经自然腔道内镜胆囊切除术的实验研究

目的初步评价经自然腔道内镜胆囊切除术不同方法的可行性和优缺点。方法采用8只雌性猪模型平均分为4组。单镜手术均为经阴道途径的双管道内镜,双镜联合时再经胃插入一条普通内镜协助。分为单条内镜法、经阴道和经胃双镜联合法、腹腔镜抓钳辅助单条内镜法、单条带透明帽的内镜法4种不同方法进行胆囊切除术。先用针刀在管壁穿透切开,ERCP拉式切开刀扩大切口,再用扩张球囊扩大通道,将胃镜送入腹腔,内镜在腹腔内寻找胆囊并进行胆囊切除术。术后管壁切口用止血夹闭合。于术后1周处死解剖动物,观察腹腔内粘连,胆囊床,邻近脏器损伤及管壁切口闭合情况。结果使用单条内镜无法完成胆囊切除术;双镜联合及腹腔镜抓钳辅助有利于胆囊管及血管的分离,均只有1例成功,1例未能最终完成胆囊切除术;2例带透明帽的单条内镜法都成功完成了胆囊切除术。腹腔镜抓钳辅助出现1例出血,双镜联合出现1例胆囊破裂。结论经自然腔道内镜胆囊切除术是可行的,带透明帽的双管道内镜法是较理想的操作方法,专用新器械的开发是手术操作顺利进行和成功的关键。     

经自然腔道内镜手术

在过去的几年中,内镜领域出现了一种新型介入操作-经自然腔道内镜手术(natural orifice transluminal endoscopic surgery,NOTES),这一创新的内镜操作是经由自然腔道(口腔、肛门、阴道等)进入腹腔进行各种诊断和治疗.同时,也可经由自然腔道进入胸腔等其他体腔进行内镜手术. 与传统的剖腹手术不同,经自然腔道内镜手术避免了腹壁的切口,并且能够给患者带来特殊的好处. 尽管仍有许多难点需要突破,经自然腔道内镜手术这一无疤痕,安全的微创手术方式必将快速发展. 本文就该项新型手术方式的发展历史,实验研究,临床应用及前景等作一综述.     

网膜填塞法闭合经自然腔道内镜手术胃壁瘘口的研究

目的应用动物模型评价网膜填塞法闭合经自然腔道内镜手术(NOTES)胃壁瘘口方法的可行性及有效性。方法 29只杂种犬经胃前壁内镜下全层切开(10 mm),经此入路完成NOTES腹腔探查术,其中12只应用网膜填塞法闭合胃壁瘘口(网膜填塞组),17只内镜钛夹闭合(钛夹组),闭合成功动物术后存活2周。比较两种胃壁瘘口闭合术的操作耗时、闭合成功率以及瘘口愈合和腹腔感染发生率。结果网膜填塞法闭合胃壁瘘口的成功率为91.7%(11/12),高于内镜下钛夹闭合方法成功率82.4%(14/17),但未见显著统计学差异(P>0.05);网膜填塞闭合法操作平均耗时(11.7±2.1)min/例次,明显低于钛夹闭合法(25.0±5.6)min/例次(P<0.05)。25只动物胃壁闭合成功后者术后均存活14 d,复查胃镜见胃壁瘘口愈合良好。处死后实验动物未发现腹腔严重感染及明显脏器损伤;网膜填塞组8只犬(72.7%,8/11)可见胃壁瘘口处胃壁浆膜面黏连,显著高于钛夹闭合组(14.3%,2/14,P<0.05)。结论网膜填塞法能有效闭合NOTES经胃壁瘘口,与传统内镜钛夹闭合法相比具有操作简单、成功率高的优点,但容易发生瘘口黏连是其明显不足。     

Early clinical experience with a new flexible endoscopic suturing method for natural orifice transluminal endoscopic surgery and intraluminal endosurgery (with videos)

BACKGROUND: To perform advanced endoscopic treatments, one has to be able to close defects and perforations. Many devices have been constructed to perform endoscopic suturing, but all are rather complicated, expensive, and difficult to use. OBJECTIVE: To develop and use a new simple stitching technique at intraluminal flexible endoscopy. DESIGN: A flexible 19-gauge needle, loaded with a metal tag attached to a 3-0 polypropylene thread is passed down the working channel of a conventional endoscope. Two tags are placed into the stomach or the intestinal wall, 1 on each side of the defect. The threads are then locked together and cut. Precise stitch positioning is possible. Multiple stitches can be placed quickly, without removal of the endoscope. SETTING: Surgical department at Sahlgrenska University Hospital in G?teborg, Sweden. PATIENTS: Three patients in whom other conventional treatments had failed. INTERVENTIONS: Initially, survival studies in pigs were performed, and full-thickness resections, pyloroplasty, and gastrojejunostomies could be completed. The technique was subsequently used in patients when surgery was not feasible and when other endoscopic interventions had failed. MAIN OUTCOME MEASUREMENTS: Clinical evaluation; successful sealing of defects, leaks, or a bleeding vessel. RESULTS: We present 3 human cases and describe endoluminal closure of a perforated duodenal ulcer, a leaking gastroenteroanastomosis after gastroplasty, and successful treatment of upper-GI bleeding by oversewing a bleeding vessel. CONCLUSIONS: This stitching technique is easy to use and makes endoscopic suturing possible for closure of perforations and tissue approximation almost anywhere in the GI tract that can be reached by a flexible endoscope.     

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。     

Natural orifice transluminal endoscopic surgery: Where are we going?

The foundation for natural orifice transluminal endoscopic surgery(NOTES) is to access the peritoneal and other body cavities through the wall of the alimentary tract via natural orifices,with the goal of performing procedures within the peritoneum and other cavities,without the need to make incisions in the abdominal wall.We have made great progress in the field of NOTES since the publication of the White Paper in 2006.There are still major fundamental goals as outlined by the Society of American Gastroint...     

Transvaginal natural orifice transluminal endoscopic surgery in the diagnosis of ascites of unknown origin

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Endoscopic gastrojejunostomy with a natural orifice transluminal endoscopic surgery technique

AIM: To determine the technical feasibility and safety of an endoscopic gastrojejunostomy with a pure natural orifice transluminal endoscopic surgery (NOTES) technique using a T-anchoring device in a porcine survival model. METHODS: An endoscopic gastrojejunostomy with a pure NOTES technique using a T-anchoring device was performed on 10 healthy female minipigs weighing approximately 40 kg each under general anesthesia. All procedures were performed with a transgastric approach using a 2-channel therapeutic endoscope. RESULTS: The transgastric gastrojejunostomy was technically successful in all cases. A total of four to sixstitched pairs of a T-anchoring device were used to secure the anastomosis. The median time required to enter the peritoneal cavity and pull the small bowel into the stomach was 34 min (range: 19-41 min); the median time required to suture the anastomosis was 67 min (range: 44-78 min). An obstruction of the efferent limb occurred in one case, and a rupture of the anastomosis site occurred in another case. As a result, the functional success rate was 80% (8/10). Small bowel adhesion to the stomach and liver occurred in one case, but the anastomosis was intact without leakage or obstruction. CONCLUSION: A transgastric gastrojejunostomy with a T-anchoring device may be safe and technically feasible. A T-anchoring device may provide a simple and effective endoscopic suturing method.     

Gastrointestinal tract access for urological natural orifice transluminal endoscopic surgery

We conducted a literature review of natural orifice transluminal endoscopic surgery(NOTES),focusing on urologic procedures with gastrointestinal tract access,to update on the development of this novel surgical approach.As part of the methods,a comprehensive electronic literature search for NOTES was conducted using Pub Med and Cochrane Library from March 2002 to February 2016 for papers reporting urologic procedures performed utilizing gastrointestinal tract access.A total of 11 peer-reviewed studies examining utility of gastrointestinal access for NOTES urologic procedures were noted,with the first report in 2007.The procedures reported in the studies were total/radical nephrectomy,partial nephrectomy,adrenalectomy,and prostatectomy.The transgastric approach was identified in five studies examining total/radical nephrectomy(n = 2),partial nephrectomy(n = 1),partial cystectomy(n = 1),and adrenalectomy(n = 1).Six studies evaluated transrectal approach for NOTES,describing total/radical nephrectomy(n = 3),partial nephrectomy(n = 1),robotic nephrectomy with adrenalectomy(n = 1) and prostatectomy(n = 1).Feasibility was reported in all studies.Most studies were preclinical and acute,and limited by concerns regarding restricted instrumentation and infection risk.We concluded that gastrointestinal access for urologic NOTES demonstrates promise as described by outlined feasibility studies in preclinical models.Nonetheless,clinical application awaits further advancements in surgical technology and concerns regarding infectious potential.     

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。