内镜下扩张联合注射博来霉素治疗食管手术后吻合口良性狭窄的安全性和有效性

目的分析内镜下扩张联合注射博来霉素治疗食管手术后吻合口良性狭窄的安全性和有效性。方法回顾性分析2015年6月至2019年6月佛山市第一人民医院收治的食管手术后吻合口良性狭窄的55例患者。其中25例患者接受内镜下扩张联合注射博来霉素治疗(内镜下扩张联合博来霉素组),30例患者接受单纯内镜下扩张治疗(单纯内镜下扩张组)。比较两组患者缓解食管狭窄需要的时间、扩张相关的治疗费用、1年无狭窄生存时间、并发症发生情况。结果两组患者均顺利完成了内镜下治疗,治疗后短期内都达到了内镜和临床缓解。两组患者术后均未出现严重并发症,且两组患者术后并发症发生率差异无统计学意义[8.0%(2/25) vs 6.7%(2/30),χ~2=0.046,P=0.83]。在1年的随访时间内,内镜下扩张联合博来霉素组患者无狭窄生存时间长于单纯内镜下扩张组患者[(11.1±0.4)个月vs (3.9±0.2)个月],前者需要达到食管狭窄缓解的扩张次数更少[1 (1,2)次vs 3 (3,4)次],费用更低[5791.2 (4987.4,9974.8)元vs 16084.0 (14036.1,19094.0)元],且差异均有统计学意义(χ~2=54.322,Z=7.103、6.653,P均<0.01)。结论内镜下扩张联合注射博来霉素治疗食管手术后吻合口良性狭窄的疗效优于单纯内镜下扩张,可获得更长的无狭窄生存时间,并减少扩张次数。     

食管吻合口良性狭窄治疗方法的临床进展

食管恶性肿瘤术后,食管吻合口狭窄是常见的并发症,其严重影响患者生活质量,主要表现为吞咽困难,严重者无法进食,食管吻合口狭窄可分为良性狭窄和恶性狭窄。良性狭窄治疗方法可分为几类：吞咽康复训练、内镜下药物局部注射、微波凝固治疗,球囊扩张术、食管支架植入术、内镜下切开治疗、联合治疗;恶性狭窄主要通过手术方式进行治疗。本文对食管吻合口良性狭窄治疗方法的研究现状作一综述。     

内镜下局部注射药物治疗老年食管贲门癌性狭窄28例

目的观察内镜下局部注射化疗药物治疗老年食管贲门癌性狭窄的治疗效果.方法老年食管贲门癌性狭窄28例,应用内镜下局部注射化疗药物(5-氟尿嘧啶,丝裂霉素)及无水乙醇姑息治疗.本组病例男18例,女10例,年龄64岁～82岁,平均72岁.其中单纯食管癌6例,食管下端及贲门部癌症15例,贲门及胃底部癌7例.吞咽阻挡史1 mo～6mo.按常规内镜操作,于癌肿及周围分多点注射丝裂霉素2mg,5氟尿嘧啶250mg,肿瘤为块状增生明显者,于瘤体部注射无水乙醇3 mL～5 mL,一般每2 wk注射一次,癌肿基本消失,梗阻症状缓解者可延长注药间隔时间.结果本组病例经内镜下局部注射化疗药物及无水乙醇治疗,瘤体缩小2/3以上,吞咽困难消失为显效有6例(21.4%),瘤体缩小1/3以上,吞咽困难症状明显改善为有效17例(60.7%),总有效率82.1%,无效及放弃重复治疗5例(17.8%).经内镜下局部注射药物治疗后,能有效的解除食管贲门梗阻(P<0.01).结论内镜下局部注射药物治疗老年食管贲门癌性狭窄有较好的缓解梗阻,改善生活条件,延长患者生命的作用     

难治性食管良性狭窄的内镜下治疗进展

大部分食管良性狭窄可通过球囊扩张治疗获得缓解,但仍有部分狭窄多次扩张治疗无效或短期内复发,即所谓的难治性良性食管狭窄。难治性食管良性狭窄以反复吞咽困难为主要表现,严重影响患者的生活质量。随着内镜技术的发展,越来越多的技术应用于难治性食管良性狭窄的治疗,并取得了一定疗效,本文就目前的内镜治疗进展进行了综述。     

内镜超声引导下反向切开术治疗食管良性难治性狭窄的初步应用

目的 探讨内镜超声引导下反向切开术治疗食管良性难治性狭窄的疗效及安全性。 方法 回顾性分析2016年1月—2019年12月在南方医科大学顺德医院消化内镜中心行内镜超声引导下反向切开术治疗的17例食管良性难治性狭窄患者的临床资料,观察手术成功率、并发症、临床疗效等。 结果 17例患者均成功一次完成内镜下反向切开术,术后胃镜均能自由通过,操作时间（38.82±24.27）min。17例患者均无大出血、穿孔、感染等严重并发症发生。随访时间3~44个月,4例患者分别于术后3、12、18、26个月再次出现吞咽困难症状,复查胃镜示狭窄复发,余13例患者未出现再次狭窄。 结论 内镜超声引导下反向切开术治疗食管良性难治性狭窄安全、有效,值得进一步研究。     

单独内镜下安置金属支架治疗食管狭窄

我们1996年8月以来开展内镜直视下安置国产金属食管支架治疗食管狭窄28例,疗效满意。现报告如下。1 资料与方法1.1 临床资料28例患者,男22例,女6例,年龄48～78岁,平均60.5岁。晚期食管癌19例,其中合并食管气管瘘者4例。食管、贲门癌术后复发3例,食管贲门癌术后吻合口狭窄2例,食管癌放疗后瘢痕狭窄4例。癌灶分布:上段2例,中段12例,下段5例。癌灶长度< 4cm16例,4～ 6cm3例,> 6cm3例。吞咽困难程度采用Wu- Wc分级法:0级为无吞咽困难,1级为进固体食物困难,2级为进半流体食物受阻,3级为进流体食物受阻,4级为液体和唾液均不能通过。     

先天性食管闭锁术后吻合口狭窄的内镜下放射状切开术联合球囊扩张术治疗初探

目的 评估内镜下放射状切开术联合球囊扩张术治疗先天性食管闭锁术后吻合口狭窄的疗效及安全性。 方法 2017年1—6月,因先天性食管闭锁术后吻合口狭窄在济南市儿童医院接受内镜下放射状切开术联合球囊扩张术治疗的患儿共4例,采用回顾性分析方法,对4例患儿的治疗及随访情况进行总结和分析。 结果 内镜下放射状切开术用时35～65 min,其中3例术程顺利,另一例术中出现呼吸困难经停止内镜操作及加压给氧后好转,4例术后3周的吞咽困难评分在2～3分,较术前的3～4分均有降低。在内镜下放射状切开术后随诊过程中,1例术后3周吞咽困难再次反复,予球囊扩张治疗后吞咽困难缓解;其余3例均在内镜下放射状切开术后3周辅以球囊扩张术1～2次,球囊扩张术过程顺利,无不良反应发生。4例随访2～3个月,上消化道造影显示造影剂可顺利通过狭窄部位,吞咽困难评分下降至0～1分。 结论 内镜下放射性切开术治疗先天性食管闭锁术后吻合口狭窄的短期疗效显著,但易出现再次狭窄,联合球囊扩张治疗后,既能做到选择性切开狭窄又能对狭窄部位瘢痕组织进行均匀扩张,从而达到更好的扩张治疗效果,同时又能有效避免穿孔并发症的发生。     

内镜下放射状切开术治疗小儿食管良性狭窄的疗效评估

目的 评价内镜下放射状切开术（ERI）对于小儿食管良性狭窄的疗效和安全性。 方法 回顾西安市儿童医院2013年1月至2018年5月期间接受ERI治疗的20例食管狭窄患儿的临床资料,总结手术情况、临床症状改善情况、手术相关并发症等。 结果 20例患儿均顺利完成ERI治疗,中位手术时间10 min（5～25 min）,中位狭窄环切开次数4次（1～8次）。所有患儿术后未出现发热、胸骨后疼痛、出血及穿孔等现象。住院时间4.5 d（4～7 d）。术后随访3～24个月,平均7.9个月。20例患儿术后1个月复查,狭窄口较术前扩张［1.0 cm（0.6～1.5 cm）比0.3 cm（0.1～0.5 cm）,t=11.018,P＜0.001］,吞咽困难评分较术前下降［0分（0～2分）比2.5分（2～4分）,Z=4.027,P＜0.001］。19例患儿术后3个月体重增加2 kg（1～4 kg）。相关性分析显示,ERI术后吞咽困难改善程度与性别、年龄、术前治疗次数、术前狭窄口直径均无明显关系（P均＞0.05）,而与狭窄段长度负相关（r=-0.514,P=0.020）。 结论 ERI治疗小儿食管良性狭窄是安全有效的,值得临床推广。     

内镜直视与无X线下安置支架治疗食管贲门狭窄26例

1996－01／1998－01我院运用内镜直视和无X线下安置支架治疗食管贲门口狭窄26例，效果显著，现报告如下．1对象和方法1．1对象本组26例，男24例，女2例，年龄20岁～78岁，平均49岁．其中良性狭窄5例包括：食管化学烧伤1例，贲门失驰缓症1例，食管吻合口瘢痕狭窄3例；恶性狭窄21例：包括食管癌16例，贲门癌4例，吻合口复发癌1例.患者均有不同程度的吞咽困难，按stooler分极：0级能正常进食，Ⅰ级能进软食，Ⅱ级能进半流液，Ⅲ级能进流质，Ⅳ级完全不能进食，本组Ⅱ级2例，Ⅲ级9例，Ⅳ级15例，其狭窄长度为2cm～12cm，平均7．5cm．1．2方法选…     

内镜直视下放置支架治疗食管贲门狭窄和瘘68例

1998年 1月～ 2 0 0 0年 12月 ,我们对食管贲门良恶性狭窄和瘘患者 6 8例进行内镜直视下放置支架治疗 ,效果满意。现报告如下。一般资料 :本组男 46例 ,女 2 2例 ;年龄 34～ 78岁 ,平均6 0 .5岁晚期食管癌 2 7例 ,食管癌术后狭窄 5例 ,贲门癌 2 4例 ,贲门癌术后狭窄 8例 ,食管气管瘘 3例 ,食管纵隔瘘 1例。其中 4例狭窄支架置入后肿瘤生长蔓延再次引起狭窄 ,行第二次置入支架治疗。本组 6 8例均经 X线造影、胃镜及病理检查确诊。狭窄口直径 2～ 9m m,狭窄段长度 5～ 80 mm,平均6 4mm。吞咽困难程度 :O级 (无吞咽困难 ) 2例 ;1级 (进固体食…     

经口内镜下肌切开术治疗贲门失弛缓症的初探

目的探讨经口内镜下肌切开术（POEM）治疗贲门失弛缓症（AC）的疗效和可行性。方法研究2010年8月至2010年12月确诊为AC并接受POEM治疗的8例患者的临床资料。患者年龄16～62岁,平均43岁,病程2-20年,平均8．4年。POEM的主要步骤包括：食管黏膜层切开;分离黏膜下层,建立黏膜下“隧道”;胃镜直视下切开环形肌;金属夹关闭黏膜层切口。结果8例患者均成功接受POEM术,手术时间45-115min,平均68．5min,黏膜下隧道长度8～13cm,平均9．5cm,环形肌切开长度7～11cm,平均8．5cm,无1例出现与POEM相关的严重并发症。术后随访1～4个月,平均2．5个月,7例吞咽困难明显得到解除;1例术后15d出现进食困难及呕吐,胃镜检查发现黏膜下窦道形成,行内镜下窦道切开。结论作为一种新的微创治疗方法,POEM治疗AC短期疗效肯定,可以迅速解除AC患者吞咽困难,但其长期疗效及远期并发症仍有待随访观察。     

Argon plasma coagulation prevents variceal recurrence after band ligation of esophageal varices: preliminary results of a prospective randomized trial

BACKGROUND: Endoscopic variceal ligation is an established procedure for eradication of esophageal varices. However, varices frequently recur after endoscopic variceal ligation. Argon plasma coagulation has been used as supplemental treatment for eradication of varices and for prevention of variceal recurrence in small uncontrolled series. The aim of this study was to determine whether argon plasma coagulation is effective in reducing variceal recurrence after endoscopic variceal ligation. METHODS: Thirty patients with cirrhosis, a history of acute esophageal variceal bleeding, and eradication of varices by endoscopic variceal ligation were randomized to argon plasma coagulation (16 patients) or observation (14 patients). The 2 groups were similar with respect to all background variables including age, Child-Pugh score, presence of gastric varices, and degree of portal hypertensive gastropathy. In the argon plasma coagulation group, the entire esophageal mucosa 4 to 5 cm proximal to the esophagogastric junction was thermocoagulated circumferentially with argon plasma coagulation in 1 to 3 sessions performed at weekly intervals. Endoscopy was performed every 3 months to check for recurrence of varices in both groups. RESULTS: During the course of the study, no serious complication was noted. After argon plasma coagulation, transient fever occurred in 13 patients and 8 complained of dysphagia or retrosternal pain/discomfort. Mean follow-up for all patients was 16 months (range 9-28 months). No recurrence of varices or variceal hemorrhage was observed in the argon plasma coagulation group, whereas varices recurred in 42.8% (6/14) of the patients in the control group (p < 0.04) and bleeding recurred in 7.2% (1/14). CONCLUSIONS: Argon plasma coagulation of the distal esophageal mucosa after eradication of esophageal varices by endoscopic variceal ligation is safe and effective for reducing the rate of variceal recurrence.     

Incision of recurrent distal esophageal (Schatzki) ring after dilation

BACKGROUND: Distal esophageal (Schatzki) ring is a frequent cause of dysphagia. Bougienage is generally effective but relapse is common. Outcomes for patients treated by endoscopic incision of distal esophageal rings after symptomatic relapses after bougienage are described. METHODS: Eleven patients (2 women, 9 men; median age 61 years; range 24 to 81 years) with recurrent dysphagia after bougienage with large caliber bougies underwent 17 sessions of endoscopic incision of the rings. Follow-up was by standardized interview at a median of 55 months (range, 7 to 84 months) after the initial incision procedure. RESULTS: A median of 3 dilation sessions (range, 1 to >25) were performed prior to incision. All patients noted complete resolution of dysphagia immediately thereafter. Seven required subsequent incision or dilation and 4 did not. The mean dysphagia score was significantly improved from that before incision to that during follow-up. There was a significant increase in the mean duration of improvement in dysphagia after the initial incision compared with that after preincision dilation (respectively, 17 months [range, 2 to 72 months] vs. 5 months [range, 0.5 to 28 months]; p = 0.034). CONCLUSIONS: Endoscopic incision of distal esophageal rings that cause recurrent dysphagia after bougienage improves dysphagia and provides a longer dysphagia-free interval compared with repeated bougienage.     

Endoscopic mucosal resection for early esophageal cancer and esophageal dysplasia

BACKGROUND/AIMS: Advances in diagnostic technology have led to increased detection of early esophageal cancer, which is suitable for endoscopic treatment. We performed endoscopic esophageal mucosal resection of such cancer and dysplasia using the endoscopic esophageal mucosal resection tube and evaluated the clinical benefit of this technique. METHODOLOGY: Twenty-nine patients with esophageal mucosal cancer (27 cases with 33 lesions) or dysplasia (2 cases with 2 lesions) diagnosed between September 1992 and March 1998 were assessed endoscopically for the depth and extent of invasion by double staining with toluidine blue and iodine. Endoscopic ultrasonography was also performed to assess the depth of invasion in 22 cases with 22 lesions. RESULTS: The 35 esophageal lesions comprised 27 esophageal carcinomas and 8 areas of dysplasia. Twenty of the 35 lesions were resected en bloc and 15 were resected piecemeal. Subsequent surgery was performed for 5 cases with 7 lesions out of 10 cases with 15 lesions that were histopathologically diagnosed as m3 or more invasive. No recurrence has been detected in 24 evaluable cases (including 1 who died of another disease, 2 in whom surgery could not be performed due to complications, and 3 who refused subsequent surgery). No patients died of esophageal cancer after a mean follow-up period of 30.9 +/- 18.9 months. The 4-year survival rate was 100% in the m2 or less invasive group of 19 cases with 20 lesions, 75% in the m3 or higher invasive group of 5 cases with 8 lesions and 100% in the surgery group of 5 cases with 7 lesions (NS). No serious complications occurred except for 1 patient. Circumferential mucosal resection was done in this patient, resulting in esophageal stenosis, which responded to esophageal dilation. CONCLUSIONS: Esophageal mucosal resection using the endoscopic esophageal mucosal resection tube is safe and beneficial for early esophageal cancer and dysplasia.     

经口内镜全层肌切开术治疗重症贲门失弛缓症的临床应用

目的探讨经口内镜全层肌切开术治疗重症贲门失弛缓症的疗效与安全性。方法经口内镜全层肌切开术治疗64例重症（至少满足以下条件之一：Eckardt评分≥6分;食管直径≥6cm或S形食管）贲门失弛缓症患者,术后定期随访和复查,收集患者一般情况、症状评分、并发症、复发、内镜及X线钡餐检查结果等资料。结果64例患者均成功完成手术,平均操作时间55min,隧道长度平均14．1cm,肌切开长度平均10．6cm,全层肌切开范围为食管胃接合部上下6．0cm。术后患者症状均得到缓解;并发症发生率为9．4％（6／64）,其中气肿发生率为6．3％（4／64）。术后6个月,Eckardt评分较术前明显改善[（7．4±1．5）分比（0．6±0．8）分,P〈0．001],食管直径较术前明显减小[（59．7±13．0）mm比（31．4±3．3）mm,P〈0．001],贲门口直径较术前明显扩大[（15．6±10．1）mm比（33．4±8．9）mm,P〈0．01]。平均随访12．3个月,98．4％（63／64）有效;随访期内无复发病例。结论经口内镜下全层肌切开术可作为重症贲门失弛缓症患者的有效治疗手段,但临床应用时间尚短,其长期疗效及远期并发症仍有待于进一步随访评估。     

Usefulness of biodegradable stents constructed of poly-l-lactic acid monofilaments in patients with benign esophageal stenosis

AIM: To report 13 patients with benign esophageal stenosis treated with the biodegradable stent. METHODS: We developed a Ultraflex-type stent by knitting poly-l-lactic acid monofilaments. RESULTS: Two cases were esophageal stenosis caused by drinking of caustic liquid, 4 cases were due to surgical resection of esophageal cancers, and 7 cases were patients with esophageal cancer who received the preventive placement of biodegradable stents for post- endoscopic mucosal dissection (ESD) stenosis. The preventive placement was performed within 2 to 3 d after ESD. In 10 of the 13 cases, spontaneous migration of the stents occurred between 10 to 21 d after placement. In these cases, the migrated stents were excreted with the feces, and no obstructive complications were experienced. In 3 cases, the stents remained at the proper location on d 21 after placement. No symptoms of re-stenosis were observed within the follow-up period of 7 mo to 2 years. Further treatment with balloon dilatation or replacement of the biodegradable stent was not required. CONCLUSION: Biodegradable stents were useful for the treatment of benign esophageal stenosis, particularly for the prevention of post-ESD stenosis.     

Electrocautery therapy for refractory anastomotic strictures of the esophagus

BACKGROUND: Anastomotic esophageal stenoses after esophageal resection are common and sometimes are refractory to Savary bougie dilation. The efficacy of electrocautery needle-knife treatment in these patients is described. METHODS: Twenty patients with a refractory anastomotic stricture of the esophagus were treated with electrocautery and were followed for 12 months. All patients had recurrence of dysphagia despite repeated bougienage. OBSERVATIONS: All 12 patients with a stricture shorter than 1 cm remained without dysphagia after a single treatment. In all 8 patients with a long-segment stenosis of 1.5 to 5 cm, dysphagia recurred, and a mean of 3 treatments were necessary. The interval between electrocautery treatments was significantly longer compared with bougienage. There were no complications. The body weight of all patients increased. CONCLUSIONS: Electrocautery seems to be a good single-treatment modality for refractory short-segment anastomotic strictures, whereas longer-segment stenoses appear to require repeated treatment sessions before similar results are obtained.     

经黏膜下隧道内镜肿瘤切除术治疗源于固有肌层的上消化道黏膜下肿瘤初探

目的探讨经黏膜下隧道内镜肿瘤切除术（STER）治疗来源于上消化道固有肌层黏膜下肿瘤（SMTs）的疗效和安全性。方法对26例经超声内镜和CT诊断为来源于固有肌层的上消化道SMTs患者全麻下行STER治疗：（1）内镜寻找到肿瘤,并准确定位;（2）建立黏膜下隧道,显露肿瘤;（3）内镜直视下完整切除肿瘤;（4）缝合黏膜切口。结果来源于固有肌层的上消化道SMTs患者26例中,食管14例,贲门7例,胃5例。来源于固有肌层浅层者11例,深层者15例,其中2例胃SMTs与浆膜层粘连,密不可分。STER成功切除所有黏膜下肿瘤,完整切除率100％,切除病变直径1．0～3．2cm（平均1．9cm）。黏膜切开至黏膜切口完整缝合时间25～145min,平均68．5min;完整缝合创面所用金属夹4—6枚,平均5枚。术后病理诊断为平滑肌瘤17例,间质瘤7例,血管球瘤1例,神经鞘膜瘤1例;切缘均为阴性。发生皮下气肿2例,左侧气胸伴皮下气肿1例,气腹2例,均予保守治疗痊愈。术后无一例出现迟发性消化道出血、消化道漏和胸腔腹腔继发感染,无一例发生黏膜下隧道内积血积液和继发感染。随访3～9个月,无一例病变残留或复发。结论STER治疗来源于固有肌层的上消化道SMTs安全、有效,可以一次性完整切除病变,提供完整的病理学诊断资料,并可避免消化道漏和胸腔腹腔继发感染。     

Use of endoscopic balloon dilation for benign esophageal stenosis in children: our 11 year experience

Endoscopic balloon dilation (EBD) is an established therapy for esophageal stenosis. To assess its usefulness in children, we reviewed 11 years of pediatric cases of EBD in our hospital. Over the last 11 years, EBD was performed on 14 pediatric patients (10 boys and four girls; 7 months–11 years) at our hospital. All EBD sessions were performed under general anesthesia and fluoroscopic monitoring. The sessions were repeated every week or alternate weeks until resolution of dysphagia or development of smooth endoscope passage. Stenosis was resolved in 14 of 14 patients (100%). None of the patients (0%) showed recurrence of stenosis. As for postoperative complications, mediastinitis occurred only in one patient (7.1%). The median number of session repeats for an individual patient was three (range 1–10). EBD is a safe and effective therapeutic modality for esophageal stenosis in children.