Method for endoprosthetics of biliary ducts

FIELD: medicine, endoscopy.

SUBSTANCE: the present innovation deals with endoscopic recanalization of biliary ducts in case of mechanical jaundice caused by neoplasm in pancreatic caput: into the lumen of endoprosthesis one should apply an electrode of diathermocoagulator so, that electrode's tip should protrude about 1-2 mm out of endoprosthesis' proximal end and with the help of electrode and endoprosthesis one should create an artificial canal between suprastenotic widening and substenotic space in common bile duct. Then one should remove the endoscope with electrode that, thus, eliminates mechanical jaundice.

EFFECT: higher efficiency.

4 dwg, 2 ex

 

The invention relates to medicine, specifically to endoscopy, and can be used for endoscopic recanalization of the affected bile ducts in the treatment of obstructive jaundice caused by a tumor of the pancreatic head.

Carrying out replacement of the bile ducts is seriously handicapped by severe stenosis OP (common bile duct) and the mismatch between the diameter of the stenotic area of the bile duct diameter conducted endoprosthesis or deformation of the stenotic area of the bile ducts (or magistratical period when two-component stenosis), causing an obstacle to the promotion of the endoprosthesis in suprastenotic extension. Electrocoagulation in these situations, it may serve as a way to overcome these technical difficulties.

There is a method of arthroplasty (EP), namely, that in the field of tumor obstruction set the device over the guidewire and catheter pusher (Assaluyeh. Endoscopic abdominal surgery. M: "IMA-press, p.47-49, 29).

The disadvantage of this method is the impossibility to perform arthroplasty in severe deformity and severe stenosis of the bile ducts caused by malignant neoplasms.

The objective of the invention is improving the efficiency endopro is tiravanija bile ducts at their deformation malignant neoplasms in the area of stenosis by creating an artificial channel, connecting suprastenotic dilatation of the common bile duct and its substantiale space through the parenchyma of the pancreatic head.

The technical result unlike the prototype is due to the fact that in the lumen of the endoprosthesis set the electrode diathermocoagulation so that the tip of the electrode is 1 to 2 mm from the proximal end of the endoprosthesis, and create when conducting the endoprosthesis by electrocoagulation and perforation artificial channel, bypassing deformed and stenotic segment of the common bile duct, which (artificial channel) connects suprastenotic dilatation of the common bile duct and its substantiale space through the parenchyma of the pancreatic head, and then clean the electrode and the endoscope.

Therefore, the proposed method meets the criterion of "novelty"as the set of distinctive features is unknown in the prior art.

The invention meets the criterion of "inventive step", as it is not obvious to a person skilled in the art.

The method is industrially applicable, as may be used in clinical medicine.

To explain how the following figures: figure 1 shows the process of arthroplasty, shown in figure 2 with the being after arthroplasty, figure 3, 4 - x-rays after surgery.

Explanations to the drawings: 1 - gall-bladder, 2 - common bile duct, 3 - electrode, 4 - endoscope, 5 - plunger endoprosthesis, 6 - parenchyma of the pancreas affected by tumor, 7 - 12 duodenal gut, 8 - endoprosthesis.

The method is as follows.

In the lumen of the endoprosthesis 8 installing the electrode 3 diathermocoagulation so that the tip of the electrode is 1 to 2 mm from the proximal end of the endoprosthesis 8 (1, 2). Then promptly access via endoscopy in 12-duodenum 7. When endoscopic hold the endoprosthesis 8 through the stenotic area of the common bile duct is used electrocoagulation. The tip of the electrode 8 burns (diathermocoagulation and hole-punches) tissue of the common bile duct 2 and the pancreatic head 6, forming an artificial channel for the endoprosthesis 8 bypass (parallel) strain and the stenotic segment of the common bile duct 2 malignant neoplasms.

Artificial channel, which is set by the endoprosthesis 8, connects suprastenotic expansion and abstentions space bile duct, passing through the parenchyma of the pancreas affected by the tumor. After holding the proximal end of the endoprosthesis PMPs in the stenotic expanding and fixing the endoscope 4 conductor (pusher) 5 and the electrode 3 are removed.

When endoscopic hold the endoprosthesis formed through an artificial channel used electrocoagulation, and the electrode protrudes from the proximal end of the endoprosthesis, which allows coagulase fabric of the common bile duct and the pancreatic head, to form an artificial channel for installation of the endoprosthesis.

Simultaneously with the formation of an artificial channel using mixed mode electrocoagulation or alternating modes ″cut″ and ″coagulation is the smooth running of it endoprosthesis. Control over the direction of advancement of the implant is radiographically poleposition (3, 4).

Due to the fact that the diameter of the electrode tip engaged in the burning wall of the common bile passage and the pancreatic parenchyma, significantly narrower than the diameter of the ongoing endoprosthesis provides tight clamping of the endoprosthesis surrounding tissues and tightness, preventing leakage of bile into the parenchyma of the pancreas.

Example 1. Patient C., 62 years history 248/02 for 2003 with Ds.: Tumor pancreas defeat intrapancreatic division of the common bile duct, mechanical jaundice. This patient was taken to the EMC Hepatology center at the emergency hospital of Krasnoyarsk in serious condition for the performance of the surgery. The severity of the condition was caused by high jaundice (>350 Ámol/l) and duration of prehospital course of the disease (late treatment). At admission the patient in the Oncology center she was cholecystostomy, but after 10 days cholecystostomy ceased to function, and jaundice again began to improve. When radiopaque study of gall-ducts system is determined dvukhkomponentnye stenosis of the distal common bile duct with the formation of minor magistratical extension (up to 1 cm in diameter), while in the field magistratical extensions formed the corner of the common bile duct to 100°. Suprastenotic dilatation of the common bile duct up to 3.5 cm in diameter. When the attempts of the endoprosthesis is determined on the x-ray control, it stopped in the area magistratical space (extension), and the direction of the axis of the endoprosthesis is focused on suprastenotic extension.

After data analysis of objective conditions (orientation ″opercula in magistratical space endoprosthesis on suprastenotic extension, itself expressed suprastenotic extension and slight diastasis from him (extensions) from magistratical space, which does not allow to pass him the endoprosthesis when the small who's vibrations - endoprosthesis direction, no way intended promotion of the endoprosthesis of the abdominal cavity and retroperitoneal space) it was decided to conduct arthroplasty using electrocoagulation, which in implant was introduced the electrode diathermocoagulation so that the tip of the electrode was performed at 1-2 mm from the proximal end of the endoprosthesis. After the introduction of the endoprosthesis at the maximum depth and creating its way into magistratical space in the direction apresentacao extensions interleaved modes electrocoagulation (cutting and coagulation) was the conduct of the endoprosthesis. It should be noted that the actual achieved through the creation of an electrical current mode ″cutting, and even a minor effort was enough for the rapid movement of the endoprosthesis. However, prevention of bleeding, especially bleeding disorders malignant tissue, used the alternating - 1-3 second - modes electrocoagulation. Hit the proximal end of the endoprosthesis in suprastenotic expansion was detected by subsequent the easy advancement of the implant without the use of electrocoagulation and enter the lumen of the endoprosthesis bile (figure 1, 2, 3).

In poslove shall include the period was marked relief of jaundice on average 20-30 Ámol/l per day. The effectiveness of arthroplasty is estimated by the secretion of bile from the distal end of the endoprosthesis 12-duodenum and mild jaundice.

Autopsy carried out after 3.5 months, it was noted that adequate drainage of the bile ducts of the endoprosthesis, signs of infection and leakage of bile into the pancreatic head was not determined.

Example 2. Patient Machnine GA, 61 years old (case history No. 827/02 2003), was admitted to emergency hospital of Krasnoyarsk 03.05.2003. diagnosed with a tumor of the pancreatic head, mechanical jaundice.

The condition of the patient is heavy, exhausted, bilirubin increased to 320 Ámol/l due to the direct fraction. Ultrasound ERCP diagnosis is confirmed. When performing arthroplasty had the following technical difficulty: the endoprosthesis rested against the wall of the deformed tumor of the distal common bile duct. When performing ERCP, it became apparent that the direction of abutting against the wall of the common bile duct endoprosthesis focused on his suprastenotic extension. The implant was fixed on the electrode diathermocoagulation so that the proximal end of the electrode protrudes from the proximal end of the endoprosthesis of 1-2 mm Using electrocoagulation in mixed mode, the implant was carried out in suprastine the systematic expansion of the common bile duct through the parenchyma of the pancreatic head under the control of fluoroscopy. The criterion of adequacy conduct was the discharge of bile and roentgenocontrast from the distal end of the endoprosthesis in the duodenum (figure 1, 2, 4). The postoperative period was uneventful, bilirubin on average decreased by 20-30 Ámol/l per day up to level 34 Ámol/l, the patient's General condition improved. Discharged, 17.05.03 from the hospital.

The proposed method of arthroplasty of the bile ducts can be widely used in medical practice, with the aim of extending the life of the patient, not subject to surgical treatment for malignant tumors of the pancreatic head.

The method of arthroplasty of the bile ducts, which includes online access via endoscopy, the installation of the implant, characterized in that the lumen of the endoprosthesis set the electrode diathermocoagulation so that the tip of the electrode is 1 to 2 mm from the proximal end of the endoprosthesis and create when conducting the endoprosthesis by electrocoagulation and perforation of the tissue wall of the common bile duct and the pancreatic head artificial channel in bypass deformed and stenotic segment of the common bile duct, with artificial canal connects suprastenotic expansion and abstentions space of the common bile duct, which then remove the endoscope from the electrode.



 

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