RU2353323C2 - Atypical endoscopic papillotomy technique - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, to operative intraluminal endoscopy, and can be used for endoscopic papillotomy in case of technical difficulties associated with standard and/or atypical techniques; for approach to common bile duct (CBD) in diagnostic and operative transpapillary interventions. Atypical endoscopic papillotomy involves X-papillotomy ensured by lengthwise dissection of bile papilla (BP) roof with approach to submucous layers. Thereafter deeper tissues are transversely incised thus opening CBD lumen within the region limited from below with BP orifice and from above with half-distance of BP orifice and the first transverse fold of duodenum.

EFFECT: more success search and rupture of terminal CBD in technically difficult cases associated with changed BP for curing acute and chronic terminal CBD obstructions in benign and malignant diseases; thus minimising the risk of duodenum wall perforation and BP sphincter injures; one-stage intervention; diagnostic cholangiography without terminal CBD dilatation in tubular ductal systems.

13 dwg, 2 ex, 1 tbl

Description

The technical field to which the invention relates. The invention relates to medicine, in particular to operative intraluminal endoscopy. The invention can be used when performing endoscopic papillotomy in case of technical difficulties in the application of both standard and other atypical techniques.

The prior art. A traditional method of endoscopic papillotomy (EPT) is known, consisting in the fact that through the instrument channel of the endoscope with a lateral arrangement of the optical system, a standard papillotome is inserted with a lateral arrangement of a current-carrying electrode-string, a standard papillotome cannulation of the large papilla of the duodenum (BSD) is performed, and current is dissected. papillary part of the terminal section of the common bile duct (OP) with a string electrode (Balalykin AS Endoscopic papillotomy // in the book: Guidelines for clinical endoscopy. Editor-compiler A.S. Balalykin. - M .: Medicine, 1985. - S.290-314).

However, EPT in the traditional way cannot be carried out, according to the literature, in 5-28% of cases, which makes it necessary to resort to EPT operations in atypical ways in order to improve treatment results (Balalykin V.D. Atypical methods of endoscopic papillotomy surgery: Diss ... cand. Honey sciences. - M., 1988. - 92 pp .; Nazarenko P.M., Kanishchev Yu.V., Nazarenko D.P. Surgical and endoscopic methods of treating diseases of the large duodenal papilla of the duodenum and their clinical and anatomical justification. Kursk: "Kursk city Tipo graphia, 2005. - 143 pp .: ill. 21; Dowsett JF, Polydorou AA, Vaira D. et al. Needle knife papillotomy: how safe and how effective // Gut. - 1990. - No. 31. - P.905 -908 .; Masci E., Toti G., Mariani A. et al. Complications of diagnostic and therapeutic ERCP: a prospective multicenter study // Am. J. Gastroenterol. - 2001. - No. 96. - P.417-423 ; Rabenstein T., Schneider H.T., Bulling D. et al. Analysis of the risk factors associated with endoscopic sphincterotomy techniques: preliminary results of a prospective study, with emphasis on the reduced risk of acute pancreatitis with low-dose anticoagulation treatment // Endoscopy. - 2000. - Vol.32. - No. 1. - P.10-19).

A similar method is known for the so-called “layer-by-layer” endoscopic papillotomy (patent No. 2004132111 with priority dated November 3, 2004), in which access to the duct structures of the BJC is carried out by layer-by-layer dissection of the “roof”. A disadvantage of the analogue is the unavoidable difficulties of using the method both in the tubular structure of duct systems and in the presence of tumor-like processes in the mouth and common channel of the BJC. In addition, the technical features of the method do not allow it to be used for incomplete relaxation of peristalsis of the duodenum (duodenum).

The prototype selected a known method of atypical EPT, called pre-dissection. When performing papillotomy in an atypical way of pre-dissection, a modified papillotome with a direct electrode-string emerging from the braid is used. The needle electrode is removed from the distal end of the catheter by 2-3 mm, is installed at the upper edge of the mouth of the BSDC and when the electric current is turned on, it goes up. A series of layered sections after opening the "roof" of the ampoule provides access to the lumen of the OP (Balalykin A.S., Tashkinov N.V., Balalykin V.D., Shukshina I.V. Atypical methods of endoscopic papillosphincterotomy // Surgery. - 1984. - No. 7. - S.30-35).

The main disadvantages of the prototype (pre-dissection with an end papillotome) are associated with the complexity and danger when carrying out atypical EPT methods using a papillotome with an end electrode and consists in the fact that after a series of incisions, as a rule, the BSDK loses its shape due to the dissection of the connective tissue and muscle corset, which is dangerous due to the loss of orientation and the initially chosen safe direction of the section, and, as a result, leads to failures and complications. In addition, with the tubular structure of the ductal systems, as well as with stenosis proximal to the intraduodenal segment of the OP, the lumen of the intraduodenal and papillary segments of the OP is not expanded and, in the depth of the longitudinal section, the papilla of the OP can be visualized as a red-pink band no wider than 2-3 mm. With an elongated shape and an increase in the diameter of the papilla, the abundance of connective and muscle tissue creates additional difficulties in identifying tubular structures. So, the combination of the above factors - the presence of undissociated longitudinal connective tissue fibers, the narrowness of the terminal section of the OP and the presence of a burn scab covering the incision surface of the papilla that has already lost its original shape - makes it difficult to identify the OP, and cutting it along it is extremely difficult.

Disclosure of the invention. The objective of the invention is to increase the success of the search and opening of the terminal section of the common bile duct using the endoscopic method in technically difficult cases: with an altered BSDK for the treatment of acute and chronic obstruction of the terminal section of the pancreas with benign and malignant diseases. The solution to this problem is to change the direction of the incision: after performing a longitudinal section of the BSDK with a needle papillotome and access to the submucosal layers with the same tool, we make a transverse section. Cross sections of tubular structures are carried out proximal to the mouth closer to the base of the BSDK. The cuts are made in the area bounded below by the mouth of the BSDC and above Ѕ the distance from the mouth of the BSDC to the first transverse fold (marginal fold) of the duodenum (see Appendix, figure 1). The depth of the cross section is regulated by the length of the working part of the needle-shaped electrode and should not exceed the diameter of the visible tubular structure (3-4 mm). We use the electric knife in the “cut” mode with a current power in the range of 40-50 W.

There are no absolute contraindications for pre-dissection with the cruciform type of incision, in our opinion.

Performing an EPT with a cruciform type of incision has the following advantages:

1) the method allows diagnostic cholangiography in cases where there is no expansion of the terminal section of the LC and in the tubular structure of duct systems;

2) the method contributes to the completion of EPT in one step with a minimal risk of perforation of the wall of the duodenum;

3) the method allows for the implementation of EPT in cases technically difficult both for the standard cannulation method and for atypical EPT methods;

4) the use of the method allows delicately open the "roof" of the BSDK with minimal damage to the sphincter apparatus.

A brief description of the drawings.

The drawings (Figs. 1-5) show the stages of endoscopic papillotomy with the proposed new atypical method - a cross-shaped incision (arrows indicate the direction of movement of the papillotomy, hatching shows dissected tissues, drawings in circles show an increase for clarity). A longitudinal section can be carried out both “from top to bottom” (FIG. 1) and “from bottom to top” (FIG. 2), however, access to the lumen of the OSJ is not possible (FIG. 3); a transverse incision (Fig. 4) leads to the success of an atypical EPT - access to the lumen of the body cavity (Fig. 5).

On endoscopic photographs (Fig.6-12) the stages of the operation of endoscopic papillotomy by the proposed new atypical method - a cruciate incision are clearly presented.

6 - inspection of the operating area: BSDK flattened.

Fig.7 - deep cannulation and receiving cholangiogram fails.

Fig - papillotome installed above the mouth of the BSDC, the electrode is removed from the braid.

Fig.9 - is a longitudinal section of the BSDC.

Figure 10 - after deepening the longitudinal section, access was made to the submucosal layers, however, access to the common bile duct fails. A transverse section is made from left to right.

11 is an additional transverse section of the tubular structure in the depth of the wound.

Fig - after a cross-sectional cannulation of a crossed tubular structure (narrow choledochus) is successful, as confirmed by Fig. 13.

Fig - cholangiopancreatorenentogram, which clearly shows one of the reasons for the technical difficulties of the primary contrasting of OPL - narrowing and inhomogeneity of the terminal department (shown by a black arrow).

Information confirming the possibility of carrying out the invention.

The following clinical cases serve as an example of using the cruciform papillotomy method in the failure of other, including atypical, methods.

Example No. 1. Patient Alfa-va (woman 62 years old, case history No. 15254-04) was admitted to the surgical clinic with complaints of frequent pain in the right hypochondrium and nausea, which returned several months after laparoscopic cholecystectomy due to the painful form of chronic calculous cholecystitis. With ultrasound and magnetic resonance imaging, the OP is moderately expanded, and stone cannot be excluded in the terminal section of the OP. This was an indication for direct contrasting of the bile ducts. Hemispherical BSDK; attempts at typical cannulation, including using conductors, are unsuccessful - the adenoma of the mouth interferes. When performing an atypical EPT for diagnostic purposes at the BDSC, swelling after multiple unsuccessful cannulation attempts, access is not possible through a longitudinal incision, narrow longitudinal cords are visible in the depth of the incision. The transition to a cruciate type of incision was made and the tubular structures were crossed by a transverse incision; one of them turned out to be a common bile duct. There was no bleeding during the incision. Cholangiography was performed, moderate expansion of a homogeneous open joint was confirmed, instrumental revision of the open joint with a Dormia basket - gall "putty". The patient noted the disappearance of pain the next day. During the control ultrasound, aerobilia, as a sign of insufficiency of sphincters of BSS, was not detected. There were no complications during the operation and in the postoperative period. Recovery.

Example No. 2. Patient Naz-va (46-year-old woman, medical history No. 5665-06) received complaints of severe intensity and spastic pain in the right hypochondrium, nausea, yellowing of the skin, darkening of the urine and lightening of feces. Indications for endoscopy: gallstone disease, exacerbation of chronic calculous cholecystitis complicated by the presence, according to ultrasound, of stones in the common bile duct. Bilirubinemia upon receipt of more than 40 μmol / L. With gastroduodenoscopy: there is no pathology in the esophagus and stomach, the duodenum is inadequately relaxed - fairly frequent peristaltic movements. In the descending section of the duodenum, there is a deep funnel-shaped diverticulum 1.5 × 1.0 cm in size with food debris. Near the left edge of the mouth of the diverticulum is BSDK: a small diameter up to 0.4-0.5 cm, flattened shape, covered by a circular fold. The mouth of the papilla is scalloped, hyperemic, at 12 o'clock at the mouth there is an adenoma of 2-3 mm in diameter, which proliferates into the lumen of the duodenum. Repeated cannulation of the BSSC mouth and attempts to introduce contrast have been undertaken, but only the terminal section of the main pancreatic duct expanded to 3-4 mm can be contrasted, contrast aspiration is carried out. An atypical EPT was made with a needle papillotome in the direction from the mouth upward with notching of the circular fold, the wound surface is the entire roof. However, among the coagulation tissue, the mouth of the common bile duct cannot be found. While searching for it “blindly”, a small submucosal depot of contrast was created (up to 10 × 15 mm) in the 12-1 hour sector. It was decided to perform a cross-shaped papillotomy: the direction of the incision was changed to transverse, and the longitudinal tubular structure was intersected with a needle papillotome. During cannulation in the incision zone and the introduction of contrast, a cholangiopancreatogram was obtained, which shows that the terminal sections of both duct systems are narrowed and envelope the diverticulum. In the common bile duct, a floating stone of irregular shape with a diameter of up to 0.5-0.6 cm was revealed. The section was expanded in a typical way. A basket of Dormia stone is captured and removed into the intestinal lumen. A quick discharge of contrast from the ducts into the intestinal lumen confirms that a good passage of bile in the duodenum has been restored. Postoperative complications were not observed, the patient recovered.

In total, we performed 11 operations with effective access to the lumen of the common bile duct in 91.6% of cases. Information about patients is shown in table 1.

Practice has shown that the described method of atypical endoscopic papillotomy is preferable in difficult cases and is currently used by us in the surgical clinic of Federal State Institution “3rd Central Military Clinical Hospital named after A.A. Vishnevsky "(Moscow region. Krasnogorsk district, post / town Arkhangelsk).

Despite the relatively frequent conduct of EPT by atypical methods, an effective and fairly safe atypical method has not yet been described. This led to the fact that patients underwent either highly traumatic surgeries or endoscopic surgeries that did not lead to a single-stage and effective access to the lumen of the OP.

For the first time, we tested the possibility of simultaneous and effective endoscopic access into the lumen of an OPJ for other transcapillary operations, even in technically difficult cases.

The solution was found in the process of long practical work and was the result of a collective scientific and creative process. The technique was developed in the process of implementation, and it can be successfully used by specialists performing surgical endoscopic interventions on the large duodenal papilla.

In our clinic, cruciform endoscopic papillotomy has become the method of choice in case of failure of the EPT operation in other ways.

Table 1 No. Surname, gender Age (years) No. Case History Diagnosis ChPO complex Complications / outcome one P-on women 66 8273-01 Adenoma of BSDC complicated by obstructive jaundice EPT no complications / recovery 2 Chus-n, husband. 57 13327-01 Acute calculous cholecystitis, choledocholithiasis, obstructive jaundice EPT operation unsuccessful / patient operated on by laparotomy 3 See wives 76 1058-01 Chronic calculous cholecystitis in the acute phase, choledocholithiasis, obstructive jaundice EPT, IEC, MLT, NBD bleeding during surgery / recovery four Alf-va, female 62 15254-04 PCES after cholecystectomy in 2002, microcholecholithiasis, adenoma of BSDC, obstructive jaundice EPT, IEC no complications / recovery 5 And-va, wives 80 11578-04 Adenoma BSDK, obstructive jaundice EPT, ES, NBD no complications / recovery 6 Shire-in, husband. 56 11606-04 Pancreatic necrosis complicated by internal abdomino-thoracic fistula, adenomatosis of BSDK EPT no complications / recovery 7 Wen-ko, husband. fifty 11716-05 Chronic calculous cholecystitis, choledocholithiasis, adenomatosis BSDK, obstructive jaundice EPT, IEC no complications / recovery 8 Woof, wives 77 21884-05 Chronic calculous cholecystitis in the phase of subsiding exacerbation, choledocholithiasis EPT, IEC, MLT, NBD no complications / recovery 9 Tug-va, wives. 71 20013-05 Chronic calculous cholecystitis in the acute phase, choledocholithiasis, obstructive jaundice EPT, IEC, MLT no complications / recovery 10 Con-in, husband. 70 5834-05 Chronic calculous cholecystitis in remission, choledocholithiasis EPT, IEC no complications / recovery eleven Naz-wives 46 5665-06 Chronic calculous cholecystitis, choledocholithiasis, adenomatosis BSDK EPT, IEC no complications / recovery Abbreviations used in the table:
BSDK - large duodenal papilla,
MLT - mechanical lithotripsy,
IEC - mechanical extraction of stones,
NBD - nasobiliary drainage,
EPT - endoscopic papillotomy.

Claims (1)

A method of atypical endoscopic papillotomy, characterized in that a cruciform papillotomy is performed, for which a “duodenal papilla” roof is longitudinally dissected with access to the submucosal layers, then a transverse incision of the underlying tissues is performed, revealing the lumen of the common bile duct, while the incisions are made in the area bounded below the mouth of the large duodenal papilla and above half the distance from the mouth of the large duodenal papilla to the first transverse fold of the duodenum.

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