Research Of Feasibility Of Peroral Esophageal Tunnel Technology In Diagnosis And Treatments Of The Diseases Around Abdomen Aorta

Background and Objective:With the development of endoscopic therapy techniques, the emergence of endoscopic tunnel technique makes many diseases, which used to need surgical or laparoscopic surgical treatments, enteredinto the endoscopic therapy. Curative effect of endoscopic therapy is the same as surgery, and endoscopic tunnel technique also have many advantages like fewertraumas, less complications, and rapid recuperation and so on. Peroral endoscopic myotomy (POEM) treamted achalasia cardia was reported in 2010, and the curative effect was well, the trauma is fewer than Heller’s operation. Based on POEM proceduresubmucosal tunnel endoscopic resection (STER) was invented to treat tumors originating from MP in esophagus and cardia. And now we consider STER is better than surgery and laparoscopy surgery. Why does endoscopic tunnel technique have such a good curative effect and also have the advantages such as fewer complications? Because the tunnel technique could wellprevent the communication between the intra-luminal and the extra-luminal spaceby sealing the entry incision of the tunnel right after endoscopic therapy,gas or fluid within the lumen was prevented from entering the extra-luminal spaceafter surgery, which could ensure the endoscopic therapy free of perforation.Natural orifice transluminal endoscopic surgery (NOTES) is a body of noninvasive endoscopy operation method. The procedure is endoscope penetrate from body’s natural orifices such as esophagus, gastric, rectum, vagina and so on to body cavity for treatment. But there are few bottlenecks in the development of NOTES. First, it is difficult to close the entrance of natural orifices. Second,the infection which is caused by liquid and air of natural orifices enter into body cavity would occur. Third, it would be lost in body cavity. These problems puzzle endoscopists.This research use endoscopic tunnel techniques to perform NOTES, the tunnel will reslove the problem of closing entrance and infection. The aim of our research is to use endoscopic tunnel technique to perform some endoscopic surgery in body cavity including beside celiac trunk ganglia damage, partial hepatectomy, partial splenectomy, resection of the retroperitoneum regional organizations, clean lympha node outside gastric wall and so on.Methods:Chapter One ①research of preoperation positioning:Total 6 pig corpses in 2 groups, each group involves 3. The 2 groups are no positioning group and methylene blue positioning group. First inject methylene blue into submucosa of cardia as positioning, establish a submucosal tunnel from lower esophagus to cardia, and then find methylene blue positioning, cut muscularis propria (MP) and serosa and enter into abdominal cavity. No positioning group when submucosal tunnel established endoscope cut MP and serosa at the end of the tunnel and enter intoabdominal cavity. Contrast the penetrate ponits of the 2 groups, the minmum error is well,②research ofaccess strategy:Total9pig corpses in 3 groups, each group involves 3. Group 1:In supine position establish a tunnel from the anterior wall of esophagus to 2cm below the gastroesophageal junction. Cut MP and serosa. Enter into abdominal cavity gastrolienica posterior. Identify the anatomy of abdominal cavity. Group 2:In left lateral position establish a tunnel from the right wall of esophagus to the lesser curvature of gastric cardia and fundus. Cut MP and serosa. Enter abdominal cavity from lesser curvature of gastric cardia. Identify the anatomy of abdominal cavity. Group 3:In supine and right shoulder raising position establish a tunnel from the right rear wall of esophagus to the lesser curvature of gastric cardia near rear wall. Cut MP and serosa and enter abdominal cavity. Identify the anatomy of abdominal cavity.We compared the difficulty of operation in three groups. When endoscope entered into abdominal cavity, we confirmed the anatomic structures by opening abdominal cavity of pig corpses. The best group was considered of less difficulty of operate endoscopy and less injury of retroperitoneal tissues,③esearch of incision ways of cardiac muscularis:Total 6 pig corpses in 2 groups, each group involves 3. Group 1 (transverse entry incision):Electricity knife was used to cut muscularis transversely in the end of tunnel and then endoscope entered into theabdominal cavity. Group 2 (longitudinal incision):Electricity knife was used to cut muscularis longitudinally in the end of tunnel and then endoscope entered into theabdominal cavity. The length of cutting muscularis, the vision exposure of endoscope and endoscopic degrees of freedom were compared. The best group was considered of the shortest in length of cutting muscularis, widest vision exposure of endoscope and best endoscopic degrees of freedom.Chapter Two:We took operation through the best access strategy from chapter one. Endoscope enter into the structure around abdominal aorta in abdominal cavity, observed anatomic structures through endoscope and confirmed these structures by opening abdominal cavity of pig corpses. This would provide experimental basis for subsequent animal experiments.Chapter Three:research of complications ①research of air related complication: Experiment was divided into three gruops:no exhaust group, insufflator group and puncture exhaust group. Endoscope enter into abdominal cavity through the best assess. In no exhaust group air continuous supplied. In insufflator group medical insufflator were connected to endoscope and adjust PCO2 of 12-15mmHg.In puncture exhaust group air continuous supplied for 90min and syringe needle was punctured into abdominal cavity to exhaust air. Observe vital sign of experimental pig during operation, such as death time, ②research of abdominal infection related complication:Experiment was divided into two gruops:No treatment group and special treatment group. Temperature, blood routine were tested before operation,24h,48h,72h and one week after operation to evaluate infection. One week later, experimental pigs were executed to observe anatomic structures in abdominal cavity.Chapter Four:Choose 9 experimental pigs. Endoscope enter into abdominal cavity through the best assess. Exhaust air by puncturing into abdominal cavity. Operate partial hepatectomy and splenectomy, around the celiac artery ganglion neurolysis, partial tissue resection in the aera of posterior peritoneum and lymph node outside gastric wall dissection. Experimental pigs were prohibited water and diet intake and took antibiotics for 5 days. Their survival situations were observed. Three days later, experimental pigs were executed and were opened to observe the structures of abdominal cavity.Results:Chapter One: ①In methylene blue positioning group, assess position was same in 3 cases, but in no positioning group assess position was significant different. ② Endoscope enter abdominal cavity through right posterior wall of cardiac in supine and right shoulder raising position. There would be less injures because of scarce of large blood vessels and vital organs in this position. And also because tunnel entry wasn’t in low position and liquid in stomach couldn’t enter into tunnel. ③sEtablish a tunnel from the right rear wall of esophagus to the lesser curvature of gastric cardia near rear wall. Vision and freedom of endoscope was poorer in ransverse entry incision group than that in longitudinal incision group. The endoscope could keep straight and free in longitudinal incision group, but it would injure muscularis of digestive tract and be bad for postoperative healing. Gradual longitudinal incision of MP was considered the best strategy. Because of vessels in MP layer and outside stomach were easily observed and the freedom of endoscope was good.Chapter Two:We obtained the knowledge of anatomy structures through endoscopy and this laid the foundation of subsequent experiments.Chapter Three: ①research of air related complication:In the situation of continuous supplying air, the effect of maintaining abdominal pressure by using syringe needle to exhaust was the same as by using medical insufflator with 15mmHg. And this could keep stable vital sign of experimental pigs, In no exhaust group, experimental pigs were died because of hyperinflation, ③research of abdominal infection related complication:There were lesser infection and better survival status in special treatment group than those in no treatment group by comparing survival situation, WBC, adhesion and exudation in abdomen.Chapter Four: ① Experimental pigs were died after operating splenectomy. ② Experimental pigs were alive after successfully operating other surgeries. Three days latter experimental pigs were executed and were found no injures in other organs, but adhesion to different degrees of tissues in surgery position. ③ Extensive intra-abdominal endoscopic therapy couldn’t be carried out with limit of current endoscopic equipment.Conclusion:In supine and right shoulder raising position establish a tunnel from the right rear wall of esophagus to the lesser curvature of gastric cardia near rear wall. Cut MP and serosa and enter abdominal cavity. Syringe needle was punctured into abdominal cavity to exhaust air. Operate partial hepatectomy and splenectomy, around the celiac artery ganglion neurolysis, partial tissue resection in the aera of posterior peritoneum and lymph node outside gastric wall dissection. This method was safety and feasible.