经自然腔道内镜手术的动物实验研究
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摘要
背景与目的：经自然孔道内镜外科(Natural Orifice Translumenal Endoscopic Surgery, NOTES)是指经人体自然孔道(口、结肠、阴道及膀胱等)而无皮肤切口应用软镜对腹腔内脏器进行的诊断及治疗。其较传统腹腔镜手术具有无腹壁手术切口、术后疼痛少、住院时间更短、美容效果更好等潜在优势。NOTES被认为是微创外科发展的又一里程碑,是目前消化内科与普通外科医生研究的热点。在欧美等发达国家,对NOTES的实验室及临床研究工作已取得很大成绩。在我国,由于研究工作起步较晚,目前仅有少数几家医院开展此项研究而且多局限于实验室工作。
本研究的目的是通过动物实验研究初步探讨NOTES技术的可行性及安全性,分析、总结NOTES技术的操作要点、面临的问题及其并发症：分析NOTES围手术期实验动物心肺功能及免疫应激指标的变化情况并与传统腹腔镜手术进行对照研究以及初步探讨NOTES操作时相关并发症的预防策略。
方法：选用五指山小型猪30只,体重20-25kg。对实验动物行静脉复合麻醉,气管插管及呼吸机辅助呼吸后,采用双孔道内镜进入胃肠道或阴道,选取胃窦体交界前壁小弯侧、距肛门15cm-20cm结肠后壁系膜对侧或阴道后穹窿位置造口,建立入路。内镜经造口进入腹腔后,应用双孔道内镜或在经脐单孔腹腔镜辅助下行腹腔内探查或/和胆囊切除。研究有三个部分组成：实验一选用五指山小型猪20只,按随机原则分为两组,每组10只动物,即单纯经胃途径NOTES胆囊切除术组(A组)和经胃途径NOTES联合经脐单孔腹腔镜胆囊切除术组(B组)。对两组动物分别行胆囊切除术,观察、比较、分析两种术式的可行性、有效性和安全性；实验二将实验一中两组实验动物分别按照随机原则再分为两组,共分为四组,每组5只实验动物,即A1、A2和B1、B2组。其中A1及B1组在行胆囊切除术前以生理盐水充分冲洗胃腔进行消毒,A2及B2组不行任何消毒处理。对实验中所有动物于术前、手术结束时分别取胃腔、腹腔冲洗液进行细菌培养,分析术前生理盐水冲洗是否会减少术后腹腔感染的发生。并对四组实验动物术后炎症反应情况进行观察、分析；实验三选用五指山小型猪10只,按随机原则分为两组,每组5只,即行NOTES腹腔探查术组(N组)和行腹腔镜腹腔探查术组(F组),监测术中、术后研究对象心肺功能(血压、心率及动脉血气)、应激反应指标(白介素-1及肿瘤坏死因子)的变化,将两种术式对实验动物围手术期的影响加以比较分析,观察NOTES对机体的创伤；
结果：实验一：共成功完成胆囊切除术12例次,成功率为60.0%(12/20);其中单纯NOTES经胃途径(A组)成功5例次,成功率为50.0%(5/10)；联合途径(B组)成功7例次,成功率为70.0%(7/10)。存活实验11例次,急性实验9例次,其中A组存活4例次,B组存活7例次；实验二：共19只动物57份标本完成细菌培养(A2组中1份标本24小时内未能送检)。四组实验动物术前胃内标本液(标本A)及术前腹腔冲洗液(标本B)细菌培养结果无明显差异；虽四组动物术后腹腔冲洗液细菌种类无明显差异,均以大肠埃希菌、肺炎克雷柏菌为主,但A1、B1组中细菌生长数目明显少于A2、B2组,而且前两组中有细菌生长标本的总例数少于后两组(30.0%vs60.0%)。同时在存活动物实验中,A1、B1组术后第1及3天平均WBC水平明显低于后两组；实验三：10只动物均成功行NOTES或腹腔镜探查术,术后均成活超过7天。两组动物间术前、术中及术后在平均心率、平均动脉血压变化上无明显区别；两组动物术后24及72小时平均IL1-β及TNF-a水平均明显高于术前水平。两组间在术后平均白介素1-B水平除术后第72小时上无明显差异,N组术后24及72小时肿瘤坏死因子明显高于F组。术后第7天两组动物平均IL1-β及TNF-a水平已基本恢复术前水平。
结论：①采用现有内镜设备,单纯NOTES途径可以完成腹腔内脏器的探查,但完成脏器切除术难度较大、成功率较低；②采用联合经脐腹腔镜辅助行NOTES胆囊切除术,可以提高自然管壁造口安全性,改善腹腔内空间定位,显著降低操作难度并提高操作成功率,具有一定的可行性；③经钛钉直接夹闭自然管壁造口的成功率较高,但有一定失败率,闭口失败后容易因造口漏而导致腹膜炎等严重并发症；④术前生理盐水冲洗胃腔是有效降低术后感染及减少细菌移位的有效方法之一;⑤与传统腹腔镜探查术相比较,由于目前内镜建立气腹压力波动较大,经胃途径NOTES腹腔探查术并没有降低对实验动物的创伤,但并没有增加实验动物围手术期并发症发生及死亡率；⑥目前内镜器械及设备完成腹腔内脏器的切除难度很大,为充分发挥NOTES技术优势,有待于发明更多先进的软镜设备及器械。
Background and objective:Natural orifice transluminal endoscopic surgery(NOTES) is a novel surgical technique that performs the diagnosis and therapy for patients via the orifice routes(as transgastric, transcolonic or transvaginal) to the peritoneal cavity without abdominal insicions. NOTES have potiental advantages as following no abdominal insicion, lesser postoperative pain, shorter length of hospital stay and better cosmesis and so on, compared to tranditional open surgery and laparoscopy. So it is regarded as a milestone of mini-invasive surgery and focused by surgeons and gastroenterologists. The NOTES-related experimental and clinical reseach has made significant achievements in western developed countries, unfortunaterly the NOTES study are carried out only in a few hospitals or laboratorys and it is still in the primary stage in our country.
To eveluate the feasibility, safety and efficacy of the NOTES to undergo the intra-abdominal surgery, this systemic animal experiment is designed. In the first part, the cholecystectomy is performed in the survival porcines to analysize and summarize the techniques, difficulty and complications of NOTES. In the second part, compared to the traditional laparoscopic surgery, the perioperatively cardiopulmonary and inflammatory response indicators are summarized to eveluate the safety of NOTES. In the third part, we summarize the prevention strategies of the postoperative infection primarily.
Methods:30female WuZhiShan small porcines(WZSSP) were involved in the study. The pigs were deprived of food for24h before surgery. General anesthesia was induced to all animals with intravenous(IV) propofol10ml/30kg and pancuronium2ml. Then a sterile double-channel video endoscopy was inserted into the stomach, The gastrotomy site was carefully chosen by observation of the indentation on the gastric wall produced by palpation of the anterior abdominal wall or the colotomy was produced in the sigmoid colon15-20cm from the anal verge. Aneedleknife was used to make a incision on the natural orifice wall, which was enlarged with a dilation bolloon. Then the endoscopy was inserted into the peritoneal cavity through the access or the hybrid cholecystectomies were performed. In the first part,20porcines were invidided into two groups randomly and received cholecystectomies with the total transgastric NOTES (group A)or laparoscopic assistance(group B), to summarize the the feasibility, safety and efficacy of the NOTES to undergo the intra-abdominal surgery. In the second part, all of animals in the first part were divided into two groups before the NOTES respectively, i.e. a gastric lavage was performed before NOTES with1,500-2,000ml of sterile saline solution0.9%in group A1and B1and the gastric lavage wasn't performed in group A2and B2. Gastroscope and peritoneal fluid aspirates in each animal were obtained prior to and after the gastrotomy. Each sample was sent for bacterial colony counts, culture, and identification of species. In the third part,10WZSSP were divided into two groups, i.e. the laparotomy was performed by the total NOTES through the oral access and the pneumoperitoneum were created with the endoscopic insufflation (N group) or by the traditional laparoscopy and the pneumoperitoneum were created with the standard autoregulated laparoscopic insufflator using carbon dioxide(CO2)(F group). In this part, the the perioperatively cardiopulmonary and inflammatory response indicators of each group were collected and summarized.
Results:In the first part, the cholecystectomy were successfully performed in12porcines and the success rate was60%.5in group A and7in group B respectively. In the second part, the specimens of19of20animals in the first part were performed NOTES through the stomach. There was no significant difference between both groups on the average platelet preoperatively and postoperatively. However, the white blood cell(WBC) on the postoperative day1and3in the group A1and B1were significant lower than in the group A2and B2. There was no different on the bacterial species bwtween two groups, however, there were fewer bacterial contamination on Contaminated peritoneum sample after NOTES(sample C) in the former two groups than in the other two(30.0%vs55.6%). In the third part, all of10porcines were performed laparotomy by NOTES or laparoscopy without periopera-tive and postoperative complications. There was no significant difference between both groups on the perioperatively and postoperatively average heart rate and arterial blood pressure(ABP). There was no significant difference between both groups on the postoperatively average interleukin-1(IL-1) except on the postoperative day3. And the average tumor necrosis factor-a(TNF-a) on the postoperative day1and3in the group N were significant higher than in the group F. The IL-1and TNF-α on the postoperative day7in both groups were reduced to the normal level almostly.
Conclusions:①Using the total transgastric or transcolonic route to expore the peritoneal cavity is feasible with safety, however, it is difficult to performed cholecystectomy using the present endoscopic instruments;②The hybrid approach increases safety of natural orifice wall incision, improves orientation and navigation of the flexible endoscope inside the peritoneal cavity, simplifies NOTES;③The natural orifice wall incision was closed with endoscopic clips is safe to most of animals, however, there are some failures which may lead to gastric and intestinal lavage and peritonitis;④compared to the trditional laparoscopic laparotomy, using the present endoscopic insufflation to create the pneumoperitoneum, the trauma to the experimental animals of the natural orifice translunimal endoscopic laparotomy is much more;⑤The gastric lavage using sterile saline solution before NOTES is one of the effective method of disinfection;⑥It is difficult to performed surgery into the peritoneal cavity using the endoscopic instruments, so much endoscopic instruments need to be improved to show the potential advantages of NOTES.
本研究的目的是通过动物实验研究初步探讨NOTES技术的可行性及安全性,分析、总结NOTES技术的操作要点、面临的问题及其并发症：分析NOTES围手术期实验动物心肺功能及免疫应激指标的变化情况并与传统腹腔镜手术进行对照研究以及初步探讨NOTES操作时相关并发症的预防策略。
方法：选用五指山小型猪30只,体重20-25kg。对实验动物行静脉复合麻醉,气管插管及呼吸机辅助呼吸后,采用双孔道内镜进入胃肠道或阴道,选取胃窦体交界前壁小弯侧、距肛门15cm-20cm结肠后壁系膜对侧或阴道后穹窿位置造口,建立入路。内镜经造口进入腹腔后,应用双孔道内镜或在经脐单孔腹腔镜辅助下行腹腔内探查或/和胆囊切除。研究有三个部分组成：实验一选用五指山小型猪20只,按随机原则分为两组,每组10只动物,即单纯经胃途径NOTES胆囊切除术组(A组)和经胃途径NOTES联合经脐单孔腹腔镜胆囊切除术组(B组)。对两组动物分别行胆囊切除术,观察、比较、分析两种术式的可行性、有效性和安全性；实验二将实验一中两组实验动物分别按照随机原则再分为两组,共分为四组,每组5只实验动物,即A1、A2和B1、B2组。其中A1及B1组在行胆囊切除术前以生理盐水充分冲洗胃腔进行消毒,A2及B2组不行任何消毒处理。对实验中所有动物于术前、手术结束时分别取胃腔、腹腔冲洗液进行细菌培养,分析术前生理盐水冲洗是否会减少术后腹腔感染的发生。并对四组实验动物术后炎症反应情况进行观察、分析；实验三选用五指山小型猪10只,按随机原则分为两组,每组5只,即行NOTES腹腔探查术组(N组)和行腹腔镜腹腔探查术组(F组),监测术中、术后研究对象心肺功能(血压、心率及动脉血气)、应激反应指标(白介素-1及肿瘤坏死因子)的变化,将两种术式对实验动物围手术期的影响加以比较分析,观察NOTES对机体的创伤；
结果：实验一：共成功完成胆囊切除术12例次,成功率为60.0%(12/20);其中单纯NOTES经胃途径(A组)成功5例次,成功率为50.0%(5/10)；联合途径(B组)成功7例次,成功率为70.0%(7/10)。存活实验11例次,急性实验9例次,其中A组存活4例次,B组存活7例次；实验二：共19只动物57份标本完成细菌培养(A2组中1份标本24小时内未能送检)。四组实验动物术前胃内标本液(标本A)及术前腹腔冲洗液(标本B)细菌培养结果无明显差异；虽四组动物术后腹腔冲洗液细菌种类无明显差异,均以大肠埃希菌、肺炎克雷柏菌为主,但A1、B1组中细菌生长数目明显少于A2、B2组,而且前两组中有细菌生长标本的总例数少于后两组(30.0%vs60.0%)。同时在存活动物实验中,A1、B1组术后第1及3天平均WBC水平明显低于后两组；实验三：10只动物均成功行NOTES或腹腔镜探查术,术后均成活超过7天。两组动物间术前、术中及术后在平均心率、平均动脉血压变化上无明显区别；两组动物术后24及72小时平均IL1-β及TNF-a水平均明显高于术前水平。两组间在术后平均白介素1-B水平除术后第72小时上无明显差异,N组术后24及72小时肿瘤坏死因子明显高于F组。术后第7天两组动物平均IL1-β及TNF-a水平已基本恢复术前水平。
结论：①采用现有内镜设备,单纯NOTES途径可以完成腹腔内脏器的探查,但完成脏器切除术难度较大、成功率较低；②采用联合经脐腹腔镜辅助行NOTES胆囊切除术,可以提高自然管壁造口安全性,改善腹腔内空间定位,显著降低操作难度并提高操作成功率,具有一定的可行性；③经钛钉直接夹闭自然管壁造口的成功率较高,但有一定失败率,闭口失败后容易因造口漏而导致腹膜炎等严重并发症；④术前生理盐水冲洗胃腔是有效降低术后感染及减少细菌移位的有效方法之一;⑤与传统腹腔镜探查术相比较,由于目前内镜建立气腹压力波动较大,经胃途径NOTES腹腔探查术并没有降低对实验动物的创伤,但并没有增加实验动物围手术期并发症发生及死亡率；⑥目前内镜器械及设备完成腹腔内脏器的切除难度很大,为充分发挥NOTES技术优势,有待于发明更多先进的软镜设备及器械。
Background and objective:Natural orifice transluminal endoscopic surgery(NOTES) is a novel surgical technique that performs the diagnosis and therapy for patients via the orifice routes(as transgastric, transcolonic or transvaginal) to the peritoneal cavity without abdominal insicions. NOTES have potiental advantages as following no abdominal insicion, lesser postoperative pain, shorter length of hospital stay and better cosmesis and so on, compared to tranditional open surgery and laparoscopy. So it is regarded as a milestone of mini-invasive surgery and focused by surgeons and gastroenterologists. The NOTES-related experimental and clinical reseach has made significant achievements in western developed countries, unfortunaterly the NOTES study are carried out only in a few hospitals or laboratorys and it is still in the primary stage in our country.
To eveluate the feasibility, safety and efficacy of the NOTES to undergo the intra-abdominal surgery, this systemic animal experiment is designed. In the first part, the cholecystectomy is performed in the survival porcines to analysize and summarize the techniques, difficulty and complications of NOTES. In the second part, compared to the traditional laparoscopic surgery, the perioperatively cardiopulmonary and inflammatory response indicators are summarized to eveluate the safety of NOTES. In the third part, we summarize the prevention strategies of the postoperative infection primarily.
Methods:30female WuZhiShan small porcines(WZSSP) were involved in the study. The pigs were deprived of food for24h before surgery. General anesthesia was induced to all animals with intravenous(IV) propofol10ml/30kg and pancuronium2ml. Then a sterile double-channel video endoscopy was inserted into the stomach, The gastrotomy site was carefully chosen by observation of the indentation on the gastric wall produced by palpation of the anterior abdominal wall or the colotomy was produced in the sigmoid colon15-20cm from the anal verge. Aneedleknife was used to make a incision on the natural orifice wall, which was enlarged with a dilation bolloon. Then the endoscopy was inserted into the peritoneal cavity through the access or the hybrid cholecystectomies were performed. In the first part,20porcines were invidided into two groups randomly and received cholecystectomies with the total transgastric NOTES (group A)or laparoscopic assistance(group B), to summarize the the feasibility, safety and efficacy of the NOTES to undergo the intra-abdominal surgery. In the second part, all of animals in the first part were divided into two groups before the NOTES respectively, i.e. a gastric lavage was performed before NOTES with1,500-2,000ml of sterile saline solution0.9%in group A1and B1and the gastric lavage wasn't performed in group A2and B2. Gastroscope and peritoneal fluid aspirates in each animal were obtained prior to and after the gastrotomy. Each sample was sent for bacterial colony counts, culture, and identification of species. In the third part,10WZSSP were divided into two groups, i.e. the laparotomy was performed by the total NOTES through the oral access and the pneumoperitoneum were created with the endoscopic insufflation (N group) or by the traditional laparoscopy and the pneumoperitoneum were created with the standard autoregulated laparoscopic insufflator using carbon dioxide(CO2)(F group). In this part, the the perioperatively cardiopulmonary and inflammatory response indicators of each group were collected and summarized.
Results:In the first part, the cholecystectomy were successfully performed in12porcines and the success rate was60%.5in group A and7in group B respectively. In the second part, the specimens of19of20animals in the first part were performed NOTES through the stomach. There was no significant difference between both groups on the average platelet preoperatively and postoperatively. However, the white blood cell(WBC) on the postoperative day1and3in the group A1and B1were significant lower than in the group A2and B2. There was no different on the bacterial species bwtween two groups, however, there were fewer bacterial contamination on Contaminated peritoneum sample after NOTES(sample C) in the former two groups than in the other two(30.0%vs55.6%). In the third part, all of10porcines were performed laparotomy by NOTES or laparoscopy without periopera-tive and postoperative complications. There was no significant difference between both groups on the perioperatively and postoperatively average heart rate and arterial blood pressure(ABP). There was no significant difference between both groups on the postoperatively average interleukin-1(IL-1) except on the postoperative day3. And the average tumor necrosis factor-a(TNF-a) on the postoperative day1and3in the group N were significant higher than in the group F. The IL-1and TNF-α on the postoperative day7in both groups were reduced to the normal level almostly.
Conclusions:①Using the total transgastric or transcolonic route to expore the peritoneal cavity is feasible with safety, however, it is difficult to performed cholecystectomy using the present endoscopic instruments;②The hybrid approach increases safety of natural orifice wall incision, improves orientation and navigation of the flexible endoscope inside the peritoneal cavity, simplifies NOTES;③The natural orifice wall incision was closed with endoscopic clips is safe to most of animals, however, there are some failures which may lead to gastric and intestinal lavage and peritonitis;④compared to the trditional laparoscopic laparotomy, using the present endoscopic insufflation to create the pneumoperitoneum, the trauma to the experimental animals of the natural orifice translunimal endoscopic laparotomy is much more;⑤The gastric lavage using sterile saline solution before NOTES is one of the effective method of disinfection;⑥It is difficult to performed surgery into the peritoneal cavity using the endoscopic instruments, so much endoscopic instruments need to be improved to show the potential advantages of NOTES.
引文
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10. Merrifield BF, Wagh MS, Thompson CC. Peroral transgastric organ resection:a feasibility study in pigs[J]. Gastrointest Endosc,2006,63:693-697.
11. Swanstrom LL, Kozarek R, Pasricha PJ, et al. Development of a new access device for transgastric surgery[J]. J Gastrointest Surg,2005,9:1129-1136.
12. Rolanda C, Lima E, Pego JM, et al. Third-generation cholecystectomy by natural orifices:transgastric and transvesical combined approach[J]. Gastrointest Endosc, 2007,65:111-117.
13. Perretta S, Dallemagne B, Coumaros D, et al. Natural orifice transluminal endoscopic surgery:transgastric cholecystectomy in a survival porcine model[J]. Surg Endosc,2008,22:1126-1130.
14. Kantsevoy SV, Jagannath SB, Niiyama H, et al. A novel safe approach to the peritoneal cavity for per-oral transgastric endoscopic procedures[J]. Gastrointest Endosc,2007,65:497-500.
15. Magno P, Giday SA, Dray X, et al. A new stapler-based full-thickness transgastric access closure:results from an animal pilot trial[J]. Endoscopy,2007,39:876-880.
16. Hazey JW, Narula VK, Renton DB, et al. Natural orifice transgastric endoscopic peritoneoscopy in humans:initial clinical trial[J].Surg Endosc,2008,22:16-20.
17. Onders RP, McGee MF, Marks J, et al. Natural orifice transluminal endoscopic surgery (NOTES) as a diagnostic tool in the intensive care unit[J].Surg Endosc, 2007,21:681-683.
18. Sumiyama K, Gostout CJ, Rajan E. et al. Submucosal endoscopy with mucosal flap safety valve[J]. Gastrointest Endosc,2007,65:688-694.
19. Sumiyama K, Gostout CJ, Rajan E, et al. Transgastric cholecystectomy: transgastric accessibility to the gallbladder improved with the SEMF method and a novel multibending therapeutic endoscope[J]. Gastrointest Endosc,2007,65: 1028-1034.
20. Sugimoto M, Yasuda H, Koda K, et al. Rendezvous gastrotomy technique using direct percutaneous endoscopic gastrostomy for transgastric cholecystectomy in hybrid natural orifice translumenal endoscopic surgery[J]. J hepatobiliary Pancreat Surg,2009,16:758-762.
21. Kantsevoy SV, Niiyama H, Jagannath SB, et al. The endoscopic transilluminator: an endoscopic device for identification of the proximal jejunum for transgastric endoscopic gastrojejunostomy [J]. Gastrointest Endosc,2006,63:1055-1058.
22. Kalloo AN, Singh VK, Jagannath SB, et al. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity[J]. Gastrointest Endosc,2004,60:114-117.
23. Ryou M, Fong DG, Pai RD, et al. Transluminal closure fo rNOTES:an ex vivo study comparing leak pressures of various gastrotomy and colotomy closure modalities[J].Endoscopy,2008,40:432-436.
24. Fong DG, Pai RD, Thompson CC. Transcolonic endoscopic abdominal exploration:a NOTES survival study in a porcine model[J].Gastrointest Endosc, 2007,65:312-318.
25. Kirschniak A, Kratt T, Stuker D, et al. A new endoscopic over-the-scope clip system for treatment of lesions and bleeding in the GI tractfirst clinical experiences[J]. Gastrointest Endosc,2007,66:162-167.
26. Ikeda K, Fritscher-Ravens A, Mosse CA, et al. Endoscopic full-thickness resection with sutured closure in a porcine model[J].Gastrointest Endosc, 2005,62:122-129.
27. Fritscher-Ravens A, Mosse CA, Ikeda K, et al. Endoscopic transgastric lymphade-nectomy by using EUS for selection and guidance[J]. Gastrointest Endosc,2006, 63:302-306.
28.Auyang ED, Hungness ES, Vaziri K, et al. Natural orifice translumenal endoscopic surgery(NOTES):dissection for the critical view of safety during transcolonic cholecystectomy[J]. Surg Endosc,2009,23:1117-1118.
29. Shih SP, Kantsevoy SV, Kalloo AN, et al. Hybrid minimally invasive surgery-a bridge between laparoscopic and translumenal surgery[J]. Surg Endosc.2007,21: 1450-1453.
30. Voermans RP, van Berge Henegouwen MI, Bemelman WA, et al. Hybrid NOTES transgastric cholecystectomy with reliable gastric closure:a nanimal survival study [J]. Surg Endosc,2011,25(3):728-736.
31.Wagh MS, Merrifield BF, Thompson CC. Endoscopic transgastric abdominal exploration and organ resection:initial experience in a porcine model [J]. Clin Gastroenterol Hepatol,2005,3:892-896.
32. Kantsevoy SV, HuB, Jagannath SB, et al. Transgastric endoscopic splenectomy:is it possible? [J]. Surg Endosc,2006,20(3):522-525.
33. Kantsevoy SV, Jagannath SB, Niiyama H, et al. Endoscopic gastrojejunostomy with survival in a porcine model[J].Gastrointest Endosc,2005,62(2):287-292.
34. Wagh MS, Merrifield BF, Thompson CC. Survival studies after endoscopic transgastric oophorectomy and tubectomy in a porcine model[J]. Gastrointest Endosc,2006,63(3):473-478.
35. Williams MD, Champion JK. Experience with routine intraabdominal cultures during laparoscopic gastric by pass with implications for antibiotic prophylaxis[J]. Surg Endosc,2004,18:755-756.
36. Grant SW, Hopkins J, Wilson SE. Operative site bacteriology as an indicator of postoperative infectious complications in elective colorectal surgery [J]. Am Surg, 1995,61(10):856-861.
37. Bartlett JG, Condon RD, Gorbach SL,et al. VA cooperative study on bowel preparation from elective colorectal operations:impact of oral antibiotic regimenon colonic flora, wound irrigation cultures, and bacteriology of septic complications[J]. Ann Surg,1978,188:249-254.
38. Narula VK, Hazey JW, Renton DB, et al. Transgastric instrumentation and bacterial contamination of the peritoneal cavity[J]. Surg Endosc,2008.22:605-611.
39. Bachman SL, Sporn E, Furrer JL et al. Colonic sterilization for natural orifice translumenal endoscopic surgery(NOTES) procedures:a comparison of two decontamination protocols[J]. Surg Endosc,2009,23:1854-1859.
40. Noguera J, Dolz C, Cuadrado A, et al. Hybrid transvaginal cholecystectomy, NOTES, and minilaparoscopy:analysis of a prospective clinical series[J]. Surg Endosc,2009,23:876-881.
41. Bingener J, Michalek J, Sickle KV, et al. Randomized blinded trial shows relative thrombocytopenia in natural orifice translumenal endoscopic surgery compared with standard laparoscopy in a porcine survival model[J]. Surg Endosc.2008,22: 2067-2071.
42. Meireles O, Kantsevoy SV, Kalloo AN, et al. Comparison of intraabdominal pressures using the gastroscope and laparoscope for transgastric surgery[J]. Surg Endosc,2007,21:998-1001.
43. Uemura N, Nomura M, Inoue S, et al. Changes in hemodynamics and autonomic nervous activity in patients undergoing laparoscopic cholecystectomy:differences bewteen pneumoperitoneum and abdominal wall-lifting method[J]. Endoscopy, 2002,34(8):643-651.
44. Bingener J, Michalek J, Winston J, et al. Randomized blinded trial comparing the cardiopulmonary effects of NOTES with standard laparoscopy in a porcine survival model [J]. Surg Endosc,2008,22:1430-1434.
45.冯梅.二氧化碳气腹对围手术期呼吸功能的影响.微创医学[J],2007,2(3)：214-216.
46.王琛,李徐生.腹腔镜胆囊切除术中气腹对呼吸系统功能的影响[J].腹腔镜外科杂志,2006,11(3)：245-246.
47.田文,李荣.结直肠癌腹腔镜切除术对机体应激反应影响的临床研究[J].中国普外基础与临床杂志,2004,11(3)：204-205.
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2. Jagannath SB, Kantsevoy SV, Vaughn CA, et al. Peroral transgastric endoscopic ligation of fallopian tubes with longterm survival in a porcine model[J]. Gastrointest Endosc,2005,61(3):449-453.
3. Park PO, Bergstrom M, Ikeda K, et al. Experimental studies of transgastric gallbladder surgery:cholecystectomy and cholecystogastric anastomosis[J]. Gastrointest Endosc,2005,61(4):601-606.
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2. Jagannath SB, Kantsevoy SV, Vaughn CA, et al. Peroral transgastric endoscopic ligation of fallopian tubes with long term survival in a porcine model[J]. Gastrointest Endosc,2005,61(3):449-453.
3. Park PO, Bergstrom M, Ikeda K, et al. Experimental studies of transgastric gallbladder surgery:cholecystectomy and cholecystogastric anastomosis[J]. Gastrointest Endosc,2005,61(4):601-606.
4. Rattner D, Kalloo AN. ASGE/SAGES working group on natural orifice translumenal endoscopic surgery[J]. Surg Endosc,2006,20(3):329-333.
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9. Bergstrom M, Ikeda K, Swain P, et al. Transgastric anastomosis by using flexible endoscopy in a porcine model (with video)[J].Gastrointest Endosc,2006,63: 307-312.
10. Merrifield BF, Wagh MS, Thompson CC. Peroral transgastric organ resection:a feasibility study in pigs[J]. Gastrointest Endosc,2006,63:693-697.
11. Swanstrom LL, Kozarek R, Pasricha PJ, et al. Development of a new access device for transgastric surgery[J]. J Gastrointest Surg,2005,9:1129-1136.
12. Rolanda C, Lima E, Pego JM, et al. Third-generation cholecystectomy by natural orifices:transgastric and transvesical combined approach[J]. Gastrointest Endosc, 2007,65:111-117.
13. Perretta S, Dallemagne B, Coumaros D, et al. Natural orifice transluminal endoscopic surgery:transgastric cholecystectomy in a survival porcine model[J]. Surg Endosc,2008,22:1126-1130.
14. Kantsevoy SV, Jagannath SB, Niiyama H, et al. A novel safe approach to the peritoneal cavity for per-oral transgastric endoscopic procedures[J]. Gastrointest Endosc,2007,65:497-500.
15. Magno P, Giday SA, Dray X, et al. A new stapler-based full-thickness transgastric access closure:results from an animal pilot trial[J]. Endoscopy,2007,39:876-880.
16. Hazey JW, Narula VK, Renton DB, et al. Natural orifice transgastric endoscopic peritoneoscopy in humans:initial clinical trial[J].Surg Endosc,2008,22:16-20.
17. Onders RP, McGee MF, Marks J, et al. Natural orifice transluminal endoscopic surgery (NOTES) as a diagnostic tool in the intensive care unit[J].Surg Endosc, 2007,21:681-683.
18. Sumiyama K, Gostout CJ, Rajan E. et al. Submucosal endoscopy with mucosal flap safety valve[J]. Gastrointest Endosc,2007,65:688-694.
19. Sumiyama K, Gostout CJ, Rajan E, et al. Transgastric cholecystectomy: transgastric accessibility to the gallbladder improved with the SEMF method and a novel multibending therapeutic endoscope[J]. Gastrointest Endosc,2007,65: 1028-1034.
20. Sugimoto M, Yasuda H, Koda K, et al. Rendezvous gastrotomy technique using direct percutaneous endoscopic gastrostomy for transgastric cholecystectomy in hybrid natural orifice translumenal endoscopic surgery[J]. J hepatobiliary Pancreat Surg,2009,16:758-762.
21. Kantsevoy SV, Niiyama H, Jagannath SB, et al. The endoscopic transilluminator: an endoscopic device for identification of the proximal jejunum for transgastric endoscopic gastrojejunostomy [J]. Gastrointest Endosc,2006,63:1055-1058.
22. Kalloo AN, Singh VK, Jagannath SB, et al. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity[J]. Gastrointest Endosc,2004,60:114-117.
23. Ryou M, Fong DG, Pai RD, et al. Transluminal closure fo rNOTES:an ex vivo study comparing leak pressures of various gastrotomy and colotomy closure modalities[J].Endoscopy,2008,40:432-436.
24. Fong DG, Pai RD, Thompson CC. Transcolonic endoscopic abdominal exploration:a NOTES survival study in a porcine model[J].Gastrointest Endosc, 2007,65:312-318.
25. Kirschniak A, Kratt T, Stuker D, et al. A new endoscopic over-the-scope clip system for treatment of lesions and bleeding in the GI tractfirst clinical experiences[J]. Gastrointest Endosc,2007,66:162-167.
26. Ikeda K, Fritscher-Ravens A, Mosse CA, et al. Endoscopic full-thickness resection with sutured closure in a porcine model[J].Gastrointest Endosc, 2005,62:122-129.
27. Fritscher-Ravens A, Mosse CA, Ikeda K, et al. Endoscopic transgastric lymphade-nectomy by using EUS for selection and guidance[J]. Gastrointest Endosc,2006, 63:302-306.
28.Auyang ED, Hungness ES, Vaziri K, et al. Natural orifice translumenal endoscopic surgery(NOTES):dissection for the critical view of safety during transcolonic cholecystectomy[J]. Surg Endosc,2009,23:1117-1118.
29. Shih SP, Kantsevoy SV, Kalloo AN, et al. Hybrid minimally invasive surgery-a bridge between laparoscopic and translumenal surgery[J]. Surg Endosc.2007,21: 1450-1453.
30. Voermans RP, van Berge Henegouwen MI, Bemelman WA, et al. Hybrid NOTES transgastric cholecystectomy with reliable gastric closure:a nanimal survival study [J]. Surg Endosc,2011,25(3):728-736.
31.Wagh MS, Merrifield BF, Thompson CC. Endoscopic transgastric abdominal exploration and organ resection:initial experience in a porcine model [J]. Clin Gastroenterol Hepatol,2005,3:892-896.
32. Kantsevoy SV, HuB, Jagannath SB, et al. Transgastric endoscopic splenectomy:is it possible? [J]. Surg Endosc,2006,20(3):522-525.
33. Kantsevoy SV, Jagannath SB, Niiyama H, et al. Endoscopic gastrojejunostomy with survival in a porcine model[J].Gastrointest Endosc,2005,62(2):287-292.
34. Wagh MS, Merrifield BF, Thompson CC. Survival studies after endoscopic transgastric oophorectomy and tubectomy in a porcine model[J]. Gastrointest Endosc,2006,63(3):473-478.
35. Williams MD, Champion JK. Experience with routine intraabdominal cultures during laparoscopic gastric by pass with implications for antibiotic prophylaxis[J]. Surg Endosc,2004,18:755-756.
36. Grant SW, Hopkins J, Wilson SE. Operative site bacteriology as an indicator of postoperative infectious complications in elective colorectal surgery [J]. Am Surg, 1995,61(10):856-861.
37. Bartlett JG, Condon RD, Gorbach SL,et al. VA cooperative study on bowel preparation from elective colorectal operations:impact of oral antibiotic regimenon colonic flora, wound irrigation cultures, and bacteriology of septic complications[J]. Ann Surg,1978,188:249-254.
38. Narula VK, Hazey JW, Renton DB, et al. Transgastric instrumentation and bacterial contamination of the peritoneal cavity[J]. Surg Endosc,2008.22:605-611.
39. Bachman SL, Sporn E, Furrer JL et al. Colonic sterilization for natural orifice translumenal endoscopic surgery(NOTES) procedures:a comparison of two decontamination protocols[J]. Surg Endosc,2009,23:1854-1859.
40. Noguera J, Dolz C, Cuadrado A, et al. Hybrid transvaginal cholecystectomy, NOTES, and minilaparoscopy:analysis of a prospective clinical series[J]. Surg Endosc,2009,23:876-881.
41. Bingener J, Michalek J, Sickle KV, et al. Randomized blinded trial shows relative thrombocytopenia in natural orifice translumenal endoscopic surgery compared with standard laparoscopy in a porcine survival model[J]. Surg Endosc.2008,22: 2067-2071.
42. Meireles O, Kantsevoy SV, Kalloo AN, et al. Comparison of intraabdominal pressures using the gastroscope and laparoscope for transgastric surgery[J]. Surg Endosc,2007,21:998-1001.
43. Uemura N, Nomura M, Inoue S, et al. Changes in hemodynamics and autonomic nervous activity in patients undergoing laparoscopic cholecystectomy:differences bewteen pneumoperitoneum and abdominal wall-lifting method[J]. Endoscopy, 2002,34(8):643-651.
44. Bingener J, Michalek J, Winston J, et al. Randomized blinded trial comparing the cardiopulmonary effects of NOTES with standard laparoscopy in a porcine survival model [J]. Surg Endosc,2008,22:1430-1434.
45.冯梅.二氧化碳气腹对围手术期呼吸功能的影响.微创医学[J],2007,2(3)：214-216.
46.王琛,李徐生.腹腔镜胆囊切除术中气腹对呼吸系统功能的影响[J].腹腔镜外科杂志,2006,11(3)：245-246.
47.田文,李荣.结直肠癌腹腔镜切除术对机体应激反应影响的临床研究[J].中国普外基础与临床杂志,2004,11(3)：204-205.
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