RU2798719C1 - Method of preventing bleeding during removal of polypoid formations of the mucous membrane of the hollow organs of the gastrointestinal tract through the use of an endoscopic ligating loop - Google Patents

Abstract

FIELD: medicine; interventional endoscopy; gastroenterology.

SUBSTANCE: invention can be used in the endoscopic treatment of polypoid formations of the mucous membrane of the gastrointestinal tract. The first step is to make a non-dissolving endoscopic Raeder's loop. The second step is to thread the movable end of the Raeder's loop into the metal loop of the device. In this case, the device is a metal loop in a hard plastic tube. The metal loop is connected with a metal thread to the handle. A bead with a channel of a suitable diameter is used as a gasket. Raeder's endoloop is tightened after it is thrown onto the leg of the formation to be removed by traction on the metal handle located at the proximal end of the proposed instrument. The release of the tightened Raeder's loop is carried out by the reverse movement of the handle, for which the traction was carried out, followed by pulling the instrument and the endoscope towards itself.

EFFECT: method is simple and easy to use, does not require the use of special equipment, provides a reduction in trauma, as it does not require cutting and removing the superimposed endoloop in the postoperative period.

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Description

The invention relates to medicine, namely to interventional endoscopy, and can be used in the endoscopic treatment of neoplasms of the mucous membrane of the gastrointestinal tract.

Early diagnosis and prevention of cancer is one of the most important tasks of modern health care. The development of high-resolution endoscopy, analog and digital image enhancement methods, as well as close-focus and magnifying endoscopy, has brought us much closer to solving the problem of early detection and minimally invasive treatment of tumors of the gastrointestinal tract.

Currently, the main way to prevent the occurrence of malignant neoplasms of the gastrointestinal mucosa is the early detection and removal of benign neoplasms with the potential for malignancy. To this end, endoscopic examinations are included in the screening and follow-up program during medical examinations. [1, 2] The formations of the mucous membranes of hollow organs identified during endoscopic studies, which have the potential for malignant degeneration, must be removed. Removal of such formations should be performed radically and in the least traumatic way available. Thus, the preferred method of removal in most cases is endoscopic, which consists in performing endoscopic resection of the mucosa with or without dissection in the submucosal layer.

Endoscopic resection of the mucosa should be performed within macroscopically intact tissues. When removing polypoid formations (0-1p according to the Paris classification), resection can be carried out within the polyp stem. A frequent complication of such an intervention is bleeding from the feeding legs of the polyp. [3] The most commonly used methods for preventing this complication are preliminary ligation or clipping of the feeding pedicle performed before resection [4]. Ligation is the preferred method in this case, as prophylactic clipping increases the cost of the procedure and has also been reported to be associated with a higher incidence of post-polypectomy syndrome compared to ligation. [5,6]

For the prevention of bleeding after polypectomy for the purpose of prophylactic ligation, most endoscopists currently prefer disposable ligation loops such as Olympus HX-400U-30. The use of this device is associated with a satisfactory result of treatment and is characterized by reliable prevention of post-manipulation complications. However, it has the disadvantage of low availability and relatively high cost.

EFFECT: creation of a simple and easily accessible method for ligation of the legs of polypoid formations of the mucous membrane of the hollow organs of the gastrointestinal tract during their endoscopic removal.

The proposed device for prophylactic ligation is a metal loop in a rigid plastic tube. The metal loop is connected with a monofilament or braided metal thread to the handle (Fig. 1, 2).

As a metal part of the assembly device, we used a loop for endoscopic resection of the mucosa with an opening of 25 mm and a sleeve from it. A Teflon tube from a polypectomy loop was used as a plastic tube of the device. As a handle, a plastic sleeve was used, usually used for rotating conductor strings.

The device is used after the introduction of the endoscope into the lumen of the hollow organ and the detection of a polypoid formation, the removal of which is planned. The first stage of the endoscopist is the manufacture of a non-dissolving endoscopic loop of Raeder (Figure 3). To do this, it is proposed to use a surgical suture material based on polypropylene with a metric diameter of 4. The second stage is the threading of the moving end of the Roeder loop into the metal loop of the device (Fig. 4, 5, 6, 7, 8). To prevent the migration of the Raeder endoloop node into the tube channel when the loop is tightened, a bead with a channel of a suitable diameter is used as a gasket (shown in Fig.5, 6, 7 and 8 at the base of the Raeder loop). The fixation of the endoloop in the channel of the device occurs due to the friction force that occurs between the movable end of the thread and the metal loop into which the thread is threaded and for which traction is subsequently carried out (Fig. 5).

Raeder's endoloop is tightened after inserting the device into the lumen of the hollow organ through the instrumental channel of the endoscope and throwing it onto the stem of the removed polypoid formation by traction on the metal handle located at the proximal end of the proposed device (Fig. 9 and 10). Traction is carried out until a feeling of resistance appears. Signs of sufficient force when tightening the loop are as follows:

1. Lack of mobility of the loop on the stem of the polyp.

2. Formation of a strangulation furrow on the stalk of the polyp at the site of the loop.

3. Change in color of the top of the polyp, the appearance of cyanosis.

The release of the tightened Roeder's loop is carried out by the reverse movement of the handle, for which the traction was carried out, with the subsequent pulling of the device and the endoscope towards itself (Fig. 11 and 12). The view of the bed of the removed polypoid formation is shown in Fig. 13. The view of the bed of the removed polypoid formation is shown in Fig. 13.

Cutting and removing the superimposed endoloop is not required later. Its rejection occurs spontaneously due to tissue necrosis in the area of the superimposed node. Necrosis with subsequent rejection of the loop, as a rule, occurs within 3 to 7 days after the intervention and is not accompanied by the occurrence of a significant mucosal defect. The specified time is sufficient for the occurrence of thrombosis of the vascular pedicle of the removed polyp and effective prevention of bleeding after polypectomy.

Brief description of the drawings

Fig. 1. General view of the proposed device (diagram).

Fig. 2. General view of the proposed device (photo).

Fig. 3. Methods of knitting a non-dissolving loop.

Fig. 4. Installing the endo loop (scheme).

Fig. 5. Installing the endo loop (scheme).

Fig. 6. Installing the endo loop (photo).

Fig. 7. View of the installed endo loop (scheme).

Fig. 8. View of the installed endo loop (photo).

Fig. Fig. 9. View of the endoloop tightened on the polyp pedicle (scheme).

Fig. 10. View of the endoloop tightened on the polyp pedicle (endophoto).

Fig. 11. View of the endoloop, tightened on the stem of the polyp and dropped from the instrument (scheme).

Fig. 12. View of the endoloop tightened on the polyp pedicle and dropped from the instrument (endophoto).

Fig. 13. Polyp removed (endophoto).

1 - handle

2 - metal rod

3 - metal sleeve

4 - Teflon tube

5 - metal thread

6 - metal loop

7 - Raeder's endo loop

8 - bead

9 - free end of the Raeder loop.

Clinical examples.

1. Patient A., 58 years old, was hospitalized in a planned manner to perform endoscopic resection of the colon mucosa for a polypoid formation of the sigmoid colon mucosa 0-1p JNET 2a 15 mm on a 7 mm stem, macroscopically defined as a tubular adenoma. The patient underwent endoscopic resection within the pedicle of the polyp with prophylactic ligation by the proposed device. The extracted biomaterial was sent for histological examination with subsequent confirmation of the macroscopic conclusion about the structure of the formation. There were no postoperative complications, including bleeding from the bed of the removed polyp, and the patient was discharged on the 2nd postoperative day.

2. Patient N., 71 years old, was hospitalized in a planned manner in order to perform endoscopic resection of the gastric mucosa for a hyperplastic polyp 0-1p 21 mm on a pedicle 8 mm, histologically confirmed. The patient underwent endoscopic resection within the pedicle of the polyp with prophylactic ligation of the proposed device with two loops. The extracted biomaterial was sent for histological examination, followed by repeated histological confirmation. There were no postoperative complications, including bleeding from the bed of the removed polyp, and the patient was discharged on the 3rd postoperative day.

Bibliography

1. Order of the Ministry of Health of the Russian Federation N 404n "On approval of the procedure for conducting a preventive medical examination and medical examination of certain groups of the adult population" dated 08.27.2021.

2. Zauber AG, Winawer SJ, O'Brien MJ et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N. Engl. J. Med. 2012; 366:687-696.

3. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. https://dx.doi.org/10.1055/s-0043-102569 | Endoscopy 2017; 49(03): 270-297

4. Therapeutic endoscopy of the gastrointestinal tract: atlas / ed. X. J. Chun, S.-K. Young, M.-G. Choi; per. from English. ed. S. A. Palevskoy. - M.: GEOTAR-Media, 2017. - 480 p. : ill.4.

5. Use and cost-effectiveness of prophylactic clips following colonoscopic polypectomy. Andrew J. Gawron, MD, Journal of Gastroenterology and Hepatology 2014 May; 10(5):322. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4076880/

6. Prophylactic clip Application before endoscopic resection of large pedunculated colorectal polyps in patients receiving anticoagulation or antiplatelet medication. Surgical Laparoscopic Endoscopic Percutaneous Techniques 2012 Oct; 22(5):254

Claims (1)

A method for preventing bleeding when removing polypoid formations of the mucous membrane of the hollow organs of the gastrointestinal tract, including the manufacture of a non-dissolving endoscopic Roeder's loop, threading the movable end of the Roeder's loop into the metal loop of the device, which is a metal loop in a rigid plastic tube connected by a metal thread to the handle, tightening the loop Roeder after throwing it on the leg of the removed polypoid formation by traction by the metal handle using a bead with a channel as a gasket, releasing the tightened Roeder loop by the reverse movement of the handle, for which traction was carried out, followed by pulling the device and the endoscope towards itself.

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