The present invention relates to a procedure for endoscopic full-thickness resection for endoscopically resecting a part of the digestive tract over the entire layer.
Conventionally, a procedure is known in which an endoscope and a laparoscope are combined to resect a part of the digestive tract over the entire layer.
In order to further reduce the invasiveness of the patient, it is examined to perform full-thickness resection using only the endoscope.
Japanese Unexamined Patent Application, First Publication No. 2007-29195 describes a method of resecting the digestive tract over the entire layer using an endoscope and a chamber. In this method, a part of the digestive tract is drawn into the chamber over the entire layer, and a loop of high frequency snare is applied to the drawn digestive tract to resect.
The present invention provides a method of resecting entire layers of a digestive tract, including: an insertion step of inserting an endoscope into the digestive tract; an everting step performed after the insertion step, to suture mucosal layers located on both sides of a target region including a lesion, cover the target region with the mucosal layers, and evert a tract wall including the target region to a side of an abdominal cavity, in the digestive tract; and an incision step performed after the everting step, to position an incision tool between the target region and the mucosal layers to incise the tract wall around the lesion by the incision tool.
An embodiment of the present invention will be described with reference to
In the case of performing a full-thickness resecting method of the digestive tract according to the present embodiment (hereinafter simply referred to as “full-thickness resection method”), the operator first inserts the endoscope from the patient's mouth or anus (insertion step), and moves the distal end portion of the endoscope to the vicinity of the target region to be resected. As the endoscope, a commonly known flexible endoscope can be used.
As the lesion L1, gastrointestinal stromal tumor (GIST), malignant tumor of the digestive tract reaching the muscle layer, and the like can be exemplified.
Next, the operator incises the mucosal layer around the target region L to form the cut end 10 in the mucosal layer around the target region L as shown in
Next, the operator removes the submucosal layer with a generally constant peel width W1 (see
Next, the operator resects the mucosal layer between the target region L and a position away from the target region L over a predetermined length and width, and forms a mucous membrane defect region R1 between the target region L and a position away from the target region L.
The width W2 of the mucous membrane defect region R1 defines the size of the tunnel described later. The value of the width W2 is preferably the same as or slightly longer than the length of the outer periphery of the insertion portion of the endoscope to be used.
Next, as shown in
In
Thereafter, when the operator tows the thread 50, the cut ends which are positioned across the target region L come close to each other, and the mucosal layer 20 is sutured so as to cover the target region L.
As the mucosal layers 20 on both sides of the mucous membrane defect region R1 are sutured together, the mucous membrane defect region R1 is also covered by the mucosal layer 20 and protrudes slightly to the abdominal cavity side as shown in
The operator inserts the endoscope into the opening T1 and causes the distal end portion of the endoscope 100 to enter the space S as shown in
Subsequently, as shown in
When the submucosal layer 30 and the muscle layer 40 (including the serosa) are incised, the wall of the digestive tract is incised throughout the entire layer and a hole communicating with the abdominal cavity is opened. However, since the mucosal layer 20 located above the target region L is closed by suturing and the tunnel T communicating with the space S is closed with the endoscope 100, the gas stored in the digestive tract is difficult to escape to the abdominal cavity. Therefore, it is preferably suppressed that the digestive tract rapidly collapses (collapses) as the incision proceeds. When the inner diameter of the tunnel T and the outer diameter of the endoscope 100 are about the same, the gas hardly escapes, and the collapse suppression effect is further enhanced.
After the tissue surrounding the target region L is incised substantially over the entire circumference, suction is performed with the endoscope, and the remaining tissue is dissected while sucking the tissue of the target region L to the endoscope. As a result, it is possible to separate the tissue from the digestive tract without dropping the tissue. When the endoscope 100 is moved backward while sucking the tissue of the target region L to the endoscope, it is possible to collect the tissue of the target region L outside the body passing through the tunnel T as shown in
Finally, when the opening T1 is closed using suturing threads, clips or the like, the full-thickness resection method of this embodiment is completed. The digestive tract after completion of the full-thickness resection is shown in
A high frequency snare may be used for separating the target region L. In this case, it is possible to grasp the lesion with the snare while incising it and collect the target region L outside the body.
When using an endoscope having two channels, it is possible to collect the lesion outside the body by inserting a grasping forceps into a channel different from the channel through which the high frequency knife is passed and separating the target region L from the digestive tract while grasping the lesion with the grasping forceps.
As described above, according to the full-thickness resection method of the present embodiment, it is possible to perform full-thickness resection of a part of the digestive tract by using the endoscope 100 and the incision tool 110 inserted from a natural opening such as a mouth. Therefore, it is not necessary to drill holes in the abdominal wall, and patient invasion can be further reduced as compared with the full-thickness resection using a laparoscope.
In the case of performing full-thickness resection only with a medical device introduced from a natural opening, the treatment of a hole formed by resection is the most difficult. When a hole communicating with the abdominal cavity is formed in the digestive tract, gas in the digestive tract will immediately begin to leak into the abdominal cavity. If the digestive tract collapses due to leakage of gas, both of observation with the endoscope and procedure of closing the hole become very difficult.
In the full-thickness resection method of this embodiment, since the mucosal layer 20 is sutured before entire layer of the surrounding of the target region L is incised, even if a hole is formed in the digestive tract afterwards, the gas in the digestive tract will not leak rapidly into the abdominal cavity. Furthermore, since the mucosal layers 20 are sutured together before separating the target region L, it is not necessary to perform a difficult procedure such as suturing after separating the target region L.
Even with the method described in Japanese Unexamined Patent Application, First Publication No. 2007-29195, it is possible to perform full-thickness resection using only medical devices introduced from natural openings. However, in this method, since entire layers are incised at the same time with respect to the tissue drawn into the chamber, “layer misalignment” in which the mucosal layer and the muscle layer or the like move relative to each other in the surface direction may occur in the tissue at incision. When layer misalignment occurs, even if sufficient margins are secured in the mucosal layer, there is no guarantee that a similar margin will be secured in the submucosal layer or muscle layer, so it is necessary to enlarge the peripheral tissue of the target region in order to ensure a sufficient margin. As a result, the target region to be resected becomes large, and it is difficult to reduce the invasiveness of the patient.
In the present embodiment, in the mucosal layer 20, the cut end 10 is formed while securing a sufficient margin for the lesion L1. Thereafter, the mucosal layer 20 around the target region L is peeled off from the submucosal layer 30, and the submucosal layer 30 and the muscle layer 40 around the target region L are incised in the space S. Therefore, since the layer misalignment does not occur at the time of incision of the submucosal layer 30 and the muscle layer 40, it is not necessary to enlarge the peripheral tissue L2 excessively, and the amount of margin can be minimized to further reduce the invasiveness of the patient.
In the present embodiment, an example in which the mucous membrane defect region R1 is formed to form the tunnel T has been described, but the method of forming the tunnel is not limited thereto.
The tunnel TA shown in
By forming the tunnel in this manner, it is not necessary to suture the mucosal layers of the tunnel portion in the everting step, thereby the procedure is further simplified.
Although the embodiment of the present invention has been described above, the technical scope of the present invention is not limited to the above embodiment, and it is possible to change the combination of constituent elements and to make various changes to each constituent element or delete them within the scope not deviating from the spirit of the present invention.
For example, the collection step may be performed using tagged suturing threads or instruments other than grasping forceps such as snare loops or the like.
In the full-thickness resection method of the present invention, it is not essential to form a tunnel. For example, when the size of the lesion L1 is small and the range of the peripheral tissue L2 is sufficiently wide, the incision step may be executed by leaving an un-sutured portion when suturing the mucosal layers around the target region and causing the endoscope enter the space from the un-sutured portion.
In the full-thickness resection method of the present invention, in the case where it is possible to ensure a sufficient space to perform sufficient treatment with the incision tool 110 in the everting step, the above-described separated end forming step and separation step are not essential.
Number | Name | Date | Kind |
---|---|---|---|
5151086 | Duh | Sep 1992 | A |
6346111 | Gordon | Feb 2002 | B1 |
7571729 | Saadat | Aug 2009 | B2 |
7704264 | Ewers | Apr 2010 | B2 |
8066689 | Mitelberg | Nov 2011 | B2 |
8771170 | Mesallum | Jul 2014 | B2 |
9039649 | Neisz | May 2015 | B2 |
9278019 | Thompson | Mar 2016 | B2 |
9445791 | Stack | Sep 2016 | B2 |
9622897 | Stangenes | Apr 2017 | B1 |
10603095 | Fischer | Mar 2020 | B2 |
20030009085 | Arai | Jan 2003 | A1 |
20050070931 | Li | Mar 2005 | A1 |
20060241691 | Wilk | Oct 2006 | A1 |
20060276810 | Kelleher | Dec 2006 | A1 |
20070112362 | Mikkaichi | May 2007 | A1 |
20070255278 | Nobis | Nov 2007 | A1 |
20080015574 | Karpiel | Jan 2008 | A1 |
20080051627 | Raju | Feb 2008 | A1 |
20080275473 | Filipi | Nov 2008 | A1 |
20090312602 | Sakamoto | Dec 2009 | A1 |
20100145352 | Chang | Jun 2010 | A1 |
20100160934 | Kelleher | Jun 2010 | A1 |
20100217151 | Gostout | Aug 2010 | A1 |
20110087222 | Miller | Apr 2011 | A1 |
20130090526 | Suzuki | Apr 2013 | A1 |
20130338680 | Harris | Dec 2013 | A1 |
20140148828 | Ewers | May 2014 | A1 |
20140214063 | Miyamoto | Jul 2014 | A1 |
20140288584 | De La Mora Levy | Sep 2014 | A1 |
20140358166 | Kelleher | Dec 2014 | A1 |
20150190166 | Mitelberg | Jul 2015 | A1 |
20170238916 | Beaven | Aug 2017 | A1 |
20170304099 | Keren | Oct 2017 | A1 |
20190290325 | Goto | Sep 2019 | A1 |
20190343528 | Fleury | Nov 2019 | A1 |
Number | Date | Country |
---|---|---|
2007-029195 | Feb 2007 | JP |
2007-508053 | Apr 2007 | JP |
2005037152 | Apr 2005 | WO |
Number | Date | Country | |
---|---|---|---|
20190290282 A1 | Sep 2019 | US |