经皮内镜胃造瘘法胃壁穿透术在自然腔道内镜手术实验中的应用

目的评估经皮内镜下胃造瘘（PEG）法胃壁穿透术在经自然腔道内镜手术（NOTES）中应用的可行性及安全性。方法总结和对比38只实验犬经胃壁入路NOTES（20只行PEG法胃壁穿透术,18只行针刀法胃壁穿透术）,在胃壁穿透成功率、术中并发症、操作耗时方面的差异。结果38例次NOTES胃壁入路穿透手术均获成功。PEG法胃壁穿透组实验犬术中无明显出血及周围脏器损伤等并发症,而针刀法胃壁穿透组并发1例胃壁切口大出血、3例损伤临近脏器（0％与22％,P〈0．05）,但PEG法胃壁穿透组操作耗时（15．0±3．7）min,比针刀法胃壁穿透组耗时（6．0±1．1）min长。结论PEG法胃壁穿透术在NOTES操作中是安全、有效的,值得推广应用。     

可调节尼龙圈荷包闭合法在经自然腔道内镜外科手术中的应用研究

目的 评价可调节尼龙圈荷包闭合术在经自然腔道内镜外科手术( NOTES)切口关闭中的可行性和安全性.方法 采用10只健康雌性犬模型,分别在5组(每组2只)犬中进行不同部位的(胃窦大弯侧,胃体小弯侧和大弯侧,胃体前壁和后壁)NOTES腹腔探查术.探查术后利用尼龙圈荷包闭合法关闭胃壁切口.术后2周通过胃镜、解剖、细菌培养及组织学检验评估腹腔感染和切口愈合情况.结果 10只动物均成功完成NOTES腹腔探查术及荷包闭合术.荷包闭合术平均操作时间为(7.3±1.8)min.术中有2只动物在胃窦和胃体大弯侧切开过程中出现微量出血,经电凝处理后出血停止.除1只动物在切口处发现单纯网膜粘连,其余动物的腹水细菌培养及解剖均未发现腹腔感染等其他并发症.内镜、解剖及组织学检查结果均提示切口完全愈合.结论 使用可调节尼龙圈荷包闭合法关闭NOTES胃切口是安全可行和简便的.该方法适用于多部位胃切口的关闭,理论上可用于医源性胃穿孔的修补.     

自然腔道内镜外科中扩张探条辅助胃壁穿透术的应用价值研究

目的 探讨扩张探条辅助PEG法胃壁穿透术在自然腔道内镜外科（NOTES）中的应用价值.方法 选择11只杂种犬,雌雄不限.首先对其中1只进行前期扩张探条辅助PEG法胃壁穿透术的可行性实验,在预实验成功后将剩余10只犬随机分成2组,分别进行传统PEG法胃壁穿透术（传统组）及胆道扩张探条辅助PEG法胃壁穿透术（改良组）,比较2种方法在胃壁穿透效力方面的差别.完成实验的动物于术后第14天行常规胃镜检查,随后处死行腹腔探查,观察瘘口愈合、腹腔内粘连等情况.结果 前期扩张探条辅助PEG法胃壁穿透术的可行性预实验获得成功.改良组均完成操作,而传统组4只完成操作,且前者平均胃壁穿透耗时（7.0±1.7）min明显少于后者（11.0±3.2）min（P＜0.05）.2组完成操作的9只动物,术后2周均存活,无体质量下降及腹膜炎表现;术后第14天内镜下见瘘后愈合良好,探察示胃瘘口均已愈合好,未见腹腔脓肿,无近脏器（如肝、胆、脾等）损伤.结论 扩张探条辅助PEG降低了NOTES穿壁过程的难度,能有效缩短操作耗时,且不会增加并发症,具有较好的应用价值.     

自然腔道内镜外科经胃路径两种造瘘术的对比实验研究

目的 对比研究自然腔道内镜外科（NOTES）中PEG胃造瘘术及针刀胃造瘘术在操作过程、并发症及瘘口愈合方面的差异.方法 实验犬随机分为4组,每组4只,每只犬胃前壁分别行内镜下PEG胃造瘘及针刀胃造瘘（两瘘口相距2 cm）,瘘口长1.5 cm,内镜进入腹腔进行探查,后均以3个内镜夹闭合瘘口;记录操作耗时、术中并发症;第一组实验犬在操作完成后即刻进行剖腹探查并取胃在体外进行胃抗压测试（0 d组）;其他3组实验犬分别在术后第3天（3 d组）、7天（7 d组）及14天（14 d组）处死,进行腹腔探查,观察瘘口愈合、腹腔内粘连情况,并进行瘘口抗压测试.结果 实验动物均完成了两种胃造瘘术,虽然PEG胃造瘘术在操作耗时方面长于针刀胃造瘘术[（8.4±2.2）min比（5.3±1.5）min,P＜0.05],但其术中出血的并发症明显减少（6.2%比37.5%,P＜0.01）;在瘘口抗压测试方面,0 d组、3 d组及7 d组PEG胃造瘘口和针刀胃造瘘口的平均突破阈值分别为（12.3±2.3）mm Hg比（11.4±2.6）mm Hg（P＞0.05）、（32.4±6.7）mm Hg比（23.7±7.7）mm Hg（P＜0.05）和（76.8±9.6）mm Hg比（52.4±8.8）mm Hg（P＜0.05）;14 d组实验动物两种方法胃造瘘口受压均超过160 mm Hg而末发生瘘口破裂.大体病理观察显示,相同时间点PEG方法所形成的瘘口具有更好的愈合表现;所有存活动物无腹腔内出血、周围脏器损伤或感染表现.结论 与针刀胃造瘘术相比,PEG胃造瘘术虽操作耗时略有延长,但其具有更好的安全性和术后瘘口愈合更快的明显优势.     

经自然腔道内镜手术的实验研究

目的初步探讨利用现有内镜器械经自然腔道内镜手术（NOTES）技术的可行性和安全性。方法采用6头雌性猪模型。经胃时首先用针刀在管壁穿透切开,ERCP拉式切开刀扩大切口,再用扩张气囊扩大通道,将胃镜送入腹腔。内镜在腹腔内寻找腹腔内器官,管壁切口用止血夹闭合,或自然旷置。NOTES术后1周经阴道切口进入腹腔观察;术后2周经胃壁其他部位切口重新进入腹腔观察,2例进行肝脏部分切除术;术后4周处死、解剖动物,观察腹腔内粘连、脏器损伤及管壁切口闭合情况。结果经胃壁进入腹腔12次,经阴道进入腹腔6次。经胃进入腹腔的平均时间为（33．4±10．9）min,经阴道平均时间为（10．1±2．5）min。用止血夹封闭胃壁切口或切口旷置,管壁切口均愈合良好,无明显并发症出现。再次腹腔探查时发现腹腔内有不同程度腹腔粘连,无腹腔脏器损伤。2例部分肝脏切除,1例出现膈肌损伤及死亡,1例成功。进入腹腔时出现切口出血2次,均为经胃切口时发生。出现腹腔脓肿1例。结论经胃、经阴道腹腔内镜探查及肝脏部分切除术是可行的,安全性较高,但NOTES专用器械的研发是NOTES顺利进行和成功的关键。     

经胃、结肠联合路径腹腔内镜探查术的实验研究

目的初步探讨经胃（口）和经结肠（肛）双路径经自然孔道内镜外科学（NOTES）技术的可行性和利弊。方法采用雌性猪模型。先经口路径用针刀在胃前壁穿透切开，用扩张球囊扩大通道，将胃镜送入腹腔，在经胃路径的内镜监视下，再经肛路径用针刀穿透结肠壁，用弓刀扩大肠壁切口，将内镜送入腹腔。两条内镜先分别单独寻找胆囊和输卵管，然后相互配合共同寻找和观察胆囊和输卵管。胃肠切口分别用止血夹闭合。术后立即剖腹探查，观察腹腔内脏器损伤及胃肠壁切口闭合情况。结果胃肠壁通过球囊和弓刀扩大切口均无出血。经胃壁穿透切开时损伤肝脏表面。在经胃路径的内镜监视下完成结肠壁切开，避免了临近脏器的损伤。单内镜寻找胆囊和输卵管困难，时间较长。而双内镜配合寻找胆囊和输卵管相对容易，时间缩短，视野暴露好。用止血夹封闭胃壁切口比结肠切口困难。结论经胃与经结肠联合路径腹腔内镜探查术是可行的，可能比单路径更容易完成NOTES操作。     

NOTES瘘口闭合技术的研究及应用

正在兴起的经自然腔道内镜外科(NOTES)是一门基于微创新理念、多学科交叉的内镜治疗新技术。过去数年来尽管人们在NOTES领域进行了大量努力和探索,但似乎NOTES由动物实验转向大规模临床应用仍有很长的路要走,且有很多技术问题需要解决。在所有NOTES未解决的技术难题中,可靠的内脏瘘口闭合技术必须优先解决。本文,我们将对NOTES瘘口闭合方面的努力和进展进行回顾和述评。     

腹腔镜联合经自然孔道内镜外科技术动物研究

目的 初步探讨腹腔镜联合经自然孔道内镜外科(NOTES)技术的操作方法、可行性及安全性.方法 采用雌性小型猪模型4头.先常规腹腔镜检查,腹腔镜监视下选择经胃壁切口的位置,经内镜用针状刀在胃前壁打孔,扩张球囊扩大切口后将内镜送入腹腔.腹腔镜和内镜配合下进行腹腔脏器探查、输卵管结扎、卵巢切除、胆囊切除及关闭胃壁切口,根据术中情况选择是否放置腹腔引流管.术后常规应用抗生素3 d,半流食饲养.2周后内镜检查胃壁切口腔内闭合情况,处死模型进行解剖,观察胃壁切口脏面闭合情况和手术部位改变.结果 两镜联合顺完成了腹腔脏器探查、输卯管结扎2次、卵巢切除2次、胆囊切除2次和胃壁切口闭合术.2头猪术后放置腹腔引流管.4头模型猪术后均存活至2周,体重增加;解剖后见胃壁切口愈合良好,脏面可见切口处少许组织粘连.手术部位无大出血及粘连,临近脏器无损伤,腹腔无脓肿.结论 腹腔镜联合经胃壁切口内镜下的腹腔脏器探查术、输卵管结扎术、卵巢切除术及胆囊切除术是可行的,具有一定的安全性.腹腔镜辅助可降低NOTES的难度.     

内镜下钛夹联合尼龙绳链式缝合食管癌术后巨大吻合口瘘一例

吻合口瘘是食管癌术后的主要并发症之一,瘘口一旦形成,很难自行愈合,再次外科手术创伤大,费用高。随着内镜辅助器械和穿孔闭合技术的发展,内镜下闭合食管吻合口瘘创伤小、恢复快。本文介绍一种内镜下钛夹联合尼龙绳链式缝合法治疗食管癌术后巨大吻合口瘘,但其长期实用性还有待进一步临床验证。     

消化道瘘内镜处理的临床研究

目的 评估内镜下空肠管置入术、钛夹夹闭术及耙状金属夹系统（OTSC）对消化道瘘治疗的应用价值。方法 回顾性分析2015年7月至2017年7月苏州大学附属第一医院收治的38例消化道瘘患者资料,其中单纯行内镜下空肠管置入术13例,行内镜下钛夹夹闭术20例,OTSC闭合5例。对患者的技术成功率、临床治愈率及术后住院时间进行统计分析。结果 所有患者顺利完成了内镜下治疗,治疗过程中未出现内镜操作相关并发症。空肠管组4例瘘口完全愈合,3例瘘口较前缩小,5例瘘口未见明显变化,1例死亡,完全治愈率30.8%（4/13）;患者术后住院天数（47.4±14.1）d。钛夹组16例瘘口完全愈合,3例瘘口未见缩小,1例死亡,完全治愈率80.0%（16/20）;术后住院天数（17.9±8.9）d。OTSC组5例患者均完全治愈,完全治愈率100.0%。其中1例难治性食管瘘患者采用多次OTSC联合钛夹夹闭的方式逐步缩小瘘口直至完全愈合,瘘口愈合时长为102 d,剩余4例患者采用单纯OTSC治疗,术后住院天数（5.3±1.7）d。结论 内镜下微创技术可有效治疗消化道瘘,且具有创伤小、操作简便、愈合快、安全等优点,值得临床推广。     

CLOSURE OF GASTROTOMY IN NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY: A FEASIBILITY STUDY USING AN EX VIVO MODEL COMPARING ENDOLOOP WITH ENDOCLIP

Background: Closure of access site is one of the key issues that will determine the development of natural orifice transluminal endoscopic surgery. Our study was designed to compare the effectiveness of gastrotomy closure using endoloop and endoclip with hand‐sewn closure as a control. Methods: Gastrotomy was carried out on 24 ex vivo porcine stomachs and the gastrotomies were randomized to be closed with either hand‐sewn, endoloop or endoclip techniques. A 2 cm gastrotomy was created with a needle knife and sphincterotome and the defects closed thereafter. We measured the time to closure of gastrotomy and the pressure at which the closure leaked. Results: Three endoloops were required for all the closures in the endoloop group. In the endoclip group, the mean (range) number of endoclips used was 10 (8–13). There was no difference in the median closure times between endoloop 28 (16–58) min and endoclip 30 (21–40) min; however, time for hand‐sewn closure was much shorter (3–5 min). All stomachs were successfully distended with air without leak at the end of the procedure and none experienced fluid leak. The endoclip closure endured a significantly higher median (range) pressure of 72.5 mmHg (15–80 mmHg) before leaking compared to that of an endoloop 25 mmHg (15–37 mmHg) (P < 0.001). The hand‐sewn gastrotomy leaked at pressure of 95 mmHg (75–130 mmHg). The majority of air leaks were from the wound site. In the endoclip group, two leaks were noted at the clip bite site. Conclusion: In a bench‐top model, endoclips seem to be better for gastrotomy closure because of their potential to endure relatively higher pressure without any prolongation of application time. Animal survival studies are needed to explore technical and wound‐closure‐related problems arising as a result of use of endoclips and endoloops for gastrotomy closure.     

Natural orifice transluminal endoscopic surgery vs laparoscopic ovariectomy: complications and inflammatory response

AIM: To compare natural orifice transluminal endoscopic surgery (NOTES) vs standard laparoscopic ovariectomy in mini pigs with respect to technical aspects, complications and parameters of systemic inflammatory response.METHODS: This was a randomized, experimental, survival study. Ten female mini pigs underwent NOTES transgastric ovariectomy (NOTES group) and ten female mini pigs underwent laparoscopic ovariectomy (LAP group). A “percutaneous endoscopic gastrostomy” approach with guidewire and sphincterotome was used for gastrotomy creation. The ovary was resected using standard biopsy forceps and a snare. The access site was closed using a “KING” closure with a single endoloop and several clips. In the laparoscopic group, a three-port laparoscopy and an ovariectomy were performed with the use of standard laparoscopic devices. C-reactive protein (CRP), white blood count and interleukin (IL)-6 plasma levels were used as indicators of systemic inflammatory response. All animals were euthanized 28 d after surgery.RESULTS: All animals survived without complications. The mean procedure time was 41.3 min ± 17.6 min (NOTES group) and 25.7 min ± 5.25 min (LAP group, P < 0.02). Postmortem examinations demonstrated that 50% and 70% of animals were free of any complications in the NOTES and LAP groups, respectively. The remaining animals developed minor complications (adhesions) in a comparable frequency between the two groups. In the NOTES group, one animal developed a small intramural gastric abscess close to the gastrotomy site. A minor serous exudate that was present in 50% and 40% of the animals in the NOTES and laparoscopy groups, respectively, was not considered a complication. In both groups CRP levels increased significantly on the 2nd and 7th postoperative days (POD) and returned to normal after 28 d. On POD 2, an increase of CRP level was significantly higher in the NOTES group compared to the LAP group. Values of IL-6 did not differ from baseline values in either of the groups postoperatively. Interestingly, the platelet count decreased significantly on POD 2, but returned close to baseline values on POD 7 and PODs 28-30.CONCLUSION: Both NOTES and laparoscopic ovariectomies had a similar frequency of minor complications. However, the NOTES technique produced an increased systemic inflammatory response on POD 2.     

Rendezvous gastrotomy technique using direct percutaneous endoscopic gastrostomy for transgastric cholecystectomy in hybrid natural orifice translumenal endoscopic surgery

Background/purpose

Transgastric access is a major route in natural orifice translumenal endoscopic surgery (NOTES); gastrotomy should be performed unless it would damage surrounding organs in the peritoneal cavity. This article describes a novel rendezvous gastrotomy technique over a direct percutaneous endoscopic gastrostomy (PEG).

Methods

In six live porcines, the gastrotomy involved applying a direct PEG through the abdominal wall into the stomach and exchanging to a needle trocar. An endoscopic balloon catheter was passed through the trocar by rendezvous technique. Then the inflated balloon and endoscope were advanced to the peritoneal cavity through the gastrotomy. Transgastric cholecystectomy was performed with a hybrid needle grasper through the same percutaneous site and the gastrotomy was closed with endoscopic clips.

Results

The rendezvous gastrotomy technique could reduce guidewire exchange. The success rate was 100% (6/6). Mean times for transgastric peritoneoscopy and cholecystectomy were 25.5 and 83.5 min. Mortality and morbidity was 0%. The addition of the extra trocar was unnecessary in all procedures.

Discussions/conclusions

The advantage of this introduction system includes the creation of controlled gastric perforation, which is easier to close. It provides reliable transgastric access and increases safety. It simplifies transgastric NOTES and provides less invasive hybrid NOTES procedure.     

人工压迫和Perclose血管缝合器的股动脉止血疗效比较

目的：观察Perclose血管缝合器在经股动脉途径行室上速射频消融治疗中止血疗效比较。方法：199例经股动脉途径室上速射频消融治疗的患者被分为Perclose血管缝合组（Perclose组,98例）与人工按压组（101例）,观察两组即刻成功率,止血时间,制动时间与术后并发症的发生率。结果：即刻止血成功率比较两组无统计学差异（98％比100％, P＞0.05）。与人工按压组比较, Perclose组止血时间[（18.9±9.1） min比（2.7±0.7） min]和制动时间[（21.6±3.4） min比（6.3±2.4） min]明显缩短,并发症总发生率（16.8％比4.1％）明显降低（P＜0.05, P＜0.01）。两组并发症发生的具体情况：迷走反射 Perclose组明显低于人工按压组（0比7.9％, P＜0.05）,其他并发症两组无统计学差异（P均＞0.05）结论：Perclose血管缝合器止血时间、制动时间短,并发症少,可作为经股动脉途径室上速射频消融治疗后股动脉止血的优先选择。     

Cholecystectomy by a combined transgastric and transparietal approach using two flexible endoscopes

Objective

This experimental study was designed to assess the technical feasibility and benefits of our novel approach for transgastric NOTES (natural orifice translumenal endoscopic surgery) cholecystectomy.

Methods

Four pigs were subjected to NOTES cholecystectomy by the combined transgastric and transparietal approach using two flexible endoscopes. Under the guidance of a transparietal endoscope inserted through a trocar placed in the right upper abdomen, a gastrotomy was constructed, and a peroral endoscope was advanced into the peritoneal cavity through the gastrotomy and moved on retroflexion toward the gallbladder. Gallbladder excision with ligation of the cystic artery and duct using endoclips was performed using the peroral endoscope. After gastrotomy closure with endoclips inside the stomach, intraperitoneal lavage were carried out using the transparietal endoscope.

Results

A complete gallbladder excision was carried out without major adverse events in all cases. The gastrotomies were successfully closed using endoclips (n = 3) or by the omentum-plug method (n = 1).

Conclusion

This approach is technically feasible and makes transgastric NOTES cholecystectomy easier and safer.     

两种微创封堵室间隔缺损术式比较

目的 比较经皮导管介入封堵和经胸微创封堵室间隔缺损（VSD）的优缺点。 方法 宁夏医科大学总医院心脏大血管外科2012年1月～2019年6月收治的168例行经皮导管介入封堵及经胸微创封堵VSD手术患者,根据术式分为2组:经皮导管介入封堵组（经皮组,n=88）,经胸微创封堵组（经胸组,n=80）,随访收集患者的年龄、体质量、缺损类型、手术方式、缺损直径、封堵器直径、手术时间、封堵是否成功、术后并发症、住院时间、住院费用等,并应用SPSS 23.0进行统计学分析。 结果 经皮组成功封堵83例,成功率94%;经胸组成功封堵74例,成功率92%。两组成功率比较差异无统计学意义。与经皮组比较,经胸组年龄小[（13±14）岁vs (8±13)岁]、体质量小[（33±20）kg vs (22±19)kg]、手术时间长[（1.4±0.7）h vs (1.6±0.8) h]、缺损直径大[（5.2±2.6）mm vs (4.2±1.8) mm）]、封堵器直径小[（7.6±3.1）mm vs (6.0±2.3) mm]、住院时间长[（8.3±2.9）d vs (10.6±3.8)d]及住院费用高[（26126±5044）元 vs (28322±5946)元]等差异均有统计学意义（P<0.05或P<0.01）;两组缺损类型比较差异无统计学意义,但从两组VSD类型来看,经胸组比经皮组治疗VSD类型更多;经胸组术后微量心包积液发生率显著高于经皮组（P<0.05）,余并发症比较差异无统计学意义。 结论 两种微创术式均安全有效。临床上对于常见室缺类型及无年龄、体质量限制的患者可首选经皮导管介入封堵,而对于低年龄低体质量患儿、干下型及隔瓣下型等特殊室缺类型患者首选经胸微创封堵治疗获益更大。     

单纯继发孔房间隔缺损导管介入封堵与外科微创封堵的比较

目的比较外科微创封堵术与经导管介入封堵治疗房间隔缺损的临床特征,为房间隔缺损患者选择治疗方法。方法回顾性分析2009年7月至2010年6月在我院接受介入治疗的房间隔缺损病例321例,其中行外科微创封堵154例(组A),行导管介入封堵治疗167例(组B)。结果组A手术成功率98.7%,手术时间(61.45±23.57)min,术后住院时间(5.06±2.01)d,并发症发生率20.1%,住院费用(2.94±0.42)万元。组B手术成功率98.8%,手术时间(25.28±10.56)min,术后住院时间(3.41±0.70)d,并发症发生率3.0%,住院费用(2.11±0.32)万元。随访3～12个月,无死亡病例。结论两种治疗方法均可有效地治疗单纯房间隔缺损,均有较高的成功率,外科微创封堵适应证广泛,无X线辐射,操作简单,易于推广;介入治疗住院时间短,创伤小,并发症少,住院费用低,有好的临床应用前景。