RU2793842C1 - Combined method for morphological verification of tumors of pancreas head and distal choledoch with bilioduodenal drainage - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to oncology, pancreato-biliary surgery. A transhepatic puncture access to the bile ducts is carried out with a metal conductor passing through the tumor stenosis along the true lumen of the common bile duct and taking material for histological examination from different sites of the tumor. Bougienage of the transhepatic puncture channel and tumor occlusion zone is performed. External and internal drainage of the bile ducts and endoscopic papillosphincterotomy of the major duodenal papilla are performed. An antegrade brush biopsy of the distal choledochus is performed simultaneously.

EFFECT: method will increase the likelihood of morphological verification of tumors of the head of the pancreas and the distal choledochus while maintaining a high efficiency of histological material sampling.

1 cl, 3 dwg, 1 ex

Description

The invention relates to oncology and oncoradiology and concerns a method for single-stage puncture transhepatic external-internal drainage of the bile ducts with antegrade brush biopsy of the distal choledochus and trephine biopsy of tumors of the pancreatic head and distal choledochus and endoscopic papillosphincterotomy of the major duodenal papilla in patients with obstructive jaundice.

In the preicteric period, the disease proceeds secretly, and it is rarely possible to diagnose cancer of the head of the pancreas and the distal choledochus. Obstructive jaundice occurs in 50-95% of patients (Yu.I. Patyutko, A.G. Kotelnikov, 2007, V.A. Kubyshkin, V.A. Vishnevsky, 2007). The treatment and diagnostic algorithm for this group of patients is a series of sequential actions, one of the links of which are puncture trephine biopsy and bilioduodenal drainage. Cytological diagnosis by brush biopsy and puncture aspiration biopsy has limitations and does not allow obtaining 100% information about the diagnosis, and does not give an answer on the histological structure of the tumor. Not in 100% of cases, when performing a trephine biopsy, it is possible to ensure targeted penetration into the tumor tissue of the head of the pancreas and the distal choledochus (E.B. Revazov, Ts.S. Khutiev, 2021).

There are several ways of morphological verification of tumors of the head of the pancreas and the distal choledochus.

Known puncture biopsy under the control of endoscopic ultrasound (Endoultrasound). (Solodinina E.N., 2016 // Endoscopic ultrasound in the diagnosis of surgical diseases of the organs of the pancreatobiliary zone. // Dissertation for the degree of Doctor of Medical Sciences). The puncture method includes several steps. The first step is to select the puncture site, taking into account the proximity of the object to the echoendoscope sensor, the absence of interposition of vessels and ducts between the sensor and the formation. Then the apparatus is positioned so that the focal formation is in the area accessible for the puncture needle. The size of this zone depends on the degree of change in the angle of the needle leaving the apparatus, which is determined by its displacement with the help of a lifter. For example, in Fujinon devices, this zone is a sector with an angular size of about 25°, located in the central part of the screen and marked on the screen by two dotted lines, a dot on the screen shows the approximate point where the needle enters the scanning plane. After the correct positioning of the object on the screen of the echoendoscope, a puncture needle is inserted into the biopsy channel and fixed in it with a special screw connector on the needle handle. Then the lower latch on the needle handle is released and the outer sheath of the needle is brought to the exit from the biopsy channel, which is controlled by its appearance on the ultrasound screen or visually on the endoscopic image, the latch is tightened. The next step is to set the upper fixator to a position that determines the depth of the puncture according to the scale printed on the needle handle, or set the maximum puncture depth (8 cm) and perform the manipulation, focusing on tactile sensations and visualization of the needle on the ultrasound monitor. This is due to the fact that during punctures, especially in the position of the device on a long loop, the needle springs in the biopsy channel and the distance to the object established on the basis of ultrasound imaging does not always correspond to the distance that the needle tip must travel to reach the given point. After the release of the upper fixator, the stylet of the needle is pulled up by 0.5-0.6 mm and the formation is punctured under ultrasound control. After positioning the needle inside the neoplasm, the stylet is first completely passed into the lumen of the needle in order to remove from its lumen the cells of the wall of the hollow organ and the unchanged parenchyma of the pancreas that got into it during the puncture. The stylet is then removed. We use vacuum aspiration with special syringes only for repeated puncture of dense formations, if the first puncture did not allow obtaining a sufficient amount of cellular material. Usually, a single puncture is used with 8-10 reciprocating movements of the needle inside the formation while changing the puncture angle using the endoscope lifter - the so-called "fan technique". Then the quantity and quality of the obtained material is visually assessed on the glass. If there is not enough material, a second and, if necessary, a third puncture is performed.

The disadvantage of this method is that the obtained material is often cytological, and the method of obtaining material using a fine-needle biopsy forcept under the control of endosonography has a lower sensitivity compared to fine-needle aspiration biopsy and a high percentage of complications in the form of bleeding. (E.R. Dvoynikova, K.V. Stegniy et al. 2018, Solodinina E.N., 2016). Bilioduodenal drainage is not a biopsy step, and its simultaneous implementation carries additional risks of complications. A larger number of medical personnel are involved in the diagnostic and treatment procedure, which reduces the efficiency of the entire medical institution. The technical complexity of the study after gastric resection, gastrectomy, significant operator-dependence.

An antegrade method for obtaining morphological material is also known (Kulezneva Yu.M., Percutaneous interventions in abdominal surgery, M.: GEOTAR-Media Publishing Group, 2016, p. 105-107). To perform these interventions, it is necessary to install an introducer through which a cholangioscope, biopsy forceps, biopsy brush, intraluminal ultrasound probe can be passed.

The standard sheath is placed on a long bougie, from which it is then pushed after the radiopaque mark is in the lumen of the duct. The standard sheath is a plastic tube with a "cut" distal tip, which is marked with a radiopaque marker; at the proximal tip there is a silicone valve that does not allow fluid to flow out of the lumen of the duct, and a side channel with a stopcock for introducing a contrast agent. The introducer ensures the tightness of the transhepatic canal, eliminating the possibility of leakage of bile and blood into the abdominal cavity and reducing the risk of damage to the liver capsule, and also creates the necessary support for the subsequent passage of instruments through the stricture. The size of the introducer depends on the diameter of the instrumentation being carried out. For a biopsy, it will be enough to choose an introducer 8-10 Fr, for cholangioscopy - from 14 to 22 Fr. A brush biopsy with a brush is carried out under the simultaneous control of cholangioscopy and fluoroscopy to reduce the risk of perforation of the duct wall, and only if the patient has had external-internal drainage for some time, that is, a channel has already been formed through the stricture area. This reduces the trauma of manipulation. Obtaining morphological material with biopsy forceps is carried out under fluoroscopic control with additional visual control using a cholangioscope. For forceps biopsy, partial bougienage of the stricture is performed, after which the distal tip of the introducer is placed directly in the zone of duct narrowing. The forceps are passed through the introducer channel in the closed state. The introducer is pulled up above the stricture, the forceps are opened and, pressing them in the open state against the wall of the duct in the area of the stricture, they try to capture a piece of tissue under constant fluoroscopic control. This is usually easier to do at the top of the stricture. After closing the forceps, they are pulled back into the sheath and removed. If there is no material in the forceps, the manipulation is repeated. But it is important to remember that this is a rather traumatic procedure, associated with the risk of damage to the liver capsule, perforation of the bile duct wall and bleeding from the stricture. Therefore, the number of attempts should be no more than two or three, they must be carried out extremely

carefully and only under general anesthesia. One option may be balloon scraping after balloon dilatation of the stricture.

The disadvantage of this method is that this intervention is complex, somewhat traumatic and requires double visual control (X-ray and cholangioscopic), which in turn entails the need to create an unsafe (in terms of bleeding and bile leakage) wide transhepatic canal, requiring further installation of transhepatic bile drainage of large diameter. This will increase the pain syndrome caused by mechanical action on the intercostal nerve, since in most cases the puncture transhepatic canal passes through the intercostal space and prolongs the time of surgical treatment. Taking morphological material is limited only to the proximal stricture, which, if not informative, requires repeated biopsies, which increase the risk of surgical complications and tumor dissemination, and the development of not only a local, but also a general infectious process. In the future, a gradual removal of the bile drainage is required with a gradual decrease in its diameter. All this lengthens the time of diagnostic and therapeutic measures.

The closest to the proposed invention is a combined method of trephine biopsy of tumors of the pancreatic head and distal choledochus with bilioduodenal drainage (E.B. Revazov, Ts.S. Khutiev, M.R. Revazova, patent No. 2747591), including transhepatic puncture access to the bile ducts, performed under fluoroscopic control with the possibility of performing cholangiography, carried out with passing a metal conductor through the tumor stenosis along the true lumen of the common bile duct and taking material for histological examination from different places with simultaneous bougienage of the transhepatic puncture canal and the zone of occlusion by the tumor and external-internal drainage of the bile ducts ducts and simultaneous performance of endoscopic papillosphincterotomy of the major duodenal papilla.

The disadvantage of this method is that not in 100% of cases, when performing a trephine biopsy, it is possible to ensure targeted penetration into the tumor tissue of the head of the pancreas and the distal choledochus, which may require a second biopsy (E.B. Revazov, Ts.S. Khutiev, 2021).

The purpose of the invention is to create the safest and most effective method for obtaining morphological material from tumors of the head of the pancreas and the distal choledochus.

This goal is achieved by the fact that the patient is injected with a metal superrigid conductor [3] of the Lunderquist type (Fig. 1) through the percutaneous puncture channel of the liver parenchyma through hepaticocholedochus into the duodenum (duodenum). At the same time, the entire soft part of the conductor and the distal end of its hard part are inserted into the duodenum, which makes it possible to maintain the rectilinear axis of the choledochus. A device for brush biopsy [10] is inserted antegradely into the zone of tumor constriction along a metal conductor [3] (Fig. 3A). In our case, we used BrushMasterV (Model #BC-V600P-3010 OLYMPUS). The biopsy brush is removed from the delivery cannula. Through several forward-return movements, cytological material is taken. The biopsy brush is reintroduced into the delivery cannula to exclude implantation metastasis along the puncture channel and loss of cytological material. The brush biopsy device is removed. The treated material on glass slides is sent for cytological examination. On a metal conductor [3], installed in the working channel [2], the device is brought into hepaticocholedochus, thereby bougienage of the puncture channel of the liver. Next, the distal end [7] is maximally inserted through the zone of tumor narrowing along the true lumen of the common bile duct, expanding it so that the inner opening of the puncture channel [4] reaches the proximal part of the tumor stenosis.

The direction and depth of the puncture is chosen based on the preoperative analysis of CT and MRI. The direction of the puncture is set by rotating the device around the guidewire axis [3]. A trephine biopsy of the biopsy needle [5] is performed using a biopsy gun [11] Fig. 3B. The distal end [7] of the device, having obturated the true lumen of the choledochus in the tumor zone, prevents the biopsy needle from “sliding” [5] into the lumen of the choledochus, increasing the efficiency of puncture. To prevent hematogenous and implantation metastasis, after puncture, antitumor drugs are injected into the lumen of the hepaticocholedochus.

Further, along a metal conductor [3], carried out transpapillarily into the duodenum in the distal direction, an external-internal bile drainage is inserted [12] Fig. 3B. At the same time, the upper wall of the major duodenal papilla becomes easily accessible for visualization and intervention. Using a video or fibroduodenoscope using a needle (end) papillotome, a major duodenal papilla is dissected. In most cases, the need to cross the sphincter apparatus does not arise. The material from which the external-internal bile drainage is made (polyurethane, PVC) is not conductive, which eliminates the risk of electrical damage to tissues throughout. External-internal drainage of the bile ducts is positioned under fluoroscopic control and fixed, providing compression of the puncture canal of the tumor and preventing bleeding.

For an explanation of the method, Fig. 1 and FIG. 2.

In FIG. 1 shows a device for trephine biopsy of tumors of the head of the pancreas and the distal choledochus, consisting of a plastic polymer tube [1], which has two channels: a channel [2] for passing a metal conductor [3], a channel [4] for a biopsy needle [ 5]. In FIG. 2 shows this device in cross section in the section indicated in FIG. 1 dotted line. The proximal ends of the channels [2] and [4] are fixed relative to each other at an angle of α=20-40°, which ensures the convenience of working with the device. Namely: it simplifies access to the puncture channel [4] when inserting a biopsy needle [5]; facilitates the rotation of the device around the axis of the conductor [3], thereby changing the direction of the puncture; control of the position of the proximal ends [2] and [4] allows you to determine the direction of the puncture. The proximal end of the puncture channel [4] has a connector [6] for a LUER-LOK type syringe, which makes it possible to perform cholangiography during surgery. The distal end of the device [7] has the shape of a truncated cone, making it easier for the device to pass through the puncture transhepatic canal with a bougie effect. Between the axis of the inner end of the puncture needle [5] and the axis of the metal conductor [3] there is an angle β=5-30°, formed due to the protrusion [8] in the distal part of the puncture channel [4], which ensures a safe axial deviation of the puncture needle when performing trephine -biopsy. At the level of the internal opening of the puncture channel [4], there is a radiopaque marker [9], which allows you to control the puncture needle during its repeated insertions in order to take biopsy specimens from different places.

The novelty of the method lies in the fact that when sampling histological material using needles by puncture transhepatic cholangiostomy access with the possibility of choosing a location and simultaneous bougienage of the transhepatic puncture canal and tumor occlusion zone, accompanied by external-internal drainage of the bile ducts and endoscopic papillosphincterotomy of the major duodenal papilla, a brush biopsy is performed simultaneously distal choledochus.

The advantage of this method lies in the fact that while maintaining a high efficiency of sampling histological material, the probability of morphological verification of tumors of the head of the pancreas and the distal choledochus increases even more.

Example No. 1 of a specific implementation.

Patient B., aged 50, was hospitalized in the surgical department of the Clinical Hospital SOGMA with a diagnosis of Tumor of the head of the pancreas with compression of the distal hepaticocholedochus. Mechanical jaundice severe.

Complete blood count dated May 26, 2021 - Hb - 140 g/l; Erythrocytes - 4.69×10 ¹² /l; Leukocytes - 6.3×10 ⁹ /l; Platelets - 349.

Biochemical blood test dated May 26, 2021 - Glucose - 6.86 mmol / l; A-Amylase - 225, Ob. Bilirubin - 380.97 µmol / l, ALT - 674.87, ACT - 150.79, Urea - 4.26, Creatinine - 68, Total protein - 69, PTI - 83%, Fibrinogen - 2.8, INR - 1.21.

Anti-HCV, Anti-HBs, Anti-HIV, Anti-RW (-) negative from 04/28/2021. Abdominal CT scan from 05/27/2021: MSCT data obtained correspond to the signs of pancreatic head cancer. Biliary hypertension.

Urgently on May 25, 21, endoscopic atypical papillosphincterotomy was performed, an attempt was made to stent the choledochus. On May 26, 2021, the patient underwent surgery in the following volume: “Percutaneous-transhepatic brush biopsy of the distal choledochus, trephine biopsy of the pancreatic head tumor, and external-internal cholangiostomy under X-ray and ultrasound control.”

The brush biopsy was performed with an endoscopic biopsy brush with a transcholangiostomy access. Puncture trephine biopsy was also performed by transcholangiostomy using an original device (patent for invention No. 2722655). The postoperative period proceeded without complications.

Cytological examination dated May 27, 2021: Cytogram of the malignant process.

Histopathological conclusion: Fragments of the pancreas with fibrosis, with single cells, which is characteristic of a malignant process. To clarify the histogenesis, an IHC study is performed.

Histopathological examination (IHC) RSK+, SK20-, Villin-, Ki67+. Conclusion: Adenocarcinoma G3.

Final diagnosis: Cancer of the head of the pancreas, T ₃ N _X M ₀ Obstructive jaundice severe.

The use of a double method of morphological verification makes it possible to increase its efficiency. The simplicity and safety of the method makes it economically more profitable and safe, significantly reducing the time of inpatient treatment of the patient.

Claims (1)

A combined method for morphological verification of tumors of the pancreatic head and distal choledochus with bilioduodenal drainage, including transhepatic puncture access to the bile ducts, performed under fluoroscopic control with the possibility of performing cholangiography, carried out by passing a metal conductor through the tumor stenosis along the true lumen of the choledochus and taking material for histological examination. studies from different tumor sites with simultaneous bougienage of the transhepatic puncture canal and tumor occlusion zone, external-internal drainage of the bile ducts and endoscopic papillosphincterotomy of the major duodenal papilla, characterized in that antegrade brush biopsy of the distal choledochus is performed simultaneously.

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