经胃与结肠双内镜联合猪胆囊切除术

Combined transgastric and transcolonic endoscopic cholecystectomy in porcine models

目的探讨经胃（口腔）和结肠（肛门）双内镜联合切除猪胆囊的可行性和安全性。方法采用雌性小型猪5头。经胃内镜下，用针型刀和扩张球囊切开胃壁，将内镜送入腹腔。用同样方法将另一条内镜经结肠送入腹腔，双镜联合切除胆囊。术后胃肠壁切口用止血夹闭合。术后动物饲养14d，剖腹探查。结果3头猪因胆囊暴露刚难，无法完成胆囊切除术。1头在切除胆囊过程中因出血过多，操作失败。另1头成功切除胆囊，但在经胃内镜进入腹腔时发现横膈有3处穿孔，可能是经结肠内镜进入腹腔时误伤临近结肠壁。动物存活14d后体重下降4kg，开腹探查见胃和结肠壁切口全层愈合。右下腹肠管粘连较严重，并见一脓肿。膈肌穿孔1处愈合，另2处融合并形成憩室，肝脏表面与之粘连并嵌顿其内。结论经胃与经结肠双内镜联合切除猪胆囊有一定困难，且安全性尚不肯定。

Objective To assess the feasihility and safety of combined transgastric and transcolonic endoscopic cholecystectomy in porcine model. Methods Five female miniature swines were subjected to cholecystectomy by the combined transgastrie and transcolonic approach using two flexible endoscopes. The gastric wall of the swine was punctured with a needle knife, followed by dilatation with a balloon-dilator via the transgastrie access, 1hen a double channel endoscope was advanced into the peritoneal cavity. Another double-channel endoscope was advanced via a transcolonic access. Gallbladder excision was performed using transcnlonic endoscope assisted by transgastric endoscope. After cholecysteclomy the gastric and lhe colonic incisions were closed with clips. The animal was examined 14 days Mter ol）eralion. Results （Tbolecystectomy was failed in 4 swines because of incomplete exposing the gallbladder （3 swines） and hemarrhage during separating the gallbladder from the liver bed （1 swine）. Only one swine was successfully performed cholecystectomy. But 3 perforations were found in tbe diaphragm which might be done by transcolonic endoscope. The swine lost 4 kg 14 days after the operation. The necropsy revealed a complete transmural healing of the gastric incision with minimal adhesions and a complete healing of the colonic incision with heavy adhesions. An abscess with severe adhesions was found in the righl lower quadrant. One perforation of the diaphragm healed, and the other two perfnrations merged and formed a diverticulum embedded with the liver. Conclusion Combined transgastric and transcolonic approach appears difficult for cholecystectomy and the safety remains to be further studied.