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Colangiografie percutana Colangiografie percutana transhepatica si drenaj biliar transhepatica si drenaj biliar
extern asociat cu drenaj extern asociat cu drenaj peritoneal complicat cu peritoneal complicat cu
angiocolita si sepsis la un angiocolita si sepsis la un pacient cu colagiocarcinom pacient cu colagiocarcinom
centrohilar,ciroza hepatica si centrohilar,ciroza hepatica si ascita refractaraascita refractara
Andritoiu AlexandruAndritoiu Alexandru*, Silosi Cristian **, Rujanu Marcel***, Resceanu Aurelia
****Sectia Medicina interna (*), Clinica Chirurgie generala (**), ATI (***)
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Colagiografia
Metoda radiologica cu substanta de contrast pentru vizualizarea cailor biliare
(utila in icterul obstructiv benign/malign, stricturi biliare)
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Colangiografia percutana transhepatica
• Tehnica Okuda
• Ghidaj Eco-Rx
• Ac Chiba 21-22 G – intr-un CBIH periferic
• Abord percutan:
• sp. VIII-XI ic. Dr.
• subcostal dr.
• subxifoidian dr.
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Drenajul biliar
• extern• extern-intern• intern
• PTC• ERCP• Chirurgical
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Istoricul metodei
• (1974) OKUDA (Univ.Chiba,Japonia) inventeaza acul fin, ultraflexibil, atraumatic ("ACUL CHIBA") si aplica prima data punctia percutana cu ac fin, ghidata imagistic (pe ficat, cai biliare) efectuind primele Colangiografii Percutane Transhepatice(CPT) cu ac fin.
• (1974) LUNDERQUIST(SUA) - efectueaza primele drenaje percutane ghidate fluoroscopic in icterul obstructiv neoplazic.
• (1980) DANIIL si STANCIU (Iasi, Romania) efectueaza primele colangiografii percutane cu ac CHIBA din Romania la cazuri cu icter obstructiv (in perioada respectiva neexistind nici CT nici ecografia in Romania);
• (1982) DANIIL si col. executa primul drenaj biliar percutan transhepatic in Romania
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Drenajul peritoneal al ascitei
• Tehnica Seldinger
• Cateter intra-peritoneal ptr. drenajul permannet al asciei refractare si/sau neoplazice
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Contraindicatii
• Coagulopatii (relativa) - se poate corecta pre-procedura
• Ascita masiva
• Alergie (substanta de contrast, xilina)
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Complicatiile drenajului biliar extern
Imediate (post-procedura)Imediate (post-procedura)• durere locala• biliragie (3-10%)• hemoragie intra-peritonealaTardiveTardive• disfunctia cateterului (40-50%)• leak biliar (scurgerea bilei in cavitatea
peritoneala)• colangita
Mortalitatea post-procedura 3%Mortalitatea la 30 zile 30% la pacientii tarati cu disfunctie hepato-renala
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Complicatii
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Caz clinicCaz clinic
P. Gheorghe, 54 aniP. Gheorghe, 54 ani
Diagnostic:Diagnostic:
• Ciroza hepatica (vir. B+alcool)
• Ascita refractara
• Icter mecanic
• Colangiocarcinom centrohilar
Primul caz in Craiova si Medicina militara din Romaniala care s-a practicat colangiografie percutana si drenaj biliar extern transhepatic
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Dilatare CBIH
Ecografie Colangio-RMN
Colangiocarcinom centrohilar (sageata)
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Plan terapeutic
• Drenajul ascitei (cateter peritoneal)• Punctie CBIH-ram periferic• Colangiografie de control• Montare cateter de drenaj biliar
Ambele tehnici (metoda Seldinger)
efectuate sub ghidaj ecografic
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Step 1. Montare cateter peritoneal de drenaj al ascitei
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Step 2. Punctia CBIH-Ac Chiba 20 G
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Step 3. Colagiografie percutana
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Step 4. Insertie cateter biliar
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Colagiografie de control la 24 ore
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Evolutie imediata <72 ore
• Reducerea icterului si pruritului
• Stare generala buna• Afebril• Diureza prezenta• Fara sangerare
peritoneala• Biliragie pasagera• TA 120/75mmHg
• Drenaj ascita:• 2000 ml/zi• Drenaj biliar • 700 ml/zi
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Evolutie ziua a 5-a
ClinicClinic• Stare generala critica• Ascita tulbure (+++)• Icter (+++)• Bila tulbure• Anurie• Coma• Exitus
Analize laboratorAnalize laborator• Leuc:19.500/mmc• Ntr 15.8%• VSH 74-90 mm/h• TGO 196-206-350 UI/L• TGP 121-127-189 UI/L• GGT 86-90 UI/L• Tb 124-86.000/mmc• BRT 14.2-17.8mg/dL
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Bilicultura pozitiva
Acinetobacter Iwoffii pluri-rezistent!
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Concluzii
• Drenajul percutan (trans-cateter) este o metoda utila, eficienta, dar grevata de riscul:
• Hemoragic
• Infectios (intra/extra-spitalicesc)