RU2618207C2 - Method of endoscopic bougienage of cicatrical strictures of choledoch using oral choledochoscope - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine and surgery. Through instrumental channel duodenoscope into lumen of choledoch ultra-fine oral choledochoscope is introduced. Through instrumental channel of choledochoscope conductor is introduced. Under visual control conductor is brought behind choledoch stricture with controlled distal end of choledochoscope. After removal of choledochoscope bougienage of stricture is made via installed conductor.

EFFECT: method enables endoscopic bougienage of cicatrical choledoch strictures, when conductor is failed to brought behind stricture area under X-ray control.

1 cl, 8 dwg, 1 ex

Description

The invention relates to medicine, namely to surgery, and can be used for endoscopic bougienage of cicatricial strictures of the common bile duct using an oral choledochoscope.

Cicatricial strictures of the common bile duct occur mainly as a result of its iatrogenic damage. Currently, the number of such patients is not only not decreasing, but also has a slight tendency to increase. So, if the frequency of iatrogenic damage to the bile ducts was stable by the end of the last century and amounted to 0.05-0.2%, then with the development and implementation of clinical practice of laparoscopic cholecystectomy, it increased to 0.3-3% (Halperin et al. 1998 ; Borisov A.E. 2003). It should be noted that in 80-90% of cases, iatrogenic damage to the bile duct during cholecystectomy results in the development of strictures, scarring of the formed bile intestinal anastomoses occurs in 8.4-28.3% of cases (Shalimov A.A. et al., 1975; Petrovsky B.V. et al., 1980). This contingent of patients is a complex group not only from a medical point of view (repeated repeated surgical interventions, the presence of complications of the disease, adhesions, concomitant diseases, etc.), but also costly from the economic one (the use of expensive drugs, prolonged hospital stay, etc.). ) The results of surgical treatment of damaged bile ducts indicate a high incidence of complications (10-48%), mortality (3.2% -28.2%) and unsatisfactory long-term results (10-38%) (Borova et al. 1987; Brazhnikova N. A. et al. 1996; Milonov et al. 1988; Halperin E.I. et al., 2001).

The difficulties of surgical correction, a significant number of unsatisfactory results, and a decrease in the quality of life of patients after reconstructive operations compel us to look for new ways to solve the problem (Beburishvili A.G. et al., 1996; Borovoi E.I. et al., 1987; Panchenkov D.N. et al., 2004).

With the development of minimally invasive technologies, many corrective interventions on the common bile duct began to be performed endoscopically. Such trans-capillary interventions, such as bougienage, dilatation, stenting of the common bile duct, are widely used in specialized medical institutions. The essence of these minimally invasive surgeries is to conduct, under X-ray control, the conductor above the stricture site, followed by the conduction of the appropriate instrument (bougie, dilator, stent, etc.) along the conductor. However, in some cases, due to the narrow clearance, the extended and tortuous course of the stricture, it is not possible to get a conductor behind the stricture. The flat image of the monitor of the X-ray machine, the inability to control the distal end of the conductor do not allow to lead the conductor above the stricture region and to perform the entire amount of corrective endoscopic interventions.

An analogue of the invention is the traditional method of endoscopic bougienage of cicatricial strictures of the common bile duct under radiological control. Its essence is as follows. Through the instrumental channel of the duodenoscope, a conductor is brought into the lumen of the common bile duct. Under X-ray control, this conductor is held above the cicatricial stricture. Further, a bougie is started along the installed conductor and bougieure of the common bile duct stricture is performed. However, it is often not possible to get under the radiological control of the conductor into the narrow lumen of the stricture. This forces you to perform more traumatic and expensive abdominal operations.

The aim of this invention is to develop a method for endoscopic bougienage of cicatricial strictures of the common bile duct in those cases when, using the traditional method of execution (under X-ray control), it is not possible to conduct the conductor beyond the stricture zone, which will allow to avoid more traumatic surgical interventions in this category of patients.

The essence of the proposed method is as follows. In the case when it is not possible to bring the conductor beyond the stricture region under X-ray control, an ultrathin oral choledochoscope (external diameter 3.2 mm) is inserted into the lumen of the choledoch through the instrument channel of the duodenoscope. This unit has its own instrument channel with a diameter of 1.0 mm. Through this instrument channel, due to visual control and the controlled distal end of the choledochoscope, a conductor is passed beyond the bile duct stricture area. After removing the choledochoscope, along the installed conductor, stricture zone is poured.

The method is as follows: in the case when the stricture (3) has a narrow clearance and a complex course, the conductor (2) is folded in front of the stricture and it cannot be brought under radiological control over the stricture region (scheme No. 1).

Scheme number 1. Difficulties with conducting the conductor through the stricture region.

In this case, an oral choledochoscope (8) is passed through the instrument channel of the duodenoscope (9). Through the large duodenal papilla (BDS) (10), the choledochoscope (8) is inserted into the choledoch (5). The lumen of the stricture (3) is visualized and, under visual control, using the controlled distal end of the choledochoscope (8), a conductor (2) is inserted through the instrument channel of the choledochoscope (11) into the lumen of the stricture (3). After removing the choledochoscope, along the installed conductor, bougieurage is performed (scheme No. 2).

Scheme number 2. Conducting a conductor through a stricture using an oral choledochoscope.

The advantages of this method: with a narrow clearance and a complex course of cicatricial stricture of the common bile duct, a flat x-ray picture and an uncontrolled distal end of the conductor sometimes do not allow the conductor to pass beyond the stricture region. After the establishment of an oral choledochoscope, we have the opportunity to visualize the stricture lumen. In addition, the choledochoscope has a distal end controlled, which greatly facilitates the conductor.

The method was tested in GBUZ "KKB number 2", Krasnodar. In the period from May 2012 to May 2014, 6 patients were treated with this method. The use of this method in these patients allowed performing endoscopic bougieuding of the common bile duct and avoiding complex surgical interventions.

Clinical example: patient Sh. 68 years old, was admitted to the clinic on August 23, 2012 with a diagnosis of Condition after cholecystectomy (2011). Cicatricial stricture in / 3 of the common bile duct. Suprastenotic dilatation of the intrahepatic ducts. Obstructive jaundice. Complaints of pain in the right hypochondrium, icteric skin and sclera, dark urine, clarified feces, a periodic increase in temperature to 38 ° C in the evenings, weakness. During further examination: transabdominal ultrasound (ultrasound) - signs of dilatation of the intrahepatic ducts, diffuse changes in the liver and pancreas, condition after cholecystectomy. Biochemical analysis of blood: total bilirubin - 148 μmol / l, direct bilirubin - 92 μmol / l, ALT - 136, ACT - 216.

After preparation of the patient, retrograde cholangiopancreatography (RCHP) was planned. On May 24, 2014, retrograde cholangiopancreatography was performed with an attempt to bougie. In this case, it was revealed: the duodenum (duodenum) is freely passable, the walls are elastic, active motility, in the lumen - a small amount of foamy bile. BDS in a typical rounded shape. The bile duct is selectively cannulated. When contrasting, the distal parts of the common bile duct up to 0.5 cm. At the level of / 3, the lumen of the common bile duct is narrowed to 0.2 cm due to scar stricture. The proximal stricture of the common bile duct is expanded to 1.3 cm. The dilatation of the intrahepatic ducts is determined. A decision was made to conduct endoscopic bougienage of the common bile duct stricture. A conductor (2) is inserted through the instrument channel of the duodenoscope (10). Due to the narrowness of the stricture lumen (3), numerous attempts to establish a conductor (2) under X-ray control through the stricture lumen (3) were not effective, the conductor (2) curled up before the stricture (photo No. 1).

Photo No. 1. Attempt to conduct a conductor beyond the stricture region.

It was decided to conduct the conductor under visual control using an oral choledochoscope (photo No. 2).

Photo No. 2. The arrangement of apparatus and instruments during oral choledochoscopy.

A choledochoscope (8) was passed through the instrumental channel of the duodenoscope (10) into the lumen of the common bile duct (5). The stricture clearance was visualized (3) (photo No. 3).

Photo No. 3. Clearance of the choledochus stricture visualized using a choledochoscope.

A conductor (2) is inserted through the instrument channel of the choledochoscope (12). Thanks to visualization of the stricture lumen and the controlled distal end of the choledochoscope, it was possible to get a conductor above the stricture (3) (photo No. 4).

Photo No. 4. Institution of a conductor for the area of stricture of the common bile duct using an oral choledochoscope.

The choledochoscope (8) is removed. According to the established conductor (2), the cicatricial stricture of the common bile duct was performed.

Photo No. 5. Bougienage of the stricture of the common bile duct.

With control contrast, the stricture clearance is up to 0.8 cm (photo No. 6).

Photo No. 6. Control radiography after bougieurage.

After infusion therapy and normalization of blood biochemical parameters, the patient was discharged home in satisfactory condition.

Medical and social effectiveness: this method will allow to avoid abdominal operations and carry out endoscopic booging in patients with choledochal stricture in complex clinical cases when, under radiological control, it is not possible to conduct a guide above the stricture zone. This will reduce the length of the patient’s stay in the hospital, reduce the cost of his treatment, increase the psycho-emotional status of patients.

Brief Description of the Drawings:

Scheme 1

1 - Duodenoscope

2 - Conductor, rolled before stricture

3 - stricture

4 - The duodenum

5 - Choledoch

6 - Pancreas

7 - Liver

10 - Instrumental channel duodenoscope

11 - Large duodenal papilla (BDS)

Scheme 2

1 - Duodenoscope

2 - Guide conducted for stricture of the common bile duct

3 - Cicatricial stricture

4 - The duodenum

5 - Choledoch

6 - Pancreas

7 - Liver

8 - Oral choledochoscope

10 - Instrumental channel duodenoscope

11 - Large duodenal papilla (BDS)

12 - Instrumental channel of the oral choledochoscope

Photo 1

1 - Duodenoscope

2 - Rolled conductor in front of stricture

3 - Cicatricial stricture in / 3 choledochus

Photo 2

1 - Duodenoscope

2 - A conductor passed through the instrument channel of the choledochoscope

8 - Oral choledochoscope conducted through the instrument channel of the duodenoscope

Photo 3

1 - Rg-photo. Duodenoscope

3 - Endophoto. Cicatricial choledoch stricture visualized with an oral choledochoscope

8 - Rg-photo. Oral choledochoscope conducted to a stricture.

Photo 4

1 - Rg-photo. Duodenoscope

2 - Conductor instituted for the area of stricture of the common bile duct

3 - Endophoto. Cicatricial choledoch stricture visualized with an oral choledochoscope

8 - Rg-photo. Oral choledochoscope

Photo 5

1 - Rg-photo. Duodenoscope

2 - Conductor instituted for the area of stricture of the common bile duct

9 - Endoscopic bougie

Photo 6

1 - Rg-photo. Duodenoscope

3 - Clearance of the area of stricture of the common bile duct after bougieurage

Claims (1)

A method for endoscopic boughening of cicatricial choledochal strictures, characterized in that if it is not possible under the x-ray control to guide the conductor beyond the stricture into the choledochus, through the instrumental channel of the duodenoscope, an oral choledochoscope is inserted and through its instrumental channel, under visual control, using the controlled distal end of the choledochoscope, a conductor is started for the area of cicatricial stricture with subsequent bougienage along the established conductor.

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