Akagi Tomonori, Yasuda Kazuhiro, Kono Youhei, Suzuki Kosuke, Kawaguchi Koji, Yoshizumi Fumitaka, Inomata Masafumi, Shiraishi Norio, Kitano Seigo
Department of Surgery I, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Oita 879-5593, Japan.
Surg Innov. 2012 Dec;19(4):415-20. doi: 10.1177/1553350611432721. Epub 2012 Feb 14.
Usefulness of submucosal tunneling for transgastric approach with clip closure of the mucosal incision in natural orifice translumenal endoscopic surgery (NOTES) has been described. Although the narrow longitudinal submucosal tunnel itself is considered good for wound approximation and healing, no reports have evaluated the sealing effect in this technique. This study was aimed at evaluating the technical feasibility of a submucosal tunnel technique for transgastric peritoneal access without mucosal closure.
Transgastric peritoneoscopy using submucosal tunneling with endoscopic submucosal dissection without mucosal closure was performed on six 40- to 45-kg female pigs. Measures included (a) evaluation of technical feasibility, (b) clinical monitoring for 7 days, (c) necropsy findings, and (d) pathological examination.
NOTES transgastric peritoneoscopy was successfully performed in all pigs, and all recovered well clinically. Necropsy findings revealed no peritonitis, confirming completeness of gastric closure in 5 of the 6 pigs. One pig in which the submucosal layer of the tunnel was injured during dissection from the muscular layer showed local peritonitis. Pathological examination at the submucosal site tunnel showed wound healing with focal transmural fibrosis and inflammatory cell infiltration in 5 pigs, whereas the pig with peritonitis had a large mucosal defect with necrotic tissue, abscess formation, and focal transmural fibrosis.
The submucosal tunnel technique without mucosal closure is safe and effective for transgastric peritoneal access and subsequent closure, when the endoscopists' learning curve is accomplished and the submucosal tunnel is produced without damaging of mucosa. It is necessary to use devices such as mucosal clips or tissue anchors in order to achieve adequate healing of mucosal defect.
已有人描述了在经自然腔道内镜手术（NOTES）中，黏膜下隧道用于经胃途径并夹闭黏膜切口的实用性。尽管狭窄的纵向黏膜下隧道本身被认为有利于伤口对合和愈合，但尚无报告评估该技术的封闭效果。本研究旨在评估一种不进行黏膜封闭的经胃腹膜入路黏膜下隧道技术的技术可行性。
对6只体重40至45千克的雌性猪进行了经胃腹膜镜检查，采用黏膜下隧道技术及内镜黏膜下剥离术，不进行黏膜封闭。测量指标包括：（a）技术可行性评估；（b）7天的临床监测；（c）尸检结果；（d）病理检查。
所有猪均成功完成NOTES经胃腹膜镜检查，且临床恢复良好。尸检结果显示无腹膜炎，6只猪中有5只证实胃封闭完整。1只猪在从肌层剥离过程中隧道黏膜下层受损，出现局部腹膜炎。5只猪的黏膜下隧道部位病理检查显示伤口愈合，伴有局灶性透壁纤维化和炎性细胞浸润，而患有腹膜炎的猪有一个大的黏膜缺损，伴有坏死组织、脓肿形成和局灶性透壁纤维化。
当内镜医师度过学习曲线且制作黏膜下隧道时不损伤黏膜时，不进行黏膜封闭的黏膜下隧道技术对于经胃腹膜入路及后续封闭是安全有效的。为实现黏膜缺损的充分愈合，有必要使用诸如黏膜夹或组织锚等器械。
