经口经食管内镜隧道技术对腹主动脉区域相关疾病诊治的可行性研究

发布时间：2018-08-01 13:34

【摘要】：研究背景及目的：近些年来内镜下治疗技术发展迅速,内镜隧道技术的出现使得很多以前属于外科手术或腔镜手术治疗的疾病进入内镜治疗范畴,其疗效与外科手术无差异,并且还具有并发症少,创伤小等优势。经口内镜肌切开术(peroral endoscopic myotomy, POEM)自2010年报道以来,由于其良好的临床治疗效果,同时兼备相比外科Heller手术症状缓解率高,复发率低以及创伤小等优点,目前在世界范围内广泛开展。内镜黏膜下隧道法切除术(Submucosal tunnel endoscopic resection, STER)是在POEM的基础上将内镜隧道技术拓展到消化道固有肌层病变的治疗方面,并且疗效确切,此手术方法在一定程度上优于外科手术及胸腔镜手术。为何内镜隧道技术拥有如此良好的疗效同时又具备并发症少等诸多优势呢?主要是因为内镜隧道技术可以有效的防止在进行固有肌层侧病变或固有肌层以外病变的内镜手术时导致的消化管腔与管腔外腔隙相通,避免消化管腔内的气体、液体直接进入消化管腔外组织间隙,以达到即治疗病变又防止穿孔的目的。经自然腔道内镜手术(natural orifice transluminal endoscopic surgery, NOTES)是一种基于人体自然腔道,如食管、胃、直肠、阴道等进入体腔,应用软式内镜完成治疗,而体表无手术切口的一种手术方式。但NOTES手术发展至今存在几个瓶颈,首先是入口缝合困难,其次是消化道内液体进入腹腔造成感染,然后是软式内镜进入腹腔后无明确解剖定位容易迷失方向;以上问题一直困绕着内镜学者,如果不能很好的解决这些问题,NOTES技术的发展将会在很大程度上受到限制。联合内镜隧道技术进行NOTES手术将会解决封闭入口困难的问题,仅需几枚金属夹即可完整封闭食管的人工入口：并且由于隧道入口位置较高(在食管中下段)可有效防止胃内液体流入体腔,因此经口经食管隧道还具备降低腹腔感染发生率等其他优势,同时通过术前定位及与体外解剖结构的对比,能更了解内镜下腹腔解剖结构,可在一定程度上解决内镜进入腹腔易迷失方向的问题。腹腔镜手术目前技术已十分成熟,但是胃后壁及腹主动脉区域一直是腹腔镜手术最困难的部位,而应用消化内镜穿透胃后壁可直接抵达该区域,理论上手术操作更简单、直接,更易操作。本课题共四部分研究,第一章研究寻找一个最佳动物手术体位和最佳内镜下建立隧道的方法;第二章我们研究了内镜在腹腔内辨认解剖结构的情况;第三章研究了术中并发症的发生及解决情况,第四章通过前几章的研究结果应用内镜隧道技术将内镜穿透贲门胃底后壁进入腹腔进行包括腹腔干旁神经节毁损术,部分肝切除术,部分脾切除术,后腹膜区域部分组织切除术以及早期胃癌ESD术后壁外淋巴结清扫等腹主动脉区域相关疾病的内镜诊疗手术。本研究旨在证明经口经食管内镜隧道技术腹主动脉周围疾病诊疗手术是安全可行的,并可在未来应用于临床诊疗中。方法：第一章：①术前定位穿入点的研究：取6头猪尸,分2组,每组3头。第一组为无术前定位组,由食管后壁建立隧道至贲门下方2cm处,切开固有肌层及浆膜层进入腹腔;第二组为美兰定位组,在贲门后壁黏膜下层注射1：2美兰生理盐水注射液定位,食管后壁建立隧道至贲门下方标记处,切开固有肌层及浆膜层进入腹腔。对比以上2组中3例进入腹腔后的结构对比图,并剖开猪尸腹部对比,观察每组间3例入路的差异,差异小者为优。②入路方式的研究：取9头猪尸,分3组,每组3头。第一组,仰卧位内镜下于食管后壁建立黏膜下隧道至贲门下方2cm处,切开固有肌层及浆膜层,进入胃后腹腔,辨认腹腔内解剖结构;第二组,左侧卧位于食管右侧壁建立隧道至贲门胃底小弯侧,切开固有肌层及浆膜层,由贲门小弯侧进入腹腔,辨认腹腔内解剖结构;第三组,仰卧右肩抬高位于食管右后壁建立隧道至贲门小弯侧偏后壁,切开固有肌层及浆膜层进入腹腔,辨认腹腔内解剖结构。以上三组通过体会各组内镜操作难易程度,内镜进入腹腔辨认解剖结构后均剖开猪尸腹部进行对照确认。以进镜困难程度小,进入腹腔后损伤组织少即可完成相关手术的一组为优。③肌切开方式的研究：取6头猪尸,分2组,每组3头。第一组为横行肌切开组,在隧道末端用电刀横切开肌层,内镜进入腹腔。第二组为纵行肌切开组,在隧道末端纵形切开肌层,内镜进入腹腔。第三组为渐进式纵行肌切开组,由浅入深逐步切开肌层,内镜进入腹腔。对比三实验组肌切开长度,肌切开后内镜视野暴露情况以及内镜进入腹腔后镜身自由度等。以肌切开长度短,壁外视野暴露好,肌层创伤小,镜身自由度好的一组为优。第二章：通过第一章得出的最佳入路在猪尸上模拟手术,内镜进入腹腔达腹主动脉周围后,观察内镜下图像,并剖开猪尸腹腔辨认解剖结构后进行对比,获得良好的内镜图像与解剖图像对比,为后续活体动物实验打下良好的实验基础。第三章：并发症的相关研究,①气体相关并发症的研究：实验分三组,无排气组,气腹机组和穿刺排气组,选择最佳入路内镜进入腹腔,无排气组内镜持续在腹腔内送气,气腹机组将内镜连接气腹机并调整PCO2维持12-15mmHg,穿刺排气组内镜持续送气,并在腹部用注射器针头穿刺排气,腹腔内注气时间90min,观察术中实验猪的生命体征,如实验猪死亡记录死亡时间。②实验分二组,无处理组和特殊处理组,2组实验猪分别于术前、术后24h、48h、72h及一周测体温,采静脉血化验血常规,内镜术后观察腹腔感染情况。3.一周后处死实验猪,腹部解剖观察腹腔内情况。第四章：选择9头实验猪,以最佳入路进入实验猪腹腔,常规腹部穿刺排气,模拟部分肝、脾组织切除术,腹腔干旁神经节毁损术,胰腺尾部周围的观察及后腹膜区域部分组织切除术,以及胃壁外淋巴结清扫术。术后禁食禁水,应用抗生素,观察实验猪生存情况,饲养3天后处死,解剖观察腹腔内情况。结果：第一章：①美兰定位组3例入路几乎相同,而无定位组入路则相对有较大差异。②采用仰卧右肩抬高位进镜,内镜由贲门右后壁进入腹腔,此处胃壁外大血管及重要脏器少,不易造成误伤,并且该体位下隧道入口不在最低位,胃内液体不易进入隧道导致腹腔污染。③横形切开肌层内镜视野较纵形切开差,内镜自由度不佳,容易自动翻转镜身；纵行全层切开肌层虽可以保证直镜身状态,内镜自由度好,但对消化道肌层损伤大,不利于术后愈合;渐进式纵行切开固有肌层内镜视野暴露好,逐层切断固有肌层更有利于发现肌层及胃壁外的血管,进入腹腔后内镜自由度更好,不易自动翻转镜身,是最佳的肌切开方式。第二章：通过多次实验,获得了一定的内镜下解剖位置知识,为后续实验打下基础。第三章：①气体相关并发症研究：内镜腹腔内持续送气,以一支或多支20ml注射针腹腔穿刺放气可维持腹腔压力相当于气腹机调控腹压15mmHg,均可保证术中实验猪生命体征平稳;无排气组实验猪在腹腔持续注气一定程度后均死亡。②腹腔感染研究：通过对比2实验组的实验猪生存情况,术后白细胞计数,处死后腹腔内组织黏连和渗出等情况,特殊处理组的实验猪术后感染较无处理组轻,并且术后生存状态良好。第四章：①模拟部分脾切除术实验猪术后死亡。②其余各模拟手术实验猪均安全、成功的实施各模拟手术。实验猪术后存活良好,三天后处死,除手术部位外其他部位无损伤破坏,但手术部分组织均有不同程度的黏连。③限于目前内镜器械,无法实施较大型的腹腔内内镜治疗。④食管建立隧道处由于瘢痕性修复无法再次应用。结论：术前美兰定位,仰卧右肩抬高位建立食管黏膜下隧道至贲门胃底侧后壁美兰定位处渐进式纵行切开固有肌层及浆膜层,内镜进入腹腔并配合20ml注射器穿刺放气,行部分肝组织切除术、腹腔干旁神经节毁损术、后腹膜周围组织切除术和胃壁外淋巴结清扫术等是安全可行的。
[Abstract]:Background and purpose: in recent years, endoscopic therapy has developed rapidly. The emergence of endoscopic tunnel technology has made many diseases which had previously been treated by surgical or endoscopic surgery into the scope of endoscopic treatment, with no difference in curative effect and surgery, and with less complications and less trauma. Endoscopic myotomy (peror Al endoscopic myotomy, POEM), since its report in 2010, has been widely used worldwide because of its good clinical therapeutic effects, high remission rate, low recurrence rate, and small trauma in surgical Heller surgery. Endoscopic submucosal tunneling (Submucosal tunnel endoscopic resection, STER) is widely carried out in the world. On the basis of POEM, endoscopic tunnel technology is extended to the treatment of the gastrointestinal myometrium, and the curative effect is accurate. This method is superior to surgery and thoracoscopy. Why endoscopy tunnel technology has such a good curative effect while having less hair and other advantages? Mainly because of endoscopy Tunnel technique can effectively prevent the interlacing of the digestive tube and the outer cavity caused by endoscopic surgery for pathological changes of the inherent muscularis lateral lesions or inherent muscularis, and avoid the gas in the digestive canal, and the liquid directly enters the outer space of the digestive canal to achieve the purpose of treating the lesions and preventing perforation. Natural orifice transluminal endoscopic surgery (NOTES) is a kind of operation method based on the natural cavity of human body, such as esophagus, stomach, rectum, vagina, etc., with soft endoscopy, without surgical incision. But there are several bottlenecks in the development of NOTES operation, first of all, the difficulty of the entrance suture is difficult, and the next is the difficulty of the entrance suture. In the digestive tract, the fluid enters the abdominal cavity to cause infection, and then the soft endoscope enters the abdominal cavity without clear anatomical location and is easy to lose direction; the above problems have been stranded by endoscopy scholars. If these problems can not be solved well, the development of NOTES technology will be limited to a large extent. Combined endoscopic tunnel technology for NOTES hands The operation will solve the difficult problem of closed entrance. Only a few metal clips can be used to complete the artificial entrance of the esophagus. And because the entrance of the tunnel is higher (in the middle and lower segment of the esophagus), the fluid inflow in the stomach can be prevented effectively. Comparing with the anatomical structure in vitro, it can better understand the anatomical structure of the abdominal cavity, and to some extent solve the problem that the endoscopy is easy to get lost in the abdominal cavity. The technique of laparoscopy is very mature, but the region of the posterior and abdominal aorta is the most difficult part of the laparoscopic operation, and the use of digestive endoscopy is penetrating. The posterior wall of the stomach can reach the area directly. In theory, the operation is simpler, direct and easier to operate. This topic is studied in four parts. The first chapter is to find a best method of animal operation and the best way to establish tunnel under the endoscope. In the second chapter, we studied the situation of the endoscopic identification of the anatomical structure in the abdominal cavity; the third chapter studied the operation. The fourth chapters use the results of the previous chapters to apply endoscopic tunnel technique to penetrate the posterior wall of the cardia and gastric fundus into the abdominal cavity, including paraplastic paraplastic ganglion lesion, partial hepatectomy, partial splenectomy, partial retroperitoneal resection, and early gastric carcinoma after ESD. The purpose of this study is to prove that transesophageal endoscopic tunnel technique is safe and feasible for the diagnosis and treatment of abdominal aorta diseases, and can be applied to clinical diagnosis and treatment in the future. Head. The first group was a non preoperative positioning group. The posterior wall of the esophagus was set up to the 2cm place below the cardia. The intraperitoneal muscle layer and serous layer were cut into the abdominal cavity. The second group was Milan location group, and 1:2 Milan saline injection was injected into the submucosa of the posterior wall of the cardia. The posterior wall of the esophagus was located to the marker below the cardia, and the intrinsic myometrium was cut and the myometrium was cut. The serous layer entered the abdominal cavity. Compared the structural contrast map of 3 cases into the abdominal cavity in the above 2 groups, and dissection of the abdominal contrast between the pigs and the pigs, and observed the difference between 3 cases in each group. The difference was excellent. The study of the way of entry: 9 pigs, 3 groups, 3 heads in each group. The first group, submucosa tunnel to the cardia under the posterior wall of the esophagus under the supine position, was set up under the supine position. In square 2cm, the intraperitoneal and serous layers were cut into the abdominal cavity to identify the intraperitoneal anatomy. In the second group, the left side of the esophagus was located on the right wall of the esophagus to establish the tunnel to the small side of the gastric fundus, and the intraperitoneal and serous layers were cut into the abdominal cavity to identify the intraperitoneal anatomy. The third group, the supine right shoulder elevation was located right in the right esophagus. The posterior wall established the tunnel to the posterior wall of the small flexural side of the cardia, incised the intraperitoneal and serous layer into the abdominal cavity to identify the intraperitoneal anatomy. The above three groups realized that the endoscopic operation was difficult and the endoscope entered the abdominal cavity to identify the abdominal anatomy. A group of fewer tissues could complete the operation. (3) the study of the operation of the surgery. (3) the study of myotomy: 6 pigs were taken, 2 groups, 3 heads in each group. The first group was the transverse myotomy group, the muscle layer was cut through the open muscle layer at the end of the tunnel, and the endoscopy entered the abdominal cavity. The second groups were longitudinal myotomy group, the myotomy at the end of the tunnel, and the endoscopy into the abdominal cavity. The third groups were in the abdominal cavity. In the progressive longitudinal muscle incision group, the myotomy length, the exposure of the endoscopic field after myotomy and the freedom of the endoscopy into the retroperitoneal mirror were compared between the three experimental groups, the length of the endoscopic field and the degree of freedom of the endoscopy into the retroperitoneal mirror. A group of second chapters with short length of myotomy, good exposure of the visual field, small trauma of the myometrium, and a good degree of freedom of the mirror body were compared. In the first chapter, the best way to simulate the operation on the porcine corpse, after the endoscope enters the abdominal aorta around the abdominal aorta, observe the image under the endoscope and dissection the anatomical structure of the porcine celiac to make a contrast, and get a good contrast between the endoscope image and the anatomical image, and make a good experimental basis for the following living animal experiment. Third chapters The study of complications: (1) the study of gas related complications: the experiment was divided into three groups: no exhaust group, pneumoperitoneum and puncture and exhaust group, the best endoscopy was selected to enter the abdominal cavity, the endoscopy without exhaust group was continued in the abdominal cavity, the pneumoperitoneum was connected to the pneumoperitoneum by endoscopy and the PCO2 was adjusted to maintain the 12-15mmHg, and the endoscopy of the puncture exhaust group was continuously delivered. Gas, puncture and exhaust in the abdomen with syringe needle and intraperitoneal injection of gas 90min, observe the life signs of the experimental pigs in the operation, such as the death time of the experimental pigs. The experiment is divided into two groups, no treatment group and special treatment group. The 2 groups of experimental pigs are before the operation, after the operation, 24h, 48h, 72h and one week to test the body temperature, the venous blood tests the blood routine, endoscopy A week after the operation, the abdominal infection was observed and the experimental pigs were killed and the abdominal anatomy was observed in the abdominal cavity. Fourth chapter fourth: select 9 experimental pigs to enter the experimental pig abdominal cavity with the best approach, routine abdominal puncture and exhaust, simulated partial liver, splenic resection, paraplastic paraplastic ganglion damage, the observation of the tail around the pancreas and the retroperitoneum area Partial tissue resection and dissection of gastric wall lymph node dissection. After operation, fasting and prohibiting water, using antibiotics to observe the survival of experimental pigs, 3 days after feeding, were sacrificed and observed in the abdominal cavity. Results: the first chapter: (1) 3 cases in the Meilan location group were almost the same, but there were relatively large differences without the orientation group. Secondly, the supine right shoulder was carried out. High position into the mirror, endoscope from the right posterior wall of the cardia into the abdominal cavity, the large blood vessels and important organs of the stomach wall are few, it is not easy to cause the injury, and the entrance of the tunnel is not at the lowest position, the fluid in the stomach is not easy to enter the tunnel to lead to the abdominal pollution. Although the whole layer of myotomy can guarantee the state of direct mirror body, the endoscopy has a good degree of freedom, but it has great damage to the myometrium of the digestive tract and is not conducive to the healing. The gradual longitudinal incision of the intrinsic myomeendoscopy is good, and the layer by layer is more beneficial to the discovery of the muscle layer and the blood vessels outside the stomach wall, and the degree of freedom of the endoscope is better after entering the abdominal cavity. It is not easy to automatically flip the mirror body, it is the best way of muscle incision. The second chapter: through several experiments, a certain knowledge of the anatomical position of the endoscope is obtained, and the foundation for the follow-up experiment is laid. Third chapters: (1) the study of gas related complications: endoscopy abdominal continuous gas delivery, abdominal puncture with one or more 20ml injection needles to maintain abdominal pressure The force equivalent to the pneumoperitoneum control abdominal pressure 15mmHg, can ensure the stable life signs of the experimental pigs in the operation, no exhaust group experimental pigs in the abdominal cavity after a certain degree of gas injection after a certain degree of death. 2. Abdominal infection study: by comparing the survival of the 2 experimental pigs, postoperative leukocyte count, the abdominal tissue adhesion and exudation after death, and other conditions, and other conditions. The infection of the experimental pigs in the treatment group was lighter than that in the non treatment group, and the survival state was good after the operation. Fourth chapters: (1) the simulated partial splenectomy experiment pigs died after operation. 2. The rest of the simulated operation pigs were safe and successful implementation of the simulated operation. The experimental pigs survived well after three days, and there were no other parts except the surgical site. Injury and destruction, but the operation part of the tissues have different degrees of adhesion. 3. Limited to the present endoscopic instruments, it is impossible to carry out a larger intraperitoneal endoscopy. (4) the esophagus building tunnel can not be used again because of scar repair. Conclusion: Milan location before operation, lying on the back of the right shoulder to establish the submucosal tunnel to the fundus of the gastric cardia The intraperitoneal and serous layer of wall Meilan location is gradually cut into the intraperitoneal cavity and the 20ml syringe is punctured and deflated. Partial liver resection, paraplastic paraplastic ganglion lesion, posterior peritoneum tissue resection and gastric parietal lymph node dissection are feasible.
【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】：2016
【分类号】：R543.1

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