JP5425149B2 - Endoscopic treatment tool - Google Patents

Description

  The present invention relates to an endoscopic treatment tool for endoscopically excising a lesion in the digestive tract.

  Conventionally, there is endoscopic mucosal resection (EMR) which removes a lesion endoscopically as a general treatment method for gastrointestinal lesions. In particular, endoscopic submucosal dissection (hereinafter referred to as ESD: Endoscopic Submucosal Dissection) is a method in which the mucous membrane surrounding the lesion is incised, and then the submucosal layer is exfoliated to remove the lesion. Known as reliable endoscopic treatment.

  When performing such ESD, a physiological saline or the like is injected into the normal mucous membrane around the lesion with an injection needle to lift the lesion, and in that state, a high-frequency incision tool such as a high-frequency knife or snare is used. Excision is performed between the lesioned part and the normal mucous membrane (see, for example, Patent Document 1). At this time, the lesion is lifted to a sufficient position to secure a sufficient excision at the border between the lesion and normal tissue, or to create an excision when the lesion is flat. The incision in the submucosa is advanced with a high-frequency incision tool while the transparent cap attached to the tip of the mirror is submerged under the mucosa to lift the mucosa.

JP 2004-261372 A

  However, according to the above-described technique, since the distal end diameter of the transparent cap is larger than the distal end diameter of the endoscope, it is difficult to open the wound by entering the fine incision. In addition, even if it is submerged inside, the mucosa may slide off the cap due to the endoscopic operation to perform incision and peeling. In this case, it is necessary to perform the operation of submerging the cap inside again. There is.

  The present invention has been made in view of the above circumstances, and provides an endoscopic treatment tool capable of performing an incision operation while continuing to secure an endoscope visual field at the time of incision of the submucosa. Objective.

In order to solve the above problems, the present invention proposes the following means.
An endoscope treatment tool according to the present invention includes a cylindrical portion that is formed in a cylindrical shape and is attached to the distal end of an endoscope , a treatment tool that has a distal end portion that holds biological tissue, and an exterior of the endoscope. The sheath is provided so as to extend along the central axis of the cylindrical portion, and the sheath through which the treatment instrument is inserted, and the distal end portion of the treatment instrument are moved so that the holding position of the living tissue is relative to the cylindrical portion A moving part to be brought into contact with and separated from, and provided on the distal end side of the moving part, the treatment instrument is inserted in a freely reciprocating manner so that the distal end part of the treatment instrument can move in the central axis direction with respect to the moving part. And the moving part is connected to the cylinder part, and the short pipe member is separated from the position along the cylinder part in the normal direction of the outer peripheral surface of the cylinder part. It is a feature.

In the endoscope treatment tool, the short tube member is provided at a distal end support portion provided at a distal end of the moving portion, and the moving portion pivotally supports the moving portion and the cylindrical portion. first rotation axis, and the moving part and the tip supporting portions and more have preferred to have a second rotary shaft pivotally supporting the to.

In the endoscope treatment tool, it is more preferable that the moving unit pivots with respect to the tube portion by an advance / retreat operation of the treatment tool with respect to the endoscope.
According to the present invention, the treatment instrument is turned by advancing / retreating the cylinder part , so that the distal end part of the treatment instrument can be made to approach or separate from the cylinder part more easily.

In the endoscope treatment tool, the moving unit may be moved to a position where the first rotating shaft and the second rotating shaft are arranged side by side in a direction orthogonal to the central axis of the endoscope. It is more preferable that the distal end portion of the treatment instrument is most separated from the endoscope.
This invention can point the front-end | tip part of a treatment tool in the direction orthogonal to a cylinder part .

  According to the present invention, in the submucosal incision, the incision operation can be performed while continuously securing an endoscope visual field suitable for the treatment.

It is a top view which shows the lifting cap which concerns on the 1st Embodiment of this invention. It is a top view including the partial cross section which shows the lifting cap which concerns on the 1st Embodiment of this invention. It is explanatory drawing which shows the effect | action of the lifting cap which concerns on the 1st Embodiment of this invention. It is a principal part top view which shows the lifting cap which concerns on the 2nd Embodiment of this invention. It is explanatory drawing which shows the effect | action of the lifting cap which concerns on the 2nd Embodiment of this invention. It is explanatory drawing which shows the effect | action of the lifting cap which concerns on the 2nd Embodiment of this invention. It is a principal part top view which shows the lifting cap which concerns on the 3rd Embodiment of this invention. It is a principal part side view which shows the lifting cap which concerns on the 3rd Embodiment of this invention. It is explanatory drawing which shows the effect | action of the lifting cap which concerns on the 3rd Embodiment of this invention. It is explanatory drawing which shows the effect | action of the lifting cap which concerns on the 3rd Embodiment of this invention. It is a side view which shows the modification of the lifting cap which concerns on the 3rd Embodiment of this invention. It is a figure which shows the other modification of the lifting cap which concerns on the 3rd Embodiment of this invention, and its effect | action. It is a principal part top view which shows the other modification of the lifting cap which concerns on the 3rd Embodiment of this invention. It is a principal part side view which shows the lifting cap which concerns on the 4th Embodiment of this invention. It is explanatory drawing which shows the effect | action of the lifting cap which concerns on the 4th Embodiment of this invention. It is explanatory drawing which shows the effect | action of the lifting cap which concerns on the 4th Embodiment of this invention. It is a principal part side view which shows the modification of the lifting cap which concerns on the 4th Embodiment of this invention. It is explanatory drawing which shows the effect | action of the modification of the lifting cap which concerns on the 4th Embodiment of this invention. It is explanatory drawing which shows the effect | action of the modification of the lifting cap which concerns on the 4th Embodiment of this invention. It is a principal part side view which shows the lifting cap which concerns on the 5th Embodiment of this invention. It is explanatory drawing which shows the effect | action of the lifting cap which concerns on the 5th Embodiment of this invention. It is a principal part side view which shows the lifting cap which concerns on the 6th Embodiment of this invention. It is a principal part side view which shows the lifting cap which concerns on the 7th Embodiment of this invention. It is a front view which shows the lifting cap which concerns on the 7th Embodiment of this invention. It is explanatory drawing which shows the effect | action of the lifting cap which concerns on the 7th Embodiment of this invention. It is a principal part side view which shows the lifting cap which concerns on the 8th Embodiment of this invention. It is a principal part side view which shows the modification of the lifting cap which concerns on the 8th Embodiment of this invention. It is a principal part side view which shows the other modification of the lifting cap which concerns on the 8th Embodiment of this invention. It is explanatory drawing which shows the effect | action of the lifting cap shown in FIG. It is a principal part side view which shows the lifting cap which concerns on other embodiment of this invention. It is explanatory drawing which shows the effect | action of the lifting cap shown in FIG. It is a figure which shows the treatment tool for endoscopes which concerns on an ESD procedure, and its effect | action. It is a figure which shows the other treatment tool for endoscopes which concerns on an ESD procedure, and its effect | action. It is a figure which shows the other treatment tool for endoscopes which concerns on an ESD procedure, and its effect | action. It is a figure which shows the other treatment tool for endoscopes concerning FIG. 35, and its effect | action. It is a figure which shows the other treatment tool for endoscopes which concerns on an ESD procedure, and its effect | action. It is a figure which shows the other treatment tool for endoscopes which concerns on an ESD procedure, and its effect | action. It is a figure which shows the other treatment tool for endoscopes which concerns on ESD procedure. It is a figure which shows the effect | action of the other treatment tool for endoscopes which concerns on an ESD procedure. It is a figure which shows the effect | action of the other treatment tool for endoscopes which concerns on an ESD procedure. It is a figure which shows the effect | action of the other treatment tool for endoscopes which concerns on an ESD procedure. It is a figure which shows the effect | action of the other treatment tool for endoscopes which concerns on an ESD procedure. It is a figure which shows the effect | action of the other treatment tool for endoscopes which concerns on an ESD procedure. It is a figure which shows the effect | action of the other treatment tool for endoscopes which concerns on an ESD procedure.

(First embodiment)
A first embodiment according to the present invention will be described with reference to FIGS.
As shown in FIGS. 1 and 2, the lifting cap (endoscopic treatment tool) 1 according to the present embodiment is formed in a cylindrical shape, and is provided with slits 2 extending along the direction of the central axis C on the side surface. A cylindrical portion 3 attached to the distal end of the endoscope E, and a capturing portion 5 that extends along the slit 2 and is disposed in the cylindrical portion 3 and holds biological tissue with respect to the endoscope E. I have.

  The cylindrical portion 3 includes a soft hood 6 having a proximal end attached to the distal end of the endoscope E, and a transparent and hard cap 7 formed in a cylindrical shape and connected to the distal end of the hood 6. The tip surface 7 </ b> A of the cap 7 is formed to be inclined with respect to the central axis C of the cylindrical portion 3. That is, the distal end surface 7A has a distal position 7a farthest from the hood 6 and a proximal position 7b closest to the hood 6. The slit 2 is provided at a distal position 7 a of the tip surface 7 A of the cap 7.

The capturing part 5 is a pair of forceps pieces 8A and 8B pivotally supported by the tip cover 8, an operation part 11 for opening and closing the pair of forceps pieces 8A and 8B via the operation wire 10, and an operation wire 10 can be moved forward and backward. And a flexible sheath 12 that is inserted through the sheath 12. The sheath 12 is arranged along the endoscope E. The operation unit 11 includes an operation unit main body 11A and a slider 11B arranged to be movable forward and backward with respect to the operation unit main body 11A. The proximal end of the sheath 12 is connected to the operation portion main body 11A, and the proximal end of the operation wire 10 is connected to the slider 11B.
With the cylindrical part 3 attached to the distal end of the endoscope E, the opening / closing operation of the pair of forceps pieces 8A and 8B is visible from the endoscope E, and the distal end cover 8 of the capturing part 5 is a slit of the cylindrical part 3 2 is arranged.

  Next, the operation of the lifting cap 1 according to the present embodiment will be described as an example in which an ESD procedure is performed using this.

  First, the endoscope E with the cylindrical portion 3 of the lifting cap 1 attached to the tip is inserted up to the vicinity of the lesion X, which is the target site, and an injection needle (not shown) is introduced into the body cavity via the endoscope E. Then, physiological saline is injected into the submucosal layer S of the lesion X, and the lesion X is raised.

  Subsequently, as shown in, for example, Patent Document 1, a known high-frequency knife (not shown) is introduced endoscopically to make an initial incision in which a hole is made in a part of the mucous membrane M around the lesion X, In this state, a knife (not shown) is moved while supplying a high-frequency current to widen the initial incision hole to a predetermined size. In this way, another knife (not shown) is brought into contact with the cut CU formed in the mucous membrane M in the vicinity of the lesion X, and the submucosal layer S of the lesion X is incised and peeled off.

  At this time, the position of the cap 7 is adjusted so that the slit 2 of the cap 7 is positioned at the uppermost position of the cylindrical portion 3 while bending the endoscope E, and further, the cylindrical portion is tilted so as to be embedded in the cut end CU. Adjust the position of 3. After positioning, the slider 11B is moved forward with respect to the operation portion main body 11A, the pair of forceps pieces 8A and 8B are opened, the incision of the mucous membrane M is sandwiched between the pair of forceps pieces 8A and 8B, and the operation portion main body 11A is left as it is. The slider 11B is retracted, the pair of forceps pieces 8A and 8B are closed, and the mucous membrane M is gripped.

Thus, as shown in FIG. 3, the mucous membrane M is positioned in the cylindrical portion 3 so that the relative position between the mucous membrane M and the cylindrical portion 3 does not change, so that the mucous membrane M is turned up and the front view of the cylindrical portion 3 can be viewed. After securing, the submucosal layer S in front of the tube part 3 is cut off by a knife. After the incision is made at a predetermined distance, the above-described operation is repeated, and the incision is advanced while holding the cut CU of the mucous membrane M with the pair of forceps pieces 8A and 8B.
After all the lesioned part X has been excised, the lesioned part X is grasped with grasping forceps or the like (not shown) and taken out endoscopically to complete the treatment.

According to this lifting cap 1, when incising the submucosal layer S, the mucosa M is turned over by the pair of forceps pieces 8A and 8B when the tube portion 3 is inserted into the endoscope E and is submerged under the mucosa M. The mucous membrane M can be held so that the submucosa S can be viewed from the front by the endoscope E. Further, since the distal end cover 8 of the capturing part 5 is arranged in the slit 2, the state of capturing the mucous membrane M by the pair of forceps pieces 8 </ b> A and 8 </ b> B is visually recognized from the inside of the tubular part 3 by the endoscope E. It can be performed.
Therefore, at the time of incision of the submucosal layer S, the endoscope operation can be performed while ensuring the endoscope visual field.

  Further, since the capturing unit 5 includes a pair of forceps pieces 8A and 8B, the biological tissue is grasped by the pair of forceps pieces 8A and 8B by moving the operation wire 10 forward and backward with respect to the sheath 12. Can do.

(Second Embodiment)
Next, a second embodiment will be described with reference to FIGS.
In addition, the same code | symbol is attached | subjected to the component similar to 1st Embodiment mentioned above, and description is abbreviate | omitted.
The difference between the second embodiment and the first embodiment is that the lifting cap 20 according to this embodiment moves the capturing part (treatment tool) 5 so that the holding position of the living tissue is set with respect to the cylindrical part 3. It is the point which is provided with the moving part 21 which touches and separates.

  As shown in FIGS. 4 and 5, the moving part 21 is connected to the cylinder part 3 and is configured to move the direction of the distal end side of the capturing part 5 outward in the radial direction of the cylinder part 3. In other words, the moving part 21 is connected to the hood (first position) 6 on the proximal end side of the cylindrical part 3 and allows the sheath 12 of the capturing part 5 to be inserted into the cylindrical part 3 so as to be able to advance and retract. A support portion 22 that restricts movement is provided to extend along the capturing portion 5, and one end is pivotally supported by a first rotating shaft 23 on a cap (second position) 7 of the cylindrical portion 3 on the tip side of the hood 6. And the other end is provided with the link member (connection part) 26 pivotally supported by the 2nd rotating shaft 25 distribute | arranged to the front-end | tip cover 8 of the capture | acquisition part 5. FIG.

  The link member 26 pivots to a position where the first rotation shaft 23 and the second rotation shaft 25 are arranged side by side in a direction orthogonal to the central axis C of the endoscope E, and The pair of forceps pieces (tip portions) 8A and 8B are most separated from the endoscope E.

  The support portion 22 is fitted to the hood 6, a ring-shaped support portion main body 22 </ b> A in which a part of the hood 6 protrudes in the radial direction and an insertion hole 22 a through which the sheath 12 can be inserted in the central axis C direction is formed. An external tube 22B having a tip connected to the support body 22A so as to communicate with the insertion hole 22a is provided. The pair of forceps pieces 8 </ b> A and 8 </ b> B are pivotally supported by the second rotation shaft 25 and are disposed so as to freely open and close about the second rotation shaft 25.

Next, the operation of the lifting cap 20 according to the present embodiment will be described together with the ESD technique as in the first embodiment.
First, the tube member 3 of the lifting cap 20 is attached to the distal end of the endoscope E in a state where the link member 26 is laid along the central axis C, and is inserted to the vicinity of the lesioned part X, which is the target site. Raise X.

  Subsequently, an initial incision is made in which a hole is made in a part of the mucous membrane M around the lesioned part X. Further, in this state, a knife (not shown) is moved while supplying a high-frequency current, so that the initial incision hole has a predetermined size. Spread it. In this way, another knife (not shown) is brought into contact with the cut CU formed in the mucous membrane M in the vicinity of the lesion X, and the submucosal layer S of the lesion X is incised and peeled off.

  At this time, the pair of forceps pieces 8A and 8B are opened, the cut end of the mucous membrane M is sandwiched between the pair of forceps pieces 8A and 8B, and the slider 11B is retracted with respect to the operation portion main body 11A, thereby the pair of forceps pieces 8A and 8B. Is closed and the mucous membrane M is gripped. Thus, similarly to the first embodiment, the mucous membrane M is positioned with respect to the cylindrical portion 3, and the submucosal layer S in front of the cylindrical portion 3 is incised and peeled off with the knife.

  Here, after incising the submucosal layer S to a predetermined distance, the sheath 12 is pulled toward the hand while holding the cut CU of the mucosa M with the pair of forceps pieces 8A and 8B. At this time, as the sheath 12 moves to the proximal end side, the axial force applied to the distal end cover 8 generates a rotational torque that rotates the link member 26 around the first rotation shaft 23. At this time, since the sheath 12 has flexibility, the link member 26 rotates around the first rotation shaft 23 to separate the distal end side of the capturing part 5 from the cylindrical part 3.

In this way, as shown in FIG. 6, the mucous membrane M is positioned with respect to the cylindrical portion 3 even when the grasping position of the mucous membrane M is a position away from the cylindrical portion 3. At this time, the visual field in front of the tube portion 3 is sufficiently secured, and the submucosal layer S in front of the tube portion 3 is incised and peeled off with a knife.
After all the lesioned part X has been excised, the lesioned part X is grasped with grasping forceps or the like (not shown) and taken out endoscopically to complete the treatment.

  According to the lifting cap 20, not only the capturing part 5 but also the moving part 21 is provided. Therefore, even if the incision is advanced, the grasping part 5 holds the mucous membrane M and the position where the procedure is easy or sufficient The capturing unit 5 can be moved by the moving unit 21 to a position where a visual field can be secured. Therefore, even if the incision is advanced, it is not necessary to grasp by the capturing portion 5, and the procedure can be performed more easily. Further, when the incision is advanced, an appropriate tension can be applied to the submucosa S, and the incision can be easily made.

(Third embodiment)
Next, a third embodiment will be described with reference to FIGS.
In addition, the same code | symbol is attached | subjected to the component similar to other embodiment mentioned above, and description is abbreviate | omitted.
The difference between the third embodiment and the second embodiment is that the moving portion 31 of the lifting cap 30 according to this embodiment enables the capturing portion 5 to move along the direction of the central axis C of the cylindrical portion 3. The distal end side support portion 32 is further provided.

As shown in FIGS. 7 and 8, the distal end side support portion 32 is pivotally supported by a short tube member 33 through which the sheath 12 is inserted so as to freely advance and retreat, and the short tube member 33 via a third rotating shaft 34. The distal end cover 36 is provided so as to penetrate the link member 26 in a direction orthogonal to the opening / closing surface formed by the distal end side link member 35 pivotally supported by the second rotating shaft 25 and the pair of forceps pieces 8A and 8B. The tip pin 37 is provided. The length of the tip pin 37 is larger than the outer diameter of the short tube member 33 and is arranged so as to protrude from the tip cover 36.
The support portion main body 38A of the support portion 38 is formed in a tubular shape having a predetermined length so that the position of the insertion hole 22a is separated from the base end of the cap 7 by the length of the link member 26.

Next, the operation of the lifting cap 30 according to the present embodiment will be described together with the ESD technique as in the first embodiment.
When incising and peeling the submucosal layer of the lesioned part, as shown in FIG. 9, first, the sheath 12 of the capturing part 5 is advanced to project the pair of forceps pieces 8A and 8B toward the distal end side from the cylindrical part 3. . In this state, the pair of forceps pieces 8A and 8B are opened by opening the pair of forceps pieces 8A and 8B by the same operation as in the second embodiment while slightly inclining the cylindrical portion 3 at a position away from the hole. The pair of forceps pieces 8A and 8B is closed by gripping the mucous membrane by sandwiching at 8B and retracting the slider 11B with respect to the operation portion main body 11A. Thus, similarly to the second embodiment, the mucous membrane is positioned in the cylindrical portion 3, and the submucosal layer in front of the cylindrical portion 3 is incised and peeled off with the knife.

  After incision at a predetermined distance, in order to secure the field of view of the endoscope E, the endoscope 12 is advanced toward the distal end side with the sheath 12 as a guide while grasping the cut of the mucous membrane with a pair of forceps pieces 8A and 8B. Let At this time, the sheath 12 moves relatively to the proximal side until the distal end pin 37 contacts the short tube member 33.

  When the incision is further advanced, the sheath 12 is further pulled to the proximal side while the distal pin 37 is in contact with the short tube member 33. At this time, as shown in FIG. 10, the distal end side link member 35 rotates around the third rotation shaft 34 with respect to the short tube member 33, and the link member 26 is first with respect to the distal end side link member 35. By rotating around the rotation shaft 23, the distal end side of the capturing part 5 is separated from the cylindrical part 3.

  In this way, as in the second embodiment, the mucous membrane is positioned with respect to the tube portion 3 even when the gripping position of the mucosa is spaced from the tube portion 3. Thereafter, after all the lesioned part is excised, the lesioned part is grasped with grasping forceps or the like (not shown) and taken out endoscopically to complete the treatment.

  According to the lifting cap 30, the sheath 12 can be moved back and forth in the direction of the central axis C with respect to the tube portion 3, and the position of the tube portion 3 and the pair of forceps pieces 8 </ b> A and 8 </ b> B can be changed during the incision of the submucosa. You can continue to pull the mucous membrane cut while changing. Therefore, a sufficient endoscope field of view can be secured and the procedure can be performed more easily.

As a modification of the present embodiment, as shown in FIG. 11, a connection terminal 41 is provided on a slider 40 </ b> B that is connected to the operation wire 10 of the capturing unit 5 and advances and retreats along the operation unit main body 40 </ b> A of the operation unit 40. A lifting cap 42 may be used. In this case, an insulating coating 43 is disposed on the sheath surface.
By connecting a high-frequency power source 44 to the connection terminal 41, a high-frequency current can be passed through at least one of the pair of forceps pieces 8A and 8B.

  Instead of having the link member 26 and the like, as shown in FIG. 12, the outer diameter of the sheath 46 of the lifting cap 45 is formed smaller than the outer diameters of the distal end cover 8 and the operation portion main body 40A of the operation portion 40. The outer tube 47 may have an outer diameter larger than the outer diameter of the tip cover 8 and the operation unit main body 40A and an inner diameter smaller than these outer diameters. At this time, the length of the external tube 47 is shorter than the sheath 46 by the length L. Accordingly, the sheath 46 can move forward and backward with respect to the external tube 22B within the range of the length L, and the pair of forceps pieces 8A and 8B can move forward and backward with the same length L with respect to the cylindrical portion 3. be able to.

  According to the lifting cap 45, the incision is advanced while continuing to pull the mucous membrane, even if the capturing portion 5 does not move in the radial direction of the cylindrical portion 3 as in the lifting cap 1 according to the first embodiment. Can do. Therefore, a sufficient visual field can be secured and the procedure can be easily performed.

As another modification, as shown in FIG. 13, an external tube support portion 49 is provided extending from the proximal end of the hood 48 toward the proximal side, and an external tube is provided at the proximal end of the external tube support portion 49. The tip of 47 may be connected.
In this case, the mucous membrane can be moved closer to the proximal side than the cap 7 while grasping the mucous membrane with the pair of forceps pieces 8A and 8B.

(Fourth embodiment)
Next, a fourth embodiment will be described with reference to FIGS.
In addition, the same code | symbol is attached | subjected to the component similar to other embodiment mentioned above, and description is abbreviate | omitted.
The difference between the fourth embodiment and the third embodiment is that the moving part 51 of the lifting cap 50 according to this embodiment is arranged on the side surface of the cap 52 instead of the link member 26 as shown in FIG. It is a point provided with the balloon 53 which is provided and expands and contracts.

The balloon 53 is disposed over either one or both of the cap 52 and the hood 6.
A supply / exhaust pipe portion 55 is connected to the proximal end of the balloon 53 to supply fluid to the inside and discharge the supplied fluid. The supply / exhaust pipe portion 55 is inserted into the external tube 22B together with the sheath 12, and a fluid supply source (not shown) is connected to the proximal end.
A concave portion 53 </ b> A for placing the balloon 53 is formed on the outer peripheral surface of the cap 52.

Next, the operation of the lifting cap 50 according to the present embodiment will be described together with the ESD technique as in the first embodiment.
As shown in FIG. 15, after the pair of forceps pieces 8A and 8B are projected from the cylindrical portion 56, the mucous membrane is positioned on the cylindrical portion 56, and the submucosal layer in front of the cylindrical portion 56 is incised and peeled off with a knife. The operation to go is the same as in the third embodiment.

  When the incision is further advanced, the fluid is supplied from the fluid supply source to the supply / exhaust pipe portion 55. At this time, as shown in FIG. 16, as the balloon 53 expands and expands in diameter, the balloon 53 presses the sheath 12 outward in the radial direction. At this time, since the balloon 53 is arranged at the distal end of the external tube 22B, the sheath 12 protruding from the external tube 22B is curved with the distal end of the external tube 22B as a base point, and the distal end side of the capturing portion 5 is cylindrical. Separated from the part 56.

  Thus, similarly to the second embodiment, the mucous membrane is positioned with respect to the cylindrical portion 56 even if the grasping position of the mucous membrane is a position away from the cylindrical portion 56. Thereafter, after all the lesioned part is excised, the lesioned part is grasped with grasping forceps or the like (not shown) and taken out endoscopically to complete the treatment.

  According to the lifting cap 50, the distal end side of the capturing part 5 can be raised with respect to the cylindrical part 56 by inflating the balloon 53.

  As shown in FIGS. 17 to 19, as a modification of the present embodiment, the balloon 53 may be a lifting cap 57 attached to the outer peripheral surface of the external tube 22 </ b> B instead of the cap 52. In this case, the external tube 22B is disposed so that a predetermined range from the tip can be separated from the cylindrical portion 56, and this portion has flexibility. Therefore, when the balloon 53 is inflated, the distal end side of the external tube 22B is raised in accordance with the diameter expansion of the balloon 53, and accordingly, the distal end side of the capturing unit 5 is also raised.

(Fifth embodiment)
Next, a fifth embodiment will be described with reference to FIGS.
In addition, the same code | symbol is attached | subjected to the component similar to other embodiment mentioned above, and description is abbreviate | omitted.
The difference between the fifth embodiment and the first embodiment is that the capturing portion 61 of the lifting cap 60 according to this embodiment protrudes and retracts from the external tube (tube member) 62 and the distal end of the external tube 62. The needle 63 is freely inserted.

  The needle 63 is connected to the tip of an operation wire (not shown), and the tip is bent. The distal end of the external tube 62 is connected to the side surface of the cap 7 of the cylindrical portion 3.

The operation of the lifting cap 60 will be described together with the ESD technique as in the first embodiment.
First, the endoscope E with the tube portion 3 of the lifting cap 60 in a state where the needle 63 is immersed in the external tube 62 is inserted to the vicinity of the lesion site X that is the target site, and the lesion site X is inserted. Raise.

  Subsequently, an initial incision is performed in the same manner as in the first embodiment, and the hole of the initial incision is further expanded to a predetermined size. In this way, another knife (not shown) is brought into contact with the cut CU formed in the mucous membrane M in the vicinity of the lesion X, and the submucosal layer S of the lesion X is incised and peeled off.

  At this time, the needle 63 protrudes from the external tube 62 to a predetermined length, and the cut end of the mucous membrane M is punctured with the needle 63 by the bending operation of the endoscope E to grip the mucous membrane M. In this way, the mucous membrane M is positioned with respect to the cylindrical portion 3, and the submucosal layer S in front of the cylindrical portion 3 is incised and peeled off with the knife.

  After incising at a predetermined distance, in order to secure the field of view of the endoscope E, the endoscope E is advanced toward the distal end side with the needle 63 as a guide while puncturing the cut surface of the mucous membrane M with the needle 63. At this time, the sheath 12 moves relatively to the proximal side until the needle 63 is immersed in the external tube 62.

  In this way, the mucous membrane M is positioned with respect to the cylindrical portion 3 even when the gripping position of the mucous membrane M is a position away from the cylindrical portion 3. After that, after all the lesioned part X is excised, the lesioned part X is grasped with grasping forceps or the like (not shown) and taken out endoscopically, and the treatment is completed.

  According to this lifting cap 60, the mucous membrane M is punctured with respect to the tubular portion 3 by protruding the needle 63 from the distal end of the external tube 62 and puncturing the mucosa M even by a method other than the opening / closing operation of the pair of forceps pieces. M can be positioned.

(Sixth embodiment)
Next, a sixth embodiment will be described with reference to FIG.
In addition, the same code | symbol is attached | subjected to the component similar to other embodiment mentioned above, and description is abbreviate | omitted.
The difference between the sixth embodiment and the fifth embodiment is that the cap 72 of the cylindrical portion 71 of the lifting cap 70 according to the present embodiment is a cap main body (cylindrical main body) 72A connected to the hood 6, and The tongue piece 72B is formed in a substantially semi-cylindrical shape and pivotally supported with respect to the cap main body 72A.

  The moving part 73 includes an operation member 75 that is formed extending along the central axis C and connected to a predetermined position of the tongue piece 72B that is separated from the pivot position 74 of the cap body 72A and the tongue piece 72B. ing. Similar to an operation wire (not shown), the operation member 75 is inserted into the external tube 62 connected to the outer peripheral surface of the cap body 72A so as to freely advance and retract. A slit 76 in which the needle 63 can advance and retract is provided on the side surface of the tongue piece 72B.

Next, the operation of the lifting cap 70 according to the present embodiment will be described together with the ESD technique as in the fifth embodiment.
First, similarly to the fifth embodiment, an endoscope E in which a cylindrical portion 71 of a lifting cap 70 with the needle 63 immersed in the external tube 62 is attached to the distal end of the endoscope E is provided in the vicinity of a lesion site as a target site. Until the lesion is raised.

  Subsequently, an initial incision is performed in the same manner as in the first embodiment, and the hole of the initial incision is further expanded to a predetermined size. In this way, another knife (not shown) is brought into contact with the cut formed in the mucous membrane in the vicinity of the lesioned part, and the submucosal layer of the lesioned part is incised and peeled off.

At this time, while the needle 63 is immersed in the external tube 62, the operating member 75 is moved forward and backward to rotate the tongue piece 72B relative to the cap body 72A, and the cylindrical portion 71 is inserted into the mucous membrane incision. insert.
When the tongue piece 72B is inserted, the needle 63 protrudes from the external tube 62 to a predetermined length, and the mucosa is punctured with the needle 63 to grip the mucous membrane. Thus, the mucous membrane is positioned with respect to the cylinder part 71, and the mucosa lower layer in front of the cylinder part 71 is incised and peeled off with the knife.

  After that, as in the fifth embodiment, the endoscope E is advanced toward the distal end side using the needle 63 as a guide while puncturing the incision of the mucous membrane with the needle 63 according to the incision. After all the lesion is excised, the lesion is grasped with grasping forceps or the like (not shown) and taken out endoscopically to complete the treatment.

  According to the lifting cap 70, the tongue piece 72B of the cylindrical portion 71 is pivotally supported by the cap main body 72A. Therefore, when the cylindrical portion 71 is inserted into the cut surface of the mucous membrane, the operating member is operated to advance and retract. Can be inserted while rotating. Therefore, it is not necessary to rely on the bending operation of the endoscope E, and the procedure can be performed in a state where the visual field of the endoscope E is fixed to the affected part.

(Seventh embodiment)
Next, a seventh embodiment will be described with reference to FIGS.
In addition, the same code | symbol is attached | subjected to the component similar to other embodiment mentioned above, and description is abbreviate | omitted.
The difference between the seventh embodiment and the first embodiment is that a capturing portion 81 of a lifting cap 80 according to this embodiment includes a tube member 82 and a suction source 83 communicated with the tube member 82. This is the point.

  The distal end side of the tube member 82 is disposed in the slit 2 provided on the side surface of the cylindrical portion 3. A normal line N of the distal end surface 82A of the tube member 82 is formed so as to be inclined and extend in a direction away from the central axis C of the cylindrical portion 3 toward the distal end side of the cylindrical portion 3.

Next, the operation of the lifting cap 80 according to the present embodiment will be described together with the ESD technique as in the first embodiment.
First, the endoscope E with the cylindrical portion 3 of the lifting cap 80 attached to the distal end is inserted to the vicinity of the lesion X as the target site, and the lesion X is raised.

  Subsequently, an initial incision is performed in the same manner as in the first embodiment, and the hole of the initial incision is further expanded to a predetermined size. In this way, another knife (not shown) is brought into contact with the cut formed in the mucous membrane M in the vicinity of the lesion X, and the submucosa S of the lesion X is incised and peeled off.

  At this time, the suction source 83 is driven and sucked while the cut end CU of the mucous membrane M is brought into contact with the distal end surface 82A of the tube member 82 by the bending operation of the endoscope E. By this suction force, the cut end CU of the mucous membrane M is gripped by the distal end surface 82A of the tube member 82. In this way, the mucous membrane M is positioned with respect to the cylinder part 3, and the mucosa lower layer S in front of the cylinder part 3 is incised and peeled off with the knife.

After the incision is made at a predetermined distance, the above operation is repeated, and the incision is advanced while sucking the cut CU of the mucous membrane M.
After all the lesioned part X has been excised, the lesioned part X is grasped with grasping forceps or the like (not shown) and taken out endoscopically to complete the treatment.

  According to the lifting cap 80, the mucous membrane M can be captured by the distal end surface 82 </ b> A of the tube member 82 by the suction force by sucking the tube member 82 with the suction source 83. In particular, since the normal line N of the distal end surface 82A of the tube member 82 extends toward the radially outward side of the cylindrical portion 3, the distal end surface is more than in the case where the normal line of the distal end surface 82A is parallel to the central axis C. The contact area between 82A and the mucous membrane M can be increased. Therefore, the mucous membrane M can be captured more reliably.

  As a modification of the present embodiment, the cap of the cylindrical portion is also formed in a cap body connected to the hood and a substantially semi-cylindrical shape, and is pivotally supported with respect to the cap body. It is good also as a lifting cap provided with the tongue piece. In this case, similarly to the sixth embodiment, the cylindrical body can be submerged while rotating the cap body, and the same treatment as that of the present embodiment can be performed.

(Eighth embodiment)
Next, an eighth embodiment will be described with reference to FIG.
In addition, the same code | symbol is attached | subjected to the component similar to other embodiment mentioned above, and description is abbreviate | omitted.
The difference between the eighth embodiment and the first embodiment is that the catching portion 91 of the lifting cap 90 according to this embodiment includes an uneven portion 92 provided on the surface of the cylindrical portion 3. It is.

  The uneven portion 92 is coated on the surface so that the coefficient of friction is higher than that of the other surface of the cylindrical portion 3. In addition, the surface roughness is not limited to the coating, but may be changed with respect to other parts. Further, a brush or the like may be provided to change the friction coefficient.

Next, the operation of the lifting cap 90 according to the present embodiment will be described together with the ESD technique as in the first embodiment.
The endoscope E with the cylindrical portion 3 of the lifting cap 90 attached to the distal end is inserted to the vicinity of the lesion, which is the target site, and an initial incision is performed as in the first embodiment, and the submucosal layer of the lesion is incised and peeled off. To go.

  At this time, while the cut end of the mucous membrane is brought into contact with the concavo-convex portion 92 of the cylindrical portion 3 by the bending operation of the endoscope E, the cylindrical portion 3 is brought into the cut end. Since the frictional force generated between the uneven portion 92 and the mucous membrane at this time is larger than the frictional force between the other surfaces, the cut end of the mucous membrane is locked to the uneven portion 92. In this way, the mucous membrane is positioned with respect to the tube part 3, and the mucosa lower layer in front of the tube part 3 is incised and peeled off with the knife.

After the incision is made at a predetermined distance, the above-described operation is repeated, and the incision is advanced while the cut end of the mucous membrane is captured by the frictional force between the uneven portion 92.
After all of the lesion is excised, the lesion is grasped with grasping forceps or the like (not shown) and taken out endoscopically to complete the treatment.

  According to the lifting cap 90, by bringing the mucous membrane into contact with the concavo-convex portion 92, it is possible to generate a larger frictional force than the other side surface of the cylindrical portion 3 without the concavo-convex portion 92. Can be gripped.

  As shown in FIG. 27, a cap main body 72A connected to the hood 6 and a cap 72 formed in a cylindrical shape and provided with a tongue piece 72B pivotally supported with respect to the cap main body 72A are provided. It is good also as the lifting cap 95 which has the cylinder part 3 distribute | arranged. In this case, similarly to the sixth embodiment, the cylindrical body 3 can be submerged while the cap main body 72A is rotated and the same treatment as that of the present embodiment can be performed.

As another modification, as shown in FIGS. 28 and 29, a lifting cap 97 including a cover portion 96 that covers the uneven portion 92 may be used.
The cover part 96 has the same curvature as that of the side surface of the cylindrical part 3, and is disposed at a position spaced radially outward from the uneven part 92 by a predetermined distance. The cover portion 96 is connected to an operation member 98 that is inserted into an external tube 62 whose tip is connected to the hood 6 so as to be freely advanced and retracted. Accordingly, by operating the operating member 98 forward and backward with respect to the external tube 62, the uneven portion 92 can be covered with the cover portion 96 or exposed from the cover portion 96.

The technical scope of the present invention is not limited to the above embodiment, and various modifications can be made without departing from the spirit of the present invention.
For example, as shown in FIGS. 30 and 31, a lifting cap 103 that directly expands a mucous membrane (not shown) by expanding the diameter of a balloon 102 provided on the cap 101 of the cylindrical portion 100 may be used.

Here, reference examples of other forms of the endoscope treatment tool used in the ESD procedure are shown below.
For example, as shown in FIG. 32, even a treatment instrument 108 including a sheath 105, a plurality of leg portions 106 arranged to protrude and retract on the sheath 105, and a knife portion 107 arranged to protrude and retract on the sheath 105. Good. The distal end side of each leg portion 106 of the treatment instrument 108 is formed by being curved and deformed in a direction gradually separating from the central axis C of the sheath 105. A claw 106A bent inward in the radial direction is provided at the tip of each leg portion 106.

The operation of the treatment instrument 108 will be described.
With the leg portion 106 and the knife portion 107 immersed in the sheath 105, the sheath 105 is inserted into one channel CH1 of the endoscope E having the two treatment instrument insertion channels CH1 and CH2. Then, the sheath 105 is projected from the tip of the channel CH1 of the endoscope E toward the hole H formed in the mucous membrane M, and each leg portion 106 is further projected from the sheath 105. At this time, since each leg portion 106 is curved, the distal end side expands in a direction away from the central axis C, and at the same time, comes into contact with the mucous membrane M to lift and hold it. Thus, the field of view of the endoscope E can be secured. In this state, the knife portion 107 is protruded, and another high-frequency knife (not shown) is protruded from the other channel CH2 as necessary to perform a predetermined procedure.

  Here, as shown in FIG. 33, instead of the leg portion 106, a treatment instrument 108 having a sheath 105 provided with a plurality of delivery ports 110A at the tip is inserted into the treatment instrument insertion channel CH1, and air is supplied from a delivery source (not shown). Or a fluid such as water may be ejected. In this case, the mucous membrane M can be pushed up by the pressure generated by the air or water ejected from the delivery port 110A.

  Further, as shown in FIGS. 34 and 35, after the entire mucous membrane M is incised, a binding tool 112 made of an annular elastic member such as rubber or a spring is hooked on the cut CU of the mucous membrane M to thereby remove the mucous membrane M. By tightening, the submucosal layer S may be easily viewed with an endoscope.

  In addition, as shown in FIG. 36, the binding tool 113 may be a curved leaf spring. In this case, the submucosal layer S may be easily viewed with an endoscope by engaging the mucous membrane M in the vicinity of the cut CU of the mucous membrane M with the end of the binding tool 113.

  In addition, as shown in FIG. 37, the snare 115 protrudes from the endoscope E, the snare wire 115A is engaged with the vicinity of the cut CU of the mucosa M, and the mucosa M is tightened, so that the submucosa S can be easily viewed with the endoscope. May be.

  Another reference example is shown in FIGS. In this reference example, as shown in FIG. 38, a pair of arm portions 120A and 120B formed by bending a single belt and a pair of arm portions 120A to close the pair of arm portions 120A and 120B. , 120B may be used with a clip 122 provided with a pipe part 121 fitted to a root part (not shown). As shown in FIG. 39, the pair of arms 120A and 120B are partially formed with a curved portion 120a that forms an insertion hole 122a through which a treatment instrument such as a grasping forceps can be inserted when closed. A claw portion 120b is provided at the tip.

The case where this clip 122 is used for a procedure will be described.
As shown in FIGS. 40 and 41, when the direction in which the endoscope E is inserted is the front side with respect to the mucous membrane M incised all around, for example, two different on the mucous membrane M not incised on the front side. The insertion hole 122a is arranged at a location so as to face the endoscope E. The grasping forceps 123 and 125 are inserted into the respective insertion holes 122a from the front side, and the mucous membrane M incised by the pair of forceps pieces 126A and 126B is grasped and lifted.

  Here, the grasping forceps 123 and 125 are inserted through the treatment instrument insertion channel of the endoscope E when an operation unit (not shown) is detached from the sheath 12, or when the operation unit is not detached, It is inserted into the treatment instrument insertion channel and inserted through the insertion hole 122a of the clip 122. The pair of forceps pieces 126A and 126B of the grasping forceps 123 and 125 are urged in an open state so that the grasping forceps 123 and 125 are not inserted carelessly after being inserted through the insertion hole 122a. Is preferred.

  Then, with the mucous membrane M lifted up, an incision tool such as a high-frequency knife 128 is projected from the endoscope E to incise the submucosal layer S. Any clip can be used as long as it can be placed on the mucous membrane M instead of the clip 122. At this time, the insertion hole 122a is not limited to the one in which the pair of arm portions 120A and 120B are curved, and may be one in which a wire or the like is formed in a loop shape.

  According to the clip 122, the grasping forceps 123 and 125 can be supported in the vicinity of the lesioned part, and the mucosa M can be turned up regardless of the movement of the endoscope E.

Further, another arrangement of the clips is shown in FIGS.
First, for example, the first clip 122A is arranged at a position P1 that is closest to the endoscope E on the incision side of the mucous membrane M that has been incised all around. Further, the second clip 122B is arranged at a position P2 on the mucous membrane M that is not dissected near the position that is the most distal side with respect to the endoscope E in the mucous membrane M on the incision side. Further, the third clip 122C is arranged at an arbitrary position P3 in the vicinity of the endoscope E. Then, the thread 130 having one end connected to the first clip 122A is passed through the insertion holes 122a of the second clip 122B and the third clip 122C, and the other end is fixed to the endoscope E. Alternatively, the thread 130 may be previously placed on the mucous membrane M and then sandwiched between the clips 122A, 122B, 122C.

  Here, as a means for fixing the thread 130 to the endoscope E, for example, a cap with an external tube (not shown) is attached, the clips 122A, 122B, and 122C are sequentially placed from the external tube, and the thread 130 is placed in the tube. In this state, the gripping forceps (not shown) may be held and fixed.

  Then, as the endoscope E moves forward toward the lesion X, the thread 130 is pulled and moved, and the mucous membrane M is turned up. In this way, an incision tool such as the high-frequency knife 128 is projected from the endoscope E to incise the submucosa S.

  According to the clips 122A, 122B, 122C and the thread 130, the endoscope E can be supported in the vicinity of the lesioned part X, and the mucous membrane M can be turned up in accordance with the forward / backward operation of the endoscope E.

  In addition, the cylindrical portion may be provided as a component of the endoscope as an endoscope distal end portion instead of as a lifting cap (endoscopic treatment tool).

1,20,30,42,45,50,57,60,70,80,90,95,97,103 Lifting cap (endoscopic treatment tool)
2,76 Slit 3,56,71,100 Tube portion 5,61,81,91 Capture portion 6,48 Hood (first position)
7, 53, 72, 101 Cap (second position)
8A, 8B, 126A, 126B Forceps piece (tip)
DESCRIPTION OF SYMBOLS 10 Operation wire 12, 46, 105, 127 Sheath 21, 31, 51, 73 Moving part 22 Support part 23 1st rotating shaft 25 2nd rotating shaft 26 Link member (connection part)
52,102 Balloon 62 External tube (tube member)
63 Needle 72 Cap 72A Cap body (Cylinder part body)
72B tongue piece 82 tube member 92 uneven portion 96 cover portion 106 leg portion

Claims (4)

A cylindrical portion that is formed in a cylindrical shape and is attached to the distal end of the endoscope;
A treatment instrument having a tip for holding a living tissue;
A sheath extending outside the endoscope along the central axis of the cylindrical portion, and through which the treatment instrument is inserted;
A moving unit that moves the distal end portion of the treatment instrument to bring the holding position of the living tissue into and out of contact with the tubular portion;
A short tube member that is provided on the distal end side of the moving part, and through which the treatment instrument is movably inserted so that the distal end part of the treatment instrument can move in the central axis direction with respect to the moving part;
With
The treatment instrument for an endoscope, wherein the moving part is connected to the cylindrical part, and the short pipe member is separated from a position along the cylindrical part in a normal direction of an outer peripheral surface of the cylindrical part. . The short tube member is provided at a tip support portion provided at a tip of the moving portion,
The said moving part has the 1st rotating shaft which pivotally supports the said moving part and the said cylinder part, and the 2nd rotating shaft which pivotally supports the said moving part and the said front-end | tip support part. The treatment tool for endoscopes described in 1.   The endoscopic treatment tool according to claim 1, wherein the moving unit turns with respect to the tube portion by an advance / retreat operation of the treatment tool with respect to the endoscope. The distal end portion of the treatment instrument is rotated by turning the moving portion to a position where the first rotating shaft and the second rotating shaft are arranged side by side in a direction orthogonal to the central axis of the endoscope. The endoscopic treatment tool according to claim 2 , wherein is farthest from the endoscope.

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