。——赫尔普斯 10、阅读一切好书如同和过去最杰出的人谈话。——笛卡儿
Thank you
DZAS覆膜食管支架安装及应用PPT课件
胃内。技术上要注意的第二点是要保持导丝的前端始终处在胃内,因为在沿导丝送入
球囊导管或支架释放器时,导丝容易从狭窄段滑脱,所以要密切注视导丝头端的位置,
以避免不必要的重复操作。
.
9
（3）避免支架放置失误，在整个操作过程中,要保持导丝前段在胃 内,以防球囊扩张或输送支架时误入假道或导丝滑脱造成失败。另外, 正确选择支架直径型号也是很重要的一环。 （4）支架置入前行球囊扩张狭窄段,应视病变程度而定。行球囊扩 张时,若球囊过度扩张易造成病变区出血、破裂,还易出现术后支架滑 脱、移位；球囊过小,支架系统不易通过狭窄段,造成支架置入困难。
.
回收钩勾取支架回收线，上口聚拢
取出食管支架
12
5、支架特殊情况下的回收方法
支架因病情得到治疗需回收或由于多种原因造成移位时，需在胃镜下取出或 重新置入。支架上端回收线由于长时间受到消化液的腐蚀，取出时可能断裂，下 面提供几种特殊情况下的取出方法：
支架滑脱：多数向下入胃，少数支架上移。
①掉入胃中应用回收钩，异物钳抓住回收线上不锈钢细管，收拢支架上拉至原
3）有严重食管静脉曲张或癌肿侵及大血管，食管扩张术易引起大出血者；
4）食管肿瘤侵蚀或压迫气管，致气管中、重度狭窄者应慎重放置食管支架，有
加重气管狭窄和引起窒息的可能。
5）患有心源性胸痛、重度贲门失弛缓、弥漫性食道溃疡者。
（2）在支架置入操作过程中, 导丝能否顺利通过狭窄段是置入术能否成功的关键一
步, 在操作时手法要轻柔,变换导丝头端的前进方向, 使其能安全地通过狭窄段进入
放置位置；如钩抓支架时对支架回收线或膜已造成破坏损伤，应取出支架另置。
②如遇支架回收线被异物钳剪断，支架掉入胃里，可根据以下步骤用胃镜取出：
覆膜金属支架治疗CDF幻灯PPT课件
16
2019/11/16
讨论
• H`ng等采用了腹部的十二指肠金属支架来封堵瘘 口促使瘘口的愈合。Neumann等报道了成功在 内镜下采用over-the-scope金属夹闭合了大的、 自发性CDF瘘口；
• 目前尚没有关于胆道内放置覆膜金属支架用于促 进瘘口愈合的报道。
• CDF主要发生在乳头旁的纵行皱襞处，其次是在十二指肠 球部的后壁，后者发生的原因是由于解剖位置的邻近，十 二指肠后壁溃疡破溃入胆总管内所致。
13
2019/11/16
讨论
• 我们报道的这例病人出现CDF的原因是十二指肠 球溃疡；
• 根据瘘管位置的不同，CDF分为三种类型：A. 距 离乳头位置大于2cm；B. 距离乳头的位置不足 2cm；C. 位于乳头处的皱襞；
H'ng MW, Yim HB. Singapore Med J. 2003; 44(4):20
• 由于本例患者的年龄较大，合并有慢性疾病，且 一般情况较差，手术治疗及麻醉的风险很大，所 以我们决定放置覆膜胆道金属支架来促进瘘口的 愈合；
• 治疗的关键在于覆膜的支架不能阻塞胆囊管，否 则可导致急性胆囊炎。我们在透视下观察支架的 上缘未超过胆囊管的位置后释放支架。
• 腹部CT示肝左右胆管及胆总管积气表现；图2 • 胃镜检查示十二指肠球部溃疡并瘘管形成。图3
图1
5
2019/11/16
图2
6
2019/11/16
图3
7
2019/11/16
8
2019/11/16
诊疗经过
• 患者年龄较大，且一般情况较差，并拒绝手术治 疗，遂行ERCP术；
READ覆膜支架治疗中心静脉狭窄学习课件
• 扩张性疾病建议快速释放，狭窄性疾病可 以慢释放：支架贴壁后不会再移动；
VIABAHN应用体会
缩小视野、应用路图、造影等手段获得精确定位
中心静脉狭窄的治疗的思考
• 中心静脉狭窄治疗首选经皮腔内血管成形 术：确认流入道、流出道可靠，采用 VIABAHN覆膜支架治疗，能起到“腔内搭 桥”的效果，预防血栓、瘢痕样物质脱落 和经网眼进入支架管腔，减少后期再狭窄 的发生；CTA&DSA导丝导管配合通过闭塞段
球囊扩张
上腔静脉复通
CASE2 顽固性中心静脉狭窄的治疗 2012年
CASE2 顽固性中心静脉狭窄的治疗 2013年
CASE2 顽固中心静脉狭窄的治疗 2014年
顽固性中心静脉狭窄的治疗 在球囊扩张中纠结
顽固性中心静脉狭窄的治疗 在支架植入后期待
• 入路选择与闭合：1、股静脉入路；2、内 瘘瘤样扩张部位入路；3、废用静脉入路； 采用血管缝线行皮肤-皮下-扩张瘘管全层缝 合关闭穿刺点消除对入路选择的纠结；
中心静脉狭窄的治疗的思考
• 介入不是万能的，没有介入是万万不能的， 中心静脉狭窄的治疗充满陷阱与挑战，从 一开始就要为患者考虑好完善的长期血透 通路计划。
长期留置中心静脉血透导管引起 上腔静脉综合征治疗前后
长期留置中心静脉血透导管引起 上腔静脉综合征治疗前后
中心静脉狭窄PTA+STENT前后
病因
• 中心静脉插管是CVS最主要的病因； • 反复置管、留置时间过长、感染等都是增
加CVS的因素； • 插管的直径、材质、位置也是影响因素：
应尽量避免和减少经中心静脉插管进行血 透，尤其是经锁骨下静脉插管； • 无中心静脉插管史的CVS：①解剖因素： 头臂静脉受压综合征； ②胸廓出口综合症； ③动静脉内瘘术后高流量状态；
血管支架ppt课件
支架手术（介入治疗） 血管支架是指在管腔球囊扩张成形的基础上，在病变段置入内支架
以达到支撑狭窄闭塞段血管，减少血管弹性回缩及再塑形，保持管腔血 流通畅的目的。部分内支架还具有预防再狭窄的作用。
整个介入手术，可分为外周介入（外周血管介入）、冠脉介入（冠 状动脉介入）、神经介入三大类。与之对应有各类支架。
• 另外,不锈钢、钛合金弹性模量大,与骨不能良好地匹配而造成“应力 遮蔽”效应,使骨的生长和发育得不到应有的刺激和强化,导致骨损伤 部位骨质疏松和自体骨退化,甚至引发“二次骨折”。
• 目前常用的金属植入物是生物惰性材料,长期固定并留在快时有一定弊 端，治愈后如需拆除则要进行第二次手术,增加了治疗费用和患者的痛 苦。
冠状动脉 心的形状如一倒置的、前后略扁的圆锥体，如将其视
为头部，则位于头顶部、几乎环绕心脏一周的冠状动脉 恰似一顶王冠，这就是其名称由来。
血管堵塞
血管中胆固醇、甘油三酯等脂类，这些脂质含量一旦过高，就会变 成血管中的“垃圾”，当垃圾在血管中越堆越多，逐渐就会形成动脉血 管斑块，当斑块增大、破裂后就会彻底堵住血管，然后形成血栓，最终 导致脑梗或心梗等严重疾病。
镁合金是最早被用于研制可降解血管支 架的金属材料，2006年，美国 ACC 年会 Summit 论坛上，德国 Erbel 医生公布了 镁合金冠状动脉可降解金属支架的人体研 究结果:该中心 63 例患者达到预期治疗效 果，手术成功率高，镁合金支架在冠脉重 建中与核磁成像( MＲT) 和 CT 兼容，无 支架内血栓形成，
与其它常用金属基生物材料相比，镁合金具有以下优势 (1)镁在人体内的正常含量为25g，半数存在于骨骼中。镁及镁合金的 密度远低于钛合金，与人骨密度接近。
(2)镁是人体细胞内的阳离子，其含量仅次于钾，镁参与蛋白质的合成， 能激活体内多种酶，调节神经肌肉和中枢神经系统的活动，保障心肌 正常收缩及体温调节。
【医学ppt课件】覆膜支架治疗孤立性肠系膜上动脉夹层动脉瘤
覆膜支架（6mm×4cm ）置入后近端破口被完全隔离，右结肠动脉起始部假 性动脉瘤形成。
选择性右结肠动脉造影见有明显侧支循环
于右结肠动脉起始部置入2个微型弹簧栓子（3mm×3cm ）后，复查造影见 假性动脉瘤内血流明显减少。
误的进行了抗凝溶栓治疗。 • 由于患者SMA真腔未完全闭塞，同时假腔内大部血
栓形成，故在CTA上极易误诊为SMA血栓形成。
讨论
• 在无创检查中，目前螺旋CT血管成像 (MSCTA)对于SMA夹层的诊断价值最高
• SMA造影是诊断SMA夹层的金标准
讨论
• 覆膜支架腔内隔绝术，具有创伤小，
【医学ppt课件】覆膜支架治疗孤立性肠系膜上动脉夹层动脉瘤
腹主动脉CTA示SMA夹层动脉瘤伴假腔血栓形成
SMA造影示SMA夹层动脉瘤，内膜破口位于近SMA起始部。
覆膜支架（6mm×4cm ）置入后近端破口被完全隔离，右结肠动脉起始部假 性动脉瘤形成。
诊治经过
• SMA造影见右结肠动脉起始部可见造影剂少量外 溢，已形成假性动脉瘤
恢复快的优点 • 本例患者术后第一日排气排便，可进半流食及下
地活动，术后第三日出院
结论
• SMA夹层是一种罕见疾病，极易漏诊及误诊，临 床医生应提高警惕
• 对于突发持续上腹痛的患者，应想到SMA夹层的 可能
• 对于可疑的病例，应及时进行MSCTA或SMA造影 检查
结论
• 覆膜支架腔内隔绝术是治疗SMA夹层安全有效 的方法
结果
• 覆膜支架置入后即刻复查造影见支架定位 准确，内膜破口封堵完全，第二日复查造 影见覆膜支架通畅，无移位及内漏发生
主动脉夹层患者覆膜支架术后护理教材教学课件
功能
覆膜支架能够隔绝主动脉夹层真 假腔，重建血流通道，降低假腔 压力，促进假腔血栓化，从而修 复主动脉夹层。
手术原理简介
• 手术原理：通过介入手术将覆膜支架送入主动脉夹层病变部位， 利用支架的支撑作用封闭夹层破口，重建主动脉血流通道，达 到治疗主动脉夹层的目的。
治疗方案选择依据
患者具体病情
患者意愿与经济状况
根据患者病情严重程度、夹层分型及 并发症情况，选择合适的治疗方案。
充分尊重患者意愿，考虑患者经济状 况，选择最佳治疗方案。
手术适应症与禁忌症
明确手术适应症和禁忌症，确保手术 安全有效。
02 覆膜支架手术原理及操作 过程
覆膜支架结构特点与功能
结构特点
定时记录体温，观察 有无发热迹象。
伤口护理技巧与感染预防策略
保持伤口清洁干燥，定期更换敷料， 避免污染。
密切观察伤口有无红肿、渗液等感染 征象，及时处理。
遵循无菌操作原则，减少医源性感染 风险。
疼痛管理方案制定及实施
评估患者疼痛程度，制定个性化 疼痛管理方案。
合理使用镇痛药物，注意观察药 物疗效及不良反应。
抗生素
02
用于预防和治疗感染，如头孢类、青霉素类等，需根据感染情
况选择。
利尿剂
03
用于减轻水肿症状，如呋塞米、氢氯噻嗪等，需注意电解质平
衡。
药物不良反应监测和处理
常见不良反应
出血、低血压、过敏反应等，需密切观察患者病情变化。
处理措施
针对不同不良反应采取相应的处理措施，如停药、调整剂量、抗过 敏治疗等。
床上坐起训练
根据患者病情和耐受能力，逐步指导患者从卧位到坐位的转换。
覆膜支架在髂动脉疾病中的应用-学习课件
CASE2 男性，78岁, 双下肢重症间跛半年术中髂动脉破裂
双向入路开通双侧髂动脉
术中左髂动脉破裂出血、球囊压迫
结果与随访
警惕髂动脉治疗的陷阱：常备覆膜支架
PART2 髂动脉扩张性疾病
CASE 3 髂动脉扩张性疾病采用覆膜支架治疗
GORE应用
髂内动脉瘤远端栓塞+动脉瘤旷置术
髂内动脉瘤远端栓塞+动脉瘤旷置术
• 临床需求推动产品更新：需要更长的长度、 更大的直径和更多的梯度（2.5cm一档）覆 膜支架可以供选择，VIABAHN任重道远！
衷心感谢各位专家同道
髂动脉硬化闭塞症的治疗选择
覆膜支架：即刻安全，不破不堵，更好的远期结果
CASE 6
女性，92岁，左足溃疡静息痛3月
Hale Waihona Puke 腔内开通与病变测量、支架选择
VIABAHN开通髂外A并保留髂内A
CASE7 男性，73岁，右足趾溃疡不愈静息痛2月
杂交手术：股动脉切开重回真腔
经股动脉逆行支架
支架释放与球囊扩张
• 确认流入道、流出道可靠，采用VIABAHN覆 膜支架治疗，能起到“腔内搭桥”的效果， 避免血栓、斑块样子物质栓塞远端，也避免 了拟行穿刺远端动脉的可能并发症，保障治 疗效果，节约治疗费用，多数患者能在局麻 下完成预定治疗，过程可控，结果确切。
VIABAHN支架应用体会
药物涂层支架 ppt课件
23
紫杉醇洗脱支架(PES,TAXUS)
药物涂层支架 ppt课件
24
药物涂层支架 ppt课件
25
药物涂层支架 ppt课件
26
药物涂层支架 ppt课件
27
药物涂层支架 ppt课件
28
药物涂层支架 ppt课件
29
药物涂层支架 ppt课件
30
药物涂层支架 ppt课件
31
ESC2005经皮冠脉介入治疗 (PCI)指南
药物涂层支架 ppt课件
6
药物涂层支架 ppt课件
7
药物涂层支架 ppt课件
8
近几年来随着DES在PCI术中的应用， 临床实验和研究均表明：在预防再狭窄 中具有独特的应用价值，因为其一方面 可以减少球囊扩张后的冠脉弹性回缩， 另一方面可对冠脉病变局部提供缓慢和 长期高浓度的药物释放，抑制细胞过度 增生和抗血管重塑。
5
冠脉内支架置入术自从1987年开始广泛应用 于经皮冠脉介入治疗(PCI)以来，虽然明显降 低了普通球囊冠脉成形术(PTCA)术后再狭窄 的发生率，但是支架内再狭窄(ISR)仍高达 20%~40%。 ISR的防治又成为一个非常棘手 的问题，已经严重限制了PCI技术的开展。尽 管采用了切割球囊，血管内放射和旋磨等措 施，但仍不能有效地解决支架内再狭窄。
DES的临床应用已成为介入心脏病学
领域继球囊成形术和支架置入术后的第
三个里程碑 药物涂层支架 ppt课件
9
A novel solution － － drug-eluting stents （ D ESs）
allow ing controlled release of a drug directly to the injured e n d o th e liu m
膜覆盖金属支架治疗进展期食管癌食管狭窄效果观察说明书
Vol. 1 No. 3 2010 1Xu meidong, Yao liqing, Zhong yunshi et al.Department of Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai, China. 200032ǏAbstract ǐObjective Methods ResultsConclusionTo evaluate the clinical value of treatment of advanced esophageal carcinoma by using membrane-covered metallic stent.The clinical data of 106 patients with advanced esophageal carcinoma treated with endoscopy from June 2003 to June 2006 were analyzed retrospectively.122 membrane-covered metallic stents were placed in 106 cases, the success rate was 100%.The degree of dysphagia was reduced from 3.17 grade to 1.01 grade. The cure rate of 11 patients with esophagotracheal fi stula was 100%. The mean survival was 8.2 months.The placement of membrane-covered metallic stent is a safe, economical, effective and well-tolerated method for relieving esophageal stricture of advanced esophageal carcinoma.Esophageal neoplasms; Esophageal stenosis; Stent; EndoscopyǏKey words ǐThe malignant stenosis and esophageal obstruction caused by advanced esophageal carcinoma and recurrence of postoperative anastomotic stoma of esophageal carcinoma are difficult problems in esophageal surgery. It is because most of the patients lose their chances of surgical operation or could not bear the operation. Dysphagia would seriously affect the survival quality and survival time of patients. In the recent years, with the incessant development of endoscopic intervention technique, a kind of palliative treatment method which is safe, effective and reasonable concerns is provided for that category of patient. From June, 2003 to June, 2006, 106 patients of advanced esophageal carcinoma were treated by endoscopic dilatation and placement of membrane-covered metallic stent, the curative effect was satisfactory and the report is as follows.Clinical evaluation of treating an advancedesophageal carcinoma by using membrane-covered metallic stent125 1 Data and method1.1 General dataFrom June, 2003 to June, 2006, 106 patients with advanced esophageal carcinoma were treated by using endoscopic dilatation and placement of membrane-covered metallic stent, including 79 male and 27 female, who were 42~89 years old. Their average age was 61.7. Among them, 85 cases were pathologically affi rmed to be squamous cell carcinoma, 19 cases glandular cancer, 1 case adenosquamous carcinoma, and 1 case lymphatic sarcoma. The stenosis length was between 3~10 cm and was 5.49 cm on average. The patients had symptom of dysphagia in varying degrees before operation, and it was confirmed to be malignant esophageal stenosis by gastroscope or GI, refer to Table 1 for details. The stooler classifi cation criterion is adopted for appraising the extentRadioactive Esophageal Stent with 125I Particles2 Vol. 1 No.3 2010of dysphagia of patients: Grade 0 means no dysphagia. Grade 1 means obstruction in eating solid food. Grade 2 means obstruction in eating semi-liquid diet. Grade 3 means obstruction in eating liquid diet. Grade 4 means difficulty in drinking water (including those with esophago-tracheal fistula), refer to Table 2 for details.1.2 Method1.2.1 PreoperativeGIF-240 or 260 Video-gastroscope or model GIF-XP260 ultrafine gastroscope (Olympus), Balloon- type CRE dilatation catheter (Boston) or Savary dilating bougie (Cook) and 400 cm long φ0.89 mm Jagwire guide wire orφ0.97 mm guide wire with metallic soft head. The patients shall be starved for 6 hours before operation, accepted an intramuscular injection of 5 mg Diazepam 15 minutes before operation, and accepted an intravenous injection of 10mg Anisodamine hydrobromide for sedation, spasmolysis and reduce excretion.1.2.2 Stenotic dilatationGastroscopy and biopsy shall be conventionally performed to confirm the cause, region, level and length of stricture. The guide wire was inserted into the distal-end of stricture through endoscope under X-ray fluoroscopy. The ERCP tube was inserted along the guide wire for injecting cardiografin. The region, form and length of stenosis affection were confirmed under the contrast medium. A lso, it provided the information whether the stenosis was correlated to esophago-tracheal fistula. For the relatively serious stricture, where the endoscope and even stent pushing system could not pass though, bougie or balloon dilation shall be used in order to dilate the stricture region. Savary dilating bougie could dilate the stricture step by step up to 13 mm. In case of balloon dilating, the dilating balloon shall be inserted into the stricture part by the help of guide wire. When the region in balloon is located at the thinnest part of stricture, the balloon was inflated by contrast medium or aseptic physiological saline with pressure pump. The pressure ranged 304.0~810.6kPa was applied according to different needs, the balloon diameter shall be maintained at 12mm~15mm, and the dilatation time shall be kept for 2~5min. The endoscope was inserted again to observe the dilation result at distal-end of stricture. The guide wire was inserted as deep as possible again. The stricture location and length was measured at the time of withdrawing endoscope. The metallic markings were made for locating the distal end and proximal end of stricture.1.2.3 Placement of internal stentA n appropriate membrane-covered stent of nickel-titanium memory alloy with individualized shape (Nanjing Micro-tech or Boston company), its diameter shall be 18~20 mm, and its length shall be the length of stricture segment plus additional about 4cm, was used. Under the X-ray guiding, the stent delivering system shall be inserted into the stricture part through guide wire, the position of distal-end was confirmed with the help of metallic label or contrast medium, and the stent was deployed so that both sides of stent projected beyond the stricture segment by 2 cm. With the combination of endoscope and X-ray fluoroscopy, the positioning of stent was closely monitoring. If the length or position of stent has not reached the requirements, it shall be corrected by endoscope immediately.1.2.4 Postoperative treatment and follow-upRestoring the nutrition by gradually drinking of warm water, eating liquid diet with no residue and low residue were recommended till the regular eating was achieved. However, chewing and swallowing was an important issue. Eating thick, sticky and high-fiber food, glutinous kind or hard type was not recommended. Meanwhile, if there was any symptom of pectoralgia, short breath, abdominal pain, hematemesis or hemafecia, consulting doctor was recommended. On the third day after operation, conventionally X-ray follow-up examination would be performed, by taking water soluble contrast medium orally or radiography directly, to observe the positioning of stent. The dietary habits and survival circumstance of patients by periodically follow-up in outpatient service or by telephone.2 Result2.1 Rate of success and curative effect122 times of stents placement through endoscope for the 106 patients in this group under X-ray guidance, with success in one time without exception, and the overall success rate of operation is 100%. Among them, 2 times of stents were placed for 14 cases, and 3 times of stents were placed for 2 cases. The stricture of whole group of patients was immediately alleviated after stent placement, the irritating cough disappeared, and they were gradually able to eat liquid, semi-liquid and even regular diet, the score for classification of dysphagia was reduced to grade 1.01 from grade 3.17 two weeks later on the average (refer to Table 2), and a significant differenceDigestive SystemDigestive SystemR a d i o a c t i v e E s o p h a g e a l S t e n t w i t h 125I P a r t i c l e sVol. 1 No. 3 2010 3between before and after treatment were found (P<0.01). 11 patients, who had esophago-tracheal fistula, orally took cardiografin for fluoroscopy after operation, no contrast medium was leaked and there was no symptom of irritating cough, etc. It indicated the esophageal fi stula orifi ce was all fully blocked after stent placement, and the blocking rate is 100%. One patient was died of respiratory failure in two days after operation. Postoperative follow-up was performed to the other 105 cases. The follow-up time was between 3 weeks to 12 months, 12 cases did not go back for follow-up and the follow-up rate was 88.57% (93/105). The reason of missing follow-up included a lack of accurate telephone number and rejection by family members of dead patients. The follow-up period was equal to survival period, and the postoperative living standard of patients who could eat food was obviously improved. A mong them, the longest survival period reached 12 months, the shortest survival period was 2 months, the stent was smooth during the survival period, and the average survival period was 8.2 months.2.2 ComplicationAll patients had retrosternal pain and epigastric pain after operation and alleviated by themselves within one week. 8 patients had relatively severe pain, narcotic analgesic was needed to be injected repeatedly for relieving pain, such as bucinnazine or dolantin, etc., and the occurrence rate was 6.56% (8/122). In the process of dilatation and stent placement, there was mild bleeding in all cases because of laceration of tumor tissue at the stricture part, and bleeding could be stopped for most patients after haemostatic medication was locally nebulized. 5 patients had symptom of hemorrhage after operation, such as hematemesis and passing tarry stools, etc., the occurrence rate was 4.10% (5/122), and the hemorrhage was stopped after antacid, homeostasis and heteropathy treatment for 3~5d. One patient (0.81%) had diffi culty in breathing after operation, and died because of respiratory failure 2 days later. No perforation was occurred. It was found through postoperative follow-up that 35 patients had symptom of reflux esophagitis, such as food reflux, regurgitation and retrosternal burning sensation, etc., the occurrence rate was 28.69% (35/122), the symptom could partly be alleviated through application of antacid and dynamic medicine. Three cases (2.46%) had a stent migration at the distal-end and caused restenosis, the stent was taken out by gastroscope after dilating the stenosis lumen, and stent was re-placed again. Stent blocking occurred in 14cases with occurrence rate of 11.48% (14/122). Among them, one patient’s stent was blocked by food. Stent blockages by tumor-overgrowing (TG) were occurred in 7 cases. Granulation and fi brosis (GF) occurred in 6 cases. For the food impaction, massive food was taken out by gastroscope, and it was dredged after repeated rinsing; 2 cases of GF accepted repeated APC treatment, and liquid diet could be maintained till patient passed away. Stents were re-placed for the other 9 cases of GF or TG, and the symptom of blocking was relieved. Stenosis and obstruction occurred in two cases within the follow-up period, and 3 times of stent placement were carried out to them individually.3 DiscussionPatient, suffered an advanced esophageal carcinoma, including advanced primary esophageal carcinoma, cancerous esophago-tracheal fistula and recurrence of anastomotic stoma after operation, etc., loses the opportunity of operation. An expected result could not be reached even if operation is performed. When the curative effect is poor and the trauma is increased in size, the occurrence rate of postoperative complication and the mortality rate is high, surgical resection is not a preferable method. Placement of self-expandable metallic stent can effectively alleviate the obstruction symptom of patients, increase food intake and improve the quality of life. It has been more extensively applied clinically, especially the clinical application effect of membrane-covered metallic stent is relatively ideal [1, 2]. It was found by Saranovic (et al.) [3] in a research on treating advanced esophageal carcinoma by using metallic stent with membrane-covered and without membrane-covered: the symptom of dysphagia of patient could be effectively alleviated after placement of stent into esophagus, the score for the average dysphagia of 98 patients in the membrane-covered group was reduced from 2.67 to 0.05, and that of those in group without membrane-covered was reduced from 2.73 to 0.15. It was considered by the report of Yang (et al.) [4] that membrane-covered stent would be adopted for the patients of advanced esophageal carcinoma accompanied by esophago-tracheal fistula, and the blocking rate of fi stula orifi ce could reach 100%. 122 times of stents were placed in the 106 cases of this group, with the success rate of operation being 100%. The score for dysphagia classification in two weeks after operation was reduced from grade 3.17 to grade 1.014 Vol. 1 No. 3 2010Radioactive Esophageal Stent with 125I ParticlesTable 1 Affection category and regionafter operation; the esophageal fi stula orifi ce of 11 cases of esophago-tracheal fi stula could be fully blocked after operation, and the blocking rate was 100%. The average survival period after operation was 8.2 months, being similar to the report in literature.The common complication of placing metallic stent into esophagus includes retrosternal and epigastric pain,hemorrhage, perforation, respiratory diffi culty or asphyxia, stent blockage (food impaction, GF or TG), stent migration and reflux esophagitis, and the report on occurrence rate differs [5~8]. The occurrence rate of severe pain in this group after operation was 6.56%, that of hemorrhage 4.10%, that of respiratory difficulty 0.81%, that of reflux esophagitis 28.69%, that of stent migration 2.46%, that of stent blocking 11.48%, and no perforation occurred. All complications could be alleviated by medication or endoscope treatment.How to improve the success rate of placement of esophageal stent and reduce the occurrence rate of complication? A ccording to our experience, the following measures will be taken. (1) Accuracy of stent deployment could be increased by the combinationof endoscopy and X-ray fluoroscopy. (2) The metal marking is an important guidance for locating the sides of stricture and the stent deployment. (3) The occurrence of postoperative pain and hemorrhage can be reduced by selecting a membrane-covered stent with appropriate diameter, shape and length. A skillful stent placement is necessary. An appropriate shape of upper rim of stent can reduce the tension between the stent and pipe wall and reduce the irritation to esophageal mucosa and ingrowth of granulation. Membrane-covered stent can prevent ingrowth of tumor into stent cavity. Both sides of stent shall go beyond the affection by 2cm. (4) the 1st week after stent placement, the patient shall take liquid or semi-liquid diet. Then, the composition of solid food shall be gradually increased till regular diet restores, patients shall chew carefully and swallow slowly, especially, avoid from eating glutinous or hard food. (5) Appropriate radiotherapy and chemotherapy shall be adopted after stent placement in order to suppress the ingrowth of tumor and granulation tissue and reduce the occurrence rate of stent blockage.RegionAffection category Case numberUpper segment Middle segmentLower segment and cardiac orifi cePrimary esophageal carcinoma stenosis 6343623Recurrence of postoperative anastomotic stoma 13265esophageal carcinoma stenosis after radiotherapy 196112Esophago-tracheal (esophagobronchial) fi stula 11281Total 105146131Digestive SystemVol. 1 No. 3 2010 5Digestive SystemR a d i o a c t i v e E s o p h a g e a l S t e n t w i t h 125I P a r t i c l e sReferences1. Morgan R, Adam A. Use of metallic stents and balloons in the esophageal and gastrointestinal tract [J]. J Vasc Interv Radiol, 2001, 12(3):283-2972. Yao Liqin, Xu Meidong. The clinical application and prospect of alimentary canal stent [J]. Chinese Journal of Practical Surgery, 2002, 22(10): 583-585.3. Saranovic Dj, Djuric-Stefanovic A , Ivanovic A , et al. Fluoroscopically guided insertion of self-expandable metal esophageal stents for palliative treatment of patients with malignant stenosis of esophagus and cardia: comparison of uncovered and covered stent types [J]. Dis Esophagus, 2005,18(4):230-238.4. Yang HS, Zhang LB, Wang TW, et al. Clinical application of metallic stents in treatment of esophageal carcinoma [J]. World J Gastroenterol, 2005, 11(3):451-453.Table 2 Contrast of classifi cation for dysphagia before and after stent treatment*P<0.01 The group of those after treatment includes 105 cases, and 1 case died within 2 days after operation.Classifi cation for dysphagiaBefore treatment (n)After treatment (n)001910662172035404350Average number3.171.015. A cunas B, Rozanes I, A kpinar S, et al. Palliation of malignant esophageal strictures with self-expanding nitinol stents: drawbacks and complications [J]. Radiology, 1996, 199(3): 648-652.6. Bartelsman JF, Bruno MJ, Jensema AJ, et al. Palliation of patients with esophagogastric neoplasms by insertion of a covered expandable modified Gianturco-Z endoprosthesis: experiences in 153 patients [J]. Gastrointestinal Endosc, 2000, 51(2): 134–138.7. Han YM, Song HY, Lee JM, et al. Esophagotracheal fistulae due to esophageal carcinoma: palliation with a covered Gianturco stent [J]. Radiology, 1996, 199(3): 65–70.8. Li ZS, Wan XJ, Xu GM, et al. Clinical study of esophageal stent restenosis [J]. Chinese Journal of Dig Endo, 2000, 17(4): 217-219.。
胆道金属支架临床应用上饶护理课件
术后感染的护理问题及解决方案
总结词
术后感染是常见的并发症，需要采取 预防和护理措施降低感染风险。
02
感染原因
手术后，由于手术创伤、免疫力下降 等原因，患者容易发生感染。
01
注意事项
密切观察患者的体温、血象等指标， 及时发现感染征象，并做好记录和报 告。
05
03
预防感染措施
在术前、术中和术后采取一系列预防 感染的措施，如抗生素的使用、手术 室消毒、伤口护理等。
跨学科合作
加强与其他学科的合作与交流， 共同推进胆道金属支架临床应用
的护理工作。
THANKS
谢谢
对于良性胆道狭窄，如炎症、创伤或手术后狭窄，胆道金属 支架可以扩张狭窄部位，恢复胆汁流通，防止进一步的胆道 梗阻。
胆道金属支架的发展历程
胆道金属支架的发展经历了数十年。最早的胆道金属支架 是裸支架，随着材料科学和医学技术的进步，逐渐发展出 了覆膜支架、可回收支架等多种类型。
近年来，随着介入放射学和微创手术的普及，胆道金属支 架的临床应用越来越广泛。支架的设计和材料也在不断改 进，以提高治疗效果和患者的生存率。
胆道金属支架临床应用上饶护 理课件
目录
CONTENTS
• 胆道金属支架概述 • 胆道金属支架的临床应用 • 上饶护理在胆道金属支架临床应用中的重要
性 • 胆道金属支架临床应用中的护理问题及解决
方案 • 上饶护理在胆道金属支架临床应用中的经验
分享
01
CHAPTER
胆道金属支架概述
胆道金属支架的定义
上饶护理在术中配合的重要性
术中监测
密切监测患者的生命体征 和病情变化，及时发现并 处理异常情况。
配合操作
- 1、下载文档前请自行甄别文档内容的完整性，平台不提供额外的编辑、内容补充、找答案等附加服务。
- 2、"仅部分预览"的文档,不可在线预览部分如存在完整性等问题,可反馈申请退款(可完整预览的文档不适用该条件!)。
- 3、如文档侵犯您的权益，请联系客服反馈,我们会尽快为您处理(人工客服工作时间：9:00-18:30)。
诊疗经过
• 由于剩余的2块结石直径较大，网篮套取困难，因 此再次置入球囊导管至结石上方，充满后通过乳 头迅速将其推向十二指肠，重复3次，顺利将2块 较大结石送入十二指肠（图3）
图3 球囊导管将2块较大结石推送入十二 指肠（箭头所指）。
诊疗经过
• 术后7天复查胆道造影未发现结石残留（图4）。 患者恢复较好，患者顺利出院。
入院情况
• 既往史 冠心病史30年，脑梗塞病史4年。 • 查体：T 38.7℃，神清状弱，全身皮肤粘膜及巩 膜轻度黄染，腹平软，无明显压痛及反跳痛，莫 菲氏征（-）肝脾未触及，肠鸣音正常。 • 辅助检查：腹部超声示胆总管下端结石并上方肝 内外胆管明显扩张，胆囊增大。
入院诊断
• 胆总管结石并胆系感染 • 冠状动脉粥样硬化性心脏病 • 脑梗塞后遗症
胆总管内植入覆膜金属支架用于 治疗十二指肠胆总管瘘一例
山东省立医院消化科 王洪波 2014-6-28
病史资料
• 患者杨某某，男，78岁，主因腹痛伴发热2月余 入院。 • 既往有高血压病及酒精性肝病史。 • 1年前曾因腹痛行腹部平片检查示消化道穿孔，但 患者及家属拒绝外科手术及进一步影像学检查以 明确诊断，经保守治疗后病情好转后出院。
图1
图2
图3
诊疗经过
• 患者年龄较大，且一般情况较差，并拒绝手术治 疗，遂行ERCP术； • 术中发现十二指肠乳头处无胆汁流出，行胆总管 造影示造影剂自胆总管溢出至十二指肠球部；图4 • 行EST术后于胆总管内置入80mm×10mm覆膜 胆道金属支架，再次造影未见造影剂进入十二指 肠球部。图5
H'ng MW, Yim HB. Singapore Med J. 2003; 44(4):205-7.
讨论
• 由于本例患者的年龄较大，合并有慢性疾病，且 一般情况较差，手术治疗及麻醉的风险很大，所 以我们决定放置覆膜胆道金属支架来促进瘘口的 愈合； • 治疗的关键在于覆膜的支架不能阻塞胆囊管，否 则可导致急性胆囊炎。我们在透视下观察支架的 上缘未超过胆囊管的位置后释放支架。
诊疗经过
• 首先在超声引导下行经皮经肝胆道引流 （PTCD），并置入了8F猪尾引流管来引流胆汁， 术后患者体温恢复正常。5天后已经形成腹壁和肝 脏之间的窦道，接下来进行PTPBD取石治疗。
PTPBD步骤
• 我们首先沿10F猪尾导管插入超滑导丝，并沿 PTCD通道置入了10F的血管鞘，并将其固定在腹 壁皮肤，并进行造影显示胆总管中下段见直径 0.5～1.6cm类圆形结石4块（图1）
病史资料
• 查体：老年男性，全身皮肤粘膜无黄染，心肺听 诊未见明显异常，腹部平软，中上腹部轻压痛， 无肌紧张及反跳痛，Murphy征阳性。 • 辅助检查：血常规WBC13.47×109/l，中性粒细 胞占82.2%。肝功生化结果正常。
诊疗经过
• 入院后完善相关辅助检查，上消化道钡餐示十二 指肠球部胆总管瘘；图1 • 腹部CT示肝左右胆管及胆总管积气表现；图2 • 胃镜检查示十二指肠球部溃疡并瘘管形成。图3
讨论
• 胆道内放置覆膜金属支架对于CDF病人是一个好 的选择，特别适合于无手术指征或者手术治疗风 险大的病人，可以促进CDF瘘口的愈合。
PTCD法联合大球囊扩张治疗老年 胆总管巨大结石一例分享
山东大学附属省立医院消化科 王洪波 2014-6-28
入院情况
• 患者男，85岁，2011.8.8入院，住院号863641 • 现病史 3个月前无明显诱因于餐后开始出现恶心、呕 吐，呕吐物为胃内容物，曾于外院诊断为胆总管 结石并胆系感染，给予保肝、降酶及抗感染治疗 后病情好转。此后患者多次于进食过多或者进油 腻食物后出现恶心、呕吐，伴寒战、高热。为行 进一步诊治入院。
文献复习
• Nagashima等[1]对5例胆总管结石的病人采用了PTPBD治 疗，其中2例经过1次治疗清除结石，另3例经过2次治疗清 除结石。Peng等[2]对2例ERCP操作不成功的病人采用 PTPBD均顺利将结石推送入十二指肠。Shirai等[3]对2例 毕II式手术后出现胆总管下端结石伴有胆管扩张而十二指 肠镜无法找到乳头的病人进行了PTPBD，成功取出了结 石。 • PTPBD用于胆总管结石治疗在国内外报道尚少。
结论
• 我们推荐对于部分高危、高龄人群或者内镜下治 疗失败的胆总管结石的病人，PTPBD可以作为一 种备选的治疗方案。
谢 谢
图1 胆道造影发现胆总管下段4个充盈缺损， 伴有肝内外胆管明显扩张。
诊疗经过
• 通过导丝导管交换，更换加硬导丝，在乳头处放 置1.5×4cm球囊导管扩张3次（图2），接下来撤 出球囊导管，采用网篮取石3次，将胆总管内2块 直径分别为0.5和0.6cm结石送入十二指肠；
图2 采用球囊导管扩张十二指肠乳头。
图4
图5
术后及随访情况
• 术后给予抑酸及营养支持治疗，患者腹痛及发热 缓解后出院； • 随访半年患者未再有腹痛及发热等症状发作，复 查胃镜示十二指肠球部瘘管已经闭合，遂在内镜 直视下拔出胆总管支架。
讨论
• 十二指肠胆总管瘘是指十二指肠或者胆总管病变所致两者 之间瘘管形成，胃液及十二指肠液可以反流入胆道而引起 反复胆系感染的临床表现； • 十二指肠胆总管瘘（CDF）的主要病因包括胆石症、壶腹 周围癌、医源性损伤、肝移植术、十二指肠溃疡等。另外 一些如十二指肠结核等罕见的病因也可以导致十二指肠胆 总管瘘的发生； • CDF主要发生在乳头旁的纵行皱襞处，其次是在十二指肠 球部的后壁，后者发生的原因是由于解剖位置的邻近，十 二指肠后壁溃疡破溃入胆总管内所致。
Jorge A et al. Endoscopy. 1991; 23(2):76-8.
Li ZH et al. ANZ J Surg. 2006; 76(9):796-800.
讨论
• Zong等[3]纳入了66例ERCP证实的CDF患者，其 中7例病因是十二指肠溃疡所致。对61例进行了手 术治疗，其中55例治疗成功。对于瘘口直径小于 0.5cm者，采用了药物保守治疗； • 对这些病例进行了6个月到10年的随访，发现手 术治疗组及药物治疗组都没有再出现胆管炎症发 作。
讨论
• CDF可以通过胃肠道造影、胃镜、ERCP等来诊断； • 传统的观点认为如果发现十二指肠胆总管瘘需要进行 手术治疗； • Li等认为对于大于1cm的CDF能够导致反复频繁发生 的胆管炎症，需要手术治疗，而对于0.5-1cm之间的 CDF，则需要进行充分的胆道引流即可，如果瘘口直 径小于0.5cm，建议进行药物的保守治疗。
Zong KC et al. Am Surg. 2011; 77(3):348-50.
讨论
• H`ng等采用了腹部的十二指肠金属支架来封堵瘘 口促使瘘口的愈合。Neumann等报道了成功在内 镜下采用over-the-scope金属夹闭合了大的、自发 性CDF瘘口； • 目前尚没有关于胆道内放置覆膜金属支架用于促 进瘘口愈合的报道。
讨论
• 我们报道的这例病人出现CDF的原因是十二指肠 球溃疡； • 根据瘘管位置的不同，CDF分为三种类型：A. 距 离乳头位置大于2cm；B. 距离乳头的位置不足 2cm；C. 位于乳头处的皱襞； • 由于瘘管对于胆汁的引流作用，病人通常不出现 黄疸。但是食物及气体可以反流入胆道及胆囊内， 导致反复的胆系感染及胆道积气。
诊疗经过
• 入院后行MRCP检查示肝内胆管、左右肝管、肝 总管、胆囊管、胆总管上段及胆囊均明显扩张， 胆总管下端呈截断征象，胆总管下端可见团块状 短T2信号灶。考虑患者年龄偏大，伴有多种慢性 病，体质较弱，可能无法耐受ERCP，且患者不 同意手术治疗，遂考虑行经皮经肝乳头球囊扩张 术（PTPBD）。
图4 术后7天复查胆道造影未见结石残留
文献复习
• 对于胆总管结石，内镜下乳头球囊扩张术 （EPBD）或者内镜下乳头括约肌切开术（EST） 是标准的治疗方法。然而，内镜下治疗通常较为 复杂或者由于解剖学因素造成无法完成内镜下治 疗。 • 经皮经肝乳头球囊扩张术（PTPBD）可以作为一 种选择用于胆总管结石的治疗。
文献复习
• Ersoz等[4]报道应用大的扩张球囊（12-20mm） 用于常规球囊扩张取石较困难的患者，并获得了 成功，且已知大的扩张球囊对较大结石的取出更 为有效。
讨论
• 患者年龄较大，且伴有多种内科疾病，内镜下取石存 在一定风险，且患者拒绝手术治疗，是PTPBD治疗的 适应证。 • 本例病人结石较大并伴有肝内外胆管扩张，我们采用 了直径1.5cm的大球囊对十二指肠乳头进行扩张，从 而有利于结石的顺利取出。 • 十二指肠乳头球囊扩张术后的并发症包括胰腺炎、胆 管炎、胆道出血及消化道穿孔等。本例患者无上述并 发症的发生。