自膨式金属支架在结直肠梗阻中的应用进展

结直肠恶性梗阻的患者通常需要急诊手术治疗解除梗阻,然而传统的急诊手术并发症发生率及病死率高,尤其对于左半结肠癌及直肠癌患者。自膨式金属支架自应用20余年来,已较广泛的应用于结直肠的各种良恶性狭窄,但支架置入是否会影响患者的长期生存及肿瘤转移目前仍有很大争议。笔者从金属支架置入的适应证与禁忌证、支架在结直肠良恶性梗阻中的应用等方面结合最新研究进展做一综述,为临床诊疗提供参考。     

经内镜金属支架植入术治疗低位结直肠癌梗阻的护理体会

目的 探讨经内镜金属支架植入术治疗低位结直肠癌梗阻的护理方法。方法 在X线辅助下经内镜放置金属支架治疗19例结直肠癌梗阻的患者。术前准备充分,术中默契配合,术后严密观察并发症发生。结果19例患者均成功放置支架。放置支架后后2-3天梗阻症状得到缓解,解除梗阻和术前肠道准备后5-9天接受I期肿物切除术,术后恢复良好,无腹腔脓肿、创口感染、吻合口漏等并发症发生。结论 经内镜放置金属支架治疗低位结直肠癌梗阻,微创、安全、见效快、重复性强,保持了生理状态的排便功能,消除了肠造口对患者带来的心理负担。手术前后护理、术中准确的配合及并发症的预防是手术成功的重要组成部分。     

微创外科技术在结直肠癌伴梗阻治疗中的临床应用

目的探讨记忆金属支架置入技术、腹腔镜手术及植入用缓释氟尿嘧啶局部化疗3种微创外科方法在治疗结直肠癌伴梗阻中的临床应用价值。方法对解放军第251医院、河北北方学院附属第一医院和第三医院2000年5月至2010年5月期间收治的68例结直肠癌伴梗阻患者分别采用下列2种方法治疗:①对可手术根治的结直肠癌伴梗阻患者,先在结肠镜引导下置入记忆金属肠管支架解除梗阻,施行暂时性过渡治疗,再经充分肠道准备后,腹腔镜下施行根治性切除手术;②对失去手术根治机会的晚期(TNMⅣ期)直肠癌患者,主要采用支架置入技术,施行永久性姑息治疗,并经支架网眼穿刺植入缓释氟尿嘧啶局部化疗。结果①采用支架置入技术施行过渡治疗,解除梗阻后采用腹腔镜手术52例,其中51例施行根治性切除,1例因侵袭、转移的乙状结肠癌未能切除。获随访41例,随访时间3~36个月,平均15个月。其中施行根治性切除40例,均无局部复发、切口肿瘤种植及吻合口狭窄,另1例未能切除者于术后93 d死亡。②对15例失去手术根治机会的晚期直肠癌和1例因患严重肺心病不能耐受手术的直肠癌,采用支架置入和植入用缓释氟尿嘧啶治疗,全部获随访,时间为3~24个月,平均14个月;现已死亡11例,其生存时间为(350±222)d(101~720 d);其余5例已存活3~13个月(平均9个月),未再发生肠梗阻。结论利用记忆金属支架与腹腔镜手术联合治疗可手术根治的结直肠癌伴梗阻患者,具有微创、安全等优点;利用记忆金属支架与植入用缓释氟尿嘧啶联合治疗失去手术根治机会的晚期直肠癌伴梗阻,可使患者避免结肠造口,延长其生存期。     

支架植入治疗左半结肠直肠癌所致的急性梗阻

目的：探讨肠道支架放置对左半结肠直肠癌所致的急性梗阻之治疗效果和安全性。方法：对2000年5月～2006年6月收治的42例左半结肠直肠癌所致的急性梗阻进行临时性或姑息性支架放置：观察支架植入后梗阻缓解情况和并发症。结果：42例中34例支架植入成功（81．0％）．24h内的临床梗阻缓解率为94．1％（32／34）．全组无死亡发生。术后并发结肠穿孔和食物残渣堵塞支架各1例，均改作Hartmann手术；支架移位和肛门疼痛各2例。18例经过肠道准备和全身支持治疗后再行根治性手术；另14例支架植入属永久性姑息性治疗。结论：肠道支架植入对左半结肠、直肠癌所致的急性梗阻是一种安全有效的临时过渡性或永久性姑息性治疗手段，可借以免除急诊结肠造瘘术。     

超细内镜联合腹腔镜在急性左半结肠恶性梗阻中的应用

目的:评价超细内镜联合腹腔镜在急性左半结肠恶性梗阻应用中的安全性和有效性。方法:回顾性分析2013年1—9月收治的11例急性左半结肠恶性梗阻患者临床资料。先通过超细内镜引导下置入肠道支架,解除梗阻,再行腹腔镜结直肠癌根治一期吻合术。结果:11例患者均成功置入结肠支架,病变部位包括结肠脾区1例、降结肠2例、乙降结肠交界4例、乙状结肠2例、直乙状结肠交界2例。9例患者在支架置入后接受了根治性手术,2例因肝转移实施姑息性手术。术后1例切口感染,1例肺部感染,1例吻合口出血,均经保守治疗后好转。结论:术前肠道支架减压联合腹腔镜一期吻合手术是治疗急性左半结肠恶性梗阻安全有效的方法。     

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目的 探讨经内镜水囊扩张和金属支架置入术治疗肠道恶性梗阻的临床价值。方法 经内镜水囊扩张和金属支架置入术共治疗12例肠道恶性梗阻的病人，其中十二指肠恶性狭窄5例，直肠恶性狭窄5例，乙状结肠恶性狭窄2例。结果 5例十二指肠恶性梗阻经水囊扩张后放置支架成功，均解除梗阻症状。7例结直肠恶性梗阻中，4例扩张后放置金属支架作姑息治疗，2例经扩张和支架治疗解除梗阻后接受手术治疗，1例直肠癌术后狭窄伴盆腔广泛转移者扩张治疗失败。结论 经内镜水囊扩张和金属支架置入术治疗肠道恶性狭窄梗阻是一种操作简单、经济有效、并发症少的方法，可以显著减少病人的创伤和痛苦，提高病人的生活质量。     

自扩张金属内支架治疗左半结直肠恶性梗阻临床观察

为探讨X线电视透视联合纤维结肠镜置入镍钛记忆合金网状支架治疗左半结直肠癌梗阻的疗效,对6例左半结直肠癌梗阻患者实施该方法。6例均一次置人成功,其中4例作为过渡性治疗于5～7d后行开腹手术切除肿瘤,2例为永久性内支架姑息治疗。结果表明,金属内支架治疗左半结肠癌梗阻创伤小,并发症少,恢复快,是一种安全、有效的替代急诊手术的治疗方法,且对肿瘤晚期、不适于外科手术或拒绝手术治疗的患者,可作为永久性姑息治疗。     

金属支架和腹腔镜在结直肠癌伴梗阻治疗中的应用价值

目的研究联合金属支架与腹腔镜手术在治疗结直肠癌伴梗阻治疗中的疗效。方法将2012年3月至2015年3月期间收治的48例高龄结直肠癌伴梗阻病人分为两组,①观察组:24例结直肠癌伴梗阻病人,植入金属支架缓解梗阻作为过渡治疗,完善相关术前准备,之后在腹腔镜下行结直肠癌根治性切除术;②对照组:24例结直肠癌伴梗阻的同期病人直接采取腹腔镜下结直肠癌切除术。结果①采取过渡性植入金属支架后进行根治性手术的病人24例,其中21例施行根治性切除,2例因转移至肝脏和肺未能切除,另1例因房颤未行金属支架置入术和腹腔镜结直肠癌切除术。术后随访24例,随访时间12~29个月,平均21个月。其中施行根治性切21例均无复发和转移,3例未能切除者死于肿瘤远处转移。对照组:24例采取直接腹腔镜手术治疗,24例行根治性手术,2例因术后肠瘘、多器官功能衰竭死亡,1例因术后发生胃转移死亡。随访:24例,随访时间10~24个月,平均15个月,对比两组病人,发现病人在支架置入后行腹腔镜根治术,术后并发症及生活质量有显著改善,生存时间并无明显差异。结论相比直接采取腹腔镜手术切除的病人,联合金属支架植入与腹腔镜手术治疗方式具有安全、术后并发症少等优点,可提高病人生存质量,两组病人在生存时间上无明显差异。     

内镜置入胆道金属支架治疗肝门部胆管癌

目的 探讨通过内镜置入自膨式胆道金属支架治疗肝门部胆管癌的疗效.方法 回顾性分析2004年7月至2009年7月成都军区总医院收治的73例肝门部胆管癌患者行内镜胆道金属支架置入术的操作成功率、减黄有效率、支架通畅时间和生存时间以及术后并发症.结果 支架置入成功70例,3例失败.其中单金属支架置入62例,双侧金属支架置入3例,金属支架+塑料支架置人5例.减黄有效率为87%(61/70),中位支架通畅时间为190 d,中位生存时间为246 d.术后发生胆管炎7例,胰腺炎3例,出血2例.结论 内镜置入自膨式胆道金属支架治疗肝门部胆管癌创伤小、减黄效果好,可作为无法手术切除的肝门部胆管癌患者解除胆道恶性梗阻的首选治疗方法.     

内镜置入胆道金属支架治疗肝门部胆管癌

目的 探讨通过内镜置入自膨式胆道金属支架治疗肝门部胆管癌的疗效.方法 回顾性分析2004年7月至2009年7月成都军区总医院收治的73例肝门部胆管癌患者行内镜胆道金属支架置入术的操作成功率、减黄有效率、支架通畅时间和生存时间以及术后并发症.结果 支架置入成功70例,3例失败.其中单金属支架置入62例,双侧金属支架置入3例,金属支架+塑料支架置人5例.减黄有效率为87%(61/70),中位支架通畅时间为190 d,中位生存时间为246 d.术后发生胆管炎7例,胰腺炎3例,出血2例.结论 内镜置入自膨式胆道金属支架治疗肝门部胆管癌创伤小、减黄效果好,可作为无法手术切除的肝门部胆管癌患者解除胆道恶性梗阻的首选治疗方法.     

Covered self-expandable metal stents are more associated with complications in the management of malignant colorectal obstruction

Background

The use of self-expandable metal stents (SEMS) for the treatment of malignant colorectal obstruction is increasing. However, results of risk factors for its complications are inconsistent. This study aimed to examine the clinical effectiveness of the procedure as well as the complications and risk factors associated with the complications.

Methods

Medical records of patients with malignant colorectal obstruction who underwent endoscopic placement of covered or uncovered SEMS were reviewed retrospectively. The procedure was performed by two endoscopists with experience in pancreatobiliary endoscopy.

Results

A total of 152 patients were included (102 men; mean age, 70 ± 12.5 years). The procedure was performed for palliative management in 83 patients and performed as a bridge to surgery in 69 patients. There were 111 uncovered stents and 41 covered stents. The technical success rate was 100 % and the clinical success rate 94.1 %. Overall complications were observed in 49 patients (32.2 %) during the follow-up period (median, 98 days; interquartile range, 19–302 days). Obstruction (17.1 %), migration (7.9 %), perforation (5.2 %), bleeding (1.3 %), and tenesmus (0.7 %) were the causes of the complications. Stage IV disease, carcinomatosis peritonei, complete obstruction of the colon, palliative intention, and covered stents increased the complications based on the univariate analysis. Multivariate analysis revealed that complete obstruction of the colon and covered stents were significantly independent risk factors for complications. In the palliative group, Kaplan–Meier analysis showed significantly shorter median duration to the onset of complications in the covered stent group than in the uncovered stent group.

Conclusions

Although SEMS in patients with malignant colorectal obstruction is effective both as palliative therapy and as a bridge to surgery, one-third of patients experienced complications. Severity of obstruction and stent type can influence outcomes.     

Self expanding wall stents in malignant colorectal cancer: is complete obstruction a contraindication to stent placement?

Objective  Technical failures have previously been associated with complete clinical obstruction and complete block to the retrograde flow of gastrograffin is considered by some to be a contraindication to the procedure. We report on the technical and clinical success rates of self-expanding metallic stents (SEMS) in both complete and incomplete obstruction in a prospective series of malignant colorectal obstructions.
Method  A prospective study of all patients undergoing attempted palliative and bridge to surgery SEMS placement for malignant colorectal obstruction over a 7-year period (April 1999–October 2006) was undertaken.
Results  Seventy-two patients (49 males) with a mean age of 71 years (range 49–98) were included. Technical success was achieved in 27 of 32 patients (84%) with complete obstruction and 33 of 36 patients (92%) with incomplete obstruction, P  < 0.46, Fishers exact test. Clinical success was achieved in 17 of 26 patients (65%) with complete obstruction and 24 of 33 patients (73%) with incomplete obstruction, P  < 0.58, Fishers exact test. Although placed correctly in 89% cases, relief of symptoms occurred in only 71%, P  = 0.002, matched pairs test. There were two colonic perforations in the series with one procedure related death.
Conclusion  Placement of SEMS for obstructing colorectal cancer is technically successful in a high proportion of cases. Complete radiological obstruction is not a contraindication to stent placement. The relief of obstructive symptoms following successful placement of a wall stent is less predictable.     

The clinical outcomes of the radiologic method for self-expandable metal-stent placement in patients with colorectal obstruction: A prospective study

ObjectivesTo assess the clinical outcomes of self-expandable metal stent (SEMS) placement for patients with colorectal obstruction.MethodsA total of 61 patients underwent SEMS placement using computerized tomography (CT) to confirm malignancy of intrinsic origin and evaluate the exact location, notch, and extent of the disruptive laceration.ResultsThe overall technical success rate and clinical success rate of SEMS placement using the radiological method were 59 (96.7%) and 57 (93.4%), respectively. The technical success rate and clinical success rate of SEMS placement in the palliative and bridge to elective surgery (BTS) groups were 35 (97.2%), 24 (96.0%), 33 (91.7%), and 24 (96.0%). The median cumulative primary stent patency duration and patients’ survival of SEMS placement was 123 days (95% CI, 65–123 days), and 133 days (95% CI, 72–133 days). The median cumulative primary stent patency duration and patient survival did not differ significantly between the palliative group 119 days; (95% CI, 59–119 days), 128 days; (95% CI, 71–128 days), and the BTS group 120 days; (95% CI, 68–120 days; p = 0.362), 130 days; (95% CI, 78–130 days); p = 0.412).ConclusionsThe colorectal obstruction had convoluted with curved angulation and located mainly at the rectum, sigmoid, descending colon, and the radiologic method of SEMS placement has more efficacious with a high technical and clinical success rate. However, SEMS placement was highly technical, and clinical success with median stent patency and patient survival did not differ significantly between the palliative group and the BTS group.     

Palliative stent implantation in the treatment of malignant colorectal obstruction

BACKGROUND: Palliative surgical interventions for the management of colonic obstruction in cases of metastasized or locally irresectable colorectal carcinoma show remarkable morbidity and mortality rates for mostly older and multimorbid patients. For manifest obstruction, placement of a self-expanding metal stent (SEMS) is considered to be a suitable minimally invasive therapeutic option. This study aimed to investigate the efficacy of stent-based treatment for malignant large bowel obstruction. METHODS: From January 1999 to June 2005, consecutive patients who had undergone placement of a SEMS for malignant colorectal obstruction were enrolled and monitored. Manifest incontinence and rectum carcinoma within 5 cm above the anocutaneous line were contraindications for SEMS implantation. For all further locations of tumor-induced stenosis, a stent was implanted using endoscopy and fluoroscopy. This case series was characterized in terms of age, carcinoma localization, complications, morbidity and mortality, and the necessity for further interventions. RESULTS: For 44 of 48 patients (92%), stents were placed successfully and obstruction was abolished. The four remaining patients experienced stent dislocation. The median of age of the patients was 77.7 years (range, 47-96 years). The distribution of malignant stenoses was as follows: rectum (n = 16, 33.3%), sigmoideal colon (n = 21, 43.8%), descending colon (n = 4, 8.3%), splenic flexure (n = 2, 4.2%), transversal colon (n = 3, 6.2%), hepatic flexure (n = 1, 2.1%), and ascending colon (n = 1, 2.1%). There was no peri-interventional morbidity or mortality. The median in situ time for the stents was 251 days (mean, 422 days), with 13 of 44 patients treated with palliative therapy showing complications (29.5%). Six patients were treated endoscopically, and three individuals underwent surgical intervention. For four patients, no further intervention was required. Overall, there was no treatment-related mortality. CONCLUSIONS: For palliative treatment of malignancy-induced colorectal obstruction, SEMS is an efficient tool associated with low morbidity and minimal mortality. From a technical point of view, all tumor locations are accessible.     

Management of acute malignant large-bowel obstruction with self-expanding metal stent

Background Colorectal stents are being used for palliation and as a “bridge to surgery” in obstructing colorectal carcinoma. The purpose of this study was to review our experience with self-expanding metal stents (SEMS) as the initial interventional approach in the management of acute malignant large bowel obstruction. Methods Between February 2002 and May 2006, 67 patients underwent the insertion of a SEMS for an obstructing malignant lesion of the left-sided colon or rectum. Results In 55 patients, the stents were placed for palliation, whereas in 12 they were placed as a bridge to surgery. Stent placement was technically successful in 92.5% (n = 62), with a clinical success rate of 88% (n = 59). Two perforations that occurred during stent placement we retreated by an emergency Hartmann operation. In intention-to-treat by stent, the peri-interventional mortality was 6% (4/67). Stent migration was reported in 3 cases (5%), and stent obstruction occurred in 8 cases (13.5%). Of the nine patients with stents successfully placed as a bridge to surgery, all underwent elective single-stage operations with no death or anastomotic complication. Conclusions Stent insertion provided an effective outcome in patients with malignant colonic obstruction as a palliative and preoperative therapy.     

结直肠梗阻支架植入后腹腔镜手术的临床疗效

目的探讨结直肠肿瘤致结肠梗阻支架植入治疗后再行腹腔镜结直肠癌根治术的可行性。方法回顾性分析2009年10月至2011年11月上海市第十人民医院收治的行支架植入治疗的21例结直肠肿瘤致急性梗阻患者的临床资料。对支架植入情况、肠梗阻症状、相关疾病缓解情况、腹腔镜手术结果等进行分析,计数资料采用Fisher确切概率法检验。结果21例左半结肠梗阻患者中17例支架植入成功;支架植入后肠梗阻症状均在24h内得到缓解。支架植入后患者Alb、Hb获得明显改善,酸碱失衡、水电解质紊乱获得纠正,高血压、糖尿病、心肌缺血、肺部感染均有明显改善,麻醉风险明显降低（P〈0．05）。心律失常、慢性阻塞性肺病等内科疾病则改善不明显（P〉0．05）。4例支架植入治疗失败患者,1例支架导致结肠穿孔,3例因完全梗阻未能植入,均行急诊Ha~mann手术。所有肠梗阻症状缓解患者顺利行腹腔镜结直肠癌根治术。腹腔镜手术时间为（142±38）min,出血量为（29±11）mL,远切缘距肿瘤距离为（3．8±0．3）em,左髂区斜切口长度为（6．2±2．8）cm。术后无吻合口瘘发生,排气时间为（2．4±0．6）d,进食时间为（3．8±1．6）d,术后住院时间为（17±4）d。21例患者随访6个月至2年,1例术后1年因脑血管意外死亡;2例发生肿瘤肝转移,目前仍在维持化疗中。其余18例患者均无瘤生存。结论肿瘤导致的结直肠梗阻经支架植入治疗使肠梗阻缓解后再行腹腔镜结直肠癌根治术是可行的。     

Comparison of treatment outcomes of endoscopic stenting for colonic and extracolonic malignant obstruction

Background

Self-expandable metal stents (SEMS) have been used as a bridging or palliative treatment for malignant colorectal obstruction. Colonic obstruction also may arise from advanced extracolonic malignancy, but the clinical outcomes of stent placement for extracolonic malignancy are unclear. This study compared the clinical outcomes of SEMS between patients with colorectal cancer and those with extracolonic malignancy.

Methods

Patients who underwent endoscopic SEMS placement for a malignant colorectal obstruction were enrolled at Seoul National University Hospital from April 2005 and August 2011. Their medical records were retrospectively reviewed in terms of success rate, complications, and duration of stent patency.

Results

Endoscopic SEMS placements were performed for colorectal cancer in 149 patients and for extracolonic malignancy in 60 patients. The causes of obstruction in extracolonic malignancy were advanced gastric cancer in 39 patients (65 %), pancreatic cancer in nine patients (15 %), ovarian cancer in three patients (5 %) and other causes in nine patients (15 %). The clinical success rates were similar between the two groups (92.6 vs 86.7 %; p = 0.688), and multivariate analysis showed no significant risk factor for unsuccessful endoscopic SEMS placement. Reobstruction in palliative endoscopic SEMS placement occurred for 16 patients with colorectal cancer (21.9 %) and 18 patients with extracolonic malignancy (30 %) during a median follow-up period of 90 days (p = 0.288). The rates did not differ significantly between the two groups (4.1 vs 8.3 %; p = 0.467). The median duration of stent patency was 193 ± 42 days for the patients with colorectal cancer and 186 ± 31 days for the patients with extracolonic malignancy (p = 0.253). The duration of stent patency was not affected by underlying malignancy, previous surgery, or palliative chemotherapy.

Conclusions

Endoscopic SEMS placement is highly effective and comparable for palliation of obstruction in extracolonic malignancy and colorectal cancer in terms of clinical success, complications, and duration of patency.     

全身麻醉下气管支架植入术治疗恶性气管狭窄

目的评价全身麻醉下气管支架植入术治疗恶性气管狭窄的疗效。方法选择因恶性肿瘤致气管狭窄、中、重度呼吸困难患者17例,行全身麻醉及气管插管,于DSA监视下经气管套管植入镍钛记忆合金支架。结果全部病例均成功植入支架,呼吸困难症状立即得到改善。随访3～24个月,支架无移位,气管通畅,患者无明显疼痛及异物感。结论全身麻醉下气管支架植入术治疗恶性气管狭窄安全、快捷、有效,患者痛苦小,可为后续治疗提供条件。     

Expandable metal stent placement for benign colorectal obstruction: outcomes for 23 cases

Background Self-expanding metal stents (SEMS) are an established treatment for palliation of malignant colorectal strictures and as a bridge to surgery for acute malignant colonic obstruction. Patients with benign colonic strictures may benefit from stent placement, but little data exist for this indication. Methods All cases of colonic stent placement identified from a prospectively collected gastrointestinal database from April 1999 to August 2006 were reviewed. During the study period, 23 patients with benign obstructive disease underwent endoscopic SEMS placement. The etiologies of the stricture were diverticular/inflammatory (n = 16), postsurgical anastomotic (n = 3), radiation-induced (n = 3), and Crohn’s (n = 1) disease. All strictures were located in the left colon. Five patients had an associated colonic fistula. Uncovered Enteral Wallstents or Ultraflex Precision Colonic stents (Boston Scientific) were endoscopically placed in all but one patient. Results Stent placement was technically successful for all 23 patients, and obstruction was relieved for 22 patients (95%). Major complications occurred in 38% of the patients including migration (n = 2), reobstruction (n = 4), and perforation (n = 2). Of these major complications, 87% occurred after 7 days. Four patients did not undergo an operation. Of the 19 patients who underwent planned surgical resection, 16 were successfully decompressed and converted from an emergent operation to an elective one with a median time to surgical resection of 12 days (range, 2 days to 18 months). Surgery was delayed more than 30 days after stent placement for six of these patients. Of the 19 patients who underwent a colectomy, 8 (42%) did not need a stoma after stent insertion. Conclusions SEMS can effectively decompress high-grade, benign colonic obstruction, thereby allowing elective surgery. The use of SEMS can offer medium-term symptom relief for benign colorectal strictures, but this approach is associated with a high rate of delayed complications. Thus, if elective surgery is planned, data from this small study suggest that it should be performed within 7 days of stent placement. Podium presentation at the annual meeting of the Society of American Gastrointestinal and Esophageal Surgeons (SAGES), 18–22 April 2007 at Las Vegas, NV, USA