腹腔镜可降解支架法结肠吻合术的动物实验研究
发布时间：2018-07-29 10:56
【摘要】：目的：研究腹腔镜可降解支架法结肠吻合术是否安全可行,与腹腔镜手工缝合法结肠吻合术相比在手术操作方面是否具有优势；研究两者在肠道愈合、并发症方面是否有差异。 方法：以巴马小型猪为研究对象,共20只。将它们随机分为2大组,分别为实验组和对照组。实验组采用腹腔镜支架法结肠端端吻合,分为A组(术后2周处死)和c组(术后3月处死)；对照组采用腹腔镜手工缝合法结肠端端吻合,分为B组(术后2周处死,A组的对照组)和D组(术后3月处死,c组的对照组),每小组5只。支架以聚乙醇酸(PGA)为主要材料,混合有12.75%的硫酸钡作为显影剂。所有动物均气管插管全身麻醉,腹腔镜下行结肠端端吻合术。记录各组吻合完成所需时间、手术时间,记录动物术后一般状况、并发症及死亡情况。A、B组术后2周处死,测定吻合口爆破压。c、D组术后3月处死,测定吻合口肠管周径。观察吻合口大体愈合情况,吻合口HE染色、Masson染色以及TGF-β1、b-FGF、α-SMA的免疫组化染色,统计数据,分析结果,探讨腹腔镜支架法结肠端端吻合的可行性及安全性,观察肠道的愈合情况,从而得出结论。 结果：各组之间动物体重没有明显差异。c组有一例动物于术后11周死于肠梗阻,尸体解剖发现肠梗阻部位位于吻合处下方,病因是先天性肠瓣膜病,梗阻部位亦未发现支架残留物。其余动物均顺利存活。 A组平均手术时间为56.6±16.6分钟,B组平均手术时间为100.8±34.1分钟,两者之间差异有统计学意义(p=0.031)。c组平均手术时间为86.6±10.9分钟,D组平均手术时间为115.8±20.8分钟,两者之间差异有统计学意义(p=0.024)。腹腔镜支架法吻合实验组(A组+c组)平均手术时间为71.6±20.6分钟,腹腔镜手工吻合对照组(B组+D组)平均手术时间为108.3±27.8分钟,两者之间有显著性差异(p=0.004)。腹腔镜支架法吻合实验组的前5例(c组)与后5例(A组)相比手术时间从86.6±10.9分钟降至56.6±16.6分钟,有统计学差异(p=0.010)。腹腔镜手工吻合对照组前5例(D组)与后5例(B组)相比手术时间从115.8±20.8降至100.8±34.1分钟,无统计学差异(p=0.426)。A组平均吻合完成时间为23.6±14.8分钟,B组平均吻合完成时间为57.2±24.3分钟,两者之间差异有统计学意义(p=0.030)。c组平均吻合完成时间为42.6±18.0分钟,D组平均吻合完成时间为73.8±11.5分钟,两者之间差异有统计学意义(p=0.011)。腹腔镜支架法吻合实验组(A组+c组)平均吻合完成时间为33.1±18.5分钟,腹腔镜手工吻合对照组(B组+D组)平均吻合完成时间为65.5±19.9分钟,两者之间有显著性差异(p=0.001)。腹腔镜支架法吻合实验组的前5例(c组)与后5例(A组)相比吻合完成时间从42.6±18.0分钟降至23.6±14.8分钟,但无明显统计学差异(p=0.106)。腹腔镜手工吻合对照组前5例(D组)与后5例(B组)相比吻合完成时间从73.8±11.5分钟降至57.2±24.3分钟,无明显统计学差异(p=0.204)。术后2周处死A、B两组动物。A组5例均无明显肠漏。B组1例发生肠漏未愈合,未测吻合口爆破压。A组5例平均吻合口爆破压为108.0±34.9cmH2O, B组4例平均吻合口爆破压为97.5±60.2cmH2O,两者之间没有统计学差异(p=0.751)。A组破裂位置2例位于原吻合口处,B组破裂位置2例为原吻合口处,A、B两组其余5例破裂位置均不在吻合口处。C组一例动物于术后11周死于肠瓣膜病引起的肠梗阻,故未测量吻合口周径。c组其余4例正常肠管平均周径为7.7±0.2厘米,吻合口平均周径7.7±0.4厘米；D组5例正常肠管平均周径为8.3±1.1厘米,吻合口平均周径为7.1±1.1厘米。两组间正常肠管周径无显著性差异(p=0.296),两组间吻合口周径无显著性差异(p=0.344)。C组吻合口平均周径与正常肠管平均周径相比无明显差异(p=1.000)。D组吻合口平均周径与正常肠管平均周径相比减小,有统计学意义(p=0.047)。 术后二周A组的支架均在肠腔内,1例发生移位,距离吻合口约10cm,其余4例仍在吻合口内,支架质地变脆易碎,部分破损。部分动物荷包线已进入肠腔内,套于支架上。A组5例均可见吻合口与周围肠管及网膜不同程度粘连,粘膜面可见充血水肿,未见明显的肠漏及肠管内腔狭窄。手工缝合的B组吻合口与周围肠管和网膜粘连,粘膜面可见充血水肿。其中3例有发生肠漏迹象,2例已愈合,1例未愈合,该例动物腹腔内可见多个包裹性脓肿形成。 术后三月C组支架均已离开吻合口,吻合口与周围肠管及网膜形成轻中度粘连。吻合口疤痕较浅,与周围肠管相比无明显变细,未见明显的肠腔狭窄及肠漏,腹腔内未见明显脓肿形成,肠腔粘膜面吻合口线均已不明显。术后三月D组吻合口与周围肠管及网膜有轻中度粘连,2例动物的肠管吻合处较周围肠管明显变细,但未见明显的肠腔狭窄,未见肠漏,腹腔内未见明显脓肿形成。 术后两周吻合口标本HE染色两组均可见吻合口处粘膜缺失,表面肉芽组织增生,伴大量炎症细胞浸润,其下纤维组织增生,胶原沉积,腹腔镜支架法组吻合口的炎症细胞浸润较手工缝合法组轻。Masson染色示两组吻合口内胶原沉积情况相似。两组免疫组化α-SMA染色强度较高,范围较广；b-FGF和TGF-β1则染色强度较低,范围较小,两组之间无明显区别。 术后三月吻合口标本HE染色两组均见吻合处肠壁表面结肠粘膜被覆,其下纤维组织增生,伴胶原沉积,直达外膜层,其间见平滑肌呈束状穿插生长入吻合口。腹腔镜支架法组吻合口的平滑肌组织多于手工缝合组。Masson染色示两组均有大量胶原沉积,疤痕组织形成,无明显差异。两组免疫组化α-SMA染色强度较术后两周时降低,范围仍较广,可见阳性的平滑肌细胞呈棕黄色,排列呈束状；b-FGF和TGF-β1则染色强度较低,范围较小,两组之间无明显区别.结论1腹腔镜可降解支架法肠吻合对于巴马小型猪的结肠吻合口愈合是安全可行的。2腹腔镜可降解支架法肠吻合与腹腔镜手工缝合法肠吻合相比在力学愈合与组织学愈合上并无明显差异。3腹腔镜可降解支架法肠吻合与腹腔镜手工缝合法肠吻合相比,操作更为简便省时,肠漏、肠腔狭窄发生率低,吻合质量更稳定,具有良好的应用前景。
[Abstract]:Objective: To investigate whether laparoscopic coloniable stent colonic anastomosis is safe and feasible, and whether it is superior to laparoscopic colonic anastomosis by laparoscopic manual colonic anastomosis, and whether there is a difference in both intestinal healing and complications.
Methods: a total of 20 Bama miniature pigs were divided into 2 groups randomly. The experimental group was divided into 2 groups, the experimental group and the control group. The experimental group was divided into group A (2 weeks after operation) and group C (after the operation in March), and the control group was divided into group B (2 weeks after the operation). Death, control group of group A and group D (death in March, control group in group C), 5 rats in each group. The scaffold was made of polyglycolic acid (PGA) as the main material and mixed with 12.75% barium sulfate as a developer. All animals were anesthetized by tracheal intubation and laparoscopic colonic end-to-end anastomosis was performed. Records of the time required for completion of the anastomosis, operation time, records were recorded. The general condition, complication and death situation after operation of animal.A, group B were killed 2 weeks after operation,.C of anastomotic blasting pressure was measured, and group D was killed in March, and the circumferential diameter of anastomotic stoma was measured. The general healing of anastomotic mouth, HE staining of anastomotic mouth, Masson staining, TGF- beta 1, b-FGF, alpha -SMA, immunohistochemical staining, statistical data, analysis results, and exploration of the abdominal cavity The feasibility and safety of endoscope anastomosis were observed, and the healing of intestinal tract was observed.
Results: there was no significant difference in body weight between the groups. One case of.C group died of intestinal obstruction at 11 weeks after operation. The autopsy found the site of intestinal obstruction located below the anastomosis. The cause was congenital enteral valvular disease, and the stents were not found. The rest of the animals survived successfully.
The average operation time of group A was 56.6 + 16.6 minutes, and the average operation time in group B was 100.8 + 34.1 minutes. The difference between the two groups was statistically significant (p=0.031) in group.C, the average operation time was 86.6 + 10.9 minutes, and the average operation time of D group was 115.8 + 20.8 minutes. The difference between the two groups was statistically significant (p=0.024). The laparoscopic stent method was in the experimental group (A The average operation time of group +c was 71.6 + 20.6 minutes, and the average operation time of the laparoscopic manual anastomosis group (group B +D group) was 108.3 + 27.8 minutes. There was a significant difference between the two groups (p=0.004). The operation time was reduced from 86.6 + 10.9 minutes to 56.6 + 16.6 minutes compared with the last 5 cases (group A). The study difference (p=0.010). The operation time of the first 5 cases (group D) and the latter 5 cases (group B) decreased from 115.8 + 20.8 to 100.8 + 34.1 minutes. There was no statistical difference (p=0.426), the average anastomosis time of.A group was 23.6 + 14.8 minutes, and the average anastomosis time of group B was 57.2 + 24.3 minutes, and there was a significant difference between the two groups (P =0.030) the average anastomosis time of group.C was 42.6 + 18 minutes, and the average anastomosis time of group D was 73.8 + 11.5 minutes. The difference between the two groups was statistically significant (p=0.011). The average anastomosis time of the laparoscopic stent anastomosis group (group +c of A group) was 33.1 + 18.5 minutes, and the average anastomosis of the laparoscope manual anastomosis group (group +D of B group) was completed. The time was 65.5 + 19.9 minutes, there was significant difference between the two (p=0.001). The first 5 cases (Group C) of the laparoscopic stent anastomosis group were compared with the latter 5 cases (A group) to 23.6 + 14.8 minutes from 42.6 + 18 minutes, but there was no significant difference (p=0.106). Compared with the last 5 cases (group D) and 5 cases (B group), the laparoscope manual anastomosis group was compared. The completion time of the anastomosis was reduced from 73.8 + 11.5 minutes to 57.2 + 24.3 minutes without significant statistical difference (p=0.204). A was killed in 2 weeks after operation, and 5 cases of group.A of group B two had no intestinal leakage in group.B, 1 cases had no intestinal leakage, 5 cases in group.A of unmeasured anastomotic blasting pressure were 108 + 34.9cmH2O, and 4 average anastomotic blasting pressure of B group was 97.. 5 + 60.2cmH2O, there was no statistical difference between the two (p=0.751).A group rupture position in the original anastomosis, B group rupture position 2 cases of the original anastomosis, the remaining 5 cases of A, B two were not in the.C group in the anastomotic group, one case died of intestinal valvular disease in the 11 weeks after the operation, so the other 4 cases in group.C did not measure the anastomotic diameter in the other 4 cases. The average circumferential diameter of normal bowel was 7.7 + 0.2 cm, the average circumference diameter of the anastomosis was 7.7 + 0.4 cm, the average circumference diameter of the D group was 8.3 + 1.1 cm and the average diameter of the anastomosis was 7.1 + 1.1 cm. There was no significant difference between the two groups (p=0.296), and there was no significant difference between the two groups (p=0.344) the average week of the anastomotic stoma of the group of.C. There was no significant difference between the diameter and the average circumferential diameter of the normal bowel (p=1.000), the average diameter of the anastomotic stoma in the.D group decreased compared with the average circumferential diameter of the normal intestinal canal, and was statistically significant (p=0.047).
Two weeks after the operation, the stents in group A were all in the intestinal cavity, 1 cases were shifted from the anastomotic stoma, and the other 4 cases were still in the anastomotic mouth. The texture of the scaffold became brittle and fragility. Part of the animal's purse line had entered the enteral cavity. In the group of.A, the conglutination of the anastomoses to the surrounding intestinal tube and omentum was found in 5 cases, and the mucous membrane was visible. There was no obvious intestinal fistula and stenosis of intestinal canal. The anastomoses of B group with hand suture were conglutination with the surrounding intestinal tube and omentum, and the mucous membrane showed congestion and edema. 3 of them had signs of intestinal fistula, 2 cases had healed, 1 cases were not healed, and multiple parcels of abscess in the abdominal cavity were found in this animal.
The stents in group C had left the anastomosis in March. The anastomotic stoma and the surrounding intestinal canal and omentum formed light and moderate adhesion. The scar of the anastomotic stoma was shallow, no obvious thinning, no obvious intestinal stenosis and intestinal fistula, no obvious abscess in the abdominal cavity, and the anastomotic line of the mucosa of the intestinal cavity was not obvious. The anastomotic mouth of group D after operation was in the anastomotic mouth after operation. There were mild and moderate adhesions with the surrounding intestinal tube and omentum. The anastomoses of the intestines in the 2 animals were obviously thinner than the surrounding intestinal tube, but no obvious intestinal stenosis, no intestinal fistula and no obvious abscess in the abdominal cavity were found.
Two weeks after the operation, the HE staining specimens were stained in the two groups. The mucosa of the anastomoses was absent, the surface granulation tissue was proliferated, and a large number of inflammatory cells were infiltrated, the lower fibrous tissue and collagen deposition. The infiltration of inflammatory cells in the anastomotic stoma of the laparoscopic stent group was similar to that of the hand suture group with light.Masson staining in the two groups of anastomotic collagenous deposits. In the two groups, the intensity of immunohistochemical -SMA staining was high and the range was wide. The staining intensity of b-FGF and TGF- beta 1 was low and the range was small. There was no significant difference between the two groups.
In March, two groups of anastomotic specimens were stained with HE staining, and the colonic mucosa of the intestinal wall surface of the anastomosis was seen. The lower fibrous tissue was proliferated, with collagen deposition, and directly to the outer membrane. The smooth muscle tissue was inserted into the anastomotic mouth. The smooth muscle tissue of the anastomotic stoma in the laparoscopic stent group was much more than that of the manual suture group of the two groups. Collagen deposition, scar tissue formation, no obvious difference. Two groups of immunohistochemical alpha -SMA staining intensity is lower than the two weeks after the operation, the range is still wider, the positive smooth muscle cells are brown yellow, arranged in a fascicular shape, b-FGF and TGF- beta 1 are low staining strength, the range is small, there is no obvious difference between the two groups. Conclusion 1 laparoscopic biodegradable scaffold method Intestinal anastomosis for colonic anastomosis in a Bama miniature pig is a safe and feasible.2 laparoscopic biodegradable scaffold with no significant difference in mechanical healing and histological healing compared with.3. It is simple and time-saving, with a low incidence of intestinal leakage, low intestinal cavity stenosis, and stable quality of anastomosis.
【学位授予单位】：浙江大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R656
本文编号：2152458
[Abstract]:Objective: To investigate whether laparoscopic coloniable stent colonic anastomosis is safe and feasible, and whether it is superior to laparoscopic colonic anastomosis by laparoscopic manual colonic anastomosis, and whether there is a difference in both intestinal healing and complications.
Methods: a total of 20 Bama miniature pigs were divided into 2 groups randomly. The experimental group was divided into 2 groups, the experimental group and the control group. The experimental group was divided into group A (2 weeks after operation) and group C (after the operation in March), and the control group was divided into group B (2 weeks after the operation). Death, control group of group A and group D (death in March, control group in group C), 5 rats in each group. The scaffold was made of polyglycolic acid (PGA) as the main material and mixed with 12.75% barium sulfate as a developer. All animals were anesthetized by tracheal intubation and laparoscopic colonic end-to-end anastomosis was performed. Records of the time required for completion of the anastomosis, operation time, records were recorded. The general condition, complication and death situation after operation of animal.A, group B were killed 2 weeks after operation,.C of anastomotic blasting pressure was measured, and group D was killed in March, and the circumferential diameter of anastomotic stoma was measured. The general healing of anastomotic mouth, HE staining of anastomotic mouth, Masson staining, TGF- beta 1, b-FGF, alpha -SMA, immunohistochemical staining, statistical data, analysis results, and exploration of the abdominal cavity The feasibility and safety of endoscope anastomosis were observed, and the healing of intestinal tract was observed.
Results: there was no significant difference in body weight between the groups. One case of.C group died of intestinal obstruction at 11 weeks after operation. The autopsy found the site of intestinal obstruction located below the anastomosis. The cause was congenital enteral valvular disease, and the stents were not found. The rest of the animals survived successfully.
The average operation time of group A was 56.6 + 16.6 minutes, and the average operation time in group B was 100.8 + 34.1 minutes. The difference between the two groups was statistically significant (p=0.031) in group.C, the average operation time was 86.6 + 10.9 minutes, and the average operation time of D group was 115.8 + 20.8 minutes. The difference between the two groups was statistically significant (p=0.024). The laparoscopic stent method was in the experimental group (A The average operation time of group +c was 71.6 + 20.6 minutes, and the average operation time of the laparoscopic manual anastomosis group (group B +D group) was 108.3 + 27.8 minutes. There was a significant difference between the two groups (p=0.004). The operation time was reduced from 86.6 + 10.9 minutes to 56.6 + 16.6 minutes compared with the last 5 cases (group A). The study difference (p=0.010). The operation time of the first 5 cases (group D) and the latter 5 cases (group B) decreased from 115.8 + 20.8 to 100.8 + 34.1 minutes. There was no statistical difference (p=0.426), the average anastomosis time of.A group was 23.6 + 14.8 minutes, and the average anastomosis time of group B was 57.2 + 24.3 minutes, and there was a significant difference between the two groups (P =0.030) the average anastomosis time of group.C was 42.6 + 18 minutes, and the average anastomosis time of group D was 73.8 + 11.5 minutes. The difference between the two groups was statistically significant (p=0.011). The average anastomosis time of the laparoscopic stent anastomosis group (group +c of A group) was 33.1 + 18.5 minutes, and the average anastomosis of the laparoscope manual anastomosis group (group +D of B group) was completed. The time was 65.5 + 19.9 minutes, there was significant difference between the two (p=0.001). The first 5 cases (Group C) of the laparoscopic stent anastomosis group were compared with the latter 5 cases (A group) to 23.6 + 14.8 minutes from 42.6 + 18 minutes, but there was no significant difference (p=0.106). Compared with the last 5 cases (group D) and 5 cases (B group), the laparoscope manual anastomosis group was compared. The completion time of the anastomosis was reduced from 73.8 + 11.5 minutes to 57.2 + 24.3 minutes without significant statistical difference (p=0.204). A was killed in 2 weeks after operation, and 5 cases of group.A of group B two had no intestinal leakage in group.B, 1 cases had no intestinal leakage, 5 cases in group.A of unmeasured anastomotic blasting pressure were 108 + 34.9cmH2O, and 4 average anastomotic blasting pressure of B group was 97.. 5 + 60.2cmH2O, there was no statistical difference between the two (p=0.751).A group rupture position in the original anastomosis, B group rupture position 2 cases of the original anastomosis, the remaining 5 cases of A, B two were not in the.C group in the anastomotic group, one case died of intestinal valvular disease in the 11 weeks after the operation, so the other 4 cases in group.C did not measure the anastomotic diameter in the other 4 cases. The average circumferential diameter of normal bowel was 7.7 + 0.2 cm, the average circumference diameter of the anastomosis was 7.7 + 0.4 cm, the average circumference diameter of the D group was 8.3 + 1.1 cm and the average diameter of the anastomosis was 7.1 + 1.1 cm. There was no significant difference between the two groups (p=0.296), and there was no significant difference between the two groups (p=0.344) the average week of the anastomotic stoma of the group of.C. There was no significant difference between the diameter and the average circumferential diameter of the normal bowel (p=1.000), the average diameter of the anastomotic stoma in the.D group decreased compared with the average circumferential diameter of the normal intestinal canal, and was statistically significant (p=0.047).
Two weeks after the operation, the stents in group A were all in the intestinal cavity, 1 cases were shifted from the anastomotic stoma, and the other 4 cases were still in the anastomotic mouth. The texture of the scaffold became brittle and fragility. Part of the animal's purse line had entered the enteral cavity. In the group of.A, the conglutination of the anastomoses to the surrounding intestinal tube and omentum was found in 5 cases, and the mucous membrane was visible. There was no obvious intestinal fistula and stenosis of intestinal canal. The anastomoses of B group with hand suture were conglutination with the surrounding intestinal tube and omentum, and the mucous membrane showed congestion and edema. 3 of them had signs of intestinal fistula, 2 cases had healed, 1 cases were not healed, and multiple parcels of abscess in the abdominal cavity were found in this animal.
The stents in group C had left the anastomosis in March. The anastomotic stoma and the surrounding intestinal canal and omentum formed light and moderate adhesion. The scar of the anastomotic stoma was shallow, no obvious thinning, no obvious intestinal stenosis and intestinal fistula, no obvious abscess in the abdominal cavity, and the anastomotic line of the mucosa of the intestinal cavity was not obvious. The anastomotic mouth of group D after operation was in the anastomotic mouth after operation. There were mild and moderate adhesions with the surrounding intestinal tube and omentum. The anastomoses of the intestines in the 2 animals were obviously thinner than the surrounding intestinal tube, but no obvious intestinal stenosis, no intestinal fistula and no obvious abscess in the abdominal cavity were found.
Two weeks after the operation, the HE staining specimens were stained in the two groups. The mucosa of the anastomoses was absent, the surface granulation tissue was proliferated, and a large number of inflammatory cells were infiltrated, the lower fibrous tissue and collagen deposition. The infiltration of inflammatory cells in the anastomotic stoma of the laparoscopic stent group was similar to that of the hand suture group with light.Masson staining in the two groups of anastomotic collagenous deposits. In the two groups, the intensity of immunohistochemical -SMA staining was high and the range was wide. The staining intensity of b-FGF and TGF- beta 1 was low and the range was small. There was no significant difference between the two groups.
In March, two groups of anastomotic specimens were stained with HE staining, and the colonic mucosa of the intestinal wall surface of the anastomosis was seen. The lower fibrous tissue was proliferated, with collagen deposition, and directly to the outer membrane. The smooth muscle tissue was inserted into the anastomotic mouth. The smooth muscle tissue of the anastomotic stoma in the laparoscopic stent group was much more than that of the manual suture group of the two groups. Collagen deposition, scar tissue formation, no obvious difference. Two groups of immunohistochemical alpha -SMA staining intensity is lower than the two weeks after the operation, the range is still wider, the positive smooth muscle cells are brown yellow, arranged in a fascicular shape, b-FGF and TGF- beta 1 are low staining strength, the range is small, there is no obvious difference between the two groups. Conclusion 1 laparoscopic biodegradable scaffold method Intestinal anastomosis for colonic anastomosis in a Bama miniature pig is a safe and feasible.2 laparoscopic biodegradable scaffold with no significant difference in mechanical healing and histological healing compared with.3. It is simple and time-saving, with a low incidence of intestinal leakage, low intestinal cavity stenosis, and stable quality of anastomosis.
【学位授予单位】：浙江大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R656
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