JP2007268000A - Excavating device to submucosa - Google Patents

Abstract

<P>PROBLEM TO BE SOLVED: To secure a site for embedding a tool comprising an elongate member such as a wire or a catheter by making invasive site minimum. <P>SOLUTION: An excavating device 4 is inserted into a treating tool inserting channel 15 of an endoscope 1 and is used for forming a passage for embedding a back flow inhibiting tool 5 in submucosal layer L in a body lumen and has a flexible tube 40 having flexibility in a bending direction but having an elasticity and also having elastic resilience, a passage forming portion 41 in which a loop is formed in a direction of crossing an axial line is formed in the distal end, an excavating balloon 42 is mounted at the front end of the passage forming portion 41, and a pumping means 43 as a fluid feed and return means feeding compressed air to the excavating balloon 42 and returning the air from the same is detachably connected to the base end portion of the flexible tube 40. <P>COPYRIGHT: (C)2008,JPO&INPIT

Description

  The present invention relates to a digging apparatus used when, for example, a medical instrument is placed in a body cavity, a passage for holding the medical instrument is formed in a submucosa.

  For example, gastro-esophageal reflux disease (GERD), in which gastric fluid flows back into the esophagus, causes symptoms such as chronic cough, asthma, sore throat, pharyngeal foreign body sensation, and ear pain. If left untreated, it can cause esophageal adenocarcinoma, and the need for treatment has been pointed out. As a method of treating this GERD, it is also possible to administer a drug such as a gastric acid secretion inhibitor. However, a bulge is formed on the inner wall of the cardia or the body cavity in the vicinity of the cardia which is the entrance from the esophagus to the stomach, and the esophagus is formed from the stomach. There is a medical device for performing a surgical procedure so as to prevent the backflow of gastric juice or the like to the stomach and to allow the food or the like to move in the forward direction, that is, to allow the flow from the esophagus to the stomach in digestive activity. This is proposed in Patent Document 1.

  The medical device according to Patent Document 1 includes a pair of clamp members, and the clamp members are connected to an actuating member to be inserted orally, and a part of the body tissue is clamped by the clamp member. By doing so, the bulging portion of the tissue protrudes into the passage to the inside of the stomach. However, when the body tissue is clamped in this way, it is not desirable in terms of generation of damage due to blood flow being blocked.

  In addition to the above-mentioned GERD treatment, it has been widely practiced to place various treatment or examination instruments in the body. As described above, the method for placing a predetermined instrument in the body differs depending on the structure of the instrument, the site where the instrument is placed, and the like. In addition to the clamp described above, for example, when a catheter is indwelled in a body cavity tube, it is possible to prevent the body cavity tube from coming out by forming a loop at the end thereof.

In this way, if it is not possible to perform such measures, whether it is clamped or placed in the body by preventing it from being pulled out, an incision is made on the inner wall of the body cavity, an instrument is attached, This instrument is fixed by sewing. When it is necessary to embed a part or the whole of the indwelling device in the inner wall of the body cavity, the electric scalpel is inserted into the body using the endoscope as a guide means so as to incise the site where the device should be embedded. Then, after attaching an instrument to the incision, a technique of suturing the incision is taken.
Japanese Patent Laid-Open No. 2005-21690

  By the way, in order to embed all or part of a wire, a catheter or the like on the inner wall of the body cavity, it is not preferable in that the embedment site is secured by incision with an electric scalpel, which causes great damage to the body tissue. In particular, when an entire long wire or catheter is to be embedded, the invasive site in the body becomes correspondingly large, and the burden on the patient increases accordingly.

  From the above points, the present invention has focused on the submucosa. That is, the muscle layer on the inner wall of the body cavity is covered with the mucous membrane, and a submucosal layer exists between the mucosa and the muscle layer. When the submucosal layer is partially pushed away, a space is formed without causing any special damage to the body tissue, and it can be secured as a site for embedding a wire, a catheter or the like. In view of the points beyond the present invention, it is an object to secure a site for embedding an instrument made of a long thin member such as a wire or a catheter with a minimally invasive site.

  In order to achieve the above-described object, a submucosal excavation device according to the present invention is attached to a flexible tube having a fluid passage and a distal end of the flexible tube, and supplies fluid to the fluid passage. The digging balloon that bulges toward the front of the flexible tube, and a fluid supply / discharge means that is connected to the proximal end of the flexible tube and supplies and discharges the pressure fluid to the digging balloon. It is characterized by that.

  The part of the flexible tube at which the excavation balloon is attached is submerged in the mucous membrane on the inner wall of the body cavity to excavate the submucosal part. For this purpose, it is necessary to incise the mucous membrane, but the incision may be substantially the diameter of the flexible tube. As a result, the degree of invasion to the inner wall of the body cavity can be minimized. When fluid is fed into the digging balloon, the digging balloon is inflated forward, and moves forward so that the tissue of the submucosa is pushed away at the tip. At this time, the submucosa is only partially pushed away, and the submucosa itself is not substantially damaged. Then, the digging balloon is reduced and the flexible tube is advanced. As a result, a space or a passage is formed at the site of the submucosa. By repeating the expansion and contraction of the digging balloon and the advancement of the flexible tube, the passage is dug to a predetermined length.

  The fluid supplied to and discharged from the digging balloon may be a gas such as air or a liquid such as water. The fluid supply / discharge means is connected to the base end portion of the flexible tube. The fluid supply / discharge means may be provided integrally with the flexible tube, or may be configured to be detachably connected. it can. The fluid supply / discharge means pressurizes, for example, air and feeds it into the digging balloon, thereby bulging the digging balloon. This bulging direction is mainly directed forward, but may bulge to some extent in the radial direction of the flexible tube.

  The digging direction can be controlled by, for example, providing an angle portion near the distal end of the flexible tube, but this digging device performs an operation of forming a passage under the monitoring of the endoscope. Is desirable from the viewpoint of operability. In this case, the diameter of the flexible tube is smaller than the inner diameter of the treatment instrument insertion channel of the endoscope. If the digging balloon is in a contracted state, it does not get in the way when inserted into the treatment instrument insertion channel.

  In order to secure the embedment location of a predetermined instrument, it is necessary to form a passage according to the shape of the instrument to be embedded. When embedding a thin wire, a thin flexible tube can be used, and when embedding a large diameter catheter or the like, the outer diameter of the flexible tube is increased accordingly. . The passage may be straight, and if the embedded device is bent, it will form a bent passage. In this case, a flexible tube that is bent so that the tip portion thereof corresponds to that is used. For example, when a loop-shaped passage is formed, the distal end portion of the flexible tube may be formed in a loop shape that intersects the axis.

  As described above, it is possible to ensure the space or passage for embedding a predetermined instrument with minimal invasiveness to the body tissue.

  Hereinafter, embodiments of the present invention will be described with reference to the drawings. Here, in this Embodiment, in order to perform the GERD treatment which prevents the backflow of the gastric acid from the stomach to the esophagus, it demonstrates as what indwells a backflow prevention instrument in the site | part from the esophagus to the cardia of the stomach.

  First, FIG. 1 shows a schematic configuration of a passage connected from the esophagus E to the cardia C of the stomach G. If it is a healthy person, it is normally closed due to the action of the diaphragm on the esophageal hiatus, etc. When food or drink flows in from the esophagus E side, this passage opens and is taken into the stomach G. As shown in FIG. 2, the GERD has a large opening from the normal state indicated by the phantom line to the stomach G, and the inherent anti-reflux function is reduced, or the anti-reflux function Is in a state of failure.

  In order to recover this backflow prevention function, a backflow prevention device that reinforces the pressure of the lower esophageal sphincter is attached and placed in a region from the lower part of the esophagus E to the cardia C of the stomach G. Such a backflow prevention device and a mechanism used to place the backflow prevention device include an endoscope 1, a local injection means 2, a high-frequency knife 3, a digging device 4, and a backflow as shown in FIG. The prevention device 5 is used, and the backflow prevention device 5 is mounted in the body cavity using the forceps 6. Here, the body cavity including the esophagus E and the stomach G is covered with the mucosa M, the lower layer portion of the mucosa M is the submucosa L, and the muscle layer N exists. Then, the backflow prevention device 5 is placed in the submucosa L.

  The endoscope 1 is connected to the body operating section 11 provided in the body cavity, the main body operating section 11 provided at the proximal end of the inserting section 10, and to the light source device (not shown). The universal cord 12 is used as a connecting portion. The insertion portion 10 is a flexible portion 10a having a structure in which most of the length from the connecting portion to the main body operation portion 11 is bent in an arbitrary direction along the insertion path, and an angle portion 10b is provided at the tip of the flexible portion 10a. Further, a hard tip portion 10c is connected to the tip of the angle portion 10b. As shown in FIG. 4, an illumination window 13 and an observation window 14 are formed on the distal end surface of the distal end hard portion 10 c, and the distal end opening 15 a of the treatment instrument insertion channel 15 is opened. The treatment instrument insertion channel 15 is a passage extending from the distal end opening 15 a to the entire length of the insertion section 10, and a base end portion thereof is connected to a treatment instrument introduction section 15 b provided in the main body operation section 11.

  The local injection means 2 is configured such that a liquid pumping unit 22 such as a syringe is connected to a proximal end portion of a flexible tube 21 provided with a needle 20 at the tip, and a liquid to be injected into the body is supplied to the liquid pumping unit 22. Saline or the like is filled. Accordingly, the physiological saline can be pumped from the liquid pumping unit 22 to flow out of the needle 20 to bulge the body cavity inner wall.

  The high-frequency knife 3 has a needle-like knife 30 at its tip, and a cable (not shown) is connected to the needle-like knife 30, and this cable is inserted into the flexible cord 31. The proximal end portion of the flexible cord 31 is attached to the operation portion 32, and the needle-like knife 30 can be projected and retracted from the distal end of the flexible cord 31 by operating the operation portion 32. The operation unit 32 is provided with an electrode connected to the end of the cable. By connecting a high-frequency power source to this electrode, a high-frequency current can be passed through the needle knife 30 and an incision can be made. It is like that.

  These local injection means 2 and the high-frequency knife 3 are inserted into the treatment instrument insertion channel 15 of the endoscope 1. That is, the needle 20 or the needle knife 30 is inserted from the treatment instrument introduction section 15b provided in the main body operation section 11, and the treatment instrument insertion channel 15 is advanced to open at the distal end of the insertion section 10. It can be derived from the tip opening 15a.

  The local injection means 2 and the high frequency knife 3 described above are used as a preparation stage for placing the backflow prevention device 5 in the body. The backflow prevention device 5 is composed of a ring wire 50 in which an elastic wire made of a springy metal or synthetic resin is wound in a ring shape. This ring wire 50 is an open ring, and spherical bulges 51, 51 are formed at both ends thereof. And as shown in FIG. 5, it is embedded between the mucous membrane M and the muscular layer N, that is, in the submucosal layer L. The ring wire 50 of the backflow prevention device 5 has an annular shape, and partially overlaps to have a winding portion of one or more rounds.

  The excavation device 4 is for forming a passage for embedding the backflow prevention device 5 in the submucosa L. This excavation device 4 has a flexible tube 40 that is flexible in the bending direction but strong and elastic, and the inside is a flow path for fluid, for example, air. The distal end of the flexible tube 40 is formed with a loop in a direction intersecting the axis, and this loop portion is a passage forming portion 41 that determines the shape of the passage. Therefore, the shape of the passage forming portion 41 depends on the shape of the device to be placed. An excavation balloon 42 is attached to the tip of the passage forming portion 41.

  The digging balloon 42 is inflated by supplying compressed air. For this reason, a pumping means 43 as a fluid supply / discharge means for supplying and discharging the compressed air to and from the digging balloon 42 is provided at the proximal end portion of the flexible tube 40. Are detachably connected. This pumping means 43 is manually operated. As shown in FIG. 5, the digging means 4 is inserted into the treatment instrument insertion channel 15 of the endoscope 1, and the passage forming portion 41 at the distal end thereof faces the distal end surface of the distal end hard portion 10c. It is supposed to be incorporated as follows.

  By using the above apparatus and instrument, the backflow preventing instrument 5 is attached and placed at the site from the lower part of the esophagus E to the cardia C of the stomach G. Here, the ring wire 50 in the backflow prevention device 5 is composed of a metal or resin wire having a predetermined diameter. The elastic force of the ring wire 50 is set so that the loop expands at the inflow pressure acting on the inflow from the esophagus E side to the stomach G, but maintains the original loop shape at a pressure lower than that. Therefore, the treatment is performed by attaching the anti-reflux device 5 to the submucosal layer L between the mucous membrane M and the muscle layer N at the GERD position shown in FIG.

  First, the insertion portion 10 of the endoscope 1 is inserted into the portion from the lower portion of the esophagus E to the cardia C by inserting the distal end hard portion 10c, the angle portion 10b is bent, and the distal end hard portion 10c is inserted into the cavity wall. Face to face. In this state, the needle 20 of the local injection means 2 in which the liquid pumping part 22 is filled with physiological saline is inserted into the treatment instrument insertion channel 15 from the treatment instrument introduction section 15b. Then, the needle 20 is projected from the distal end opening 15a of the treatment instrument insertion channel 15 by a predetermined length, and is inserted into the cavity wall. Here, the insertion depth of the needle 20 passes through the mucous membrane M, but is not long enough to reach the muscle layer N, that is, the tip of the needle 0 is positioned in the submucosa L. Then, by sending physiological saline into the flexible tube 21 from the liquid pumping unit 22, the cavity wall of the transition part from the esophagus E to the cardia C is bulged.

  Next, with the insertion portion 10 of the endoscope 1 held in that position, the local injection means 2 is taken out from the treatment instrument insertion channel 15 and the high frequency knife 3 is inserted into the treatment instrument insertion channel 15 instead. . The needle knife 30 of the high-frequency knife 3 is protruded from the tip opening 15a, and the expanded mucosa M is incised by a predetermined length. However, the size of the incision portion is as small as possible so as not to hinder the insertion of the excavation balloon 42 attached to the distal end of the passage forming portion 41, which will be described later, and to minimize damage to the inner wall of the body cavity. It shall be small. The reason for injecting physiological saline in advance to the site to be incised is that the muscle layer N is not damaged at the time of incision. In addition, when there is no possibility of damaging the muscle layer N at the time of incision, the local injection described above may not be performed.

  After the incision of the wall of the body cavity by the high frequency knife 3 is completed and the high frequency knife 3 is removed from the treatment instrument insertion channel 15, the endoscope 1 is once taken out of the body cavity. This is because the digging device 4 is attached to the treatment instrument insertion channel 15 of the endoscope 1. Since the passage forming portion 41 is formed on the distal end side of the digging device 4, the flexible tube 40 is separated from the pumping means 43, and the proximal end portion of the flexible tube 40 is separated from the distal opening 15a side. Insert and feed into the treatment instrument introduction portion 15b. Preferably, the distal end passage forming portion 41 is brought into contact with the distal end surface of the distal end hard portion 10c in the insertion portion 10. In addition, a pumping means 43 is connected to the proximal end portion of the flexible tube 40. In this way, the insertion part 10 of the endoscope 1 incorporating the digging device 4 is inserted again into the body cavity and advanced to the site where the incision has been made. The excavation device 4 does not necessarily need to be replaced with the high-frequency knife 3, and the endoscope 1 incorporating the excavation device 4 can be prepared separately.

  Here, when the insertion portion 10 is inserted into the body cavity, as shown in FIG. 4, the passage forming portion 41 at the distal end portion of the flexible tube 40 in the digging device 4 is placed on the distal end surface of the distal end hard portion 10 c. In order to smoothly perform the insertion operation of the insertion portion 10, it is desirable that the insertion portion 10 is not in contact with the side and does not protrude to the side. Further, since the entire flexible tube 40 has flexibility, it can be drawn into the treatment instrument insertion channel 15 in advance.

  When the distal end hard portion 10c of the insertion portion 10 is positioned in the vicinity of the bulging portion of the body cavity wall, the distal end of the passage forming portion 41 is operated by pushing out the flexible tube 40 as shown in FIG. The part to which the excavation balloon 42 is attached is made to face the bulging and incised part P. Then, by rotating the portion led out from the treatment instrument introduction portion 15b on the proximal end side of the flexible tube 40 around the axis, as shown in FIG. The digging balloon 42 attached to the tip of the digging balloon 42 is allowed to enter the incision.

  In this state, the position of the passage forming portion 41 is maintained, and the pumping means 43 is operated to feed compressed air into the excavation balloon 42. As a result, as shown in FIG. 8, the excavation balloon 42 is inflated and protrudes forward, and the mucous membrane M is separated from the muscle layer N. Then, by operating the pumping means 43 in the reverse direction, the compressed air is discharged from the digging balloon 42 and contracted. At the same time, by rotating the insertion portion 10 about its axis, as shown in FIG. 9, the position of the digging balloon 42 at the tip of the passage forming portion 41 is equal to the length of the separation of the mucous membrane M. Can be dug up. In this state, the excavation balloon 42 is inflated again to advance the peeling of the mucous membrane M, the excavation balloon 42 is contracted, and the insertion portion 10 is rotated to excavate the submucosa L.

  By repeating the above operation, the tunnel is dug until the tunnel passage communicates between the mucous membrane M and the muscle layer N in an annular shape. Here, this tunnel passage only pushes away the submucosa L to form a space between the mucosa M and the muscle layer N, and does not cause any damage to the mucosa M and of course the muscle layer N. . When the loop of the tunnel passage is completed, the insertion portion 10 is rotated in the reverse direction to be separated from the tunnel passage that has been dug.

  Then, the insertion portion 10 of the endoscope 1 is taken out from the body cavity. The digging device 4 is removed from the endoscope 1 and the forceps 6 is inserted into the treatment instrument insertion channel 15, or the forceps 6 is inserted into the treatment instrument insertion channel of the endoscope 1 using another endoscope 1. 15 is inserted. Then, the gripping claw 60 of the forceps 6 is led out from the tip opening 15a, and the ring wire 50 of the backflow prevention device 5 is gripped.

  Then, the grasping claw 60 of the forceps 6 is protruded from the distal end surface of the insertion portion 10, and one spherical bulging portion 51 of the ring wire 50 in the backflow prevention device 5 is inserted into the incised portion P to enter the tunnel passage. Operate to push in. The other spherical bulging portion 51 of the ring wire 50 is completely embedded in the tunnel passage, and the incised portion P is sutured. As a result, the backflow prevention device 5 is attached to the transition portion from the esophagus E to the stomach G, and the backflow prevention device 5 is indwelled by pulling out the insertion portion 10 from the body cavity. As described above, the indwelling backflow prevention device 5 is provided with the spherical bulging portion 51 at the tip portion to be introduced into the submucosal layer L of the ring wire 50, so that the ring wire 50 is inserted. At this time, the mucous membrane M, muscle layer N, and the like can be protected from being damaged.

  The anti-reflux device 5 exerts a function of narrowing the passage from the esophagus E to the stomach G. Therefore, if the diameter of the ring wire 50 is appropriately set, it exerts an auxiliary function for the pressure of the lower esophageal sphincter. The passage can be in a substantially closed state, that is, in a state in which there is almost no gap in the body wall, thereby preventing gastric juice or the like from flowing back from the cardia C of the stomach G toward the lower part of the esophagus E. Specifically, by setting the diameter of the ring wire 50 in a free state to about 10 mm, this backflow prevention function is sufficiently exhibited. Further, the passage forming portion 41 of the digging means 4 is also formed in a loop like the backflow prevention device 5. These loop shapes do not necessarily need to match, but the passage forming portion 41 is inserted into the body cavity in a state where it is positioned in front of the distal end rigid portion 10c of the insertion portion 10, so that the side of the distal end rigid portion 10c is It is desirable to hold it so that it does not protrude. Therefore, the diameter of the passage forming portion 41 can be formed to be approximately the same diameter as the ring wire 50.

  Wearing the backflow prevention device 5 prevents backflow to the esophagus E side, but allows forward flow of food and drink based on digestive activity including peristalsis by swallowing, that is, flow from the esophagus E to the stomach G Is. For this reason, if there is a movement for feeding food and drink or the like into the stomach G, the throttle part to which the above-described backflow prevention device 5 is attached opens. For this purpose, the diameter of the ring wire 50 must be increased. However, since the ring wire 50 has an appropriate elasticity, it does not interfere with the digestive activity for taking in food and drink to the stomach G. Absent. Moreover, since the spherical bulging part 51 is formed in the both ends of the ring wire 50, the expansion / contraction operation | movement of this backflow prevention instrument 5 can be performed smoothly.

It is sectional drawing which shows a stomach and an esophagus typically. It is explanatory drawing which shows a gastric / esophageal reflux disease typically. BRIEF DESCRIPTION OF THE DRAWINGS FIG. 1 is a configuration explanatory view showing an apparatus and an instrument used when treating gastric / esophageal reflux disease as one embodiment of the present invention. It is a general-view figure of the front-end | tip part in the insertion part of an endoscope. It is a general-view figure of the front-end | tip part in the insertion part of the endoscope with which the excavation apparatus was mounted | worn. It is operation | movement explanatory drawing which shows the step before inserting a digging apparatus in a submucosa. It is action | operation explanatory drawing which shows the state which inserted the excavation apparatus in the submucosa. It is operation | movement explanatory drawing which shows the state which expanded the digging balloon of the digging apparatus. It is action | operation explanatory drawing which shows the state which dug the channel | path with the digging apparatus.

Explanation of symbols

DESCRIPTION OF SYMBOLS 1 Endoscope 4 Digging apparatus 5 Backflow prevention instrument 40 Flexible tube 41 Passage formation part 42 Digging balloon 43 Pumping means M Mucosa N Muscle layer L Submucosa

Claims (3)

A flexible tube forming a fluid passage;
A digging balloon attached to the distal end of the flexible tube and bulging toward the front of the flexible tube by supplying fluid to the fluid passage;
An apparatus for digging into the submucosal layer, comprising a fluid supply / discharge means connected to the base end of the flexible tube and supplying / discharging pressure fluid to / from the digging balloon. The flexible tube has an outer diameter that can be inserted into a treatment instrument insertion channel of an endoscope, and the fluid supply / discharge means is detachably connected to a proximal end portion of the flexible tube. The apparatus for digging into the submucosa according to claim 1. 2. The apparatus for digging into the submucosa layer according to claim 1, wherein the distal end portion of the flexible tube is formed in a loop shape intersecting the axis thereof.

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