Khereba Mohamed, Thiffault Vicky, Goudie Eric, Tahiri Mehdi, Hadjeres Rachid, Razmpoosh Maryam, Ferraro Pasquale, Liberman Moishe
Division of Thoracic Surgery, Department of Surgery, CHUM Endoscopic Tracheobronchial and Oesophageal Center (CETOC), University of Montréal, Montreal, QC, Canada.
Department of Pathology, Centre Hospitalier de l'Université de Montréal, University of Montréal, Montreal, QC, Canada.
Surg Endosc. 2016 Feb;30(2):783-788. doi: 10.1007/s00464-015-4228-4. Epub 2015 May 28.
Natural orifice transluminal endoscopic surgery (NOTES) has the potential to be the final frontier in minimally invasive procedures in thoracic surgery. In order for thoracic pleural NOTES to 1 day be ready for clinical trials, each step of the procedure must be independently evaluated for both safety and efficacy. The aim of this study was to evaluate the trachea as a portal of entry for thoracic NOTES.
Eight 40-kg swine underwent right thoracic pleuroscopy in a survival model. In order to avoid inadvertent injury to the superior vena cava, endobronchial ultrasound was employed to select the location of airway incision. A 7-mm linear incision was then performed at the chosen location using an endoscopic electrocautery needle knife through a therapeutic flexible videobronchoscope. The mediastinal fat and parietal pleura were then dissected with electrocautery, and complete right pleuroscopy was performed. The tracheal and mediastinal portal of entry were then sealed with 1-2 cc of fibrin sealant. The pigs were kept alive for 21 days postoperatively. Postmortem diagnostic bronchoscopy was performed to assess tracheal healing. All tracheal specimens underwent histologic examination for healing and signs of mediastinal infection.
Thoracic NOTES procedures on all eight pigs were successful. There were no intraoperative complications except for one minor bleeding episode within the mediastinal dissection site which stopped spontaneously. Two pigs died from severe laryngospasm in the early postoperative period. Six pigs survived for 21 days post-procedure and experienced uneventful postoperative courses. Postmortem examination demonstrated complete tracheal healing with appropriate scarring in all pigs.
The trachea appears to be a safe port of entry for thoracic NOTES procedures in a swine model. Smaller tracheal incisions followed by balloon dilatation are associated with less postoperative morbidity and mortality. Tracheal incisions sealed with fibrin sealant healed rapidly and without signs of mediastinal infection. This procedure represents a work in progress and is not yet ready for human trials.
自然腔道内镜手术（NOTES）有潜力成为胸外科微创手术的最终前沿领域。为了使胸段胸膜NOTES有朝一日能准备好进行临床试验，该手术的每一步都必须针对安全性和有效性进行独立评估。本研究的目的是评估气管作为胸段NOTES的进入门户。
八只40千克的猪在生存模型中接受了右胸段胸膜镜检查。为避免意外损伤上腔静脉，采用支气管内超声来选择气道切口的位置。然后使用内镜电灼针刀通过治疗性可弯曲视频支气管镜在选定位置进行一个7毫米的线性切口。接着用电灼法分离纵隔脂肪和壁层胸膜，并完成右胸段胸膜镜检查。然后用1 - 2毫升纤维蛋白密封剂封闭气管和纵隔进入门户。术后猪存活21天。术后进行尸体诊断性支气管镜检查以评估气管愈合情况。所有气管标本均进行组织学检查以评估愈合情况和纵隔感染迹象。
所有八只猪的胸段NOTES手术均成功。除纵隔分离部位有一次轻微出血事件且自行停止外，无术中并发症。两只猪在术后早期死于严重喉痉挛。六只猪术后存活21天，术后过程平稳。尸体检查显示所有猪的气管均完全愈合且有适当瘢痕形成。
在猪模型中，气管似乎是胸段NOTES手术的安全进入门户。较小的气管切口随后进行球囊扩张与较低的术后发病率和死亡率相关。用纤维蛋白密封剂封闭的气管切口愈合迅速且无纵隔感染迹象。该手术仍在进行中，尚未准备好进行人体试验。
