RU2180243C1 - Method for draining bile ducts and device to take out string from bile ducts - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves making cholangiography under radiological control, conducting string through endoscope canal in retrograde way through the major duodenal papilla into the bile ducts beyond the stenosis zone into the proximal segments of extrahepatic bile ducts. The stent is set using the string and the string is removed. The working end if the string is taken outside in transcutaneous and transhepatic way. The string is stretched holding both ends and then the stent is set. The device has hollow needle having piston telescopically mounted inside. The ends of the needle and piston are beveled. The needle tip has notch shaped as hook 2-3 mm distant from the end on one side. The other needle end has coupling member. The coupling member has mark coaxial with the notch. Piston end has flange fixably mounted on the coupling member. EFFECT: reduced risk of traumatic complications; accelerated patient recovery after surgical operation. 2 cl, 2 dwg

Description

 The invention relates to the field of medical equipment and can be used for drainage of intra- and extrahepatic bile ducts.

 A known method of percutaneous drainage of the proximal bile ducts, including puncture of the intrahepatic ducts, holding the string over the stenosis area, installing drainage in the stenosis area of the ducts using a special device containing a metal conductor and a screwdriver punch ("Annals of surgical hepatology": V.G. Ivshin Percutaneous transhepatic bile duct prosthetics: results of the use of instruments of own design. 1999, v. 4, No. 2, pp. 42-48).

 The disadvantage of this method is the complexity and invasiveness of bougienage and drainage, a decrease in the accuracy of the installation of drainage in the distal extrahepatic bile ducts (VLP).

 The closest is the method of drainage of the bile ducts ("Surgery" by MV Khrustalev. Endoscopic duodenobiliary drainage in the treatment of obstructive jaundice of blastomatous etiology ", N 5, 1998, pp. 85-87). With endoscopic drainage of intra- and extrahepatic bile ducts ducts (installation of a stent) carry out cholangiography and palillosphincterotomy under X-ray control, retrograde conduction of the string along the endoscope channel through the large duodenal nipple into the bile ducts beyond the stenosis zone to the proximal sections of the IDT. The pressure of the strings is carried out after the installation of stent traction on the free end executed by the surgeon.

 When using this method, there are the following disadvantages: the need to have a wide-channel endoscope, through whose channel a stent can be inserted into the stenosis area, great technical difficulties, and more often the inability to install the stent in the proximal sections of the VZHP due to the lack of string tension when the conductor string ceases to fulfill its the role and the deviation of the drainage in any direction occurs, technical difficulties with drainage in the conditions of an almost complete block of VZhP, because it is endoscopically difficult to walk around the stenosis region.

 The task is to eliminate these shortcomings by reducing the invasiveness of the operation, reducing the risk of complications, the ability to bougie and install a stent in any department of VZhP, i.e. expanding the functionality of the method.

 To do this, in a method for drainage of the bile ducts, including cholangiography and papillosphincterotomy under X-ray control, retrograde passage of the string through the endoscope channel through the large duodenal nipple into the bile ducts beyond the stenosis zone into the proximal sections of the ventricular arteries, it is proposed to extract the transcutaneous transcutaneous transverse end of the string.

 Known pneumatic extractor for extracting the intraosseous rod from the bone marrow canal (RF patent N 2018267, IPC A 61 B 17/92, publ. 1994), comprising a housing with a working chamber, a rod with a grip.

 However, such a constructive implementation of the capture cannot be applied in parenchymal organs.

 In the material "Surgery" by MV Khrustalev "Endoscopic duodenobiliary drainage in the treatment of obstructive jaundice of blastomatous etiology" N 5, 1998, p. 85-87 - the string is removed by traction for the free end. Moreover, at the moment of traction, the tension of the string in the bile ducts does not occur.

 The result of the application of the proposed design is the ability to transdermally remove the working end of the string from the VZhP out. Removing the working end of the string to the skin surface allows you to create the necessary string tension and the necessary "emphasis" to move the stent along the string to the stenosis area in any section of the IDL.

 A device for extracting strings from the bile ducts contains a hollow needle in which a piston is telescopically placed, their distal ends aligned and made with a bevel, while the needle is made with a hook-shaped cutout at a distance of 2-3 mm from the distal edge, and its proximal end equipped with a sleeve with a mark, coaxial cutout, while the proximal end of the piston is equipped with a flange mounted with the possibility of fixing on the sleeve.

 Removing the working end of the string to the outside allows you to create its tension, which, in turn, makes it possible to bougie and drain any section of the IDP, including both the proximal and distal sections. These manipulations were not previously performed due to the lack of an appropriate device.

 Figure 1 presents a General view of the device, figure 2 - capture of the string of the proposed device.

The device comprises a hollow needle 1, in which the piston 2 is telescopically placed, their distal ends are aligned and made with a bevel preferably of 30 ^° . The needle 1 is equipped with a curly cut in the form of a hook 3, located at a distance of 2-3 mm from the distal edge. This allows you to provide sufficient rigidity at the moment of traction while ensuring minimal liver injury. The hook grip is made corresponding to the diameter of the string 4. The proximal end of the needle is equipped with a sleeve 5 with a slot 6, and the proximal end of the piston has a flange 7 with a stop 8. Mark 9 is made coaxially to the notched cutout on the sleeve 5.

 The method using the proposed device is as follows.

 Performed endoscopic retrograde cholangiography, endoscopic papillotomy according to standard methods. Under X-ray control, through the endoscope channel, through the large duodenal papilla, retrograde, the string gradually moves into the proximal bile ducts, with its working end in the liver ducts.

 String 4 is endoscopically conducted beyond the zone of stenosis or structure and is located in the hepatic choledochus or lobar duct of the liver. Under local anesthesia (novocaine 0.25% - 20.0 ml) in the 8th intercostal space on the right, percutaneous transhepatic duct puncture is performed along the front axillary line, in which the working end of the string 4 is located. Needle 1 is brought to string 4, while the surgeon determine the position of the hook 3 by the mark 9. By means of the flange, the piston 2 is partially removed, opening the lumen of the hook 3. The string is caught by the hook 8, focusing on the flange 7 is fixed in the hook by the piston 2 and is pulled out. For two ends, the string is stretched inside the bile ducts. After this, the stent moves into the stenosis area under the radiological and endoscopic control by a pushing tube of the appropriate diameter. Then, along the working end of string 4, external drainage is installed percutaneously in the bile ducts to prevent complications and subsequent control. After that, the string and pusher are removed.

 Example.

 Patient Yu., Born in 1941, (medical history N 18693.1999).

 Diagnosis: hepatic choledoch tumor in the middle third, obstructive jaundice. Concerned severe skin itching, light feces, dark urine, yellowness of the skin. Sick about 3 months when these complaints appeared. A history of cholecystectomy (1985). Upon admission, a moderate condition, severe yellowness of the skin and mucous membranes, moderate phenomena of encephalopathy, hepatic-renal failure. In the analyzes: bilirubin-174/72 μmol / l, creatinine-100 μmol / l, ALT / AST-412/233, alkaline phosphatase-2055 u / l, GGTP-1661 u / l. The patient underwent ERCP, the formation of hepatic choledoch, exophytic growing in the lumen of the duct, sharp ectasia of the bile ducts over the block area was revealed. The patient attempted percutaneous transhepatic installation of external drainage. The attempt is ineffective, unsuccessful. 11.24.99 - according to our proposed technique, endoscopic cholangiography was performed, the string was drawn beyond the area of tumor stenosis, percutaneous transhepatic capture and extraction of the working end, strings was performed, and the stent was installed under X-ray and endoscopic control in the area of the extrahepatic bile duct block. Percutaneous drainage is established for the prevention of blood and bile ducts, as well as for subsequent x-ray control (cholangiography). In the postoperative period, regression of negative symptoms was noted: after 3 days, yellowness of the skin decreased, overall well-being improved, bilirubin 42/21 μmol / L, creatinine-87 μmol / L, ALT / AST-96/58, alkaline phosphate - 1197 units / L, GTPP-667 u / l: after 2 weeks, the patient is in satisfactory condition, there is no jaundice, the phenomena of liver failure are stopped, bilirubin-14/15 µmol / l, ALT / AST-86/58, alkaline phosphatase-418 u / l, GGTP- 230 units / l, was discharged under the supervision of a doctor at the clinic in the community.

 The advantages of the proposed method are: high efficiency, the ability to install a stent in any department of the bile ducts, the ability to install a stent with the ineffectiveness of other methods of decompression of the biliary tract, low invasiveness of the operation, reducing the number of postoperative complications, quick recovery of patients after surgery, shortening the length of hospital stay.

Claims (2)

 1. A method for draining the bile ducts, including cholangiography under X-ray control, retrograde passage of the string through the endoscope channel through the large duodenal nipple into the bile ducts beyond the stenosis zone into the proximal extrahepatic bile ducts, install a stent along the string, and then remove the string, characterized in that the working end of the string is transdermally-transhepatically removed, the string is pulled at two ends, and only then is the stent installed along the string.  2. A device for extracting strings from the bile ducts, characterized in that it contains a hollow needle in which the piston is telescopically placed, and on one side the ends of the needle and piston are aligned and beveled, while the end of the needle is made with a cut in the shape of a hook on 2-3 mm from the edge on the one hand, and on the other hand equipped with: the end face of the needle - a sleeve with a mark, a coaxial cutout, and the end face of the piston - a flange mounted with the possibility of fixing on the sleeve.

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