消化道狭窄的内镜治疗

消化道狭窄的内镜治疗 病理类型 我国鳞癌为主97 6 上1 3段8 8 中1 3段65 9 下1 3段25 3 西方国家以下段食管为主 主要为腺癌 60 以上 食管癌的治疗 强调早期发现 早期诊断 早期治疗 手术治疗 姑息性手术 根治性手术内镜下治疗 食管扩张 食管支架取代传统的旁路手术 内镜下电灼切除 Nd YAG激光切除 光动力疗法等化疗 5 Fu和顺铂为主放疗 外放射为主以手术为主的综合治疗 手术适应证 早期食管癌中期 中下段食管癌病变在5cm内 上段在3cm内 全身情况好者中期 病变在5cm以上 无明显远处转移 全身条件允许 可采用术前放化疗与手术综合疗法放射治疗后复发 病变范围尚不大 无远处转移 全身情况良好者 手术禁忌证 食管癌病变广泛或累及邻近器官如气管 肺 纵隔等者已有锁骨上窝淋巴结等远处转移者有严重心 肺或肝功能不全者严重恶病质者 Surgicalresectionistheonlycurativetreatmentoptionforinvasiveesophagealcancer However despitecarefulstagingandadvancesinadjuvanttherapyandsurgicaltechniques 5 yearsurvivalratesrarelyexceed40 1 2Manypatientspresentwithlocoregionalrecurrenceanddistantmetastasiswithin2yearsaftercurativeesophagectomy 3Treatmentofpatientswithlocaldiseaserecurrenceaimsatrelievingdysphagia 食管气管瘘金属支架置放术 复查碘油造影未见造影剂瘘出 EsophagealdiseasesandtypesofSEMSusedUUCUEGZWEsophagealcarcinomaCervical n 14 77 Thoracic n 93 3147735G Ejunction n 79 44262 7Locallyrecurrentcarcinoma1236 n 48 Achalasia n 8 44 UU UncoveredUltraflex BostonScientific Boston Mass CU coveredUltraflex BostonScientific E Esophacoil InstentInc EdenPrarie Minn GZ GianturcoZ stent CookInc Bloomington Ind W Wallstent BostonScientific Factorsthatmaypredisposetoesophagealstentmigration multivariateanalysisNMigration pvalueGenderFemale588 13 61 5 0 0038StrictureTC802 13 15 4 0 954GEJ679 13 11 4 0 017EAC82 13 25 0 625PrevioustherapyS B42 13 15 4 0 997R102 13 15 4 0 997Dilation10mm246 13 46 1 0 000StentGZ32 13 15 4 0 719E124 13 30 7 0 104UU874 13 30 7 0 169CU953 13 23 0 0 166TC Esophagealthoraciccarcinoma GEJ carcinomaofthegastroesophagealjunction EAC esophagealachalasia S B surgeryCU coveredUltraflex GastrointestEndosc2001 53 96 97 Esophagealstentsformalignantstricturesclosetotheupperesophagealsphincter GastrointestEndosc2007 66 1082 90 Esophagealstentsforthepalliationofmalignantdysphagiaandfistularecurrenceafteresophagectomy Luminalpatency Themediansurvivaltimeafterstentingforallpatientswithstenosiswas70days range1dayto34months Stentinsertionwastechnicallysuccessfulinallbut1patient 98 Fig 1 Mediandurationofprimarystentpatencywas56days range1dayto33months Fig 2 Atotalof20episodesofstentdysfunctionoccurredin18 27 of66patientsatamedianof38dayspost SEMSinsertion range2 406days Stentdysfunctionwascausedbytissuein orovergrowth n8 stentmigration n9 andfoodimpaction n3 Tissuein andovergrowthoccurredatamedianof119dayspost SEMSinsertion range33 297days 5patientsweresuccessfullytreatedwithasecondSEMS Six 24 of25fullycoveredstentsversus3 7 of41partiallycoveredSEMSmigrated P 07 atamediantimeintervalof66daysafterSEMSinsertion range12 406days Ofthesepatients 6patientsrequiredasecondSEMS Foodbolusimpactionoccurredin3 20 patientsatamediantimeintervalof11daysafterSEMSinsertion all3weresuccessfullyclearedendoscopically InsertionofasecondSEMSwassuccessfulinallpatients 100 Medianpatencyofthesestentswas59days range5 286days Fistulasealing Themediansurvivaltimeofpatientswithmalignantfistulacausedbytumorrecurrencewas73days range10daysto91months Thecoatedsegmentofthestenteffectivelysealedfistulaeinallbut1patient 93 Thispatientwassuccessfullytreatedwithasecondstent Stentdysfunctionoccurredin6 40 of15patients In5 33 patients additionalstentsweresuccessfullyinsertedtomanagestentmigration n4 andpersistentleakageduringstenttreatment n1 Two 22 of9fullycoveredstentsversus2 33 of6partiallycoveredSEMSsmigratedatamediantimeintervalof5monthspost SEMSinsertion range5daysto11months Foodbolusimpactionoccurredin1patient17dayspost SEMSinsertion thispatientwasalsosuccessfullytreatedendoscopicallybystentclearance OverallcomplicationsMildcomplicationsafterstentplacementoccurredin7 9 patientsincludingretrosternalpainandsymptomaticgastroesophagealreflux Majorcomplicationsoccurredin9 11 patients Stridordevelopedimmediatelyafterinsertionin3patientswithalesionwithin4cmoftheupperesophagealsphincter Inall3patients thestentwasremoved andtheyweremanagedconservatively ThreepatientshadanupperGIhemorrhagefromthetumorsiteatamediantimeintervalof26daysafterSEMSinsertion range11daysto10months Thebleedingsubsidedspontaneouslyin1ofthesepatients theother2patientsdiedofthepersistentbleeding Anesophagealfistuladevelopedduringstenttreatmentin2patients bothofwhichwerelocatedatthedistalfunnelofthepartiallycoveredstentatamediantimeintervalof48dayspost SEMSinsertion Thesewalldefectsweresuccessfullysealedwithanadditionalstent Onepatienthadstent inducedulcerationafterstentmigrationat7monthsafterSEMSinsertionandrequiredendoscopicstentextraction SEMSplacementinrecurrentesophagealcanceraftersurgicalresectionoffersadequatepalliationbyrelievingdysphagiaandsealingoffesophagealrespiratoryfistula Therefore inthesepatientswhohavearelativelyshortlifeexpectancy theimplantationofSEMSstoshouldbeconsideredthetreatmentofchoice Esophagealrespiratoryfistulaeoccurin5 to10 ofpatientswithesophagealcancer Inourseries 19 ofpatientswithrecurrentcanceraftergastrictubeinterpositionpresentedwithafistula Thisrepresentsadevastatingcomplicationleadingtorecurrentpulmonaryinfectionsandtheinabilitytoeatorevenswallowsaliva Thisconditionisassociatedwithaveryhighshort termmortalityrate ThetechnicalsuccessoffistulasealingbySEMSswas93 whichiswithintherangeofthe80 to100 reportedbyotherseries Inthemajorityofpatientswithcancerrecurrenceafteresophagectomy thefistulaorstenosisislocatedclosetotheupperesophagealsphincter Atthislocation SEMSplacementmaycauseforeign bodysensation trachealcompression orrespiratoryfistula Ithasbeenhypothesizedthatstentsshouldhaveabodydiameterof18mmorlesstoavoidthesecomplications Inourseries however stridordevelopedin3 4 patientsandafistuladevelopedin2 2 patientsafterstentplacement despitetheuseofsmall diameterstentsin4ofthem Noneofthepatientsreportedglobussensation GastrointestEndosc2010 72 249 54 ComparisonofTemporaryandPermanentStentPlacementwithConcurrentRadiationTherapyinPatientswithEsophagealCarcinoma JVascIntervRadiol2005 16 67 74 MATERIALSANDMETHODS Coveredretrievableexpandablenitinolstentswereplacedin47patientswithesophagealcarcinoma1weekbeforestartingradiationtherapy thestentswereelectivelyremoved4weeksafterplacementin24patients groupA whilenotelectivelyremovedintheother23patients groupB Incasesofcomplications thestentswerealsoremovedfrompatientsingroupsAandB Thedysphagiascore complications severepain granulationtissueformation stentmigration esophagorespiratoryfistula andhematemesis tumorovergrowth regrowth reinterventionrates anddysphagia progression freeandoverallsurvivalrateswerecomparedinthetwogroups RESULTS Stentplacementorremovalwastechnicallysuccessfulandwelltoleratedinallpatients Thedysphagiascorewassignificantlyimprovedinbothgroupsafterstentplacement P 01 Eachofthestent relatedcomplicationswaslessingroupAthaningroupBbuttherewasnosignificantdifference However thetotalnumberofpatientswithoneormorethanonecomplicationsandwhoneededrelatedreinterventionswassignificantlylessingroupAthaningroupB P 042and 030 respectively Tumorovergrowth regrowthandthetotalnumberofpatientswhorequiredrelatedreinterventionswasnotsignificantlydifferent P1 00and 517 respectively Dysphagia progression freeandoverallsurvivalratesweresignificantlylongeringroupAthaningroupB P 005and 001 respectively CONCLUSION Temporaryplacementofacoveredretrievableexpandablemetallicstentwithconcurrentradiationtherapyforpatientswithesophagealcarcinomaisbeneficialforreducingcomplicationsandrelatedreinterventionsandforincreasingresultantsurvivalratescomparedwithpermanentesophagealstentplacement Useofself expandablemetalstentsforthetreatmentofesophagealperforationsandanastomoticleaks SurgEndosc 2009 23 1526 1530 EsophagorespiratoryFistula Long termResultsofPalliativeTreatmentwithCoveredExpandableMetallicStentsin61Patients RadiologyVol232 253 259 MATERIALSANDMETHODS SixtypatientswithERFsduetoesophagealorbronchogeniccarcinomaandonepatientwithERFduetopressurenecrosiscausedbyinitialesophagealstentplacementforesophagealcarcinomaweretreatedwithcoveredexpandableesophagealortracheobronchialmetallicstents Informationabouttechnicalsuccessofstentplacement initialclinicalsuccessandfailure fistulareopening andcomplicationswasobtained SurvivalcurvesforbothpatientgroupswithinitialclinicalsuccessandfailurewereobtainedandcomparedwithKaplan Meiermethodsandlog ranktest RESULTS Stentplacementwastechnicallysuccessfulinallpatients withnoimmediateproceduralcomplications Thestentcompletelysealedoffthefistulain49 80 of61patientssothattheyhadnofurtheraspirationsymptoms initialclinicalsuccess Twelve 20 of61patientshadpersistentaspirationsymptomsduetoincompleteERFclosure initialclinicalfailure Duringfollow up thefistulareopenedin17 35 of49patientswithinitialclinicalsuccess Ineightpatients thereopenedERFwassealedoffsuccessfullywithstentplacementorballoondilation IntwopatientswithreopenedERFcausedbyfoodimpaction thereopenedfistularesolvedspontaneously Sevenpatientsdidnotundergofurthertreatment Allpatientsdiedduringfollow up andmeansurvivalwas13 4weeks range 1 56weeks afterstentplacement Meansurvivalinpatientswithinitialclinicalsuccesswassignificantlylongerthanthatinpatientswithinitialclinicalfailure 15 1vs6 2weeks P 05 CONCLUSION Coveredexpandablemetallicstentswereplacedin61patientswithERFs buttheinitialclinicalsuccessratewaspoorandtherateofreopeningwashigh however interventionaltreatmentwaseffectiveforsealingoffreopenedERFs Useofself expandablemetalstentsforthetreatmentofesophagealperforationsandanastomoticleaks P SalminenSurgEndosc 2009 23 1526 1530 10 6 4 weretreatedwithSEMSforsealingofaniatrogenicesophagealperforation n 4 aspontaneousesophagealruptureinBoerhaave ssyndrome n 4 orananastomoticleakage n 2 ResultsThemediantimefromperforationoranastomoticleaktostentinsertionwas13days range 2hto48days Theesophagealleakwastotallysealedfor8 80 of10patients Theoverallmortalityratewas50 n 5 andthree 30 ofthefivedeathswererelatedtotheperforation n 2 orleakage n 1 Inbothoftheperforationcases thediagnosisandtreatmentweresubstantiallydelayed OnepatientwithananastomoticleakaftergastrectomydiedofthecomplicationdespitesuccessfuloperativeandSEMStreatment Twoofthedeathswereunrelatedtotheperforation Inbothcases thecauseofdeathwasadisseminatedmalignantdisease ConclusionsTraumaticperforationsandanastomoticleakscanbetreatedeffectivelywithcoveredSEMStogetherwithadequatedrainageofthethoraciccavityevenincasesofseverelyillpatientswithinveterateesophagealperforationsandleaks PostoperativeesophagealleakmanagementwiththePolyflexesophagealstent JThoracCardiovascSurg2007 133 333 8 Objective Leakafteresophagealanastomosisorperforationrepairprolongshospitalization preventsoralhydrationandnutrition andcanproducelocalizedinfectionorsepsis ThisinvestigationreviewsourexperiencetreatingpostoperativeesophagealleakswiththePolyflexesophagealstent BostonScientific Natick Mass Methods Overa30 monthperiod patientswithapostoperativeesophagealleakweretreatedwiththePolyflexstentforleakocclusion Leakocclusionwasconfirmedbymeansofesophagraphy Patientswerefolloweduntiltheirstentwasremovedandtheiresophagealleakhadresolved Results Twenty onepatientshad27stentsplacedforleakocclusionafteresophagectomy Results Twenty onepatientshad27stentsplacedforleakocclusionafteresophagectomy n5 esophagealperforation n5 surgical n4 orendoscopic n2 antirefluxprocedure andesophagealdiverticulectomy n3 ormyotomy n2 Themeanintervalbetweensurgicalinterventionandstentplacementwas128days range 3 31days Occlusionoftheleakoccurredin20patients Onepatientexperiencedadehiscenceofthesurgicalesophagealperforationrepairrequiringesophagealdiversion Stentmigrationrequiringrepositioning n3 orreplacement n4 occurredin5 24 patients Twenty 95 stentswereremovedwithoutresidualleak mean 5143days range 15 175days Onepatienthadastrictureafterstentremovalthatrequiredendoscopicdilatation Onepatientinthisseriesdied Conclusions ThePolyflexesophagealstentisaneffectivemethodforoccludingapostoperativeesophagealleak Itrapidlyeliminatescontaminationofthemediastinum pleura andperitoneum allowsoralhydrationandnutrition andiseasilyremovable Thesestentsalsoofferanappealingalternativetotraditionalesophagealdiversionandsubsequentreconstructioninpatientswithapersistentesophagealleak