RU2367375C1 - Malchikov's method of removing bile calculus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to surgery, can be used for removing large bile calculus. A flexible endoscope is introduced into a body lumen through natural physiological orifices. The endoscope comprises tool channels, a surgical tool with a contact to connect a high-frequency electrosurgical apparatus, and a video system. Liquid is supplied, and a concrement location is visualised. An endoscopic surgical tool with a solid tip is brought close to the concrement. The tool is removed with the concrement. A bile duct piece from the concrement to duodenum is washed with a astringent solution of an acid astringent singly before to push the tip through. Simultaneously with this, the video system aided vacuum venting is actuated to aspirate the lumen contents. A sprayed continuously colourless transparent alkaline coating being equally related is directed on a working part of the tip which is a piezoelectric scaler comprising a chisel with axial concave sieve. The tip is exposed to ultrasonic longitudinal vibration of frequency 25-43 kHz. The tip is pushed through while being reciprocated within the concrement body to be destroyed completely. Thus solutions are heated to 37°C. The meshed concrement is removed through a passage of the vacuum venting.

EFFECT: method improves efficiency, safety and reduces injuries of removing calculus due to intraorganic meshing and reduced damaged of bile ducts.

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Description

The invention relates to medicine, in particular to surgery, and can be used to remove stones from the bile ducts.

A known method of calculus removal during intraorgan endoscopic choledochoscopy, including introducing through the natural physiological holes into the lumen of a flexible endoscope organ with a video system, instrumental channels, endoscopic instruments for monopolar coagulation, having a contact for connecting a high-frequency electrosurgical apparatus, separate supply of air and water, pushing the basket Dormia for calculus and its extension (Fedorov IV Surgical instruments. Functions and purpose. - Kazan, AKP "Adelaide", 2001. - p. 125 - 135).

The disadvantage of this method is the low efficiency, safety and high invasiveness when removing the calculus, the dimensions of which are many times greater than the internal dimensions of the biliary tract. The fact is that the effectiveness of the method is limited by the size of the calculus, since the method does not ensure the removal of calculi, the dimensions of which significantly exceed the dimensions of the bile ducts.

Despite the use of a flexible endoscope with a video system, the method does not provide an atraumatic and visual push of the basket beyond the stone. In this regard, the bile ducts are damaged during the forced and blind (uncontrolled) pushing of the Dormia basket into the narrow space between the calculus and the wall of the bile duct. Moreover, due to the blind and forced pushing of the elastic basket and its strong tip beyond the giant calculus, the wall of the bile duct can be damaged by the type of abrasion, contusion, rupture, and even perforation.

In addition, the method involves damage to the biliary tract with a basket of Dormia and a calculus in the process of forcibly pulling it out.

Despite the presence in the flexible endoscope of instrument channels and endoscopic instruments for monopolar coagulation, which have a contact for connecting a high-frequency electrosurgical apparatus, separate supply of air and water, the method does not provide effective and safe intraorgan destruction of the calculus and subsequent safe removal to the outside. The method provides forcible stretching of the calculus within the narrow bile duct. Therefore, the application of the method inevitably damages the bile and wirsung ducts, as well as the Oddi sphincter when stretched excessively due to the lack of safe intraorgan grinding of the calculus while maintaining the abrasive properties of its surface and in the absence of covering the mucous membranes of the biliary tract with a protective layer that protects against mechanical abrasions.

The mechanical damage to the biliary tract that occurs during the implementation of the method leads to the appearance of cholecystitis, bleeding, perforation and peritonitis, delaying the healing and recovery process, as well as contributing to the new appearance of calculus in the bile ducts.

The introduction of water and air into the bile ducts without heating to a temperature of 37 ° C causes a cold spasm of a reactive nature in them, since without heating water and air have room temperature (most likely 24 ± 2 ° C), that is, they are cold. Moreover, local cooling and cold spasm of the bile ducts is created directly on the path in front of the moving calculus. Therefore, the method creates an additional obstacle for the safe removal of calculus in the form of narrowing of the bile duct, which requires additional efforts to stretch the calculus in the narrowed channel, and this increases the damage to the duct with calculus and increases the invasiveness of the method.

The use of monopolar coagulation to stop the bleeding that has arisen causes additional damage to the mucous membranes and contributes to the appearance of a new intraorgan calculus due to denaturing coagulation of the protein components of the blood and tissues of the bleeding wound, since the method does not effectively remove secondary calculi (calculi that appeared after the disappearance of the primary calculus).

The objective of the invention is to increase the efficiency of the method due to intraorgan grinding of large stones, increasing safety and reducing the invasiveness of the method by reducing damage to the bile duct.

The essence of the proposed method, which includes introducing, according to general rules, through natural physiological openings into the lumen of the organ to the calculus of a flexible endoscope with instrumental channels, a surgical instrument that has contact for connecting a high-frequency electrosurgical apparatus, a video system, fluid supply, visualization of the location of the calculus, extension of the endoscopic surgical a tool with a strong tip, pushing it for a calculus and subsequent removal to the outside, consists in the fact that the segment of the bile duct from the calculus to the duodenum is washed with a solution of an astringent with acidic properties once before pushing the tip, simultaneously with the start of pushing under the control of the tip video system they turn on the vacuum suction, begin to suck out the contents of the lumen and apply continuously colorless at equal costs transparent alkaline solution of the coating agent in the form of a jet directed to the working part of the tip, which is a piezoelectric scaler m, made in the form of a chisel with an axially arranged concave sieve, and ultrasonic longitudinal vibrations with a frequency of 25-43 kHz are applied to it, the tip is pushed in the form of multiple reciprocating movements inside the calculus body until complete destruction, while the solutions are used heated up to 37 ° C, and the crushed stone to the mesh size is removed through the vacuum suction channel.

In the proposed method, due to the preliminary (before pushing the tip) single washing of the bile duct segment from the calculus to the duodenum with a solution of an astringent with acidic properties, the mucous membrane of the bile ducts is coated with a layer of compacted (folded) proteins. The protective layer is created under the local action of an astringent that coagulates protein mucus, deflated epithelium, and even microbial residues located on the surface of the bile ducts. A single washing of the bile ducts with a solution of astringent provides the creation of a protective layer covering the mucous surface of the bile duct and remaining on it for several tens of minutes. This turns out to be sufficient for reliable protection of the bile ducts from damage from the destroyed parts of the calculus during its subsequent destruction and removal of crushed calculi during washing with a solution of the coating agent.

The filing from the endoscope side simultaneously with pushing the tip of a colorless transparent alkaline solution of the coating agent continuously in the form of a jet directed to the working part of the tip, made in the form of a bit, provides reliable removal of fragments of calculus that occur under the influence of the tip, oscillating with the frequency of ultrasound. In this case, the solution of the enveloping agent envelops the particles of calculus and the mucous membrane of the biliary tract, which reduces their damage. The fact is that fragments of calculus, like abrasive material, pose a threat to the mucous membranes, therefore, intensive and continuous removal of them immediately after the formation of a coating agent in the solution reduces their damaging effect on the inner surface of the biliary tract. The use of a transparent and colorless coating means provides visualization of the destruction process using a video system. The use of enveloping agents with a pH above 7.0 gives them the necessary flushing properties and the properties of surfactants (surfactants), which ensures the effective removal of fragments of calculus from the biliary tract. Turning on the vacuum suction and aspirating the contents of the lumen simultaneously with the supply of the solution of the enveloping agent with equal costs eliminates the change in intraluminal pressure and ensures timely removal of the contents of the lumen together with the crushed parts of the calculus.

Due to the use of a tip in the form of a chisel with an axially arranged concave sieve, which is a piezoelectric scaler, to which longitudinal ultrasonic vibrations with a frequency of 25-43 kHz are supplied (from connecting an ultrasonic device, for example, Pieson Master 400) during repeated reciprocating movements into the calculus body under the control of the video system, it is possible to mechanically destroy the calculus without damaging the soft tissues of the biliary tract. Moreover, due to a sieve with a mesh equal to the size of the channel of the vacuum suction, sieving of crushed stones and their removal by vacuum suction to the outside is provided. Due to the supply of ultrasonic vibrations to the sieve, the jammed stones are crushed and the clogging of the sieve is eliminated.

The use of solutions of astringents and enveloping agents in a heated state to a temperature of 37 ° C increases the efficiency and safety of their local action, since it eliminates the development of a cold spasm of the bile ducts, ensures a high speed of physicochemical processes and eliminates thermal burns of the mucous bile ducts as a result of safe initial the temperature regime of the solution, and because of the exclusion of its overheating due to ultrasonic crushing of calculus. A warmed solution of an astringent has a pronounced astringent effect, and a heated solution of an alkaline enveloping agent has a pronounced washing effect.

Example 1. Patient S., 28 years old, was admitted to the clinic with cholelithiasis for elective surgery. Ultrasound examination revealed the presence of a round-shaped stone with a diameter of about 10 mm, which was stuck in the supraduodenal part of the common bile duct. To remove it, a flexible endoscope was introduced through the esophagus, stomach, 12 duodenum into the common bile duct with a video system, instrumental channels, endoscopic surgical instruments, separate supply of water and air, brought the endoscope end to the calculus, tried to push the Dormia basket through the calculus, but this caused bleeding. After that, it was decided to use the claimed method. To do this, we used a flexible endoscope equipped with a vacuum suction, an ultrasound device and a surgical instrument with a durable tip, which is a piezoelectric scaler made in the form of a chisel with an axially arranged concave sieve.

Once washed the segment of the common bile duct from the calculus to the duodenum with a standard solution of tannin at 37 ° C and pH 3.5, brought the endoscope to the calculus, at the same time began to push the tip towards the calculus under the control of the video system, turned on the vacuum suction, and began to aspirate the contents of the lumen and to supply, with equal costs, a continuously colorless transparent starch jelly at a temperature of 37 ° C and a pH of 8.5 in the form of a jet supplied to the working part of the bit, the ultrasonic apparatus was turned on and vibrations I bit and concave sieve with a frequency of 43 kHz. After that, multiple reciprocating movements of the tip into the body of the calculus were carried out and after 6 minutes the removal of the calculus crushed to mesh size was completed through the vacuum suction channel. The performed cholecystoscopy confirmed the absence of calculus in the bile duct. The patient was discharged in satisfactory condition on the same day.

Claims (1)

A method of removing stones from the bile ducts, including introducing a flexible endoscope with instrumental channels, a surgical instrument with a contact for connecting a high-frequency electrosurgical apparatus and a video system, fluid supply, visualizing the location of the calculus, and extending the endoscopic surgical instrument with a durable tip and their subsequent removal, characterized in that the segment of the bile duct the current from the calculus to the duodenum is washed with a solution of an astringent with acidic properties once before pushing the tip, simultaneously with the start of pushing the tip under the control of the video system they turn on a vacuum suction, begin to suck the contents of the lumen and apply continuously equal colorless transparent alkaline solution of the coating agent in the form of a stream, at equal costs, directed to the working part of the tip, which is a piezoelectric scaler, made in the form of a bit with ak located concave sieve, and ultrasonic longitudinal vibrations with a frequency of 25-43 kHz are applied to it, the tip is pushed in the form of multiple reciprocating movements into the body of the calculus up to complete destruction, while the solutions are used heated to 37 ° C, and ground to mesh-sized calculus is removed through a vacuum suction channel.