食管癌术后良性吻合口狭窄的内镜治疗探讨

食管癌术后良性食管吻合口狭窄因进食困难，患者痛苦，既往需再次手术治疗。随着内镜技术的发展，也可采用内镜下Savary—Gilliard探条扩张或球囊扩张治疗，但狭窄易复发，需反复治疗。镍钛记忆合金食管支架治疗良性吻合口狭窄则可显著提高临床疗效一为比较不同方法的疗效，选择我院近年来分别应用食管探条扩张术和镍钛记忆合金食管支架置入术治疗的食管癌术后良性吻合口狭窄患者116例和24例，现将结果报告如下.     

食管胃切除术后良性吻合口狭窄内镜治疗的进展

胃肠道切除术后良性吻合口狭窄会降低患者的生活质量,严重时导致重度营养不良并危及生命。目前该类型狭窄的内镜下治疗方法包括球囊扩张术、支架植入、局部药物注射以及新技术内镜下放射状切开术等。本文就食管胃切除术后良性吻合口狭窄的内镜治疗进展作一综述。     

食管重建术后并发症的内镜诊断和处理

目的 对食管重建术后患者的上消化道病变进行内镜诊断和治疗。 方法 食管重建患者54例,术后3周-3年进行内镜随访检查。 结果 残余食管、吻合口和代食管病变的发生率分别为11.6％,69.0％和27.8％。食管重建后患者最常见的疾病为非特异性残余食管炎、吻合口炎及不同程度的吻合口狭窄和慢性胃炎。对5例吻合口重度狭窄患者成功地进行了内镜下吻合口狭窄切开或切开 扩张治疗。 结论 内镜检查有助于食管重建术后并发症的诊断,对作咽造口 食管旁路术患者也是安全可行的。对某些严重吻合口疤痕狭窄者内镜下电切 扩张治疗可解除症状。     

中国食管良恶性狭窄内镜下防治的专家共识意见（2020，北京）

食管黏膜发生良恶性病变或较大损伤时,极易发生狭窄,如何防治食管狭窄,国内尚无内镜下规范化治疗的相关共识。2020年,中华医学会消化内镜学分会和中国医师协会内镜医师分会联合组织全国相关领域权威专家讨论,提出了食管良恶性狭窄内镜下防治专家共识,以期对该类疾病的防治提供指导作用。本共识内容分为食管大面积病变内镜下切除术后狭窄预防、食管良性狭窄治疗、难治性食管良性狭窄治疗、食管恶性狭窄治疗4个部分,共17条陈述建议。     

镍钛记忆合金带膜金属支架治疗食管癌术后吻合口瘘

镍钛记忆合金带膜金属支架置入术治疗各种食管恶性及良性狭窄、食管癌术后致吻合口瘘是采用内镜直视下置入镍钛记忆合金带膜金属支架，取得了满意的效果，我院内镜室2001年12月～2005年2月共收治23例患者，现报告如下。     

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。     

内镜下激光或高频电灼治疗食管胃吻合口狭窄

我院自１９８７年以来，采用内镜下激光及高频电灼治疗食管、胃吻合口良恶性狭窄１４３例，取得了较好的近期效果，现报告、分析如下。１．病例来源：１９８７年２月至１９９３年１２月，本组１４３例中，男９４例，女４９例，年龄２４－７５岁。外科术后病程为１５天～４年。弓上吻合４８例，弓下吻合９５例。经内镜观察及活检证实为良性狭窄７７例，恶性狭窄６６例。狭窄口直径均＜５ｍｍ，其中＜３ｍｍ者７５例。能缓慢进半流质者５６例，进流质者８７例，其中有２５例饮水均困难。２．治疗方法：高频电灼术选用前视型内镜及ＰＳＤ－２高…     

内镜电化学治疗食管贲门癌近期疗效观察

目的 研究内镜电化学对食管、贲门癌及其术后食管胃吻合口狭窄的治疗作用。 方法 对6例食管癌、6例贲门癌及4例食管贲门癌术后食管胃吻合口狭窄患者,在纤维内镜监视导引下对癌肿及吻合口狭窄局部行电化学治疗。 结果 治疗后,6例食管癌达CR 2例,PR 3例,NC 1例总有效率83％(5/6);6例贲门癌达CR 3例,PR 3例,总有效率100％(6/6);4例吻合口狭窄明显扩张,吞咽困难明显改善。 结论 本法能使癌组织坏死,吻合口狭窄扩张,解除食管腔的机械性梗阻,使患者能经口进食。     

内镜下扩张治疗食管贲门癌术后吻合口狭窄43例

目的：总结食管-胃-空肠吻合口狭窄内镜下扩张治疗的疗效及经验．方法：对43例食管癌贲门癌术后食管胃和食管空肠吻合口狭窄患者行国产Savary-Gilliard探条扩张器胃镜下扩张术,术后进行局部活检,其中5例置放了食管支架．结果：所有病例扩张术后吞咽困难stooler分级明显提高,吞咽困难解除,近期有效率100%,扩张术后活检病理证实3例复发．12例行4-7次扩张,2例吻合口狭窄仍再发．结论：胃镜下探条扩张器治疗食管胃空肠吻合口狭窄安全有效,少部分经多次连续规则扩张仍狭窄再发者可置放食管支架,扩张术后应常规活检以排除局部癌症复发．     

内镜下微波合并扩张术治疗食管狭窄15例报告

我院１９９３年２月～１１月在内镜直视下应用微波和食管扩张器综合治疗食管良恶性狭窄１５例，共２２次，取得良好效果，现报告如下。１．一般资料：本组１５例均为男性，年龄１８－７０岁，平均５１岁，其中食管癌、食管贲门癌术后吻合口良性狭窄及吻合口复发癌１３例；放疗后复发癌１例；重度食管静脉曲张治疗后疤痕性狭窄１例。狭窄部位：食管上段２例，中段１０例，食管－胃吻合口３例。狭窄长度：＜２ｃｍ７例，２－３ｃｍ３例，４－５ｃｍ３例，环形膜状狭窄２例。狭窄症状程度和时间：滴水不进３例，仅能进流汁１２例。症状持续时间…     

Endoscopic management of difficult or recurrent esophageal strictures

Esophageal strictures are a common problem in gastroenterological practice. In general, the management of malignant or benign esophageal strictures is different and requires a different treatment approach. In daily clinical practice, stent placement is a commonly used modality for the palliation of incurable malignant strictures causing dysphagia, whereas, if available, intraluminal brachytherapy can be considered in patients with a good performance status. Recurrent dysphagia frequently occurs in malignant cases. In case of tissue in- or overgrowth, a second stent is placed. If stent migration occurs, the stent can be repositioned or a second (preferably partially covered) stent can be placed. Food obstruction of the stent lumen can be resolved by endoscopic cleansing. The cornerstone of the management of benign strictures is still dilation therapy (Savary-Gilliard bougie or balloon). There are a subgroup of strictures that are refractory or recur and an alternative approach is required. In order to prevent stricture recurrence, steroid injections into the stricture followed by dilation can be considered. In case of anastomotic strictures or Schatzki rings, incisional therapy is a safe method in experienced hands. Temporary stent placement is a third option before considering self-bougienage or surgery as a salvage treatment. In this review, the most frequently used endoscopic treatment modalities for malignant and benign stricture management will be discussed based on the available literature, and some practical information for the management in daily clinical practice will be provided.     

超声内镜检查在儿童上消化道狭窄诊断与治疗中的应用价值

目的探讨超声内镜检查在儿童上消化道狭窄诊断与治疗中的应用价值。 方法回顾性分析2015年5月至2020年5月山东大学附属儿童医院收治的上消化道狭窄患儿48例,包括食管狭窄27例（其中食管闭锁术后吻合口狭窄18例,化学腐蚀性食管狭窄3例,异物所致食管狭窄1例,病因不明食管狭窄5例）,贲门失弛缓症4例,胃输出端狭窄12例,十二指肠狭窄5例。所有患儿均在麻醉状态下行超声内镜检查进行术前评估,根据上消化道狭窄部位、狭窄口大小及超声内镜下改变,选择不同的治疗方案。 结果18例食管闭锁术后吻合口狭窄患儿超声内镜显示食管管壁层次分界不清,环狭窄口周围管壁厚度不均;3例腐蚀性食管损伤患儿超声内镜显示食管损伤程度不一;异物所致食管狭窄1例患儿超声内镜显示异物回声;病因不明食管狭窄5例患儿超声内镜示管壁层次分界不清。贲门失弛缓症4例患儿超声内镜显示贲门固有肌层厚度为0.9~4.0 mm。胃输出端狭窄12例患儿超声内镜显示狭窄部位层次不清、厚薄不均。十二指肠狭窄5例患儿中,4例为先天性发育异常,超声内镜显示狭窄部位局部组织呈均匀回声;1例为消化性溃疡所致十二指肠狭窄,超声内镜显示幽门黏膜隆起处管壁层次模糊。 结论超声内镜检查可以明确儿童上消化道狭窄病变的起源及层次,有助于诊断和术前风险的评估,并为治疗方案的选择提供重要依据。     

Endoscopic treatment of benign esophageal strictures: a literature review

Introduction: Benign esophageal strictures arise from various etiologies and are frequently encountered. Although endoscopic dilation is still the first-line therapy, recurrent strictures do occur in approximately 10% of the cases and remains a challenge to gastroenterologists.

Areas covered: A literature search was performed using PubMed and Google Scholar databases for original and review articles on endoscopic treatment of benign esophageal strictures. This review outlines the main available treatment options and its controversies in the management of refractory benign esophageal strictures.

Expert commentary: Adding local steroid injections to dilation can be effective for peptic stenosis and strictures after endoscopic submucosal dissection, but remains uncertain for anastomotic strictures. Intralesional injections of mitomycin-C could be useful in corrosive strictures. Incisional therapy can be a reliable alternative in Schatzki rings and in anastomotic strictures, in experienced hands. By contrast, long-term outcome with endoprosthetic treatment is disappointing, and stent placement should be carefully considered and individualized.     

New approach to malignant strictures of the esophagus

Primary esophageal cancer is the most common cause of malignant esophageal stricture. Prognosis and treatment outcomes vary with the stage of the disease. Endoscopic ultrasound has a high accuracy rate for local and regional staging. Surgery is curative for early cancer. Endoscopic mucosal resection, photodynamic therapy, or brachytherapy can be used with curative intent for early cancer, especially in patients with comorbid conditions precluding surgery. Unfortunately, the majority of patients with esophageal cancer present with advanced disease. The primary aim in these patients is to alleviate symptoms with a minimum of side effects and reinterventions. Palliative surgery or chemoradiotherapy can be associated with high morbidity and mortality rates. Several endoscopic techniques for palliation are available, and all have the potential of significantly improving swallowing. The choice of a particular endoscopic approach is usually determined by local expertise and characteristics of the stricture.     

A guidewire-assisted endoscopic knife-cutting salvage technique for near-total esophageal obstruction

There are many potential strategies for endoscopic treatment of benign esophageal strictures. However, total esophageal strictures still remain difficult to treat. We report a case of a 53-year-old woman with a near-total esophageal stricture with multiple webs and postoperative stenosis. A guidewire-assisted endoscopic cutting method and endoscopic dilation technique were used for total esophageal obstruction in a relatively long segment in a patient with Plummer–Vinson syndrome. This case shows that balloon dilation plus guidewire-assisted endoscopic cutting may be an effective salvage therapy for near-total esophageal obstruction when performed by experienced endoscopists.     

Removable, Fully Covered, Self-expandable Metal Stents for the Treatment of Refractory Benign Esophagogastric Anastomotic Strictures

The use of metal stents for malignant esophageal strictures for palliation is well accepted. However, utilization of metal stents for benign esophageal diseases has been controversial. Given the availability of removable, fully covered, self-expandable metal stents (RFCSEMSs), this study was undertaken to evaluate the effectiveness and safety of RFCSEMSs in patients with refractory benign esophagogastric anastomotic strictures. Twenty-four patients with RFCSEMSs were enrolled in this study. All patients had undergone endoscopic Savary-Gilliard bougie dilatation five times or more but there was no significant improvement in symptoms. For all 24 patients, the symptom of dysphagia was alleviated significantly while the stent was in place and for a short time after stent removal, and dysphagia scores decreased from 3-4 to 0-1. After 12?months of follow-up, 18 patients were free from dysphagia but the other 6 patients still suffered obvious dysphagia. RFCSEMSs are still not perfect and can induce some complications. The treatment failure rate of restenting was remarkably high after the first failure. Given that effective methods for treating refractory stricture have not been found, RFCSEMSs could be considered for treating refractory benign esophagogastric anastomotic stricture.     

Usefulness of self-expanding biodegradable prosthesis in the treatment of refractory benign stenosis: a case series study

Background: The use of self-expanding biodegradable prosthesis treatment of refractory benign stenosis is still undefined. Objective: To determine the utility and safety of biodegradable polydioxanone prostheses as treatment of gastrointestinal tract refractory benign strictures. Methods: Consecutive patients diagnosed with refractory benign stricture of gastrointestinal tract following Kochman′s criteria were included. The type of stenosis were anastomotic (n = 5), peptic (n = 1), post-radiotherapy (n = 1) and they were located in proximal esophagus-hypofarynge (n = 2), esophagus medium (n = 1), distal esophagus (n = 2) and rectum (n = 2). The prosthesis was placed under endoscopic and fluoroscopic control under conscious sedation with propofol. Results: Seven patients (8 prosthesis) were included. Mean patient age was 49 years-old (range: 37 - 70). Insertion prosthesis was successful in all cases. Distal migration of prosthesis was observed in both rectal stenosis and was the indication of a second prosthesis placement in one case. At the end of follow-up (median follow-up 30 weeks for esophageal stricture, 33 weeks for rectal stricture) 5 patients remained asymptomatic. Eighty per cent of patients with esophageal stenosis showed partial and transient re-stenosis due to hyperplastic reaction during the degradation of the prosthesis, with transient dysphagia in two patients resolved medically. Complete prosthesis degradation was confirmed by endoscopy in all cases. Conclusions: The use of self-expanding biodegradable polydioxanone prosthesis is a safe and utile therapeutic option for refractory benign gastrointestinal stenosis.     

The future of esophageal endoprosthetics including the use of biodegradable materials

Endoscopic esophageal stent placement is an effective palliative treatment for malignant dysphagia and complications related to esophageal malignancies. Lately, esophageal stents have also been successfully used for benign indications including anastomotic stricture, iatrogenic perforation or leak, achalasia, fistula and to stabilize patients with esophageal variceal bleeding. At present, there are a wide variety of esophageal stents available to choose from; however, an ideal esophageal stent, which is both effective and without complications, has yet to be developed. Despite the evolution in this field, challenges such as stent migration, malignant tissue ingrowth, and recurrent stricture are some of the unsolved problems. In this article, we discuss about currently available esophageal stents including biodegradable stents, various stent materials, stent designs, indications for esophageal stent placement in treating both benign and malignant esophageal diseases, clinical outcomes, complications, novel esophageal stents including drug fiber coated stents, dynamic esophageal stents, and the future direction of esophageal endoprosthetics.     

Progress in the endoscopic management of benign biliary strictures

Benign biliary strictures can now be effectively treated with endoscopic therapy in a variety of clinical situations. Despite recent developments in imaging techniques (endoscopic ultrasound and magnetic resonance imaging), it is often difficult to differentiate benign from malignant biliary strictures. The sensitivity of tissue diagnosis (cytology and needle biopsy) at endoscopic retrograde cholangiopancreatography (ERCP) remains poor (40-50%), and further diagnostic methods are required. Endoscopic therapy offers a definitive treatment in 70-90% of patients following post-operative biliary stricture, including anastomotic strictures following liver transplant. Endoscopic therapy successfully achieves symptomatic, biochemical, and cholangiographic response, and may improve survival in patients with primary sclerosing cholangitis. Strictures secondary to chronic pancreatitis are resistant to standard endoscopic therapy and metallic endoprotheses have been trialed with varying success. Endoscopic therapy is technically difficult and should be performed in specialized centres using a multidisciplinary approach.