经自然腔道内镜外科技术在胸外科的实验研究及初步临床应用
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摘要
目的
通过动物实验研究初步探讨分别经食道、阴道和脐实施胸交感神经切断术和心包开窗术的可行性和安全性。在积累动物实验经验的基础上，将经脐胸交感神经切断术初步应用于临床，探讨其可行性、安全性和有效性，为胸部NOTES手术的开展积累经验。
方法
动物实验部分以猪为实验动物，分别开展经食道、阴道-膈肌、脐-膈肌实施胸交感神经切断术和心包开窗术。每组各进行10例实验，其中急性实验3例，存活实验7例。急性实验术后立即处死尸检，存活实验4周后尸检。临床经脐胸交感神经切断术在全麻双腔气管插管下完成，记录术中情况，并对手术结果进行跟踪随访。
结果
共进行动物实验30例次，经食道组术中死亡2例，其余28例均成功完成目标手术。急性实验尸检发现经食道组发生胸主动脉损伤1例，左奇静脉损伤1例；经阴道组发生胸壁损伤2例，直肠损伤1例。各组胸交感神经切断准确彻底，心包开窗术完成良好。存活实验尸检发现食管造口愈合良好，食管外膜层和肺组织发生粘连3例；经阴道组阴道和膈肌切口均愈合良好，膈肌切口与肺组织粘连4例；经脐组膈肌切口与肺组织粘连3例。各组未见明显胸、腹腔感染迹象。临床共实施36例经脐胸交感神经切断术，均顺利完成。平均手术时间54min，均于术后第一天出院。术后随访6~12个月，手汗和腋汗的治愈率分别为100%和76%。共发生代偿性出汗13例（36.1%），所有患者手汗无复发，无膈疝、脐疝及霍纳氏综合征等严重并发症发生。
结论
1、经食道入路虽然具有操作路径短的优势，但是该入路难度较大，就目前的技术而言在消毒、切口的选择和闭合上仍无法确保安全。
2、阴道入路的切开和缝合均可在直视下完成，安全性高，但实施胸腔内手术路径太长，器械的可控性差。
3、经脐入路具有较高的可行性和安全性，就胸交感神经切断术治疗手汗症而言可以获得等同于胸腔镜手术的有效率，而且美容效果显著，但手术时间较长，其潜在的风险和优势有待于进一步评估。
Objective
To evaluate the feasibility and safety of transesophageal, vaginal and umbilicalendoscopic thoracic sympathectomy and pericardial window creation in pig model.On the basis of accumulated experience in animal experiments, translate the techniqueof transumbilical endoscopic sympathectomy into human clinical studies and explorethe feasibility, safety and efficacy of this technique.
Methods
This feasibility study was conducted on the porcine model (domestic pig). Flexibleendoscopic thoracic sympathectomy and pericardial window creation were performedin10animals (3acute and7four-week survivals) in three groups: transesophageal,transvaginal and transumbilical group. Animals in the acute experiment wereeuthanized after completion of the operating procedure. The pigs in the survivalexperiment were kept alive for4weeks and then killed. Necropsy was then performed.The clinical study of transumbilical thoracic sympathectomy was performed undergeneral anesthesia. The patients were placed in the supine position with the armsabducted and intubated with a dual lumen endotracheal tube. Intraoperative eventsand surgical results were recorded and analysed.
Results
The animal experiment was successfully performed in28of30swine. One swine wasdied of the thoracic aorta injury and another one was died of the left azygos veininjury in transesophageal group. Additionally, chest wall injury and rectal injury werefound in2and1cases, respectively in the transvaginal group. In the acute group, thepostoperative autopsy confirmed that bilateral T3ganglias were identified accurately,and cauterization was successful in all pigs, so as the pericardial window creation. In the survival group, all pigs survived well after surgery for4weeks without adverseconsequences. Postoperative autopsy confirmed that the esophageal, vesical anddiaphragmatic incision was completely healed, and there were no vital structure injuryor diaphragmatic hernia, and no signs of infection in both thoracic and peritonealcavities. Howerer, adhesions were found between extraesophageal layer and lungtissue in3animals in transesophageal group. The adhesions were also found betweendiaphragm and lung tissue in4and3animals in transvaginal and transumbilical grouprespectively.
During the study period, transumbilical thoracic sympathectomy was successfullyperformed in all36patients with a mean operation time of54min (range48–107min).Most patients were discharged on the first postoperative day. Follow-up was100%complete (range6–12months). Palmar hyperhidrosis was resolved completely onboth sides of all the patients, and the axillary hyperhidrosis was completely improvedin11(76%) patients. Compensatory hyperhidrosis was noticed in13(36.1%) patients.There was no mortality, no diaphragmatic hernia and no Horner’s syndrome wasobserved.
Conclusions
1、 Transesophageal approach has the advantage of short operating path and no scarsleft in the surface. But this approach is technically difficult, and many barriersneed to be overcome, such as safe enterotomy creation, infection prevention,tissue manipulation, and, primarily, safe and secure closure of perforations.
2、 Transvaginal approach is comparatively safe. The incision and suture can beperformed under direct vision. However, the surgical path is too long, and thecontrollability of the instrument is poor.
3、 This study demonstrates that transumbilical thoracic sympathectomy is technicallyfeasible and safe. It is as effective as thoracoscopic surgery in the treatment ofpalmar hyperhidrosis. This novel procedure affords maximum cosmetic benefitsby hiding the surgical incision in the umbilicus. But the operative time was longerthan that of thoracoscopic surgery, and the potential risks and benefits of thisapproach will be confirmed by more randomized clinical trials.
通过动物实验研究初步探讨分别经食道、阴道和脐实施胸交感神经切断术和心包开窗术的可行性和安全性。在积累动物实验经验的基础上，将经脐胸交感神经切断术初步应用于临床，探讨其可行性、安全性和有效性，为胸部NOTES手术的开展积累经验。
方法
动物实验部分以猪为实验动物，分别开展经食道、阴道-膈肌、脐-膈肌实施胸交感神经切断术和心包开窗术。每组各进行10例实验，其中急性实验3例，存活实验7例。急性实验术后立即处死尸检，存活实验4周后尸检。临床经脐胸交感神经切断术在全麻双腔气管插管下完成，记录术中情况，并对手术结果进行跟踪随访。
结果
共进行动物实验30例次，经食道组术中死亡2例，其余28例均成功完成目标手术。急性实验尸检发现经食道组发生胸主动脉损伤1例，左奇静脉损伤1例；经阴道组发生胸壁损伤2例，直肠损伤1例。各组胸交感神经切断准确彻底，心包开窗术完成良好。存活实验尸检发现食管造口愈合良好，食管外膜层和肺组织发生粘连3例；经阴道组阴道和膈肌切口均愈合良好，膈肌切口与肺组织粘连4例；经脐组膈肌切口与肺组织粘连3例。各组未见明显胸、腹腔感染迹象。临床共实施36例经脐胸交感神经切断术，均顺利完成。平均手术时间54min，均于术后第一天出院。术后随访6~12个月，手汗和腋汗的治愈率分别为100%和76%。共发生代偿性出汗13例（36.1%），所有患者手汗无复发，无膈疝、脐疝及霍纳氏综合征等严重并发症发生。
结论
1、经食道入路虽然具有操作路径短的优势，但是该入路难度较大，就目前的技术而言在消毒、切口的选择和闭合上仍无法确保安全。
2、阴道入路的切开和缝合均可在直视下完成，安全性高，但实施胸腔内手术路径太长，器械的可控性差。
3、经脐入路具有较高的可行性和安全性，就胸交感神经切断术治疗手汗症而言可以获得等同于胸腔镜手术的有效率，而且美容效果显著，但手术时间较长，其潜在的风险和优势有待于进一步评估。
Objective
To evaluate the feasibility and safety of transesophageal, vaginal and umbilicalendoscopic thoracic sympathectomy and pericardial window creation in pig model.On the basis of accumulated experience in animal experiments, translate the techniqueof transumbilical endoscopic sympathectomy into human clinical studies and explorethe feasibility, safety and efficacy of this technique.
Methods
This feasibility study was conducted on the porcine model (domestic pig). Flexibleendoscopic thoracic sympathectomy and pericardial window creation were performedin10animals (3acute and7four-week survivals) in three groups: transesophageal,transvaginal and transumbilical group. Animals in the acute experiment wereeuthanized after completion of the operating procedure. The pigs in the survivalexperiment were kept alive for4weeks and then killed. Necropsy was then performed.The clinical study of transumbilical thoracic sympathectomy was performed undergeneral anesthesia. The patients were placed in the supine position with the armsabducted and intubated with a dual lumen endotracheal tube. Intraoperative eventsand surgical results were recorded and analysed.
Results
The animal experiment was successfully performed in28of30swine. One swine wasdied of the thoracic aorta injury and another one was died of the left azygos veininjury in transesophageal group. Additionally, chest wall injury and rectal injury werefound in2and1cases, respectively in the transvaginal group. In the acute group, thepostoperative autopsy confirmed that bilateral T3ganglias were identified accurately,and cauterization was successful in all pigs, so as the pericardial window creation. In the survival group, all pigs survived well after surgery for4weeks without adverseconsequences. Postoperative autopsy confirmed that the esophageal, vesical anddiaphragmatic incision was completely healed, and there were no vital structure injuryor diaphragmatic hernia, and no signs of infection in both thoracic and peritonealcavities. Howerer, adhesions were found between extraesophageal layer and lungtissue in3animals in transesophageal group. The adhesions were also found betweendiaphragm and lung tissue in4and3animals in transvaginal and transumbilical grouprespectively.
During the study period, transumbilical thoracic sympathectomy was successfullyperformed in all36patients with a mean operation time of54min (range48–107min).Most patients were discharged on the first postoperative day. Follow-up was100%complete (range6–12months). Palmar hyperhidrosis was resolved completely onboth sides of all the patients, and the axillary hyperhidrosis was completely improvedin11(76%) patients. Compensatory hyperhidrosis was noticed in13(36.1%) patients.There was no mortality, no diaphragmatic hernia and no Horner’s syndrome wasobserved.
Conclusions
1、 Transesophageal approach has the advantage of short operating path and no scarsleft in the surface. But this approach is technically difficult, and many barriersneed to be overcome, such as safe enterotomy creation, infection prevention,tissue manipulation, and, primarily, safe and secure closure of perforations.
2、 Transvaginal approach is comparatively safe. The incision and suture can beperformed under direct vision. However, the surgical path is too long, and thecontrollability of the instrument is poor.
3、 This study demonstrates that transumbilical thoracic sympathectomy is technicallyfeasible and safe. It is as effective as thoracoscopic surgery in the treatment ofpalmar hyperhidrosis. This novel procedure affords maximum cosmetic benefitsby hiding the surgical incision in the umbilicus. But the operative time was longerthan that of thoracoscopic surgery, and the potential risks and benefits of thisapproach will be confirmed by more randomized clinical trials.
引文
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