RU2766741C1 - Method for bile duct stenting in patients with mechanical jaundice of tumor etiology using access through cholecystostomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to hepatobiliary surgery. The stent is implanted according to the “Rendezvous” method. An introducer is installed along the conductor into the gallbladder to the mouth of the cystic duct, through which a manipulative catheter “Cobra” is installed into the cystic duct, cholangiography is performed. Then the recanalization of the cystic duct and catheterization of the choledochus are carried out. With the help of the “hydrophilic conductor plus hydrophilic catheter” system, recanalization of the tumor stricture is performed. After penetration behind the stricture area, a conductive catheter is installed. An endoscopic conductor is inserted through the catheter, which is captured through the endoscope with endoscopic forceps and removed through the mouth. Perform a papillosphincterotomy on the conductor. Catheterization of hepaticocholedoch is performed. Hepaticocholedoch stenting is performed with stent implantation, while the proximal end of the stent is installed above the tumor stricture by 20 mm, the distal end is installed transpapillarly into the duodenum. A control drainage catheter is inserted into the gallbladder. After 1 day, a control cholangiography is performed, the patency of the stent is evaluated, the absence of congestion. After 2-3 days, the drainage catheter is removed.

EFFECT: method is minimally invasive, provides adequate, often lifelong decompression of the biliary tract in patients with inoperable tumors of the hepatopancreatoduodenal zone, to increase the effectiveness of treatment and improve the patients’ life quality.

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Description

The method relates to medicine, namely to surgery, and can be used in the treatment of patients with unresectable tumors of the organs of the hepatopancreatobiliary zone, complicated by obstructive jaundice syndrome.

Patients with malignant neoplasms of the liver and bile ducts still constitute one of the most difficult categories of patients. The most serious complication of hepatopancreatobiliary cancer is obstructive jaundice, which is often the first symptom of the disease. Most patients are admitted to the hospital in serious condition and require palliative care aimed at decompressing the biliary tract. The preferred method in this situation is percutaneous transhepatic external or externally internal bile duct drainage (PTCD). Nevertheless, it is often impossible to perform PTCHD due to a small degree of dilation of the bile ducts, as well as other technical difficulties. The method of choice in this situation is percutaneous cholecystostomy. However, this method of decompression does not always provide effective bile flow and significantly reduces the quality of life of patients, which is due to external bile excretion. The final method of palliative treatment that improves the quality of life of patients and which should be given preference is stenting of the bile ducts.

A known method is percutaneous transhepatic stenting of the bile ducts and percutaneous transhepatic stenting of the bile ducts with laparoscopic assistance (S.A. Alentiev, B.N. Kotiv, S.Ya. Ivanusa and others. Endobiliary stenting with laparoscopic assistance - hybrid technologies in a difficult clinical situation // Grekov Bulletin of Surgery, 2014, No. 2, pp. 33-37; Kulezneva Yu.V., Izrailov R.E., Urakova N.A. Percutaneous transhepatic stenting of the bile ducts (indications, technique, results) // Diagnostic and Interventional Radiology, 2008, No. 4, pp. 87-93).

The disadvantage of these methods is the impossibility of catheterization of the intrahepatic bile ducts due to their small diameter due to the presence of cholecystostomy in the patient.

The aim of the invention is to increase the efficiency of treatment of patients with obstructive jaundice of tumor etiology, as well as to improve the quality of life of patients with malignant neoplasms of the organs of the hepatobiliary zone, with previously imposed cholecystostomy.

The solution of this problem is realized by the fact that in the method of stenting the bile ducts in patients with obstructive jaundice of tumor etiology using access through a cholecystostomy using a coated nitinol self-expanding biliary stent, the stent is implanted according to the Rendezvous method, in an X-ray operating room under local infiltration anesthesia, under fluoroscopy control, fistulocholangiography is performed, the anatomical structure of the gallbladder, bile ducts, the length and patency of the tumor stricture are assessed, then a 5 F introducer is installed through the guide into the gallbladder to the cystic duct mouth, a manipulation catheter "Cobra" is installed through the introducer into the cystic duct, cholangiography is performed , then the cystic duct is recanalized and the choledochus is catheterized, then the tumor stricture is recanalized using the “hydrophilic conductor plus hydrophilic catheter” system, after penetration a guide catheter with a diameter of 5 F is placed behind the stricture area, an endoscopic guide is inserted along the catheter, which is captured through the endoscope with endoscopic forceps and removed through the mouth, then papillosphincterotomy is performed on the guide, catheterization of the hepaticocholedochus is performed, then, under fluoroscopic and endoscopic control, stenting of the hepaticocholedochus is performed with implantation of the stent, at the same time, the proximal end of the stent is placed 20 mm above the tumor stricture, the distal end is placed transpapillary into the duodenum, a control drainage catheter is placed into the gallbladder; after 1 day, a control cholangiography is performed, the stent patency is assessed, the absence of streaks, after 2-3 days the drainage catheter is removed.

The advantages of this method is the minimal invasiveness of the technique, which allows for adequate, often lifelong decompression of the biliary tract in patients with inoperable tumors of the hepatopancreatoduodenal zone. The presence of internal bile excretion significantly improves the quality of life of patients, eliminating the presence of drainage on the skin and the need for oral bile intake.

The invention is illustrated in FIG. 1, which shows an endophoto, the guide catheter and endoscopic guidewire are indicated by an arrow. In FIG. 2 shows a cholangiogram through a cholecystostomy. The conductor (indicated by the arrow) is captured by the endoscope. In FIG. 3 shows a cholangiogram after stent placement. The arrow indicates a partially expanded stent.

The method is implemented as follows.

In the conditions of an X-ray operating room under local infiltration anesthesia with a 0.5% solution of lidocaine or novocaine under the control of fluoroscopy, fistulocholangiography is performed, the anatomical structure of the gallbladder, bile ducts, the extent and patency of the tumor stricture are assessed. An introducer with a diameter of 5 F is installed along the guide into the gallbladder to the orifice of the cystic duct. A manipulation catheter "Cobra" is installed through the introducer into the cystic duct. Cholangiography is performed. Next, recanalization of the cystic duct and catheterization of the choledochus is carried out. The tumor stricture is then recanalized using the hydrophilic conductor plus hydrophilic catheter system. After penetration beyond the area of the stricture, a guiding catheter with a diameter of 5 F is installed. An endoscopic guidewire is inserted along the catheter, which is captured through the endoscope with endoscopic forceps and removed through the mouth (Fig. 1, 2). Next, a typical papillosphincterotomy is performed on the conductor, catheterization of the hepaticocholedochus is performed. Under fluoroscopic and endoscopic control, stenting of the hepaticocholedochus is performed with the implantation of a metal self-expanding stent with a polymer coating (Fig. 3). The proximal end of the stent is placed 20 mm above the tumor stricture, the distal end is placed transpapillary into the duodenum. A control drainage catheter is placed in the gallbladder. After 1 day, a control cholangiography is performed, the stent patency is assessed, the absence of streaks. After 2-3 days, the drainage catheter is removed.

Using this technique, stenting of the bile ducts in patients with obstructive jaundice of tumor etiology using access through cholecystostomy was performed in 15 patients. There were no complications associated with the procedure. Technical success was achieved in 100% of cases.

Example. Patient E., 72 years old.

In March 2020, she was hospitalized for the first time in the NRB of the city of Vyborg with a diagnosis of obstructive jaundice. A neoplasm of the head of the pancreas T4NxMx was revealed. Surgical treatment was carried out in the amount of laparotomy, revision of the abdominal organs, cholecystostomy, the postoperative period was without complications. According to the histological examination: pancreatic adenocarcinoma with a necrotic component.

In July, the patient was admitted to the clinic of general surgery of the Military Medical Academy with complaints of functioning drainage, periodic pain in the area of standing cholecystostomy, moderate weakness, and malaise.

On July 3, 2020, percutaneous external-internal drainage of the bile ducts through a cholecystostomy was performed. When performing fistulocholangiography at the confluence of the cystic duct into the hepaticocholedochus, a malignant stricture was determined. An external-internal biliary drainage catheter with a diameter of 8.5 F was placed.

07/09/2020 - stenting of hepaticocholedochus through cholecystostomy according to the above-described rendezvous method with implantation of a metal self-expanding stent with a polymer coating measuring 100 by 10 mm. During the control cholangiography, the contrast agent freely enters the bile ducts and duodenum, no contrasting of the arterial and venous vessels of the liver was detected. There were no complications associated with the surgical treatment, the postoperative period was without complications, the patient was discharged under the supervision of an oncologist at the place of residence. At the control examination after 1 month, the patient does not complain, the fistula passage is closed. There was no recurrence of jaundice.

Thus, the results of bile duct stenting in patients with unresectable tumors of the organs of the hepatopancreatobiliary zone complicated by the obstructive jaundice syndrome according to the Rendezvous method using access through a cholecystostomy allow us to speak about the effectiveness of this decompression method and the possibility of its application in clinical practice.

Claims (1)

A method for stenting the bile ducts in patients with obstructive jaundice of tumor etiology using access through a cholecystostomy using a coated nitinol self-expanding biliary stent, characterized in that the stent is implanted according to the Rendezvous method, under the conditions of an X-ray operating room under local infiltration anesthesia, fistulocholangiography is performed under fluoroscopy control , evaluate the anatomical structure of the gallbladder, bile ducts, the extent and patency of the tumor stricture, then a 5 F introducer is installed through the guide into the gallbladder to the orifice of the cystic duct, a manipulation catheter "Cobra" is installed through the introducer into the cystic duct, cholangiography is performed, then recanalization is performed of the cystic duct and catheterization of the choledochus, then, using the “hydrophilic conductor plus hydrophilic catheter” system, recanalization of the tumor stricture is performed, after penetration beyond the area of the stricture, a a guide catheter with a diameter of 5 F is inserted, an endoscopic conductor is inserted through the catheter, which is captured through the endoscope with endoscopic forceps and removed through the mouth, then papillosphincterotomy is performed on the conductor, catheterization of the hepaticocholedochus is performed, then, under fluoroscopic and endoscopic control, stenting of the hepaticocholedochus is performed with implantation of the stent, while the proximal the end of the stent is placed 20 mm above the tumor stricture, the distal end is placed transpapillary into the duodenum, a control drainage catheter is placed into the gallbladder; after 1 day, a control cholangiography is performed, the stent patency is assessed, the absence of streaks, after 2-3 days the drainage catheter is removed.

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