胸腔镜心脏外科手术现状及展望

胸腔镜应用于心脏外科已有十多年,相对于传统心脏外科手术具有减少外科创伤、减缓疼痛、失血少、恢复快、美容效果好等优点。国外胸腔镜心脏外科多以机器人辅助完成多种心脏手术,国内一般单用胸腔镜辅助完成房间隔缺损修补术、室间隔缺损修补术、二尖瓣置换术,以及心房颤动射频消融术,现将胸腔镜辅助心脏外科手术的现状及进展进行综述。     

Status of endoscopic liver surgery in Japan: a questionnaire survey conducted by the Japanese Endoscopic Liver Surgery Study Group

Background/purpose

In 2007, the First Annual Meeting of the Japanese Endoscopic Liver Surgery Study Group was convened. We report the results of a questionnaire survey conducted by this study group that attempted to assess the current status and safety of endoscopic liver surgery.

Methods

A questionnaire survey was conducted at 26 hospitals to determine the operative procedures, rates of conversion to open surgery, and morbidity rates in patients who had undergone laparoscopic hepatectomy and endoscopic ablation therapy.

Results

Laparoscopic hepatectomy was performed in 471 patients by means of nonanatomical partial resection (57.7%), left lateral sectionectomy (24.6%), hemihepatectomy (12.5%), sectionectomy other than lateral sectionectomy (2.5%), and segmentectomy (2.5%). Hepatectomy was performed by a totally laparoscopic procedure in 47% of the patients and by a hybrid procedure in 53%. The rate of complications was 12.3%; there was no case of serious liver failure or operative mortality. Endoscopic ablation therapy was performed in 169 patients through a thoracoscopic (25.4%) or laparoscopic approach (74.6%), using radiowaves (55.6%), microwaves (40.2%), cryotherapy (1.8%), or ethanol (0.6%). The incidence of complications was 6.6%.

Conclusions

In properly selected patients, laparoscopic hepatectomy and endoscopic ablation therapy are safe treatments for liver tumors.     

Endoscopic Resection of Gastric Plasmacytoma

Gastric plasmacytoma is a rare form of extramedullary plasmacytoma. It is usually diagnosed with a barium meal or endoscopy for various gastrointestinal symptoms. Most gastric plasmacytomas are treated by surgical resection, even when they are confined to gastric mucosal lamina propria or submucosa, that is, in the early stages. We present here a case of gastric plasmacytoma showing an endoscopic feature of submucosal tumor approximately 2.5 cm in diameter, found through an X‐ray study in a mass screening. Endoscopic ultrasonography revealed a hypoechoic tumor located in the submucosal layer, and the tumor appeared to be safely excised by routineendoscopic resection. In order to obtain histlogical diagnosis, we resected the tumor, which was diagnosed as a plasmacytoma. The patient did not shown any sign of local and/or generalized recurrence during follow up for 2.5 years. We have not found a successful case of endoscopic resection of gastric plasmacytoma reported previously.     

Effects of Radiofrequency Catheter Ablation on Patients with Permanent Pacemakers

The objective of this study was to assess the effects ofradiofrequency energy application on implanted pacemaker functions.Radiofrequency (RF) catheter ablation may cause pacemaker dysfunction dueto electromagnetic interferences. The effects of RF on pacemaker behaviorwere studied in a series of 38 pacemakers, implanted 18 ± 26 monthsprior to a RF procedure using either a right ventricular approach (AV nodeablation, n = 35) or a left ventricular approach (left concealedaccessory pathway ablation, n = 1; VT ablation, n = 2). The38 patients (mean age 65 ± 9 years) included 20 men and 18 women.Before energy applications, the 23 different pacemaker models wereprogrammed to the VVI mode at the lowest available rate. The continuoussurface ECG was recorded throughout the procedure. Thorough testing of thedevices was performed before and after each RF delivery. Unusual pacemakerresponses occurred in 20 of the 38 cases studied (53%). The impactof RF delivery was unpredictable, and variable dysfunctions were observedat different times for a given patient or could vary for a given model.Unusual pacemaker responses included pacemaker inhibition (n = 8), untoggled backup mode (n = 3), electromagnetic interference noisemode (n = 3), temporary RF-induced pacemaker tachycardia (n =2), erratic behavior (n = 1), oversensing of RF onset and offset (n= 8), and transient loss of ventricular capture, (n = 1).Postablation, most devices automatically toggled back to fullfunctionality. The three devices in the untoggled backup mode had to bereprogrammed to obtain normal operations. At the end of the procedure,pacing thresholds remained unchanged in all but one patient, in whom theincrease in ventricular threshold was due to a nicked lead. In conclusion,implanted pacemakers frequently exhibit transient, unpredictable responsesto RF energy application. Although all pacemaker functions were restored postablation, some devices had to be reset manually. The anomalies observedduring the RF application argue for the simultaneous use of an externalpacemaker in pacing-dependent patients.     

Endoscopic Therapy of Early Gastric Cancer —Comparison of Endoscopic Mucosal Coagulation and Resection—

Abstract: The clinical efficacy of various methods of endoscopic treatment was evaluated in 70 patients with early gastric cancer. The treatments included using an Nd- YAG laser on 22 patients (2 IIa cases, 3 IIa + IIc cases and 17 IIc cases), a heater probe on 2 patients (IIc) and endoscopic mucosal resection (EMR) on 46 patients (13 I cases, 15 IIa cases, 2 IIa + IIc cases and 16 IIc cases). Laser irradiation and the heater probe method (endscopic mucosal coagulation; EMC), which cause coagulation and necrosis to lesions using heat energy, were found to be successful for well differentiated adenocarcinoma confined to the mucosa even if the size of the lesions was 20 mm and over. Poorly differentiated adenocarcinoma with lesions 20 mm or smaller reoccurred, and only well differentiated adenocarcinoma with infiltration limited to the mucosa seemed to be treatable endoscopically by EMR. Whether or not total resection was possible was determined with respect to the size and site of lesions in patients treated by EMR. Great therapeutic efficacy was achieved when the lesions were 10 mm or smaller and located in the anterior wall or the greater curvature. Piecemeal resection had to be made in a majority of cases when the lesions measured 10 mm or more or were located in the lesser curvature or the posterior wall. Therefore, endoscopic EMR is recommended if the size of the lesions is 10 mm or less, while EMC must also be considered if the lesions are larger or piecemeal resection is required.     

Endoscopic Resection of Small Gastric Adenoma

Abstract: We endoscopically resected 32 small adenomas of the stomach. The diagnosis was made using a bite biopsy technique in each case. On histological examination it was found that 34% of the totally resected specimens contained focal cancer. Endoscopic features, such as shape, surface texture and color, were not useful in identifying lesions harboring focal cancer. Nuclear DNA analysis of the biopsy specimens was not useful for differentiating between adenomas and lesions with focal cancer. We therefore recommend total endoscopic resection, as a biopsy, in all patients with a small adenoma of the stomach.     

Gastric Emptying and Gastroesophageal Reflux in Patients Fed via Percutaneous Endoscopic Gastrostomy: Effects of Erythromycin

Abstract: Percutaneous endoscopic gastrostomy (PEG) has been suggested to affect gastric emptying. The aims of this prospective study were to examine the effects of erythromycin, known to act as a motilin agonist, on gastroesophageal motility in nine patients fed via PEG tubes and nine fed via nasogastric tubes. The gastric emptying time and gastroesophageal reflux index were simultaneously measured in each patient after the intravenous administration of erythromycin (200 mg) or a placebo on different days, using a radioisotopic method. The alteration of gastric emptying time produced by intravenous erythromycin in the PEG group was smaller than that in the nasogastric group (p<0.05). However, gastroesophageal reflux indices in the two groups were similar. We conclude that PEG may impair gastric emptying subclinically without affecting gastroesophageal reflux.     

High-frequency Intraductal Ultrasound Images of Biliary Tract Lesions: Experimental Studies

Abstract: To investigate the differences in images obtained with a 3.75 MHz, 7.5 MHz or 20 MHz transducer, 27 stones, five debris samples, and three cholesterol polyps were examined in a water tank. All stones showed definite acoustic shadowing on images produced with the 20 MHz transducer, although the acoustic shadowing was weak or absent on images produced by 3.75 MHz or 7.5 MHz transducers. Regarding the relation between stone size and the acoustic shadowing, this shadowing was visualized for stones as small as 1.5 mm when the 20 MHz transducer was used. The hyperechoic appearance changed to a sharp crescent shape with the high frequency transducer. Images of cholesterol polyps and debris produced by the 20 MHz transducer showed no fundamental differences when compared with conventional ultrasonographic images obtained with a 3.75 MHz transducer, and there was no accompanying acoustic shadowing. In conclusion, ultrasonic images obtained with high frequency transducers which are used in intraductal ultrasound are different from those produced with conventional ultrasound probes. These phenomena may be useful for differential diagnosis of biliary tract diseases.     

Gastric per-oral endoscopic myotomy: Current status and future directions

Gastroparesis, or symptomatic delayed gastric emptying in the absence of mechanical obstruction, is a challenging and increasingly identified syndrome. Medical options are limited and the only medication approved by the Food and Drug Administration for treatment of gastroparesis is metoclopramide, although other agents are frequently used off label. With this caveat, first-line treatments for gastroparesis include dietary modifications, antiemetics and promotility agents, although these therapies are limited by suboptimal efficacy and significant medication side effects. Treatment of patients that fail first-line treatments represents a significant therapeutic challenge. Recent advances in endoscopic techniques have led to the development of a promising novel endoscopic therapy for gastroparesis via endoscopic pyloromyotomy, also referred to as gastric per-oral endoscopic myotomy or per-oral endoscopic pyloromyotomy. The aim of this article is to review the technical aspects of the per-oral endoscopic myotomy procedure for the treatment of gastroparesis, provide an overview of the currently published literature, and outline potential next directions for the field.     

A Case of Gastric Lipoma Removed by Endoscopic Polypectomy

Abstract: A rare case of gastric lipoma removed by endoscopic polypectomy is presented herein. A 64-year-old female was found to have a polypoid lesion in the stomach on periodic X-ray examination. Endoscopy revealed a submucosal tumor located on the posterior wall of the antrum. Endoscopic ultrasonography demonstrated a homogeneous, hyperechoic mass continuous with the submucosal layer, suggesting a lipoma. Because the likelihood of the tumor ultimately causing obstruction or prolapse into the duodenum was high, endoscopic polypectomy was performed. There were no complications. The histological examination revealed a mass of mature adipose tissue underneath the normal mucosa, which was consistent with the diagnosis made prior to polypectomy. The preferred treatment for gastric lipomas to date has been surgical excision, because the diagnosis is difficult to make prior to treatment. In the literature, only 17 cases undergoing endoscopic treatment for gastric lipomas have been reported. Endoscopic ultrasonography and computed tomography apparently facilitate preoperative diagnosis of lipomas.     

心肌缺血高压氧治疗对心脏起搏器的影响

为探讨高压氧对安装心脏起搏器的心肌缺血病人的治疗价值和安全性 ,前瞻性地分析了 38例安装心脏起搏器伴心肌缺血的病人高压氧治疗前后起搏阈值、心电图、血压及一氧化氮 (NO)、心钠素 (ANP)、血管紧张素Ⅱ(AT Ⅱ )的变化。结果 :高压氧治疗后 ,心肌缺血的心电图表现改善 ,总有效率为 92 .1% ;起搏阈值电压显著降低(1.6 2± 0 .6 8vs 1.91± 0 .6 1V ,P <0 .0 1)、脉宽显著变窄 (0 .2 5± 0 .12vs0 .2 9± 0 .10ms ,P <0 .0 1) ;NO由治疗前 5 7.89± 6 0 .82 μmol/L提高到治疗后 6 3.87± 48.0 7μmol/L(P <0 .0 1) ;ANP、AT Ⅱ起搏后显著降低 (分别为 179.95±5 2 .2 9vs 186 .37± 5 4.11pg/ml,P <0 .0 1;312 .37± 6 7.84vs 331.71± 75 .44pg/ml,P <0 .0 5 ) ,血压下降 (P <0 .0 1)。结论 :高压氧治疗可改善心肌缺氧 ,降低起搏阈值     

Endoscopic Reduction of Acute Gastric Volvulus in a Child

Abstract: An 11-year-old girl with cerebral palsy was admitted with complaints of frequent vomiting and upper abdominal distension. After plain X-ray examination and upper gastrointestinal contrast study, she was diagnosed as having acute mesenterioaxial volvulus of the stomach. Endoscopic reduction was successfully performed. We describe herein the technical details of the endoscopic reduction in this rare case. In non-infant pediatric patients with primary gastric volvulus, we recommend that endoscopic reduction be considered prior to surgical intervention.     

Endoscopic Treatment of Early Gastric Cancer

Abstract: Successful radical endoscopic treatment of early gastric cancer has recently progressed using chiefly the high frequency electric current method and the laser method. The forms of treatment can be classified into mucosal resection and non mucosal resection. The high frequency electric current method is a typical method for mucosal resection and makes it possible to confirm by pathology the complete curability of the excised and collected lesion, but it has limits in terms of the size of the lesion. Of the high frequency electric current method, there are two chief methods used which are endoscopic polypectomy and strip biopsy or ERHSE. Laser endoscopy is a typical method for non mucosal resection, however it cannot remove the lesion and therefore needs a follow-up study including biopsy after the treatment, it can treat however much larger lesions than the mucosal resection method. Laser endoscopy includes the three main methods of vaporization, photodynamic therapy and laserthermia. Indications for radical treatment of early gastric cancer by endoscopy should be limited to lesions without lymph node metastasis. Radical endoscopic treatment for early gastric cancer has recently become the treatment of choice for lesions, even in patients without surgical risk, because of the decreased quality of life which may follow after surgery. The ratio of radical endoscopic treatment to surgery for early gastric cancer has been increasing yearly. Recent advances in the area are reviewed, here.     

Review: Endoscopic biliary therapy in the era of bariatric surgery

There is an increasing demand and availability of bariatric surgery, with a range of procedures performed, some leading to altered upper gastrointestinal anatomy. The patient population undergoing bariatric surgery is also at increased risk of gallstones and biliary stone disease. Endoscopy (ie, endoscopic retrograde cholangiopancreatography) is the cornerstone of management of biliary stone disease, but may be challenging after bariatric surgery. In this review the endoscopic, surgery assisted, or percutaneous options that may be considered are discussed, based on the details of surgical anatomy and available expertise.