Animal Experiment And Primarily Clinical Application Of Natural Orifice Transluminal Endoscopic Surgery In Thoracic Surgery

ObjectiveTo evaluate the feasibility and safety of transesophageal, vaginal and umbilicalendoscopic thoracic sympathectomy and pericardial window creation in pig model.On the basis of accumulated experience in animal experiments, translate the techniqueof transumbilical endoscopic sympathectomy into human clinical studies and explorethe feasibility, safety and efficacy of this technique.MethodsThis feasibility study was conducted on the porcine model (domestic pig). Flexibleendoscopic thoracic sympathectomy and pericardial window creation were performedin10animals (3acute and7four-week survivals) in three groups: transesophageal,transvaginal and transumbilical group. Animals in the acute experiment wereeuthanized after completion of the operating procedure. The pigs in the survivalexperiment were kept alive for4weeks and then killed. Necropsy was then performed.The clinical study of transumbilical thoracic sympathectomy was performed undergeneral anesthesia. The patients were placed in the supine position with the armsabducted and intubated with a dual lumen endotracheal tube. Intraoperative eventsand surgical results were recorded and analysed.ResultsThe animal experiment was successfully performed in28of30swine. One swine wasdied of the thoracic aorta injury and another one was died of the left azygos veininjury in transesophageal group. Additionally, chest wall injury and rectal injury werefound in2and1cases, respectively in the transvaginal group. In the acute group, thepostoperative autopsy confirmed that bilateral T3ganglias were identified accurately,and cauterization was successful in all pigs, so as the pericardial window creation. In the survival group, all pigs survived well after surgery for4weeks without adverseconsequences. Postoperative autopsy confirmed that the esophageal, vesical anddiaphragmatic incision was completely healed, and there were no vital structure injuryor diaphragmatic hernia, and no signs of infection in both thoracic and peritonealcavities. Howerer, adhesions were found between extraesophageal layer and lungtissue in3animals in transesophageal group. The adhesions were also found betweendiaphragm and lung tissue in4and3animals in transvaginal and transumbilical grouprespectively.During the study period, transumbilical thoracic sympathectomy was successfullyperformed in all36patients with a mean operation time of54min (range48–107min).Most patients were discharged on the first postoperative day. Follow-up was100%complete (range6–12months). Palmar hyperhidrosis was resolved completely onboth sides of all the patients, and the axillary hyperhidrosis was completely improvedin11(76%) patients. Compensatory hyperhidrosis was noticed in13(36.1%) patients.There was no mortality, no diaphragmatic hernia and no Horner’s syndrome wasobserved.Conclusions1、 Transesophageal approach has the advantage of short operating path and no scarsleft in the surface. But this approach is technically difficult, and many barriersneed to be overcome, such as safe enterotomy creation, infection prevention,tissue manipulation, and, primarily, safe and secure closure of perforations.2、 Transvaginal approach is comparatively safe. The incision and suture can beperformed under direct vision. However, the surgical path is too long, and thecontrollability of the instrument is poor.3、 This study demonstrates that transumbilical thoracic sympathectomy is technicallyfeasible and safe. It is as effective as thoracoscopic surgery in the treatment ofpalmar hyperhidrosis. This novel procedure affords maximum cosmetic benefitsby hiding the surgical incision in the umbilicus. But the operative time was longerthan that of thoracoscopic surgery, and the potential risks and benefits of thisapproach will be confirmed by more randomized clinical trials.