RU2258480C1 - Method for nontypical endoscopic papillotomy - Google Patents

Abstract

FIELD: medicine, endoscopy.

SUBSTANCE: while performing nontypical endoscopic papillotomy one should dissect the top of large duodenal papilla ampoule in the center at "cutting" mode for the whole length against transitional fold to its mouth: mucous, submucous, muscular layers. The method enables to perform accurate visual control during interference, exclude complications associated with papillotome's shift.

EFFECT: higher efficiency.

4 dwg, 2 ex, 2 tbl

Description

The present invention relates to medicine, namely to endoscopy, and can be used for the diagnosis and treatment of diseases associated with the defeat of biliary and pancreatic duct systems.

There is no doubt about the prevalence of hepatopancreatoduodenal zone in the general structure of pathology, benign and malignant diseases, for the diagnosis and treatment of which both direct contrasting of biliary and pancreatic duct systems and the possibility of instrumental access to these systems are necessary. At the present stage of the development of medicine, the method of choice is direct transverse renal access with the aim of performing x-ray diagnostic and diapevic interventions. As a rule, in most cases, to achieve this goal it is necessary to perform endoscopic papillotomy (EPT).

Introduced into clinical practice in 1974, endoscopic papillotomy is now widely used in specialized medical institutions.

The classical (typical) - cannulation method of papillotomy is a universally recognized method of choice and adopted by us as an analogue (I.L. Nastashenko, OV Dovbenko "Endoscopic papillosphincterotomy". Endoscopic surgery, 6, 2002, p. 48-52) . In this method, a papillotome (1) is inserted into the mouth of Vater's nipple (2) and set in the direction of the choledochus. Introduction, the correct installation (at 10-11 o'clock of the dial) of the papillotome and to a sufficient depth is the basis of a successful operation. Before making the cut, the electrode-string is pulled (3) until the roof of the nipple ampoule begins to rise. The incision is made by alternating inclusion of the “cutting” and “coagulating” currents of the minimum required power. The length of the incision in each case is determined individually and depends on the anatomical version of the structure and purpose of the operation.

Figure 1 shows a diagram of cannulation endoscopic papillotomy. The advantages of this method:

1. Good controllability, due to the fact that the papillotome is fixed in the terminal section of the duct and basically only control over the length of the incision is required.

2. The likelihood of serious complications, in comparison with pre-dissection and suprapapillary choledochoduodenostomy, is significantly less.

3. EPT can be performed in one stage in the vast majority of cases.

Disadvantages:

1. The main drawback is that cannulation is necessary to perform this technique, and in about one third of cases it fails.

2. There may be extensive thermal damage that occurs when the cutting part of the string electrode is deeply inserted, especially in cases when the common bile duct falls into the duodenum at an acute angle and the wrong choice of electrocutter modes. This leads to the development of postoperative complications: the early ones - such as pancreatitis, bleeding, perforation, and the late ones - fibrosis and restenosis.

In case of unsuccessful cannulation attempts, non-cannulation endoscopic papillotomy (atypical) is performed. Two main variants are known in the literature - pre-dissection and suprapapillary choledochoduodenostomy. Pre-dissection was taken by us as a prototype. The technique for its implementation is as follows: the end electrode (1) is removed from the catheter by 2-3 mm, is installed at the upper edge of the mouth (2), and when the electric current is turned on, it is sent up and to the left. In this case, cut the entire thickness of the roof of the ampoule (3). In order to avoid infusion of the mouth, it is necessary to apply current in cutting mode. The length of the cut can vary from 3-4 mm to 6-8 mm.

Figure 2 shows a diagram of atypical endoscopic papillotomy (pre-dissection).

The main advantage of this method is the absence of cannulation and the so-called “quick” incision.

Disadvantages:

1. The papillotomy is not fixed in the duct and during the movements of either the endoscope or the intestinal wall can freely move in any direction, and this, with sudden involuntary movements, leads to a loss of controllability during the operation — significant difficulties arise in fulfilling the optimal characteristics of the direction, length and depth of the incision .

2. Difficulties with the right choice of direction, length and depth of the incision arise due to loss of orientation in those cases when a quick incision is not immediately possible and tissue swelling develops or bleeding begins - the manipulation has to be postponed for 2-4 days.

3. The listed technical difficulties cause a much larger number of intra- and postoperative complications of pre-dissection in comparison with the cannulation technique.

The technique of suprapapillary choledochoduodenostomy (SPKhDS) (A.S. Balalykin "Endoscopic abdominal surgery". M., 1996, pp. 34-36).

The principle of SPHDS operation is that access to duct structures is carried out in two stages. The initial incision is made in the upper third of the roof of the BDS ampoule, and then cannulation of the common bile duct is made through the hole obtained and, if necessary, the incision is enlarged. Figure 3 shows a diagram of suprapapillary choledochoduodenostomy.

The initial incision is made with an end papillotome (1) arcuate or transverse to a depth of 2-3 mm. After opening the lumen of the BDS ampoule, which is usually seen by the beginning of bile flow, cannulation of the common bile duct with cannulation papillotome (2), its contrasting and, if necessary, increase the length of the incision (3).

All of the listed disadvantages of pre-dissection are characteristic for this method.

From our point of view, the main disadvantage of this method is the lack of clear visual criteria for the required length and depth of the cut. After all, bile does not always begin to flow into the duodenum, and if the incision is made incorrectly, an attempt at cannulation often leads to the creation of a false move.

Tasks:

1. Development of the technique of non-cannulation endoscopic papillotomy, which provides better controllability and orientation in the tissues when performing an incision in comparison with the pre-dissection technique and suprapapillary choledochoduodenostomy.

2. Reducing the number of complications in non-cannulation endoscopic papillotomy.

3. Reducing the number of stages when performing EPT.

4. Improving the results of endoscopic diagnosis and the immediate and long-term results of treatment of this group of patients.

The technical novelty of the method is that access to the duct structures of the large duodenal papilla (BDS) is achieved by layer-by-layer dissection of its roof. The technical result is due to the fact that the following principles are based on a layered non-cannulation papillotomy:

1. The section of the mucous membrane is made immediately over the entire length from the transitional fold in the suprapapillary section in the center of the roof of the nipple ampoule to its mouth. This allows you to immediately have a clear reference to the direction and length of the cut.

2. The papillotome electrode is positioned along the incision line and is supported on the mucosa along the entire length, which ensures the fixation of the papillotome sufficiently reliable against accidental displacements. Then briefly turn on the current in cutting mode. Subsequently, the procedure is repeated. With this technique, we have one variable - turning on, turning off the current, and with the pre-dissection technique two - turning on, turning off the current and moving the knife electrode in the tissues.

3. A clear visual control of the depth of the incision is achieved due to the fact that dissected muscle fibers (lamina propria tunika mucosae) contract and stretch the edges of the wound, providing a good visualization of the site of intervention. The end-knife electrode is completely in the field of view all the time, and is not located in the lumen of the ampoule - this significantly reduces the thermal damage to the surrounding tissues and controls the depth of its penetration.

4. If bleeding from such an incision occurs, it is easier to stop it (since the bleeding vessel is usually clearly visible and is not in the depth of the wound, but on a practically horizontal surface) and then continue the operation without delaying to the 2nd stage.

5. Significantly reduced operation time. In almost all situations, with the right technique for performing a layered EPT, an operation can be completed in one step. In relation to the prototype, the claimed method has the following distinctive features: in our method, the roof of the large duodenal nipple (1) is dissected in layers, starting from the surface tissues, advancing to the deeper ones (mucous (2), submucous (3), muscularis (4)) immediately for the entire specified length of the cut (5), depending on the goal. We use only the "cutting" mode. Figure 4 shows a diagram of a layered atypical endoscopic papillotomy.

The proposed method of atypical EPT is carried out as follows: the patient is premedicated 30-40 minutes before surgery (methacin solution 0.1% -4.0, relanium 2.0). When performing an atypical EPT, patient premedication is very important, since the papillotome is not fixed in the BDS ampoule (as with a typical EPT) and involuntary regurgitation during the operation is fraught with formidable complications.

The study is performed in the operating room under Rg control. The patient is placed on his left side, his left arm is placed behind his back. The left leg is straight, the right leg is in a bent state. Local anesthesia (posterior pharyngeal wall, left and right palatine arches) is carried out 3-5 minutes before the study with 2% lidocaine solution. The first step is to bring the BDS into a comfortable position and inspect this area. At the same time, they ask the patient to turn on his stomach (the head remains in the same position). In the case when a typical EPT fails (stricture or stenosis of the BDS mouth, papillitis, wedged calculus, atypical location of the BDS with parapapillary diverticula), a decision is made to perform an atypical EPT. A papillotome is installed over the roof of the BDS ampoule. Dissection is carried out in layers, gradually opening the roof of the BDS ampoule (mucous membrane, submucous membrane, muscle sphincter), using only the "cutting" mode of electric current. The crucial point is to make a cut along the entire length of the roof of the BDS ampoule - from the transverse fold to the mouth, gradually deepening the cut. When deepening the incision, due to the reduction of crossed muscle fibers (lamina muscularis tunica mucosa), its edges begin to move apart, which allows you to clearly visualize all the tissues in the wound, so the moment of opening the lumen of the BDS ampoule is clearly defined.

With this technique, a good visualization of the location of the papillotome, dissected tissues, bleeding vessels (if any), the mouth of the common bile duct is provided. This, in turn, helps to avoid such serious complications as bleeding, retroduodenal perforation, pancreatitis, as well as reduce the number of repeated endoscopic interventions.

Example 1. Patient O., 91 years old, was admitted to the clinic 02.11.00, with D-s: ZhKB. Choledocholithiasis (Cholecystectomy 1998). November 2, 00, was conducted by the RCP. At the same time, it was revealed that the nipple is swollen, enlarged, an adenoma in its mouth. Cannulation in this case is impossible due to a sharp narrowing of the mouth of the BDS. The patient produced an atypical "layer-by-layer" EPT of 0.8 cm. After visualization of the mouth of the common bile duct, cannulation was performed with a catheter. The choledoch extended to 2 cm is contrasted. In his lumen - the shadows of 7 calculi. Using a basket probe of the Dormia type, mechanical lithoextraction (MBE) was performed. Bile flow in the duodenum is restored. After minor infusion therapy and monitoring of the patient's condition, on 04.11.00, the patient was discharged from the hospital in satisfactory condition.

Example 2. Patient Ch., 72 years old, was admitted to the clinic on January 08, 2004 with a diagnosis of cholelithiasis, the condition after cholecystectomy with external drainage of the common bile duct from the mini-access, residual choledocholithiasis. When performing fistulography in n / 3 of the common bile duct, the calculus is determined in D up to 1.0 cm. When performing RCP, it was revealed that the BDS is located at the bottom of the diverticulum. Previously known methods of papillotomy endoscopically sanitize bile ducts is not possible: cannulation is unsuccessful, and the use of atypical papillotomy in the classic version is dangerous with retroduodenal perforation. We used the technique of atypical layer-by-layer papillotomy using an antegrade conductor conducted into the lumen of the duodenum. The operation ended successfully. In two stages, the calculus of the common bile duct was removed. 01/19/2004, in a satisfactory condition the patient was discharged.

From 1998 to 2003 In our clinic, 1904 endoscopic papillotomies were performed for various diseases. Of these, in a typical way - 32% (609 patients), atypical - 42% (800 patients), combined - 26% (495 patients).

Two teams of surgeons with approximately the same work experience carried out work in the X-ray room. One team performed atypical EPT according to the standard method described in the literature. Another team used a layered EPT. The number of patients in each team was approximately the same.

We analyzed the work of each team according to two indicators: the number of one-stage papillotomies (i.e., achieving the goal of papillotomy in one stage in a particular patient) and the number of complications obtained when performing EPT in an atypical way.

Table 1.
The number of one-stage operations (in%). Year 1st brigade 2nd brigade 1998 63.6 71.1 1999 72.6 76.1 2000 79 84.2 2001 75 90.1 2002 64.3 90 2003 76.5 87.9

The table shows that the use of layered EPT significantly increases the number of one-stage operations.

Table 2.
The frequency of complications when performing EPT in an atypical way (in%). Year 1st brigade 2nd brigade 1998 3.8 2.2 1999 3.6 2,8 2000 10.5 7.7 2001 12.5 5.5 2002 14.3 10 2003 5.3 2,8

The table shows that the number of complications in the 2nd brigade is significantly lower than in the first.

Thus, the developed method when used will improve the efficiency of specialized medical care for patients by reducing complications and reducing the hospital stay of patients.

Claims (1)

A method of atypical endoscopic papillotomy, including dissection of the ampoule of the large duodenal papilla (BDS), characterized in that the roof of the BDS ampule is cut in the center in the "cutting" mode for the entire length from the transitional fold to its mouth in layers: mucous, submucous, muscle layers.

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