RU2743610C1 - Method for combined treatment of choledocholithiasis - Google Patents

Abstract

FIELD: invention relates to medicine, namely to minimally invasive surgery, endoscopy.SUBSTANCE: 5 mm long skin incision is made in the right hypochondrium at the costal arch level. Then, under ultrasound control, puncture of the lobular duct and antegrade cholangiography are performed. A guidewire is installed intrabilliary under X-ray control; the canal is bouginaged to 8 Fr. An introducer with a diameter of 10 Fr is installed in the lumen of the lobular duct, through the port of which a video endoscope is inserted into the lumen of the bile ducts and antegrade cholangioscopy is performed. Through the channel of the video endoscope, a fiber-optic quartz cable is installed, through which a laser pulse consisting of infrared radiation Nd: YAG 1064 nm infrared radiation and 532 nm greenish radiation is supplied. The absorption of greenish radiation by the calculus makes plasma, which absorbs the infrared part; the resulting plasma produces a mechanical shock wave and destroys the calculus. Then, through the introducer, balloon cholangioplasty of the zone of the major duodenal papilla is performed, followed by bringing down the calculus fragments using Dormium basket into the duodenum lumen. After that, external cholangiostomy is performed with a Dawson-Muller drainage having a diameter of 10.2 Fr for decompression of the biliary system.EFFECT: method allows to perform lithotripsy of calculi with a diameter of more than 30 mm, regardless of the composition and density of the calculus, to reduce the injury rate of surgical aggression due to the absence of the formation of additional surgical access and opening of the extrahepatic bile ducts, which provides a decrease in postoperative complications and mortality, to increase the effectiveness of treatment.1 cl, 1 ex, 3 dwg

Description

The present invention relates to medicine, namely to hybrid minimally invasive X-ray interventional surgical and intraluminal endoscopic interventions, and can be used to remove calculi from the lumen of the bile ducts and resolve obstructive jaundice syndrome in patients with "complex" choledocholithiasis complicated by obstructive jaundice syndrome.

Choledocholithiasis complicates the course of cholelithiasis (GSD). Concomitant complications of choledocholithiasis (obstructive jaundice and cholangitis) aggravate the general condition of patients and are the cause of a high percentage of complications and mortality in traditional methods of treating the age category of patients.

Currently, endoscopic transepapillary methods of treatment have been introduced into practical health care, which are the "gold standard" in the treatment of choledocholithiasis.

However, the frequency of successful retrograde litho extraction in "complex" choledocholithiasis is rather low due to the difficulties in removing calculus. In cases of impossibility of removing calculus from the duct system due to their size and the impossibility of performing mechanical lithotripsy, the only treatment option is to perform choledochotomy by laparoscopic or laparotomic access.

Surgical methods of treatment of patients with cholelithiasis complicated by "complex" choledocholithiasis are being improved every year, supplemented by new methods of operative and non-operative elimination of the pathology of the biliary tract.

At the present stage of development of surgery, the treatment of choledocholithiasis is multivariate. Each method has both advantages and disadvantages, therefore, new technical approaches and solutions are required to remove calculi from the biliary tract.

As a result of the conducted patent information search, the following patents were selected.

There is a known method of antegrade treatment of choledocholithiasis (RF 2721872), including performing a paraumbilical access 4-5 cm long, installing three laparoscopic ports at a distance from each other, without using a device for a single laparoscopic access, then isolating the cystic duct with laparoscopic instruments, clipping at the neck, cystic the duct is opened with scissors below the clip or choledochotomy is performed, the gallbladder is clamped through the left trocar with a clip and the choledochoscope is passed through the right trocar through the formed opening, the calculus is removed with a Dormia basket or destroyed using laser radiation transmitted through a laser light guide introduced into the working channel of the choledochoscope under the visual choledochoscope control, the choledochoscope is removed, the cystic duct is clipped and the choledochotomy opening is cut or sutured, the gallbladder is removed.

The disadvantage of this method is the lack of X-ray control of the procedure for performing litextraction, which increases the risk of leaving residual calculi and the need to perform choledochotomy, which leads to an increased risk of complications associated with desermitisation of the biliary tract and leakage of bile into the abdominal cavity, the risk of cicatricial strictures in the area of the choledochotomy opening. Also, the disadvantage of this method is the impossibility of performing repeated lithotripsy in case of residual calculus.

There is a known method of cannulation of the common bile duct (RF No. 2447849), which consists in performing a percutaneous transhepatic cholangiostomy, introducing a conductor into the lumen of the bile duct through a duodenoscope, characterized in that after performing a percutaneous transhepatic cholangiostomy through the cholangiostoma antegrade the cholangiostomy is inserted into the cholangiostomy a bougie with an introducer with a diameter of at least 3 mm is introduced through the guidewire into the duodenum so that the introducer protrudes from the large papilla of the duodenum, the bougie with the guidewire is removed, the guidewire is inserted through the working channel of the duodenoscope into the lumen of the introducer, the introducer is pulled up, while the cannulation of the common bile duct occurs , which allows you to start endoscopic transpapillary intervention.

There is a known method for minimally invasive treatment of choledocholithiasis (RF 2556574), including endoscopic removal of calculi, characterized in that in case of impossibility of traditional endoscopic access to the large duodenal papilla (BDS) previously under ultrasound control, antegrade through the choledoch into the lumen of the duodenum (Duodenum) is conducted, which is captured by a loop, passed through the instrument channel of the duodenoscope, and brought out, through which the papillotome is first brought down to the BDS to perform endoscopic papillotomy, and then - the basket probe of the Dormia type for performing mechanical lithoextraction. This method will allow avoiding surgery and implementing minimally invasive treatment of patients in complex clinical cases when traditional access to OBD is not possible. This will shorten the length of stay of the patient in the hospital, reduce the costs of his treatment, and increase the psychoemotional status of patients.

There is a known method of dissolving calculi in the bile ducts, which includes bringing the drug mixture directly to the gallstone through a thin catheter drawn through the drainage tube of the common bile duct (RF Pat. No. 223473, 2189178, 1491472). One of the main disadvantages of this method is the flow of the dissolving substance back (onto the skin) near the tube installed in the biliary fistula, since it is impossible to absolutely tightly install the tube in the fistulous opening. 100% dissolution of stones is not ensured due to their different chemical structure, dissolution is carried out for a sufficiently long time, the operation requires constant medical supervision of the patient due to the known toxicity of monooctanoin, inadequate removal.

There is a known method of contact laser lithotripsy (RF 2334486) by performing a laparoscopic operation, characterized in that when conducting a laparoscopic operation under visual control, the calculus is captured and fixed using a basket, then a laser light guide is brought to the calculus and laser contact laser lithotripsy is performed using YAG radiation Ho laser with a wavelength of 2.09 μm in a pulsed mode with a frequency of 5-10 Hz and an radiation energy of 0.5-1.0 J. Disadvantages: the method of contact laser lithotripsy requires much higher energy and time costs than contact electrical pulse lithotripsy , i.e. less effective in terms of physical parameters. The cost of the apparatus for contact laser lithotripsy significantly exceeds the cost of the apparatus "Urolit".

There is a known method of extracting congestions from the bile ducts in patients after cholecystectomy and drainage of the common bile duct according to Keru (RF 2654412), characterized in that cholangiography is performed through the previously installed Kera drainage, then, under X-ray control, a hydrophilic conductor is installed in the lumen of the bile ducts through the Kera drainage channel. the lumen of the bile ducts, using an angiographic catheter with a CMR tip, the hydrophilic guide is directed into the duodenal lumen, the hydrophilic guide is replaced with a super-rigid guide, the angiographic catheter is removed, and the previously installed Kera drainage is used as an intraducer, lithotripsy of this calculi is performed with the help of a mechanic balloon cholangioplasty is performed, then the balloon is removed and a Dormia basket is installed through the Kera drainage channel to lower the calculus into the duodenal lumen, after control cholangiography, the Kera drainage is removed.

A known method of removing calculus from the bile ducts (RF 2595059) selected as a prototype, including determining the localization and number of calculi, the impact on the large duodenal papilla followed by the removal of calculus through the duodenum, characterized in that under X-ray control in the lumen of the bile ducts set a standard metal guidewire for performing bougienage of the canal up to 8 Fr., an introducer with a diameter of 10 Fr. is inserted into the lumen of the lobar duct, then an angiographic catheter is inserted into the lumen of the duodenum through the port of the introducer through the large duodenal papilla, with the help of which the Lunderquist guide is inserted, then the catheter A dilator balloon with a diameter of 10 mm and a length of 40 mm is removed and placed along the Lunderquist guide into the area of the large duodenal papilla, after which, using a high-pressure injector, a pressure is created in the balloon in stages from 4 atm to 10-12 atm with a step of 2 atm and time exposure 5 minutes, after reaching the set pressure in 15 minutes, the balloon is removed, and a mechanical lithotriptor is installed through the port of the introducer into the lumen of the bile ducts, after performing lithotripsy with the help of the Dormia basket, the calculi are lowered into the lumen of the duodenum and along the Lunderkvist guide drainage is installed into the lumen of the choledochus Dawson-Müller with a diameter of 10.2 Fr, according to which control cholangiography is performed after 3 days and the drainage is removed.

The objective of the present invention is to develop a method for the combined minimally invasive treatment of "difficult" choledocholithiasis in difficult clinical cases, when performing mechanical lithotripsy using a retrograde or anegrade method is not possible due to the size of the calculus or its density, expanding therapeutic options, increasing the effectiveness of treatment by reducing labor intensity and duration, reducing the trauma of surgery by eliminating the need for additional surgical access, no need to open the lumen of the extrahepatic bile ducts, as well as reducing the risk of complications.

The technical result obtained: the possibility of performing lithotripsy of calculi with a diameter of more than 30 mm, regardless of the composition and density of the calculus, no need to open the extrahepatic bile ducts, which ensures a decrease in postoperative complications and mortality, a decrease in the trauma of the operation.

The technical result is achieved when using the method of combined treatment of choledocholithiasis, which consists in performing a skin incision with a length of 5 mm in the right hypochondrium at the costal arch level, then performing ultrasound-guided puncture of the lobar duct and antegrade cholangiography, placing a conductor under X-ray control in the lumen of the bile ducts, performing bougienage channel up to 8 Fr, a 10 Fr introducer is installed in the lumen of the lobar duct, through the port of which a video endoscope is inserted into the lumen of the bile ducts and antegrade cholangioscopy is performed, a fiber optic quartz cable is installed through the video endoscope channel, through which a laser pulse consisting of Nd: YAG infrared radiation ( 1064 nm) and from greenish radiation (532 nm), the absorption of greenish radiation by the stone makes plasma, which absorbs the infrared part, the resulting plasma produces a mechanical shock wave and destroys the calculus, then through the intraday Ser, balloon cholangioplasty of the OBD zone is performed, followed by bringing down the stones fragments with the Dormium basket into the duodenal lumen 12, and then external cholangiostomy is performed with Dawson-Müller drainage 10.2 Fr in diameter to decompress the biliary system.

If a patient has a calculus in the lumen of the bile ducts requiring lithotripsy and if it is impossible to perform mechanical lithotripsy, it is advisable for the patient to perform a hybrid mini-invasive X-ray interventional surgical and intraluminal endoscopic interventions with short-pulse double-pulse laser lithotripsy, with partial frequency doubling of Nd laser and partial frequency doubling of Nd laser.

The invention is illustrated by the following example.

Under general anesthesia, a 5 mm skin incision is made in the right hypochondrium at the costal arch level. Under ultrasound control, puncture of the lobar duct with a Chiba needle with a diameter of 18 G is performed. The mandrel of the needle is removed and antegrade cholangiography is performed to determine the cause of the block, localization and the number of calculi. Under X-ray control in real time, a standard metal conductor is inserted into the lumen of the bile ducts. The needle is removed. The channel is bougie up to 8 Fr. An introducer with a diameter of 10 Fr is installed in the lumen of the lobar duct. A vidioendoscope with an outer diameter of 2.5 mm and an internal working channel of 1.2 mm is inserted through the intradeser port into the lumen of the bile ducts. Antegrade cholangioscopy is performed - calculus / you identified by cholangiography are visualized. A flexible fiber-optic quartz cable is installed through the endoscope channel through which a laser pulse consisting of Nd: YAG 1064 nm infrared radiation is supplied, and from greenish (532 nm) radiation, the absorption of greenish radiation by a stone makes plasma, which absorbs the infrared part, the plasma further expands and produces mechanical shock wave that destroys calculus. After lithotripsy, antegrade lithotomy is performed. An angiographic catheter is installed through the guidewire, through the intraducer port, through the large duodenal papilla into the duodenal lumen 12. Using an angiographic boat, a Lunderquist guide is inserted into the duodenum lumen 12 through an introducer. The angiographic cutter is removed. A dilator balloon with a diameter of 10 mm and a length of 40 mm is placed along the Lunderquist guide into the area of the large duodenal papilla. With the help of a high-pressure injector, a pressure is created in the cylinder in stages from 4 atm to 10-12 atm with a step of 2 atm and an exposure time of 5 minutes. After reaching the specified pressure of 10-12 atm, the exposure time of the balloon is set to 15 minutes. After the exposure time has elapsed, the balloon is removed. Through the port of the introducer, the basket of Dormia is inserted into the lumen of the bile ducts. Small calculi are captured by Dormia's basket and are lowered into the intestinal lumen. Dormia's basket is removed. According to the Lunderquist guide, a Dawson-Muller drainage with a diameter of 10.2 Fr is installed in the middle aunt of the common bile duct. After 3 days, cholangiography is performed to monitor the patency of the duct system. The drain is removed.

Clinical example

Patient G., 68 years old, was hospitalized on an emergency basis with complaints of constant pain in the upper abdomen, mostly on the right, yellowing of the skin.

With ultrasound of the abdominal organs - biliary hypertension: lobar enlarged to 10 mm, total hepatic 14 mm, common bile duct 20 mm. In the lumen of the common bile duct, a calculus up to 20 mm in diameter is determined.

The patient made an attempt at endoscopic litextraction. When ERCP in the lumen of the common bile duct calculus up to 22 mm in diameter and calculus 12 mm in diameter, EPST was performed, while trying to perform mechanical lithotripsy, the basket was destroyed due to the density of the calculus (Figure 1).

In view of the impossibility of performing retrograde lithotripsy and litextraction, it was decided to switch to antegrade approach.

Under general anesthesia in the right hypochondrium under ultrasound control, puncture of the left lobar duct was performed and antegrade cholangiography was performed (Figure 2) in the lumen of the common bile duct, 2 calculi 22 and 12 mm in diameter were revealed. Into the lumen of the left lobar duct, a 10 Fr introducer is installed. Through the port of the intradeser, a vidioendoscope was introduced into the lumen of the bile ducts, antegrade cholangioscopy was performed, calculi were visualized. A flexible fiber-optic quartz cable was installed through the endoscope channel, through which a laser pulse consisting of Nd: YAG 1064 nm infrared radiation and greenish (532 nm) radiation was supplied, laser lithotripsy of 2 calculi was performed, followed by antegrade lithotraction of fragments into the duodenum. Control cholangiography showed no calculi in the duct system (Figure 3).

The patient was discharged home on the 6th day after the operation in a satisfactory condition.

Claims (1)

A method of combined treatment of choledocholithiasis, which consists in performing a 5 mm skin incision in the right hypochondrium at the level of the costal arch, then performing ultrasound-guided puncture of the lobar duct and antegrade cholangiography, placing a guidewire under X-ray control in the lumen of the bile ducts, performing bougie of the canal up to 8 Fr, an introducer with a diameter of 10 Fr is installed in the lumen of the lobar duct, through the port of which a vidioendoscope is inserted into the lumen of the bile ducts and antegrade cholangioscopy is performed, a fiber-optic quartz cable is installed through the vidioendoscope channel, through which a laser pulse consisting of Nd: YAG 1064 nm infrared radiation and greenish radiation is supplied 532 nm, the absorption of greenish radiation by a stone makes plasma, which absorbs the infrared part, the resulting plasma produces a mechanical shock wave and destroys the calculus, then balloon cholangioplasty of the large duo zone is performed through the introducer of the denal papilla, followed by bringing the stone fragments down with the Dormium basket into the duodenum lumen, and then an external cholangiostomy is performed with a Dawson-Muller drainage 10.2 Fr in diameter to decompress the biliary system.

Images