RU2841979C2 - Method for mechanical lithotripsy in treatment of cholangiolithiasis using disposable cholangioscope - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to biliary surgery, and may be used for endoscopic treatment of the patients with complicated choledocholithiasis. If it is impossible to capture a large and/or fixed calculus, a cholangioscope is inserted through an instrumental canal of a duodenoscope into a lumen of the choledoch duct, by means of which the calculus is visualized in the lumen of the choledoch duct. Metal loop is inserted through an instrumental canal of the cholangioscope; the loop is thrown on the calculus under visual control and pulled to a distal end of the cholangioscope. Calculus is fragmented visually with a metal loop against a distal end of a cholangioscope, and then the calculus fragments are removed with a dormia’s basket into a duodenal lumen.

EFFECT: method allows for endoscopic fragmentation of large and/or fixed calculi of the common bile duct in patients with "complex" choledocholithiasis when it is impossible to perform lithotripsy under X-ray control, which will allow to avoid performing more traumatic conventional surgical interventions in this category of patients by performing a combined manipulation using a cholangioscope and crushing the calculus using a loop.

1 cl, 2 dwg, 1 ex

Description

The invention relates to medicine, namely to surgery, and can be used to treat patients with “complex” choledocholithiasis.

Currently, diseases of the pancreatobiliary system are often encountered, accompanied by persistent obstruction of the common bile duct (CBD), which leads to the development of mechanical jaundice, purulent cholangitis, sepsis and, ultimately, without emergency medical care, can cause death.

These conditions, despite the development of medicine, remain an important problem of urgent surgery. Most often, the cause of obstruction of the common bile duct is choledocholithiasis (the presence of stones in the common bile duct). The goal of minimally invasive surgical methods in such situations is to sanitize the common bile duct and restore bile outflow.

The main minimally invasive surgical methods of treating choledocholithiasis are transpapillary endoscopic interventions, which are increasingly used in specialized medical institutions and have proven to be highly effective. Transpapillary endoscopic interventions are performed using specialized endoscopes with lateral optics - video duodenoscopes. Transpapillary endoscopic interventions include: retrograde cholangiography (RCG) - a method of contrasting the common bile duct to determine the size and location of the calculus (choledocholithiasis) in the lumen of the common bile duct; endoscopic papillosphincterotomy (EPST) - a method of dissecting the major duodenal papilla (BS DNA) to extract (extract) calculi from the common bile duct; endoscopic mechanical lithoextraction (EMLE) - a method of extracting calculi from the common bile duct using a Dormia-type basket; endoscopic mechanical lithotripsy (EMLT) is a method of crushing (fragmenting) stones directly in the common bile duct when it is impossible to perform EMLE due to the large size of the stone or the narrowed part of the common bile duct for further extraction of fragments using standard EMLE.

EMLT is most often performed in cases of “complex” choledocholithiasis. In turn, the concept of “complex” choledocholithiasis includes not only large CBD stones, but also fixed stones in the lumen of the duct, for which it is not possible to pass the Dormia basket to capture them and perform EMLT and/or EMLT under X-ray control. In such situations, traditional surgical intervention (choledocholithotomy) is performed using laparotomic or laparoscopic access.

An analogue of the proposed invention is standard endoscopic mechanical lithotripsy in "complicated" choledocholithiasis, when it was possible to capture a calculus in a Dormia-type basket inside the lumen of the CBD, but it is not possible to perform EMLE and extract the calculus from the CBD into the lumen of the duodenum. In such a situation, the Dormia-type basket is crossed in the area of the handle, the video duodenoscope is removed, and the plastic shell is removed from the basket. Then, a metal shell is passed through the metal strings that make up the basket in the CBD to the calculus to create a stop when crushing the calculus. A handle is attached to the proximal end of the basket and then, under X-ray control, endoscopic mechanical lithotripsy is performed - fragmentation of the calculus with metal strings of the Dormia-type basket against the metal shell brought to the calculus. After EMLT of the calculus into smaller fragments, standard EMLT of the fragments into the lumen of the duodenum is performed.

The aim of this invention is to develop a new method of EMLT using a cholangioscope when it is impossible to pass a Dormia-type basket behind the calculus, capture it and perform standard lithotripsy under X-ray control, which will avoid performing more traumatic traditional surgical interventions in this category of patients.

The essence of the method we propose is as follows. In patients with "complicated" choledocholithiasis, when it is impossible to pass a Dormia-type basket behind the calculus to capture it and perform standard EMLT, the cholangioscopy method is used - direct visualization of the CBD using the SpyGlass DS cholangioscope manufactured by Boston Scientific (USA). Today, this model of cholangioscope is the only one in the practice of endoscopists. The diameter of the cholangioscope is 3.33 mm with a working channel of 1.2 mm in diameter. The total length of the cholangioscope is 214 cm.

To perform cholangioscopy, a delivery or mother endoscope is required - a video duodenoscope. We used a video duodenoscope HD + ED34-i10T manufactured by Pentax (Japan). The length of the video duodenoscope is 156 cm, the diameter is 13 mm. The diameter of the working channel is 4.2 mm.

The cholangioscope is passed through the instrument channel of the videoduodenoscope into the CBD, the calculus is visualized, and then it becomes possible to perform visually controlled crushing of “complex” calculi. The angle of rotation of the distal end of the cholangioscope in the CBD is easily controlled in three planes, as with a conventional endoscope, due to the presence of two screws on the handle located at the proximal end.

After visualization of the calculus, an ultra-thin specialized metal loop with its own plastic shell is passed through the instrument channel of the cholangioscope. Under visual control, the loop is thrown over the fixed calculus and pulled to the distal end of the cholangioscope. The proximal end of the loop is connected to the handle, after which visually controlled fragmentation of the calculus is performed with the metal loop on the distal end of the cholangioscope into two parts. After successful lithotripsy, the cholangioscope is removed from the working channel of the duodenoscope and then standard EMLE of the fragments of the destroyed calculus is performed into the lumen of the DNA using a Dormia-type basket.

The method is carried out as follows: if it is impossible to extract a common bile duct calculus using a Dormia basket, and also to perform traditional mechanical lithotripsy through the instrument channel of the video duodenoscope (1), a cholangioscope (3) is inserted into the lumen of the common bile duct (2).

Using a cholangioscope, the CBD calculus (4) is visualized (Fig. 1). An ultra-thin specialized metal loop (5) is passed through the instrument channel of the cholangioscope (3). Under visual control, the loop is passed beyond the area of the impacted calculus (4), the calculus is grasped by the loop and, pressing it firmly against the metal tip of the cholangioscope (3), lithoripsy is performed (Fig. 2).

Next, fragments of the calculus are mechanically extracted into the DNA lumen using a Dormia-type basket.

Advantages of this method: Standard methods of endoscopic lithotripsy of common bile duct stones have a high percentage of efficiency, provided that it is possible to capture the stone in the Dormia basket. There are effective energy methods of lithotripsy, such as electrohydraulic or laser, but they are not available in every clinic. The advantage of this method is that with the help of an oral cholangioscope it is possible to visualize the stone and accurately pass a thinner instrument (loop) behind it, capture it and mechanically destroy it. Then, fragments of the stone are extracted into the lumen of the DNA using a Dormia basket. This allows avoiding more traumatic traditional surgical interventions in this category of patients, reducing the time of hospital stay and, thereby, reducing the cost of treatment, improving the psychoemotional status of patients.

The method was tested in the State Budgetary Healthcare Institution "Krasnodar Regional Clinical Hospital No. 2". In 2023. This method was used to treat 3 patients.

Clinical case: Patient V., 57 years old, was admitted to the emergency department of the City Clinical Hospital No. 2 for the first time with mechanical jaundice, complaints of pain in the right hypochondrium, yellowing and itching of the skin, darkening of the urine, and light-colored stool. Objectively: during the initial examination, icterus of the skin and sclera was noted. Digital examination revealed light-colored stool. A series of examinations was performed. According to the results of transabdominal ultrasound: ultrasound signs of cholelithiasis, cholecystolithiasis, choledocholithiasis, and dilation of the common bile duct. Biochemical parameters revealed an increase in bilirubin levels to 180 μmol/l, direct bilirubin - 163 μmol/l. A decision was made to perform emergency retrograde cholangiography (ERC). During RCH, dilation of the CBD and a block in the upper third of the CBD due to an impacted calculus were observed. Numerous attempts to pass a Dormia-type basket above the impacted calculus under X-ray navigation were unsuccessful. A decision was made to perform retrograde cholangioscopy. A cholangioscope (3) was passed through the instrumental channel of the videoduodenoscope (1) into the lumen of the CBD (2). The calculus (4) was visualized (Fig. 1). Under visual control, an ultra-thin loop (5) was passed above the calculus (Fig. 2). The calculus was captured in the loop and then, pulling it toward the distal end of the cholangioscope, its fragmentation was performed, after which mechanical lithoextraction of calculus fragments into DNA was performed using a standard Dormia-type basket.

Medical and social efficiency: this method allows performing EMLT of stones under visual control in the common bile duct in patients with choledocholithiasis in complex clinical cases when it is impossible to insert a Dormia-type basket under radiographic control for the stone to perform standard EMLE and EMLT. This will avoid performing more traumatic traditional surgical interventions in this category of patients, reduce the time of hospital stay and improve the psychoemotional status of patients.

Claims (1)

A method of mechanical lithotripsy of common bile duct (CBD) stones in patients with complex choledocholithiasis, including fragmentation and extraction of the stone under X-ray control, characterized in that if it is impossible to capture a large and/or fixed stone, a cholangioscope is inserted through the instrument channel of the duodenoscope into the lumen of the CBD, with the help of which the stone is visualized in the lumen of the CBD, then a metal loop is inserted through the instrument channel of the cholangioscope, under visual control the loop is thrown over the stone and pulled to the distal end of the cholangioscope; visually controlled fragmentation of the stone is performed with the metal loop on the distal end of the cholangioscope, then the stone fragments are removed with a Dormia basket into the lumen of the duodenum.