The anatomy of the nipple is very different, some small openings (such as granular openings) are difficult to insert, and some are difficult to insert due to obstruction of the upper bile duct or the channel of the ampulla of the T-tube after the bile duct has been "disused" for a long time. . At this time, after the traditional catheter intubation method fails, medical ercp can be guided by a guide wire. Generally, a hydrophilic ultra-smooth guide wire is used. According to the shape of the nipple and the longitudinal direction of the bile duct and pancreatic duct, the front end of the catheter is aligned with the possible common bile duct. Or the opening of the pancreatic duct, the ERCP guidewire is gently inserted back and forth under the monitoring of endoscopy and X-ray, and with the change of the direction of the catheter, when the 4-5 cm is successfully inserted, the pancreatic duct or bile duct is generally successfully inserted.
Bile duct stones, bile duct tumors and hilar tumors often cause obstruction of the first-level branches of the bile duct and above. In this case, the success rate of the operation is low. Performing stone extraction or internal and external drainage of bile can eliminate jaundice and improve the quality of life of patients. Endoscopic treatment is completed on the premise of superselection to the target bile duct, and the key to superselection is the insertion of the guide wire. We use the following methods to continuously improve the success rate: (1) direct insertion method; (2) with the help of catheter method, including ordinary angiography catheter and special catheter; (3) by the incision method; (4) by the balloon method; (5) by the shaping method of the tip of the guide wire.
When the guide wire crosses the stenotic section, the dilation of the stenotic section can be performed to perform internal and external drainage of bile. First, look for the position of the crack at the lower end of the stenosis under fluoroscopy, adjust the position of the catheter (including balloon catheter, incision knife, etc.), the position of the guide wire and the distance between them. After aligning the ercp guidewire with the crack, push the guide wire forward, and stir if necessary. The guide wire is advanced by twisting the guide wire in a clockwise or counterclockwise direction.
The kissing method is the kissing between the guide wire and the catheter. When the conventional nipple intubation fails, and the patient has undergone T tube intubation or PTC surgery, the guide wire is inserted from the external end of the T tube or PTC tube, and the fluoroscopic monitoring is performed. The front end of the guide wire reaches the ampulla along the bile duct. When the guide wire protrudes 2-3mm from the nipple under the endoscope, use the catheter to approach and try to make it cover the guide wire (at this time, the angle of the catheter should be adjusted so that the two On the same axis), once the guide wire enters the catheter, the assistant advances the guide wire 4-5cm, and then inserts the catheter into the nipple and common bile duct under the guidance of the guide wire, so that the intubation is completed by the kiss between the catheter and the guide wire.
Medical ercp should use 0.035in guide wire when placing bile duct stent or pancreatic duct stent under endoscope. This guide wire has a certain strength and is conducive to the support and placement of the stent, even if a 0.025in guidewire was initially selected due to obvious stenosis or difficulty in intubation, a 0.035in guidewire should be used after intubation or dilation. Secondly, when placing a plastic stent, attention should be paid to tightening the knob for fixing the guide wire, so that the guide wire cannot move or slip off, so as to complete the smooth placement of the stent.
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