小松田 智也, 石田 秀明, 山田 真美子, 古川 佳代子, 大野 秀雄, 八木澤 仁, 佐藤 亜紀子, 勝浦 由美

Tomoya KOMATSUDA, Hideaki ISHIDA, Mamiko YAMADA, Kayoko FURUKAWA, Hideo OONO, Hitoshi YAGISAWA, Akiko SATO, Yumi KATSUURA

秋田赤十字病院消化器科

Center for Diagnostic Ultrasound, Akita Red Cross Hospital

キーワード : ultrasound, bile duct, puncture, complication, artifact

超音波工学の急速な進歩に伴い, 超音波ガイド下穿刺も比較的安全に行われるようになった. しかし穿刺は浸襲性がある ため, 技術の習得なしでは合併症を起こす危険性がある. この項では, 胆道系の超音波下穿刺のポイントを中心に述べる. 以下に注意点をあげる. 1) 穿刺点の決定：拡張胆管への穿刺(多くはドレナージ目的) は原則として肝左葉外側区を対 象とする. 2) 穿刺断面の決定：一般に門脈臍部とその周囲の拡張胆管が一望に見渡せる横走査面を基本とし, そこから プローブをわずかに頭側や尾側に振りながら拡張胆管が最も観察しやすい断面を探す. 3) 穿刺経路の決定：長い経路は 極力避けるようにし, 仮想穿刺経路の周囲をカラードプラで丹念に観察し, 候補断面の中から血管を極力避ける経路を最 終的に選択する. 4) 穿刺角の最適化：超音波ビームが穿刺針になるべく直角にあたるようにして, 穿刺針全体の動きを 確実に捉える. 5) 穿刺回数：極力一回で. 6) その他：アーチファクトの機序とパターンを理解することで, 穿刺を正確 かつ安全に施行可能となる.

Thanks to recent advances in ultrasound (US) technology, biliary puncture is now easily performed under US-guidance. Although this invasive procedure should be performed by an experienced and skilled sonographist, most procedures are performed by clinicians lacking sufficient experience, and a number of complications have been reported. The aim of this article is to describe important ways to minimize such problems. 1) Localization of puncture point: theoretically it should be performed through the left lateral segment. 2) Determination of the most desirable field of view: The needle path must avoid vessels by using color Doppler US. 3) Determination of the most desirable path: the shortest path to the lesion (or puncture point) should be sought. 4) Determination of the most optimal angulation: it is to have the US beam perpendicular to the needle as it passes through the liver. The instantaneous dynamic visualization of the needle permits fine adjustments in angulation and depth. 5) Insertion of puncture needle: it should be performed at one try. The greater the number of punctures is the more postpuncture problems there will be. 6) A better knowledge of US artifacts helps one perform an accurate and safe puncture. Finally, young beginners must keep the following in mind when performing a US-guided puncture. If you have limited experience, seek the advice of a more skilled and experienced sonographist to assist you.