Method for carrying endoscopic hemostasis

FIELD: medicine.

SUBSTANCE: method involves carrying out contact-mode laser photocoagulation with laser having wavelength of 1064 nm and power of 6-10 W. exposure time is equal to 2-4 s. Autoblood injections are additionally introduced before applying laser radiation treatment, in peripheral zone relative to hemorrhage source.

EFFECT: enhanced effectiveness in arresting gastroduodenal hemorrhages.

 

The invention relates to medicine, in particular to surgery, and is intended for endoscopic stop gastrointestinal bleeding.

For endoscopic stop gastrointestinal bleeding proposed many ways, each of which has both positive and negative properties.

There are a variety of techniques easy to use endoscopic injection hemostasis, for example: Kornukov GV ravens A.V. Potapov A.S. the Biogel hydrophilic polyacrylamide to stop ulcerative gastroduodenal bleeding (patent No. 2188596, 1999). In the bottom of the ulcer, in parabasal zone, 3-4 point at a distance within 5 mm from the source of hemorrhage enter Biogel hydrophilic polyacrylamide, pre-diluted in physiological solution, to create a compression of the infiltrate. Term effectiveness of this method of endogenous estimated hours: if the resolution of the infiltrate compression orosirian vessels stopped and the bleeding resumes.

Sometimes injection hemostasis perform the introduction of biologically active drug, which not only causes compression orosirian vessels, but also resorptive hemostatic action, for example: Lutsevich EV, Malyukov AU, Holidays E.N. the manual stop bleeding from gastroduodenal ulcers (patent No. 2159631, 1999). During endoscopic studies produce around the submucosal layer around the perimeter of the ulcer with a solution of sandostatin 50 mcg at four equidistant points. The method stops gastroduodenal bleeding due to regulatory effects on mesenteric blood flow, and leads to an increase of the regenerative process by reducing secretion of hydrochloric acid in the affected area. The disadvantage of this technique can be considered as the need to use expensive and not readily available drug "Sandostatin"; in addition, to ensure systemic effects of sandostatin is not necessary to enter it transendoscopic is quite a subcutaneous injection of the drug.

It is promising to use for endoscopic stop bleeding hemostatic drugs: Lipnitsky E.M., alekberzade AV, Shulgin K.A. Method of preventing recurrent bleeding from peptic ulcers of the stomach and duodenum (patent No. 2209638, 2002) is as follows: in the distal canal biopsy channel of the endoscope to inject flap collagen sponge "Tramacol" in accordance with the dimensions and form ulcers. Appliciruut it on the ulcer and hold 3-5 minutes the Disadvantage of this technique is the difficulty of carrying out a sponge through a biopsy channel of the endoscope and unreliability commit "Tr is mokola" to the source of bleeding. It is considered that the application methods significantly inferior in the efficiency of injecting endogamous (Lubyanka V.G. et al. The results of the use of temporary methods of endoscopic hemostasis with gastroduodenal bleeding: proceedings of the exit Plenum REACH, Barnaul, may 2002 - 2002. - S-169).

One of the most effective methods of injection engagements is the introduction of fibrin glue by direction of the source of hemorrhage endoscopic needle (Grubnik J.V. et al. The use of local endoscopic hemostasis in complex treatment of patients of elderly and senile age with bleeding gastroduodenal ulcers // Visnyk marsico medicine, 2001. No. 2 (14) (Quan-Cherven). - P.14-19). When submucosal injection of fibrin glue (the main ingredients are fresh frozen plasma, thrombin and calcium chloride) in periultseroznoy area is not only the compression ratio erozirovanne vessels, and stimulation of hemostasis due to the saturation of the tissues with blood coagulation factors. Although very effective, this technique has not found wide spread due to the high cost and low availability of fibrin glue produced by the Swiss firm "Tissucol".

One of the best ways of engagements is lazarettgasse (Suguro the VA et al. Physical techniques in endoscopic treatment of bleeding from the upper parts of the gastrointestinal tract // Kremlin medicine. Clinical journal, 1998. No. 4. P.18-20). Laser endogenous used in two basic versions: contactless and contact lazarettgasse. Contactless lazarettgasse not without certain drawbacks: it is accompanied by a rapid damage to the end face of the fiber during its execution, with the fall of the radiation power, as a result, this technique requires high power (50 W) and prolonged exposure (up to 10 sec) (Neurotin A.I. Introduction to laser surgery: SPb.: Spec lit, 2000. - 175 C.). High power radiation leads to more pronounced damage to the end face of the fiber, which causes a vicious circle contactless lazarettgasse. The requirement for prolonged exposure at one point practically difficult to implement.

Closest to the proposed method of endoscopic hemostasis is contact lazarettgasse. Contact lazarettgasse is a near infrared laser with a wavelength of 1064 nm (YAG-Nd laser or semiconductor laser) radiation power up to 10 watts and an exposure time exposure to 2-4 seconds (Geinitz AV, Eliseenko V.I. Peculiarities of the interaction of radiation of the semiconductor laser is biological tissues // J. struct. Dokl. III International, Semin. "Semiconductor and solid state lasers in medicine 2000". - SPb.: 2000; Evstigneev, A.R. Application of semiconductor lasers and LEDs in medicine (scientific-methodical material). - Kaluga, LAN, RF, 2000. - 57 S.).

Disadvantages of contact coagulation are not sufficiently uniform distribution of the power density, the prevalence of ablation processes on coagulation, the formation of excessively deep ablational crater, which often leads to perforation of the wall of a hollow organ (Kiefhaber P., F. Huber, K., Kiefhaber Endoscopic use of the neodymium YAG laser in the upper and lower gastrointestinal tract. // Langenbecks Arch. Chir. Suppl.II Verh. Dtsch. Ges. Chir. - 1989; 331-6.). The area of the new zone of coagulation in contact laser exposure is limited by the diameter of the end face of the fiber (400-600 μm) and its numerical aperture (not exceeding 0.2 for quartz fiber). This limits the potential of endoscopic hemostasis way contact lazarettgasse (Neurotin A.I., Vodni A., Agapov D.P. and other Analysis of laser lesions in living tissue. / Collection of scientific works (editor Petrishchev N.N.) Actual problems of laser medicine. - Publishing house of St. Petersburg state medical University, St. Petersburg. 2001. - P.46-63; Ruchkin V. et al. The use of a neodymium laser for endoscopic hemostasis of gastroduodenal bleeding // all-Russian conference of surgeons "Modern problems of emergency and PLA the new treatment of patients with peptic ulcer of stomach and duodenum". - Conference materials. - September 25-26, 2003 - Saratov. 2003. - S).

We first proposed a method of endoscopic hemostasis, including contact lazarettgasse laser with a wavelength of 1064 nm, with a capacity of 6-10 W, exposure time exposure to 2-4 seconds, characterized in that it further before laser exposure is performed injection of autologous blood in four equidistant from the source of the bleeding point.

The method is as follows: during the endoscopic examination of the patient from the cubital vein is taken with a syringe and blood. Native blood of the patient using the endoscopic injector is injected into the submucosal in point (usually 3-4) on the periphery of the source of hemorrhage. Each point is entered by 2 ml of blood. To create more homogeneous hematoma point equidistant from the source. Following the injection, you should contact lazarettgasse source of bleeding. Uses a near infrared laser with a wavelength of 1064 nm (YAG-Nd laser Raduga-1 or semiconductor "Lasermed 1-10"). Lower radiation power (less than 6 watts) does not lead to reliable hemostasis; the increase in output power greater than 10 W leads to a pronounced damaging effect. The performance criteria of engagements are bleeding and the formation of coagulation scab on the surface and the source of hemorrhage.

While injecting autologous blood is compression orosirian vessels created by infiltration. During the subsequent contact lazarettgasse intense laser radiation is absorbed by the injected blood, which leads to a more uniform distribution of power density and the formation of a common zone of coagulation in the submucosa of the stomach or duodenum. At the same time injected the blood escapes subject to layers of the wall of a hollow organ that protects it from the perforation. Absorption of laser radiation injected by Autocraft leads to her not concatenated (not associated with activation of coagulation factors) coagulation, aggregation of erythrocytes and platelets, the deposition of fibrin and partial hemolysis with the release of the formed elements of blood coagulation factors, i.e. simulated the effect of injection of fibrin glue.

Held in the experiment morphological studies of drugs gastric wall in vitro after application of the described method showed imbibition submucosal layer of uniform elements of blood, aggregation and partial hemolysis of eritrotsitov, loss of filaments of fibrin in the submucosa of the. However, the marked compression of the blood vessels at the injection site and the presence in their lumen fixed to an intim of blood clots. The detection is on the common coagulation submucosal layer, moreover, the muscular layer of the stomach was unchanged.

Successfully performed endoscopic hemostasis allows you to postpone a dangerous emergency surgery for bleeding ulcers or even prevent it in the case of diagnosis of symptomatic ulcer or non-ulcer gastroduodenal hemorrhage.

The proposed method of endogamous was successfully applied in 6 patients with bleeding gastroduodenal ulcer. In 2 patients were diagnosed with duodenal ulcer, 4 - a stomach ulcer. Initial hemostasis was achieved in all patients. Recurrent bleeding was not observed in any patient.

Clinical observation 1: the patient B. Alexander, 56 years was hospitalized in the emergency surgical unit MMU "City clinical hospital №6 of them. Acad. Wenceslav" 28.01.2005, with the clinic gastrointestinal bleeding. Ulcer history with 18. At emergency endoscopy detected sore back wall of the duodenum up to 2 cm in diameter with ongoing bleeding. In the course of the study from the cubital vein taken 8 ml of blood. The blood through the injector put in 4 points on the periphery of the ulcer. Bleeding while significantly decreased. Made contact coagulation through a quartz optical fiber, the semiconductor laser LASERMED 1-10" is a wavelength of 1064 nm and a power at the end of the light guide 6 watts. Exposure to 4 seconds. Achieved stable hemostasis. Recurrent bleeding is not observed. Held conservative therapy. After replacement of blood loss after 14 days completed deferred operation. Operational preparation revealed a scar in the place of the former ulcers.

Clinical observation 2. Patient S. Natalia Andreevna, 49, was hospitalized in the emergency surgical unit MMU "City clinical hospital №6 of them. Acad. Wenceslav" 14.02.2005, with the clinic gastrointestinal bleeding. Ulcer-gastritises history no. Before illness to treat SARS took aspirin at a dose of 4 tablets per day for 2 weeks. At emergency endoscopy detected ulcer antral about 0.5 cm in diameter with ongoing bleeding. In the course of the study from the cubital vein taken 8 ml of blood. The blood through the injector put in 4 points on the periphery of the ulcer. Active bleeding while stopped. Made contact coagulation through a quartz optical fiber, the semiconductor laser LASERMED 1-10" with a wavelength of 1064 nm and a power at the end of the optical fiber 10 watts. Exposure to 4 seconds. Achieved stable hemostasis. Recurrent bleeding is not observed. Held conservative therapy. Subsequent endoscopic control - ulcer healed in 10 days. Bittern is Ana in satisfactory condition.

The advantage of the proposed method of engagements is the ability to stop gastroduodenal bleeding with a high degree of reliability without the use of expensive medicines. The method includes the positive properties of lazarettgasse, injection hemostasis and application of fibrin glue.

A method of endoscopic hemostasis, including contact lazarettgasse laser with a wavelength of 1064 nm, with a capacity of 6-10 W, exposure time exposure with 2-4, characterized in that it further before laser action perform the injection of autologous blood on the periphery of the source of bleeding.



 

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