Fibrocholangioscope is a new instrument invented in recent years with the development of fiber optics, mainly used to diagnose biliary tract diseases, and fiber gastroscope, fiber duodenoscope, etc., it is also a hollow tube composed of many optical fibers. When the surgeon cuts the patient’s common bile duct for bile duct exploration during surgery, he can put the fiberoptic choledochoscope into the bile duct through the incision of the common bile duct, through which he can directly see the lesions in the bile duct.
(1) Determine the site and nature of bile duct lesions Through fiberoptic cholangioscopy, the walls and lumen of the common bile duct, common hepatic duct, and even intrahepatic bile duct can be directly visualized to help determine whether there is inflammation, tumor, or narrowing of the duct lumen. If a tumor or luminal stricture is found in the bile duct and its nature cannot be determined, a small piece of tissue can be taken with biopsy forceps for sectioning, or the lesion can be scrubbed with a special small brush, followed by cytological examination.
(2) Determine whether there are stones left in the bile duct Some patients are found to have stones left in the bile duct after T-tube imaging after surgery. For these patients, sometimes the T-tube can be removed first, and the fiberoptic cholangioscope can be inserted immediately into the bile duct through the fistula of the T-tube, and then the lithotripsy mesh can be inserted to remove the gallstones, so that the gallstones can be removed by re-operation.
The specific clinical applications are as follows.
(I) Intraoperative application of fiberoptic choledochoscope (IOC)
[Indications].
1, common bile duct stones, intrahepatic stones.
2.Extrahepatic bile duct obstruction, bile duct cancer.
3, Parasites, foreign bodies and other seen in the bile duct, such as benign tumors, polyps, stress ulcers, granulomas, etc.
4.Choledochal duct wall thickening, thickening more than 1cm; bile turbidity; the lower part of the common bile duct can be palpable hard nodes or the pancreas has hard nodes.
5, obstructive jaundice, severe pancreatitis or gallstone pancreatitis.
6, post-biliary surgery syndrome; unexplained biliary bleeding; abnormal bile duct manometry.
7, biliary stricture, sclerosing cholangitis.
8, intravenous cholangiography, percutaneous hepatic puncture cholangiography, duodenoscopic retrograde cholangiopancreatography and preoperative ultrasound showing abnormalities in intrahepatic and extrahepatic bile duct.
9.Verify false positives, such as air bubbles, that appear on intraoperative contrast.
[Contraindication]
Thin common bile duct, diameter less than 0.5cm or thin and brittle common bile duct wall.
[Method of use]
Fiberoptic choledochoscope and its accessories are disinfected with 40% formaldehyde gas sealed for 24 hours; or 0.2% chlorhexidine soaked for 30 minutes; or 1:1000 Neosporin soaked for more than 1 hour and set aside; or 2% glutaraldehyde soaked for 20 minutes, effective for HBsAg. After disinfection of the choledochoscope, wipe it with saline gauze. Adjust the height of the cold light source and prepare the flushing device system (common sling bottle with sterilized saline).
Instrument storage: after use should be rinsed clean, cleaning biliary mirror should pay special attention not to make the eyepiece water, such as dirt, available gauze or skim cotton dip disinfection with ethanol, squeeze dry and wipe, wipe dry, eyepiece, objective mirror with wipe paper lightly wipe clean, placed in a ventilated place cool and dry (including inside and outside the mirror) after collection, shall not be distorted, dedicated storage. Clamp with a fine brush carefully cleaned.
[Operation steps]
After removing the gallbladder, fully expose the common bile duct, and if necessary, separate the descending duodenum to facilitate the end of the common bile duct. A 1 cm long straight incision is made in the anterior wall of the lower part of the common bile duct, and a traction line is sewn on each side. After removing the stone, the choledochoscope is inserted under aseptic operation, while saline is instilled through the flushing port and aspirated at any time.
Generally, the proximal bile duct, left and right hepatic ducts, secondary and tertiary hepatic ducts, and sometimes up to quaternary hepatic ducts are examined first. After the stone is clearly seen in the bile duct under the scope, the stone basket is inserted to remove the stone. Then, the distal end of the common bile duct is examined until the lack of the jugular belly is clearly seen. Half of the jugular sphincters seen by choledochoscopy are radiolucent, while the others are fish-mouth, triangular and amorphous. The radiolucent jugular opening is cleaner, less inflammatory, and easier to pass through with a fiberoptic choledochoscope.
When inserting the choledochoscope, if resistance is encountered, it should not be inserted hard to avoid complications. When examining the distal common bile duct, it is not necessary to insert the duodenum.
Biliary flushing, in order to flush the bile, bile sludge, blood, etc. in the bile duct, to facilitate the visualization of the lesion, the flushing water pressure should not be too high, otherwise it is easy to cause biliary tract infection, generally to 20cmH2O pressure can be; or the saline bottle hanging higher than the patient 1m can.
After choledochoscopy, a thick T-tube (22-24 latex tube) is built into the common bile duct for drainage, with the long arm perpendicular to the common bile duct and passed through the abdominal wall poke hole, so that the T-tube fistula is thick, straight and short, which helps to perform choledochoscopy for stone extraction later when needed.
[Clinical significance]
Fibrocholangioscopy can directly see the internal situation of the bile duct, see the morphology of the bile duct mucosa, the condition of the branches, and understand the function of the sphincter of Oddi.
(B) Fiberoptic cholangioscopy through the T-shaped sinus tract (postoperative cholangioscopy, POC)
[Indications]
Anyone with T-tube drainage and suspected residual bile duct stones is suitable for this method. If the patient is febrile due to stone obstruction in the bile duct, the stone should be removed decisively.
[Contraindications]
Use with caution in patients with severe heart failure and bleeding tendency. If the fever is due to causes other than the biliary tract, suspend the examination.
[Preoperative preparation]
1, Generally, stone extraction is started 4-6 weeks after common bile duct exploration and T-tube drainage, i.e., when a stronger fibrous fistula has formed around the T-tube.
2. One hour before surgery, inject fentanyl 0.1-0.2mg, luminal 0.1g, atropine 0.5mg, or Valium 10mg, dulcolax 50mg, sometimes without analgesic.
[Anesthesia]
Local surface anesthesia in the sinus tract and biliary tract is used, with 5% to 10 ml of 2% lidocaine a cross, plus 0.1% epinephrine 0.1 ml.
[Operation steps]
1.Use surgical adhesive film, stick to the right side of the sinus tract, and then tilt the patient to the right 5°～10° to prevent the saline infused into the bile duct from flowing out of the sinus tract and soaking the patient’s bedding.
2.Extract the T-tube, disinfect the operating field and spread the towel.
3.Under aseptic conditions, insert the choledochoscope slowly into the sinus tract and see the dark red granulation trauma, which is light red after reaching the common bile duct. The stone free end is explored first, followed by the stone end. When examining the upper end, the intrahepatic bile duct is examined first, followed by the extrahepatic bile duct, and the branches are examined sequentially, focusing on understanding whether there are lesions such as dilatation, stenosis, inflammation, residual stones, worms, fibrin, granulomas and tumors in the bile duct lumen, while paying attention to bile viscosity and turbidity, estimating the diameter and nature of fistula, bile duct lumen and stones, and adopting treatment methods such as foreign body basket retrieval, stenosis expansion and inflammation drainage, respectively.
4.During the operation, a continuous drip of saline containing 80,000 U of gentamicin in 500 ml was injected into the bile duct to fill the bile duct lumen and maintain a clear view.
5.After determining the location of the stone, the stone is placed in the lower left corner of the choledochoscopic field of view, so that the stone is kept at a distance of about 1 cm from the mirror surface to avoid the stone blocking the field of view.
6.Under direct vision, hold the mirror control knob with the left hand and grasp the mesh basket with the right hand. Through the choledochoscope, insert the closed retrieval basket so that it slides through the upper right corner of the stone. When the tip of the outer casing of the retrieval basket exceeds the position of the stone, open the retrieval basket and repeatedly make continuous movements of in and out, opening and closing, while the left hand holds the choledochoscope for gyration and up and down movements so that the stone keeps rolling outside the open basket. Once the stone is in the net, tighten the basket net, but be careful not to be too strong, otherwise the stone will be easily broken.
7. After the stone is snared, pull it out together with the speculum. When the stone is not easily caught by the basket net, care should be taken to choose the size of the basket. For a few embedded stones in the lower part of the common bile duct, the method of pushing into the duodenal cavity can be adopted.
8. After stone extraction, a drainage tube is repositioned through the sinus tract into the common bile duct to preserve the access for stone extraction, and should be opened to drain bile for 24 hours to avoid postoperative fever. The straight tube is often easy to fall off and needs to be fixed properly. A Foley balloon catheter of appropriate thickness can be inserted and the balloon can be dilated with air to prevent dislodgement. When inserting the tube, the length of the sinus tract can be determined through the cholangioscope, and then placed and pay attention to the direction and length, do not violently insert.
After the stone is removed, X-ray cholangiogram should be taken to prevent residual stones from being left behind.
[Intraoperative precautions]
1.Choledochoscopy should always be performed under direct vision with gentle movements to avoid puncturing the sinus tract.
2, direct vision to observe whether the stone is caught by the net and with the feeling when closing the net, there is a resistance to limit the closure of the net, which is an important sign of successful stone extraction.
3.Stones of about 1 cm in size and hard texture are easier to remove. Large stones, although they are in the net, are easy to get stuck at the junction of bile duct and sinus tract and are not easy to remove. At this time, the assistant can press the abdominal wall around the sinus opening, and the operator tightens the lithotripsy basket net, intermittently and slowly pulling outward with force, and patiently carrying out continuous weighted traction along the direction of the sinus tract. If the stone is soft and fragmented, the basket net can be used to crush the stone and remove it piece by piece. If the stone is tight and hard, use biopsy forceps to crush it and remove it.
If the stone is embedded, the stone should be loosened first, and can be retrieved by basket net traction, three-jawed forceps, double grasping forceps or biopsy forceps, until the stone is loosened.
5. Smaller stones, located at the blind end of the bile duct, may also cause difficulties in stone extraction. This is because the blind end of the thinner bile duct is difficult to open the basket net, even if the stone is caught, it is easy to slip off. At this time, the net should be opened half, so that the patient coughs, the operator shakes the patient’s abdominal wall, and when the stone floats up, the net is quickly closed, but should not be closed too tightly, slowly pulled out of the body, often to receive satisfactory results. If a small stone is located at the end of the common bile duct, the stone can be pushed downward into the duodenum using the basket net or the tip of the choledochoscope.
If it is difficult to remove the stones with the basket net, as long as there is no stenosis in the lower end of the common bile duct, a reverse jet tube can be inserted through the choledochoscope and flushed with saline with gentamicin to drain the stones into the intestine.
It is advisable to remove the stones in several times, and each choledochoscopy operation should not take too long, within 1 to 2 hours. The second stone extraction interval should be 5-10 days.
8. In chronic purulent cholangitis combined with mud gauze like stones and large amount of purulent fibrin, the bile is often cloudy and affects the observation field.
9. Transcholedochoscopic T-tube sinus extraction with transendoscopic papillary sphincter dissection facilitates the discharge of small stones.
[Clinical significance]
The application of trans-T-shaped duct sinusoidal fiberoptic choledochoscopy opens up a new realm for the treatment of residual bile duct stones and can spare most patients from reoperation.