| Objective:1)To evaluate clinical value of TG-NOTES in diagnoses of patients with ascites of unknown origin;2)To analyze the best entry site of stomach in TG-NOTES for gallbladder exploration and its safety and feasibility in a survival porcine model;3)To evaluate the closing effects of biotitanium clips(Micro-Tech(Nanjing)ROCC-D-26-195-C)and their influence on abdominal organs during TG-NOTES in an animal experiment.Method:1)A retrospective analysis of the clinical data of patients with unexplained ascites who were diagnosed by TG-NOTES(32cases)and laparoscopic operation(32cases)in our institute from April 2016 to March 2019.Do comparative analysis of patients'diagnosed rate,postoperative complications,postoperative pain,hospital stay and operative time.T test was used to compare the measurement data between the two groups,and X~2 test was used to count data(test level:?=0.05).2)Thirteen mini-pigs(20-30kg)were selected to undergo TG-NOTES.Six of the pigs were entered abdominal cavity through the greater curved side of the gastric antrum(n=2),the lesser curved side of the anterior wall of the gastric antrum(n=2),and the junction of the gastric body and antrum(n=2)respectively and completed abdominal exploration.During the exploration,record the scope and determine the best place to explore the gallbladder and liver.The remaining pigs were entered the abdominal cavity through the best site and performed gallbladder exploration,gallbladder biopsy,and polypectomy.Document the operation time,calculate the success rate of gallbladder exploration,intraoperative and postoperative complications and mortality of experimental animals.Dissect the pigs three months after operation to observe the intraperitoneal condition and gallbladder healing.3)Twelve mini-pigs(20-30kg)were selected and assigned into three groups to undergo TG NOTES:Gallbladder Exploration Group(GE group,n=4),Intestinal Repair Group(IR group,n=4),and Control Group(n=4).The incisions of gallbladder,bowel and gastric wall were closed by biotitanium clips(Micro-Tech(Nanjing)ROCC-D-26-195-C)during operations.Compare the activity and eating status of experimental animals,record activity time on the first day after surgery,the transition time to normal diet and complications such as bleeding,perforation and death.The animals were dissected 3 months after operation to observe the adhesion in the abdominal cavity and the healing of the mucosal surface of the gastric wall,serous surface of the intestinal wall and gallbladder wall.The tissues surrounding the titanium clips were excised and sent for pathological biopsy to observe scar and inflammatory infiltration compared with the normal tissues of the control group.One-way analysis of variance was used to compare between groups(test level:?=0.05).Result:1)Diagnosed rate of NOTES group was 84.4%while laparoscopic group was93.8%,and there were no statistical differences in diagnosed rate between two groups(P=1.44,P>0.05).There were no complications such as abdominal infection,bleeding,perforation,puncture/incision fistula after operation in both groups.The operative time was shorter in the NOTES group than that of laparoscopic group(P<0.05).The postoperative visual analogue scale(VAS)of was lower in the patients of NOTES group than laparoscopic group(P<0.05).There were no statistical differences in the hospital stays and hospitalization costs between two groups.2)All three entrances of stomach could showed abdominal organs well.Three entrances to explore the gallbladder from easy to difficult were:the lesser curved side of the anterior wall,the junction of the gastric body and antrum,the greater curved side of the gastric antrum(n=2).So the lesser curved side of the anterior wall of the gastric antrum was seen as the best entry site for gallbladder exploration.The success rate of gallbladder exploration through lesser curved side of the anterior wall of the gastric antrum was 77.78%.The failures of the two cases were due to the deep gallbladder location and heavy intra-abdominal adhesions.The average operation time was 75±17.68min.In addition,we obtained local gallbladder tissue by snare and biopsy forceps successfully during operation.Eleven of thirteen experimental animals survived postoperatively with no postoperative complications such as abdominal hemorrhage,infection,and perforation.Two deaths were due to respiratory depression because of excessive abdominal pressure during surgery.The average weight 3 months after operation increased by 2.5±1.41kg compared with that before operation.Anatomy showed adhesion between liver,intestinal wall and abdominal wall in 1 case.No obvious adhesion was found in other cases.Only the place where the titanium clip was placed and the surrounding area could see fascia or fibrous connective tissue attached to the liver which was easy to separate.The gallbladder healed well.3)All operations were successfully completed.Compared with the experimental animals in control group,the animals in the gallbladder exploration group and intestinal repair group had less POD1 activities and longer average time to transition to normal diet(P<0.05).No hemorrhage,perforation,peritonitis and other symptoms occurred after the operation and no experimental animals died.Dissection of the experimental animals at 3 months postoperatively showed that 1 case of the intestinal repair group could see extensive intra-abdominal adhesion(related to preoperative factors),while the remainders was not obvious.The pathological results showed that the stomach wall,intestinal wall and gallbladder were all full-thickness healing.Compared with the control group,the gastric wall mucosa showed a slight hyperplasia of glands,the gallbladder wall showed an inflammatory reaction,and the liver and intestine had no obvious changes.In one case,a cystic mass about 7cm was seen at the spleen hilum,and the possibility of vascular origin was considered pathologically.Conclusion:1)TG-NOTES is a valid,safe and economical diagnostic method which is comparable to laparoscopy with high diagnosis rate,few complications and minimal invasion which is worthy of clinical promotion.2)The lesser curved side of the anterior wall of the gastric antrum was seen as the best entry site for gallbladder exploration.Gallbladder polypectomy and mucosal biopsy are feasible and safe,and the feasibility of TG-NOTES gallbladder-preserving surgery has been preliminary verified.3)Titanium clips have a small impact in the abdominal cavity for a short period time and have a definite sealing effect,which play an important role in closure organ incisions in NOTES surgery. |
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