消化道狭窄的内镜治疗课件.ppt

消化道狭窄的内镜治疗病理类型病理类型qq我国我国我国我国 鳞癌为主鳞癌为主鳞癌为主鳞癌为主 97.6%97.6%上上上上1/31/3段段段段 8.8%8.8%中中中中1/31/3段段段段 65.9%65.9%下下下下1/31/3段段段段 25.3%25.3%qq西方国家西方国家西方国家西方国家 以下段食管为主、主要为腺癌（以下段食管为主、主要为腺癌（以下段食管为主、主要为腺癌（以下段食管为主、主要为腺癌（6060以上）以上）以上）以上）食管癌的治疗食管癌的治疗（强调早期发现、早期诊断、早期治疗）手术治疗手术治疗 -姑息性手术姑息性手术 -根治性手术根治性手术内镜下治疗内镜下治疗 -食管扩张，食管支架取代传统的旁路手术食管扩张，食管支架取代传统的旁路手术 -内镜下电灼切除、内镜下电灼切除、Nd:YAG激光切除、激光切除、光动力疗法等光动力疗法等化疗：化疗：5-Fu和顺铂为主和顺铂为主放疗：外放射为主放疗：外放射为主以手术为主的综合治疗以手术为主的综合治疗手术适应证早期食管癌早期食管癌中期（中期（）、中下段食管癌病变在）、中下段食管癌病变在5cm内，上段在内，上段在3cm内，全身情况好者内，全身情况好者中期（中期（）、病变在）、病变在5cm以上，无明显远处转移，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，放射治疗后复发，病变范围尚不大，无远处转移，全身情况良好者全身情况良好者 手术禁忌证手术禁忌证食管癌病变广泛或累及邻近器官如气管、食管癌病变广泛或累及邻近器官如气管、肺、纵隔等者肺、纵隔等者已有锁骨上窝淋巴结等远处转移者已有锁骨上窝淋巴结等远处转移者有严重心、肺或肝功能不全者有严重心、肺或肝功能不全者严重恶病质者严重恶病质者Surgical resection is the only curative treatment optionfor invasive esophageal cancer.However,despite carefulstaging and advances in adjuvant therapy and surgicaltechniques,5-year survival rates rarely exceed 40%.1,2Many patients present with locoregional recurrence anddistant metastasis within 2 years after curative esophagectomy.3 Treatment of patients with local disease recurrenceaims at relieving dysphagia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。Esophageal diseases and types of SEMS used UU CU E GZ WEsophageal carcinoma Cervical(n=14)7 7 Thoracic(n=93)31 47 7 3 5 G-E junction(n=79)44 26 2 7 Locally recurrent carcinoma 12 36 (n=48)Achalasia(n=8)4 4 UU,Uncovered Ultraflex(Boston Scientific,Boston,Mass.);CU,covered Ultraflex(Boston Scientific);E,Esophacoil(Instent Inc.,Eden Prarie,Minn.);GZ,Gianturco Z-stent(Cook Inc.,Bloomington,Ind.);W,Wallstent(Boston Scientific).Factors that may predispose to esophageal stent migration:multivariate analysis N Migration(%)p value Gender Female 58 8/13(61.5)0.0038Stricture TC 80 2/13(15.4)0.954 GEJ 67 9/13(11.4)0.017 EAC 8 2/13(25)0.625Previous therapy S+B 4 2/13(15.4)0.997 R 10 2/13(15.4)0.997Dilation 10 mm 24 6/13(46.1)0.000Stent GZ 3 2/13(15.4)0.719 E 12 4.13(30.7)0.104 UU 87 4/13(30.7)0.169 CU 95 3/13(23.0)0.166TC,Esophageal thoracic carcinoma;GEJ,carcinoma of the gastroesophageal junction;EAC,esophageal achalasia;S+B,surgery&balloon dilation;R,radiotherapy;GZ,Gianturco Z-stent;E,Esophacoil;UU,uncovered Ultraflex;CU,covered Ultraflex(Gastrointest Endosc 2001;53:96-97.)Esophageal stents for malignant strictures close to the upper esophageal sphincterGastrointest Endosc 2007;66:1082-90Esophageal stents for the palliation of malignant dysphagia and fistula recurrence after esophagectomyLuminal patency.The median survival time afterstenting for all patients with stenosis was 70 days(range 1day to 34 months).Stent insertion was technically successful in all but 1 patient(98%)(Fig.1).Median duration of primary stent patency was 56 days(range 1 day to 33 months)(Fig.2).A total of 20 episodes of stent dysfunction occurred in 18(27%)of 66 patients at a median of 38 days post-SEMS insertion(range 2-406 days).Stent dysfunction was caused by tissue in-or overgrowth(n 8),stent migration(n 9),and food impaction(n 3).Tissue in-and overgrowth occurred at a median of 119 days post-SEMS insertion(range 33297 days);5 patients were successfully treated with a second SEMS.Six(24%)of 25 fully covered stents versus 3(7%)of 41 partially covered SEMS migrated(P .07)at a median time interval of 66 days after SEMS insertion(range 12-406 days).Of these patients,6 patients required a second SEMS.Food bolus impaction occurred in 3(20%)patients at a median time interval of 11 days after SEMS insertion;all 3 were successfully cleared endoscopically.Insertion of a second SEMS was successful in all patients(100%).Median patency of these stents was 59 days(range 5286 days)Fistula sealing.The median survival time of patients with malignant fistula caused by tumor recurrence was 73 days(range 10 days to 91 months).The coated segment of the stent effectively sealed fistulae in all but 1 patient(93%).This patient was successfully treated with a second stent.Stent dysfunction occurred in 6(40%)of 15 patients.In 5(33%)patients,additional stents were successfully inserted to manage stent migration(n 4)and persistent leakage during stent treatment(n 1).Two(22%)of 9 fully covered stents versus 2(33%)of 6 partially covered SEMSs migrated at a median time interval of 5 months post-SEMS insertion(range 5 days to 11 months).Food bolus impaction occurred in 1 patient 17 days post-SEMS insertion,this patient was also successfully treated endoscopicallyby stent clearance.Overall complications Mild complications after stent placement occurred in 7(9%)patients including retrosternal pain and symptomatic gastroesophageal reflux.Major complications occurred in 9(11%)patients.Stridor developed immediately after insertion in 3 patients with a lesion within 4 cm of the upper esophageal sphincter.In all 3 patients,the stent was removed,and they were managed conservatively.Three patients had an upper GI hemorrhage from the tumor site at a median time interval of 26 days after SEMS insertion(range 11 days to 10 months).The bleeding subsided spontaneously in 1 of these patients;the other 2 patients died of the persistent bleeding.An esophageal fistula developed during stent treatment in 2 patients,both of which were located at the distal funnel of the partially covered stent at a median time interval of 48 days post-SEMS insertion.These wall defects were successfully sealed with an additional stent.One patient had stent-induced ulceration after stent migration at 7 months after SEMS insertion and required endoscopic stent extraction.SEMS placement in recurrent esophageal cancer after surgical resection offers adequate palliation by relieving dysphagia and sealing off esophageal respiratory fistula.Therefore,in these patients who have a relatively short life expectancy,the implantation of SEMSs to should be considered the treatment of choiceEsophageal respiratory fistulae occur in 5%to 10%of patients with esophageal cancer.In our series,19%of patients with recurrent cancer after gastric tube interposition presented with a fistula.This represents a devastating complication leading to recurrent pulmonary infections and the inability to eat or even swallow saliva.This condition is associated with a very high short-term mortality rate.The technical success of fistula sealing by SEMSs was 93%,which is within the range of the 80%to 100%reported by other series.In the majority of patients with cancer recurrence after esophagectomy,the fistula or stenosis is located close to the upper esophageal sphincter.At this location,SEMS placement may cause foreign-body sensation,tracheal compression,or respiratory fistula.It has been hypothesized that stents should have a body diameter of 18 mm or less to avoid these complications.In our series,however,stridor developed in 3(4%)patients and a fistula developed in 2(2%)patients after stent placement,despite the use of small-diameter stents in 4 of them.None of the patients reported globus sensationGastrointest Endosc 2010;72:249-54Comparison of Temporary and Permanent StentPlacement with Concurrent Radiation Therapyin Patients with Esophageal CarcinomaJ Vasc Interv Radiol 2005;16:6774MATERIALS AND METHODS:Covered retrievable expandable nitinol stents were placed in 47 patients with esophagealcarcinoma 1 week before starting radiation therapy;the stents were electively removed 4 weeks after placement in 24patients(group A),while not electively removed in the other 23 patients(group B).In cases of complications,the stents werealso removed from patients in groups A and B.The dysphagia score,complications(severe pain,granulation tissueformation,stent migration,esophagorespiratory fistula,and hematemesis),tumor overgrowth/regrowth,reinterventionrates,and dysphagiaprogression-free and overall survival rates were compared in the two groups.RESULTS:Stent placement or removal was technically successful and well tolerated in all patients.The dysphagia scorewas significantly improved in both groups after stent placement(P .01).Each of the stent-related complications was lessin group A than in group B but there was no significant difference.However,the total number of patients with one or morethan one complications and who needed related reinterventions was significantly less in group A than in group B(P .042and.030,respectively).Tumor overgrowth/regrowth and the total number of patients who required related reinterventionswas not significantly different(P1.00 and.517,respectively).Dysphagiaprogression-free and overall survival rates weresignificantly longer in group A than in group B(P .005 and.001,respectively).CONCLUSION:Temporary placement of a covered retrievable expandable metallic stent with concurrent radiationtherapy for patients with esophageal carcinoma is beneficial for reducing complications and related reinterventionsand for increasing resultant survival rates compared with permanent esophageal stent placement.Use of self-expandable metal stents for the treatmentof esophageal perforations and anastomotic leaksSurg Endosc(2009)23:15261530Esophagorespiratory Fistula:Long-term Results of Palliative Treatment withCovered Expandable Metallic Stents in 61 PatientsRadiology Vol 232 ,253-259MATERIALS AND METHODS:Sixty patients with ERFs due to esophageal orbronchogenic carcinoma and one patient with ERF due to pressure necrosis causedby initial esophageal stent placement for esophageal carcinoma were treated withcovered expandable esophageal or tracheobronchial metallic stents.Informationabout technical success of stent placement,initial clinical success and failure,fistulareopening,and complications was obtained.Survival curves for both patient groupswith initial clinical success and failure were obtained and compared with Kaplan-Meier methods and log-rank test.RESULTS:Stent placement was technically successful in all patients,with noimmediate procedural complications.The stent completely sealed off the fistula in49(80%)of 61 patients so that they had no further aspiration symptoms(initialclinical success).Twelve(20%)of 61 patients had persistent aspiration symptomsdue to incomplete ERF closure(initial clinical failure).During follow-up,the fistulareopened in 17(35%)of 49 patients with initial clinical success:In eight patients,the reopened ERF was sealed off successfully with stent placement or balloondilation.In two patients with reopened ERF caused by food impaction,the reopenedfistula resolved spontaneously.Seven patients did not undergo further treatment.Allpatients died during follow-up,and mean survival was 13.4 weeks(range,156weeks)after stent placement.Mean survival in patients with initial clinical successwas significantly longer than that in patients with initial clinical failure(15.1 vs 6.2weeks,P .05).CONCLUSION:Covered expandable metallic stents were placed in 61 patients withERFs,but the initial clinical success rate was poor and the rate of reopening washigh;however,interventional treatment was effective for sealing off reopened ERFs.Use of self-expandable metal stents for the treatmentof esophageal perforations and anastomotic leaksP.Salminen Surg Endosc(2009)23:1526153010(6.4%)weretreated with SEMS for sealing of an iatrogenic esophagealperforation(n=4),a spontaneous esophageal rupture inBoerhaaves syndrome(n=4),or an anastomotic leakage(n=2).Results The median time from perforation or anastomoticleak to stent insertion was 13 days(range,2 h to 48 days).The esophageal leak was totally sealed for 8(80%)of 10patients.The overall mortality rate was 50%(n=5),andthree(30%)of the five deaths were related to the perforation(n=2)or leakage(n=1).In both of theperforation cases,the diagnosis and treatment were substantiallydelayed.One patient with an anastomotic leakafter gastrectomy died of the complication despite successfuloperative and SEMS treatment.Two of the deathswere unrelated to the perforation.In both cases,the causeof death was a disseminated malignant disease.Conclusions Traumatic perforations and anastomoticleaks can be treated effectively with covered SEMS togetherwith adequate drainage of the thoracic cavity even incases of severely ill patients with inveterate esophagealperforations and leaks.Postoperative esophageal leak management with thePolyflex esophageal stentJ Thorac Cardiovasc Surg 2007;133:333-8Objective:Leak after esophageal anastomosis or perforation repair prolongs hospitalization,prevents oral hydration and nutrition,and can produce localized infectionor sepsis.This investigation reviews our experience treating postoperative esophagealleaks with the Polyflex esophageal stent(Boston Scientific,Natick,Mass).Methods:Over a 30-month period,patients with a postoperative esophageal leakwere treated with the Polyflex stent for leak occlusion.Leak occlusion was confirmedby means of esophagraphy.Patients were followed until their stent wasremoved and their esophageal leak had resolved.Results:Twenty-one patients had 27 stents placed for leak occlusion after esophagectomyResults:Twenty-one patients had 27 stents placed for leak occlusion after esophagectomy(n 5),esophageal perforation(n 5),surgical(n 4)or endoscopic(n 2)antireflux procedure,and esophageal diverticulectomy(n 3)or myotomy(n 2).The mean interval between surgical intervention and stent placement was12 8 days(range,331 days).Occlusion of the leak occurred in 20 patients.Onepatient experienced a dehiscence of the surgical esophageal perforation repairrequiring esophageal diversion.Stent migration requiring repositioning(n 3)orreplacement(n 4)occurred in 5(24%)patients.Twenty(95%)stents wereremoved without residual leak(mean,51 43 days;range,15175 days).Onepatient had a stricture after stent removal that required endoscopic dilatation.Onepatient in this series died.Conclusions:The Polyflex esophageal stent is an effective method for occluding apostoperative esophageal leak.It rapidly eliminates contamination of the mediastinum,pleura,and peritoneum;allows oral hydration and nutrition;and is easily removable.These stents also offer an appealing alternative to traditional esophageal diversionand subsequent reconstruction in patients with a persistent esophageal leak.