Cholangioscopic examination

The choledochoscopy mainly consists of two intraoperative fiber choledochoscopy and T-tube sinus fiber choledochoscopy. Fiber choledochoscopy can directly look inside the biliary tract, see the morphology and branching of the bile duct mucosa, and understand the function of the Russian sphincter. However, its important clinical significance is that it can diagnose the biliary tract disease and treat it more accurately. You can see stones in the bile duct under the speculum. Basic Information Specialist classification: Digestive examination classification: endoscope Applicable gender: whether men and women apply fasting: fasting Tips: Pay attention to rest before eating, reasonable diet, prevent fatigue, and maintain a normal state of mind. Normal value The biliary examination did not have any abnormalities. Clinical significance Abnormal result 1. Fiber choledochoscopy can directly look at the internal conditions of the biliary tract, see the morphology and branching of the bile duct mucosa, and understand the function of the biliary sphincter. However, its important clinical significance is that it can diagnose the biliary tract disease and treat it more accurately. You can see stones in the bile duct under the speculum. 2. The application of T-tube sinus fiber choledochoscopy opens up a new environment for the treatment of residual biliary stones, which can save most patients from reoperation. Need to check the crowd: patients with biliary diseases. Precautions Taboo before inspection: 1. Generally, the stone is taken from the common bile duct exploration and T-tube drainage 4 to 6 weeks after the T-shaped tube has formed a relatively firm fibrous sac. 2. One hour before surgery, intramuscular injection of fentanyl 0.1 ~ 0.2mg, luminal 0.1g, atropine 0.5mg; or diazepam 10mg, dulidine 50mg. Sometimes you don't need an analgesic. Taboo when checking: 1. The choledochoscopy should always be carried out under direct vision, and the movement is gentle, avoiding wearing the sinus. 2. Looking directly at the stone to see if it is caught by the net, and with the feeling of closing the net, there is a limit to the resistance of the closed net, which is an important sign of the success of the stone. The size and hardness of the stone around 3.1cm is easier to remove. The stone is large, although it has entered the net, but the card can not be pulled out at the junction of the biliary tract and the sinus. At this point, the assistant can press the abdominal wall around the sinus ostium, and the surgeon tightens the stone basket net, pulls it intermittently and slowly, and patiently pulls along the direction of the sinus. Sometimes it takes 15 to 30 minutes to pull out. If the texture of the stone is broken, the stone can be crushed by the net and taken out one by one. If the texture of the stone is tight, it can be taken out by a biopsy forceps. 4. Stone incarceration, the first should loosen the stone, can be pulled by the net, three-jaw forceps, double grasping forceps or biopsy forceps to grab, until the stone loosening and then take the stone. 5. The stone is small, and it is located at the blind end of the bile duct, which can also cause difficulty in stone removal. Because of the blind end of the thin bile duct, it is difficult to open the stone basket net. Even if the stone is covered, it is easy to slip off. At this time, the semi-net should be opened to make the patient cough. The surgeon shakes the abdominal wall of the patient and the net is quickly closed when the stone floats. However, it should not be too tight, slowly pulled out of the body, often can receive satisfactory results, and can also be used to continuously attract and absorb stones. If the small stone is located at the end of the common bile duct, the stone can be pushed down into the duodenum by the tip of the stone basket or the tip of the choledochoscope. 6. Mixed sand or small stones, it is difficult to remove it with a stone basket net, as long as there is no stenosis at the lower end of the common bile duct, it can be inserted through the choledochoscope with a reverse nozzle, and flushed with physiological saline with gentamicin to discharge it. Intestinal. 7. The stones should be taken out in multiple parts. The operation time of the choledochoscope should not be too long, and it should be within 1~2 hours. The second stone removal interval is 5 to 10 days. 8. Chronic purulent cholangitis with mud-like stones and a large amount of purulent cellulose, bile often turbid, affecting the field of view, can be directly instilled with normal saline irrigation, and with the basket multiple times in and out and closed until flushing clean. 9. The choledochoscopy T-shaped tube sinus stone is combined with the endoscopic papillary sphincter to facilitate the discharge of small stones. Inspection process Intraoperative fiber choledochoscopy 1. The fiber choledochoscope and its accessories are sealed with 40% formaldehyde gas for 24 hours. After disinfection of the gallbladder, wipe it off with saline gauze. Adjust the height of the cold light source, and prepare the flushing device system (normal bottled disinfection saline). 2. Generally, the proximal bile duct, the left and right hepatic ducts, the second and third grade hepatic ducts, and sometimes the fourth grade hepatic duct can be examined first. When the mirror is removed, the confluence of the left and right hepatic ducts, the common hepatic duct and the cystic duct are examined. After seeing the stones in the bile duct under the speculum, insert the stone basket and remove the stones. Then, check the distal end of the common bile duct until you see the ampulla. The ampulla of the ampulla is seen by the choledochoscope, half of which is radial, and the others are fish-shaped, triangular and amorphous. The radial ampulla opening is relatively clean, the inflammation is light, and the fiber choledochoscope is easy to pass. Bile tract irrigation, in order to flush the bile, biliary mud, blood, etc. in the biliary tract, which is conducive to peeping lesions, flushing water pressure should not be too high, otherwise it may cause biliary tract infection, generally 20cmH2O pressure; or the saline suspension bottle is higher than the patient 1m can be. After choledochoscopy, the thick T-tube drainage (22~24 latex tube) is built in the common bile duct. The long arm is perpendicular to the common bile duct, and the T-shaped tube is thick, straight and short. Helps to perform choledochoscopy and stone removal operations when needed later. 2. T-tube sinus fiber choledochoscopy 1. Use local surface anesthesia in the sinus and biliary tract, add 5-10 ml with 2% lidocaine, and add 0.1% adrenaline 0.1 ml. 2. Surgical adhesive film, attached to the right side of the sinus, and then tilt the patient to the right 5 ° ~ 10 °, to prevent the normal saline perfused to the biliary tract from the sinus, soaking the patient's plaque. 3. Pull the T-shaped tube and operate the field to disinfect and spread the towel. 4. Under sterile conditions, the choledochoscope is slowly inserted into the sinus, and a dark red granulation wound can be seen. After reaching the common bile duct, the color is reddish. First visit the no-stone end, then explore the stone end. When examining the upper end, the intrahepatic bile duct, the posterior extrahepatic bile duct, and the stepwise branch are examined in order, focusing on the presence or absence of dilatation, stenosis, inflammation, residual stones, worms, cellulose, granuloma and tumors in the bile duct. Pay attention to the viscosity and turbidity of bile, and estimate the diameter and nature of the sacral canal, bile duct lumen and stone. The treatment methods include foreign body net extraction, stenosis expansion and inflammatory drainage. 5. During the operation, the saline is continuously instilled into the biliary tract (80,000 U of gentamicin in 500 ml to fill the bile duct to keep the visual field clear. 6. After determining the position of the stone, place the stone in the lower left corner of the choledochoscope field, so that the stone and the mirror surface are kept at a distance of about 1 cm to prevent the stone from blocking the field of view. 7. Under direct vision, the left hand mirror control knob, the right hand to master the basket. Through the choledochoscope, insert the closed stone basket to slide it from the upper right corner of the stone. When the top of the casing exceeds the stone position, the stone basket is opened and the continuous movement of the entrance and exit, opening and closing is repeated, and the left hand is used for choledochoscopy. The spin and the up and down movements cause the stones to roll continuously outside the open basket. Once the stone enters the net, it will tighten the net, but it should be noted that the force can not be too strong, otherwise the stone is brittle. 8. After the stone is placed, pull it out together with the sight glass. When the stone is not easily caught by the net, you should pay attention to the size of the stone basket. A small number of common bile duct incarcerated stones can be pushed into the duodenal cavity. 9. After removing the stone, place the drainage tube through the sinus to the common bile duct to retain the channel for taking the stone, and drain the bile for 24 hours to avoid postoperative fever. Straight tube placement is often easy to fall off and needs to be properly fixed. The Foley balloon catheter can be inserted with a suitable thickness and the balloon can be inflated to prevent the escape. When the catheter is placed, the length of the sinus can be measured by choledochoscopy, and then placed in the direction and length, and violent insertion should be avoided. 10. After the stone is taken out, it should be treated with X-ray cholangiography to prevent residual stones. Not suitable for the crowd Not suitable for people: 1. The common bile duct is small, the diameter is less than 0.5cm or the common bile duct wall is thin and brittle. 2. Use with caution in patients with severe heart failure and bleeding tendency. High fever caused by reasons other than biliary tract, and suspended inspection. Adverse reactions and risks Nothing.