Method for endoscopic treatment of pancreatic pseudocysts

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, specifically to endoscopic surgery. In patients with chronic pancreatitis complicated by pancreatic pseudocysts, under intravenous sedation, a duodenoscope with an external diameter of 12.6 mm is introduced into the descending part of the duodenum. The major duodenal papilla is visualized, and endoscopic papillosphincterotomy is performed using a bipolar papillotome. Selective cannulation of the main pancreatic duct (MPD) is performed through the major duodenal papilla using a plastic catheter with a diameter of 1.65 mm and a length of 250 cm. After positioning the catheter in the MPD, an iodine‑containing water‑soluble contrast agent is administered in a volume of 20–40 ml, and endoscopic retrograde pancreatography is performed. The diameter of the duct, the presence of strictures, and the filling of the pseudocyst with a contrast agent are determined. An ultra‑thin daughter endoscope with a diameter of 5 mm and an instrumental channel of 1.2 mm is introduced into the lumen of the GPP through the instrumental channel of the duodenoscope. The cavity of the pseudocyst is visualized. A hydrophilic guide wire with a diameter of 0.89 mm and a length of 450 cm is passed through the instrumental channel of the ultra‑thin endoscope. After the guide is inserted into the pseudocyst cavity, the ultra‑thin endoscope is removed, leaving the guide in the pseudocyst cavity. A plastic perforated pancreatic stent with a diameter of 2.3 mm and a length of 10 cm is inserted into the pseudocyst cavity via a guide wire; it is positioned under fluoroscopic control so that the proximal end is located in the pseudocyst cavity, and the distal end protrudes into the lumen of the duodenum.EFFECT: method increases the effectiveness of endoscopic treatment of pancreatic pseudocysts, reduces the risk of complications, makes it possible to avoid performing more traumatic traditional surgical interventions in this category of patients, and reduces the length of hospital stay.1 cl, 14 dwg, 2 ex

Description

[0001] Technical field

[0002] The invention relates to medicine, namely to endoscopic surgery, and can be used to treat patients with chronic pancreatitis complicated by pancreatic pseudocysts.

[0003] Technology Level

[0004] Chronic pancreatitis (CP) is a common pathology of the pancreatobiliary system, characterized by progressive impairment of the exocrine and endocrine functions of the pancreas. This disease leads to irreversible changes in the morphology and function of the pancreas, replacement of the pancreatic parenchyma with fibrous tissue, dilation of the main pancreatic duct (MPD), and decreased exocrine and endocrine function of the pancreas. CP can lead to various complications. One common complication of CP is the formation of pancreatic pseudocysts. According to various data from the international literature, pancreatic pseudocysts in CP occur in 20-45% of patients with chronic pancreatitis.

[0005] Historically, pseudocysts were treated either conservatively or surgically, with acceptable rates of complications and recurrence. Since the first surgical internal drainage in 1921, surgery has remained the cornerstone of pancreatic pseudocyst treatment until recently. Cystogastrostomy, cystoduodenostomy, and cystojejunostomy are common types of surgery, performed either open or laparoscopically, with the creation of an anastomosis between the gastrointestinal lumen and the cyst using suturing devices. There are also endoscopic cystogastrostomy and cystoduodenostomy techniques under endoscopic ultrasound guidance using plastic or self-expanding stents.

[0006] Surgery remains a common treatment for pancreatic pseudocysts. Surgical treatment includes internal and external drainage, as well as resection. Arguments in favor of surgical intervention include the following: 1) a reasonable suspicion of severe complications of the cystic formation; 2) a progressive increase in the size of the formation despite conservative treatment; 3) the presence of reliable signs of a tumor-like nature of the cystic process. The persistently high proportion of open interventions for this pathology, as well as the high number of complications in the early and late postoperative periods, necessitate the search for new approaches and methods for treating this group of patients.

[0007] Open surgery for pancreatic pseudocysts is rarely performed in specialized centers. Internal drainage of pseudocysts by ultrasound-guided cystogastrostomy (percutaneous transgastric) or endoscopic ultrasound (EUS) is the preferred method. If technical limitations exist and the cyst is not adjacent to the stomach, external ultrasound-guided drainage is performed.

[0008] With the development of minimally invasive technologies, the treatment of a large number of pancreatobiliary diseases has become endoscopic. A few specialized centers are attempting minimally invasive treatment of pancreatic pseudocysts using transpapillary endoscopic procedures.

[0009] The prototype of the claimed invention is a method of endoscopic transpapillary drainage of pseudocysts (Barthet, M, Sahel, J., Bodiou-Bertei, C, & Bernard, JP (1995). Endoscopic transpapillary drainage of pancreatic pseudocysts. Gastrointestinal endoscopy, 42(3), 208-213). This method consists of the following: an endoscope with lateral optics (duodenoscope) is inserted into the duodenum (DG) to the major duodenal papilla (MDP), and endoscopic papillosphincterotomy (EPST) is performed. The MPD of the pancreas is cannulated and contrasted. If a pseudocyst is detected, a guidewire is inserted into the lumen of the MPD of the pancreas under X-ray control. Next, a perforated plastic stent is inserted through the pancreatic MPD into the lumen of the pseudocyst using a guidewire under X-ray control. However, the effectiveness of this method is 2.6-6.8% (Catalano MF, 1999; Cohen SA et al., 2007; Oza VM, et al., 2013).Most failures are due to the inability to insert an unguided guidewire directly into the pseudocyst cavity under radiographic control (Fig. 1). In this case, endoscopic treatment of the pseudocyst is not possible, and patients undergo traditional surgical intervention.

[0010] The objective of the claimed invention is to develop a method for endoscopic treatment of patients with pancreatic pseudocysts, allowing for minimally invasive treatment by inserting a guidewire directly into the pseudocyst cavity using an ultra-thin endoscope, in cases where it is not possible to insert a guidewire under X-ray control, thereby avoiding more traumatic traditional surgical interventions in this category of patients. Disclosure of the invention

[0011] The technical result of the claimed invention is to increase treatment effectiveness and reduce the risk of complications due to the ability to visualize the pseudocyst cavity. The presence of an instrument channel and a controllable distal portion of the ultra-thin endoscope allows for the insertion of a guidewire directly into the pseudocyst cavity under visual control. Controlled insertion of the guidewire followed by stenting of the pseudocyst cavity using a perforated plastic stent will avoid the need for more traumatic traditional surgical interventions in this category of patients, reduce treatment costs, shorten the hospital stay, and thereby improve the patient's psycho-emotional well-being.The location of the proximal end of the stent in the cavity of the pseudocyst and the distal end in the lumen of the duodenum ensures effective outflow of contents, rapid relief of pain and a reduced risk of complications (bleeding, migration) due to fixation of the stent between the walls.

[0012] The technical result is achieved through a combination of the following techniques. Under intravenous sedation, a duodenoscope with an outer diameter of 12.6 mm is inserted into the descending duodenum, the major duodenal papilla is visualized, and endoscopic papillosphincterotomy is performed with a bipolar papillotome. Selective cannulation of the MPD is performed through the major duodenal papilla using a plastic catheter with a diameter of 1.65 mm and a length of 250 cm. After positioning the catheter, 20-40 ml of an iodine-containing water-soluble contrast agent is injected into the MPD, and endoscopic retrograde pancreatography is performed to determine the duct diameter, the presence of strictures, and the filling of the pseudocyst with contrast agent. An ultra-thin daughter endoscope with a diameter of 5 mm and an instrument channel of 1.2 mm is inserted into the lumen of the MPD through the instrument channel of the duodenoscope, and the cavity of the pseudocyst is visualized.A hydrophilic guidewire, 0.89 mm in diameter and 450 cm in length, is passed through the instrument channel of the ultra-thin endoscope. After inserting the guidewire into the pseudocyst cavity, the ultra-thin endoscope is withdrawn, leaving the guidewire in the pseudocyst cavity. A perforated plastic pancreatic stent, 2.3 mm in diameter and 10 cm in length, is inserted into the pseudocyst cavity through the guidewire. Under fluoroscopic guidance, the stent is positioned so that the proximal end is located within the pseudocyst cavity and the distal end protrudes into the duodenum.

[0013] Brief description of drawings

[0014] Fig. 1. Attempt at pseudocyst (PC) stenting under X-ray control (1-pancreas, 2-duodenum, 3-pseudocyst, 4-GPN, 5-catheter, 6-guide, 7-duodenoscope, 8-major duodenal papilla)

[0015] Fig. 2. Inserting a guidewire into the pseudocyst cavity (PC) under visual control (9-ultrathin daughter endoscope)

[0016] Fig. 3. Installation of a plastic perforated stent into the pseudocyst cavity (PC) along a pre-installed guidewire (10-stent)

[0017] Fig. 4. Pseudocyst (PG) on transabdominal ultrasound

[0018] Fig. 5. Pseudocyst (PG) on CT

[0019] Fig. 6. Retrograde pancreatography

[0020] Fig. 7. An attempt to introduce a guidewire into the pseudocyst cavity under X-ray control

[0021] Fig. 8. Insertion of an ultra-thin daughter endoscope into the MPD and visualization of the cavity of the pancreatic pseudocyst (12 - ultra-thin daughter endoscope on the X-ray image)

[0022] Fig. 9. Insertion of an ultra-thin daughter endoscope into the MPD and insertion of a string into the pancreatic pseudocyst

[0023] Fig. 10. A guidewire inserted into the cavity of a pancreatic pseudocyst using an ultra-thin daughter endoscope

[0024] Fig. 11. A guidewire left in the cavity of the pancreatic pseudocyst with the ultra-thin daughter endoscope removed.

[0025] Fig. 12. Plastic perforated stent installed in the lumen of the pancreatic pseudocyst along a pre-installed guidewire (11 - plastic perforated stent in the MPB)

[0026] Fig. 13. Adequate stent positioning

[0027] Fig. 14. Contrast enhancement of the cyst during control X-ray examination. Implementation of the invention.

[0028] Under intravenous sedation, a 12.6 mm external diameter duodenoscope is inserted into the descending duodenum, the major duodenal papilla is visualized, and endoscopic papillosphincterotomy is performed with a bipolar papillotome. Selective cannulation of the MPD is performed through the major duodenal papilla using a 1.65 mm diameter, 250 cm long plastic catheter. After positioning the catheter, 20-40 ml of iodine-containing water-soluble contrast agent is injected into the MPD, and endoscopic retrograde pancreatography is performed to determine the duct diameter, the presence of strictures, and the filling of the pseudocyst with contrast agent. An ultra-thin daughter endoscope with a 5 mm diameter and a 1.2 mm instrument channel is inserted into the lumen of the MPD through the duodenoscope's instrument channel, visualizing the pseudocyst cavity. A hydrophilic guidewire with a diameter of 0.89 mm and a length of 450 cm is passed through the instrument channel of the ultra-thin endoscope.After inserting the guidewire into the pseudocyst cavity, the ultra-thin endoscope is removed, leaving the guidewire in the pseudocyst cavity (Fig. 2). A 2.3 mm diameter, 10 cm long, plastic perforated pancreatic stent is inserted into the pseudocyst cavity along the guidewire. Under fluoroscopic control, the stent is positioned so that the proximal end is located in the pseudocyst cavity and the distal end protrudes into the lumen of the duodenum (Fig. 3).

[0029] The method was tested at the State Healthcare Institution "Krasnodar Clinical Hospital No. 2". Between 2019 and 2025, 22 patients were treated using this method.

[0030] Clinical example 1.

[0031] Patient "Z". 43 years old, admitted to the clinic in 2019 with the diagnosis: "Chronic complicated pancreatitis. Pancreatic pseudocyst." Complaints on admission of constant pain in the left hypochondrium radiating to the back, bloating, periodic diarrhea. During additional examination: transabdominal ultrasound (TAUS) - signs of moderate diffuse changes in the tissue of the head of the pancreas, pseudocyst in the tail (PT) measuring 46 × 33 mm. (Fig. 4) pronounced diffuse changes in the parenchyma, body and tail of the pancreas, moderate dilation of the MP.

[0032] Additionally, a computed tomography (CT) scan was performed to clarify the diagnosis. The CT images also revealed a pseudocyst of the pancreatic tail (Fig. 5).

[0033] After preoperative preparation, the patient underwent retrograde pancreatography (Fig. 6).

[0034] ERCP revealed a patent duodenum with elastic walls and circular folds. Peristalsis is active, and a small amount of foamy bile is present in the lumen. The major duodenal papilla is in a typical location and accessible for cannulation. The main pancreatic duct was selectively cannulated. Contrast imaging revealed that the main pancreatic duct is up to 8 mm in diameter and tortuous. A pseudocyst cavity is identified at the level of the tail of the pancreas. Multiple attempts to insert a guidewire under radiographic control into the pseudocyst cavity using the standard technique for minimally invasive treatment were unsuccessful—the guidewire curled up. (Fig. 7).

[0035] After unsuccessful attempts to introduce a guidewire and drain the pseudocyst using the standard method, stenting of the pseudocyst was performed using the stated method (Fig. 8-14).

[0036] The postoperative period was uneventful. The day after surgery, the patient reported mild, girdle-like pain and an increase in amylase to 450 U / L. After intravenous fluid therapy and normalization of blood biochemistry, the patient was discharged home on the fifth day in satisfactory condition.

[0037] Clinical Example 2

[0038] Patient "R." 55 years old, admitted to the clinic in 2022 with the diagnosis of "Chronic complicated pancreatitis. Pancreatic pseudocyst." Complaints on admission included persistent pain in the left hypochondrium radiating to the back, and abdominal distension. Further examination: transabdominal ultrasound (TAUS) revealed signs of moderate diffuse changes in the tissue of the head of the pancreas, a pseudocyst in the tail (PT) measuring 35 × 41 mm, pronounced diffuse changes in the parenchyma, body and tail of the pancreas, and moderate dilation of the main pancreatic duct.

[0039] Stenting of the pancreatic pseudocyst was performed according to the stated method.

[0040] Under intravenous sedation, a 12.6 mm external diameter duodenoscope was inserted into the descending duodenum, the major duodenal papilla was visualized, and endoscopic papillosphincterotomy was performed with a bipolar papillotome. Selective cannulation of the MPD was performed through the major duodenal papilla using a 1.65 mm diameter, 250 cm long plastic catheter. After positioning the catheter in the MPD, 20 ml of iodine-containing water-soluble contrast agent was injected, and endoscopic retrograde pancreatography (ERP) was performed to determine the duct diameter, the presence of strictures, and the filling of the pseudocyst with contrast agent. An ultra-thin daughter endoscope with a 5 mm diameter and a 1.2 mm instrument channel was inserted into the lumen of the MPD through the duodenoscope's instrument channel, visualizing the pseudocyst cavity. A hydrophilic guidewire with a diameter of 0.89 mm and a length of 450 cm was passed through the instrument channel of the ultra-thin endoscope.After inserting the guidewire into the pseudocyst cavity, the ultra-thin endoscope was removed, leaving the guidewire within the pseudocyst cavity. A 2.3 mm diameter, 10 cm long, plastic perforated pancreatic stent was inserted through the guidewire into the pseudocyst cavity. Under fluoroscopic guidance, the stent was positioned so that its proximal end was located within the pseudocyst cavity and its distal end protruded into the duodenum.

[0041] The postoperative period was uneventful. After infusion therapy and normalization of blood biochemistry, the patient was discharged home on the fifth day in satisfactory condition.

[0042] Medical and social effectiveness: This method enables endoscopic treatment of pseudocysts (PC) in patients with chronic pancreatitis (CP) in cases where it is impossible to insert a guidewire into the pseudocyst cavity under radiographic control. The introduction of an ultra-thin daughter endoscope, thanks to visual control and a steerable distal portion, allows for the guidewire to be inserted directly into the pseudocyst cavity and then performed endoscopic treatment using stenting. This will avoid more traumatic traditional surgical interventions in this category of patients, reduce treatment costs, shorten the hospital stay, and thereby improve the patient's psycho-emotional well-being.

Claims

A method for endoscopic treatment of pancreatic pseudocysts, including inserting an endoscope into the duodenum (DU), performing endoscopic papillosphincterotomy (EPS), identifying a pseudocyst, installing a stent along a guidewire through the main pancreatic duct (MPD) into the lumen of the pseudocyst, characterized in that under intravenous sedation, a duodenoscope with an outer diameter of 12.6 mm is inserted into the descending part of the duodenum, the large duodenal papilla is visualized and endoscopic papillosphincterotomy is performed with a bipolar papillotome, then selective cannulation of the MPD is performed through the large duodenal papilla with a plastic catheter with a diameter of 1.65 mm, 250 cm long, after positioning the catheter in the MPD, an iodine-containing water-soluble contrast agent is introduced in a volume of 20-40 ml and endoscopic retrograde pancreatography, determining the diameter of the duct, the presence of strictures and filling of the pseudocyst with a contrast agent,then, an ultra-thin daughter endoscope with a diameter of 5 mm and an instrument channel of 1.2 mm is inserted into the lumen of the MPD through the instrument channel of the duodenoscope, the cavity of the pseudocyst is visualized, a hydrophilic conductor with a diameter of 0.89 mm and a length of 450 cm is passed through the instrument channel of the ultra-thin endoscope, after installing the conductor into the cavity of the pseudocyst, the ultra-thin endoscope is removed, leaving the conductor in the cavity of the pseudocyst, then a plastic perforated pancreatic stent with a diameter of 2.3 mm and a length of 10 cm is installed along the conductor into the cavity of the pseudocyst, which is positioned under fluoroscopic control so that the proximal end is located in the cavity of the pseudocyst, and the distal end protrudes into the lumen of the duodenum.

Images