RU2354417C1 - Method of installation of duodenal decompressive feeding probe - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, in particular to surgery, and can be used in treatment of surgical diseases for decompression of upper part of digestive tract and carrying out enteral probe feeding. Fibrogastroscopy is carried out with parallel passing of duodenal probe to low horizontal part of duodenum. Guiding fishing line is passed through nasal meatus and taken out through mouth cavity. Further guiding fishing line is passed through biopsy canal of endoscope from distal end and taken out from proximal end of endoscope. Then endoscope is passed to low horizontal part of duodenum with guiding fishing line. Biopsy forceps are passed through duodenal probe. Guiding fishing line going out from nasal meatus is caught with biopsy forceps. Biopsy forceps with seized guiding fishing line are brought into duodenal probe opening. With translational movements through nasal meatus parallel to endoscope duodenal probe is introduced into digestive tract to low horizontal part of duodenum. Simultaneously, with reverse movements other end of guiding fishing line passed through biopsy canal of fibrogastroscope is taken out. Biopsy forceps are taken out of duodenal probe opening. Guiding fishing line is released. Fishing line is removed through biopsy canal of endoscope. Mucosa of low horizontal part of duodenum is gripped with biopsy forceps to prevent probe displacement. Endoscope is removed under vision control. Biopsy forceps are detached from duodenum mucosa and are removed from duodenal probe opening with reverse-translational movements.

EFFECT: method allows to pass probes, including ones with diametre 14-15 mm, to low horizontal part of duodenum under control of endoscope vision, excluding displacement of probe out of duodenum due to reliable fixation of probe during endoscope removal.

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Description

The invention relates to medical equipment, in particular to surgery, and in particular to instruments used in the treatment of surgical diseases for decompression of the upper digestive tract and conducting enteral tube feeding.

It is known to hold a probe into the small intestine during surgery for decompression of the gastrointestinal tract and enteral nutrition and is widely used in emergency surgery. Probing of the small intestine is necessary primarily for aspiration of the contents of the gastrointestinal tract, study of the state of digestion and absorption function of the small intestine in order to establish indications for enteral trans-probe nutrition or only decompression, as well as the choice of media for its implementation.

Nasogastric intubation is used in cases where it is necessary to leave the probe for a long time for continuous evacuation of contents from the upper digestive tract and conducting enteral tube feeding in case of obstruction of the upper digestive tract caused by blastomatous lesions of the esophagus, stomach or duodenum, with decompensated pyloric pyloric mechanical or functional obstruction of the esophageal, gastrointestinal, and gastrointestinal tract echnyh anastomoses, when inconsistency superimposed digestivnyh anastomosis at high external or internal fistula gastrointestinal tract obstructive and adhesive intestinal obstruction without signs of peritonitis; dynamic intestinal obstruction, which cannot be eliminated by conventional conservative measures (decompression of the stomach, perinephric blockade, correction of electrolyte disturbances, medicamentous stimulation of intestinal motility, etc.) and some other pathological conditions. (Pantsyrev Yu.M., Galinger Yu.I. Operative endoscopy of the gastrointestinal tract. - M., 1984 - Page 154) - [1]. In some cases, it is only this way that it is possible to effectively and safely compensate for the loss of energy-plastic substances and electrolytes, and to correct metabolic processes (Tsatsanidi K.N., Pugaev A.V. et al. Endoscopic installation of the ejunal probe and the technique for carrying out special mixtures. Surgery Herald, 1987 , No. 7, S.61) - [2]. The probes are carried out behind the pyloric pulp using an endoscope through the instrument channel of the fibroendoscope, since the installation of the probe distal to the pyloric pulp increases the efficiency of decompression of the upper digestive tract. The methods for endoscopic installation of the nasoenteric probe are different and depend on the diameter of the probe being carried out, its length and design features.

Authors Smolsky B.G., Kanshin N.N. et al. used a multichannel probe made of soft material (organosilicon rubber) having perfusion and aspiration channels, labels for measuring the length of the wound section, and olive at the distal end of the aspiration channel. The probe makes it possible to sequentially examine the digestive and absorption functions of the small intestine and establish indications for decompression or enteral tube feeding (Surgery, 1980, No. 10, p. 91) - [3].

Other authors have proposed the use of flexible elastic catheters with an outer diameter of up to 3.5 mm, which allows them to be carried out through the biopsy channel of the endoscope and installed under the control of optics. For this, long (250 cm) catheters with an elastic metal mandrin or shorter (100-120 cm) catheters with a pusher mandrin are used. Elastic catheters can also be performed without mandrin. After x-ray control, the probe is removed through the nasal passage and fixed with fixatives (Alexandrova M.I., Semenchenya V.A. Endoscopic probe for enteral nutrition of patients after operations on the stomach with a complicated course of the postoperative period. - (Book: Pathogenesis, clinic and treatment of diseases gastrointestinal tract and liver. Saratov, 1983, T. 109, p. 42-44) - [4]. However, in some cases, install a nasoenteric probe for enteral tube feeding and decompression of the upper digestive tract using these methods bami succeeds not always due to persistent functional impairment of motility of the upper digestive tract.

Mathus-Vligeon E.M.H., Tytgat G.N.J. and co-authors, if it is impossible to hold the endoscope to the desired level due to cicatricial, tumor or other nature of narrowing of the intestinal lumen, a soft plastic catheter along the string is used to install a nasoenteric probe. To do this, a flexible steel conductor is preliminarily drawn through the endoscope channel into the intestine below the stenotic area, and after removing the optical device and X-ray examination of the position of the conductor, a catheter is inserted through it for feeding, and the conductor itself is carefully removed. (Mathus-Vligeon E.M.H., Tytgat G.N.J. The role of endoscopy in the correct and rapid positioning of feeding tubes. - Endoscopy, 1983, vol. 15, No. 1 p. 78-84.) - [5].

A variant of this approach is the use of two soft plastic catheters, both equal to the length of the endoscope, having a common metal conductor, proposed by domestic authors. In this case, one of the catheters serves to push the other through the instrument channel of the endoscope (Savelyev BC, Isakov Yu.F., Lopatkin N.A. et al. Guidelines for clinical endoscopy. - M., 1985 - S.345-346) - [ 6]. It is preferable to use the method of domestic authors, because firstly, soft plastic catheters do not cause discomfort in patients, do not injure the mucous membrane of the digestive tract, do not cause pressure sores and pass well along the bends of the duodenum or small intestine, and secondly, they have a larger internal diameter compared to a hard catheter, which allows carry out a more complete perfusion with nutritious mixtures and decompression of the upper digestive tract. However, the passage of a soft plastic catheter through the pyloric pulp causes rapid deformation (bending), displacement of the probe when removing the endoscope, which does not allow for adequate decompression of the digestive tract.

When using probes with a larger diameter (over 3.5 mm) and limiting their length, the method of parallel conducting the probe with an endoscope is used. R.Chung and coauthors for conducting a nutritional probe with a larger diameter than the biopsy channel of the endoscope created an additional channel by fixing a tube of the required diameter to the endoscope. After this tube is installed, the probe is inserted after the endoscope to the required level in the intestine, and the probe is advanced using biopsy forceps, capturing the ligatures, strengthened along the length of the probe - [2, p. 62]. But with this method, when the endoscope is removed from the digestive tract, the duodenal probe changes its position, bends and does not function, or extends beyond the duodenum through the pyloric pulp and loses its functional significance. In addition, the additional channel of the endoscope increases its diameter and makes it difficult to conduct the probe through the pyloric pulp.

It is known for endoscopic use of a decompression probe equipped with a series of loops for gripping with biopsy forceps, which is inserted through the nasal passage into the stomach, then an endoscope is carried out and, grabbing the probe by loop with biopsy forceps, a probe is inserted into the intestine simultaneously with the endoscope (O. Efimov, Kuvshinov Yu.P. et al. Conducting a probe for enteral nutrition in patients in the postoperative period under the control of an endoscope. P. 98) - [7].

The endoscopic conduct of a decompression probe into the small intestine according to the methods described above is technically challenging - it is not possible to carry out a probe into the intestine to the desired level either due to anatomical features or due to deformation of the duodenum.

Known endoscopic method of intubation of the small intestine with a decompression probe along a metal guide, which is as follows. The endoscopic endoscope under control of vision is carried out as deep as possible into the duodenum or small intestine. Then, through the instrument channel of the endoscope, a long, rather rigid metal spiral probe conductor with a diameter of 2 mm is introduced into the lumen of the small intestine. The endoscope is removed, the decompression probe is strung on a metal conductor and inserted through it into the small intestine - [1, p.167]. However, it is not always possible to bring the probe into the intestine to the lower horizontal part of the duodenum due to the lack of control of the field of view of the endoscope.

The closest way to the proposed taken as a prototype is a method of conducting a decompression probe with a length of up to 2.5-3 m and an outer diameter of not more than 7-8 mm under the control of an endoscope. Why it is advisable to use lateral perforations located at least 30-40 cm in the distal part of the probe, which improves subsequent aspiration of intestinal contents through it. In the region of the distal end, the probe is flashed with 5-6 silk ligatures (No. 6-8), which are located at a distance of 4-5 cm from each other. To give the probe greater rigidity, a metal conductor is introduced into its lumen. A decompression probe well lubricated with liquid paraffin and a metal conductor introduced into its lumen is passed through the nasal passage or mouth into the stomach. Then, in parallel with the probe, an endoscope is advanced into the stomach cavity. After detecting the distal end of the probe with biopsy forceps, they capture the first ligature, pulling the probe against it, push it to the endoscope and in this position, the endoscope and the probe are carefully carried through the pylorus into the duodenum. Then the probe is further advanced from the outside into the stomach so that it is not in a tense position, but is located along a large curvature. Only after this, the biopsy forceps are removed from the ligature and the endoscope is slowly returned to the stomach. To prevent the probe from slipping into the stomach, it must be fixed at the edge of the teeth or nasal passage and the endoscope should be removed with small forceps for the next ligature. The described manipulation is repeated until the decompression probe reaches the lower horizontal section of the duodenum or passes into the small intestine beyond the ligament of the treitz, which is undoubtedly preferable. In cases of pyloric stenosis or gastroenteroanastomosis, when the endoscope together with the probe cannot be inserted into the duodenum or small intestine, the procedure is performed as follows. By means of biopsy forceps, the decompression probe is captured by the first ligature and, under visual control, is advanced through the pylorus or gastroenteroanastomosis to a depth of 6-8 cm. Then, the forceps are returned to the stomach or stump and the procedure is repeated using the following silk ligature fixed on the probe. The use of ligatures or ribbons fixed to the probe is optional. The probe can be grabbed with biopsy forceps at the lateral openings and thus advanced into the duodenum or small intestine. Along with biopsy forceps, other instruments can be used for performing endoscopic surgery: crocodile forceps, rat teeth, etc. - [1, p.166].

The disadvantages of the method are:

- technical difficulties in parallel holding an endoscope with a duodenal probe to the desired level without a special conductor through the pyloric pulp.

- when removing the endoscope, the duodenal probe extends beyond the duodenum or is deformed.

The technical result to which the invention is directed is to increase the efficiency of the installation of a duodenal decompression-feeding probe - improving the conduct of a duodenal probe to the lower horizontal part of the duodenum while achieving reliable fixation of the probe when removing the endoscope.

The technical result is achieved by the fact that according to the method of installation of the duodenal decompression-feeding probe, through which fibrogastroscopy is performed with parallel holding of the duodenal probe to the lower horizontal part of the duodenum, the new thing is that the fishing line is guided through the nasal passage and brought out through the oral cavity,

- a fishing line-conductor brought out through the oral cavity is passed through the biopsy channel of the endoscope from the distal end and brought out from the proximal end, and then an endoscope is held to the lower horizontal part of the duodenum with a fishing line-conductor,

- through the duodenal probe conduct biopsy forceps, which capture the fishing line-conductor emerging from the nasal passage, and enter the biopsy forceps with the captured fishing line-conductor into the lumen of the duodenal probe,

- translational movements through the nasal passage parallel to the endoscope introduce a duodenal probe into the digestive tract to the lower horizontal part of the duodenum,

- at the same time, they reverse the other end of the fishing line through the biopsy drip of the fibrogastroscope,

- biopsy forceps are removed from the lumen of the duodenal probe, the conductor line is released, which is removed through the biopsy channel of the endoscope, and biopsy forceps capture the mucosa of the lower horizontal part of the duodenum,

- after which the endoscope is removed under the control of vision, biopsy forceps are disconnected from the mucosa of the duodenum and removed from the lumen of the duodenal probe by reverse translational movements.

The invention is illustrated in figure 1 - figure 4, which shows the implementation of the inventive method of installing a duodenal decompression-feeding probe.

Here: 1 - probe-conductor;

2 - fishing line conductor;

3 - the oral cavity;

4 - nasal passage;

5 - endoscope

6 - biopsy forceps

7 - duodenal decompression-nutritional probe;

8 - lower horizontal part of the duodenum.

The installation method of the duodenal decompression and nutritional probe is carried out under the control of an endoscope and is carried out as follows.

Using an elastic probe-conductor 1 with a length of 25 cm through the nasal passage 4, conduct a fishing line-conductor 2 with a diameter of 0.4 mm and a length of 250 cm with exit from the oral cavity 3 (Figure 1). The end of the fishing line 2, which comes out of the oral cavity 3, is carried out through the biopsy channel of the endoscope 5 from its distal end. An endoscope is carried out to the lower horizontal part of the duodenum 8. In a duodenal probe 7 with a length of 150 cm and an external diameter of 14-15 mm, biopsy forceps 6 are carried out, which capture the fishing line 2 coming out of the nasal passage 4 and introduce 3-4 cm into the lumen of the duodenal probe (Figure 2). By translational movements, the duodenal decompression-feeding probe 7 through the nasal passage 4 is inserted into the digestive tract to the lower horizontal part 8 of the duodenum parallel to the endoscope, while simultaneously removing the other end of the line with reverse movements through the biopsy channel. Biopsy forceps 6 with a fishing line 2 are removed from the lumen of the duodenal probe 7, the fishing line 2 is released by opening the biopsy forceps 6 and removed through the biopsy channel of the endoscope 5 (Figure 3). To prevent displacement of the probe 7 capture the mucosa of the lower horizontal part 8 of the duodenum with biopsy forceps 6, then remove the endoscope 5 under the control of vision (Figure 4). Biopsy forceps 6 are uncoupled and removed from the lumen of the duodenal probe 7 through the nasal passage 4 by translational reverse movements. The final stage of manipulation is the fixation of the proximal end of the probe to the face skin with a band-aid.

Thus, the proposed method of installing a duodenal decompression and nutritional probe allows you to reliably conduct a probe with a diameter of 14-15 mm to the lower horizontal part of the duodenum under the control of the endoscope vision using a fishing line through the biopsy channel of the endoscope; the duodenal probe does not move beyond the duodenum, in addition, the diameter of the probe allows you to effectively decompress the upper digestive tract during emergency surgery, which will give the right to use this method mainly with traditional, generally accepted methods.

Claims (1)

A method of installing a duodenal decompression-nutritional probe, according to which fibrogastroscopy is performed with a parallel duodenal probe to the lower horizontal part of the duodenum, characterized in that the fishing line is guided through the nasal passage and brought out through the oral cavity,
a fishing line-conductor brought out through the oral cavity is passed through the biopsy channel of the endoscope from the distal end and brought out from the proximal end, and then an endoscope is held to the lower horizontal part of the duodenum with a fishing line-conductor,
biopsy forceps are passed through the duodenal probe, which capture the conductor line coming out of the nasal passage, and biopsy forceps with the captured conductor line are inserted into the lumen of the duodenal probe,
by translational movements through the nasal passage parallel to the endoscope, a duodenal probe is inserted into the digestive tract to the lower horizontal part of the duodenum,
at the same time, they reverse the other end of the fishing line through the biopsy channel of the fibrogastroscope,
biopsy forceps are removed from the lumen of the duodenal probe, the conductor line is released, which is removed through the biopsy channel of the endoscope, and biopsy forceps capture the mucosa of the lower horizontal part of the duodenum to prevent probe displacement,
after which the endoscope is removed under the control of vision, biopsy forceps are disconnected from the mucosa of the duodenum and removed from the lumen of the duodenal probe by reciprocating movements.

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