Kainuma Satoshi, Nakajima Kiyokazu, Miyagawa Shigeru, Fukushima Satsuki, Saito Atsuhiro, Harada Akima, Hirota Masashi, Miyazaki Yasuhiro, Sawabata Noriyoshi, Watabe Tadashi, Watabe Hiroshi, Toda Koichi, Hatazawa Jun, Okumura Meinoshin, Sawa Yoshiki
Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
Department of Next Generation Endoscopic Intervention, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
Interact Cardiovasc Thorac Surg. 2018 Jun 1;26(6):993-1001. doi: 10.1093/icvts/ivx430.
We previously reported that cell sheet transplantation combined with an omentopexy (OP) procedure is more effective for repairing heart damage when compared with cell sheet transplantation alone. However, a simultaneous (conventional) laparotomy as part of the OP may adversely affect the general condition of critically ill heart failure patients who would otherwise benefit from cell sheet transplantation, which is a paradox to be reconciled before this treatment can be applied in a clinical setting. We devised a novel endoscopic approach termed 'transphrenic peritoneoscopy' (TPP) for minimal access to abdominal organs from the thoracic cavity. Herein, we evaluated the feasibility and safety of TPP with an OP in a porcine myocardial infarction model.
Myocardial infarction was induced in 4 mini pigs by placing an ameroid constrictor around the left anterior descending artery. One month later, a left thoracotomy was performed in 2 randomly selected mini pigs, and a laparoscopic port was placed on the left diaphragm to gain access into the abdominal cavity. Using a low-pressure pneumoperitoneum, a flexible gastrointestinal endoscope was advanced, then the omentum was partially grasped with endoscopic forceps and brought back into the thoracic cavity via the diaphragm. Skeletal myoblast cell sheets were then implanted over the impaired myocardium, followed by placing the omentum over the sheets.
TPP-assisted OP was accomplished in 2 post-myocardial infarction mini pigs with severe heart failure with an intra-abdominal pressure ≤8 mmHg within 30 min (22 and 27 min, respectively). Necropsy findings revealed a viable omentum flap and pedicle in both animals, with no evidence of procedure-related complications. Angiographic and histological analyses confirmed vessel communication between the omentum and the left ventricle.
Our TPP approach was shown to be feasible and safe with a low-pressure pneumoperitoneum, while the omentum flap was durable. This successful combination of techniques may provide less-invasive endoscopic intervention and regenerative therapy.
我们之前报道过，与单纯的细胞片移植相比，细胞片移植联合网膜固定术（OP）在修复心脏损伤方面更有效。然而，作为OP一部分的同期（传统）剖腹手术可能会对重症心力衰竭患者的一般状况产生不利影响，而这些患者原本会从细胞片移植中获益，在这种治疗方法能够应用于临床之前，这是一个需要解决的矛盾。我们设计了一种名为“经膈腹腔镜检查”（TPP）的新型内镜方法，用于从胸腔对腹腔器官进行微创操作。在此，我们在猪心肌梗死模型中评估了TPP联合OP的可行性和安全性。
通过在4只小型猪的左前降支周围放置阿梅罗氏缩窄环诱导心肌梗死。1个月后，随机选择2只小型猪进行左胸切开术，并在左膈肌上放置一个腹腔镜端口以进入腹腔。使用低压气腹，推进一根柔性胃肠内窥镜，然后用内镜钳部分夹住大网膜并通过膈肌带回胸腔。然后将骨骼肌成肌细胞片植入受损心肌上方，随后将大网膜放置在细胞片上。
2只患有严重心力衰竭的心肌梗死后小型猪在30分钟内（分别为22分钟和27分钟）完成了TPP辅助的OP，腹腔内压力≤8 mmHg。尸检结果显示两只动物的大网膜瓣和蒂均存活，没有与手术相关并发症的证据。血管造影和组织学分析证实了大网膜与左心室之间的血管连通。
我们的TPP方法在低压气腹下被证明是可行且安全的，同时大网膜瓣是持久的。这种技术的成功结合可能提供侵入性较小的内镜干预和再生治疗。
