Method of endoscopic retrograde cholangiopancreatography in patient with earlier performed cholecystostomy

FIELD: medicine.

SUBSTANCE: introduction of endoscope into duodenum is realised. After that, "tight" filling of choledoch is performed through cholecystostoma with sterile solution, for instance, 0.25% Novocain. After that major duodenal papilla is catheterised and endoscopic papillosphincterotomy is carried out.

EFFECT: method makes it possible to provide effective surgical treatment of cholelithiasis with simultaneous reduction of probability of development of complications due to provision of possibility of fast identification and good visualisation of major duodenal papilla.

1 ex


The present invention relates to the field of medicine, namely to surgery.

It is known that one of the stages of treatment of gallstone disease (GSD) is an endoscopic retrograde cholangiopancreatography (ERCP).

The known method ERCP, wherein the radiopaque substance using a special retrograde catheter is inserted through the endoscope directly into the biliary system and pancreatic ducts. ERCP allows you to visualize, diagnose and document the stones in the ducts and gall bladder, changes in the ducts in chronic pancreatitis, tumors, as well as stenosis and stricture of the ducts (the Journal news of beam diagnostics. [Electronic resource] news of beam diagnostics 1999 1: 28-30, link date of access: 3.02.2014).

The closest in technical essence to the proposed method is ERCP in a patient with previously performed by cholecystectomies, including the introduction of the endoscope into the duodenum (duodenum), catheterization of the large duodenal papilla (MDP) and holding EPST.

The known method is as follows. Includes staging treatment: at the first stage examination of the patient using ultrasound (USG) of the abdomen. If there are signs of biliary and intravesical hypertension� under perform ultrasound-guided puncture and drainage of the gallbladder (cholecystectomy) or common bile duct (cholangiostomy).

The second stage performs ERCP, endoscopic papillosphincterotomy (EPST). After the pre-pass sedation for endoscopic transpapillary interventions, which include catheterization of BDS, EPST and control the contrast of the ducts with the registration of the free flow of contrast from the biliary ducts into the duodenum (Scientific electronic library disserCat - the modern science of the Russian Federation, article, dissertation research, scientific literature, texts theses [Electronic resource] // title of thesis and abstract by WAC 14.01.17, PhD Belenkov A. V.: "On the tactics of treatment of patients with the syndrome of obstructive jaundice gallstone Genesis" date of access: 3.02.2014).

The disadvantages of the known method, and similar, should be attributed to the technical difficulties associated with the introduction of a catheter into the mouth of BDS due to poor visualization.

It is known that during prolonged manipulation attempt at imaging and catheterization of BDS may develop complications such as pancreatitis, bleeding, perforation, cholangitis and other infectious complications (Med-Practic [Electronic resource] JOURNAL of SURGERY in ARMENIA. G. S. TAMAZIAN, 3.2011 // Twenty-year analysis of complications after PR�changes ERCP, EPST in "Erebuni"

In addition, the increase in execution time of this manipulation leads to increased radiation load on the patient and the duration of anaesthesia.

The aim of the invention is the ability to perform ERCP and endoscopic papillosphincterotomy with less technical difficulties identify the mouth of the LDP and the least likelihood of postoperative complications.

The technical result of the proposed method ERCP is to increase the efficiency of treatment by reducing the complexity and duration of detection of the mouth of BDS, as well as reducing the risk of developing complications.

The technical result of the claimed method ERCP in a patient with previously performed by cholecystostomy is achieved by the introduction of the endoscope into dwenadzatiperstnuu intestine, catheterization of BDS and holding EPST.

Distinctive techniques of the proposed method lies in the fact that prior to catheterization OBD hold "tight" filling via the common bile duct cholecystitis sterile fluid such as a solution of novocaine 0.25%.

Comparative analysis of the proposed method and the prototype shows that the inventive method differs from the known above-mentioned techniques. These differences allow to draw a conclusion about conformity of the proposed technical �decision criterion of the invention of "novelty."

The analysis of patent and scientific and medical literature showed that the proposed method has the characteristics that distinguish it not only from the prototype, but also from other variants of endoscopic retrograde cholangiopancreatography.

Receiving "tight" filling via the common bile duct cholecystitis liquid can reduce the complexity and duration of detection of the mouth of BDS, through visualisation and the unfolding of the flowing fluid, which facilitates its catheterization when performing ERCP and EPST.

The use of novocaine 0.25% as a fill choledoch solution and also provides an analgesic effect, which is important when performing ERCP, because the spasmolysis facilitates catheterization of the OBD.

Distinctive techniques of the proposed method provide the possibility of obtaining the specified technical result - improving the efficiency and safety of treatment by reducing the complexity and duration of detection of the mouth of BDS, reduce the risk of developing complications.

Stated allows to draw a conclusion about conformity of the proposed method the criterion of "inventive step".

The method constituting the invention, intended for use in medicine. This method can be used in surgery in the treatment of cholelithiasis in patients with previously performed cholecystostomy�th. The possibility of its implementation confirmed as described in the application of methods and means, therefore, the proposed solution meets the criterion of invention "industrial applicability".

The essence of the proposed method ERCP in a patient with previously performed by cholecystostomy is illustrated by a clinical example.

Example. Patient B., 64 years old, was admitted to the emergency surgery Irkutsk regional clinical hospital about cholelithiasis, acute cholecystitis, complicated by mechanical jaundice with complaints of pain in the right hypochondrium and epigastric region, nausea, bitter taste in the mouth, yellowness of the skin and sclera. The examination revealed a sharp pain at the point of Kera, positive symptoms Murphy, Grekov-Ortner. In General, the analysis of blood (OAK) - leukocytosis with a shift leukocyte formula to the left, increased erythrocyte sedimentation rate. In the biochemical blood test: total bilirubin - 20.8 µmol/l; direct bilirubin of 5.4 µmol/l; ALT 89,9 IU/l; ACT 100,2 IU/l; alpha - amylase (diastase) 130,0 IU/L. abdominal ultrasound: liver is not enlarged, smooth contours, homogeneous parenchyma. Gallbladder irregular shape 10*6 cm, 5 mm wall is doubled, sealed. Volume 70 CC In the lumen of dense echostructure, giving an acoustic shadow. Choledoch 11 mm. Signs of biliary hypertension.

Breath the patient to breath under ul�travacalm control a puncture of the gallbladder. The correct position of the needle was controlled by the dark evacuation of bile. When successfully completed the puncture and there are indications for biliary decompression performed cholecystostomy, the drainage catheter was placed directly into the cavity of the gallbladder.

After pre-treatment under local anesthesia of the pharynx 10% spray lidocaine executed videothoracoscopy, fistulography, EPST.

The esophagus is freely pass on all over, slimy pink all over, longitudinal folds, straightened air well, cardia 39 cm, peristaltic, closes completely, the Z - line level, clear - on 39 see the Stomach was well disposed of air, active peristalsis, the folds are expressed in the lumen modest amount of food (Gasterosteus-?). The porter round, peristaltic, closes completely.

The mucous membrane of the duodenum is not changed. In the upper horizontal with the transition to the descending part of the duodenum revealed a diverticulum with a diameter of 15-20 mm without signs of inflammation. OBD poorly expressed point the mouth of 2 mm, the bile in the time of the survey from the mouth into the duodenum has not been received.

Made shallow, up to 2-3 mm, canulate OBD. Canulate of the common bile duct is not possible because of the presence of stricture of the terminal segment of the common bile duct (TOX) - according to fistulography has a conical narrowing of the TOX in the form of "Peschiera". After the introduction of cholecystitis (respectively in the gallbladder and bile ducts) solution of novocaine 0,25%, the flow through the common bile duct (OVC), the liquid spreads and renders the mouth and relieves spasms of the OBD.

The creation of high pressure fluid in the ducts and prolapse of BDS in the lumen of the duodenum was able to freely spend canulation the catheter into the lumen of the OVC.

Performed antegrade filling of the ducts: OVC is not expanded, the contents are homogeneous, the contours of smooth ducts. When fistulography marked uniform constriction TOCH (cicatricial stricture). Choledoch entered the stretch papillotome made EPST to 9-10 mm; minimal bleeding from papillotomes incision stopped by coagulation. On the control cholangioscopy revealed free flow of contrast from the biliary ducts into the duodenum.

Conclusion: Stricture (scar?) the terminal segment of the common bile duct. Diverticulum of the duodenum. Gastrulas. Chronic gastritis.

The postoperative period was uneventful. The symptoms of pain fully docked, nausea, bitter taste in the mouth does not bother me. The skin is clean, pale pink. Urine light yellow. Labratory indicators normalized. In the control ultrasound gallbladder 6,6*4 cm, wall 3 mm. Volume 55 CC In the lumen of dense echostructure, giving ten acoustic�. Choledoch 7 mm. Signs of biliary hypertension no.

Thus, the proposed method allows to visualize the mouth of BDS with less technical difficulties, to reduce the time necessary manipulations and reduces the risk of possible complications.

Method of endoscopic retrograde cholangiopancreatography in a patient with previously performed by cholecystectomies, including the introduction of the endoscope into the duodenum, catheterization of the major duodenal papilla and endoscopic papillosphincterotomy, characterized in that prior to catheterization papillary hold "tight" filling via the common bile duct cholecystitis sterile fluid such as novocaine 0.25% solution.


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