RU2809203C1 - Method of endoscopic intraoperative truction of gastrointestinal tract forms using polypectomy loop - Google Patents

Abstract

FIELD: medicine; endoscopy; gastroenterology.

SUBSTANCE: endoscopic loop is preliminarily fixed on the outside of the endoscope tube at its distal end, and closed with a silicone cap. Forceps are passed through the instrumental channel of the endoscope to fix the formation. After fixation, the formation is pulled to the distal cap, the loop is opened, and by pushing it forward in relation to the endoscope, the loop is inserted onto the formation. Simultaneous movement of the endoscope, forceps and formation towards the doctor, and the loop away from the doctor, positions the loop on the formation and its subsequent fixation.

EFFECT: method provides the ability to control the endoscopic loop, securely fix the loop to the area of interest to provide traction of varying strength, simplifies, speeds up and increases the safety of the operation.

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Description

The invention relates to medicine, namely to endoscopic surgery and can be used for endoscopic intraoperative traction of formations using a polypectomy loop.

Removal of epithelial and subepithelial lesions of the gastrointestinal tract using flexible intraluminal endoscopy is currently the preferred technique.

One of the limitations of resection using this method is the work with one instrument, passed through the instrumental channel of the endoscope, which excludes bimanual work. To solve this problem, flexible endoscopes with two working channels were developed [1], however, working with instruments using these channels is only possible in the direction away from you and towards you, in a coaxial direction, which significantly limits their use; it should also be noted that two-channel endoscopes have larger diameter compared to standard devices and relatively limited flexibility.

Another direction of development is the use of traction devices, in the form of which various versions of threads and elastic bands are proposed, which are fixed to the wall of the organ at one end and to the zone of interest (removable formation) at the other [2]. The limitations of this technique are the need to use disposable clipping devices, which increase the cost of the procedure, as well as the impossibility of strong mechanical traction due to the weakness of fixation of the clip to the tissue, which is especially important when removing submucosal tumors, which are often deeply implanted in the muscle layer and, with their high density , it is difficult to attach a clip to them.

In this regard, it seems promising to use a reusable endoscopic loop, which can be reliably fixed to the tumor, transferred to different parts of it if necessary, and traction of varying strength.

One of the most difficult issues was the method of inserting a loop, which has a fairly rigid tube, to the area of interest, as well as fixing it to the formation, since it should be located outside the canal and therefore uncontrollable.

The technical result of the invention is the ability to control the endoscopic loop and securely fix the loop to the area of interest (formation) to provide traction of varying strength, simplifying, speeding up and increasing the safety of the operation.

The specified technical result is achieved in a method of endoscopic intraoperative traction of formations using a loop for polypectomy, including delivery of the loop to the area of formation using an endoscope, in which the endoscopic loop is fixed on the outside of the endoscope tube - at its distal end, closed with a silicone cap, after delivery of the loop to the formation zone is carried out by simultaneously releasing the loop from the distal end of the endoscope and placing it on the formation as follows: forceps or a grip are passed through the instrumental channel of the endoscope to fix the formation; after fixation, the formation is pulled as close as possible to the distal cap, the loop is opened and by pushing it forward in relation to To the endoscope, a loop is inserted onto the formation, then the endoscope, forceps and the formation are simultaneously moved towards themselves, and the loops are positioned away from themselves on the formation, followed by its fixation.

Thus, an essential feature of the invention is the delivery of an endoscopic loop to the zone of interest (zone of formation), fixed to the endoscope tube, which expands its manipulative capabilities.

To prevent damage to the endoscope shell, we suggest pre-installing a standard silicone cap used for endoscopic operations on the distal end. After releasing the loop from the distal end of the endoscope, it becomes uncontrollable and fixing it on the tumor is difficult, especially if the tumor has a fairly large volume and density.

Another essential feature of the invention is that the release of the loop and its application to the tumor must be carried out simultaneously. To do this, it is necessary to approach the tumor, pass forceps or a grip through the instrumental channel and use them to fix the tumor in the required area. After fixation, the tumor is pulled as close as possible to the distal cap and then a loop is opened, which is fixed to the cap; then lightly pushing forward in relation to the endoscope leads to its transition to the tumor, then movement of the endoscope, forceps and tumor towards itself, and the loop away from itself at the required distance leads to correct positioning, then the loop is fixed on the tumor.

The method is confirmed by the following clinical examples.

Example 1. Submucosal neoplasm of the esophagus.

Patient B., 54 years old. According to VEGDS data from 03/21/2022, at the level of the cardioesophageal junction, a submucosal formation of a plexiform shape is determined, occupying up to half the circumference of the esophagus along the right wall of the esophagus with a diameter of up to 3 cm. According to endo-ultrasound data from 03/30/2022, a submucosal formation of a plexiform shape is determined, occupying up to half-circumference of the esophagus, transverse size 24.1×6.8 mm, heterogeneous hypoechoic structure with hyperechoic inclusions, with uneven clear contours, most likely emanating from the 4th echo layer (muscular layer) of the esophageal wall (leiomyoma?), formation predominantly with extraorgan growth.

03/30/2022 The tumor was removed using the method of submucosal tunnel endoscopic resection, during which an initiating mucosal incision was made 4 cm proximal to the formation. The device is passed into the submucosal layer. A tunnel has been formed. Using the technique of the proposed method, “the loop is fixed at the distal end of the endoscope tube, previously protected with a silicone cap and delivered to the area of interest, the loop is immediately released from the distal end of the endoscope and applied to the tumor as follows: forceps or a grip are passed through the instrumental channel of the endoscope and fixed they hold the tumor, after fixing the tumor, pull it as close as possible to the distal cap and then open the loop fixed on the cap; by pushing forward in relation to the endoscope, the loop is transferred to the tumor; by a simultaneous movement of the endoscope, forceps and tumor towards itself, and the loops away from themselves at the required distance, the loop is positioned on the tumor and fixed,” the formation is isolated from the surrounding tissues using an electrosurgical knife. The edges of the initiating incision were closed with endoclips.

The operation time was 45 minutes. No intraoperative or postoperative complications were noted.

According to histological examination: leiomyomacardioesophageal junction.

Example 2. Epithelial neoplasm.

Patient R., 75 years old. According to the VKS data, in the ascending colon, closer to the Bauginian valve, an epithelial formation of type 0-IIa+Is with a creeping component and a villous surface, measuring 6.0 × 5.5 cm, is visualized. 09.09.2022. endoscopic dissection of the tumor in the submucosal layer was performed using the claimed method. The tumor was removed en bloc and removed for histological examination. The operation time was 110 minutes. No intraoperative or postoperative complications were noted.

According to histological examination: tubular villous adenoma with low-grade intraepithelial neoplasia and areas of high-grade intraepithelial neoplasia.

The claimed method performed jktt 100 operations. In all cases, thanks to the ability to control the endoscopic loop and reliable fixation of the loop to the area of interest (formation), traction of varying strength was provided, while the operation time was reduced and no complications arose.

The method provides the ability to control the endoscopic loop, securely fix the loop to the area of interest to provide traction of varying strength, simplifies, speeds up and increases the safety of the operation.

Information sources:

1. Lu J, Wang R, Ji R, Lu X. Double-endoscope assisted endoscopic submucosal dissection for treating gastric neuroendocrine tumor. Endoscopy 2022 Jul; 54(7):E342-E343. doi:10.1055/a-1540-6226. Epub 2021 Jul 19. PMID: 34282584.

2. Nomura T, Kamei A, Sugimoto S. Gastric endoscopic submucosal dissection using the "pulley clip with elastic line" method. Endoscopy May 2018; 50(5): E104-E106. doi:10.1055/s-0043-125358. Epub 2018 Feb 2. PMID: 29396974.

Claims (1)

A method of endoscopic intraoperative traction of formations of the gastrointestinal tract using a loop for polypectomy, including delivery of the loop to the area of formation using an endoscope, characterized in that the endoscopic loop is first fixed on the outside of the endoscope tube at its distal end with a closed silicone cap, after delivery of the loop to the formation zone is carried out by simultaneously releasing the loop from the distal end of the endoscope and inserting it onto the formation as follows: forceps are passed through the instrumental channel of the endoscope to fix the formation; after fixation, the formation is pulled to the distal cap, the loop is opened and by pushing it forward in relation to the endoscope, insertion is carried out loops on the formation, then simultaneous movement of the endoscope, forceps and formation towards you, and the loops away from you, position the loop on the formation with its subsequent fixation.