JP2013248523A - Sheath for gastrostoma, sheathed dilator, sheath for gastrostoma with insertion aid, and gastrostomy catheter kit - Google Patents

Abstract

PROBLEM TO BE SOLVED: To provide a technology capable of reducing insertion resistance when placing a button type gastrostomy catheter in gastrostomy or exchanging the gastrostomy catheter, and capable of facilitating air-supply control of an endoscope to stabilize the endoscopic visual field in the course of operation.SOLUTION: A sheath 1 for gastrostoma includes a sheath body 11, into which a gastrostomy catheter 2 is inserted, and a handle 12. The sheath 1 for gastrostoma is preliminarily inserted into a fistula when inserting the gastrostomy catheter 2 to the fistula and placing it in the body to thereby reduce the resistance against the insertion of the gastrostomy catheter 2. A dilator provided with a sheath, and a gastrostomy catheter kit are also provided.

Description

 The present invention relates to a gastrostomy sheath used for insertion and placement of a gastrostomy catheter in a fistula and a catheter exchange, a dilator with a sheath, a sheath for gastrostoma with an insertion aid, and a gastrostomy catheter kit.

Nutritional administration methods for patients who cannot take nutrition through the mouth are generally intravenous nutritional administration, transgastric nutritional administration by inserting a tube from the nose into the stomach, etc., and enteral administration from the gastrostomy Three kinds of nutrition administration are performed.
In recent years, enteral nutrition and administration thereof have been frequently used for enteral nutrition management by percutaneous endoscopic gastrostomy (PEG).

 Conventionally, there are three general methods for installing this PEG: the Pull method for inserting a gastrostomy tube from the oral cavity, the Push method, and the Introducer method for inserting a tube from the body surface through a sheath. Are known.

 In the Pull method and the Push method, in order to pass the gastrostomy tube through the pharynx, there is a possibility of wound infection at the site where the gastrostomy tube is placed, and it is necessary to insert an endoscope twice. Had drawbacks. On the other hand, the Introducer method does not pass the gastrostomy tube through the pharynx, so the risk of the above wound infection is low, and the endoscope can be inserted only once, but a thick puncture needle is inserted without using a guide wire. Furthermore, since only a small-diameter balloon catheter can be placed through a sheath, the balloon is reduced in terms of long-term placement, and management is complicated.

Recently, a new method for inserting and placing a large-diameter button-type gastrostomy catheter into the stomach directly from outside the body through the abdominal wall is becoming widespread.
In this method, an abdominal wall and stomach wall are fixed with a suture using a device called a stomach wall abdominal wall fixing tool, a fistula is opened in the abdominal wall and stomach wall using a dilator under the guide wire, and an obturator is formed in the fistula under the guide wire. By inserting a large-diameter button-type gastrostomy catheter with the indwelling part extended, the catheter is placed.

 A button-type gastrostomy catheter used in this method includes a tube part that is inserted in a fistula as an introduction passage for introducing a nutrient or a drug solution from the outside of the body into the stomach, and a distal end of the tube part An indwelling portion formed in a dome shape (more specifically, a hook shape) projecting radially outward of the tube portion by a plurality of elastically deformable belt-like members attached to the portion; and the distal end portion of the tube portion; Is composed of an extracorporeal fixing portion that is attached to the opposite end portion (base end portion), protrudes outward in the radial direction of the tube portion, and contacts the body surface from the outside of the body. The indwelling portion is deformed into a reduced diameter state (extending in the virtual extension direction on the distal end side of the tube portion) to reduce the insertion resistance into the fistula (for example, patent document) 1)The in-vivo indwelling portion is in the stomach by having a shape that protrudes outward in the radial direction of the tube portion in the stomach.

Japanese Patent Publication No. 2006-296794

However, the fistula is generally about the same size as the outer diameter of the tube, and when a new fistula is formed by the dilator, the abdominal wall will fill the fistula by removing the dilator from the body. Can be expected to be smaller before insertion of the gastrostomy catheter. On the other hand, even if the indwelling portion of the button-type gastrostomy catheter is reduced in diameter by an obturator, it is difficult at present to make the outer diameter smaller than the tube portion. Therefore, when the button-type gastrostomy catheter is inserted, the indwelling part pushes and expands the fistula, increasing the insertion resistance.
In addition, when a new fistula is formed, it is a normal method that the stomach is inflated with sufficient air supply from the endoscope. However, in order to insert a large-diameter button-type gastrostomy catheter, a large fistula must be opened with a dilator, and when the dilator is removed, air sent from the endoscope may escape through the fistula. Therefore, the visual field of the endoscope may be deteriorated, and air supply control is often required.

 The present invention has been made in view of the above circumstances, can reduce insertion resistance when placing a button-type gastrostomy catheter, facilitates air supply control of an endoscope, An object of the present invention is to provide a sheath for gastrostoma capable of stabilizing the visual field of an endoscope, a dilator with a sheath, a sheath for gastrostoma with an insertion aid, and a gastrostomy catheter kit.

In order to solve the above problems, the present invention provides the following configuration.
1st invention is formed in the dome shape which is attached to the front-end | tip part of the said tube part, and is extended in the radial direction outside of the said tube part which has the channel | path which introduces a nutrient solution or a chemical | medical solution from the body into the stomach inside. A gastrostomy for inserting and placing a gastrostomy catheter into the fistula, the gastrostomy catheter having a diameter that can be reduced by an action of an extension force applied from an extension obturator of the body indwelling part. A sheath for gastrostoma used for surgical operation and replacement of a gastrostomy catheter, comprising: a cylindrical sheath body into which the gastrostomy catheter is inserted; and a handle projecting from one longitudinal end of the sheath body Further, the sheath body is rotatably provided at the proximal end portion, which is the end portion on the handle side, of the sheath body via a hinge portion and is disposed in an internal passage that is a through hole inside the sheath body, Hinge part A lid that opens and closes the internal passage of the sheath body by pivoting about the core, and the lid of the sheath body is coupled to the proximal end portion of the sheath body by pivoting about the hinge portion; Is provided with a lid abutting portion that abuts from the tip side that is the opposite end, and the lid abuts the lid abutting portion at a closed position that closes the internal passage, There is provided a sheath for gastrostoma characterized in that the internal passage is opened by being rotated from the closed position toward the distal end of the sheath body.
According to a second aspect of the present invention, the lid abutting portion is provided on a side of the sheath body that faces the hinge portion via the internal passage, and the lid abutting portion includes the hinge portion side of the lid. The gastrostomy sheath according to the first aspect of the present invention is provided in which the opposite end is brought into contact.
According to a third aspect of the present invention, the handle is rotatably provided at a proximal end portion of the sheath body via the hinge portion, and the lid projects from the handle into an internal passage, and the handle The sheath for gastrostoma according to the first or second aspect of the invention is characterized in that the internal passage of the sheath body is opened and closed by integral rotation with the sheath.
In a fourth aspect of the invention, the hinge portion is an elastic support portion that elastically supports the lid in the closed position while allowing the lid to rotate in the open direction from the closed position. A sheath for gastrostoma according to any of the inventions is provided.
According to a fifth aspect of the present invention, an urging force is applied to the handle to allow the lid to rotate in the opening direction from the closed position and to function as an elastic support portion for elastically supporting the lid in the closed position. A gastrostomy sheath according to any one of the first to fourth inventions, comprising a member.
According to a sixth aspect of the invention, in the stomach according to any one of the first to fifth aspects, a recess for storing a lid for storing the lid is formed on an inner surface of the internal passage of the sheath body. A vaginal sheath is provided.
According to a seventh aspect of the present invention, an extension portion is formed at the base end portion of the sheath body so that the sheath body expands radially outward. The gastrostomy sheath according to the sixth aspect of the present invention is a space secured so as to expand the internal passage inside the portion.
According to an eighth aspect of the present invention, a handle main piece that constitutes part or all of the handle, the sheath body, and the hinge portion are formed as a single piece integrally formed of synthetic resin. A gastrostomy sheath according to any one of the first to seventh inventions is provided.
According to a ninth aspect of the present invention, in the first to eighth aspects, a grip ring is provided on a side opposite to the hinge portion of the handle so that a user can insert and grip a finger. A sheath for gastrostoma according to any of the inventions is provided.
According to a tenth aspect of the present invention, in the first to ninth aspects, the sheath body is formed with one or a plurality of longitudinal tear notches extending along the longitudinal direction of the sheath body. The sheath for gastrostoma of any invention is provided.
In an eleventh aspect of the invention, the cutout portion is a cutout groove formed in the sheath body so as not to penetrate the thickness thereof, and the thickness of the sheath body is locally disposed on the groove bottom side of the cutout groove. A gastrostomy sheath according to a tenth aspect of the present invention is provided, wherein a thinly cut non-cut portion is secured.
According to a twelfth aspect of the invention, the sheath body is formed with a V-shaped end notch that is recessed from the end face on the base end side, and the notch groove is located at the back of the end notch. The sheath for gastrostoma according to the eleventh invention is provided, wherein the sheath is formed so as to extend from the bottom toward the distal end side of the seal body.
In a thirteenth aspect of the invention, the notch is a slit formed so as to extend along the longitudinal direction of the sheath body, and the slit has a length shorter than the overall length in the longitudinal direction of the sheath body. The sheath for gastrostoma according to the tenth invention, characterized in that the sheath body is formed in a part in the longitudinal direction, and the sheath body has a non-cut portion in which the slit is not formed on a virtual extension of the slit. To do.
In a fourteenth aspect of the invention, any one of the first to thirteenth aspects is characterized in that a load applied to the inner surface of the sheath body is 0.5N or more and 5N or less in order to destroy at least one of the non-cut portions. The invention provides a sheath for gastrostoma.
In a fifteenth aspect of the present invention, the cutout portion is formed in a wedge shape whose cross-sectional shape increases in opening width from the inner surface side to the outer surface side of the sheath body. The sheath for gastrostoma of any invention is provided.
A sixteenth aspect of the invention provides the sheath for gastrostoma according to any one of the tenth to fifteenth aspects of the invention, wherein the notch is formed by laser processing of the sheath body.
In a seventeenth aspect of the invention according to the sixteenth aspect, the sheath body is formed of a material containing FEP, and the portion of the sheath body where the notch is formed is whitened by the laser processing. A gastrostomy sheath is provided.
According to an eighteenth aspect of the invention, the handle is provided at a position avoiding the notch in the circumferential direction of the sheath body. The sheath for gastrostoma according to any one of the nineteenth to twenty-sixth aspects of the invention I will provide a.
According to a nineteenth aspect of the invention, there is provided the gastrostomy sheath according to the eighteenth aspect of the invention, wherein the notch is formed only at one place in the circumferential direction of the sheath body, and the handle is one. To do.
According to a twentieth aspect of the invention, there is provided the sheath for gastrostoma according to any one of the first to nineteenth aspects, wherein the sheath body is oriented in the longitudinal direction.
In a twenty-first aspect of the invention, the gastrostomy according to any one of the first to twenty-first aspects, wherein an end surface of the sheath body on the proximal end side is formed obliquely with respect to the axis of the sheath body. A sheath is provided.
A twenty-second invention provides the gastrostomy sheath according to any one of the first to twenty-first inventions, wherein an inner diameter of the sheath body is larger than an outer diameter of a tube portion of the gastrostomy catheter.
A twenty-third invention provides the sheath for gastrostoma according to any one of the first to twenty-second inventions, wherein the material of the sheath body includes a fluorine-based resin.
A twenty-fourth invention provides the sheath for gastrostoma according to the twenty-third invention, wherein the fluororesin contains any one of PTFE, ETFE, and FEP.
A twenty-fifth invention provides the sheath for gastrostoma according to any one of the first to twenty-fourth inventions, wherein the sheath body can be externally inserted into and removed from a fistula-forming dilator.
A twenty-sixth invention provides the sheath for gastrostoma according to the twenty-fifth invention, wherein the dilator has a guide wire passage penetrating in the longitudinal direction thereof.
In a twenty-seventh aspect of the invention, the dilator is provided with a scale for measuring a distance between the inner surface of the stomach wall and the body surface on the outer peripheral surface thereof. A sheath is provided.
A twenty-eighth invention provides the sheath for gastrostoma according to the twenty-seventh invention, wherein the sheath body has transparency that allows the scale of the dilator to be viewed from the outside.
In a thirty-ninth aspect of the invention, the dilator integrates a thin dilator having the guide wire passage therein and a large dilator that is externally attached to the thin dilator and assembled to the thin dilator. A gastrostomy sheath according to any one of the twenty-fifth to twenty-eighth inventions is provided.
A thirtieth aspect of the invention is characterized in that the inner diameter of the sheath body is smaller than the maximum outer diameter when the indwelling portion of the gastrostomy catheter is in a reduced diameter state by an extension force applied from an obturator. A sheath for gastrostoma according to any of the 29 inventions is provided.
In a thirty-first aspect, the sheath body can be longitudinally split by insertion of the gastrostomy catheter in which the indwelling portion is reduced in diameter by the obturator. Providing a sheath.
A thirty-second invention provides the sheath for gastrostoma according to any one of the first to thirty-first inventions, wherein the sheath body is configured to be radially expandable by a material capable of stretching and deforming. .
A thirty-third invention is characterized in that the inner diameter of the sheath body is larger than the maximum outer diameter when the indwelling portion of the gastrostomy catheter is in a reduced diameter state by an extension force applied from an obturator. A sheath for gastrostoma according to any of the 29 inventions is provided.
In a thirty-fourth aspect of the invention, the sheath body is configured to be removably inserted into a sheath insertion assisting tool that is formed into a rod-like appearance. The sheath insertion assisting tool includes a rod-shaped body and the rod-shaped body. A gastrostomy sheath according to any one of the first to thirty-third inventions, comprising: a tapered tapered tip projecting from one end in the longitudinal direction.
A thirty-fifth invention provides the sheath for gastrostoma according to the thirty-fourth invention, wherein the sheath insertion assisting tool has a guide wire insertion hole penetrating in the longitudinal direction.
A thirty-sixth invention provides the sheath for gastrostoma according to the thirty-fourth or thirty-fifth invention, wherein the sheath insertion assisting tool can be used as a dilator for fistula formation.
A thirty-seventh aspect of the present invention provides a dilator with a sheath, characterized in that the gastrostomy sheath of any of the first to thirty-sixth aspects of the invention is extrapolated to a dilator for fistula formation.
In a thirty-eighth aspect of the invention, there is provided a sheath insertion assist wherein the sheath main body of the sheath for gastrostoma according to any one of the first to thirty-six is provided with a tapered tapered tip projecting at one end in the longitudinal direction of the rod-shaped main body. A sheath for gastrostoma with an insertion assisting device, wherein the device is inserted.
A thirty-ninth aspect of the invention is a gastrostomy catheter for percutaneously replenishing a patient with a nutrient solution or a drug solution from outside the body into the stomach, an obturator, and the sheath for gastrostoma according to any one of the first to thirty-sixth inventions. A gastrostomy catheter kit including a dilator with a sheath according to a thirty-seventh aspect of the present invention, wherein the gastrostomy catheter includes a tube portion having a passage for introducing a nutrient solution or a drug solution from the outside of the body into the stomach, and the tube portion. An indwelling portion formed in a dome shape attached to the distal end portion and projecting radially outward of the tube portion, and the indwelling portion acts by an extension force applied from an extension obturator of the indwelling portion The sheath for gastrostoma according to any one of the first to thirty-sixth inventions and the sheath for gastrostoma of the dilator with sheath according to the thirty-seventh invention are inserted in a fistula, The gastrostomy catheter and contracted state the indwelling section provides a gastrostomy catheter kit, characterized in that inserted by Buchureta.
In a fortieth aspect of the invention, the obturator includes an outer cylinder, an extension pressing rod having a rod body inserted into the outer cylinder so as to be movable in a longitudinal direction of the outer cylinder, and the gastrostomy catheter as the outer cylinder. A distal end protruding from the outer cylinder of the rod body of the extension pressing rod in a state where the gastrostomy catheter is locked to the outer cylinder by the stopper. A gastrostomy catheter kit according to a thirty-ninth aspect of the present invention is provided, wherein the gastrostomy catheter kit is inserted into the body indwelling portion of the gastrostomy catheter and the indwelling portion is extended by pressing the most distal portion of the body indwelling portion.
In a forty-first aspect of the present invention, the gastrostomy catheter and the obturator have a guide wire passage, and the obturator is placed in the body of the gastrostomy catheter while being externally inserted into a guide wire inserted into the gastrostomy catheter. A gastrostomy catheter kit according to the thirty-ninth or forty inventions is provided, wherein the portion is configured to be capable of reducing the diameter.
The forty-second invention further includes the gastrostomy sheath according to any one of the first to thirty-sixth inventions as a replacement gastrostomy sheath, wherein the obturator is inserted into a fistula. The gastrostomy catheter kit according to any of the 39th to 41st inventions is provided, wherein the gastrostomy catheter having the indwelling portion reduced in diameter is inserted.
The 43rd invention comprises the sheath for gastrostoma with an insertion aid according to claim 47, which is constructed by using the replacement sheath for gastrostoma. 42. The gastrostomy catheter kit according to the 42nd invention, I will provide a.

According to the present invention, it is possible to reduce the insertion resistance when placing a button-type gastrostomy catheter.
Also, the internal passage of the sheath body is opened and closed using a plug member that is detachably fitted to the proximal end portion of the sheath body, or the gastrostomy sheath itself functions as the plug member that opens and closes the internal passage of the sheath body. By adopting the configuration (second invention) including the lid to be opened, the internal passage can be easily opened and closed. Thereby, the air supply control of the endoscope can be facilitated, and the visual field of the endoscope during the operation can be stabilized.

(A) The perspective view when the lid | cover of the sheath for gastrostoma of this invention closes is shown. (B) A cross-sectional view of the left side when the lid of the sheath for gastrostoma of the present invention is closed is shown. (A) The top view when the lid | cover of the sheath for gastrostoma of this invention closes is shown. (B) The front view when the lid | cover of the sheath for gastrostoma of this invention closes is shown. (C) The right view when the lid | cover of the sheath for gastrostoma of this invention closes is shown. (D) The rear view when the lid | cover of the sheath for gastrostoma of this invention closes is shown. (E) The bottom view when the lid | cover of the sheath for gastrostoma of this invention closes is shown. (A) The perspective view when the lid | cover of the sheath for gastrostoma of this invention opens is shown. (B) The left side sectional view when the lid of the sheath for gastrostoma of the present invention is opened is shown. (A) The top view when the lid | cover of the sheath for gastrostoma of this invention opens is shown. (B) The front view when the lid | cover of the sheath for gastrostoma of this invention opens is shown. (C) The right view when the lid | cover of the sheath for gastrostoma of this invention opens is shown. (D) The rear view when the lid | cover of the sheath for gastrostoma of this invention opens is shown. (E) The bottom view when the lid | cover of the sheath for gastrostoma of this invention opens is shown. It is sectional drawing which shows the structure which has arrange | positioned the elastic member to the outer side of a sheath main body base end as an elastic support part in order to elastically support a lid to a closed position in the sheath for gastrostoma of this invention, (a) is a lid (B) shows a state in which the lid is moved from the closed position and the internal passage of the sheath body is opened. (A) The perspective view of the button for gastrostoma used for this invention is shown. (B) The top view of the button for gastrostoma used for this invention is shown. (C) The bottom view of the button for gastrostoma used for this invention is shown. It is sectional drawing which shows the structure of the button for gastrostoma used for this invention. (A) The left side sectional view of the obturator used in the present invention and the side view of the stopper are shown. (B) The front view of the obturator used for this invention is shown. (C) The right view of the obturator used for this invention is shown. It is a figure which shows the relationship between the obturator used for this invention, and the stopper attached to this obturator, Comprising: (a) is a state when the stopper can lock the extracorporeal fixing part of the button for gastrostoma, (b) Indicates when the stopper is unlocked. (A) The front view at the time of setting the button for gastrostoma and obturator used for this invention is shown. (B) The front view at the time of setting the gastrostoma button and obturator used for this invention and extending the gastrostoma button is shown. (A) The front view at the time of extending the button for gastrostoma in the state which set the button for gastrostoma and obturator used for this invention, and also used the guide wire together is shown. (A) The front view of the dilator used for this invention is shown. (B) The front view of the thin diameter dilator used for this invention is shown. (C) It is a front view which shows the dilator with a sheath which combined the sheath for gastrostoma of this invention with the dilator. (D) It is sectional drawing which shows the dilator with a sheath which combined the sheath for gastrostoma of this invention with the dilator. The front view just before putting the button for gastrostoma extended with the obturator in the sheath for gastrostoma of this invention is shown. The front view in the middle of putting the button for gastrostoma extended with the obturator in the sheath for gastrostoma of this invention is shown. It is a figure which shows the sheath for gastrostoma of this invention, Comprising: It is a perspective view which shows the structure which formed the slit as a notch part in the sheath main body, Comprising: (a) is a state in which a lid | cover is in a closed position, (b) Shows a state in which the lid is moved from the closed position and the internal passage of the sheath body is opened. It is a figure which shows typically the cross-section of the sheath main body of the sheath for gastrostoma of this invention, and the position of a handle, (a) The structure which formed the notch groove as a notch part in a sheath main body, (b) is a sheath The structure which formed the slit as a notch part in the main body is shown. It is sectional drawing which shows the structure of the sheath for gastrostoma of the structure which formed the slit in two places of the circumferential direction of a sheath main body. The abdominal wall and the stomach wall are not in close contact with each other. The abdominal wall and the stomach wall are shown in close contact with the suture. A state where the guide wire is placed is shown. The state which inserts the dilator (dilator with a sheath) which covered the gastrostomy sheath together with a guide wire in the abdominal wall and the stomach wall is shown. The state where the sheath for gastrostoma was indwelled is shown. The state which inserts the button for gastrostoma in the sheath for gastrostoma is shown. The state which inserted the button for gastrostoma from the internal channel | path of the sheath for gastrostoma is shown. The state where only the gastrostoma button after removing the gastrostoma sheath is shown is shown. The state when the extension of the obturator is canceled is shown. The state when the obturator is removed is shown. The state where the placement of the gastrostoma button is completed is shown. The state before inserting the button for gastrostoma extended by the obturator in the sheath main body which can be expanded radially is shown. The state of the process which inserts the button for gastrostoma extended with the obturator in the sheath main body which can expand radially is shown. (A) It is a figure which shows the other aspect of the sheath for gastrostoma of this invention, Comprising: The perspective view at the time of a lid | cover closing is shown. (B) A cross-sectional view of the left side when the lid of the sheath for gastrostoma of FIG. 31 (a) is closed. (A) The top view when the lid | cover of the sheath for gastrostoma of FIG. 31 is closed is shown. (B) The left view when the lid | cover of the sheath for gastrostoma of FIG. 31 is closed is shown. (C) The front view at the time of the lid | cover of the sheath for gastrostoma of FIG. 31 closing is shown. (D) The right view when the lid | cover of the sheath for gastrostoma of FIG. 31 is closed is shown. (E) The rear view when the lid | cover of the sheath for gastrostoma of FIG. 31 closes is shown. (F) The bottom view when the lid | cover of the sheath for gastrostoma of FIG. 31 is closed is shown. It is a figure which shows the button detained in the fistula. It is a figure which shows the state which removed the cap of the button for gastrostoma. It is a figure which shows the state which inserted the obturator in the button lumen for gastrostoma, and hold | gripped the external fixing part of the button with the stopper. It is a figure which shows the state which inserted the guide wire from the guide wire insertion hole of an obturator, and took out the guide wire from the gastrostomy button front-end | tip. It is a figure which shows the state which pushed the operation part of the obturator assembled | attached to the gastrostoma button, and made the indwelling part of the gastrostoma button the indwelling state. It is a figure which shows the state which extracted the obturator, the button for gastrostoma, and the guide wire in the state which only left the guide wire in the fistula. It is a figure which shows the state which inserted the sheath with an insertion auxiliary tool formed by extrapolating the sheath for gastrostoma in a sheath insertion auxiliary tool into a fistula by using a guide wire as a guide member. It is a figure which shows the state which removed the sheath insertion auxiliary tool and the guide wire and only the sheath for gastrostoma is indwelling. It is a figure which shows the state which inserted the button for gastrostomy into the fistula through the sheath for gastrostoma. It is a figure which shows the state by which the button for gastrostoma was detained in the stomach through the sheath for gastrostoma. It is sectional drawing which shows the other example of the sheath for gastrostoma of the structure which carried out the lid | cover on the handle via the lid hinge part different from a hinge part. (A) It is a perspective view which shows the example of the sheath for gastrostoma which formed in the sheath main body the V-shaped end part notch part which can be utilized as a starting point (starting point) of the longitudinal tear of this sheath main body. (B) It is an enlarged front view (enlarged front view of the area | region X of FIG. 44 (a)) which shows the structure of the edge part notch part vicinity of the sheath main body of the said FIG. 44 (a). (A) It is a perspective view which shows the example of the sheath for gastrostoma of the structure which provided the grip ring in the handle. (B) It is left sectional drawing which shows the structure of the sheath for gastrostoma of Fig.45 (a). (A) The top view when the lid | cover of the sheath for gastrostoma of FIG. 45 is closed is shown. (B) A left side view when the lid of the sheath for gastrostoma of FIG. 45 is closed is shown. (C) The front view at the time of the lid | cover of the sheath for gastrostoma of FIG. 45 closing is shown. (D) A right side view when the lid of the sheath for gastrostoma of FIG. 45 is closed is shown. (E) A rear view when the lid of the sheath for gastrostoma of FIG. 45 is closed is shown. (F) A bottom view when the lid of the sheath for gastrostoma of FIG. 45 is closed is shown. It is a figure which shows an example of the grip type | mold with the fingers of the grip ring of the sheath for gastrostoma of FIG.

Examples of the gastrostomy sheath, sheathed dilator, gastrostomy catheter kit, and gastrostomy sheath dividing method embodying the present invention will be described below, and preferred embodiments of the present invention will be described with reference to the drawings.
In the following description, the vertical direction is defined, but this is defined for the sake of simplicity in explaining the relative relationship of the components of the present invention. It does not limit the direction during use.
In all the drawings, common constituent elements are denoted by the same reference numerals, and detailed description will be appropriately omitted in the following description. In the drawing, the upper side is the upper end side and the lower side is the lower end side.

 FIG. 1 and FIG. 2 show an embodiment in which the lid 13 of the gastrostomy sheath 1 of the present invention is closed, FIG. 1 (a) is a perspective view, and FIG. 1 (b) is a cross-sectional view. 2 (a) is a top view, FIG. 2 (b) is a front view, FIG. 2 (c) is a right side view, FIG. 2 (d) is a rear view, and FIG. 2 (e) is a bottom view.

The gastrostomy sheath 1 is inserted into a fistula formed using a dilator in gastrostomy (see FIG. 21). In this insertion state, the gastrostomy catheter is inserted.
As shown in FIGS. 1A, 1B, and 2A to 2E, the gastrostomy sheath 1 includes a cylindrical sheath body 11 (sheath tube), a handle 12, and a lid 13. Composed.

 The sheath body 11 has an internal passage 113 for inserting a gastrostomy catheter (button for gastrostoma, see FIG. 6A and the like). Furthermore, the internal passage 113 is formed with a sheath for gastrostoma 1 (specifically, the sheath body 11 in detail) in order to form a hole (hereinafter referred to as a fistula) for placing a gastrostoma button. It is also used to cover the dilator shown in

The handle 12 is provided on the upper end side of the gastrostomy sheath 1. The handle 12 can be used for grasping the sheath 1 for gastrostoma when inserting the button for gastrostoma.
The handle 12 extends from one end of the sheath body 11 in the longitudinal direction (the end of the sheath body 11 on the handle 12 side, hereinafter also referred to as a base end, the upper end in FIGS. 1A and 1B). The first handle member 121 and the second handle member 122 are fixed to the tongue-shaped handle main piece 114. The first handle member 121 and the second handle member 122 are plate-like members, and are fixed to and integrated with the handle main piece 114 so as to sandwich the handle main piece 114 therebetween. ing. The handle 12 has a tongue-like shape extending from the proximal end portion of the sheath body 11.

The handle main piece 114 is a portion cut out from the resin tube together with the sheath main body 11 when the sheath main body 11 is cut out from the resin tube, and is formed integrally with the sheath main body 11. It is continuous from. Further, by applying an adhesive between the first handle member 121 and the second handle member 122 sandwiching the handle main piece 114, the attachment strength of the handle can be ensured.
The first handle member 121 and the second handle member 122 may be configured as separate members or may be formed by integral molding.
Further, the handle 12 may have a structure in which the entire handle 12 is constituted only by the handle main piece 114.

 The handle 12 is rotated with respect to the sheath body 11 around a boundary portion between the sheath body 11 and a handle main piece 114 that is a tongue-like extending portion continuous from the sheath body 11. Can do. That is, the boundary portion functions as a hinge portion 116 that enables the handle 12 to rotate relative to the sheath body 11. The handle 12 is provided so as to be rotatable with respect to the sheath body 11 via the hinge portion 116.

 The handle 12 is rotated about the hinge portion 116 around the axis of rotation in the direction perpendicular to the axis of the sheath body 11 (the central axis of the internal passage 113; C1 in FIG. 1B). Rotation. The handle 12 rotates as indicated by an arrow A in FIG.

In addition, as the hinge part 116, it may be easy to bend by performing a process such as cutting the boundary part, thinning by cutting, or thinning by pressing a hot plate or a hot wire.
Further, a resin molded product in which the sheath body 11, the hinge portion 116, and the handle main piece 114 are integrated can be obtained by molding.

As will be described later, the handle 12 can rotate integrally with a lid 13 that opens and closes an internal passage 113 that is a through-hole penetrating the inside of the sheath body 11.
The lid 13 will be described.
In the illustrated example of the gastrostomy sheath 1 shown in FIGS. 1A, 1 </ b> B, 2 </ b> A to 2 </ b> E, the lid 13 is specifically fixed to the handle main piece 114. The first handle member 121 is a tongue-like portion that extends from the handle 12 so as to protrude into the internal passage 113 of the sheath body 11. The lid 13 is disposed in the internal passage 113 of the sheath body 11.

 The first handle member 121 is a sheath through the hinge portion 116 through the upper surface of the handle main piece 114 (the upper surface in the state shown by the solid line in FIGS. 1A and 1B (the lid closed state)). It is provided on the surface on the side continuous with the inner surface of the main body 11. The lid 13 has a distal end portion of the sheath body 11 (opposite to the proximal end portion on the handle 12 side in the longitudinal direction of the sheath body 11) with respect to a virtual vertical plane perpendicular to the axis of the sheath body 11 from the hinge portion 116. 1 is extended to the inside passage 113 of the sheath body 11 so as to be inclined toward the lower end portion in FIGS.

The lid 13 rotates around the hinge portion 116 in the internal passage 113. The axis of rotation by the hinge portion 116 of the lid 13 is located at the mouth edge of the base end portion of the sheath body 11.
The turning radius of the lid 13 around the hinge portion 116 is larger than the inner diameter D of the inner passage 113 of the sheath body 11 (the inner diameter of a portion where an extension portion 115 described later is not formed).

 In addition, in the sheath 1 for gastrostoma of the illustrated example, in detail, an expanded portion shaped so as to expand a part in the circumferential direction of the proximal end portion of the sheath body 11 outward in the radial direction of the sheath body 11. 115 (shaped part) is formed. The hinge part 116 is provided in the extension part 115 and is located at the mouth edge of the base end part of the sheath body 11, and is a space (inner space 115 a) secured inside the extension part 115 so as to expand the internal passage 113. The distance from the axis of the sheath body 11 (the central axis C1 of the internal passage 113) is larger than the radius of the internal passage 113 by the size.

 The extended portion 115 is formed in a U-shaped cross section (a cross section perpendicular to the axis of the sheath main body 11 is U-shaped) so as to protrude from the side of the sheath main body 11, and the hinge portion 116 is formed in the sheath main body 11. From the axial center (center axis C1 of the internal passage 113) through the inner space 115a of the extension 115 to the back wall 115b located on the back side. However, the radius of rotation about the hinge portion 116 of the lid 13, that is, the tip of the portion extending from the hinge portion 116 of the lid 13 and inserted into the internal passage 113 of the sheath body 11 and the rotation center. The distance between them is greater than the sum of the radius of the internal passage 113 of the sheath body 11 and the distance L1 from the axial center (center axis C1) of the sheath body 11 to the back wall 115b of the extension 115.

In FIG. 1, reference numeral 117 denotes a lid abutting portion with which the tip of the lid 13 abuts.
The lid abutting portion 117 is a portion located on the side opposite to the hinge portion 116 via the internal passage 113 at the proximal end portion of the sheath body 11. The lid abutting portion 117 abuts the distal end of the lid 13 from the distal end side of the sheath body 11 by rotation about the hinge portion 116. The position where the tip of the lid 13 abuts against the lid abutting portion 117 is a closed position where the internal passage 113 is closed. The lid abutting portion 117 functions as a stopper portion that restricts the rotation of the lid 13 in the direction opposite to the distal end portion of the sheath body 11 from the closed position when the lid 13 abuts. Thereby, the lid 13 does not jump out from the opening of the internal passage 13 at the proximal end portion of the sheath body 11, and the lid 13 exists only in the sheath 1 for gastrostoma.

 The lid abutting portion 117 is not necessarily limited to a portion located on the side opposite to the hinge portion 116 via the internal passage 113 at the proximal end portion of the sheath body 11, and depends on the shape of the lid 13. For example, a configuration in which the entire substrate portion of the sheath body functions as a lid contact portion may be employed.

 The lid 13 is supported in the closed position by a bending rod applied to the hinge portion 116. Further, it is more preferable that the lid 13 is urged against and abutted on the lid abutting portion 117 (that is, urged by the elasticity of the hinge portion 116) by a bending rod applied to the hinge portion 116.

 That is, in a natural state where no force is applied to the gastrostomy sheath 1, the lid 13 is closed as shown in FIG. The hinge portion 116 functions as an elastic support portion that elastically supports the lid 13 in the closed position, and when the lid 13 is separated from the lid abutting portion 117 by rotation about the hinge portion 116, the hinge portion 116. Due to the elasticity, an urging force for returning to the closed position acts on the lid 13. By forming in this way, the internal passage 113 can be closed with the lid 13 when the handle 12 of the sheath 1 for gastrostoma is not grasped by hand.

 In this way, if the internal passage 113 is closed by the lid 13, the outflow of air supplied from the endoscope into the stomach can be prevented during the operation, as will be described later. It goes without saying that foreign matters such as dust can be prevented from entering the sheath 1.

 As a structure of the hinge portion 116 that functions as an elastic support portion that elastically supports the lid 13 in the closed position, for example, the hinge portion 116 is formed in an arc shape to function as a leaf spring in order to increase the elasticity of the hinge portion 116. It is also possible to make it.

 In addition to the hinge portion 116, for example, as shown in FIGS. 5A and 5B, the outer peripheral surface of the sheath body 11 is disposed on the handle 12 by being disposed outside the sheath body 11 proximal portion. It is also possible to separately provide an elastic member 14 that applies an urging force in a direction of pulling to the side as an elastic support portion that elastically supports the lid 13 in the closed position. In this case, it is not necessary for the hinge portion 116 to function as an elastic support portion, and it is sufficient if it has a function of providing the handle 12 and the lid 13 so as to be rotatable with respect to the sheath body 11.

 The elastic member 14 is, for example, an elastic member (for example, an elastic member made of silicone rubber, a coil spring, etc.) that extends radially outward from the base end of the sheath body 11 and is connected to the handle 12. And a biasing force that is fixed to the outer surface of the base end portion of the sheath body 11 and the handle 12 so as to approach the outer peripheral surface of the base end portion of the sheath body 11 is applied to the handle 12. Various configurations such as a leaf spring can be employed.

 5A and 5B, an elastic member made of silicone rubber is used as the elastic member 14, and the plate-like handle 12 is attached to the end (near the root) of the handle 12 on the hinge portion 116 side. An example is shown in which an inclined piece 123 that is inclined with respect to the distal end side of the sheath body 11 and a proximal end portion of the sheath body 11 are connected using the elastic member 14. When the lid 13 is in the closed position, the inclined piece 123 that is a part of the handle 12 is disposed in proximity to the proximal end portion of the sheath body 11, and when the lid 13 is rotated in the opening direction from the closed position, As the handle 12 rotates around the portion 116, the handle body 12 is separated from the proximal end portion of the sheath body 11.

 In this configuration, the inclined piece 123 moves from the position of the inclined piece 123 when the lid 13 is in the closed position (hereinafter also referred to as a re-approaching position) by turning around the hinge portion 116, and the re-approaching is performed. When separated from the position, the elastic member 14 is stretched (elongation deformation, elastic deformation in the extension direction). The stretched elastic member 14 functions as a pulling spring, and exerts a biasing force to pull back to the re-approaching position on the handle 12 (specifically, the inclined piece 123). This urging force functions as an elastic force for elastically supporting the lid 13 in the closed position.

 As described above, the present invention employs the hinge portion 116 having the function of elastically supporting the lid 13 in the closed position, and the lid is covered by the elastic support portion in a natural state where no force is applied to the gastrostomy sheath 1. 13 is more preferably closed, but it does not have the function of elastically supporting the lid 13 in the closed position, and the state in which the internal passage 113 is closed by the lid 13 can be realized by the operation of the handle 12. This does not exclude the configuration in which the hinge portion 116 is adopted. In this case, the lid 13 realizes a state in which the internal passage 113 is closed by the operation of the handle 12, so that the lid 13 passes through the internal passage 113 by the pressure of air supplied into the stomach from the endoscope during the operation. You may make it maintain a closed state.

Since the lid 13 blocks the internal passage 113 of the gastrostomy sheath 1, the dilator is removed from the fistula expanded by the dilator 5 and inserted into the stomach orally until the gastrostomy button 2 is inserted. It is possible to reduce leakage of air supplied from the endoscope from the stomach.
In the closed state of the lid 13, it is not always necessary to ensure airtightness to completely prevent the outflow of air from the distal end side to the proximal end side. It is only necessary to prevent leakage of air supplied from the mirror into the stomach (hereinafter also referred to as air supply leakage). It is further desirable if the lid 13 is formed so that air supply leakage can be completely prevented.

 3A is a perspective view of the sheath for gastrostoma 1 in a state where the lid 13 is opened, and FIG. 3B is a cross-sectional view thereof. 4A is a top view when the lid of the sheath for gastrostoma of the present invention is opened, FIG. 4B is a front view when the lid of the sheath for gastrostoma of the present invention is opened, and FIG. (C) is a right side view when the lid of the sheath for gastrostoma of the present invention is opened, and FIG. 4 (d) is a rear view when the lid of the sheath for gastrostoma of the present invention is opened. The bottom view when the lid | cover of the sheath for gastrostoma of this invention opens is shown.

When the lid 13 is in an open state, the internal passage 113 needs to be maintained so as not to block the route for inserting the gastrostoma button 2 and the dilator 5. For example, in order to store the lid 13 rotated from the closed position, it is desirable to secure a lid storage recess that is recessed from the inner surface of the internal passage 113. In the illustrated example, the inner space 115a of the expansion part 115 functions as a lid storage recess for storing the lid 13 rotated from the closed position.
Thereby, insertion resistance at the time of inserting the button 2 for gastrostoma and the dilator 5 in the sheath main body 11 can be reduced.

FIGS. 6A to 6C and FIG. 7 show an embodiment of a gastrostomy catheter 2 (hereinafter also referred to as a gastrostomy button) used with the gastrostomy sheath 1 of the present invention.
6A is a perspective view, FIG. 6B is a top view, FIG. 6C is a bottom view, and FIG. 7 is a front sectional view.

As shown in these drawings, the gastrostoma button 2 includes a tube portion 21, an indwelling portion 22, and an external fixation portion 23.
The indwelling portion 22 is provided on one end side in the longitudinal direction (hereinafter referred to as the distal end side) of the tube portion 21, and the extracorporeal fixing portion 23 is provided on the other end side in the longitudinal direction of the tube portion 21 (hereinafter referred to as the proximal end side).

More specifically, the through-hole penetrating the inside of the tube portion 21 functions as a passage 24 for containing a nutrient (nutrient solution), a chemical solution, or the like. The extracorporeal fixing part 23 is provided with a cap 28 for closing the passage 24 in order to shut off the inside of the body and the outside of the body when no nutrient or the like is put into the passage 24. The cap 28 is provided at the distal end of a strip-shaped flexible piece 231 extending to the extracorporeal fixing portion 23 and is detachably fitted to the opening portion of the passage 24 of the tube portion 21.
Further, a valve 25 is provided at the distal end of the tube portion 21 to prevent backflow from the stomach.

 The indwelling portion 22 surrounds a plurality of elastically deformable (in the illustrated example, four) strips 221 around a central axis 21C of the tube portion 21 (specifically, a portion obtained by extending the central axis 21C toward the distal end). Thus, it has a configuration arranged around it.

 Each belt-like piece 221 has one end in the longitudinal direction extending from a base end side converging portion 222 integrally provided at the tip of the tube portion 21, and the other end in the longitudinal direction is separated from the base end side converging portion 222. The tube portion 21 is integrated at the distal end side converging portion 223 (the most advanced portion of the indwelling portion 22) disposed on the central axis 21C (specifically, the portion extending the central axis 21C toward the distal end). Yes. The indwelling portion 22 has a dome-like shape (round shape) as a whole by a plurality of strip-shaped pieces 221 that are curved in an arc shape between the proximal-side focusing portion 222 and the distal-side focusing portion 223. It is configured in a bowl shape.

One end in the longitudinal direction of the plurality of strip-shaped pieces 221 extends radially from the base end-side focusing section 222, and the other end in the longitudinal direction of the plurality of strip-shaped pieces 221 extends from the distal-end focusing section 223. It extends radially.
In addition, the in-vivo indwelling portion 22 has a maximum outer diameter at the intermediate portion between the proximal-side focusing portion 222 and the distal-side focusing portion 223 (maximum outer diameter).

The gastrostomy button 2 is preferably an integrally molded product made of synthetic resin.
The proximal-side focusing portion 222 and the distal-side focusing portion 223 of the indwelling portion 22 each have a structure in which the longitudinal ends of the plurality of strip-shaped pieces 221 are integrated together.

FIG. 8 is a diagram showing the obturator 3 used for extending the protruding in-vivo indwelling portion 22 that is expanded radially outward of the gastrostomy button 2 and changing it to a reduced diameter state. ) Is a side sectional view (left side sectional view of FIG. 8B), FIG. 8B is a front view, and FIG. 8C is a side view (right side view of FIG. 8B).
8A to 8C, the upper side is described as the proximal end side of the obturator 3, and the lower side is described as the distal end side of the obturator 3.

 As shown in FIGS. 8A to 8C, the obturator 3 includes an extension pressing rod 31, an outer cylinder 32, a spring 312, and a stopper 33.

The extension pressing rod 31 includes an operation unit 311, a rod body 313, and a lock piece 316.
Reference numeral 317 denotes a distal end portion of the rod body 313, and 314 denotes a reinforcing member provided at the distal end portion 317 of the rod body 313. Reference numeral 315 denotes a wire insertion groove (guide wire passage) formed along the longitudinal direction of the rod body 313.
The operation unit 311 is fixedly attached to the rod body 313.

 The outer cylinder 32 includes a cylindrical part 321, a finger hook 322, a fitting part 323, a groove 324, a groove hole 325, and a lock hole 326. The finger hook 322, the fitting part 323, the groove 324, the groove hole 325, and the lock hole 326 are provided in the cylindrical part 321.

 The spring 312 urges the extension pressing rod 31 in a direction that reduces the amount of protrusion of the tip of the extension pressing rod 31 (specifically, the tip of the rod main body 313) from the tip of the outer cylinder 32. The spring 312 is specifically a coil spring and is externally inserted into the rod body 313.

 Inside the cylindrical portion 321 of the outer cylinder 32, a rod body 313 of the extension pressing rod 31 is provided so as to be slidable in the longitudinal direction of the outer cylinder 32, and the extension pressing rod 31 is attached to the outer cylinder 32. On the other hand, it is movable in the longitudinal direction.

 In this obturator 3, the rod body 313 is fixed to a portion protruding from one end portion (base end portion) in the longitudinal direction of the outer cylinder 32 (base end portion, which also functions as a base end portion of the extension pressing rod 31). When the operating portion 311 is pushed in the pushing direction of the outer cylinder 32, the extension pressing rod 31 moves along the longitudinal direction of the outer cylinder 32, and the rod body 313 tip protrudes from the tip of the outer cylinder 32. The amount increases. In the illustrated example, the distal end portion 317 of the rod body 313 is projected from the distal end of the outer cylinder 32 before the operation portion 311 is pushed in (initial state), but may not be projected.

 As the extension pressing rod 31 moves with respect to the outer cylinder 32 by the pushing operation of the operation unit 311, the lock piece 316 of the extension pressing rod 31 passes through the inside of the outer cylinder 32 from the groove 324 of the outer cylinder 32. The extension push rod 31 is prevented from moving with respect to the outer cylinder 32 by being fitted into the lock hole 326 of the outer cylinder 32 (this state is also referred to as a protruding state hereinafter). The lock piece 316 is urged by the urging force of a spring incorporated in the rod main body 313 and protrudes from the side surface of the rod main body 313, and can be pushed into the rod main body 313.

In the protruding state, the protruding amount from the distal end of the outer cylinder 32 at the distal end of the extension pressing rod 31 (the distal end of the rod main body 313) is maintained. When the lock piece 316 is pushed in this projecting state to release the engagement with the lock hole 326 of the outer cylinder 32, the extension pressing rod 31 is moved relative to the outer cylinder 32 by the urging force of the spring 312, and the lock piece 316 moves from the lock hole 326 of the outer cylinder 32 to the groove 324 and returns to the initial state.
The initial state is a state in which the amount of protrusion from the tip of the outer cylinder 32 at the tip of the rod body 313 is small (including a state in which the rod body 313 is not protruded) compared to the protruding state.

The spring 312 is provided on the extension pressing rod 31 in order to switch from the protruding state to the initial state only by pressing the lock piece 316.
In the illustrated example, the spring 312 is a coil spring, and is disposed between the operation portion 311 and the proximal end portion of the outer cylinder 32 by being extrapolated to the proximal end portion of the rod main body 313, but from the protruding state to the initial state. The arrangement and configuration of the spring 312 for performing the switching by simply pressing the lock piece 316 is not limited to the illustrated example.

As shown in FIGS. 10A and 10B, the obturator 3 is brought into a protruding state after being fitted to the gastrostomy button 2 in the initial state. By setting the protruding state, the distal end portion 317 of the rod main body 313 has the rod contact portion 27 (see FIG. 7) provided on the inner surface side of the indwelling portion 22 of the distal end side converging portion 223 of the gastrostoma button 2. Press to separate from the proximal-side focusing portion 222. As shown in FIG. 7, the rod contact portion 27 is formed integrally with the distal-side focusing portion 223 at a position facing the inner surface of the indwelling portion 22 of the distal-side focusing portion 223 and the proximal-side focusing portion 222. It is a wall part (rod contact wall). In FIG. 7, specifically, the rod contact portion 27 has a shape in which the position facing the inner surface indwelling portion 22 of the distal-side focusing portion 223 and the proximal-side focusing portion 222 is built up. It is continuous with the side focusing portion 223 and is integrated with the tip side focusing portion 223.
For this reason, when the obturator 3 (the obturator 3 in the initial state) fitted to the gastrostomy button 2 is set in the protruding state, the distal-side focusing portion 223 and the rod contact portion 27 are separated from the proximal-side focusing portion 222. As a result, the indwelling portion 22 of the gastrostomy button 2 is extended to a reduced diameter state.
The extension pressing rod 31 is inserted into the indwelling part 22 of the gastrostomy catheter 2 and is a member for extending the indwelling part 22 by pressing the rod contact part 27 of the indwelling part 22. Function as.

The rod abutting wall 27 also functions as a reinforcing wall that reinforces the distal-end-side converging portion 223.
As shown in FIG. 7, the rod abutting portion 27 is reinforced by a reinforcing member 272, and when an extension force is applied to the extracorporeal indwelling portion 22 by the obturator 3, the distal end portion 317 of the rod body 313 of the obturator 3 is at the distal end. This is preferable in that the indwelling portion 22 can be easily and surely inserted into the body in a reduced diameter state without penetrating through the side converging portion 223. The reinforcement by the reinforcing member 272 is also preferable in terms of maintaining the shape of the communication path 26 (described later) which is a small hole penetrating the rod abutting portion 27 and the distal end side converging portion 223.
Examples of the material of the reinforcing member 272 include metal, reinforced fiber, reinforced plastic, and the like, and the reinforcing member 272 is preferably mesh-shaped. The reinforcing member 272 is embedded in the rod contact portion 27 as illustrated in FIG. 7, for example, and fixed to the surface of the rod contact portion 27 (the surface facing the distal end of the tube portion 21 of the gastrostoma button 2). It is provided integrally with the rod contact portion 27 by (for example, adhesive fixing) or the like.
The reinforcing member 272 can be easily extended by forming a mesh. The configuration in which the reinforcing member 272 is easily extended is preferable from the viewpoint of reducing the diameter of the indwelling portion 22.

It should be noted that the distal end portion of the indwelling portion 22 of the gastrostomy button 2 is provided with the rod contact portion 27 and the distal end in order to draw the guide wire 4 from the distal end portion of the indwelling portion 22 into the gastrostoma button 2. A communication path 26 that is a small hole penetrating the side converging portion 223 is formed. The connecting path 26 is provided through the rod contact portion 27 and the distal end side converging portion 223 on the central axis 21C of the tube portion 21 (specifically, the portion extending the central axis 21C toward the distal end side). ing.
Further, in FIG. 7, reference numeral 271 denotes a rod fitting protrusion that protrudes annularly from the outer peripheral portion of the rod contact portion 27. The rod fitting protrusion 271 is coaxial with the central axis 21C of the tube portion 21 of the gastrostomy button 2 (specifically, a portion obtained by extending the central axis 21C toward the distal end side), and communicates with the rod contact portion 27. It is formed in a ring shape surrounding the opening of the passage 26. As shown in FIG. 10A, when the obturator 3 is fitted to the gastrostomy button 2, the rod body 313 of the obturator 3 has its tip 317 inserted and fitted inside the rod fitting protrusion 271. Thus, the rod contact portion 27 is positioned, that is, positioned so as to be coaxial with the communication path 26.

Specifically, the obturator 3 is fitted to the gastrostomy button 2 by inserting the obturator 3 into the passage 24 of the tube part 21 of the gastrostomy button 2 from the external fixing part 23 side and fitting to the gastrostomy button 2. The obturator 3 is inserted into the tube portion 21 from the distal end side.
When the obturator 3 is fitted to the gastrostomy button 2, the outer peripheral surface of the outer cylinder 32 contacts the inner surface of the passage 24 of the tube portion 21 and is positioned so as not to rattle. In addition, the distal end portion of the rod body 313 protruding from the distal end of the outer cylinder 32 is placed in the body via a valve 25 (see FIG. 7) provided at the end portion of the tube portion 21 on the indwelling portion 22 side. It is inserted into the portion 22 and is in contact with or close to the rod contact portion 27 of the indwelling portion 22.

 The valve 25 is formed in an elastically deformable umbrella shape that closes the opening at the end of the tube portion 21 on the indwelling portion 22 side with a synthetic resin, and a slit 251 is provided at the top. The distal end of the rod body 313 is pushed into the indwelling portion 22 from the passage 24 of the tube portion 21 so as to be inserted into the slit 251, and the central axis 21 </ b> C of the tube portion 21 of the gastrostomy button 2 (see FIG. 7). Arranged coaxially. Thereby, the rod contact part 27 can be pressed in the protrusion state, and the indwelling part 22 can be extended.

 As shown in FIG. 8B, the distal end portion 317 of the rod body 313 of the obturator 3 is provided with a reinforcing member 314 in order to apply a large load when the gastrostomy button is extended. In the illustrated example, the reinforcing member 314 is a thin reinforcing sleeve.

As shown in FIG. 11, the wire insertion groove 315 (see FIGS. 8A, 9A, and 9B) of the rod body 313 is directed from the distal end of the rod body 313 toward the proximal end of the rod body 313. The rod body 313 is formed along the longitudinal direction. The guide wire 4 can be inserted into the wire insertion groove 315 from an opening opening at the tip of the rod body 313.
Further, the wire insertion groove 315 is exposed so that it can always be seen from the outside of the outer cylinder 32 through the groove hole 325 provided in the outer cylinder 32 in both the extended state and the retracted state of the obturator 3. Has been. The slot 325 of the outer cylinder 32 serves as an outlet of the guide wire 4 inserted from the gastrostomy button 2 into the wire insertion groove 315.

A finger hook 322 protrudes from the outer cylinder 32, and the obturator 3 is configured such that the user can easily hold the finger 3 with the finger by this finger hook 322.
Further, a fitting portion 323 for fitting and fixing a stopper 33 described later is installed on the outer peripheral portion of the outer cylinder 32.

 The stopper 33 functions as a locking member for locking the gastrostomy button 2 to the obturator 3. When the gastrostomy button 2 is locked to the obturator 3 by the stopper 33, when the obturator 3 fitted to the gastrostomy button 2 is brought into the protruding state from the initial state, the gastrostomy button for the obturator 3 is used. 2 to prevent the rod main body 313 of the extension pressing rod 31 from pressing the rod abutting portion 27 of the indwelling portion 22 as the extension force of the indwelling portion 22. Can act.

 The fitting portions 323 of the obturator 3 are protrusions that are provided on both sides of the outer cylinder 32 of the obturator 3 so as to project at a plurality of locations (three or more locations) along the longitudinal direction of the outer tube 32 at a predetermined interval. Are provided with a pair of arm portions 331 that are removably fitted into fitting grooves 323 a secured between adjacent fitting portions 323.

 As shown in FIGS. 9A and 9B, the stopper 33 includes a back plate 333, a plate-like pushing portion 334, and a pair of rod-like arm portions 331, and is formed in a square frame shape. Has been. The stopper 33 is provided by being extrapolated to the outer cylinder 32 of the obturator 3. Both arm portions 331 serve to connect the back plate 333 and the push-in portion 334 that are opposed to each other via the obturator 3 that is passed through the inner space of the rectangular frame-shaped stopper 33.

 The stopper 33 is attached to the obturator 3 by fitting both the arm portions 331 to the one selected from the plurality of fitting grooves 323a. Moreover, the stopper 33 can change the attachment position with respect to the obturator 3 by changing the fitting groove 323a which fits both the arm parts 331. FIG.

 By rotating the stopper 3 around the axis of the outer cylinder 32 with respect to the obturator 3, both arm portions 331 fitted in the fitting groove 323a can be extracted from the fitting groove 323a. As shown in FIGS. 9A and 9B, the outer cylinder 32 of the obturator 3 has an outer periphery of the outer cylinder 32. From the area where the fitting portion 323 protrudes (fitting area), the shaft of the outer cylinder 32 is provided. There is a region (non-fitting region) where the fitting portion 323 is not provided protruding at a position shifted 90 degrees around. The stopper 3 can be switched between a fitting state and a fitting releasing state with respect to the obturator 3 by the rotation of the outer cylinder 32 around the axis. The distance between the back plate 333 and the push-in portion 334 of the stopper 33 is larger than the distance between the pair of arm portions 331. If both the arm portions 331 are in the non-fitting region, the stopper 3 has the back plate 333, The pushing portion 334 can be slid along the longitudinal direction of the outer cylinder 32 without contacting the fitting portion 323. Thereby, selection and change of fitting slot 323a which fits both arm parts 331 are possible.

 Furthermore, both arm portions 331 fitted in the fitting groove 323a of the obturator 3 can slide in the longitudinal direction of the both arm portions 331 with respect to the obturator 3 while remaining in the fitting groove 323a. It is. In other words, the obturator 3 is slidable along the longitudinal direction of the both arm portions 331 with respect to the stopper 33 attached to the obturator 3, using the both arm portions 331 fitted in the fitting groove 323a as a guide. .

 The back plate 333 and the push-in portion 334 are used as operation pieces for easily performing an operation of sliding the stopper 33 attached to the obturator 3 with respect to the obturator 3 (sliding movement in a direction perpendicular to the longitudinal direction of the obturator 3). Can do.

The stopper 33 can switch the engagement / disengagement of the clamping part 332 protruding from the back plate 333 with respect to the extracorporeal fixing part 23 of the gastrostomy button 2 fitted with the obturator 3 by this sliding movement operation.
The sandwiching portion 332 is a hook-like piece that protrudes from the surface on which the both arm portions 331 of the back plate 333 project at a position spaced apart from the both arm portions 331 on the back plate 333. FIG. (B) As shown in FIG. 11, the obturator 3 is fitted by sliding the stopper 33 attached to the obturator 3 with respect to the obturator 3 (sliding in a direction perpendicular to the longitudinal direction of the obturator 3). The combined gastrostomy button 2 is inserted into and removed from the body surface contact surface 232 side of the body fixing part 23, and is engaged with and disengaged from the body fixing part 23.

 When the pushing portion 334 of the stopper 33 is in contact with the outer cylinder 32 of the obturator 3, the holding portion 332 is separated from the extracorporeal fixing portion 23 of the gastrostoma button 2 fitted with the obturator 3. 2 is not locked (the unlocked state, the state shown in FIG. 9B). In this unlocked state, the gastrostomy button 2 can be freely slid along the longitudinal direction of the outer cylinder 32 of the obturator 3.

 From this unlocked state, the stopper 33 is slid relative to the obturator 3 so that the back plate 333 approaches the obturator 3, so that the clamping part 332 is inserted into the body surface contact surface 232 side of the external fixing part 23. Then, it engages with the extracorporeal fixing portion 23 (the state shown in FIG. 9A). The clamping portion 332 contacts the body surface contact surface 232 and engages with the external body fixing portion 23. Accordingly, the gastrostomy button 2 is locked by the holding portion 332 so as not to move to the distal end side of the obturator 3. As a result, when the obturator 3 fitted to the gastrostomy button 2 is changed from the initial state to the protruding state, the extension force from the extension pressing rod 31 (specifically, the rod body 313) is surely applied to the indwelling portion 22. While being able to transmit, the extended state of the indwelling part 22, ie, a reduced diameter state, can be maintained stably.

 In order to assemble the obturator 3 to the gastrostoma button 2, as shown in FIG. 10 (a), the outer tube 32 of the obturator 3 (which is in the initial state) is inserted into the passage 24 of the gastrostoma button 2. The body plate fixing portion 23 of the gastrostoma button 2 is held (locked) by the clamping portion 332 of the stopper 33 by pushing the back plate 333 of the stopper 33 in the direction of the pushing portion 334. When the outer tube 32 of the obturator 3 is inserted into the passage 24 of the gastrostoma button 2, the back plate 333 of the stopper 33 is removed from the outer tube 32 so as not to contact the extracorporeal fixing part 22 of the gastrostoma button 2. Separate and leave in the unlocked state.

In this set state, as shown in FIG. 10B, the operation part 311 of the extension pressure bar 31 is operated to bring the obturator 3 into a protruding state, and the indwelling part 22 of the gastrostomy button 2 is extended.
In addition, after setting the state of FIG. 10 (a), as shown in FIG. 11, before the obturator 3 is in the protruding state, the rod contact portion 27 and the distal-side focusing of the indwelling portion 22 of the gastrostomy catheter 2 are provided. The guide wire 4 is passed through the extension pressing rod 31 of the obturator 3 (that is, passed through the wire insertion groove 315 of the rod main body 313) through the communication path 26 (see FIG. 7) penetrating the portion 223, and the outer cylinder The guide wire 4 is drawn out from the 32 slot 325.

 When the obturator 3 is fitted to the gastrostomy button 2, the opening portion of the wire insertion groove 315 that opens at the distal end of the extension pressing rod 31 of the obturator 3 and the rod contact portion 27 of the indwelling portion 22 of the gastrostomy catheter 2. In addition, the communication path 26 penetrating through the distal-end-side converging portion 223 is in a positional relationship in communication with each other. For this reason, in the set state, the operation of passing the guide wire 4 through the extension pressing rod 31 can be easily performed.

FIG. 12 is a diagram showing an embodiment of a dilator (expander) 5 for forming a fistula, where (a) is a front view, (b) is a front view of a small diameter dilator 52 constituting the dilator, (C) is a front view of the state in which the sheath 1 for gastrostoma is covered with the dilator 5 (sheathed dilator 5A), in which only the sheath 1 for gastrostoma is represented by a sectional view, and FIG. It is sectional drawing of the covered dilator 5 (dilator 5A with a sheath).
12 (a) to 12 (d), the left side in the figure is the front end side, and the right side in the figure is the rear end side.

As shown in FIGS. 12A to 12D, the dilator 5 is assembled to the thin dilator 52 by extrapolating the thin dilator 52 (see FIG. 10B) and the thin dilator 52. And a large-diameter dilator 51 which is a cylindrical body (integrated dilator).
The small-diameter dilator 52 is a rod-shaped member having a tapered tip portion 522 (a thin-diameter dilator tip portion 522) at the tip. Further, a guide wire passage 524 penetrating in the longitudinal direction is provided inside the small diameter dilator 52.

 The large-diameter dilator 51 includes a cylindrical large-diameter dilator body portion 511 and a tapered large-diameter dilator tip portion 512 protruding from the tip of the large-diameter dilator body portion 511. A thin dilator tip 522 of the thin dilator 52 projects from the thick dilator tip 512.

 Further, connectors 513 and 523 are provided on the rear end sides of the two dilators 51 and 52, and are fitted to each other by a luer taper. By fitting the connectors 513 and 523, the small-diameter dilator 52 is assembled and integrated with the large-diameter dilator 51.

 As shown in FIG. 12A, a scale 514 is attached to the outer peripheral surface of the large diameter dilator body 511, and a base point (zero point) 5141 is provided on the large diameter dilator tip 512 side. This scale can measure the distance from the body surface to the stomach wall inner surface by inserting the dilator 5 and aligning the base point 5141 with the stomach inner wall surface under the endoscope and reading the scale on the body surface side. it can. By this measurement, the length of the tube portion 21 of the gastrostomy button 2 can be selected and used.

FIG. 12C shows a state in which the dilator 5 is covered with the gastrostomy sheath 1 to form the sheathed dilator 5A.
The sheath 1 for gastrostoma is installed with the tip portion aligned with the tip of the large-diameter dilator body 511. The gastrostomy sheath 1 is not particularly provided with positioning means for the dilator 5, but the dilator 5 is provided with a movement restricting means (for example, stomach) that restricts the sliding movement of the gastrostomy sheath 1 toward the rear end side. A protrusion or the like on which the proximal end portion of the sheath body 11 of the heel sheath 1 abuts may be provided.

 Moreover, it is preferable that the front-end | tip part of the sheath 1 for gastrostoma is provided with the taper part 112 (refer FIG.3 (b)) so that a level | step difference with the large diameter dilator trunk | drum 511 may be eliminated. By providing the tapered portion 112, it is possible to reduce insertion resistance when the dilator 5 (the dilator with sheath 5A) covered with the gastrostomy sheath 1 is inserted into the abdominal wall and the stomach wall. The tapered portion 112 can be provided by a method such as tube stretching or heat shaping. However, when adjusting the inner diameter, the inner diameter of the sheath body 11 is adjusted so as to be in pressure contact with the outer diameter of the large-diameter dilator body portion 511. Thereby, the position shift of the sheath 1 for gastrostoma with respect to the trunk portion 511 of the dilator 5 can be regulated.

FIG. 13 shows a state before the gastrostomy button 2 whose diameter has been reduced by extending the indwelling portion 22 with the obturator 3 is inserted into the internal passage 113 of the gastrostomy sheath 1.
By the way, it is desirable that the sheath 1 for gastrostoma is sized so that the inner diameter of the sheath body 11 matches the outer diameter of the tube portion 21 of the button 2 for gastrostoma.
However, the indwelling portion 22 of the gastrostomy button 2 has a maximum outer diameter in the initial state before the diameter reduction is larger than the outer diameter of the tube portion 21 and is larger in the radial direction from the tube portion 21 due to indwelling in the body. It is formed to overhang. For this reason, it is technically difficult in many cases to reduce the diameter of the indwelling portion 22 having a greatly protruding shape to the same outer diameter as the tube portion 21.

 On the other hand, the internal passage 113 of the gastrostomy sheath 1 is preferably formed to have a size substantially equal to the maximum outer diameter of the dilator 5, and the maximum outer diameter of the dilator 5, that is, the outer diameter of the large-diameter dilator body 511. Determines the size of the fistula formed. This fistula size is preferably approximately the same as the outer diameter of the tube portion 21 of the gastrostomy button 2 or larger by 1 to 2 mm or more.

Therefore, even when the maximum outer diameter of the extended indwelling portion 22 is larger than the diameter of the internal passage 113 of the gastrostomy sheath 1, the sheath 1 is used to connect to the fistula of the indwelling portion 22. We examined the configuration to reduce the resistance of insertion and passage and to perform the indwelling work efficiently. Since the diameter of the sheath main body 11 of the sheath 1 can be made smaller than the maximum outer diameter of the in-vivo indwelling portion 22, the size of the fistula can be reduced.
The inner diameter of the internal passage 113 of the sheath 1 for gastrostoma is made smaller than the maximum outer diameter of the in-vivo indwelling portion 22, and it is outside the diameter of the internal passage 113 in the in-vivo placement portion 22 of the gastrostomy button 2. The sheath body 11 is configured to tear when a portion having a large diameter tries to pass through the internal passage 113. The diameter of the internal passage 113 of the gastrostomy sheath 1 is preferably larger than the outer diameter of the most distal portion of the indwelling portion 22.

 FIGS. 13 and 14 show the gastrostomy sheath 1 having the above-described dimensional relationship, and the internal passage 22 in the indwelling portion 22 of the gastrostomy button 2 that has been expanded (reduced diameter) by the obturator 3. The case where the gastrostomy button 2 is inserted into the sheath 1 for gastrostoma in which the sheath main body 2 can be longitudinally split when a portion having an outer diameter larger than the diameter of 113 attempts to pass through the internal passage 113 will be described. It is a figure to do. The gastrostomy button 2 to be inserted into the sheath body 11 of the gastrostomy sheath 1 has a maximum outer diameter in the reduced diameter state of the indwelling portion 22 larger than the diameter of the internal passage 113 of the gastrostomy sheath 1.

 Since the outer diameter of the most distal portion (tip-side converging portion 223) of the indwelling portion 22 is smaller than the diameter of the internal passage 113 of the gastrostomy sheath 1, insertion into and passage through the internal passage 113 is easy. When a portion having a larger outer diameter than the diameter of the internal passage 113 of the gastrostomy sheath 1 in the indwelling portion 22 of the gastrostomy button 2 attempts to pass through the internal passage 113, the sheath body 11 is torn.

Also in the case of FIG. 14, since the lumen through which the most distal portion of the indwelling portion 22 passes is formed by the internal passage 113 of the gastrostomy sheath 1, insertion resistance can be reduced.
The material constituting the sheath body 11 is not particularly limited, but polyethylene resin, polypropylene resin, polytetrafluoroethylene resin (PTFE), tetrafluoroethylene / hexafluoropropylene copolymer (FEP), tetrafluoroethylene / ethylene copolymer. A polymer (ETFE) or the like is preferable. Among these, it is particularly preferable that the resin is made of a fluororesin having a low frictional resistance. When the gastrostomy button 2 is inserted, the frictional resistance when passing through the internal passage 113 is reduced, and the gastrostomy button 2 is reduced. Insertion resistance can be reduced.

 A configuration for tearing the sheath body 11 by inserting a portion having a larger outer diameter than the diameter of the inner passage 113 of the gastrostomy sheath 1 in the indwelling portion 22 is not particularly limited. A configuration using a PTFE tube having an orientation in the longitudinal direction and capable of longitudinal tearing as the main body 11, and a notch groove (notch portion) formed extending along the longitudinal direction of the sheath main body 11. There are a configuration in which the thickness is locally reduced, a configuration in which a cut portion is formed in the sheath body 11 in advance by a slit (notch portion) extending along the longitudinal direction of the sheath body 11, and the like. When a notch such as a cut groove or slit is formed, the sheath body 11 is divided along the length of the notch by the insertion of the indwelling portion 22 over the entire length in the longitudinal direction.

1A, 1B, 4A, 4B, 4A, 4E, 13A, and 14B specifically illustrate a configuration in which a cutout groove 111A is formed as a cutout portion in the sheath body 11. To do.
As shown in FIG. 16A, the cutout groove 111 </ b> A is formed in the sheath body 11 so as not to penetrate the wall thickness. The sheath body 11 has an uncut portion 111a in which the thickness of the sheath body 11 is locally reduced on the groove bottom side of the notch groove 111A.

When the non-cutting portion 111a is inserted into the inside of the sheath body 11, a portion having a larger outer diameter than the diameter of the internal passage 113 of the gastrostomy sheath 1 in the indwelling portion 22 in a reduced diameter state is inserted. It is destroyed and cut.
As a result of cutting the non-cutting portion 111a, the sheath body 11 is longitudinally split.

On the other hand, FIGS. 15A and 15B illustrate a configuration in which a slit 111B is formed as a notch in the sheath body 11. FIG.
In the case of the configuration in which the slit 111B is formed, the slit 111B is formed in a part of the sheath body 11 in the longitudinal direction, and the non-cut portion 118 in which the slit 111B is not formed is secured on the virtual extension of the slit 111B. Until the gastrostomy button 2 is inserted into the sheath body 11 (more specifically, a part of the indwelling portion 22 having a larger outer diameter than the diameter of the internal passage 113 of the gastrostomy sheath 1 is inserted. Until the shape of the sheath body 11 is maintained by the non-cutting portion 118. 15A and 15B, the slit 111B is not formed up to both end surfaces in the longitudinal direction of the sheath body 11, and the non-cut portions 118 are secured at both ends in the longitudinal direction of the sheath body 11.

 When the non-cutting portion 118 is inserted inside the sheath body 11, a portion having a larger outer diameter than the diameter of the internal passage 113 of the gastrostomy sheath 1 in the indwelling portion 22 in a reduced diameter state is inserted. Or the part is pressed and deformed so that the portion of the sheath body 11 where the slit 111B is formed is pushed and expanded from the inner passage 113 side, so that the slit 111B is the starting point. Will be cut off. As a result of cutting the non-cutting portion 118, the sheath body 11 is longitudinally split.

The formation position of the non-cut portion 118 on the virtual extension of the slit 111B does not necessarily have to be at both ends in the longitudinal direction of the sheath body 11, and may be only at one end in the longitudinal direction of the sheath body 11. It is also possible to form a plurality of slits 111B at intervals along the longitudinal direction of the sheath body 11 (formation of a slit row), and in this case, non-slits are formed between the slits 111B constituting the slit row. The cutting part 118 will be secured.
The length of the non-cutting portion 118 (the dimension in the direction along the longitudinal direction of the sheath body 11) is 0.5 to 10 mm, preferably 1 to 5 mm.
The non-cutting portion 118 may be easily cut by forming a cut groove (notch portion) extending along the longitudinal direction of the sheath body 11.

 The sheath body 11 preferably has a load applied to the inner surface of the sheath body 11 (the inner surface of the internal passage 113) of 0.5 N or more and 5 N or less in order to destroy at least one of the non-cut portions 111a and 118. . This load is more preferably 0.5N or more and 3N or less. In this case, the sheath body 11 can be easily split longitudinally by inserting the indwelling portion 22 that has been reduced in diameter.

In addition, when the cutout portion is the cutout groove 111A, the shape stability of the sheath body 11 is enhanced as compared with the case of the slit 111B, and the internal passage of the sheath body 11 when the sheath body 11 is inserted into the fistula. There is an advantage that the shape of 113 is easily maintained.
In FIG. 16B, the sheath body 11 is configured such that the portions located on both sides of the sheath body 11 are arranged close to each other via the slit 111B and the slit 111B is almost closed, but the slit 111B is completely closed. It is not easy to be closed and to keep the closed state stable. On the other hand, in the case of the notch groove 111A, the non-cut portion 111a is secured on the groove bottom side, and the sheath body 11 is formed non-penetrating in the thickness of the sheath body 11, so compared to the case of the slit 111B, There is an advantage that the air supplied from the endoscope does not leak from the middle of the internal passage 113 inside the sheath body 11 to the outside in the radial direction of the sheath body 11.

In the illustrated sheath 1, the cutout portion is formed in the sheath body 11 at only one position in the circumferential direction of the sheath body 11. However, the present invention includes a configuration in which cutout portions are formed at a plurality of locations in the circumferential direction of the sheath body 11.
16 (a) and 16 (b) are diagrams schematically showing an example in which a cutout portion is formed at only one circumferential direction of the sheath body 11, and (a) shows a case of the cutout groove 111A. ) Shows the case of the slit 111B.
In FIGS. 16A and 16B, the handle 12 is provided at a position in the circumferential direction of the sheath body 11 that avoids the notches (notch grooves 111 </ b> A and slits 111 </ b> B).

 In this case, a portion having an outer diameter larger than the diameter of the internal passage 113 of the gastrostomy sheath 1 in the indwelling portion 22 in the reduced diameter state is inserted into the sheath main body 11, thereby causing the sheath main body 11. However, when the cut-away portion is used as a cutting line, the sheath body 11 is not divided into a plurality of members, and the state of one component is maintained. For this reason, there is an advantage that the entire sheath body 11 can be easily removed from the fistula by pulling the handle 12.

FIG. 17 schematically shows an example in which cutout portions (specifically, in the illustrated example, slits 111 </ b> B) are formed at two locations in the circumferential direction of the sheath body 11.
The handle 12 is provided at a position avoiding the notch, but when the sheath body 11 is split vertically by insertion of the gastrostomy button 2 (hereinafter referred to as a split piece 119). 17 is divided into two divided piece portions 119), and is provided in each divided piece portion 119.
In FIG. 17, the sheath body 11 is denoted by reference numeral 11B.
Needless to say, a notch groove 111A may be employed instead of the slit 111B.

 In the case of FIG. 16, the work of removing the sheath body 11 from the fistula after vertical tearing is simpler than the configuration of FIG. 17.

The cutout portions (notch grooves 111A, slits 111B) are preferably formed in a wedge shape whose cross-sectional shape increases in width from the inner surface side to the outer surface side of the sheath body 11.
In the case of the cutout portion having the cross-sectional shape, when the sheath body 11 is deformed so as to be expanded outward in the radial direction by the indwelling portion 22 inserted into the internal passage 113, the cross section of the cutout portion is also expanded. Accordingly, the non-cut portions 111a and 118 starting from the notches are likely to be cut.

The notch can be formed by, for example, laser processing or machining of the sheath body 11.
In particular, the laser processing is preferable in that the opening width of the notch can be easily adjusted, and a notch having a wedge-shaped cross-sectional shape can be easily formed by adjusting the focal position of the laser.

In addition, when a notch portion is formed by laser processing (particularly processing using a YAG laser) in a sheath body 11 made of FEP (which means a material containing FEP as a main component), the sheath body 11 may be The part where the notch is formed can be whitened by the laser processing.
By this whitening, marking that is easy to visually recognize is formed, and the position of the notch is easily understood by the user. Therefore, the sheath body 11 inserted in the fistula is vertically split and removed from the body. Work can be done efficiently.

Further, the sheath 1 for gastrostoma is formed such that the end surface on the proximal end side of the sheath body 11 is inclined with respect to the axial center (center axis C <b> 1) of the sheath body 11.
In the illustrated gastrostomy sheath 1, the end surface on the proximal end side of the sheath body 11 is positioned on the distal end side of the sheath body 11 as it goes from the hinge part 116 side to the lid contact part 117 side. Is so inclined.
Thus, if the end surface on the proximal end side of the sheath body 11 is formed obliquely with respect to the axial center (center axis C1) of the sheath body 11, the proximal end portion of the sheath body 11 is used. Since the size of the opening of the internal passage 113 is substantially increased, the indwelling portion 22 of the gastrostomy button 2 is smoothly inserted into the sheath body 11 from the proximal end portion of the sheath body 11. It can be carried out. In particular, when the indwelling portion 22 whose maximum outer diameter is larger than the inner diameter of the sheath body 11 is pushed into the sheath body 11, it effectively contributes to smoothing the pushing operation.

Next, an embodiment of a method for using the sheath for gastrostoma, the dilator with sheath, and the gastrostomy catheter kit of the present invention will be described with reference to FIGS.
The gastrostomy catheter kit comprises a gastrostomy sheath 1, a gastrostomy button 2, an obturator 3, and a dilator 5. The description of the gastrostomy catheter kit will be described later.

 Before using the gastrostomy sheath 1 of the present invention, an endoscope is inserted into the stomach of a patient who is a living body, air is sufficiently supplied, and the abdominal wall 900 and the stomach wall 901 are brought into close contact (before contact, FIG. The abdominal wall 900 and the stomach wall 901 are not in close contact with each other as shown in FIG. Next, the position of the stomach is confirmed by the transmitted light from the endoscope, abdominal palpation is performed from the body surface side, the stomach wall fixing site is determined, the abdominal skin as the body surface is disinfected, and local anesthesia is performed.

Next, the abdominal wall 900 and the stomach wall 901 are fixed with a suture using a stomach wall abdominal wall fixing tool (FIG. 19).
Fixation of the abdominal wall 900 and the stomach wall 901 with sutures usually requires two places to be sutured and fixed in order to form the subsequent gastrostomy catheter construction site on the surface.

 After the gastric wall abdominal wall fixation, the guide wire 4 is placed by puncturing a cannula needle from the body surface to the abdominal wall and the stomach wall.

 The dilator 5 is passed through the placed guide wire 4 (the guide wire 4 is passed through the guide wire passage 524 of the dilator 5), and the dilator 5 (sheathed dilator 5A) covered with the gastrostomy sheath 1 is passed from the body surface to the abdominal wall, It is inserted into the stomach wall and a fistula is formed temporarily (FIG. 21). At this time, the dilator can be safely expanded by inserting it while twisting.

Further, when a fistula is formed by insertion into the abdominal wall or stomach wall, the base point 5141 of the scale 514 (FIG. 12A) on the outer peripheral surface of the large-diameter dilator body 511 is placed on the stomach wall surface (inner surface) under the endoscope. In addition, the distance from the body surface to the stomach wall inner surface is measured by reading the scale displayed on the body surface side. Based on this measurement, the length of the tube portion 21 of the gastrostomy button 2 is selected and used.
Further, the position of the stopper 33 of the obturator 3 (the attachment position of the stopper 33 in the longitudinal direction of the outer cylinder 32) is determined in accordance with the selection of the tube 21.
Depending on the length of the tube portion 21 of the gastrostomy button 2, the length of the portion inserted into the tube portion 21 of the obturator 3 also changes. The adjustment of the attachment position of the stopper 33 in the longitudinal direction of the outer cylinder 32 realizes that the obturator 3 acts on the indwelling portion 22 of the gastrostoma button 2 locked by the stopper 33 with certainty. is there. The attachment position of the stopper 33 in the longitudinal direction of the outer cylinder 32 is the selective fitting of the arm part 331 of the stopper 33 to the fitting part 323 and the fitting groove 323a provided at a plurality of positions in the longitudinal direction of the outer cylinder 32. It is selected by combination.

 In order to make it easy to read the scale 514 of the dilator 5, the sheath body 11 preferably has transparency that allows the scale 514 of the dilator 5 to be viewed from the outside.

When the expansion is completed, the dilator 5 and the guide wire 4 are removed outside the body, leaving only the gastrostomy sheath 1 (FIG. 22).
When the dilator 5 is removed from the gastrostomy sheath 1, the lid 13 of the gastrostomy sheath 1 is closed so as to block the internal passage 113. The lid 13 is in the closed position by the elasticity of the hinge portion 116 as described above. Further, the internal passage 113 may be closed by air itself supplied from the endoscope into the stomach.
Thereby, it is possible to reduce that the air supplied from the endoscope leaks out of the body.

 Thereafter, the gastrostomy button 2 in which the indwelling portion 22 is extended by the obturator 3 with the handle 12 so that the lid 13 of the gastrostoma sheath 13 is opened is inserted into the internal passage 113 of the gastrostoma sheath. (FIG. 23).

 Since the gastrostomy sheath 1 is formed with means for tearing in the longitudinal direction, a portion where the outer diameter of the indwelling portion 22 in which the gastrostomy button 2 is extended is larger than the inner diameter of the gastrostomy sheath 1 is inserted. As a result, the sheath body 11 is split in the longitudinal direction and the sheath body 11 expands. The gastrostoma button 2 penetrates the indwelling portion 22 through the sheath 1 to reach the stomach and is placed in the stomach (FIG. 24).

 Further, when inserting the gastrostomy button 2 extended by the obturator 3, the distal end of the indwelling portion 22 is smooth because the insertion route is secured in the internal passage 113 of the gastrostomy sheath 1. Insertion and insertion resistance can be reduced.

 After the gastrostomy button 2 is left in the stomach, the gastrostomy sheath 1 is removed from the body while the gastrostomy button 2 is extended by the obturator 3 (FIG. 25).

 By pushing the pushing portion 334 of the stopper 33 attached to the obturator 3 toward the back plate 333 side, both arms 331 are slid to extend the indwelling portion of the gastrostomy button 2 (FIG. 26).

 The obturator 3 set on the gastrostoma button 2 is removed (FIG. 27), and a cap 28 attached to the extracorporeal fixing portion 23 of the gastrostoma button 2 is fitted so as to close the passage 24, thereby causing the gastrostomy. The placement of the button 2 is finished (FIG. 28).

 As described above, by using the gastrostomy sheath 1 of the present invention, the insertion resistance when the gastrostomy button 2 is inserted can be reduced, and the air supply of the endoscope during the construction procedure can be easily controlled. It is possible to

Further, the sheath body 11 in the sheath for gastrostoma may be formed so as to be capable of expanding in the radial direction by a material that can be expanded and deformed (FIG. 29). When the outer diameter of the indwelling portion of the gastrostomy button 2 in which the indwelling portion 22 is extended by the obturator 3 with the insertion of the gastrostomy button is larger than the inner diameter of the sheath main body 11, The diameter is increased in the radial direction (FIG. 30).
Examples of the material of the sheath body 11 in this case include plastic materials or elastomer materials such as polyurethane resin, tetrafluoroethylene, and fluorinated ethylene-propylene.
Further, the sheath body 11 may be a braid configured in a mesh shape using, for example, an inelastic filament such as polyamide fiber or stainless steel. In this case, the braid constituting the sheath body 11 may be configured such that, for example, the radial expansion of the sheath body 11 causes the axial shortening of the sheath body 11.

In this way, by forming the sheath body 11 from a material that can be radially expanded, the gastrostomy button 2 can reduce insertion resistance when it is inserted into the internal passage 113 of the sheath body 11. is there.
In addition, it is preferable to adopt a configuration in which the sheath body 11 formed of a material capable of expanding in the radial direction can be longitudinally split. For example, the sheath main body 11 made of the above-described plastic material or elastomer material is extended over the entire length in the axial direction so as to extend a thin wire for longitudinal splitting (hereinafter referred to as a longitudinal splitting wire, for example, polyamide fiber). High tensile fiber) is embedded, and the end of the longitudinal tear wire that has been extended toward the proximal end of the sheath body 11 is pulled strongly, so that the longitudinal tear wire is pulled out of the sheath body 11. A configuration in which a thin portion for vertical tearing is formed in the sheath body 11 so that the sheath body 11 can be easily split vertically can be employed. In this case, for example, after the indwelling portion 22 of the gastrostomy button 2 is passed through the sheath body 11 inserted in the fistula from the outside of the body, the longitudinal tearing wire is extracted from the sheath body 11 and the sheath body 11 is By tearing, the sheath body 11 can be removed from the fistula while maintaining the indwelling state of the gastrostomy button 2.

(Another embodiment of the sheath for gastrostoma)
31 (a), (b), and FIGS. 32 (a) to (e), the gastrostomy sheath according to the present invention includes a hinge portion 62 (hereinafter referred to as a hinge portion 62) separate from the hinge 116 on the handle 61. A configuration in which the lid 63 is rotatably provided via a lid hinge portion) can also be employed.
The sheath 6 for gastrostoma exemplified in FIGS. 31A and 31B has a schematic configuration including a sheath body 11 (sheath tube), a handle 61, a lid hinge portion 62, and a lid 63.

The handle 61 is formed in a tongue-like shape extending from the proximal end portion of the sheath main body 11 of the sheath 6 for gastrostoma. When inserting the button for gastrostoma into the sheath 6 for gastrostoma, the handle 61 is used. It can be used for grasping the sheath 6.
The handle 61 has a configuration in which a pair of plate-like handle members 611 and 612 are fixed to a tongue-like handle main piece 114 extending from the proximal end portion of the sheath body 11. The pair of handle members 611 and 612 are integrally attached to the handle main piece 114 such that the handle main piece 114 is sandwiched therebetween.

 Further, the illustrated gastrostomy sheath 6 includes a long plate member 64 for a lid made of a synthetic resin, on which a lid hinge 62 and a lid 63 are formed. The lid long plate member 64 is a single part integrally molded of synthetic resin. Further, the lid long plate member 64 is formed of a rubber elastic material such as silicone rubber or elastomer.

The long plate member for lid 64 has a mounting portion 641 on the side opposite to the lid 63 via a lid hinge portion 62, and the mounting portion 641 is fixed to the handle 61 and integrated. . A portion of the lid long plate member 64 on the side of the lid 63 from the attachment portion 641 has a tongue-like shape that extends from the handle 61 and is inserted into the sheath body 11.
The lid 63 is disposed in the internal passage 113 of the sheath body 11, and is elastically supported in a closed position (position shown in FIG. 31B) that closes the internal passage 113 by the elasticity of the lid plate member 64 itself. .

Specifically, the handle 61 is fixed by sandwiching a flat plate-like attachment portion 641 of the cover long plate member 64 and the handle main piece 114 between a pair of handle members 611 and 612. It has an integrated configuration.
The pair of handle members 611 and 612 (the lid-side handle member 611 and the main one-side handle member 612) are fixed so that the attachment portion 641 of the lid long plate member 64 and the handle main piece 114 are sandwiched therebetween. As a technique (configuration) for integrating the two handle members, for example, the other handle member is attached to one handle member by an engaging claw protruding from one or both of the pair of handle members 611 and 612. A structure in which the attachment portion 641 of the lid long plate member 64 and the handle main piece 114 are sandwiched and fixed between the pair of handle members and the pair of handle members 611 and 612 and the lid long plate member. The structure etc. which adhere | attach the 64 attachment parts 641 and the handle main piece 114 using an adhesive agent, etc. are employable.

 In addition, a pair of handle members 611 and 612 and a lid long plate are separately used by separately using a binding member for binding the attachment portion 641 of the lid long plate member 64 and the handle main piece 114. The attachment portion 641 of the member 64 and the handle main piece 114 may be bound and integrated. As the binding member, the pair of handle members 611 and 612, the attachment portion 641 of the lid long plate member 64, and the handle main piece 114 can be bound and integrated (the handle members 611 and 612, the lid long plate). The mounting portion 641 of the member 64 and the handle main piece 114 can be integrated so as not to cause a relative positional shift), and there is no particular limitation. A configuration may be adopted in which the pair of handle members 611 and 612, the attachment portion 641 of the lid long plate member 64, and the handle main piece 114 are bundled together by heat contraction of the contraction tube.

The pair of handle members 611 and 612 may be configured as separate members or formed by integral molding.
Further, the lid long plate member 64 is formed by fixing and fixing the attachment portion 641 to the handle 61 so that the portion on the lid 63 side extends from the handle 61 to the sheath body 11. It is only necessary to form a tongue-like portion to be inserted therein, and the fixing position of the attachment portion 641 in the handle 61 is not limited between the pair of handle members 611 and 612.
Further, the handle is not necessarily limited to a configuration having a plate-like handle member. For example, the handle is not provided with a handle member, and the handle main piece 114 and the attachment portion 641 of the lid long plate member 64 are used. A configured structure may be used.

As shown in FIG. 31 (b), the tip of the lid 63 is in contact with or close to the inner wall surface on the side opposite to the handle 61 via the internal passage 113 of the sheath body 11.
The lid hinge portion 62 is provided on the base end side of the lid 63 and is formed in a tongue-like portion extending from the handle 61 of the lid long plate member 64.
The lid 63 extends from the lid hinge portion 62 so as to incline toward the distal end side of the sheath body 11 at an angle of less than 90 degrees with respect to the axial center (center axis C1) of the sheath body 11. It is elastically supported by the elasticity of 62, and its distal end is in contact with or close to the inner wall surface on the side opposite to the handle 61 via the internal passage 113 of the sheath body 11.

The lid 63 is supported so as to be rotatable about the lid hinge portion 62 with an axis in a direction perpendicular to the axis of the sheath body 11 (that is, an axis parallel to the pivot axis of the hinge portion 116). The internal passage 113 of the sheath body 11 is opened by turning clockwise (turning in the opening direction) from the closed position shown in FIG. For example, the lid 63 rotated in the opening direction from the closed position by the action of an external force applied by insertion of a device such as the dilator 5 into the sheath body 11 is the sheath body of the dilator 5 that has been inserted into the sheath body 11. When the external force acting as a displacement force in the opening direction is removed by removal from 11 or the like, it returns to the closed position by the elasticity of the lid hinge portion 62.
Further, the lid 63 rotates in the direction opposite to the opening direction from the closed position, that is, in the counterclockwise direction from the closed position in FIG. The state in which the inner passage 113 of the sheath body 11 is restricted and blocked can be maintained. For example, in FIG. 31B, when the handle 61 is rotated counterclockwise about the hinge portion 116, the turning force in the direction opposite to the opening direction acts on the lid 63 in the closed position. Therefore, the rotation of the lid 63 in contact with the sheath body 11 is restricted, and the lid hinge portion 62 is elastically deformed. As described above, in this gastrostoma sheath 6, when the turning force from the closed position to the direction opposite to the opening direction acts on the lid 63, the lid 63 blocks the internal passage 113 of the sheath body 11. Can maintain the state. For this reason, there exists an advantage that the outflow of the air supplied in the stomach from an endoscope can be prevented.

The distal end of the lid 63 is pressed against the sheath body 11 by rotating the lid 63 in the direction opposite to the opening direction from the closed position.
In the sheath body 11, a portion with which the tip of the lid 63 abuts is hereinafter referred to as a lid abutting portion (reference numeral 117 a is used).
The hinge portion 116 and the lid hinge portion 62 are provided on the side of the sheath body 11 facing the lid contact portion 117a through the internal passage 113. The distal end of the lid 63 is brought into contact with the lid abutting portion 117a from the distal end side of the sheath body 11 as the lid 63 is rotated from the closed position in the direction opposite to the opening direction.

Between the attachment portion 641 of the lid long plate member 64 and the lid 63, the lid hinge portion 62 and a stopper projection 642 are formed.
The stopper projecting piece 642 is formed in the shape of a projecting piece that protrudes from the handle 61 and is inserted into the sheath body 11, and faces the lid contact portion 117a through the internal passage 113. It is arranged along the inner surface of the side. Specifically, the stopper projecting piece 642 is in contact with or close to the inner surface of the extension 115 formed on the sheath body 11.
The lid hinge portion 62 is provided at the tip of the stopper protrusion 642 in the protruding direction from the handle 61. The lid 63 is inclined toward the distal end side of the sheath body 11 at an angle of less than 90 degrees with respect to the axial center (center axis C1) of the sheath body 11 from the distal end of the stopper projection 642 from the handle 61. The lid hinge portion 62 is located at a continuous portion where the stopper projecting piece 642 and the lid 63 are continuous, and corresponds to a bent portion formed by bending the lid long plate member 64. .

When a force that rotates the lid 63 in the opening direction from the closed position is applied, the stopper protrusion 642 is pressed against the inner surface of the sheath body 11 to restrict the rotation with respect to the sheath body 11. The rotation of the lid 63 from the closed position to the opening direction is realized by elastic deformation of the lid hinge portion 62.
At this time, even if the lid 63 rotates in the opening direction from the closed position due to the elastic deformation of the lid hinge portion 62, the stopper protrusion 642 does not rotate, so that the handle 61 is interlocked with the lid 63. Rotation is restricted. Since the position of the handle 61 with respect to the sheath body 11 is stable, it is difficult for the user of the gastrostomy sheath 6 to fail to grasp the handle 61 with fingers, and good workability can be ensured. In other words, the configuration of the sheath for gastrostoma 6 is such that when the handle 61 is rotated about the hinge portion 116 in the clockwise direction in FIG. When the inner wall surface is pressed and its rotation is restricted, the lid 63 is restricted from being turned in the opening direction from the closed position, and the state where the inner passage 113 of the sheath body 11 is blocked can be maintained. is there.

That is, in the gastrostomy sheath 6, the state in which the lid 63 is disposed in the closed position is not easily affected by the rotation of the handle 61 around the hinge portion 116, and the handle 61 or In the state where no external force is applied to the lid long plate member 64, the lid 63 is elastically supported in the closed position by the elasticity of the lid hinge portion 62, so that the user of the gastrostomy sheath 6 is not prepared. Even if the handle 61 is touched, the lid 63 is difficult to rotate in the opening direction, and even if it rotates in the opening direction, it immediately returns to the closed position. For this reason, the state which closed the internal channel | path 113 of the sheath main body 11 with the lid | cover 63 can be maintained stably.
Further, a stopper protrusion 642 formed of a rubber elastic material such as silicone rubber or elastomer is interposed between the handle 61 and the lid hinge 62, and the stopper 61 is rotated when the handle 61 is rotated. Due to the elastic deformation of the projecting piece 642, the lid hinge part 62 and the lid 63 are less likely to follow the handle 61 with respect to the handle 61, and the internal passage 113 of the sheath body 11 is kept closed by the lid 63. Contributes effectively.

The long plate member for lid 64 is made of the lid hinge portion 62 and the lid 63 is opposed to the lid abutting portion 117a in the sheath body 11 from the closed position (position shown in FIGS. 31A and 31B). Elasticity that allows the lid 63 rotated to a position in contact with the inner surface on the side to be in contact with the inner surface on the side facing the lid abutting portion 117a in the sheath body 11 to return to the closed position. Any material can be used as long as it can be ensured, and the material is not limited to a material having rubber elasticity such as the above-described silicone rubber and elastomer, and a synthetic resin material can be widely used. For example, what can be employ | adopted as a material which forms the sheath main body 11 can also be used.
In addition, in the sheath for gastrostoma according to the present invention, for example, in the lid long plate member, the lid hinge portion and the lid are integrally formed of a material having rubber elasticity such as silicone rubber or elastomer, or It is also possible to adopt a configuration in which only the lid hinge portion is formed of a material having rubber elasticity such as silicone rubber or elastomer, and the other portion is formed of a hard resin or metal such as metal that does not have rubber elasticity.

The gastrostomy sheath 6 described here also has a fistula formed (constructed) in the same manner as the previously described gastrostomy sheath described with reference to FIGS. The button 2 can be used for the operation of placing in the body.
The dilator 5 is inserted into the sheath body 11 so that a dilator with a sheath can be configured (see FIG. 39), similarly to the previously described sheath for gastrostoma.
In addition, as described above, the gastrostomy sheath 6 has the lid 63 rotated in the opening direction from the closed position by inserting the dilator 5 into the sheath body 11, and the dilator 5 inserted into the sheath body 11. Is removed from the sheath body 11 so that the lid 63 that has been rotated in the opening direction from the closed position returns to the closed position by the elasticity of the lid hinge portion 62 and closes the internal passage 113 of the sheath body 11. In the inserted state, it is possible to prevent outflow of air supplied from the endoscope into the stomach, and to construct a fistula and place the gastrostomy button 2 in the body, It is suitable for use in replacement work.

Here, the operation | work which replaces the gastrostomy button 2 already indwelling using the sheath 6 for gastrostoma is demonstrated.
FIG. 33 shows the gastrostomy button 2 indwelling in the body.
In order to replace the gastrostoma button 2, first, as shown in FIG. 34, the cap 28 fitted in the opening on the extracorporeal fixing portion 23 side of the passage 24 of the gastrostoma button 2 is attached to the passage 24. The opening of the passage 24 is opened by being separated from the opening. Next, as shown in FIG. 35, the obturator 3 is inserted into the passage 24 from the outside of the body and set to the gastrostoma button 2 (the distal end portion 317 of the extension pressing rod 31 and the distal end side of the outer cylinder 32 are used for gastrostoma). 36, the stopper 33 (specifically, the clamping part 332) is engaged with the extracorporeal fixing part 23 of the gastrostoma button 2), and the wire insertion of the obturator 3 is performed as shown in FIG. The groove 315 is used to reach the stomach 24 through the guide wire 4 from the outside of the body to the passage 24 in the tube portion 21 of the gastrostoma button 2. Next, as shown in FIG. 37, the obturator 3 is operated to extend the indwelling portion 22 of the gastrostoma button 2 (reducing the diameter), and the obturator 3 and the gastrostomy button 2 are together removed from the fistula to the outside of the body. (See FIG. 38). However, as shown in FIG. 38, the guide wire 4 remains in the body.

Next, as shown in FIG. 40, the sheath 6 for gastrostoma is inserted into the fistula and placed.
At this time, for example, as shown in FIG. 39, a gastrostomy sheath 70 with an insertion assisting tool (hereinafter also referred to as a sheath with an insertion assisting tool) is assembled by inserting a sheath insertion assisting tool 7 having an external appearance into the sheath body 11. It is preferable to perform the operation of inserting the sheath 70 with an insertion aid into the fistula and inserting the sheath 6 for gastrostoma into the fistula and placing it therein.

 The sheath insertion assisting tool 7 includes a rod-like main body 71 and a tapered tapered tip portion 72 projecting from one end (tip) in the longitudinal direction of the rod-like main body. The sheath insertion assisting tool 7 is formed such that the outer diameter of the rod-shaped main body 71 is the same as or slightly smaller than the inner diameter of the sheath main body 11, and can be inserted into the sheath main body 11 in a detachable manner. The sheath insertion assisting tool 7 has a guide wire insertion hole 73 penetrating in the longitudinal direction thereof, and can be externally inserted into the guide wire 4 by passing the guide wire 4 through the guide wire insertion hole 73. One of both ends of the guide wire insertion hole 73 is opened at the tip of the tapered tip 72 of the sheath insertion aid 7, and the other is the end (rear end) of the rod-like main body 71 opposite to the taper tip 72. Part).

 As shown in FIG. 39, the operation for inserting and placing the gastrostomy sheath 6 into the fistula using the sheath 70 with the insertion assisting tool first extends from the fistula of the guide wire 4 placed in the body to the outside of the body. The inserted portion is passed through the guide wire insertion hole 73 of the sheath insertion assisting tool 7, and the sheath insertion assisting tool 7 and the entire sheath 70 with the insertion assisting tool are extrapolated to the guide wire 4, and the insertion assisting tool using the guide wire 4 as a guide member. After inserting the sheath 70 into the fistula, as shown in FIG. 40, the sheath insertion aid 7 is removed from the body while the gastrostomy sheath 6 is left in the fistula.

The sheath 70 with an insertion assisting tool inserts the sheath insertion assisting tool 7 from the distal end side into the opening on the proximal end side of the sheath body 11 of the sheath for gastrostoma 6, and the tapered distal end portion of the sheath insertion assisting tool 7. 72 is assembled from the distal end of the sheath body 11. By projecting the tapered distal end portion 72 from the distal end of the sheath body 11, the insertion resistance when the sheath 70 with insertion assisting tool is inserted into the fistula (inserted from the tapered distal end portion 72 side) can be reduced, and insertion work can be reduced. It can be done smoothly.
In addition, the tapered distal end portion 72 also functions to expand the fistula when the sheath 70 with an insertion aid is inserted into the fistula.
It should be noted that the sheath insertion aid 7 may be any one that performs the functions of facilitating the operation of inserting the entire gastrostomy sheath 6 and the sheath 70 with the insertion aid into the fistula and the function of expanding the fistula. There is no need to have the function of forming. However, the sheath insertion aid 7 may be one that can be used for fistula formation. In this regard, the dilator described above may be used as the sheath insertion aid 7.

 As shown in FIG. 39, in the sheath 70 with an insertion assisting tool in which the sheath insertion assisting tool 7 is inserted into the sheath for gastrostoma 6, the lid 63 of the sheath for gastrostoma 6 is inserted into the sheath body 11. The sheath insertion assisting tool 7 is moved in the opening direction from the closed position, and is housed in the extended portion 115 (inside the inner space 115 a) at the proximal end portion of the sheath body 11. As shown in FIG. 40, when the sheath insertion aid 7 is removed from the gastrostomy sheath 6, the lid 63 immediately returns to the closed position due to the elasticity of the lid hinge portion 62. That is, when the sheath insertion assisting tool 7 is pulled out from the gastrostomy sheath 6 of the sheath 70 with the insertion assisting instrument inserted into the fistula, the lid 63 is automatically attached to the sheath body 11 without operating the handle 61. The internal passage 113 is blocked, and foreign matter can be prevented from entering the internal passage 113. In addition, when an endoscope is used, there is an advantage that the outflow of air supplied from the endoscope into the stomach can be prevented.

 The configuration including the sheath main body 11 into which the sheath insertion assisting tool 7 can be inserted, and the configuration capable of assembling the sheath 70 with the insertion assisting tool by inserting the sheath insertion assisting tool 7 into the sheath main body are as follows. The present invention can be commonly applied to the sheath for gastrostoma of the embodiment.

As shown in FIG. 31 (b), the distal end portion (the lower end portion in FIG. 31 (b)) of the sheath body 11 of the gastrostomy sheath 6 is tapered to reduce the diameter. The leading end taper portion 11a. The inner diameter of the distal end taper portion 11 a, that is, the minimum inner diameter of the distal end taper portion 11 a is substantially the same as the outer diameter of the sheath insertion assisting tool 7.
The tip tapered portion 11a avoids the formation of a step due to the difference between the outer diameter of the sheath insertion assisting tool 7 inserted in the sheath body 11 and the inner diameter of the sheath body 11, and the sheath body of the sheath 6 for gastrostoma The function which makes the insertion to 11 fistulas smooth is fulfilled.
The configuration in which the distal end portion of the sheath body 11 is provided with the distal end tapered portion 11a can be commonly applied to the respective embodiments according to the present invention.

Next, as shown in FIG. 41, the obturator 3 is assembled and set to the newly installed gastrostomy button 2, and the operation unit 311 of the obturator 3 is operated (push-in operation) to fix the body fixing portion 23 of the gastrostoma button 2. A sheath of the gastrostomy sheath 6 in which the gastrostomy button 2 is placed in the fistula from the body fixing part 23 side while the extension part of the body fixing part 23 is maintained. It inserts in the internal channel | path 113 of the main body 11, and makes the body fixing | fixed part 23 protrude inside a body rather than the sheath 6 for gastrostoma (refer FIG. 42).
Thereafter, the gastrostomy sheath 6 is removed from the body, the progress of the body fixing part 23 is released (expanded), and the obturator 3 is removed from the body as described with reference to FIGS. The indwelling of the gastrostomy button 2 is completed.

In the replacement operation of the gastrostoma button 2 using the gastrostoma sheath 6, as described above, the sheath insertion assisting tool 7 is pulled out from the gastrostomy sheath 6 of the sheath 70 with the insertion assisting instrument inserted into the fistula. At this time, even if the handle 61 is not operated, the state in which the internal passage 113 of the sheath main body 11 is closed by the lid 63 can be automatically obtained, and the work of closing the internal passage 113 can be omitted.
When the sheath insertion aid 7 is pulled out from the gastrostomy sheath 6 of the sheath 70 with the insertion aid inserted into the fistula, the lid 63 is automatically connected to the internal passage of the sheath body 11 without operating the handle 61. The advantage of being able to prevent the outflow of the air supplied into the stomach from the endoscope is not limited to the replacement of the gastrostomy button 2 but can be obtained even in a new gastrostomy construction. it can. The gastrostomy using the gastrostomy sheath 6 is realized by using the gastrostomy sheath 6 in place of the gastrostomy sheath 1 in the gastrostomy procedure described with reference to FIGS.

The gastrostomy button 2 described with reference to FIGS. 34 to 42 is replaced by the gastrostomy sheath 1 described in FIGS. 1A and 1B instead of the gastrostomy sheath 6. It is also possible to apply this.
The use of the gastrostomy sheath (the sheath for gastrostoma according to the present invention) in the replacement operation of the gastrostomy button 2 reduces the insertion resistance when the gastrostomy button 2 (the replacement gastrostomy sheath) is inserted. There is an advantage that can be made.

As shown in FIG. 43, the sheath for gastrostoma according to the present invention may employ a lid long plate member 64A in which the stopper protrusion 642 is omitted from the lid long plate member 64 described above. (Gastrostomy sheath 6A). The structure of the handle 61 can be the same as that of the previously described sheath for gastrostoma 6.
The sheath for gastrostoma 6A is configured to elastically support the lid 63 in a closed position that closes the internal passage 113 of the sheath body 11 by the elasticity of the hinge portion 116 and the elasticity of the lid hinge portion 62.

The lid 63 extends from the lid hinge portion 62 so as to incline toward the distal end side of the sheath body 11 at an angle of less than 90 degrees with respect to the central axis C1 of the sheath body 11, and is inserted into the sheath body 11 It is in the shape of a piece.
Further, the tip of the lid 63 is opposite to the hinge portion 116 and the lid hinge portion 62 via the internal passage 113 in the sheath body 11 by the lid 63 being rotated from the closed position in the direction opposite to the opening direction. The sheath body 11 is brought into contact with the portion located on the side from the distal end side. At this time, a portion of the sheath body 11 with which the tip of the lid 63 abuts is denoted by reference numeral 117b, and hereinafter also referred to as a lid abutting portion. The hinge part 116 and the lid hinge part 62 are located on the side opposite to the lid contact part 117b via the internal passage 113.
The lid 63 rotates in the opening direction against the elasticity of the hinge portion 116 and the lid hinge portion 62 (rotation in a direction away from the lid abutting portion 117b. Rotation in the clockwise direction in FIG. 43). It is possible to return to the closed position by the elasticity of the hinge part 116 and the lid hinge part 62 from the position after the rotation.

Also in the case of the gastrostoma sheath 6A, for example, if the user of the gastrostoma sheath 6A does not hold the handle 61 with fingers and no external force is applied to the handle 61 and the lid 63, The lid 63 is elastically supported in the closed position (position shown in FIG. 43) by the elasticity of the hinge portion 116 and the lid hinge portion 62.
Further, the lid hinge portion 62 is configured to be elastically deformed (bending deformation) with a weaker force than the hinge portion 116. For this reason, in the case of the gastrostomy sheath 6A, the handle 61 can be freely rotated by the elastic deformation of the lid hinge portion 62 regardless of the position of the lid 63. 43, if the lid 63 is not provided and the lid 63 rotates integrally with the handle 61, the lid 63 is in contact with the lid abutting portion 117b. The rotation of the handle 61 in the counterclockwise direction in FIG. 43 is restricted by the lid 63, and the orientation of the handle 61 with respect to the sheath body 11 is restricted. On the other hand, in the configuration having the lid hinge portion 62 as described above, the handle 61 is moved counterclockwise in FIG. 43 even when the lid 63 is in contact with the lid contact portion 117b. (For example, the position indicated by the phantom line 61 in FIG. 43. This position is hereinafter also referred to as a retracted position), and the angle (orientation) of the handle 61 with respect to the sheath body 11 can be freely set. The degree is great. For this reason, for example, the handle 61 can be held in an arbitrary direction when the gastrostomy button 2 is inserted, and the insertion workability of the gastrostomy button 2 can be improved. For example, when the handle 61 is placed at the retracted position, it is possible to avoid that the finger holding the handle 61 contacts the gastrostoma button 2 to be inserted into the sheath body 11 and obstructs the insertion operation.

 The fact that the degree of freedom of the angle (orientation) of the handle 61 with respect to the sheath body 11 can be secured largely by the presence of the lid hinge portion is the same for the sheath for gastrostoma 6 described with reference to FIG.

 Further, although the position of the lid hinge portion 62 is arranged in the vicinity of the hinge portion 116, it is separate from the hinge portion 116, and even if the handle 61 does not rotate around the hinge portion 116. The lid 63 can be rotated by elastic deformation of the lid hinge portion 62. Therefore, for example, when the lid 63 is rotated in the opening direction by the sheath insertion assisting tool 7 inserted into the internal passage 113 of the sheath body 11 of the gastrostomy sheath 6A, the handle 61 follows the lid 63 and rotates. Can be suppressed. As a result, fluctuations in the position of the handle 61 due to the rotation of the lid 63 can be suppressed, and it is difficult for the user of the gastrostomy sheath 6A to fail to grasp the handle 61 with fingers, improving work efficiency. There is an advantage that can be done.

44 (a) and 44 (b), the sheath for gastrostoma according to the present invention forms a V-shaped end notch 151 that is recessed from the end surface on the proximal end side of the sheath body 11. In addition, a notch groove 111A extending in the longitudinal direction (axial direction) of the sheath body 11 is formed so as to extend from the deep bottom portion 152 of the end notch portion 151 toward the distal end side of the seal body 11. The sheath body 15 having the configuration is adopted.
According to the gastrostomy sheath employing the sheath main body 15, there is an advantage that when the sheath main body 15 is torn longitudinally, the longitudinal tearing can be easily and smoothly performed from the back bottom 152 of the end notch 151. .

 44 (a) and 44 (b), the end notch 151 and the end cutout 151 are formed in the sheath body 11 of the gastrostoma sheath 6 described with reference to FIGS. 31 (a) and 31 (b). Although the sheath 6B for gastrostoma having a configuration in which the sheath body 15 including the notch groove 111A extending from the back bottom portion 152 of the end notch portion 151 toward the distal end side of the seal body 11 is employed is illustrated, As described above, the sheath including the end notch 151 and the notch groove 111A extending from the back bottom 152 of the end notch 151 toward the distal end side of the seal body 11. The main body is applicable to each embodiment according to the present invention.

As shown in FIGS. 45 (a) and (b) to FIG. 47, the sheath for gastrostoma according to the present invention has the user insert his / her finger on the side of the handle 61 opposite to the hinge part 116. A configuration provided with a gripping ring 16 that can be gripped can also be employed.
The gastrostomy sheath 6C shown in FIGS. 45 (a) and 45 (b) to 47 is the hinge portion 116 of the handle 61 of the gastrostomy sheath 6 described with reference to FIGS. 31 (a) and 31 (b). The grip ring 16 is provided on the opposite side to the general configuration. Further, in this gastrostomy sheath 6C, instead of the lid long plate member 64, a gripping ring 16, an attachment portion 641, a stopper projection 642, a lid hinge portion 62, and a lid 63 are integrally formed. The ring-attached lid long plate member 64B is used, and the attachment portion 641 of the ring-attached lid long plate member 64B is integrated with the handle 61.

The lid-attached long plate member 64B with the ring is configured to include the grip ring 16 on the opposite side of the lid hinge portion 62 via the attachment portion 641 of the lid long plate member 64.
Further, here, the lid-attached long plate member 64B with a ring employs a member integrally formed of rubber elastic material such as silicone rubber or elastomer.
The method (configuration) for integrating the attachment portion 641 of the lid long plate member 64B with the ring into the handle 61 is a method (configuration) for integrating the attachment portion 641 of the lid long plate member 64 with the handle 61. ) Can be used.

As shown in FIG. 47, the gastrostomy sheath 6C can be firmly held by the user of the gastrostomy sheath 6C by gripping the grip ring 16 with fingers. There is an advantage that the gastrostomy button 2 can be reliably performed without being dropped from the hand when the button 2 is inserted into the sheath body 11. Further, when the sheath insertion assisting tool 7 is inserted into the sheath body 11 to assemble the sheath 70 with the insertion assisting tool, the insertion and assembling work can be reliably performed in the same manner.
As shown in FIG. 47, one or more fingers (for example, one or more of the middle finger, ring finger, and little finger) are inserted inside the grip ring 16 in order to grip the grip ring 16 with fingers. Then, it is preferable to hook the gripping ring 16 in terms of gripping reliability.
However, the present invention is not limited to this. For example, one or more fingers (for example, one or more of the middle finger, ring finger, and little finger) are inserted inside the grip ring 16 and hooked on the grip ring 16. A gripping method in which the handle 61 is gripped by the remaining fingers of the same hand can also be employed.

Note that the grip ring 16 does not necessarily have a flexible configuration made of a material having rubber elasticity, and may be formed of a hard resin, for example. However, since the grip ring 16 made of a hard material may interfere with the work, rubber elasticity is made of the material and excellent in flexibility and flexibility in terms of ensuring good workability. It is advantageous to employ a gripping ring 16 of construction.
The grip ring 16 may be provided on the opposite side of the handle 61 from the hinge portion 116 so as to be firmly fixed to the handle 61, and a lid long plate member 64B with a ring is adopted. It is not essential to do so, and it may be fixed to the handle as a member different from the members constituting the attachment portion 641, the lid hinge portion 62, and the lid 63.

 FIGS. 45A and 45B to 47 illustrate the configuration in which the grasping ring 16 is applied to the gastrostoma sheath 6 described with reference to FIGS. 31A and 31B. As described above, the configuration in which the grip ring 16 is provided on the side opposite to the hinge portion 116 of the handle is applicable to each embodiment according to the present invention.

The present invention also provides a gastrostomy catheter kit comprising a gastrostomy sheath 1, a gastrostomy button 2, an obturator 3, and a dilator 5. As the gastrostomy catheter kit, for example, it is more preferable that the gastrostomy sheath 1, the gastrostomy button 2, the obturator 3, and the dilator 5 are stored in a storage case and can be carried together. . The sheath for gastrostoma 1 and the dilator 5 may be a dilator with sheath 5 </ b> A in which the sheath for gastrostoma 1 is covered outside the dilator 5. The gastrostomy catheter kit further includes a replacement gastrostomy sheath, or a sheath 70 with an insertion assisting tool in which the sheath insertion assisting tool 7 is inserted into the replacement gastrostomy sheath. May be. The gastrostomy catheter kit including a replacement gastrostomy sheath that does not constitute the sheath 70 with an insertion assisting tool further includes a sheath insertion assisting tool 7 that can be inserted into the sheath body of the replacement gastrostomy sheath. You may have. As the replacement gastrostomy sheath, the sheath 70 with the insertion assisting tool, and the sheath insertion assisting instrument 7, those that can be accommodated in the storage case are employed.
Needless to say, the gastrostomy catheter kit may further include a guide wire.

The present invention is not limited to a configuration in which the lid rotates integrally with the handle.
For example, it is possible to adopt a configuration in which a lid separate from the handle is rotatably provided on the sheath body via a hinge portion.
The present invention also includes a configuration that does not include a lid. In this case, for example, it is also possible to open and close the internal passage of the sheath body using a plug member that is detachably fitted to the proximal end portion of the sheath body. By closing the internal passage with the plug member, it is possible to facilitate air supply control from the endoscope.
In addition, the present invention includes a configuration in which the diameter (inner diameter) of the internal passage of the gastrostomy sheath is equal to or larger than the maximum outer diameter when the indwelling portion is extended.

DESCRIPTION OF SYMBOLS 1 sheath for gastrostoma, 11 sheath main body, 11a tip taper part, 11B sheath main body, 111A notch part (notch groove), 111a non-cut part, 111B notch part (slit), 112 taper part, 113 internal channel, 114 handle main piece (tube piece), 115 expansion part (shaped part), 115a inner space, 115b inner wall part, 116 hinge part, 117 lid contact part, 117a lid contact part, 117b lid contact part, 118 Non-cutting part, 119 Split piece part, 12 Handle, 121 Handle member (first handle member), 122 Handle member (second handle member), 123 Inclined piece, 13 Lid, 14 Elastic member, 15 Sheath body, 151 end cutout, 152 bottom, 16 grip ring,
2 Gastrostomy catheter (gastric fistula button), 21 tube portion, 21C central axis, 22 indwelling portion, 221 strip, 222 proximal end focusing portion, 223 distal focusing portion, 23 extracorporeal fixing portion, 231 flexible , 232 body surface contact surface, 24 passage, 25 valve, 251 slit, 26 communication path, 27 rod contact portion, 271 rod fitting protrusion, 272 reinforcing member, 28 cap,
3 Obturator, 31 Extension pressure bar, 311 Operation part, 312 Spring, 313 Rod body, 314 Reinforcement member, 315 Wire insertion groove, 316 Lock piece, 317 Tip, 32 Outer cylinder, 321 Cylindrical part, 322 Finger hook, 323 Fitting part, 323a Fitting groove, 324 groove, 325 groove hole, 326 lock hole, 33 stopper, 331 arm part, 332 clamping part, 333 back plate, 334 pushing part,
4 Guide wire,
5 Dilator (dilator), 5A Dilator with sheath, 51 Large diameter dilator, 511 Large diameter dilator body, 512 Large diameter dilator tip, 513 Large diameter dilator side connector, 514 Scale, 5141 Base point (zero point), 52 Fine Diameter dilator, 521 Thin diameter dilator body, 522 Thin diameter dilator tip, 523 Thin diameter dilator side connector, 524 Guide wire passage 6 Gastric fistula sheath, 6A Gastrostomy sheath, 6B Gastrostomy sheath, 61 handle, 611 Handle member (lid-side handle member), 612 Handle member (main-side handle member), 62 Lid hinge part, 63 Lid, 64 Lid long plate member, 64A Lid long plate member, 64B Lid with ring Long plate member, 641 mounting portion, 642 stopper protrusion,
7 sheath insertion aid, 70 gastrostomy sheath with insertion aid, 71 rod-shaped body, 72 taper tip, 73 guide wire insertion hole,
900 Abdominal wall, 901 Gastric wall, 902 Suture

Claims (43)

A tube portion having a passage for introducing nutrient solution or drug solution from outside the body into the stomach, and an indwelling portion formed in a dome shape attached to the distal end portion of the tube portion and projecting radially outward of the tube portion A gastrostomy for inserting and placing a gastrostomy catheter into the fistula, the gastrostomy catheter having a diameter that can be reduced by the action of an extension force applied from the extension obturator of the body indwelling part A sheath for gastrostoma used for replacement of
A cylindrical sheath body into which the gastrostomy catheter is inserted, and a handle projecting at one end in the longitudinal direction of the sheath body,
Furthermore, the hinge part is provided in a base end part which is an end part on the handle side of the sheath body so as to be rotatable via a hinge part, and is disposed in an internal passage which is a through hole inside the sheath body, and the hinge part A lid that opens and closes the internal passage of the sheath body by pivoting about
The sheath body has a lid abutting portion with which the lid abuts from a distal end side which is an end portion on the opposite side to the base end portion of the sheath body by rotation about the hinge portion. Provided,
The lid is brought into contact with the lid abutting portion at a closed position that closes the internal passage, and is rotated from the closed position toward the distal end portion of the sheath body to open the internal passage. A sheath for gastrostoma.  The lid contact portion is provided on a side of the sheath body that faces the hinge portion via the internal passage, and an end portion of the lid opposite to the hinge portion side is provided on the lid contact portion. The sheath for gastrostoma according to claim 1, wherein the sheath is brought into contact.  The handle is rotatably provided at the proximal end portion of the sheath body via the hinge portion, and the lid protrudes from the handle into the internal passage, and rotates integrally with the handle. The sheath for gastrostoma according to claim 1 or 2, wherein the inner passage of the sheath body is opened and closed by movement.  The said hinge part is an elastic support part which accept | permits the rotation to the open direction from the said closed position, and is an elastic support part which elastically supports to the said closed position. Sheath for gastrostoma.  An elastic member functioning as an elastic support part for allowing the handle to be biased and allowing the lid to rotate in the opening direction from the closed position and elastically supporting the lid in the closed position; The sheath for gastrostoma according to any one of claims 1 to 4, wherein the sheath is for gastrostoma.  The sheath for gastrostoma according to any one of claims 1 to 5, wherein a lid housing recess for housing the lid is formed on an inner surface of the internal passage of the sheath body.  An extension portion formed so that the sheath body expands radially outward is formed at the proximal end portion of the sheath body, and the lid storage recess is formed on the inner side of the extension portion. The gastrostomy sheath according to claim 6, wherein the sheath is a space secured to expand the passage.  The handle main piece constituting part or all of the handle, the sheath main body, and the hinge portion are formed as a single part integrally formed of synthetic resin. The sheath for gastrostoma in any one of -7.  9. A grip ring that allows a user to insert a finger and grip it on a side opposite to the hinge portion of the handle is provided. Sheath for gastrostoma.  10. The sheath body is formed with one or a plurality of longitudinal tear notches extending along the longitudinal direction of the sheath body. A sheath for gastrostoma.  The notch is a notch groove formed in the sheath main body so that the thickness thereof is not penetrating, and the sheath main body is locally thinned on the groove bottom side of the notch groove. The sheath for gastrostoma according to claim 10, wherein a portion is secured.  The sheath body is formed with a V-shaped end notch that is recessed from the end face on the base end side, and the notch groove extends from the bottom of the end notch to the seal body. The sheath for gastrostoma according to claim 11, wherein the sheath for gastrostoma is formed so as to extend toward the distal end side. The notch is a slit formed extending along the longitudinal direction of the sheath body, and the slit is shorter than the overall length in the longitudinal direction of the sheath body and is part of the longitudinal direction of the sheath body. Formed,
The sheath for gastrostoma according to claim 10, wherein the sheath body has a non-cut portion in which the slit is not formed on a virtual extension of the slit.  The gastrostomy device according to any one of claims 11 to 13, wherein a load applied to the inner surface of the sheath body is 0.5N or more and 5N or less in order to destroy at least one of the uncut portions. sheath.  15. The cutout portion is formed in a wedge shape whose cross-sectional shape increases in opening width from the inner surface side to the outer surface side of the sheath body. A sheath for gastrostoma.  The sheath for gastrostoma according to any one of claims 10 to 15, wherein the notch is formed by laser processing of the sheath body.  The sheath for gastrostoma according to claim 16, wherein the sheath body is made of a material containing FEP, and a portion of the sheath body where the notch is formed is whitened by the laser processing.  The sheath for gastrostoma according to any one of claims 10 to 17, wherein the handle is provided at a position avoiding the notch in the circumferential direction of the sheath body.  The sheath for gastrostoma according to claim 18, wherein the notch is formed only at one place in the circumferential direction of the sheath body, and the handle is one.  The sheath for gastrostoma according to any one of claims 1 to 19, wherein the sheath body has orientation in a longitudinal direction.  21. The sheath for gastrostoma according to any one of claims 1 to 20, wherein an end surface of the sheath body on the proximal end side is formed obliquely with respect to the axis of the sheath body.  The sheath for gastrostoma according to any one of claims 1 to 21, wherein an inner diameter of the sheath body is larger than an outer diameter of a tube portion of the gastrostomy catheter.  The sheath for gastrostoma according to any one of claims 1 to 22, wherein a material of the sheath body includes a fluorine-based resin.  The sheath for gastrostoma according to claim 23, wherein the fluororesin includes any one of PTFE, ETFE, and FEP.  The sheath for gastrostoma according to any one of claims 1 to 24, wherein the sheath body can be externally inserted into and removed from a fistula forming dilator.  26. The sheath for gastrostoma according to claim 25, wherein the dilator has a guide wire passage extending therethrough in a longitudinal direction thereof.  27. The sheath for gastrostoma according to claim 25 or 26, wherein a scale for measuring the distance between the stomach wall inner surface and the body surface is provided on the outer peripheral surface of the dilator.  28. The sheath for gastrostoma according to claim 27, wherein the sheath main body is transparent so that the scale of the dilator can be viewed from the outside.  The dilator is obtained by integrating a thin diameter dilator having the guide wire passage therein and a large diameter dilator externally attached to the thin diameter dilator and assembled to the thin diameter dilator. Item 25. The sheath for gastrostoma according to any one of Items 25 to 28.  30. The inner diameter of the sheath body is smaller than a maximum outer diameter when the indwelling portion of the gastrostomy catheter is in a reduced diameter state by an extension force applied from an obturator. The sheath for gastrostoma as described.  31. The sheath for gastrostoma according to claim 30, wherein the sheath body can be longitudinally split by inserting the gastrostomy catheter in which the indwelling portion is reduced in diameter by the obturator.  The sheath for gastrostoma according to any one of claims 1 to 31, wherein the sheath body is configured to be radially expandable by a material that can be stretched and deformed.  30. The inner diameter of the sheath body is larger than a maximum outer diameter when the indwelling portion of the gastrostomy catheter is in a reduced diameter state by an extension force applied from an obturator. The sheath for gastrostoma as described.  The sheath body is configured to be removably inserted into a sheath insertion aid that is formed into a rod-like appearance. The sheath insertion aid is attached to the rod-like body and one end in the longitudinal direction of the rod-like body. 34. The sheath for gastrostoma according to any one of claims 1 to 33, further comprising a tapered tapered tip projectingly provided.  35. The sheath for gastrostoma according to claim 34, wherein the sheath insertion aid has a guide wire insertion hole penetrating in the longitudinal direction.  36. The gastrostomy sheath according to claim 34 or 35, wherein the sheath insertion aid is usable as a dilator for fistula formation.  A dilator with a sheath, wherein the sheath for gastrostoma according to any one of claims 1 to 36 is extrapolated to a dilator for fistula formation.  37. A sheath insertion aid formed by a tapered tapered tip projecting from one end of the rod-shaped body in the longitudinal direction is inserted into the sheath body of the gastrostoma sheath according to any one of claims 1 to 36. A sheath for gastrostoma with an insertion aid. The gastrostomy catheter according to any one of claims 1 to 36 or the gastrostomy sheath according to any one of claims 1 to 36, or a gastrostomy catheter for percutaneously replenishing a patient with a nutrient solution or a drug solution from outside the body into the stomach. A gastrostomy catheter kit comprising a sheathed dilator,
The gastrostomy catheter is formed in a dome shape that is attached to a distal end portion of the tube portion and that extends outward in the radial direction of the tube portion, having a passage for introducing nutrient solution or drug solution from outside the body into the stomach An indwelling portion that has been placed, and the indwelling portion can be reduced in diameter by the action of an extension force provided from an obturator for extension of the indwelling portion,
The sheath for gastrostoma according to any one of claims 1 to 36 and the sheath for gastrostoma of the dilator with sheath according to claim 37, wherein the indwelling portion is reduced in diameter by the obturator while being inserted into the fistula. A gastrostomy catheter kit, wherein the gastrostomy catheter in a state is inserted. The obturator includes an outer cylinder, an extension pressing rod having a rod main body inserted in the outer cylinder so as to be movable in the longitudinal direction of the outer cylinder, and an anchor for locking the gastrostomy catheter to the outer cylinder. Equipped with a stopper,
With the gastrostomy catheter locked to the outer cylinder by the stopper, the distal end of the extension pressing rod protruded from the outer cylinder of the rod body is inserted into the indwelling portion of the gastrostomy catheter. 40. The gastrostomy catheter kit according to claim 39, wherein the indwelling portion is extended by pressing the most distal portion of the indwelling portion.  The gastrostomy catheter and the obturator have a guide wire passage, and the obturator is capable of reducing the diameter of the indwelling portion of the gastrostomy catheter while being externally inserted into the guide wire inserted into the gastrostomy catheter. 41. The gastrostomy catheter kit according to claim 39 or 40, wherein the kit is configured.  Furthermore, the gastrostomy sheath according to any one of the first to thirty-sixth inventions is provided as a replacement gastrostoma sheath, and the gastrostomy sheath is inserted into the fistula, and the indwelling portion is held by the obturator. The gastrostomy catheter kit according to any one of claims 39 to 41, wherein the gastrostomy catheter in a reduced diameter state is inserted.  43. A gastrostomy catheter kit according to claim 42, comprising the gastrostomy sheath with an insertion aid according to claim 38, wherein the gastrostomy sheath is constructed using the replacement gastrostomy sheath.

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