Onders Raymond P, McGee Michael F, Marks Jeffrey, Chak Amitabh, Rosen Michael J, Ignagni Anthony, Faulx Ashley, Schomisch Steve, Ponsky Jeffrey
Department of Surgery, Case Western Reserve University and University Hospitals of Cleveland, Cleveland, OH, USA.
Surg Endosc. 2007 Apr;21(4):681-3. doi: 10.1007/s00464-007-9214-z. Epub 2007 Feb 16.
Autopsy studies confirm that many intensive care unit (ICU) patients die from unrecognized sources of abdominal sepsis or ischemia. Computed tomography (CT) scans can be of limited use for these diagnoses and difficult to obtain in critically ill patients who require significant support for transport. Bedside laparoscopy has been described but still is cumbersome to perform. Bedside flexible endoscopy as a diagnostic tool or for placement of gastrostomy tubes is a standard ICU procedure. Natural orifice transluminal endoscopic surgery (NOTES) can provide access to the peritoneal cavity as a bedside procedure and may decrease the number of patients with unrecognized intra-abdominal catastrophic events.
Pigs were anesthetized and peritoneal access with the flexible endoscope was obtained using a guidewire, needle knife cautery, and balloon dilatation. The transgastric endoscope was used to explore all quadrants of the abdominal cavity. The small bowel was visualized to complete the exploration. The transgastric access location was then managed with the use of a gastrostomy tube. The animals were euthanized and analyzed.
Eight pigs were studied and complete abdominal exploration, including diaphragm visualization, was possible in all cases. Endoscopy-guided biopsies were performed, adhesions lysed, and the gallbladder successfully drained percutaneously. The small bowel was run successfully with percutaneous needlescopic suture graspers.
These animal studies support the concept that NOTES, with management of the gastric opening with a gastrostomy tube, may be another approach for finding unrecognized sources of abdominal sepsis or mesenteric ischemia in difficult ICU patients. These encouraging results warrant a prospective human trial to assess safety and efficacy.
尸检研究证实，许多重症监护病房（ICU）患者死于未被识别的腹部脓毒症或局部缺血。计算机断层扫描（CT）扫描对于这些诊断的作用有限，且在需要大量转运支持的重症患者中难以进行。床边腹腔镜检查虽有报道，但操作仍很繁琐。床边柔性内镜检查作为一种诊断工具或用于放置胃造瘘管是ICU的标准操作。经自然腔道内镜手术（NOTES）可作为床边操作进入腹腔，可能会减少未被识别的腹腔灾难性事件患者的数量。
对猪进行麻醉，使用导丝、针刀烧灼和球囊扩张，通过柔性内镜获得腹腔通路。经胃内镜用于探查腹腔的所有象限。观察小肠以完成探查。然后使用胃造瘘管处理经胃通路部位。对动物实施安乐死并进行分析。
研究了8头猪，所有病例均能完成包括观察膈肌在内的全腹腔探查。进行了内镜引导下活检，松解了粘连，并成功经皮引流了胆囊。使用经皮针式内镜缝合抓钳成功检查了小肠。
这些动物研究支持这样一种观念，即NOTES结合胃造瘘管处理胃开口，可能是在困难的ICU患者中寻找未被识别的腹部脓毒症或肠系膜缺血来源的另一种方法。这些令人鼓舞的结果值得进行前瞻性人体试验以评估安全性和有效性。
