| Objective: Both benign and malignant diseases can cause obstruction of gastric outlet tract.Benign diseases include duodenal ulcer,chronic pancreatitis,acute pancreatitis,postoperative stenosis and malignant diseases include gastric cancer,duodenal cancer,pancreatic cancer,bile duct cancer,ampullary carcinoma.Gastric outlet obstruction can lead to nausea,vomiting and insufficient food intake,which lead to poor general conditions.Traditional treatment includes surgery and endoscopic enteral stent.Each treatment has advantages and disadvantages.Surgery can be performed by laparoscopic or open surgery,but the surgical trauma is relatively large,especially for patients with gastric outlet obstruction caused by malignant tumors and the complication rate and mortality rate are high.Endoscopic enteral stent placement has an ideal short-term effect and the re-intervention rate is relatively high for patients,which reduces the quality of life of patients and increases the economic burden of patients.Endoscopic ultrasound-guided gastrointestinal anastomosis is a minimally invasive surgery for the treatment of gastric outflow tract obstruction,which can achieve long-lasting patency without the risk of tumor ingrowth.However,endoscopic ultrasound-guided gastrointestinal anastomosis is difficult to perform,because the jejunum is not fixed,free-floating and has a small lumen,which makes endoscopic ultrasound guided gastroenterostomy technically challenging.With the development of technology,assisted endoscopic ultrasound-guided gastrointestinal anastomosis procedures have been developed,such as indwelling nasal biliary drainage tube in the bowel and double balloon-assisted endoscopic ultrasound guided gastroenterostomy.These technologies have increased the success rate of this technology.This study aims to evaluate the safety,success rate and adverse events of retrievable anchor-assisted endoscopic ultrasound-guided gastrointestinal anastomosis,gastrointestinal anastomosis formation process and the role of transforming growth factor ?1,smad3 in the process of gastrointestinal anastomosis formation.Methods: 1.the clinical outcome of retrievable anchor assisted endoscopic ultrasound-guided gastrointestinal anastomosis in the treatment of gastric outflow tract obstructionWe retrospectively reviewed 10 patients receiving retrievable anchor-assisted endoscopic ultrasound guided gastroenterostomy for the treatment of gastric outlet obstruction from January 2018 to August 2019 in Shengjing hospital of China Medical University and recorded the patient's general information,etiology,operation time,technical success rate,clinical success rate and complications.2.The gastrointestinal anastomosis formation after endoscopic ultrasound guided gastroenterostomy and the role of transforming growth factor ?1 and smad3 in the formation processThis study used 12 healthy Bama miniature pigs,weighing 22kg-30 kg.Endoscopic ultrasound guided gastroenterostomy was performed at peripancreatic-head region.Four experimental animal pigs were dissected 3 days,7 days,and 14 days after operation to observe gastrointestinal anastomosis,measure the distance between the anastomosis site and the pylorus and excise the gastrointestinal anastomosis specimen,then we performed HE staining and immunohistochemical staining for transforming growth factor ?1,smad3.Result: 1.Retrievable anchor assisted endoscopic ultrasound-guided gastrointestinal anastomosis in the treatment of gastric outflow tract obstructionA total of 10 patients(6 women;average age 63.2±5.8 years)were enrolled in this study.Nine patients had gastric outflow tract obstruction caused by malignant disease,and one patient had gastric outflow tract obstruction caused by benign disease,acute pancreatitis.Nine patients underwent retrieval anchor assisted endoscopic ultrasound guided gastroenterostomy and one patient underwent both endoscopic ultrasound guided gastroenterostomy and endoscopic ultrasound-guided biliary drainage.The average operation time of EUS-GE is 30.6±4.2 minutes.There is no bleeding,perforation and other complications during the operation.The technical and clinical success rate is 100%.2.The gastrointestinal anastomosis formation after endoscopic ultrasound guided gastroenterostomy and the role of transforming growth factor ?1 and smad3 in the formation process12 experimental pigs successfully received retrievable anchor assisted-endoscopic ultrasound guided-gastrointestinal anastomosis.Four experimental animal pigs were dissected 3 days after the operation.The stomach and the small intestine did not form a stable structure and connected by the stent.Four experimental animal pigs were dissected 7 days after the operation.The stomach and the small intestine formed a fixed structure.Four experimental animal pigs were dissected 14 days after the operation.The stomach and the small intestine formed a stable structure.All stents were in right position and there was no tissue proliferation around ends of the stent at any pigs.At gastric side,the anastomotic sites were located at posterior wall of stomacha.At intestinal side,the mean distance between the site of gastroenterostomy and pylorus was 33.9±3.5 cm in 11 pigs.The site of gastroenterostomy of one pig was at ileum.The HE staining of tissue sections 3 days after operation showed more inflammatory cell infiltration,a few fibroblasts,and a small amount of granulation tissue in the interstitium.From 7 to 14 days after surgery,inflammatory cell infiltration decreased,a small amount of fibroblasts increased,and a small amount of granulation tissue increased.TGF-?1 began to express in tissue samples 3 days after surgery,and the degree of staining was weakly positive.TGF-?1 expression began to increase in tissue samples7 days after surgery,and the degree of staining was strongly positive.TGF-?1maintained high expression in tissue samples 14 days after surgery,and most of the staining degrees were strongly positive.Smad3 began to express in tissue samples 3days after surgery,and the degree of staining was weakly positive.The expression of smad3 began to increase in tissue specimens after 7 days,and the staining degree was strongly positive.The expression of smad3 maintained high expression in tissue samples 14 days after surgery.Smad3 and TGF-?1 changed in the same trend.Western blot showed that the expression of TGF-?1 and smad3 gradually increased at3 days,7 days,and 14 days after endoscopic ultrasound guided gastroenterostomy(P<0.05).Conclusions: 1.Retrievable anchor assisted-endoscopic ultrasound guided-gastrointestinal anastomosis is a safe and effective method for the treatment of gastric outlet obstruction.2.In the first 3 days after endoscopic ultrasound-guided gastrointestinal anastomosis,the structure of the gastrointestinal anastomosis is maintained by the metal stent.From 3 to 7 days after the operation,the gastrointestinal anastomosis gradually forms a stable structure,and TGF-?1 and Smad3 play an important role in the formation of a stable structure of gastrointestinal anastomosis. |
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