Method of endoscopic hemostasis of bleeding from pyloroduodenal ulcers

FIELD: medicine.

SUBSTANCE: invention pertains to medicine, surgery and may be used for hemostasis in pyloroduodenal ulcers when there is no clear visualisation of the source of bleeding. Endoscopic examination of the pyloroduodenal zone is done followed by consecutive injection of solution of vasoconstrictor. Injection points are selected from 6 points of pylorus at 1, 3, 5, 7, 9, and 11 hours of the reference clock-face. A point located in the central part of the upper wall of pylorus is accepted for 12 hours. With the source of bleeding located on the front wall of the bulb DNA injections are made into pylorus points corresponding to 7,9,11 hours of the reference clock-face. With the source of bleeding located on the upper wall of the bulb DNA injections are made into pylorus points corresponding to 1 and 11 hours of the reference clock-face. With the source of bleeding located on the back wall of the bulb DNA injections are made into pylorus points corresponding to 1,3,5 hours of the reference clock-face. With the source of bleeding located on the lower wall of the bulb DNA injections are made into pylorus points corresponding to 5 and 7 hours of the reference clock-face.

EFFECT: use of the method decreases number of complications through clear visualisation of the source of bleeding.

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The invention relates to the field of medicine, surgery, and concerns the methods of endoscopic stop bleeding from ulcers piloroduodenalnoy zone in the absence of a clear visualization of the source of bleeding.

There are various ways endoscopic stop bleeding from ulcers piloroduodenalnoy zones: electrocoagulation; b) laser coagulation; argon plasma coagulation; d) sighting irrigation hemostatic and vasoconstrictor drugs such as aminocaproic acid, norepinephrine, mezaton; d) injection of vasoconstrictor solutions.[1, 2, 3, 4, 5].

However, the known methods require accurate localization of the source of bleeding, i.e. removal of a bleeding vessel in a position in which the gushing blood would cover the bleeding site. The relatively small size of the bulb of the duodenum, a large number of continuous incoming blood, peristalsis of the intestine, fixed clot that completely covers the source of the bleeding, make difficult or impossible the accurate localization of the bleeding site. In this situation there is a high risk of perforation of the wall of the duodenum.

For endoscopic electrocoagulation requires special equipment: electrosurgical devices, probes for thermocoagulation. If this is manipulatie it is also necessary to clearly see the source of bleeding. The disadvantage of this method is the contact head determined with the surface of the ulcer and sticking it during coagulation, the high risk of perforation.

When using laser and argon plasma coagulation for the source of bleeding is the proximity effect. However, you need precise "aiming" on the bleeding vessel and the maximum distance from the open surface flowing blood. These techniques endoscopic stop bleeding require expensive equipment, specially equipped premises and may not be used in the network of medical institutions.

Sighting irrigation source of bleeding hemostatic and vasoconstrictor drugs is the most simple and accessible way of therapeutic effects. Hemostasis using methods of irrigation source of bleeding is possible only at small capillary bleeding. For heavier bleeding solutions of drugs are rapidly removed by the blood stream and do not have time to provide the desired actions.

The feasibility of using endoscopy not only to diagnose the location of the source of bleeding, the intensity of the blood loss, but also for the treatment of this serious complication of duodenal ulcer, such as bleeding, it is recognized and has a high p is actionshow value [1, 2, 4, 6].

Closest to the present invention is a method of endoscopic stop bleeding by injection of vasoconstrictor drugs [1, 7, 8], including endoscopic study piloroduodenalnoy zone, the detection of the source of bleeding and subsequent injection of solutions of vasoconstrictor drugs in the edges of the ulcer, if possible in the area of the bleeding vessel. The effect of hemostasis based on the mechanical compression of the damaged vessel infiltration shaft.

However, the implementation of the known method is the accurate localization of the source of bleeding, but a large number of continuous incoming blood, fixed clot that completely covers the source of bleeding, peristalsis of the intestine often complicates or makes it impossible. If it is impossible to clearly localize the bleeding vessel injection solution does not give the desired effect.

New technical problem - increasing efficiency by reducing complications and extend the scope of application of the method.

To solve the problem in the way endoscopic stop bleeding from ulcers piloroduodenalnoy areas, including endoscopy piloroduodenalnoy zone with subsequent intravenous injection of vasoconstrictor solution PR is parathas, injection is carried out directly in the 6 points of the pylorus is preserved, located at 1, 3, 5, 7, 9 and 11 hours conditional dial, 12 o'clock accept a point located in the Central part of the upper wall of the pylorus is preserved, and when the location of the source of bleeding in the anterior wall of the duodenal bulb, the injection is carried out in a point of the pylorus is preserved, corresponding to 7, 9, 11 hours conditional dial when placed on the top of the bulb of the duodenum - in point of the pylorus is preserved, corresponding to the 1 and 11 o'clock conditional dial when placed on the back of the bulb of the duodenum in the points corresponding 1, 3, 5 o'clock conditional dial, and when placed on the bottom wall of the duodenal bulb in the point corresponding to the 5 and 7 o'clock conditional dial.

In the analyzed scientific medical and patent literature no data found new distinctive characteristics and they explicitly do not follow to a person skilled in the art. This method is passed clinical trials in the surgical ward No. 3, Department of intensive therapy and reanimation of the City hospital №2 Central medical and sanitary unit # 81 city of Seversk. Thus, this solution meets the criteria of the invention of "novelty", "inventive step" and "industrial applicability"

The method is as follows.

Endosco the systematic study conducted on the standard principles of this method of endoscopic diagnosis (Vasilenko V.H. Modern methods of research in gastroenterology. - M.: Medicine, 1979).

The research is being done at the time of admission to hospital for an emergency with clinical signs of gastrointestinal bleeding in the position of a patient lying on the left side" on the universal surgical table with a raised head end of the table. Local pharyngeal anesthesia rings perform just before fibrogastroscopy irrigation with 10% lidocaine solution volume of 2 ml Endoscopic study conducted by fibrogastroscopy company "Olympus" GiF Q - 10, GIF, Q - 20, with the end location of the optics. The introduction of fibergastroscope produce under visual control. The device is promoted to the level of the duodenal bulb. In one procedure carefully examine the esophagus, stomach, duodenum. Visually assess the condition of the mucous membranes, the presence of erosive and ulcerative defects. The location and the greatest accumulation of blood determine the Department with a possible source of bleeding, and if possible examine in detail to detect the bleeding site. Up to 60% of cases the cause of gastrointestinal bleeding ulcer defects are piloroduodenalnoy zone.

Endoscopic hemostasis piloroduodenalnoy zone is performed by the injection of 5-10 ml soudas the maintenance of the drug, for example, epinephrine directly into the pylorus is preserved from 6 points on 1, 3, 5, 7, 9, 11 hours conditional dial, the layout of which is shown in Fig 1, 2, where the starting point 12 hours take a point in the Central part of the upper wall of the pylorus is preserved (sector 1). Adnea the wall of the pylorus is preserved designated as sector II, the bottom wall of the pylorus is preserved - sector III, the front wall of the pylorus is preserved sector IV. Thus, point 1 is located on the border of the upper and rear walls of the pylorus is preserved, which corresponds to 1 hour of conditional dial, point 2 is located in the Central part of the rear wall of the pylorus is preserved, which corresponds to 3 hours conditional dial, point 3 is located on the border of the back and bottom walls of the pylorus is preserved, which is 5 hours conditional dial, point 4 is located on the border of the bottom and front walls of the pylorus is preserved, which corresponds to 7 hours conditional dial, point 5 is located in the Central part of the front wall of the pylorus is preserved, which corresponds to 9 hours of conditional dial, point 6 is located on the border of the front and top walls the pylorus is preserved, which corresponds to 11 o'clock conditional dial.

When the location of the source of bleeding in the anterior wall of the duodenal bulb, the injection is carried out in a point of the pylorus is preserved, corresponding to 7, 9, 11 hours conditional dial when placed on the top of the bulb D Is K - in point of pylorus is preserved, corresponding to the 1 and 11 o'clock conditional dial when placed on the back of the bulb of the duodenum in the points corresponding 1,3,5 hours conditional dial and under the bottom wall of the duodenal bulb in the point corresponding to the 5 and 7 o'clock conditional dial.

The solution was prepared immediately before use, based on 1 ml of 0.01% adrenaline in 40 ml of 0.9% solution of sodium chloride, and enter through the endoscopic injector conducted under visual control through a biopsy channel of fibergastroscope, at one point you enter 3 ml, depth of insertion of the needle injector 0.5 cm

Absolute contraindication to perform research is a critical condition of the patient. Relative contraindications to esophagogastroduodenoscopy: large goiter, deformity of the cervical-thoracic spine, pronounced kyphosis (scoliosis, lordosis), the rigidity of the throat, narrowing of the esophagus (stomach), diverticula of the esophagus. If necessary, the study can be performed under General anesthesia.

Specific examples of the complete method.

Example 1. Patient I., aged 57. Case history No. 1159, received 16.07.2006, with the clinic gastrointestinal bleeding. At the initial endoscopic examination revealed a blood clot cherry size 2.5 cm, which occupies a large part of the bulb of Dvenadtsat the duodenum, fixed to the front wall, when viewed from traces of fresh blood was not detected. The source of bleeding to explore failed. Conclusion: held the bleeding forest 2 A. signs of ongoing bleeding at the time of inspection were not found. Probable cause bleeding ulcer of the duodenal bulb.

The patient after 3 hours from the receipt against the backdrop of ongoing infusion therapy was performed control fibrogastroscopy. In the study noted that the blood clot cherry still fixed to the front wall of the duodenal bulb, and defined load and with poor selection of red blood in the lumen of the antrum. Held endoscopic hemostasis according to the proposed method: the injection of epinephrine in point pylorus is preserved, corresponding to 7, 9, 11 hours conditional dial.

Obtained a good result: the selection of fresh blood had stopped, the blood clot at last injection "fell off". Became available to inspect the source of the bleeding ulcer of the duodenal bulb, located on the front wall, the size of 0.5 cm with a thrombosed vessel in the center (figure 3). Addition was completed, the electrocoagulation vessel. On the following day when esophagogastroscopy found that the ulcer is covered by fibrin, threatening bleeding not. The patient from the emergency Department transferred to branch the surgery for further treatment. Complications are not checked.

Example 2. Patient I., 19 years old, history 2311 delivered brigade ambulance, ulcer history no, according to the patient noted the unconscious with loss of consciousness, vomiting, black stool no notes. Clinical signs: in consciousness, pale skin, moist, pulse 120 beats per minute. By rectal examination melena is not revealed. In the calcaneus was performed fibrogastroscopy. In the study noted a rich scarlet color of blood into the lumen of the duodenal bulb. The source of bleeding inspection is not available. Presumably the source is located on the bottom (medial) wall of the duodenal bulb. The patient was hospitalized in the intensive care unit. When re-endoscopy - indications of ongoing bleeding. Held endoscopic hemostasis, according to the proposed method: the injection of epinephrine in the pylorus is preserved in the point corresponding to the 5 and 7 o'clock conditional dial.

The bleeding stopped. On the medial wall defined ulcerative defect size 0.7 cm with thrombosed vessel diameter of 0.1 see against the backdrop of ongoing infusion and antiulcer therapy of recurrent bleeding is not observed. The patient on the 3rd day he was transferred for treatment in the Department of surgery.

Example 3. Patient S., 68 years, the history of the disease, 635, 06.02.2007, he was transferred from the Department of cardiology, where he was treated for 5 days about unstable angina. 06.02.2007, the patient began to complain of increasing weakness, increased shortness of breath, dizziness. The patient is examined by a surgeon, was suspected gastrointestinal bleeding. When endoscopic study noted a rich scarlet color of blood from the bulb of the duodenum through the pylorus is preserved in the lumen of the antrum of the stomach, on the back of the bulb of the duodenum is fixed a bunch of cherry-0.7 see the source of bleeding to explore failed. Considering comorbidity and ongoing bleeding, performed endoscopic hemostasis according to the proposed method: the injection of epinephrine in the pylorus is preserved in the points corresponding 1,3 and 5 o'clock conditional dial. Bleeding was significantly reduced, allowing to remove the blood clot, visualize ulcerative defect and to achieve the final stop bleeding argon plasma coagulation of the bleeding site. When the control endoscopy bleeding recurrence was not detected. The patient received anti-ulcer and substitution therapy. On the 5th day he was transferred for treatment in the Department of surgery.

Example 4. Patient I., aged 77, STO is I disease 1842, did 17.07.2007 year with the clinic severe gastrointestinal bleeding. Ulcer history for more than 30 years, periodically conducts courses of anti-ulcer therapy, the last time 4 years ago. The patient systematically alcoholized, lives alone. When entering a serious condition, skin pale with yellowish tinge, tachycardia 127 beats per minute, repeatedly vomiting, face and clothes smeared the contents of the color "coffee grounds". The patient was hospitalized in the intensive care unit. At the initial endoscopic examination shows massive bleeding. The blood red color in the lumen of the antrum and duodenal bulb. Were trying to remove some blood sucking through a biopsy channel of fibergastroscope. However, there was an abundant flow of blood. To localize the source of bleeding was impossible. Performed endoscopic hemostasis according to the proposed method: the injection of epinephrine in the pylorus is preserved in the point corresponding to the 1 and 11 o'clock conditional dial. The flow of blood stopped. Managed to look ulcerative defect of the bulb of the duodenum, which had dimensions of 2.5 cm and the top of the wall with the transition to the rear wall. On the upper wall in the bottom of the ulcer became available to examination quite a large vessel cherry color with a diameter of 2 the m The wall of the duodenal bulb with a rough scar deformity. Despite the successful stop of bleeding, the risk of recurrent bleeding remained high. The patient performed the catheterization of Central veins, within 2 hours was conducted infusion therapy. When the control endoscopic examination noticed the recurrence of bleeding. The patient was operated, performed resection of the stomach. In this case, endoscopic hemostasis helped to prepare the patient for surgery, to perform the necessary remedial measures to stabilize the patient's condition.

Localization of the place of introduction and the number of points in which you must enter vasoconstrictor drug, is determined by the structure of the area of passage of the neurovascular bundles, selected on the basis of clinical observations of patients based on clinical studies and dynamic endoscopic surveillance for 14 patients admitted to the intensive care unit of the City hospital №2 cities of Seversk, with signs of ongoing bleeding or recurrent bleeding on the background of treatment

As a result of application of a new method of endoscopic stop bleeding from ulcers piloroduodenalnoy zone, good results: in 11 (78.6 per cent) patients were able to achieve a stable hemostasis, 2 (14,3%) patients n the second day after endoscopic stop bleeding developed recurrent bleeding, have been operated, at 1 (7,1%) patients endoscopic hemostasis was not a success, was operated on.

Thus, the application of this method in clinical practice enables successful endoscopic hemostasis, as the final method of treatment, or to improve the visual quality of the picture when combined endoscopic treatment.

Sources of information

1. Podshivalov VY Endoscopy bleeding gastroduodenal ulcers. // Surgery. - 2006. No. 5. - Pp.33-38.

2. Fedorov DU, Mikhalev A.I., Orlov HE Endoscopic diagnostics and stop acute gastroduodenal bleeding and prediction of risk of recurrence. // ROS. Journe. Gastroenterol., gepatol., coloproctol. - 2002. No. 1. - P.9-18.

3. Comparative evaluation of physical methods of hemostasis at the stop gastroduodenal ulcer bleeding. / Vphantom [and other] // Endoscopic surgery. - 2003. No. 4. - P.32-35.

4. Gastroduodenoscopy in the diagnosis and treatment of gastroduodenal ulcer bleeding. / NView [and other] // Surgery. - 2007. No. 3. - P.17-21.

5. Fedorov DU, Plakhov W., Mikhalev A. I. Endoscopic hemostasis with the use of argon plasma coagulation in acute gastrointestinal bleeding. // Clinical endoscopy. - 2003. No. 1. - P.10-25.

6. Chernavskaya N.E. Diagnostic and therapeutic gastroduodenoscopy the I in the gastro-intestinal bleeding ulcer etiology. // Honey. help. - 2006. No. 4. - C-16.

7. Tactics of treatment of patients with gastroduodenal ulcer bleeding. / Aeschliman [and other] // ROS. the honey. log. - 2007. No. 2. - P.16-18.

8. Krylov, N.N. Bleeding from the upper gastrointestinal tract: causes, risk factors, diagnosis, treatment. // ROS. Journe. Gastroenterol., gepatol., coloproctol. - 2001. No. 2. - P.76-87.

A method of endoscopic stop bleeding from ulcers piloroduodenalnoy areas, including endoscopy piloroduodenalnoy zone with subsequent intravenous injection of vasoconstrictor solution of the drug, wherein the point of injection is chosen from the 6 points of the pylorus is preserved, located on 1, 3, 5, 7, 9, and 11 hours conditional dial, 12 o'clock accept a point located in the Central part of the upper wall of the pylorus is preserved, and when the location of the source of bleeding in front of the bulb of the duodenum (duodenal) injection is carried out in a point of the pylorus is preserved, corresponding to 7, 9, 11 hours conditional dial, when placed on the top of the bulb of the duodenum - in point of the pylorus is preserved, corresponding to the 1 and 11 o'clock conditional dial when placed on the back of the bulb of the duodenum in the point corresponding to 1, 3, 5 o'clock conditional dial and under the bottom wall of the duodenal bulb in the point corresponding to 5 and 7 cha is the conditional am dial.



 

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EFFECT: increased number of mobile spermatozoa in ejaculate.

FIELD: medicine, miniinvasive abdominal surgery.

SUBSTANCE: the present innovation deals with treating gastric and/or duodenal ulcerous disease along with gastroesophageal reflux disease. It is necessary to remove the compression of celiac artery due to notching interganglonar comissures of celiac plexus, introduce a flexible tube into abdominal cavity through trocar point: cannula-free injection needle is connected to tube's one end, the cannula of injection needle - towards another end. With the help of a manipulator one should capture the tube at the border with the needle. Under visual control it is necessary to fulfill the puncture of celiac plexus till the support into the arresting device. By not removing a manipulator one should inject cytiton and physiological solution at 1:20 ratio to stimulate celiac plexus, 1.0 1.5%-gangleron solution. Moreover, due to regulating the length of free part of injection needle it is possible to alter the depth of injection. Through the tube into the site of puncture in into celiac plexus it is important to introduce a catheter for medicinal stimulation of celiac artery in post-surgical period. The plasty of diaphragmatic passage should be fulfilled with a spherical polymer explant of 10 cm diameter. In the center of the explant one should cut a circle of 3 cm diameter. Due to radial incision this circle is connected with external border. The explant should be applied so to keep the esophagus in the cut foramen of the prosthesis. The latter should be sutured without tension towards the diaphragm. The innovation enables to suppress gastric secretory function, provides anti-reflux action in area of gastroesophageal passage, prevents complications associated with excessive traumatism of the organs, ischemia of celiac artery and pathological narrowing of esophageal foramen.

EFFECT: higher efficiency of therapy.

1 dwg, 1 ex

FIELD: medicine.

SUBSTANCE: invention pertains to medicine, namely, to surgery and may be used for extrafascial removal of the lobe of thyroid gland. Thyroid gland is approached. Anteroposterior and transverse dimensions of the pathologically changed lobe of the thyroid gland, anteroposterior size of the auxiliary lobe of the thyroid gland are measured intraoperatively. Version of the structure of the pathologically changed lobe of the thyroid gland is determined on the bases of the received data: slightly enlarged mobile lobe of the thyroid gland - slight increase of any dimension by not more than 15 mm against the norm, barrel-shaped thyroid gland - anteroposterior size increased by more than 15 mm against the norm, enlarged auxiliary lobe - anteroposterior size of the auxiliary lobe increased by more than 15 mm against the norm. Different sequences of the surgery stages are performed for every type of structures.

EFFECT: method minimises risk of the injury of the recurrent laryngeal nerve.

3 ex, 6 dwg

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