RU2555378C1 - Method of endoscopic arrest and prevention of ulcerous bleedings from duodenum defects - Google Patents

Abstract

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

Description

The method of endoscopic stop and prevention of ulcerative bleeding from defects of the duodenal wall.

The invention relates to medicine and can be used to stop and prevent relapse of ulcerative bleeding localized in the duodenum 12.

Despite the rapid development of medical technologies, bleeding of the gastrointestinal tract (GIT) still poses a significant threat to the patient's life and is often accompanied by mortality.

The modern approach [1, 3, 4, 5] provides primarily for the use of minimally invasive endoscopic methods for the diagnosis and treatment of ulcerative bleeding. Existing endoscopic methods of physical, chemical, combined hemostasis in most cases can achieve hemostasis and prevent recurrence of bleeding.

However, in practice, well-known techniques often prove to be either unable to effectively seal the defect area while maintaining the minimally invasive effect or do not solve the bleeding problem at all. So, for example, with jet arterial bleeding, endoscopic methods remain ineffective due to the impossibility of a clear localization of the source of bleeding, developed coagulopathy, lack of time for hemostasis [2, 3, 4, 5]. In such cases, the endoscopic benefit comes down to a statement of the ongoing bleeding, and the patient in a state of hemorrhagic shock is subjected to additional trauma during a forced surgical operation.

As a sealing device in literary sources, the possibility of using coated metal self-expanding stents for separation of the gaps in the esophageal-tracheobronchial fistula, to restore the lumen and maintain the patency of the tubular organs with benign or malignant constrictions is mentioned.

As an analogue, the method of using the JAMIC-3 sinus catheter [6] to stop bleeding was chosen.

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

Achievable technical result is the provision of effective sealing of the defect area of the wall of the duodenum 12 under conditions of minimally invasive exposure. In addition, the resulting isolation of the defect area prevents its contact with body fluids (for example, gastric juice), which prevents the development of complications associated with the underlying disease.

The achievement of these results is due to the following.

The duodenum, 12, is an organ of low displacement and tightly fixed to the surrounding tissues. The physiological boundaries of the duodenal bulb are represented by two distinct formations - the pyloric muscle ring, which provides constant tone from the proximal side, and a rigidly fixed, slightly tensile area of the bulb-duodenal junction from the distal side. These two obstruction sites at the entrance and exit of the duodenum, on the one hand, limit the possibility of using conventional stents to create full compression on the bleeding area, and on the other, it is these anatomical features that create conditions for effective tamponade if we use the technique developed by us . According to the technique developed by us, a stent with specially expanded funnel-shaped edges is installed so that these edges, abutting against the organ wall from the distal and proximal sides, create a closed cavity and, on the one hand, cause hemotamponade and, on the other, have direct compression on the wall .

Using the developed technique allows almost blindly, in conditions of ongoing bleeding, to work in this zone, because There are clear permanent anatomical landmarks (the gatekeeper).

In addition, after installing the stent, it is possible to easily and safely wash the stomach from the blood and fully examine both the stomach and the distal part of the 12-intestine.

Installation of a coated stent immediately ceases access to ulceration of aggressive gastric contents and, therefore, effectively promotes its healing.

An installed stent allows monitoring the effectiveness of stopping bleeding and, if necessary, it is possible to change the position of the stent.

Application of the method allows to reduce the duration of endoscopic intervention to stop bleeding and, thus, significantly reduce the total amount of blood loss.

Provided using the claimed method, express stopping of bleeding allows you to stabilize the patient and fully prepare him for a possible subsequent planned surgical intervention.

The specified result is ensured by the endoscopic installation of a coated metal self-expanding prosthesis (stent) in the lumen of the duodenum. The stent is installed in such a way that its funnel-shaped edges abut against the walls of the intestine, creating a closed cavity between the proximal and distal edges of the stent. Thus, the source of bleeding is localized in a closed cavity of small volume between the edges of the stent (not more than 20-50 cm ² ). With continued bleeding, blood from the cavity does not evacuate, accumulates, which leads to tamponade of a bleeding vessel, activation of local hemostasis factors and, as a result, bleeding stop.

Stent placement is possible, including as a preventive measure for high risk of recurrence of bleeding and the difficult use of standard methods for the prevention of recurrence of bleeding - with large callous ulcers, ulcers against cicatricial deformity of the organ, and the patient’s general general condition.

The method is as follows.

For clinical signs of bleeding, a prospective bleeding site is preliminarily examined with a flexible endoscope with a wide instrument channel (the diameter required for the delivery device must be at least 3.4 mm). On examination, they try to determine the localization of the source of ongoing bleeding (a pulsating stream, or the flow of light arterial

blood) or localization of a peptic ulcer with a high risk of recurrence of bleeding.

If it is impossible to conduct a standard endoscopic benefit or its ineffectiveness, a decision is made to install a stent in the area of bleeding or ulcerative defect.

A flexible conductor string (for example, MET-35-480 string from Willson-Cook, Ireland) is passed through the instrumental channel of a flexible endoscope beyond the bleeding area. Through the inner braid (Fig. 1, position 4), a delivery device is carried out over the bleeding area along the string to the conductor.

The safe conduct of the device is facilitated by a soft protective distal cap (Fig. 1, position 6). The external braid (Fig. 1, position 3) of the delivery device is unlocked using the external braid lock (Fig. 1, position 5) located on the handle (Fig. 1, position 1) and is displaced in the proximal direction so that the stent (Fig. . 1, position 2) is expanded and fixed in the lumen of the intestine, capturing the area of the bleeding vessel and forming a closed cavity.

Considering that the diameter of the stent lumen in the expanded state is not less than 22 mm, immediately after installation it is possible to conduct an endoscope in the distal direction beyond the stent area. This allows you to examine the distal and proximal edges of the stent, to assess the tightness of the edges of the stent to the walls of the hollow organ and to exclude leakage of blood from under the edges of the stent.

If necessary, reposition of the stent is possible using proximal and distal reposition loops (“lasso”) (Fig. 2, positions 7, 8).

With the correct installation of the stent, blood flow to the organ stops. After washing the blood and clots from the lumen of the tubular organ, a second examination is performed, and in the absence of blood leakage, the study is terminated.

Control studies with examination of the stent area are carried out as planned once a day for three days from the moment of bleeding, or urgently at the clinic of bleeding recurrence.

The stent remains in the lumen of the organ for up to 4 weeks - until the patient is completely stabilized and the alleged defect is scarred. Next, the stent is removed using an endoscope. The area previously covered by the stent is inspected again.

Clinical example

Patient S., 77 years old, was hospitalized in the surgical department after 7 days from the onset of the disease with a diagnosis of Exacerbation of calculous cholecystitis. Exacerbation of chronic pancreatitis. Biliary hypertension.

On admission: complaints of pain in the upper right abdomen of the girdle, dry mouth, nausea. Deterioration after an error in the diet. She independently took no-shpa, pentalgin, nurofen without effect. Due to persistent abdominal pain, it caused an SMP. On examination, the condition is moderate. Consciousness is clear. Blood pressure 150/90 mm. Hg. Art. The abdomen is symmetrical, does not swell, on palpation it is soft, painful in the right hypochondrium, there are no symptoms of peritoneal irritation, the gases go away.

Ultrasound: diffuse changes in the parenchyma of the liver, pancreas, choledoch hypertension - 14 mm in diameter.

The patient underwent infusion-antispasmodic therapy with positive dynamics - abdominal pain decreased.

In the morning of March 15, 2014, at 8.30, the patient's condition worsened. Complaints of chest pain, weakness, malaise. Blood pressure 90/60 mm. Hg. Art. Examined by a duty therapist, cardiorenatologist. Suspected of acute coronary syndrome, the patient was transferred to ICU. The department conducted complex conservative therapy. The troponin test is positive. The diagnosis was made: acute myocardial infarction. Complications: unstable supraventricular arrhythmia.

03/19/14, at 09:50, the patient’s condition worsened sharply: profuse scarlet vomiting, extremely severe condition, pale skin, heart sounds weakened, heart rate 100 beats per minute, blood pressure 60/40 mm RT, art. intestinal bleeding.

On emergency endoscopy, the duodenal bulb cavity is made with a fresh blood clot, there is a jet of scarlet blood from under the clot, it is not possible to thoroughly examine the source of bleeding, and attempts to conduct injection hemostasis “blindly” were unsuccessful. In order to stop bleeding, a pyloroduodenal coated metal self-expanding stent (Hanarostent, M.I. Tech South Korea) was delivered to the lumen of the bulb of the duodenum. Hemostasis achieved.

The patient was transferred to the OAR for further treatment, where intensive conservative therapy was continued. During the control endoscopy on March 20, 2014, there were no signs of recurrence of bleeding. When trying to inspect the lower horizontal branch of the duodenum, a stent dislocation developed. The wall of the duodenal bulb was exposed, represented by a giant ulcer defect, occupying up to half the circumference of the duodenum, a pigment spot in the center of the defect up to 2-3 mm in diameter (risk of Forrest 2C bleeding recurrence). To prevent recurrence of bleeding, the stent was repositioned to the area of the ulcer defect. Against the background of conservative treatment, a gradual stabilization of the state.

Control endoscopy was carried out on March 21, March 23, and March 25, there were no signs of recurrence of bleeding. March 27, during the control endoscopy, the stent was removed. The examined ulcerative defect decreased to 2 cm in diameter, the bottom of the defect was covered with a grayish coating (risk of Forrest 3 bleeding recurrence).

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

Bibliography:

1. Order of April 13, 2011 n 320 on a common tactic for the diagnosis and treatment of acute surgical diseases of the abdominal cavity in medical institutions of the Moscow City Health Department.

2. Gastroduodenal bleeding of ulcerative etiology 2008, Gostishchev VK, Evseev MA, Geotar-media ISBN: 978-5-9704-0923-7, 384 pp.

3. Consensus Recommendations for Managing Patients with Nonvariceal Upper Gastrointestinal Bleeding, Clinical Guidelines Alan Barkun, MD, PhD and John K. Marshall, MDm MSc, 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 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.

Claims (2)

1. The method of endoscopic stop and prevention of ulcerative bleeding from defects in the wall of the duodenum, including endoscopic installation in the lumen of the duodenum with a bleeding source or ulcerative wall defect of a coated metal self-expanding stent, using a stent with an opening diameter of at least 22 mm, delivery the stent device is carried out beyond the bleeding area, and the stent is installed so that its funnel-shaped edges abut against the walls of the duodenum, creating closed cavity between the proximal and distal edges of the stent. 2. The method according to claim 1, in which, after the stent is installed, an examination of the area of bleeding or defect is performed and, if necessary, the stent is repositioned.

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