經(jīng)口食管隧道診治范疇拓展的關(guān)鍵技術(shù)研究
發(fā)布時(shí)間：2018-08-06 19:59
【摘要】：研究背景及目的：食管黏膜下隧道技術(shù)已經(jīng)逐漸應(yīng)用于食管比鄰結(jié)構(gòu)等范疇拓展的治療,比如內(nèi)鏡下肌切開術(shù)(per-oral endoscopic myotomy, POEM)、食管早癌剝離、食管黏膜下腫瘤切除等方面突顯優(yōu)點(diǎn),這些治療中經(jīng)常困擾內(nèi)鏡醫(yī)生的并發(fā)癥如氣胸等的研究也成為了食管隧道技術(shù)研究中至關(guān)重要的一環(huán)；同時(shí)隧道技術(shù)也加快了經(jīng)口食管隧道診治范疇的拓展,但是相關(guān)拓展手術(shù)的安全性仍需要實(shí)驗(yàn)論證。希望通過動(dòng)物實(shí)驗(yàn)初步論證經(jīng)口食管隧道診治范疇的拓展手術(shù)如縱隔內(nèi)鏡下手術(shù)治療的可行性和安全性,摸索手術(shù)必要條件,從而為臨床內(nèi)鏡下診治縱隔病變建立理論和實(shí)踐基礎(chǔ)；通過動(dòng)物氣胸模型實(shí)驗(yàn)尋找氣胸相關(guān)聯(lián)敏感指標(biāo),為現(xiàn)今食管比鄰結(jié)構(gòu)臨床手術(shù)提供參考。方法：①選取6頭家豬,內(nèi)鏡下建立食管黏膜下隧道進(jìn)入縱隔,術(shù)中辨別縱隔器官,進(jìn)行縱隔組織模擬淋巴結(jié)活檢；②選擇6頭家豬建立胸腔穿刺C02氣胸模型,并監(jiān)測(cè)不同程度胸腔穿刺C02氣胸模型中的生理、呼吸力學(xué)及血流動(dòng)力學(xué)變化；選擇注氣前10min作為觀察基礎(chǔ)點(diǎn)Baseline,監(jiān)測(cè)左側(cè)少量、中量、大量氣胸時(shí)共3個(gè)時(shí)相點(diǎn)生理、呼吸力學(xué)及血流動(dòng)力學(xué)變化。③18頭家豬隨機(jī)分為無壓力調(diào)控組(A組10mmHg)、超低壓力調(diào)控組(B組5mmHg)和高壓力調(diào)控組(C組10mmHg)3組,選擇注氣前10min作為觀察基礎(chǔ)點(diǎn)Baseline,監(jiān)測(cè)注氣10分鐘、20分鐘和30分鐘3個(gè)時(shí)相點(diǎn)生理、呼吸力學(xué)及血流動(dòng)力學(xué)變化，組與組之間進(jìn)行對(duì)比。結(jié)果：①6頭動(dòng)物均順利完成操作,術(shù)中可清晰辨別縱隔器官(如肺、脊椎、降主動(dòng)脈等),并進(jìn)行縱隔組織模擬淋巴結(jié)活檢,其中2例因嚴(yán)重氣胸死亡,2例發(fā)生少量氣胸,食管切口均用金屬夾成功關(guān)閉。②胸腔穿刺C02充氣模型均成功建立,少量氣胸時(shí)只有氧合指數(shù)(OI)降低、二氧化碳分壓(PaCO2)升高和氣道阻力壓升高有統(tǒng)計(jì)學(xué)差異,中量氣胸時(shí)PH值降低,氧合指數(shù)(OI)降低,二氧化碳分壓(PaCO2)升高,氣道阻力壓升高,心率(HR)增加,平均動(dòng)脈壓(MAP)升高,心輸出指數(shù)(CI)及胸腔內(nèi)血容量指數(shù)(ITBI)降低,與術(shù)前基礎(chǔ)值均有統(tǒng)計(jì)學(xué)差異,大量氣胸時(shí)大部分指標(biāo)變化同前,MAP降低,有統(tǒng)計(jì)學(xué)差異。③三組動(dòng)物手術(shù)順利,A組PH值降低,氧合指數(shù)(0I)降低、二氧化碳分壓(PaCO2)升高和氣道阻力壓升高有統(tǒng)計(jì)學(xué)差異,心率(HR)增加,平均動(dòng)脈壓(MAP)升高,心輸出指數(shù)(CI)及胸腔內(nèi)血容量指數(shù)(ITBI)降低,與術(shù)前基礎(chǔ)值均有統(tǒng)計(jì)學(xué)差異,C組隨著時(shí)間延長(zhǎng)逐漸出現(xiàn)以上變化,與術(shù)前基礎(chǔ)值均有統(tǒng)計(jì)學(xué)差異,B組各項(xiàng)指標(biāo)變化無統(tǒng)計(jì)學(xué)差異。A組6頭豬術(shù)中均出現(xiàn)不同程度氣胸,2頭出現(xiàn)重度單側(cè)氣胸,術(shù)后死亡,其余4頭輕中度氣胸,穿刺抽氣及常規(guī)搶救后均存活；C組中出現(xiàn)1例單側(cè)重度氣胸,3例輕中度氣胸,穿刺抽氣及常規(guī)搶救后均存活。結(jié)論：現(xiàn)有內(nèi)鏡手術(shù)條件下,經(jīng)食管黏膜下隧道診治范疇拓展如縱隔治療手術(shù)是可行的,但是仍有較大風(fēng)險(xiǎn),而縱隔手術(shù)中腔內(nèi)壓力監(jiān)測(cè)和調(diào)控是保證手術(shù)安全進(jìn)行的必要條件；內(nèi)鏡下縱隔或胸腔手術(shù)中血?dú)庵笜?biāo)、呼吸力學(xué)及血流動(dòng)力學(xué)監(jiān)測(cè)是非常必要的,血?dú)夥治龊秃粑鼊?dòng)力監(jiān)測(cè)對(duì)于氣胸的預(yù)警作用明顯。
[Abstract]:Background and objective: submucosal tunnel technique of the esophagus has been gradually applied to the treatment of esophagus adjacent structures, such as endoscopic myotomy (per-oral endoscopic myotomy, POEM), early esophageal carcinoma dissection, and submucosal tumor resection of the esophagus, which often perplex the complications of endoscopes. The study of pneumothorax, such as pneumothorax, has also become a key link in the study of the esophageal tunnel technology. At the same time, the tunnel technology has also accelerated the expansion of the scope of the diagnosis and treatment of the esophagus tunnel, but the safety of the related operation still needs the experimental demonstration. The feasibility and safety of endoscopic surgery, and explore the necessary conditions for the operation, establish the theoretical and practical basis for the diagnosis and treatment of mediastinal lesions under clinical endoscopy, and find the related sensitive indexes of pneumothorax through the animal pneumothorax model experiment, and provide reference for the clinical operation of the adjacent structure of the esophagus. Methods: (1) 6 pigs and endoscopy were selected. The submucosal tunnel of the esophagus was established into the mediastinum, the mediastinal organs were identified and the mediastinal tissue was performed to simulate the lymph node biopsy. 6 pigs were selected to establish the thoracic C02 pneumothorax model, and the physiological, respiratory and hemodynamic changes were monitored in the C02 pneumothorax model of the thoracic puncture, and the 10min before the injection of gas was selected as the observation base. Basic point Baseline, monitoring the left small amount, medium amount, and a large number of pneumothorax in 3 time phase point physiology, respiratory mechanics and hemodynamic changes. (3) 18 head pigs were randomly divided into no pressure control group (group A 10mmHg), ultra low pressure control group (B group 5mmHg) and high pressure control group (C group 10mmHg) 3 groups, select the pre injection 10min as the observation basis Baseline, monitoring Blood injection of 10 minutes, 20 minutes and 30 minutes of 3 phase point physiology, respiratory mechanics and hemodynamic changes between groups and groups were compared. Results: (1) 6 animals were successfully completed. During the operation, mediastinal organs (such as lung, spine, descending aorta, etc.) were clearly identified, and mediastinal tissue simulated lymph node biopsy was performed, of which 2 cases died of severe pneumothorax. 2 cases had a small amount of pneumothorax and the esophageal incision was successfully closed with metal clips. 2. The C02 inflatable model of the thoracic cavity was successfully established. Only a small amount of pneumothorax was reduced in oxygenation index (OI), the pressure of carbon dioxide (PaCO2) increased and the airway resistance pressure increased statistically. The pH value of the pneumothorax was reduced, the oxygen index (OI) decreased, and the carbon dioxide partial pressure was reduced. (PaCO2) increased, airway resistance pressure increased, heart rate (HR) increased, average arterial pressure (MAP) increased, cardiac output index (CI) and intrathoracic blood volume index (ITBI) decreased, and had statistical differences with preoperative values. Most of the index changes in pneumothorax were the same before, MAP decreased, and there were statistical differences. (3) the three groups of animals were operated smoothly, the pH value of the A group was reduced, oxygen was reduced, oxygen was reduced, oxygen was reduced in the A group. There were statistical differences in 0I, PaCO2 and airway resistance pressure. Heart rate (HR) increased, mean arterial pressure (MAP) increased, cardiac output index (CI) and intrathoracic blood volume index (ITBI) decreased. There were statistical differences from preoperative basic values. Group C increased gradually with time, and the basis of pre operation basis. There was no significant difference in the value of the B group, and there were no statistical differences in the changes of the indexes in the group.A 6 head pigs, 2 of the severe unilateral pneumothorax, the other 4 light and moderate pneumothorax, the puncture aspiration and the routine rescue. In group C, there were 1 cases of unilateral severe pneumothorax, 3 cases of mild and moderate pneumothorax, puncture aspiration and routine Conclusion: under the existing endoscopic surgery, it is feasible to extend the diagnosis and treatment of the submucosal tunnel through the esophagus, such as mediastinal surgery, but there is still a great risk, and the pressure monitoring and control in the mediastinal operation is the necessary condition to ensure the safety of the operation; the blood gas index and respiration in the endoscopic mediastinal or thoracic surgery Mechanical and hemodynamic monitoring is very necessary. Blood gas analysis and respiratory dynamic monitoring have obvious effect on early warning of pneumothorax.
【學(xué)位授予單位】：中國(guó)人民解放軍醫(yī)學(xué)院
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2015
【分類號(hào)】：R655
本文編號(hào)：2168832
[Abstract]:Background and objective: submucosal tunnel technique of the esophagus has been gradually applied to the treatment of esophagus adjacent structures, such as endoscopic myotomy (per-oral endoscopic myotomy, POEM), early esophageal carcinoma dissection, and submucosal tumor resection of the esophagus, which often perplex the complications of endoscopes. The study of pneumothorax, such as pneumothorax, has also become a key link in the study of the esophageal tunnel technology. At the same time, the tunnel technology has also accelerated the expansion of the scope of the diagnosis and treatment of the esophagus tunnel, but the safety of the related operation still needs the experimental demonstration. The feasibility and safety of endoscopic surgery, and explore the necessary conditions for the operation, establish the theoretical and practical basis for the diagnosis and treatment of mediastinal lesions under clinical endoscopy, and find the related sensitive indexes of pneumothorax through the animal pneumothorax model experiment, and provide reference for the clinical operation of the adjacent structure of the esophagus. Methods: (1) 6 pigs and endoscopy were selected. The submucosal tunnel of the esophagus was established into the mediastinum, the mediastinal organs were identified and the mediastinal tissue was performed to simulate the lymph node biopsy. 6 pigs were selected to establish the thoracic C02 pneumothorax model, and the physiological, respiratory and hemodynamic changes were monitored in the C02 pneumothorax model of the thoracic puncture, and the 10min before the injection of gas was selected as the observation base. Basic point Baseline, monitoring the left small amount, medium amount, and a large number of pneumothorax in 3 time phase point physiology, respiratory mechanics and hemodynamic changes. (3) 18 head pigs were randomly divided into no pressure control group (group A 10mmHg), ultra low pressure control group (B group 5mmHg) and high pressure control group (C group 10mmHg) 3 groups, select the pre injection 10min as the observation basis Baseline, monitoring Blood injection of 10 minutes, 20 minutes and 30 minutes of 3 phase point physiology, respiratory mechanics and hemodynamic changes between groups and groups were compared. Results: (1) 6 animals were successfully completed. During the operation, mediastinal organs (such as lung, spine, descending aorta, etc.) were clearly identified, and mediastinal tissue simulated lymph node biopsy was performed, of which 2 cases died of severe pneumothorax. 2 cases had a small amount of pneumothorax and the esophageal incision was successfully closed with metal clips. 2. The C02 inflatable model of the thoracic cavity was successfully established. Only a small amount of pneumothorax was reduced in oxygenation index (OI), the pressure of carbon dioxide (PaCO2) increased and the airway resistance pressure increased statistically. The pH value of the pneumothorax was reduced, the oxygen index (OI) decreased, and the carbon dioxide partial pressure was reduced. (PaCO2) increased, airway resistance pressure increased, heart rate (HR) increased, average arterial pressure (MAP) increased, cardiac output index (CI) and intrathoracic blood volume index (ITBI) decreased, and had statistical differences with preoperative values. Most of the index changes in pneumothorax were the same before, MAP decreased, and there were statistical differences. (3) the three groups of animals were operated smoothly, the pH value of the A group was reduced, oxygen was reduced, oxygen was reduced, oxygen was reduced in the A group. There were statistical differences in 0I, PaCO2 and airway resistance pressure. Heart rate (HR) increased, mean arterial pressure (MAP) increased, cardiac output index (CI) and intrathoracic blood volume index (ITBI) decreased. There were statistical differences from preoperative basic values. Group C increased gradually with time, and the basis of pre operation basis. There was no significant difference in the value of the B group, and there were no statistical differences in the changes of the indexes in the group.A 6 head pigs, 2 of the severe unilateral pneumothorax, the other 4 light and moderate pneumothorax, the puncture aspiration and the routine rescue. In group C, there were 1 cases of unilateral severe pneumothorax, 3 cases of mild and moderate pneumothorax, puncture aspiration and routine Conclusion: under the existing endoscopic surgery, it is feasible to extend the diagnosis and treatment of the submucosal tunnel through the esophagus, such as mediastinal surgery, but there is still a great risk, and the pressure monitoring and control in the mediastinal operation is the necessary condition to ensure the safety of the operation; the blood gas index and respiration in the endoscopic mediastinal or thoracic surgery Mechanical and hemodynamic monitoring is very necessary. Blood gas analysis and respiratory dynamic monitoring have obvious effect on early warning of pneumothorax.
【學(xué)位授予單位】：中國(guó)人民解放軍醫(yī)學(xué)院
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2015
【分類號(hào)】：R655
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