EUS导下消化道与胆囊暂时性支架吻合及关闭吻合口后对胆囊病理生理改变的研究

The prevalence of gallstones increases significantly in our country, and is associated with a number of major risk factors. Patients presenting with "symptomatic" do need treatment because of the high rates of poor disease outcomes, such as choledocholithiasis, or even gallbladder carcinoma., which decreases the life quality of patients and poses a huge burden on society. Although laparoscopic cholecystectomy is currently considered the gold standard in treating patients with symptomatic gallstones, the incidence of dyspepsia , choledocholithiasis, colon cancer maybe improved. Recent years, gall bladder-preserving cholelithotomy has become a hot spot in recent research. Open cholecystectomy and laparoscopic cholecystectomy (LC) both cause greater surgical trauma, and that both these procedures are cost-ineffective compared with our research project. In this project, we will implant a kind of self-made retrivable fully covered metal stent to anastomose the Gastrointestianl tract and gallbladder, and form a channel for extracting gall stones.After the procedure, we will remove the stent and observe the closure of the stoma, and influences on the bacteria colonization, histological ultrastructure and emptying function of the gallblader. This project intends to deliver a new, mini-invasive ,scientific and reasonable modality for cholelithiasis，and establish the fundamental theroy of the clinical application. At the same time, it will provide new therapy ideas for other gallbladder diseases.

胆囊结石在我国发病率高，且有上升趋势，不仅可导致化脓性胆囊炎、胆管炎等急重症，甚至诱发胆囊癌，极大地影响患者生活质量，影响社会发展。目前临床治疗胆囊结石的"金标准"为胆囊切除术，但切除胆囊后易引发消化不良、胆总管结石和结肠癌发病率增高，因此近年来保胆取石的意识和理念日渐增强，成为研究热点。本项目采取全新的思路，通过动物实验，借助内镜超声引导，研究吻合器式可回收支架由消化道植入，形成消化道-胆囊吻合，且具有防反流瓣防止消化道反流。借助支架通道，满足网篮或胆道镜取出胆囊结石，完全取石后取出支架，闭合吻合口。着重观察术后吻合口闭合情况，和手术对胆囊内细菌定植和组织超微结构的影响，评定术前术后胆囊收缩舒张功能，本研究将为胆囊结石治疗提出一种全新的、创伤更小、并且拥有自主知识产权的治疗方案，更为这种新术式的临床应用提供坚实的理论基础。同时也为胆囊息肉等其它胆囊疾病提供新的治疗思路。

胆囊结石在全球发病率约10％至15％，它可导致炎症、胆道梗阻甚至肿瘤的形成,严重影响人们的健康。随着现代医学对胆囊结石形成机制和胆囊复杂生理功能的认识加深，及内镜学和微创外科学的发展和进步，保留胆囊功能而只取结石治疗方法逐步得以实现。近年来我们开展了通过内镜超声辅助精准定位，选择胃壁或十二指肠壁与胆囊利用支架吻合建立瘘道，并借助瘘道进行内镜直视下胆囊内及胆囊管内结石取出的技术。但是，通过支架建立稳定的瘘道需要8至10天时间，这段时间可能由于消化道与胆囊的连通，导致胃内的胃液、十二指肠液、食物及消化道细菌等进入胆囊，造成胆囊病理生理的改变。针对上述问题，我们首先通过自主设计和改良电植入器和吻合器式可回收支架，使支架能安全植入，缩短了手术时间，减少了并发症发生可能性，制定了简便易学的操作流程；利用该术式模拟胆囊取石的过程并闭合吻合口，初步探索了消化道胆囊瘘的建立和闭合规律：瘘道建立时间大致为2-4周，闭合时间大致为24-48h；初步评定该术式对胆囊功能及菌群的影响：术后胆囊内细菌含量增加，原有菌落结构发生改变，虽然存在胆汁微环境的改变，但是细菌致成石相关活性的主要物质没有增加，因此手术对胆囊结石复发的影响较小；随后项目组对该术式进行了初步的临床治疗，对内镜超声下保胆取石的患者进行了长达20个月的超声随访评估中，仅1例术后12个月检查发现胆囊结石复发，其余显示没有胆囊结石或息肉复发，并且胆囊的功能仍然令人满意。内镜超声引导下消化道-胆囊吻合术在解决胆囊结石、缓解胆囊炎症的治疗方面效果肯定，值得推广。

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