RU2195208C1 - Device for concrements mechanical extraction - Google Patents

Abstract

FIELD: surgery; applicable for mechanical extraction concrements from biliferous tracts after endoscopic papillosphincterotomy and in urology. SUBSTANCE: device has guide and S-shaped loop with metal threads fixed to its top and to sides. Threads converge in one point. Thread end connected to loop top and loop end have length corresponding to length of guide catheter. As a result, with low cost of device, reliable catching and extraction of concrements from bilifeous tracts are ensured, reduced number of complications and risk of their occurrence, provided control of device and possible freeing of it from concrement inside biliferous tract and subsequent attempt of stone catching after sufficient papillosphincterotomy. EFFECT: higher efficiency. 9 dwg

Description

 The invention relates to medicine, namely to surgery, and can be used for the mechanical removal of calculi from the biliary tract after endoscopic papillosphincterotomy.

 Domestic and foreign data over recent years indicate a steady increase in the number of patients with gallstone disease. The growth of surgical operations with this pathology, in turn, causes an increase in the number of patients with postcholecystectomy syndrome, mainly due to choledocholithiasis. The extraction of calculi from the biliary tract is often carried out at the height of obstructive jaundice, cholangitis, acute pancreatitis, which cause a fairly large number of complications, high mortality. Considering the advantages (speed of implementation and obtaining a positive effect, relatively easy tolerance to patient manipulation), endoscopic operations for calculus calculus using the papilla papilla after a previously performed papillosphincterotomy are very popular. Under the control of the duodenoscope and x-ray control, the manipulation of the extraction of calculi from the bile ducts is carried out by technological methods (washing, suction) and constructive devices: spoons, balloon catheters, baskets, forceps.

 Famous Fogarty probe [Vinogradov V.V., Winter P.I., Kochnashvili V.I. Bile duct obstruction. - M., 1977]. It is an elastic cuff that is inserted into the bile duct for calculus and inflated by pumping air from a syringe through an elastic tube. Then traction of the cuff is carried out in the direction of the Vater papilla, in the expectation that it will entrain the calculus.

 Disadvantages: the cuff breaks easily, often does not capture the calculus, i.e. it is an unreliable design for removing stones from the bile ducts. Its effectiveness, as noted by surgeons, is mainly only 15-16%. The Fogarty probe is generally intended for single use only. Additional difficulties and complications arise in such a situation, when the stone wedges during traction into the bile duct or into the hole in the papilla.

 Known mechanical extraction of calculi from the biliary tract with a basket of Dormia, adopted by us for the prototype [Baguslav Niederle et al. Surgery of the biliary tract. - Prague: Avicenum. - 1982. - S. 213]. The Dormia basket is a semi-elastic catheter with a row of thin cables attached to its distal end. When introduced into the bile duct, the cables should be inserted behind the calculus, and with reverse traction, grab it between the cables and remove the papilla through the vectors.

 Disadvantages: the design does not provide reliable grip of calculus. Extraction is fraught with "loss" of calculus in the duct during traction. When infringing the calculus Dormia trapped in the basket, in an insufficiently dissected papilla, the problem arises of emptying the basket and removing it, which requires emergency surgery. Such emergency operations, according to some authors, entail serious complications, and mortality reaches 4-8%.

 It is also known to use a lithotripter, which is an enhanced Dormia basket. It consists of a soft plastic and hard metal spiral shell, in which there is a basket for gripping the stone, which serves to transfer crushing forces to the stone and the handle, which develops the crushing force. There are baskets of different diameters and lengths [Endoscopic abdominal surgery // Ed. Balalykina A.S. - M .: IMA-press. - 1996. - S. 38] and additional cables. The cables are soldered with a traction string fixed on the handle or twisted into a cable. Such lithotrips are produced by a number of foreign firms. Variants of their manufacture are distinguished by rigidity and the principle ("winch" or "nut") of transferring forces to the cables by rotation of the handle.

 The lithotripter is used as follows. After endoscopic retrograde pancreatocholangiography and papillosphincterotomy, the basket is inserted into the bile duct through the endoscope channel and the calculus is taken into it. The stone is pulled into the basket, which then fits it and is pulled to the endoscope. The soft plastic shell of the basket is replaced with a metal one, stones are crushed and fragments are extracted. Then control the results of the extraction, performing cholangiography. With a plurality of stones, the manipulations are repeated.

 Disadvantages: the complexity of the design, the risk of trauma, the unreliability of the capture of calculus, the single use of the lithotripter. In addition, the real threat of a stone wedging in an unsuccessful attempt at lithotripsy. Often it is not possible to hold the basket behind the stone and grab it well (the basket slides from the calculus when closing).

TASKS:
- ensuring the reliability of the capture and extraction of calculi from the biliary tract;
- reducing the number of complications and the risk of their occurrence;
- ensuring the controllability of the device: the possibility of releasing it from the calculus inside the bile duct and subsequent repeated attempts to capture the stone after sufficient papillosphincterotomy;
- ensuring low cost of the device.

 The device for the mechanical extraction of calculi has a conductor and a loop pushed out of the conductor, to the top of which flexible threads converging at one point are fixed. Unlike the closest analogue, the device has a loop made S-shaped bent, and the flexible threads converging at one point are made of metal and are fixed to the sides of the loop, while the end of the thread connected to the top of the loop and the end of the loop have a length commensurate with the length conductor.

 The device has been tested in clinical conditions for 16 patients. Moreover, in all patients, calculi from the bile duct were successfully removed without any complications.

 The device is schematically shown in figure 1, where 1 is a rigid S-shaped loop, 2 is a flexible metal thread, 3 is a conductor. In Fig.2-5, the device is shown in action, where 4 is a duodenoscope, 5 is a papilla veterus, 6 is a calculus, 7 is a bile duct (choledochus).

 The device is used as follows.

 Prior to endoscopic manipulation, the patient is preliminarily prepared using known drug methods. For the operation, duodenoscopes (jE-B2, jF-B3, etc.) are used, an X-ray television installation is used to control it. After the introduction of the duodenoscope 4, the papilla 5 is dissected with a papillotome and the device is inserted through the duodenoscope 3 through the duodenoscope 3 into the bile duct 7. In this case, the flexible metal threads 2 are located in the conductor 3 along a rigid S-shaped loop 1 (the device is “folded”). Under x-ray control it is carried out for a calculus (Fig. 2), open the basket by pushing the ends of the loop and threads from the conductor (Fig.3). Carrying out traction for the conductor 3, ensure the capture of stone 6 with a rigid S-shaped loop in the choledochus 7 and grasping it with threads 2 (Fig. 4), the basket is pulled to the distal end of the conductor 3 and traction of the conductor with a calculus from the common bile duct 7 (Fig. 5) .

 If the stone with the basket wedged into the papilla of the papilla (Fig.6), the proposed device allows you to free the basket from the stone by the return movement of the loop along the conductor to the choledochus (Fig.7), followed by return traction for the end of the elastic thread. When this thread is pulled, a rigid loop is straightened and the calculus is released (pushed) (Fig). The basket in a straightened form is drawn into the conductor by traction at the ends of the elastic thread 2 and the rigid loop 1 (Fig. 9). The device is being removed.

 To ensure the removal of the stone in this case, two options are possible: a) repeated papillosphincterotomy with the aim of expanding the opening in the Vater papilla and repeating the manipulation of calculus extraction from the common bile duct by the method described above; b) an open method of treatment (in case of failure). However, we never had to resort to the second option.

 The proposed device allows you to expand the capabilities of the endoscopic method for the treatment of choledocholithiasis. Despite the simplicity of the design, the device has established itself as a reliable, low-cost, minimally invasive tool for mechanical removal of calculi, which avoids the "unpleasant" situation of wedging of the calculus together with the basket in the Vater papilla with subsequent open surgery, which entails a number of sometimes insoluble technical problems. The device can also be used in urology for the mechanical extraction of calculi from the ureters.

 The device is recommended for widespread use in practical surgery.

Claims (1)

 A device for the mechanical extraction of calculi, having a conductor and a loop pushed out of the conductor, to the apex of which flexible threads converging at one point are fixed, characterized in that the loop is S-shaped, the flexible threads converging at one point are made of metal and fixed to the sides of the loop while the end of the thread connected to the top of the loop, and the end of the loop have a length commensurate with the length of the conductor.

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