内镜下射频联合记忆合金支架治疗食管贲门重度癌性狭窄

内镜下射频联合记忆合金支架治疗食管贲门重度癌性狭窄 ,给吞咽困难达滴水难进的重度狭窄 (Ｓｔｏｏｌｅｒ分级Ⅳ级 )患者提供了良好的治疗手段 ,使无法常规安置支架的病例得以顺利完成支架术 ,并使用射频治疗解除支架术后食管癌性再狭窄 ,提高支架术的疗效。我院自 1999年以来 ,使用内镜下射频联合记忆合金支架治疗食管 -贲门重度癌性狭窄 2 4例 ,对支架术后癌性再狭窄 10例予射频治疗 ,疗效满意。1　材料和方法1.1　临床资料　射频治疗 +合金支架组 2 4例 ,男 18例 ,女 6例。年龄 4 3～ 73岁 ,平均 62 3岁。所有病人均经胃镜及活组织病检…     

微波在食管贲门癌性狭窄安置金属支架前后的应用

目的　探讨微波在食管贲门癌性狭窄安置金属支架前后的治疗作用。方法　先用微波在癌性狭窄处烧灼 ３～４ 次，使狭窄处有一直径１．０ｃｍ 通道，在 Ｘ 线下安放金属支架；对金属支架内癌性再狭窄也用微波烧灼２～４ 次，使食管再通。结果　２８ 例安置支架成功，术后无明显痛苦；１４ 例支架内再狭窄再获通畅。结论　用微波烧灼后再放金属支架及用微波烧灼使支架内癌性再狭窄再通，可减少病人术后痛苦，改善生活质量，延长生命。     

微波在食管贲门癌性狭窄安全金属支架前后的应用

目的 探讨微波在食管贲门癌性狭窄安置金属支架前后的治疗作用。方法 先用微波在癌性狭窄处烧灼３～４次，使狭窄处有一直径１．０ｃｍ通道，以Ｘ线下安放金属支架；对金属丢架内癌性再狭窄也用微波烧灼２～４次，使食管再通。结果 ２８例安置支架成功，术后无明显痛苦；１４例支架内再狭窄再获通畅。结论 用微波烧灼后再放金属支架及用微波烧灼使支架内癌性再狭窄再通，可减少病人术后痛苦，改善生活质量，延长生命。     

食管贲门癌支架置入术后再狭窄的观察

内镜下食管支架置入术后再狭窄的发生率较高,很大程度上约束了支架的广泛应用,现将资料较完整的未经手术治疗的食管贲门癌性狭窄支架置入术后发生再狭窄的28例临床资料报道如下。 一、资料与方法 1.一般资料:全部病例均来自于作者所属3个医院消化内科近5年的门诊及住院患者,其中男22例,女6例;年龄51～76岁,平均60.3岁;所有病例均经胃镜检查有不同程度的狭窄且经病理证实为食管癌11例,贲门癌8例,食管贲门癌9例;狭窄长度<3cm者5例,3～6cm者16例,～9cm者7例,>9cm者不在本文观察范围内;全部病例均未作手术治疗。 2.方法:按常规一次成功置入国产钛镍记忆合金网状覆膜支架（常州产）,直径10～20mm,长度4～14cm,上口呈喇叭状。3d后作食管吞钡观察支架位置无移位且扩张良好,均未作局部放化疗。 3.再狭窄的观察:按Stoller吞咽困难分级,如出现Ⅱ级以上（含Ⅱ级）者定为再狭窄,统一在狭窄部位取4块以上组织作病理检查,记录狭窄原因、部位及时间。     

胃镜直视下置放记忆合金支架治疗食管狭窄的体会

1996年 2月至 1998年 12月 ,我科采用国产记忆合金支架治疗食管良恶性狭窄 6 3例 ,疗效满意 ,现报告如下。1　临床资料6 3例食管狭窄患者中 ,男 46例 ,女 17例 ,年龄 5 3～ 82岁 ,平均 6 2 5岁。狭窄性质 :良性狭窄 42例 ,包括贲门及食管癌手术或放疗后瘢痕性狭窄。癌性狭窄 2 1例 ,包括癌复发性狭窄和未经治疗的贲门及食管晚期癌 ,其中 2例为癌复发性食管上段狭窄合并食管气管瘘。狭窄部位 :最短 2ｃｍ ,最长 10ｃｍ。狭窄程度 :均为重度狭窄 ,直径小于 5ｍｍ ,仅能进流质或不能进食。2　器械与方法2 1　器械设备　日本潘太克斯电子胃镜 …     

内镜直视下置放支架术治疗食管贲门癌性狭窄

目的 探讨内镜直视下置放支架治疗食管贲门癌性狭窄的临床疗效。方法选择67例食管贲门癌性狭窄病人，行内镜检查以明确狭窄部位，在直视下先行内镜扩张术，再置入食管支架，术后密切观察临床疗效和并发症。结果全部病人吞咽困难均显著改善，梗阻好转率100％。术后发生食管返流40例(59．7％)，胸痛28例(41．8％)，发热5例(7．5％)，消化道出血4例(6％)。结论内镜直视下置入支架术能够有效地治疗食管贲门癌性狭窄，定位准确，置放安全，成功率高，严重并发症少，是一项很有价值、值得推广应用的技术。     

内镜引导置入食管支架的选择与疗效观察

经内镜置入记忆合金支架治疗食管、贲门狭窄,具有迅速解除吞咽困难、明显改善患者生活质量的作用。根据狭窄的原因和特点选用不同类型、型号的支架是治疗成功的关键。1995年1月～1998年10月,我们对无手术适应症的63例食管贲门癌性狭窄、术后吻合口狭窄患者实施食管内支架置放术。现报告如下。临床资料:本组63例中,男43例,女20例;年龄34～80岁,平均57.8岁。食管癌性狭窄37例(合并食管—气管瘘5例,高位狭窄3例)贲门癌狭窄5例,吻合口狭窄21例。方法:术前空腹8h,含服润滑止痛胃镜胶、肌注安定和山莨菪碱各10mg。用内镜直视气囊扩张器将狭窄处扩…     

内镜下覆膜食管支架治疗食管癌性狭窄及食管气管瘘的临床应用价值

目的探讨内镜下覆膜食管支架治疗食管癌性狭窄及食管气管瘘的临床价值及食管支架置入术并发症的防治。方法回顾性分析163例晚期食管癌患者内镜下覆膜食管支架治疗食管癌性狭窄及食管气管瘘的临床资料,其中7例患者为食管癌性狭窄并食管-支气管瘘伴双下肺感染,19例患者为食管癌术后复发吻合口狭窄置入镍钛记忆合金覆膜支架。102例患者由于食管过于狭窄先行食管扩张,再进行内镜下放置食管支架,35例患者直接内镜下置入食管支架。结果 163例患者先后放置174个支架,均一次性置入成功,成功率为100%。163例患者均有不同程度胸痛不适,有32例支架再狭窄,其中19例单纯行支架内球囊扩张,11例于原支架上端内部分重叠再放置一支架,有26例行氩气刀再通治疗。7例患者出现支架移位,有2例支架进入食管瘘管内于次日在内镜下取出支架重新放置。所有病例均未出现食管破裂、食管血肿或出血等严重并发症,术后患者进食能力提高,食管气管瘘闭合。结论内镜下覆膜食管支架置入术是中晚期食管癌性狭窄简单、安全、有效的姑息治疗方法,能提高患者的生活质量,延长患者的生存期。     

食管带膜支架置入术后再狭窄的机制和治疗

食管支架在食管良恶性狭窄和食管气管瘘的治疗中有广泛的应用,再狭窄成为食管支架置入术后最常见的并发症.其中炎性再狭窄占很大比例,在食管支架异物刺激下炎性细胞,生长因子,细胞因子和相关酶相互作用在带膜支架的上下端促进肉芽组织形成并最终演变为瘢痕组织,并引起食管支架术后再狭窄.各种预防和治疗食管支架术后再狭窄的方法在缓解再狭窄中有一定的临床意义.     

支架置入治疗食管贲门吻合口癌性狭窄

1997年以来,我科对 48例晚期食管贲门吻合口癌性狭窄的患者经内镜置入国产镍钛记忆合金支架治疗,术后患者的吞咽困难及咽下疼痛明显改善,现报告如下.一、资料和方法 1. 一般资料 : 48例中男 37例,女 11例,年龄 45～ 76岁,平均 57.49岁.所有患者均以吞咽困难、咽下疼痛或进食后呛咳、胸痛等症状为主诉,按 Stooler分级,Ⅰ级 6例,Ⅱ级 19例,Ⅲ级 20例,Ⅳ级 3例.其中晚期食管癌 36例,晚期贲门癌 9例,吻合口癌 3例.5例并发食管气管瘘,13例曾行单纯扩张治疗术,12例曾行微波治疗 .     

SELF‐EXPANDABLE METALLIC STENT FOR PATIENTS WITH NON‐RESECTABLE MALIGNANT COLORECTAL STRICTURE: REVIEW OF 102 CASES IN THE JAPANESE LITERATURE

Alternative procedures using endoscopy have been developed, one of which is treatment with self‐expandable metallic stents (SEMS). In Japan, as SEMS for colorectal stricture has not been approved by the public insurance system, esophageal stent is used for colon and rectum exceptionally as a colonic SEMS after obtaining informed consent from the patient. This situation is very different to other countries. In the present study, we review the Japanese medical literature to determine the current status, feasibility, and challenges remaining for SEMS to show the current status of SEMS usage for colonic strictures in Japan. We investigated SEMS for patients with non‐resectable malignant colorectal stricture in 102 Japanese case reports. Primary colorectal cancer comprised half of the cases. The insertion success rate was 100% and the clinical effectiveness rate was 93%. Restricture occurred in 12 cases (12%), and half of those cases were treated by stent in stent. Stent migration occurred in eight cases (8%) and perforation in two cases (2%). The range of SEMS insertion duration was 1 to 576 days (mean: 132 days, median 142 days). There were no deaths related to the procedure. This procedure allows patients to forgo colostomy and is cheap, safe and effective, with a short treatment time. This procedure is a viable palliative alternative to colostomy for patients with inoperative malignant colorectal stricture. Widespread application of the procedure has been hampered.     

Clinical outcomes of self-expandable metal stents in palliation of malignant anastomotic strictures caused by recurrent gastric cancer

AIM： To examine the technical feasibility and clinical outcomes of the endoscopic insertion of a selfexpandable metal stent （SEMS） for the palliation of a malignant anastomotic stricture caused by recurrent gastric cancer. METHODS： The medical records of patients, who had obstructive symptoms caused by a malignant anastomotic stricture after gastric surgery and underwent endoscopic insertion of a SEMS from January 2001 to December 2007 at Kangnam St Mary＇s Hospital, were reviewed retrospectively. RESULTS： Twenty patients （15 male, mean age 63 years） were included. The operations were a total gastrectomy with esophagojejunostomy （n = 12）, subtotal gastrectomy with Billroth-Ⅰ reconstruction （n = 2） and subtotal gastrectomy with Billroth- Ⅱ reconstruction （n = 8）. The technical and clinical success rates were 100% and 70%, respectively. A small bowel or colon stricture was the reason for a lack of improvement in symptoms in 4 patients. Two of these patients showed improvement in symptoms after another stent was placed. Stent reobstruction caused by tumor ingrowth or overgrowth occurred in 3 patients （15%） within 1 mo after stenting. Stent migration occurred with a covered stent in 3 patients who underwent a subtotal gastrectomy with Billroth-Ⅱ reconstruction. Two cases of partial stent migration were easily treated with a second stent or stent repositioning. The median stent patency was 56 d （range, 5-439 d）. The median survival was 83 d （range, 12-439 d）. CONCLUSION： Endoscopic insertion of a SEMS provides safe and effective palliation of a recurrent anastomotic stricture caused by gastric cancer, A meticulous evaluation of the presence of other strictures before inserting the stent is essential for symptom improvement.     

How to treat intestinal obstruction due to malignant recurrence after Whipple's resection for pancreatic head cancer: description of 2 new endoscopic techniques

The prognosis of pancreatic cancer remains poor,even after initial surgical therapy. Local recurrence after Whipple's pancreatico-duodenectomy may lead to intestinal obstruction at the level of the afferent limb or the alimentary limb. Endoscopic insertion of a selfexpandable metal stent(SEMS) into the intestinal malignant stricture is the preferred method of choice for palliation. We describe two new endoscopic techniques to treat a malignant intestinal obstruction with the insertion of a SEMS into the afferent limb and the alimentary limb. A case of malignant gastric outlet obstruction after a Whipple's resection was treated by the creation of an endoscopic gastrojejunostomy by the insertion of a lumen apposing Hot Axios stent in between the stomach and the alimentary limb under fluoroscopic and endoscopic ultrasound control. Biliary obstruction and jaundice caused by a malignant stricture of the afferent limb after a Roux-en-Y Whipple's resection was treated by the insertion of a SEMS by means of the single-balloon overtube-assisted technique under fluoroscopic control. Feasibility and advantages of both techniques are discussed.     

Development of Severe Acute Pancreatitis Following Uncovered Metallic Stent Placement: A Rare Case Report

Self-expandable metallic stents (SEMSs) are widely used for malignant biliary stricture (MBS). Acute pancreatitis is an early complication following SEMS placement. In the present case, the patient developed severe acute pancreatitis after SEMS placement for MBS because of metastatic lymph nodes. Endoscopic retrograde cholangiopancreatography, endoscopic sphincterotomy and an endoscopic nasobiliary drainage tube placement were performed. After seven days, an uncovered SEMS was placed; however, severe acute pancreatitis occurred, and the SEMS was drawn out emergently. In SEMS placement for patients with MBS caused by non-pancreatic cancer, SEMS should be selected carefully while considering each patient''s case.     

ENDOSCOPIC TREATMENT OF A BENIGN COLOCUTANEOUS AND ENTEROCOLIC FISTULA BY INSERTION OF OVERLAPPING SELF‐EXPANDABLE METAL STENTS

We report the successful closure of fistulae at the site of a benign colocolonic anastomotic stricture using self‐expandable metal stents (SEMS). The stricture and fistulae developed after sigmoid colon resection for diverticulitis. After closure of the fistulae with a covered stent and resolution of inflammation, 10 months later the patient elected to undergo one‐stage resection of the diseased colon and stent. Although there have been previously reported cases of SEMS for closure of malignant colonic fistula, there are limited reports of SEMS for closure of benign colonic fistulae and none demonstrate long‐term success. We conclude that this patient exemplifies the potential applications of SEMS as definitive therapy for benign colorectal disease.     

Clinical Efficacy of Endoscopic Treatment for Benign Colorectal Stricture: Balloon Dilatation versus Stenting

Background/Aims

There has been a lack of research comparing balloon dilatation and self-expandable metal stent (SEMS) placement to determine which is better for long-term clinical outcomes in patients with benign colorectal strictures. We aimed to compare the clinical efficacy and complication rates of balloon dilatation and SEMS placement for benign colorectal strictures from a variety of causes.

Methods

Between January 1999 and January 2012, a total of 43 consecutive patients who underwent endoscopic treatment for benign colorectal stricture (balloon only in 29 patients, SEMS only in seven patients, and both procedures in seven patients) were retrospectively reviewed.

Results

Thirty-six patients underwent endoscopic balloon dilatation, representing 65 individual sessions, and 14 patients received a total of 17 SEMS placements. The initial clinical success rates were similar in both groups (balloon vs SEMS, 89.1% vs 87.5%). Although the reobstruction rates were similar in both groups (balloon vs SEMS, 54.4% vs. 57.1%), the duration of patency was significantly longer in the balloon dilatation group compared with the SEMS group (65.5±13.3 months vs. 2.0±0.6 months, p=0.031).

Conclusions

Endoscopic balloon dilatation is safe and effective as an initial treatment for benign colorectal stricture and as an alternative treatment for recurrent strictures.     

Esophageal stent fracture:case report and review of the literature

Endoscopic esophageal stent placement is widely used in the treatment of a variety of benign and malignant esophageal conditions.Self expanding metal stents(SEMS)are associated with significantly reduced stent related mortality and morbidity compared to plastic stents for treatment of esophageal conditions;however they have known complications of stent migration,stent occlusion,tumor ingrowth,stricture formation,reflux,bleeding and perforation amongst others.A rare and infrequently reported complication of SEMS is stent fracture and subsequent migration of the broken pieces.There have only been a handful of published case reports describing this problem.In this report we describe a case of a spontaneously fractured nitinol esophageal SEMS,and review the available literature on the unusual occurrence of SEMS fracture placed for benign or malignant obstruction in the esophagus.SEMS fracture could be a potentially dangerous event and should be considered in a patient having recurrent dysphagia despite successful placement of an esopha-geal SEMS.It usually requires endoscopic therapy and may unfortunately require surgery for retrieval of a distally migrated fragment.Early recognition and prompt management may be able to prevent further problems.     

Optimization of light dosimetry for photodynamic therapy of Barrett's esophagus: efficacy vs. incidence of stricture after treatment

BACKGROUND: Photodynamic therapy (PDT) may be used to ablate high-grade dysplasia/early stage cancer (HGD/T1) in patients with Barrett's esophagus. PDT may result in esophageal stricture. This nonrandomized, unblinded, dose de-escalation study in consecutive patients was designed to determine the lowest light dose effective for ablation of HGD/T1 while reducing the incidence of stricture. METHODS: A total of 113 patients received an injection of porfimer sodium (2 mg/kg). Three days later, 630 nm light was delivered by using a 20-mm-diameter PDT balloon at doses of 115 J/cm (n=59), 105 J/cm (n=18), 95 J/cm (n=17), or 85 J/cm (n=19). Treatment efficacy was determined by obtaining biopsy specimens of the treated area 3 months later. The incidence of stricture was determined by the need for esophageal dilation to treat dysphagia. A stricture was considered severe if 6 or more dilations were required. RESULTS: The incidence of severe stricture was related to the light dose. At 115 J/cm, 15.3% of patients developed severe strictures compared with 5.3% to 5.6% of those treated with the lower doses. At a light dose of 115 J/cm, 17.0% of patients had residual HGD/T1. Light doses of 105 J/cm, 95 J/cm, and 85 J/cm resulted in residual HGD/T1 in 33.3%, 29.4%, and 31.6% of patients, respectively. None of the observations were statistically significant. CONCLUSIONS: Decreasing the light dose below 115 J/cm appeared to result in a reduced incidence rate of severe stricture but higher relative frequencies of residual HGD/T1 in Barrett's esophagus.     

Endoscopic removal of a spontaneously fractured biliary uncovered self-expandable metal stent

Self-expandable metal stents (SEMS) are widely used for the palliative treatment of unresectable malignant biliary obstruction. However, the long-term durability of SEMSs in biliary strictures is not clear. We describe a case of endoscopic removal of spontaneously fractured uncovered biliary SEMS. A 59-year-old woman presented to our institution with a 1-year history of recurrent cholangitis. Her medical history included a proctectomy for rectal cancer and right hemihepatectomy for liver metastasis 10 years earlier. Five years after these operations, she developed a benign hilar stricture and had an uncovered SEMS placed in another hospital. Endoscopic retrograde cholangiopancreatography demonstrated that the SEMS was torn in half and the distal part of the stent was floating in the dilated common bile duct. The papillary orifice was dilated by endoscopic papillary large balloon dilation (EPLBD) using a 15-mm wire-guided balloon catheter. Subsequently, we inserted biopsy forceps into the bile duct and grasped the distal end of the broken SEMS under fluoroscopy. We successfully removed the fragment of the SEMS from the bile duct, along with the endoscope. The patient was discharged without complications. Placement of an uncovered biliary SEMS is not the preferred treatment for benign biliary strictures. Spontaneous fracture of an uncovered biliary SEMS is an extremely rare complication. We should be aware that stent fracture can occur when placing uncovered biliary SEMSs in patients with a long life expectancy. EPLBD is very useful for retrieving the fractured fragment of SEMS.     

CURRENT STATUS OF ENDOSCOPIC TREATMENT FOR UPPER GASTROINTESTINAL STRICTURE: CHAIRPERSON's REVIEW

Endoscopic management for upper gastrointestinal stricture has been discussed. First‐line treatment for unresectable esophageal cancer is chemothepary (or chemoradiotheapy). When the first‐line treatment is not effective, intubation of self expandable metallic stent (SEMS) is considered. A poor‐risk patient who has no tolerance to radiochemotherapy is also a candidate for direct SEMS stenting. Prompt recovery from dysphagia is the major advantage to SEMS stenting. Nevertheless, SEMS stenting is a non‐curative treatment to the original disease and it induces a temporary relief only from dysphasia. Bleeding, perforation, and re‐stenosis are often encountered drawbacks after intubation of SEMS. Stricture after widespread EMR may also be successfully controlled by temporarily stenting of covered SEMS. Balloon dilatation or Botox injection is used to control stricture in achalasia, but the effectiveness is limited to short duration of relief from dysphasia. For complete response to stricture of achalasia, laparoscopic surgery is mandatory. Stenting to gastric outlet obstruction is one of the treatment choices that induces temporary but rapid recovery from dysphasia. However, the patient is still exposed to risks of bleeding, perforation, and re‐stenosis continuously after SEMS intubation. Its efficacy should be clarified by further studies. Chemotherapy is also recognized as a first‐line treatment for unresectable gastric cancer. Chemotherapy has a small chance to cure the disease, but stenting has no chance to cure the cancerous disease.