本帖最後由 goodcat1111 於 2009-5-13 17:19 編輯
作者：Laura Newman
出處：WebMD醫學新聞
May 1, 2009 —根據美國胃腸道與內視鏡手術協會(SAGES)2009年科學小組會議與畢業後課程中的新研究，使用「經自然管口內視鏡手術(natural orifice transluminal endoscopic surgery，NOTES)」，是手術發展中最熱門的領域之一。
當合併使用最小的腹腔鏡器械時，NOTES可以讓手術中進入腹腔的外漏減到最小，外漏是一種可能致命的後遺症。
西班牙Son Llatzer醫院一般外科Angel Cuadrado-Garcia博士報告人類合併使用經陰道NOTES以及微型腹腔鏡器械進行膽囊切除術，取代傳統腹腔鏡膽囊切除術的初步結果。
Cuadrado-Garcia博士表示，這是真正的改革，20年前，開始了腹腔鏡革命，現在，我們使用經陰道手術開始一個新的變革；不同於胃與直腸，陰道容易關閉且可完整清潔。
混合技術讓外科醫師以最少的腹壁開孔進行腹腔內手術，用的是一般外科醫師於內視鏡和腹腔鏡習於使用的相同器械。
【混合技術的效果】
Cuadrado-Garcia博士的研究包括了隨機挑選的25名女性病患，沒有控制組，所有病患都接受聯合經陰道NOTES/2套管之微型腹腔鏡手術(一個5-mm肚臍套管以及一個3-mm上方象限套管)；沒有手術中併發症。2位病患有泌尿道感染，1位有輕微血尿、在24小時內緩解。這25人中有20人在術後24小時內出院；5人在手術後12小時內出院。追蹤140天時，發現並無殘留的併發症。Cuadrado-Garcia博士也使用聯合方式進行一例闌尾切除術與一例「半結腸切除術 」。
根據Cuadrado-Garcia博士表示，此技術的好處包括外觀改善以及沒有疼痛。不過，他表示，只有婦女能從聯合技術中獲得好處。為了讓NOTES也可運用於男性的類似手術，目前已經進行經胃、經大腸、經尿道的NOTES手術。
哥倫比亞大學-紐約長老教會醫學中心內視鏡主任、臨床醫學副主任Peter Stevens醫師在Medscape General Surgery的訪問中表示，經陰道手術在過去數十年來主要是婦產科醫師的強項，對一般外科醫師來說，陰道確實是一個新的進入路徑。
【提升經陰道技術】
本研究指出的是一系列其他中心進行的混合版或聯合版NOTES。此類研究對於提升經陰道技術有重要影響，但問題在於它是否最終會取代腹腔鏡膽囊切除術這個低併發症比率手術，我對於建議它作為標準手術步驟有一點顧慮，它應該有減少皮膚切口之外的其他好處。
Stevens醫師預見，在更多有限的手術進行之後，對於混合型手術會有許多驚嘆。它比較像用NOTES方法讓一些有利的手術，如內視鏡空腸造口術、減重手術、加護病房病患之診斷評估、插入橫膈節律以及阻斷神經緩解疼痛更容易、更安全或者更有效。
其他的附加好處是有關手術室與手術無菌環境有限的地區，如戰場。Stevens醫師表示，此類環境中，NOTES手術可以使用特殊的內視鏡工具，把病患腹內環境作為手術室。
Cuadrado-Garcia博士以及 Stevens醫師宣告沒有相關財務關係。
美國胃腸道與內視鏡手術協會2009年科學小組會議與畢業後課程：小組S077。發表於2009年4月25日。
SAGES 2009: Hybrid Transvaginal Cholecystectomy Found Safe in Human Study
By Laura Newman
Medscape Medical News
May 1, 2009 — Operating through the body’s natural orifices, using a technique known as natural orifice transluminal endoscopic surgery (NOTES) is one of the hottest areas in surgery development, according to new research at the Society of American Gastrointestinal and Endoscopic Surgery (SAGES) 2009 Annual Scientific Session and Postgraduate Course.
When used in combination with the smallest laparoscopic instrumentation, NOTES has the potential to minimize the likelihood of leakage into the abdominal cavity during surgery, a consequence that could be lethal.
Angel Cuadrado-Garcia, MD, PhD, from the Department of General Surgery, Hospital Son Llatzer, Palma de Mallorca, Spain, reported early results with the technique in humans using a hybrid technique that combined transvaginal NOTES with minilaparoscopy for cholecystectomy as an alternative to conventional laparoscopic cholecystectomy.
“This is really revolutionary: 20 years ago, the laparoscopy revolution began,” said Dr. Cuadrado-Garcia. “Now we are beginning a new revolution using transvaginal procedures. The vagina is easy to close and completely clean, unlike the stomach or rectum.”
What the hybrid technique allows surgeons to do is perform intraperitoneal surgical procedures with a minimum number of access points in the abdominal wall using the same instruments that general surgeons are accustomed to using for endoscopy and laparoscopy.
Effectiveness of Hybrid Technique
Dr. Cuadrado-Garcia’s study consisted of 25 consecutive female patients randomly chosen. There was no control group. All patients underwent a fusion transvaginal NOTES/minilaparascopy procedure with 2 trocars (a 5-mm umbilical trocar and a 3-mm trocar for the upper quadrant). There were no intraoperative complications. Two patients had urinary tract infections, and 1 had mild hematuria that resolved within 24 hours. Twenty of 25 patients were discharged within 24 hours of surgery; 5 were discharged less than 12 hours after the procedure. Follow-up at 140 days revealed no residual complications. Dr. Cuadrado-Garcia has also used a fused approach to perform an appendectomy and a hemicolectomy.
Advantages of the technique are improved cosmesis and no pain, according to Dr. Cuadrado-Garcia. However, one limitation is that “only 50% of the population [women] can benefit” from the fusion technique, he said. To make NOTES available to men for similar surgeries, research is actively underway exploring transgastric, transcolonic, and transurethral NOTES procedures.
Although transvaginal procedures have been a mainstay for gynecologists for decades, the vagina is “truly a novel access factor” for general surgeons, said Peter Stevens, MD, associate director of clinical medicine and director of endoscopy at Columbia University – New York Presbyterian Medical Center, said in an interview with Medscape General Surgery.
Refining Transvaginal Techniques
“What this study adds is a new series at another center performing hybrid or fusion NOTES.” Series like these play a valuable role in refining transvaginal techniques, but he questioned whether it would ever supplant laparoscopic cholecystectomy — a surgery that has a very low complication rate. “I am a little cautious about recommending it as standard operating procedure. It should be able to show that it has benefits beyond the lack of skin incisions.”
What Dr. Stevens foresees is a burst of “wow” with hybrid surgeries, followed by using them in more limited surgeries. It is most likely to play a role in “niche operations ... [making them] easier, safer, or more effective by the NOTES approach, including endoscopic jejunostostomy, bariatric procedures, diagnostic evaluation of ICU [intensive care unit] patients, insertion of diaphragmatic pacemakers, and nerve blocks for pain relief,” he said.
Another setting where it will provide added benefit is in settings where access to operating rooms and to a surgical sterile environment is limited — for example, the battlefield. “In that setting,” said Dr. Stevens, “a NOTES procedure could make the patient’s own abdomen the operating room where specially developed endoscopic tools would be used.”
Dr. Cuadrado-Garcia and Dr. Stevens have disclosed no relevant financial relationships.
Society of American Gastrointestinal and Endoscopic Surgery (SAGES) 2009 Annual Scientific Session and Postgraduate Course: Session S077. Presented April 25, 2009. |
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