腹腔鏡可降解支架法結腸吻合術的動物實驗研究
發(fā)布時間：2018-07-29 10:56
【摘要】：目的：研究腹腔鏡可降解支架法結腸吻合術是否安全可行,與腹腔鏡手工縫合法結腸吻合術相比在手術操作方面是否具有優(yōu)勢；研究兩者在腸道愈合、并發(fā)癥方面是否有差異。 方法：以巴馬小型豬為研究對象,共20只。將它們隨機分為2大組,分別為實驗組和對照組。實驗組采用腹腔鏡支架法結腸端端吻合,分為A組(術后2周處死)和c組(術后3月處死)；對照組采用腹腔鏡手工縫合法結腸端端吻合,分為B組(術后2周處死,A組的對照組)和D組(術后3月處死,c組的對照組),每小組5只。支架以聚乙醇酸(PGA)為主要材料,混合有12.75%的硫酸鋇作為顯影劑。所有動物均氣管插管全身麻醉,腹腔鏡下行結腸端端吻合術。記錄各組吻合完成所需時間、手術時間,記錄動物術后一般狀況、并發(fā)癥及死亡情況。A、B組術后2周處死,測定吻合口爆破壓。c、D組術后3月處死,測定吻合口腸管周徑。觀察吻合口大體愈合情況,吻合口HE染色、Masson染色以及TGF-β1、b-FGF、α-SMA的免疫組化染色,統(tǒng)計數(shù)據(jù),分析結果,探討腹腔鏡支架法結腸端端吻合的可行性及安全性,觀察腸道的愈合情況,從而得出結論。 結果：各組之間動物體重沒有明顯差異。c組有一例動物于術后11周死于腸梗阻,尸體解剖發(fā)現(xiàn)腸梗阻部位位于吻合處下方,病因是先天性腸瓣膜病,梗阻部位亦未發(fā)現(xiàn)支架殘留物。其余動物均順利存活。 A組平均手術時間為56.6±16.6分鐘,B組平均手術時間為100.8±34.1分鐘,兩者之間差異有統(tǒng)計學意義(p=0.031)。c組平均手術時間為86.6±10.9分鐘,D組平均手術時間為115.8±20.8分鐘,兩者之間差異有統(tǒng)計學意義(p=0.024)。腹腔鏡支架法吻合實驗組(A組+c組)平均手術時間為71.6±20.6分鐘,腹腔鏡手工吻合對照組(B組+D組)平均手術時間為108.3±27.8分鐘,兩者之間有顯著性差異(p=0.004)。腹腔鏡支架法吻合實驗組的前5例(c組)與后5例(A組)相比手術時間從86.6±10.9分鐘降至56.6±16.6分鐘,有統(tǒng)計學差異(p=0.010)。腹腔鏡手工吻合對照組前5例(D組)與后5例(B組)相比手術時間從115.8±20.8降至100.8±34.1分鐘,無統(tǒng)計學差異(p=0.426)。A組平均吻合完成時間為23.6±14.8分鐘,B組平均吻合完成時間為57.2±24.3分鐘,兩者之間差異有統(tǒng)計學意義(p=0.030)。c組平均吻合完成時間為42.6±18.0分鐘,D組平均吻合完成時間為73.8±11.5分鐘,兩者之間差異有統(tǒng)計學意義(p=0.011)。腹腔鏡支架法吻合實驗組(A組+c組)平均吻合完成時間為33.1±18.5分鐘,腹腔鏡手工吻合對照組(B組+D組)平均吻合完成時間為65.5±19.9分鐘,兩者之間有顯著性差異(p=0.001)。腹腔鏡支架法吻合實驗組的前5例(c組)與后5例(A組)相比吻合完成時間從42.6±18.0分鐘降至23.6±14.8分鐘,但無明顯統(tǒng)計學差異(p=0.106)。腹腔鏡手工吻合對照組前5例(D組)與后5例(B組)相比吻合完成時間從73.8±11.5分鐘降至57.2±24.3分鐘,無明顯統(tǒng)計學差異(p=0.204)。術后2周處死A、B兩組動物。A組5例均無明顯腸漏。B組1例發(fā)生腸漏未愈合,未測吻合口爆破壓。A組5例平均吻合口爆破壓為108.0±34.9cmH2O, B組4例平均吻合口爆破壓為97.5±60.2cmH2O,兩者之間沒有統(tǒng)計學差異(p=0.751)。A組破裂位置2例位于原吻合口處,B組破裂位置2例為原吻合口處,A、B兩組其余5例破裂位置均不在吻合口處。C組一例動物于術后11周死于腸瓣膜病引起的腸梗阻,故未測量吻合口周徑。c組其余4例正常腸管平均周徑為7.7±0.2厘米,吻合口平均周徑7.7±0.4厘米；D組5例正常腸管平均周徑為8.3±1.1厘米,吻合口平均周徑為7.1±1.1厘米。兩組間正常腸管周徑無顯著性差異(p=0.296),兩組間吻合口周徑無顯著性差異(p=0.344)。C組吻合口平均周徑與正常腸管平均周徑相比無明顯差異(p=1.000)。D組吻合口平均周徑與正常腸管平均周徑相比減小,有統(tǒng)計學意義(p=0.047)。 術后二周A組的支架均在腸腔內,1例發(fā)生移位,距離吻合口約10cm,其余4例仍在吻合口內,支架質地變脆易碎,部分破損。部分動物荷包線已進入腸腔內,套于支架上。A組5例均可見吻合口與周圍腸管及網(wǎng)膜不同程度粘連,粘膜面可見充血水腫,未見明顯的腸漏及腸管內腔狹窄。手工縫合的B組吻合口與周圍腸管和網(wǎng)膜粘連,粘膜面可見充血水腫。其中3例有發(fā)生腸漏跡象,2例已愈合,1例未愈合,該例動物腹腔內可見多個包裹性膿腫形成。 術后三月C組支架均已離開吻合口,吻合口與周圍腸管及網(wǎng)膜形成輕中度粘連。吻合口疤痕較淺,與周圍腸管相比無明顯變細,未見明顯的腸腔狹窄及腸漏,腹腔內未見明顯膿腫形成,腸腔粘膜面吻合口線均已不明顯。術后三月D組吻合口與周圍腸管及網(wǎng)膜有輕中度粘連,2例動物的腸管吻合處較周圍腸管明顯變細,但未見明顯的腸腔狹窄,未見腸漏,腹腔內未見明顯膿腫形成。 術后兩周吻合口標本HE染色兩組均可見吻合口處粘膜缺失,表面肉芽組織增生,伴大量炎癥細胞浸潤,其下纖維組織增生,膠原沉積,腹腔鏡支架法組吻合口的炎癥細胞浸潤較手工縫合法組輕。Masson染色示兩組吻合口內膠原沉積情況相似。兩組免疫組化α-SMA染色強度較高,范圍較廣；b-FGF和TGF-β1則染色強度較低,范圍較小,兩組之間無明顯區(qū)別。 術后三月吻合口標本HE染色兩組均見吻合處腸壁表面結腸粘膜被覆,其下纖維組織增生,伴膠原沉積,直達外膜層,其間見平滑肌呈束狀穿插生長入吻合口。腹腔鏡支架法組吻合口的平滑肌組織多于手工縫合組。Masson染色示兩組均有大量膠原沉積,疤痕組織形成,無明顯差異。兩組免疫組化α-SMA染色強度較術后兩周時降低,范圍仍較廣,可見陽性的平滑肌細胞呈棕黃色,排列呈束狀；b-FGF和TGF-β1則染色強度較低,范圍較小,兩組之間無明顯區(qū)別.結論1腹腔鏡可降解支架法腸吻合對于巴馬小型豬的結腸吻合口愈合是安全可行的。2腹腔鏡可降解支架法腸吻合與腹腔鏡手工縫合法腸吻合相比在力學愈合與組織學愈合上并無明顯差異。3腹腔鏡可降解支架法腸吻合與腹腔鏡手工縫合法腸吻合相比,操作更為簡便省時,腸漏、腸腔狹窄發(fā)生率低,吻合質量更穩(wěn)定,具有良好的應用前景。
[Abstract]:Objective: To investigate whether laparoscopic coloniable stent colonic anastomosis is safe and feasible, and whether it is superior to laparoscopic colonic anastomosis by laparoscopic manual colonic anastomosis, and whether there is a difference in both intestinal healing and complications.
Methods: a total of 20 Bama miniature pigs were divided into 2 groups randomly. The experimental group was divided into 2 groups, the experimental group and the control group. The experimental group was divided into group A (2 weeks after operation) and group C (after the operation in March), and the control group was divided into group B (2 weeks after the operation). Death, control group of group A and group D (death in March, control group in group C), 5 rats in each group. The scaffold was made of polyglycolic acid (PGA) as the main material and mixed with 12.75% barium sulfate as a developer. All animals were anesthetized by tracheal intubation and laparoscopic colonic end-to-end anastomosis was performed. Records of the time required for completion of the anastomosis, operation time, records were recorded. The general condition, complication and death situation after operation of animal.A, group B were killed 2 weeks after operation,.C of anastomotic blasting pressure was measured, and group D was killed in March, and the circumferential diameter of anastomotic stoma was measured. The general healing of anastomotic mouth, HE staining of anastomotic mouth, Masson staining, TGF- beta 1, b-FGF, alpha -SMA, immunohistochemical staining, statistical data, analysis results, and exploration of the abdominal cavity The feasibility and safety of endoscope anastomosis were observed, and the healing of intestinal tract was observed.
Results: there was no significant difference in body weight between the groups. One case of.C group died of intestinal obstruction at 11 weeks after operation. The autopsy found the site of intestinal obstruction located below the anastomosis. The cause was congenital enteral valvular disease, and the stents were not found. The rest of the animals survived successfully.
The average operation time of group A was 56.6 + 16.6 minutes, and the average operation time in group B was 100.8 + 34.1 minutes. The difference between the two groups was statistically significant (p=0.031) in group.C, the average operation time was 86.6 + 10.9 minutes, and the average operation time of D group was 115.8 + 20.8 minutes. The difference between the two groups was statistically significant (p=0.024). The laparoscopic stent method was in the experimental group (A The average operation time of group +c was 71.6 + 20.6 minutes, and the average operation time of the laparoscopic manual anastomosis group (group B +D group) was 108.3 + 27.8 minutes. There was a significant difference between the two groups (p=0.004). The operation time was reduced from 86.6 + 10.9 minutes to 56.6 + 16.6 minutes compared with the last 5 cases (group A). The study difference (p=0.010). The operation time of the first 5 cases (group D) and the latter 5 cases (group B) decreased from 115.8 + 20.8 to 100.8 + 34.1 minutes. There was no statistical difference (p=0.426), the average anastomosis time of.A group was 23.6 + 14.8 minutes, and the average anastomosis time of group B was 57.2 + 24.3 minutes, and there was a significant difference between the two groups (P =0.030) the average anastomosis time of group.C was 42.6 + 18 minutes, and the average anastomosis time of group D was 73.8 + 11.5 minutes. The difference between the two groups was statistically significant (p=0.011). The average anastomosis time of the laparoscopic stent anastomosis group (group +c of A group) was 33.1 + 18.5 minutes, and the average anastomosis of the laparoscope manual anastomosis group (group +D of B group) was completed. The time was 65.5 + 19.9 minutes, there was significant difference between the two (p=0.001). The first 5 cases (Group C) of the laparoscopic stent anastomosis group were compared with the latter 5 cases (A group) to 23.6 + 14.8 minutes from 42.6 + 18 minutes, but there was no significant difference (p=0.106). Compared with the last 5 cases (group D) and 5 cases (B group), the laparoscope manual anastomosis group was compared. The completion time of the anastomosis was reduced from 73.8 + 11.5 minutes to 57.2 + 24.3 minutes without significant statistical difference (p=0.204). A was killed in 2 weeks after operation, and 5 cases of group.A of group B two had no intestinal leakage in group.B, 1 cases had no intestinal leakage, 5 cases in group.A of unmeasured anastomotic blasting pressure were 108 + 34.9cmH2O, and 4 average anastomotic blasting pressure of B group was 97.. 5 + 60.2cmH2O, there was no statistical difference between the two (p=0.751).A group rupture position in the original anastomosis, B group rupture position 2 cases of the original anastomosis, the remaining 5 cases of A, B two were not in the.C group in the anastomotic group, one case died of intestinal valvular disease in the 11 weeks after the operation, so the other 4 cases in group.C did not measure the anastomotic diameter in the other 4 cases. The average circumferential diameter of normal bowel was 7.7 + 0.2 cm, the average circumference diameter of the anastomosis was 7.7 + 0.4 cm, the average circumference diameter of the D group was 8.3 + 1.1 cm and the average diameter of the anastomosis was 7.1 + 1.1 cm. There was no significant difference between the two groups (p=0.296), and there was no significant difference between the two groups (p=0.344) the average week of the anastomotic stoma of the group of.C. There was no significant difference between the diameter and the average circumferential diameter of the normal bowel (p=1.000), the average diameter of the anastomotic stoma in the.D group decreased compared with the average circumferential diameter of the normal intestinal canal, and was statistically significant (p=0.047).
Two weeks after the operation, the stents in group A were all in the intestinal cavity, 1 cases were shifted from the anastomotic stoma, and the other 4 cases were still in the anastomotic mouth. The texture of the scaffold became brittle and fragility. Part of the animal's purse line had entered the enteral cavity. In the group of.A, the conglutination of the anastomoses to the surrounding intestinal tube and omentum was found in 5 cases, and the mucous membrane was visible. There was no obvious intestinal fistula and stenosis of intestinal canal. The anastomoses of B group with hand suture were conglutination with the surrounding intestinal tube and omentum, and the mucous membrane showed congestion and edema. 3 of them had signs of intestinal fistula, 2 cases had healed, 1 cases were not healed, and multiple parcels of abscess in the abdominal cavity were found in this animal.
The stents in group C had left the anastomosis in March. The anastomotic stoma and the surrounding intestinal canal and omentum formed light and moderate adhesion. The scar of the anastomotic stoma was shallow, no obvious thinning, no obvious intestinal stenosis and intestinal fistula, no obvious abscess in the abdominal cavity, and the anastomotic line of the mucosa of the intestinal cavity was not obvious. The anastomotic mouth of group D after operation was in the anastomotic mouth after operation. There were mild and moderate adhesions with the surrounding intestinal tube and omentum. The anastomoses of the intestines in the 2 animals were obviously thinner than the surrounding intestinal tube, but no obvious intestinal stenosis, no intestinal fistula and no obvious abscess in the abdominal cavity were found.
Two weeks after the operation, the HE staining specimens were stained in the two groups. The mucosa of the anastomoses was absent, the surface granulation tissue was proliferated, and a large number of inflammatory cells were infiltrated, the lower fibrous tissue and collagen deposition. The infiltration of inflammatory cells in the anastomotic stoma of the laparoscopic stent group was similar to that of the hand suture group with light.Masson staining in the two groups of anastomotic collagenous deposits. In the two groups, the intensity of immunohistochemical -SMA staining was high and the range was wide. The staining intensity of b-FGF and TGF- beta 1 was low and the range was small. There was no significant difference between the two groups.
In March, two groups of anastomotic specimens were stained with HE staining, and the colonic mucosa of the intestinal wall surface of the anastomosis was seen. The lower fibrous tissue was proliferated, with collagen deposition, and directly to the outer membrane. The smooth muscle tissue was inserted into the anastomotic mouth. The smooth muscle tissue of the anastomotic stoma in the laparoscopic stent group was much more than that of the manual suture group of the two groups. Collagen deposition, scar tissue formation, no obvious difference. Two groups of immunohistochemical alpha -SMA staining intensity is lower than the two weeks after the operation, the range is still wider, the positive smooth muscle cells are brown yellow, arranged in a fascicular shape, b-FGF and TGF- beta 1 are low staining strength, the range is small, there is no obvious difference between the two groups. Conclusion 1 laparoscopic biodegradable scaffold method Intestinal anastomosis for colonic anastomosis in a Bama miniature pig is a safe and feasible.2 laparoscopic biodegradable scaffold with no significant difference in mechanical healing and histological healing compared with.3. It is simple and time-saving, with a low incidence of intestinal leakage, low intestinal cavity stenosis, and stable quality of anastomosis.
【學位授予單位】：浙江大學
【學位級別】：博士
【學位授予年份】：2014
【分類號】：R656
本文編號：2152458
[Abstract]:Objective: To investigate whether laparoscopic coloniable stent colonic anastomosis is safe and feasible, and whether it is superior to laparoscopic colonic anastomosis by laparoscopic manual colonic anastomosis, and whether there is a difference in both intestinal healing and complications.
Methods: a total of 20 Bama miniature pigs were divided into 2 groups randomly. The experimental group was divided into 2 groups, the experimental group and the control group. The experimental group was divided into group A (2 weeks after operation) and group C (after the operation in March), and the control group was divided into group B (2 weeks after the operation). Death, control group of group A and group D (death in March, control group in group C), 5 rats in each group. The scaffold was made of polyglycolic acid (PGA) as the main material and mixed with 12.75% barium sulfate as a developer. All animals were anesthetized by tracheal intubation and laparoscopic colonic end-to-end anastomosis was performed. Records of the time required for completion of the anastomosis, operation time, records were recorded. The general condition, complication and death situation after operation of animal.A, group B were killed 2 weeks after operation,.C of anastomotic blasting pressure was measured, and group D was killed in March, and the circumferential diameter of anastomotic stoma was measured. The general healing of anastomotic mouth, HE staining of anastomotic mouth, Masson staining, TGF- beta 1, b-FGF, alpha -SMA, immunohistochemical staining, statistical data, analysis results, and exploration of the abdominal cavity The feasibility and safety of endoscope anastomosis were observed, and the healing of intestinal tract was observed.
Results: there was no significant difference in body weight between the groups. One case of.C group died of intestinal obstruction at 11 weeks after operation. The autopsy found the site of intestinal obstruction located below the anastomosis. The cause was congenital enteral valvular disease, and the stents were not found. The rest of the animals survived successfully.
The average operation time of group A was 56.6 + 16.6 minutes, and the average operation time in group B was 100.8 + 34.1 minutes. The difference between the two groups was statistically significant (p=0.031) in group.C, the average operation time was 86.6 + 10.9 minutes, and the average operation time of D group was 115.8 + 20.8 minutes. The difference between the two groups was statistically significant (p=0.024). The laparoscopic stent method was in the experimental group (A The average operation time of group +c was 71.6 + 20.6 minutes, and the average operation time of the laparoscopic manual anastomosis group (group B +D group) was 108.3 + 27.8 minutes. There was a significant difference between the two groups (p=0.004). The operation time was reduced from 86.6 + 10.9 minutes to 56.6 + 16.6 minutes compared with the last 5 cases (group A). The study difference (p=0.010). The operation time of the first 5 cases (group D) and the latter 5 cases (group B) decreased from 115.8 + 20.8 to 100.8 + 34.1 minutes. There was no statistical difference (p=0.426), the average anastomosis time of.A group was 23.6 + 14.8 minutes, and the average anastomosis time of group B was 57.2 + 24.3 minutes, and there was a significant difference between the two groups (P =0.030) the average anastomosis time of group.C was 42.6 + 18 minutes, and the average anastomosis time of group D was 73.8 + 11.5 minutes. The difference between the two groups was statistically significant (p=0.011). The average anastomosis time of the laparoscopic stent anastomosis group (group +c of A group) was 33.1 + 18.5 minutes, and the average anastomosis of the laparoscope manual anastomosis group (group +D of B group) was completed. The time was 65.5 + 19.9 minutes, there was significant difference between the two (p=0.001). The first 5 cases (Group C) of the laparoscopic stent anastomosis group were compared with the latter 5 cases (A group) to 23.6 + 14.8 minutes from 42.6 + 18 minutes, but there was no significant difference (p=0.106). Compared with the last 5 cases (group D) and 5 cases (B group), the laparoscope manual anastomosis group was compared. The completion time of the anastomosis was reduced from 73.8 + 11.5 minutes to 57.2 + 24.3 minutes without significant statistical difference (p=0.204). A was killed in 2 weeks after operation, and 5 cases of group.A of group B two had no intestinal leakage in group.B, 1 cases had no intestinal leakage, 5 cases in group.A of unmeasured anastomotic blasting pressure were 108 + 34.9cmH2O, and 4 average anastomotic blasting pressure of B group was 97.. 5 + 60.2cmH2O, there was no statistical difference between the two (p=0.751).A group rupture position in the original anastomosis, B group rupture position 2 cases of the original anastomosis, the remaining 5 cases of A, B two were not in the.C group in the anastomotic group, one case died of intestinal valvular disease in the 11 weeks after the operation, so the other 4 cases in group.C did not measure the anastomotic diameter in the other 4 cases. The average circumferential diameter of normal bowel was 7.7 + 0.2 cm, the average circumference diameter of the anastomosis was 7.7 + 0.4 cm, the average circumference diameter of the D group was 8.3 + 1.1 cm and the average diameter of the anastomosis was 7.1 + 1.1 cm. There was no significant difference between the two groups (p=0.296), and there was no significant difference between the two groups (p=0.344) the average week of the anastomotic stoma of the group of.C. There was no significant difference between the diameter and the average circumferential diameter of the normal bowel (p=1.000), the average diameter of the anastomotic stoma in the.D group decreased compared with the average circumferential diameter of the normal intestinal canal, and was statistically significant (p=0.047).
Two weeks after the operation, the stents in group A were all in the intestinal cavity, 1 cases were shifted from the anastomotic stoma, and the other 4 cases were still in the anastomotic mouth. The texture of the scaffold became brittle and fragility. Part of the animal's purse line had entered the enteral cavity. In the group of.A, the conglutination of the anastomoses to the surrounding intestinal tube and omentum was found in 5 cases, and the mucous membrane was visible. There was no obvious intestinal fistula and stenosis of intestinal canal. The anastomoses of B group with hand suture were conglutination with the surrounding intestinal tube and omentum, and the mucous membrane showed congestion and edema. 3 of them had signs of intestinal fistula, 2 cases had healed, 1 cases were not healed, and multiple parcels of abscess in the abdominal cavity were found in this animal.
The stents in group C had left the anastomosis in March. The anastomotic stoma and the surrounding intestinal canal and omentum formed light and moderate adhesion. The scar of the anastomotic stoma was shallow, no obvious thinning, no obvious intestinal stenosis and intestinal fistula, no obvious abscess in the abdominal cavity, and the anastomotic line of the mucosa of the intestinal cavity was not obvious. The anastomotic mouth of group D after operation was in the anastomotic mouth after operation. There were mild and moderate adhesions with the surrounding intestinal tube and omentum. The anastomoses of the intestines in the 2 animals were obviously thinner than the surrounding intestinal tube, but no obvious intestinal stenosis, no intestinal fistula and no obvious abscess in the abdominal cavity were found.
Two weeks after the operation, the HE staining specimens were stained in the two groups. The mucosa of the anastomoses was absent, the surface granulation tissue was proliferated, and a large number of inflammatory cells were infiltrated, the lower fibrous tissue and collagen deposition. The infiltration of inflammatory cells in the anastomotic stoma of the laparoscopic stent group was similar to that of the hand suture group with light.Masson staining in the two groups of anastomotic collagenous deposits. In the two groups, the intensity of immunohistochemical -SMA staining was high and the range was wide. The staining intensity of b-FGF and TGF- beta 1 was low and the range was small. There was no significant difference between the two groups.
In March, two groups of anastomotic specimens were stained with HE staining, and the colonic mucosa of the intestinal wall surface of the anastomosis was seen. The lower fibrous tissue was proliferated, with collagen deposition, and directly to the outer membrane. The smooth muscle tissue was inserted into the anastomotic mouth. The smooth muscle tissue of the anastomotic stoma in the laparoscopic stent group was much more than that of the manual suture group of the two groups. Collagen deposition, scar tissue formation, no obvious difference. Two groups of immunohistochemical alpha -SMA staining intensity is lower than the two weeks after the operation, the range is still wider, the positive smooth muscle cells are brown yellow, arranged in a fascicular shape, b-FGF and TGF- beta 1 are low staining strength, the range is small, there is no obvious difference between the two groups. Conclusion 1 laparoscopic biodegradable scaffold method Intestinal anastomosis for colonic anastomosis in a Bama miniature pig is a safe and feasible.2 laparoscopic biodegradable scaffold with no significant difference in mechanical healing and histological healing compared with.3. It is simple and time-saving, with a low incidence of intestinal leakage, low intestinal cavity stenosis, and stable quality of anastomosis.
【學位授予單位】：浙江大學
【學位級別】：博士
【學位授予年份】：2014
【分類號】：R656
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