Fritscher-Ravens A, Ghanbari A, Cuming T, Kahle E, Niemann H, Koehler P, Patel K
Department of Gastroenterology, Homerton University Hospital, London, UK.
Endoscopy. 2008 Nov;40(11):925-30. doi: 10.1055/s-2008-1077732. Epub 2008 Nov 13.
Natural-orifice transluminal endoscopic surgery (NOTES) is in the developmental stage for various indications, but several obstacles remain to be overcome before NOTES procedures can come into routine clinical use. Of these obstacles, (1) transluminal injury due to exclusive use of endoluminal endoscopy to create the incision and (2) lack of orientation might be prevented by employing endoscopic ultrasound guidance. In this comparative study we assessed the role of endoscopic ultrasound guidance in various NOTES procedures.
Three transesophageal (mediastinoscopy/thoracoscopy) or transgastric procedures (gastrojejunostomy, adrenal gland removal) were performed in pigs using NOTES alone or with endoscopic ultrasound guidance (EUS). In NOTES alone the study end point was three major complications, at which point EUS guidance was added for the same procedures up to the same number of cases. The primary outcome was the rate of major complications; secondary outcome parameters were all complications and technical success.
Forty-six pigs were included. Three major complications occurred in the first 24 NOTES-alone procedures: these were bleeding and organ injury, all during mediastinoscopy/thoracoscopy procedures. Adrenal gland removal failed in all procedures in which it was attempted, while gastrojejunostomy (n = 6) was performed successfully and without complications. In the next 22 animals EUS guidance enabled safe mediastinal access (n = 10) and adrenal gland removal (n = 6). For gastrojejunostomy, EUS guidance offered no additional benefit.
EUS guidance appears to be helpful in gaining access or identifying structures in anatomically difficult areas in NOTES procedures.
自然腔道内镜手术（NOTES）在多种适应证方面尚处于发展阶段，但在NOTES手术能够常规应用于临床之前，仍有若干障碍有待克服。在这些障碍中，（1）仅使用腔内内镜进行切口操作导致的腔道损伤以及（2）缺乏定位，或许可通过采用内镜超声引导来预防。在本比较研究中，我们评估了内镜超声引导在各种NOTES手术中的作用。
在猪身上进行三种经食管（纵隔镜检查/胸腔镜检查）或经胃手术（胃空肠吻合术、肾上腺切除术），分别单独使用NOTES或在内镜超声引导（EUS）下进行。仅使用NOTES时，研究终点为出现3例主要并发症，此时对相同手术增加EUS引导，直至达到相同病例数。主要结局为主要并发症发生率；次要结局参数为所有并发症及技术成功率。
共纳入46头猪。在前24例单独使用NOTES的手术中出现了3例主要并发症：均为出血和器官损伤，且都发生在纵隔镜检查/胸腔镜检查过程中。所有尝试进行的肾上腺切除术均失败，而胃空肠吻合术（n = 6）成功实施且无并发症。在接下来的22只动物中，EUS引导实现了安全的纵隔入路（n = 10）和肾上腺切除（n = 6）。对于胃空肠吻合术，EUS引导未带来额外益处。
在NOTES手术中，EUS引导似乎有助于在解剖结构复杂的区域获得入路或识别结构。
