Method of endoscopic arrest and prevention of ulcerous bleedings from duodenum defects

FIELD: medicine.

SUBSTANCE: endoscopic installation of a covered metal self-extending stent is performed into a lumen of the duodenum with a source of bleeding or an ulcerous wall defect. Applied is the stent with a diameter of an opening of not less than 22 mm. In order to perform installation the delivery device of the stent is passed behind the area of bleeding. After that the stent is placed in such a way that its funnel-shaped extended edges tightly rest against walls of the duodenum, creating a closed cavity between the proximal and distal edges of the stent.

EFFECT: method makes it possible to ensure reliable haemostasis, effective sealing of the area of the tubular organ wall defect and prevent its contact with physiological liquids due to which ensure the prevention of development of complications, accompanying the main disease.

2 cl, 1 ex, 2 dwg

 

The endoscopic method for stopping and prevention of ulcer bleeding from defects in the wall of the duodenum 12.

The invention relates to medicine and can be used when you stop and prevention of recurrence of ulcer bleeding, localized in the 12-duodenum.

Despite the rapid development of medical technologies of bleeding gastro-intestinal tract (GIT) still pose a significant threat to patient's life and often involve a fatality.

A modern approach [1, 3, 4, 5] involves primarily the use of minimally invasive endoscopic methods of diagnostics and treatment of peptic ulcer bleeding. Existing endoscopic methods of physical, chemical, combined hemostasis in most cases allow you to achieve hemostasis and prevent bleeding recurrence.

In practice, however, known techniques are often or unable to effectively seal the defect region while maintaining miniinvasive impact or do not allow to solve the problem of bleeding. For example, when a jet of arterial bleeding endoscopic methods are ineffective due to the inability of a clear localization of the bleeding source, developed coagulopathy, lack of time for carrying out hemostasis[2, 3, 4, 5]. In t�such cases, endoscopic allowance is reduced to the findings of fact of the continued bleeding, while the patient is in a state of hemorrhagic shock is subjected to additional trauma during a forced surgery.

As the sealing device in literary sources mention the possibility of using covered self-expanding metal stents for the separation of the gaps in esophageal-tracheobronchial fistula, for the restoration of the lumen and maintain the patency of the tubular bodies in benign or malignant strictures.

As an analogue of the selected method of application sinus catheter Yamik-3 [6] to stop the bleeding.

The principle of operation of the catheter is the presence of two latex cuffs at the proximal and distal end, the simultaneous inflation which allows you to create a closed cavity in the nasal cavity, limiting the amount of bleeding and contributing to its stop. In addition, balloon inflation, by itself, allows you to compress the bleeding vessel.

Achievable technical result is to ensure effective sealing area of the defect wall 12 duodenal ulcer in the conditions of a minimally invasive exposure. In addition, the resulting isolation of the defect area to prevent contact with body fluids (e.g., gastric juice), which ensures the prevention of the development related about�major disease complications.

The achievement of these results are based on the following.

12 duodenal same gut body malaclemys and tightly fixed to the surrounding tissues. Physiological limits of the bulb 12 duodenal ulcer presents two distinct entities - the pyloric muscle ring, ensuring a constant tone with the proximal side, and is rigidly fixed, there is little tensile region Bulbo-duodenal transition from the distal side. These two obturator portion at the inlet and outlet 12 duodenal ulcer, on the one hand, limited the use of conventional stents to create a complete compression on the bleeding area, and on the other, these anatomical features create conditions for effective tamponade in case of use of the procedures developed by us. According to our method the stent with a specially enlarged funnel-shaped edges is set so that these edges, tightly braced against the wall of the body with distal and proximal sides, creating a closed cavity and provide, on the one hand, the emergence of hematophagy and provide direct compression on the wall.

The use of the developed technique allows almost blindly, in the face of ongoing bleeding, work in this area, because there is clearly an ongoing�tonicheskie benchmarks (the gatekeeper).

In addition, after stent placement, it is possible to easily and safely clean the stomach from the blood and fully inspect both the stomach and the distal part 12-p of the colon.

Installation of a covered stent immediately terminate access to the aggressive ulceration of the gastric contents and thus effectively contributes to its healing.

Mounted stent allows you to monitor the effectiveness of the bleeding and, if necessary, is available to change the position of the stent.

The application of the method allows to reduce the duration of endoscopic intervention to stop the bleeding and, thus, significantly reduce the total volume of blood loss.

Afforded by the claimed method of rapid hemostasis allows you to stabilize the patient and to fully prepare him for a possible subsequent elective surgery.

This result is achieved through endoscopic installation of covered self-expanding metal prosthesis (stent) into the lumen of duodenum 12. The stent is positioned so that its funnel-shaped extended edges tightly abuts the wall of the intestine, creating a closed cavity between the proximal and distal edge of the stent. Thus the source of bleeding is localizo�EN in a closed cavity of small volume between the edges of the stent (not more than 20-50 cm 2). With continued bleeding, the blood from the cavity is not evacuated, accumulate, leading to tamponade the bleeding vessel, activation of factors of local hemostasis and eventually stop the bleeding.

Stent are possible, including, as preventive measures at high risk of rebleeding and difficult to apply standard methods of prevention of rebleeding is when a large callous ulcers, ulcers on the background of scar deformity, severe General condition of the patient.

The method is as follows.

When clinical signs of bleeding perform pre-inspection of the proposed site of bleeding a flexible endoscope with a wide instrumental channel diameter required for holding the carrier device must be at least 3.4 mm). When viewed from trying to determine the localization of the source of ongoing bleeding (pulsating stream, or the flow of bright blood

blood) or the localization of the ulcer with a high risk of rebleeding.

If it is impossible for a standard endoscopic tool or inefficiency of the decision on the placement of the stent in the area of bleeding or ulcer.

For the area of bleeding through Instrumentalnaya a flexible endoscope is a flexible string-the conductor (for example, string METH-35-480 firm Willson-Cook, Ireland). Through the inner sleeve (Fig. 1 item 4) on the wire conductor over the area of bleeding is held delivery device.

The safe holding of the device contributes to a distal soft protective cap (Fig. 1, item 6). External braiding (Fig. 1, item 3) delivery device is unlocked using the lock outer braid (Fig. 1, item 5) located on the handle (Fig. 1, position 1) and is shifted in the proximal direction so that the stent (Fig. 1, position 2) is straightened and fixed in the lumen of the intestine, capturing an area of the bleeding vessel and forming a closed cavity.

Given that the diameter of the lumen of the stent in the expanded state is at least 22 mm, immediately after the installation creates the possibility of holding the endoscope in the distal direction over the region of the stent. This allows you to inspect the distal and proximal edge of the stent, to assess the fit of the edges of the stent to the walls of the hollow body and to eliminate the dripping of the blood from under the edges of the stent.

If necessary, reposition the stent through the proximal and distal repositioning loops ("lasso") (Fig. 2, position 7, 8).

When properly installed, the stent blood flow in the body stops. After washing the blood and clots from the lumen of the tubular body, a sub�usual re-examination, and in the absence of bleeding blood the study is terminated.

Control study with the examination zone of the stent are scheduled once a day for three days from the moment of bleeding or emergency at the clinic of rebleeding.

The stent is left in the lumen of the body for the period up to 4 weeks to fully stabilize the patient's condition and scarring of the alleged defect. Next, the stent is removed by means of an endoscope. The area previously covered by the stent, re-inspected.

Clinical example

Patient S., aged 77, was hospitalized to the surgical Department after 7 days from the onset of the disease with a diagnosis of Exacerbation of calculous cholecystitis. The exacerbation of chronic pancreatitis. Biliary hypertension.

Admission: complaints of pain in the right upper abdomen, zoster character, dry mouth, nausea. Deterioration after errors in diet. Independently took pamprin, Pentalgin, Nurofen without effect. In response to continuing abdominal pain caused SMP. When inspecting the condition of average weight. Consciousness is clear. Blood pressure 150/90 mmHg. article Abdomen symmetrical, swollen, palpation soft, painful in the right hypochondrium, symptoms of peritoneal irritation no, gases depart.

Ultrasound: diffuse changes of a parenchyma of a liver, pancreas, GI�ARTESIA of the common bile duct - 14 mm in diameter.

Patients underwent infusion-inflammatory therapy with positive dynamics - abdominal pain decreased.

The morning 15.03.14 G. at 8.30 the patient's condition deteriorated. Complaints of pain in the chest, weakness, malaise. Blood pressure 90/60 mmHg. the article Examined the duty therapist, cardioreanimation. With suspected acute coronary syndrome, the patient was transferred to the NICU. The Department conducted a comprehensive conservative therapy. A troponin test is positive. Was diagnosed with acute myocardial infarction. Complications: unstable supraventricular arrhythmia.

19.03.14 G. at 09:50, the patient's condition deteriorated: profuse vomiting red blood, the condition is very serious, pale skin, heart sounds are weakened, heart rate 100 beats per min, BP 60/40 mmHg, art - clinic gastrointestinal bleeding.

Emergency endoscopy cavity of the bulb 12 duodenal ulcer is a fresh blood clot, clot is observed jet flow of red blood, to carefully examine the source of bleeding is not possible, attempts at injecting the hemostatic blind unsuccessful. For the purpose of stopping bleeding into the lumen of the bulb 12 duodenal ulcer delivered pyloro-covered duodenal self-expanding metal stent (Hanarostent, M. I. Tech South Korea). Achieved hemostasis.

The patient for further treatment was transferred to the UAR, which was continued intensive conservative therapy. When the control endoscopy 20.03.14 G. signs of recurrence of bleeding was not detected. When you try inspecting the lower horizontal branch of the duodenum 12 developed dislocation of the stent. Exposing the wall of the bulb 12 duodenal ulcer, presents a giant ulcer defect, occupying up to half the circumference of the duodenum, in the center of the defect pigment stain to 2-3 mm in diameter (the risk of rebleeding Forrest 2C). For the prevention of rebleeding produced repositioning of the stent to the area of the ulcer. On the background of conservative treatment gradual stabilization of the condition.

Control endoscopy was performed 21.03, 23.03 25.03 and, signs of recurrence of bleeding is not noted. 27.03 when the control endoscopy stent removed. Examined ulcerative defect decreased to 2 cm in diameter, the bottom of the defect covered with a grayish bloom (risk of rebleeding 3 Forrest).

For further treatment, the patient was transferred to cardiology Department.

References:

1. The order of April 13, 2011 No. 320 on common tactics of diagnosis and treatment of acute surgical diseases of abdominal organs in health care institutions health Department of the city of Moscow.

2. Gastrodia�analnye bleeding ulcer etiology 2008, Gostishchev V. K., Evseev M. A., GEOTAR-media ISBN: 978-5-9704-0923-7, p. 384

3. Consensus Recommendations for Managing Patients with Nonvariceal Upper Gastrointestinal Bleeding, Clinical Guidelines Alan Barkun, MD, PhD and John K. Marshall, MSc MDm, for the Nonvariceal Upper GI Bleeding Consensus Conference Group, Ann Inter Med. 2003:139-843-857.

4. Management of acute upper and lower gastrointestinal bleeding. A national clinical guidelines, Scottish Intercollegiate Guidelines Network, Sep. 2008 - Guidelines for Prevention of NSAID-Related Ulcer Complications, Frank L. Lanza, MD, FAGG, Francis K L Chan, MD, FRCP, FAGG, Eamonn M. M. Quigley, MD, FAGG and the Practice parameters Committee of American College of Gastroenterology, The American Journal of Gastroenterology, V/ 104, March 2009.

5. International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding, Alan N Barkun, MD, MSc (Clinical Epidemiology): Marc Bardou, MD, PhD: Ernst J. Kuipers, MD; Joseph Sung, MD; Richard H. Hunt, MD; Myriam Martel, BSc; and Paul Sinclair, MSc, for the Nonvariceal Upper GI Bleeding Consensus Conference Group, Arm Inter Med. 2010: 152-101-113.

6. Diagnosis and treatment of sinusitis by YAMIK sinus catheters. Kozlov VS, Markov GI. Rhinology. 1996 Jun; 34(2): 123-4.

1. The endoscopic method for stopping and prevention of ulcer bleeding from defects in the wall of the duodenum 12, including endoscopic installation in the lumen of duodenum 12 with a source of bleeding or ulcerative defect of a wall covered self-expanding metal stent, and using a stent with a diameter of disclosure not less than 22 mm, the delivery device of the stent is carried out for the area of bleeding and the stent is mounted so that its funnel-shaped extended edges tightly against the wall 12 duodenal ulcer, creating a closed�Yu cavity between the proximal and distal edges of the stent.

2. A method according to claim 1, wherein, after the establishment of the stent, conduct a field examination of bleeding or defect and, if necessary, perform reposition the stent.



 

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4 dwg, 1 ex

FIELD: medicine.

SUBSTANCE: group of inventions relates to field of medical equipment, namely to implanted medical devices and methods, associated with them, in particular, to devices and methods for closing holes in vessel walls. Closing device for vessel contains supporting frame, capable of extending inside vessel, and closing membrane, at least, partially supported by extendable supporting frame. Supporting frame is located around closing membrane periphery. Device is configured with possibility of folding and unfolding along longitudinal axis, in fact, coinciding with vessel axis, and with possibility of intraluminal positioning, after extension of supporting frame inside vessel, closing membrane near place of puncture, made in vessel wall. Method of vessel closing includes introduction of closing device into vessel through place of puncture by means of cover, positioning and extension of supporting frame from folded configuration in, at least, partially unfolded configuration by means of its unfolding inside vessel along longitudinal axis, in fact, coinciding with vessel axis, providing in this way, at least, partial closing of puncture place with closing membrane. System for closing vessel puncture contains closing device, cover, made with possibility to accept closing device in folded configuration and facilitate introduction of closing device through puncture into vessel; and pusher-rod, made with possibility of passing closing device through cover.

EFFECT: group of inventions provides faster and more effective closing; reduces time and cost; requires only inconsiderable additional surgical manipulations by operator in the course of delivery.

30 cl, 11 dwg

FIELD: medicine.

SUBSTANCE: method involves a transanal Doppler controlled dearterialisation of internal haemorrhoids. Haemorrhoid vessel branches are underrun through an anoscope at the haemorrhoid base. A figure-of-eight non-traumatic absorbable suture is applied. The rectal mucosa and haemorrhoid are anchored with the same suture. A submucosal suture is applied in the distal direction towards an apex of the haemorrhoid. Then it is turned perpendicularly and encloses the submucosal layer. The suture is placed back towards the ligatured haemorrhoid and the second free end of the suture. After the needle pricks out, the suture ends are tied together. The haemorrhoid is ligatured to pull up and fixed to the point of vascular underrunning above the anorectal line.

EFFECT: method provides the minimally invasive treatment of the patients suffering from stages 3-4 chronic haemorrhoid by limiting the blood flow along the haemorrhoid arteries, fixing and preventing haemorrhoid prolapsed with the minimum deformity of the anal canal, preserving its function and observing the good functional and aesthetic effect.

3 ex, 1 dwg

FIELD: medicine.

SUBSTANCE: method involves applying one or two parallel through draining tubes having lateral perforations. Flow lavage of the retroperitoneal space with antiseptic solutions is carried out via the perforations at room temperature and cooled solutions are administered concurrently with vacuum suction. Omental bursa is concurrently drained using the two parallel through draining tubes. Flow lavage of the omental bursa is carried out using these tubes.

EFFECT: enhanced effectiveness of treatment in healing pyo-inflammation foci.

5 cl, 1 dwg

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