国产自膨式镍钛记忆合金带膜食管支架的临床应用

背景与目的：晚期恶性食管狭窄、食管癌或贲门癌术后单纯吻合口狭窄、食管癌放疗后狭窄所致的进食困难甚至出现食管气管瘘、食管纵隔瘘是影响患者生存质量及生存时间的一个重要因素。如何微创、简便、有效的治疗上述食管狭窄或食管气管瘘、食管纵隔瘘一直是临床工作者研究的热点之一。本研究探讨国产自膨式镍钛记忆合金网状带膜支架治疗食管狭窄的价值和注意事项。方法：自1998年4月至2005年10月，我科采用国产自膨式镍钛记忆合金网状带膜支架治疗食管狭窄患者96例（其中食管恶性狭窄65例，包括食管气管瘘18例、食管纵隔瘘3例；食管癌或贲门癌术后单纯吻合口狭窄26例；食管癌放疗后狭窄5例），男性71例，女性25例，平均年龄70岁。所有患者均在X线辅助下行食管内支架置入术。结果：本组共置入食管内支架114枚，均一次成功，成功率100％，近期疗效满意。随访1～60个月，无一例发生支架移位，术后平均生存时间8．6个月。恶性食管狭窄行内支架置入后联合化疗，中位生存期7．4个月。本组患者术后再狭窄率38．5％，予球囊扩张或再次内支架置入治疗（再次介入治疗29．2％）。结论：食管内支架置入是恶性食管狭窄的良好的姑息性治疗手段，也适用于食管癌或贲门癌术后单纯吻合口狭窄、食管癌放疗后狭窄，有助于延长患者生存时间、提高生活质量。但如何降低食管内支架置入后的再狭窄仍有待进一步的研究。     

食管狭窄的支架治疗

目的：介绍经内镜或开胸单纯探查术中放置自膨式食管支架治疗贲门和食管狭窄的方法及注意事项。方法：1998年3月-2002年8月对4l例食管、贲门狭窄患者进行了内镜下或开胸术中扩张及内支架置入术。结果：38例一次性置入成功，2例异位经调整后达到满意，1例异位拒绝再行调整1个月后死亡，恶性病变28例中21例完成了放、化疗疗程，1年生存率67．8％(19／28)。结论：经内镜下放置食管支架操作简单、安全，疗效可靠，并发症少；开胸单纯探查术中放置自膨式食管支架是有效的补救治疗手段。     

自膨式食管支架的临床应用

介绍胃镜放置自膨式食管支架的方法,个人体会以及常见并发症的预防和处理。方法：１９９６年６月－１９９８年６月作者使用国产自膨胀式食管支架,对１０６例食管良恶性疾病所致的食梗阻及食管－气瘘进行治疗。结果１０６例中包括恶性疾病７１例：食管癌４２例,贲门癌１４例,食管、贲门癌术后吻合口复发１１例,食管癌放疗后复发４例。     

应用金属内支架治疗非血管性空腔脏器狭窄

目的采用自膨式金属内支架治疗非血管性空腔脏器狭窄,评价其临床价值.方法对非血管性空腔脏器狭窄行自膨式金属内支架置入治疗,并通过多种分析来评价本治疗的疗效.结果自膨式金属内支架置入成功率为100%,食管良、恶性狭窄病例行支架置入术后病人的吞咽困难明显好转,由术前的Ⅱ-Ⅲ级改善为0级,胆道的恶性狭窄病人术后,黄疸症状逐渐减退.食欲增加.胆红素水平下降,平均生存时间为9.5个月.大气管狭窄病人,放置气管支架后,病人通气情况明显改善,生活质量明显提高.结论自嘭式金属内支架用于非血管性空腔脏器狭窄病人,是一种疗效明显、可靠的介入治疗方法.     

自膨式食管支架在治疗食管狭窄中的应用

目的：探讨自膨式食管支架在治疗食管狭窄、梗阻致进食困难及食管—气管瘘中的作用。方法：在胃镜下放置带膜食管支架对57例食管良、恶性狭窄及食管—气管瘘患者进行治疗。结果：本组55例，经治疗后吞咽困难症状明显好转，由术前的1～3级改善为0级，2例食管—支气管瘘均及时闭合。结论：自膨式食管支架临床应用范围广泛，疗效明显，操作简单易行，病人易于接受，是一项很有价值、值得推广应用的技术。     

金属内支架对45例胃十二指肠恶性梗阻的治疗

目的：探讨不能手术切除的胃十二指肠恶性梗阻介入治疗的临床价值方法：45例患者均有明显的梗阻症状，其中胃窦及幽门梗阻17例（37．8％），十二指肠梗阻22例（48.9％）．胃十二指肠吻合口梗阻6例（13.3％）在X线透视监视下，经口腔置入自膨式金属内支架47枚．并对13例患者支架术后1～2周行局部动脉灌注化疗，结果：45例患者中44例一次成功置放支架，一次性技术成功率为97．8％支架置入后梗阻症状缓解．当日即能进软食．无严重并发症发生，随访时间2～15个月，患者平均生存5.5个月。结论：对于不能或拒绝手术的胃十二指肠恶性梗阻的患者，金属内支架置入是简单、有效、安全、创伤小的治疗方法。     

食管狭窄的支架治疗

目的介绍经内镜或开胸单纯探查术中放置自膨式食管支架治疗贲门和食管狭窄的方法及注意事项.方法1998年3月-2002年8月对41例食管、贲门狭窄患者进行了内镜下或开胸术中扩张及内支架置入术.结果38例一次性置入成功,2例异位经调整后达到满意,1例异位拒绝再行调整1个月后死亡,恶性病变28例中21例完成了放、化疗疗程,1年生存率67.8%(19/28).结论经内镜下放置食管支架操作简单、安全,疗效可靠,并发症少;开胸单纯探查术中放置自膨式食管支架是有效的补救治疗手段.     

自膨式食管支架在治疗食管狭窄中的应用

目的:探讨自膨式食管支架在治疗食管狭窄、梗阻致进食困难及食管-气管瘘中的作用.方法:在胃镜下放置带膜食管支架对57例食管良、恶性狭窄及食管-气管瘘患者进行治疗.结果:本组55例,经治疗后吞咽困难症状明显好转,由术前的1～3级改善为0级,2例食管-支气管瘘均及时闭合.结论:自膨式食管支架临床应用范围广泛,疗效明显,操作简单易行,病人易于接受,是一项很有价值、值得推广应用的技术.     

食管内支架置入结合动脉内化疗治疗食管恶性狭窄

[目的]探讨食管内支架放置及结合动脉插管化疗治疗食管恶性狭窄的临床效果.[方法]食管恶性狭窄病例24例(男性16例,女性8例),经口置入自扩式食管金属内支架27枚.其中22例在支架置入后定期行肿瘤供血动脉插管灌注化疗.[结果]所有患者均一次顺利完成支架置放,患者进普食顺利,疗效满意.4例半年后再次出现吞咽困难,3例置入了第2枚,疗效满意.随访4～28个月,平均生存期12个月,最长者28个月,除2例未行动脉化疗外,生存期均明显延长.[结论]食管内支架是治疗食管恶性狭窄的有效方法,术后结合动脉插管化疗,可减少再狭窄,并且可延长生存期.     

食管内支架对恶性食管梗阻的疗效评价

对72例恶性食管梗阻且不能耐受剖胸手术的患者置入食管内支架治疗。男56例．女16例．中位年龄63岁。其中食管癌55例(合并食管气管瘘3例)。胃底、贲门癌13例，肺癌并气管食管瘘4例。结果所有内支架开放良好,吞咽困难计分提高2分；主要并发症为胸骨后不适与胸痛。占52．8％(38／72)。初步研究结果提示．食管内支架能有效改善恶性食管梗阻及食管气管瘘的呛咳症状。     

Risk Factors of Duodenobiliary Reflux-Related Dysfunction of Covered Biliary Metal Stents after Treatment of Duodenal Stricture in Patients with Malignant Biliary and Duodenal Obstruction

Duodenal obstruction is often accompanied with unresectable malignant distal biliary obstruction in patients who have undergone biliary self-expandable metal stent (SEMS) placement. Duodenobiliary reflux (DBR) is a major cause of recurrent biliary obstruction (RBO) after covered biliary SEMS placement. We analyzed the risk factors for DBR-related SEMS dysfunction following treatment for malignant duodenal obstruction. Sixty-one patients with covered SEMS who underwent treatment for duodenal obstruction were included. We excluded patients with tumor-related stent dysfunction (n = 6) or metal stent migration (n = 1). Fifty-four patients who underwent covered biliary SEMS placement followed by duodenal metal stenting or surgical gastrojejunostomy were included. Eleven patients had DBR-related biliary SEMS dysfunction after treatment of duodenal obstruction. There was no difference between the duodenal metal stenting group and the surgical gastrojejunostomy group. Duodenal obstruction below the papilla of Vater and a score of ≤2 on the Gastric Outlet Obstruction Scoring System after treatment for duodenal obstruction were associated with DBR-related covered biliary SEMS dysfunction. Thus, creating a reliable route for ensuring good oral intake and avoiding DBR in patients with duodenal obstruction below the papilla of Vater are both important factors in preventing DBR-related covered biliary SEMS dysfunction.     

食管内支架对恶性食管梗阻的疗效评价

目的：研究食管内支架在恶性食管梗阻及食管气管瘘治疗中的价值。方法：１９９５～１９９８年对７２例恶性食管梗阻且不能耐受剖胸手术的患置入食管内支架治疗。男５６例,女１６例,平均年龄７３．５岁（３８～９０岁）。食管癌５５例（并食管气管瘘３例）,胃贲门癌１３例,肺癌并气管食管瘘４例。结果：所有内支架开放良好,吞咽困难计分提高２分。７２例中,５３例（７３．６％）无并发症,最多见的并发症是胸痛,有１１例（２     

双支架治疗恶性肿瘤引起的食管、气管狭窄

目的:探讨双支架治疗恶性肿瘤所致的食管、气管狭窄的安全性及其疗效。方法:恶性肿瘤引起气管、食管狭窄24 例,其中食管癌侵犯食管、气管20例,肺癌纵隔转移累及气管、食管4例。经食管造影、胸部CT及气管三维重建,明确食管、气管狭窄位置及长度,置入覆膜镍钛合金食管支架,自膨胀网状镍钛合金气管支架。结果:24例均成功置入气管、食管双支架。术后呼吸困难及进食困难明显缓解,随访8个月,存活平均4.2 个月;1例术后7天大咯血死亡。2例食管气管支架术后2个月出现呛咳。结论:双支架可短期有效缓解晚期恶性肿瘤所致气管、食管狭窄引起的呼吸、吞咽困难症状,改善患者存活质量。     

Endoscopic stenting versus operative gastrojejunostomy for malignant gastric outlet obstruction-a systematic review and meta-analysis of randomized and non-randomized trials

Background

Open surgical gastrojejunostomy (GJ) has been the treatment of choice, but it has high morbidity and mortality rates. During the last decade, endoscopic self-expandable metal stents (SEMS) have been used. This meta-analysis aimed to compare surgical GJ and endoscopic stenting in palliation of malignant gastric outlet obstruction (GOO).

Methods

A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google Scholar, Science Direct, and Web of Science. The search identified 3 randomized controlled trials (RCTs) and 14 non-RCTs reporting on patients who underwent surgical GJ or endoscopic stenting for malignant gastroduodenal outflow obstruction

Results

The results of the three RCTs demonstrated that SEMS resulted in comparable major [odds ratio (OR): 0.62, 95% confidence intervals (CI): 0.021-18.371] and minor (OR: 0.32, 95% CI: 0.049-2.089) complications in a shorter time to tolerating an oral intake (SEMS: 3.55 days and GJ: 7.15 days) and shorter hospital stay (SEMS: 5.1 days and GJ: 12.13 days, however, statistical insignificant P value =0.11). Among the non RCTs: SEMS resulted in a shorter time to tolerating an oral intake (SEMS: 1.48 days and GJ: 8.07 days, P value <0.01), similar rate of complications (OR: 0.33, 95% CI: 0.1-1.08), lower mortality (OR: 0.5, 95% CI: 0.21-1.20, P value <0.01) and a shorter hospital stay (SEMS: 7.61 days and GJ: 19.04 days, P value <0.0001). There was no significant difference between median survival times among RCTs and non RCTs.

Conclusions

These findings suggest that stent placement is associated with better short-term outcomes and hence, duodenal stenting is a safe means of palliating malignant gastric outflow obstruction. However, a large RCT is needed to systematically compare stent placement with GJ with regard to medical effects, quality of life and costs.     

The efficacy of SEMS for malignant upper gastrointestinal stenosis, evaluated by a "home index"

We used a self expandable metalic stent (SEMS) on 24 patients (average age 68.6 years, 20 males, 4 females) with malignant upper gastrointestinal stenosis from August, 1997 to March, 1999. The primary diseases of the 24 patients were gastric cancer (13 cases: 54%), esophageal cancer (10 cases: 42%) and paraesophageal lymph node metastasis of breast cancer (one case: 4%). In this study, we present a "Home Index" as an indicator to evaluate a patient's quality of life, and investigated the efficacy and problem of SEMS.     

自膨式金属食管支架安置治疗吞咽困难

目的：探讨自膨式食管支架（Self-Expanding Metal Stent,SEMS)治疗吞咽困难患者临床适应证、疗效及其并发症。方法：收集我院安置的食管支架患者36例临床相关资料。以5分法记录支架安置前后吞咽困难程度。并发症出现的时间以30天为界。结果：吞咽困难评分由安置前的3．4降为安置后的1．1（P＜0．05）。食管－支气管瘘全部痊愈4例。6例患者支架安置后发生了早期并发症：出血2例、胸骨后疼痛不适4例。1例发生了远期并发症：支架移位。结论：自膨式食管支架安置能迅速、有效地改善吞咽困难，提高患者生活质量，延长生存期。是否适用于良性食管梗阻尚有争议。严格掌握适应证及新型食管支架的问世，有望减少安置术后并发症。     

Endoscopic palliation of colorectal cancer

Multiple endoscopic options exist for physicians seeking to provide palliative therapy for patients with colorectal cancer. Endoscopic decompression tubes can allow urgent stabilization for patients with malignant obstruction requiring some form of surgical palliation. Patients who are not candidates for palliative surgery can experience good symptomatic relief from malignant large bowel obstruction via laser therapy or placement of a colonic stent. Laser therapy can be used in conjunction with SEMS to recanalize and decompress large bowel in certain situations. The use of colonic stents is rapidly becoming more commonplace as acceptance of the technique becomes more widespread. Patients with unresectable disease may be able to avoid surgery altogether and achieve successful and lasting palliation of large bowel obstruction. Overall, they provide effective and durable palliation in patients with malignant obstruction, have an excellent risk/benefit profile, and are within the technical means of both gastroenterologists and interventional radiologists.     

A case report of esophageal cancer with tracheoesophageal fistula--improving the quality of life by using a covered self-expandable metallic stent

We present the case of a 64-year-old male who was diagnosed with esophageal cancer with tracheal invasion and distant lymph node metastases, and he received chemoradiation therapy. The therapy resulted in complete remission. However, he was unable to eat anything because of missed swallowing caused by a large tracheoesophageal fistula. The placement of a covered self-expandable metallic stent (SEMS) improved his quality of life and palliated dysphagia for 3 months. Stenting in the cervical or upper esophagus may cause discomfort. However, the placement of a covered SEMS is one of the useful palliative treatments for esophageal cancer with tracheoesophageal fistula.     

经皮肝穿胆道支架置入治疗恶性胆道梗阻的临床研究

目的：总结经皮肝穿刺胆道金属内支架植入治疗恶性胆道梗阻的临床疗效及经验。方法：92例恶性胆道梗阻性黄疸患者,采用经皮肝穿刺肝胆管支架置入术。根据胆道梗阻狭窄的不同部位和狭窄的程度采用相应的放置方式。结果：92例患者中,91例胆道支架成功放置,其中12例放置双支架,支架扩张良好,引流通畅,血清胆红素下降明显。术后死亡2例,胆道出血3例,腹水渗漏6例,胆漏2例,支架移位1例,胆管炎9例,胆道再阻塞11例。结论对不能手术的恶性胆道梗阻性黄疸患者,经皮肝穿刺胆道内支架植入术创伤小,可提高患者的生存质量,延长生存期,是一种较为安全、有效的方法。