经口食管隧道诊治范畴拓展的关键技术研究
发布时间：2018-08-06 19:59
【摘要】：研究背景及目的：食管黏膜下隧道技术已经逐渐应用于食管比邻结构等范畴拓展的治疗,比如内镜下肌切开术(per-oral endoscopic myotomy, POEM)、食管早癌剥离、食管黏膜下肿瘤切除等方面突显优点,这些治疗中经常困扰内镜医生的并发症如气胸等的研究也成为了食管隧道技术研究中至关重要的一环；同时隧道技术也加快了经口食管隧道诊治范畴的拓展,但是相关拓展手术的安全性仍需要实验论证。希望通过动物实验初步论证经口食管隧道诊治范畴的拓展手术如纵隔内镜下手术治疗的可行性和安全性,摸索手术必要条件,从而为临床内镜下诊治纵隔病变建立理论和实践基础；通过动物气胸模型实验寻找气胸相关联敏感指标,为现今食管比邻结构临床手术提供参考。方法：①选取6头家猪,内镜下建立食管黏膜下隧道进入纵隔,术中辨别纵隔器官,进行纵隔组织模拟淋巴结活检；②选择6头家猪建立胸腔穿刺C02气胸模型,并监测不同程度胸腔穿刺C02气胸模型中的生理、呼吸力学及血流动力学变化；选择注气前10min作为观察基础点Baseline,监测左侧少量、中量、大量气胸时共3个时相点生理、呼吸力学及血流动力学变化。③18头家猪随机分为无压力调控组(A组10mmHg)、超低压力调控组(B组5mmHg)和高压力调控组(C组10mmHg)3组,选择注气前10min作为观察基础点Baseline,监测注气10分钟、20分钟和30分钟3个时相点生理、呼吸力学及血流动力学变化，组与组之间进行对比。结果：①6头动物均顺利完成操作,术中可清晰辨别纵隔器官(如肺、脊椎、降主动脉等),并进行纵隔组织模拟淋巴结活检,其中2例因严重气胸死亡,2例发生少量气胸,食管切口均用金属夹成功关闭。②胸腔穿刺C02充气模型均成功建立,少量气胸时只有氧合指数(OI)降低、二氧化碳分压(PaCO2)升高和气道阻力压升高有统计学差异,中量气胸时PH值降低,氧合指数(OI)降低,二氧化碳分压(PaCO2)升高,气道阻力压升高,心率(HR)增加,平均动脉压(MAP)升高,心输出指数(CI)及胸腔内血容量指数(ITBI)降低,与术前基础值均有统计学差异,大量气胸时大部分指标变化同前,MAP降低,有统计学差异。③三组动物手术顺利,A组PH值降低,氧合指数(0I)降低、二氧化碳分压(PaCO2)升高和气道阻力压升高有统计学差异,心率(HR)增加,平均动脉压(MAP)升高,心输出指数(CI)及胸腔内血容量指数(ITBI)降低,与术前基础值均有统计学差异,C组随着时间延长逐渐出现以上变化,与术前基础值均有统计学差异,B组各项指标变化无统计学差异。A组6头猪术中均出现不同程度气胸,2头出现重度单侧气胸,术后死亡,其余4头轻中度气胸,穿刺抽气及常规抢救后均存活；C组中出现1例单侧重度气胸,3例轻中度气胸,穿刺抽气及常规抢救后均存活。结论：现有内镜手术条件下,经食管黏膜下隧道诊治范畴拓展如纵隔治疗手术是可行的,但是仍有较大风险,而纵隔手术中腔内压力监测和调控是保证手术安全进行的必要条件；内镜下纵隔或胸腔手术中血气指标、呼吸力学及血流动力学监测是非常必要的,血气分析和呼吸动力监测对于气胸的预警作用明显。
[Abstract]:Background and objective: submucosal tunnel technique of the esophagus has been gradually applied to the treatment of esophagus adjacent structures, such as endoscopic myotomy (per-oral endoscopic myotomy, POEM), early esophageal carcinoma dissection, and submucosal tumor resection of the esophagus, which often perplex the complications of endoscopes. The study of pneumothorax, such as pneumothorax, has also become a key link in the study of the esophageal tunnel technology. At the same time, the tunnel technology has also accelerated the expansion of the scope of the diagnosis and treatment of the esophagus tunnel, but the safety of the related operation still needs the experimental demonstration. The feasibility and safety of endoscopic surgery, and explore the necessary conditions for the operation, establish the theoretical and practical basis for the diagnosis and treatment of mediastinal lesions under clinical endoscopy, and find the related sensitive indexes of pneumothorax through the animal pneumothorax model experiment, and provide reference for the clinical operation of the adjacent structure of the esophagus. Methods: (1) 6 pigs and endoscopy were selected. The submucosal tunnel of the esophagus was established into the mediastinum, the mediastinal organs were identified and the mediastinal tissue was performed to simulate the lymph node biopsy. 6 pigs were selected to establish the thoracic C02 pneumothorax model, and the physiological, respiratory and hemodynamic changes were monitored in the C02 pneumothorax model of the thoracic puncture, and the 10min before the injection of gas was selected as the observation base. Basic point Baseline, monitoring the left small amount, medium amount, and a large number of pneumothorax in 3 time phase point physiology, respiratory mechanics and hemodynamic changes. (3) 18 head pigs were randomly divided into no pressure control group (group A 10mmHg), ultra low pressure control group (B group 5mmHg) and high pressure control group (C group 10mmHg) 3 groups, select the pre injection 10min as the observation basis Baseline, monitoring Blood injection of 10 minutes, 20 minutes and 30 minutes of 3 phase point physiology, respiratory mechanics and hemodynamic changes between groups and groups were compared. Results: (1) 6 animals were successfully completed. During the operation, mediastinal organs (such as lung, spine, descending aorta, etc.) were clearly identified, and mediastinal tissue simulated lymph node biopsy was performed, of which 2 cases died of severe pneumothorax. 2 cases had a small amount of pneumothorax and the esophageal incision was successfully closed with metal clips. 2. The C02 inflatable model of the thoracic cavity was successfully established. Only a small amount of pneumothorax was reduced in oxygenation index (OI), the pressure of carbon dioxide (PaCO2) increased and the airway resistance pressure increased statistically. The pH value of the pneumothorax was reduced, the oxygen index (OI) decreased, and the carbon dioxide partial pressure was reduced. (PaCO2) increased, airway resistance pressure increased, heart rate (HR) increased, average arterial pressure (MAP) increased, cardiac output index (CI) and intrathoracic blood volume index (ITBI) decreased, and had statistical differences with preoperative values. Most of the index changes in pneumothorax were the same before, MAP decreased, and there were statistical differences. (3) the three groups of animals were operated smoothly, the pH value of the A group was reduced, oxygen was reduced, oxygen was reduced, oxygen was reduced in the A group. There were statistical differences in 0I, PaCO2 and airway resistance pressure. Heart rate (HR) increased, mean arterial pressure (MAP) increased, cardiac output index (CI) and intrathoracic blood volume index (ITBI) decreased. There were statistical differences from preoperative basic values. Group C increased gradually with time, and the basis of pre operation basis. There was no significant difference in the value of the B group, and there were no statistical differences in the changes of the indexes in the group.A 6 head pigs, 2 of the severe unilateral pneumothorax, the other 4 light and moderate pneumothorax, the puncture aspiration and the routine rescue. In group C, there were 1 cases of unilateral severe pneumothorax, 3 cases of mild and moderate pneumothorax, puncture aspiration and routine Conclusion: under the existing endoscopic surgery, it is feasible to extend the diagnosis and treatment of the submucosal tunnel through the esophagus, such as mediastinal surgery, but there is still a great risk, and the pressure monitoring and control in the mediastinal operation is the necessary condition to ensure the safety of the operation; the blood gas index and respiration in the endoscopic mediastinal or thoracic surgery Mechanical and hemodynamic monitoring is very necessary. Blood gas analysis and respiratory dynamic monitoring have obvious effect on early warning of pneumothorax.
【学位授予单位】：中国人民解放军医学院
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R655
本文编号：2168832
[Abstract]:Background and objective: submucosal tunnel technique of the esophagus has been gradually applied to the treatment of esophagus adjacent structures, such as endoscopic myotomy (per-oral endoscopic myotomy, POEM), early esophageal carcinoma dissection, and submucosal tumor resection of the esophagus, which often perplex the complications of endoscopes. The study of pneumothorax, such as pneumothorax, has also become a key link in the study of the esophageal tunnel technology. At the same time, the tunnel technology has also accelerated the expansion of the scope of the diagnosis and treatment of the esophagus tunnel, but the safety of the related operation still needs the experimental demonstration. The feasibility and safety of endoscopic surgery, and explore the necessary conditions for the operation, establish the theoretical and practical basis for the diagnosis and treatment of mediastinal lesions under clinical endoscopy, and find the related sensitive indexes of pneumothorax through the animal pneumothorax model experiment, and provide reference for the clinical operation of the adjacent structure of the esophagus. Methods: (1) 6 pigs and endoscopy were selected. The submucosal tunnel of the esophagus was established into the mediastinum, the mediastinal organs were identified and the mediastinal tissue was performed to simulate the lymph node biopsy. 6 pigs were selected to establish the thoracic C02 pneumothorax model, and the physiological, respiratory and hemodynamic changes were monitored in the C02 pneumothorax model of the thoracic puncture, and the 10min before the injection of gas was selected as the observation base. Basic point Baseline, monitoring the left small amount, medium amount, and a large number of pneumothorax in 3 time phase point physiology, respiratory mechanics and hemodynamic changes. (3) 18 head pigs were randomly divided into no pressure control group (group A 10mmHg), ultra low pressure control group (B group 5mmHg) and high pressure control group (C group 10mmHg) 3 groups, select the pre injection 10min as the observation basis Baseline, monitoring Blood injection of 10 minutes, 20 minutes and 30 minutes of 3 phase point physiology, respiratory mechanics and hemodynamic changes between groups and groups were compared. Results: (1) 6 animals were successfully completed. During the operation, mediastinal organs (such as lung, spine, descending aorta, etc.) were clearly identified, and mediastinal tissue simulated lymph node biopsy was performed, of which 2 cases died of severe pneumothorax. 2 cases had a small amount of pneumothorax and the esophageal incision was successfully closed with metal clips. 2. The C02 inflatable model of the thoracic cavity was successfully established. Only a small amount of pneumothorax was reduced in oxygenation index (OI), the pressure of carbon dioxide (PaCO2) increased and the airway resistance pressure increased statistically. The pH value of the pneumothorax was reduced, the oxygen index (OI) decreased, and the carbon dioxide partial pressure was reduced. (PaCO2) increased, airway resistance pressure increased, heart rate (HR) increased, average arterial pressure (MAP) increased, cardiac output index (CI) and intrathoracic blood volume index (ITBI) decreased, and had statistical differences with preoperative values. Most of the index changes in pneumothorax were the same before, MAP decreased, and there were statistical differences. (3) the three groups of animals were operated smoothly, the pH value of the A group was reduced, oxygen was reduced, oxygen was reduced, oxygen was reduced in the A group. There were statistical differences in 0I, PaCO2 and airway resistance pressure. Heart rate (HR) increased, mean arterial pressure (MAP) increased, cardiac output index (CI) and intrathoracic blood volume index (ITBI) decreased. There were statistical differences from preoperative basic values. Group C increased gradually with time, and the basis of pre operation basis. There was no significant difference in the value of the B group, and there were no statistical differences in the changes of the indexes in the group.A 6 head pigs, 2 of the severe unilateral pneumothorax, the other 4 light and moderate pneumothorax, the puncture aspiration and the routine rescue. In group C, there were 1 cases of unilateral severe pneumothorax, 3 cases of mild and moderate pneumothorax, puncture aspiration and routine Conclusion: under the existing endoscopic surgery, it is feasible to extend the diagnosis and treatment of the submucosal tunnel through the esophagus, such as mediastinal surgery, but there is still a great risk, and the pressure monitoring and control in the mediastinal operation is the necessary condition to ensure the safety of the operation; the blood gas index and respiration in the endoscopic mediastinal or thoracic surgery Mechanical and hemodynamic monitoring is very necessary. Blood gas analysis and respiratory dynamic monitoring have obvious effect on early warning of pneumothorax.
【学位授予单位】：中国人民解放军医学院
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R655
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