内镜下覆膜可回收食管支架与扩张器治疗食管吻合口良性狭窄的疗效与安全性比较

背景：随着食管支架工艺技术的不断进步,可回收食管支架治疗食管术后吻合口良性狭窄的疗法快速发展。目的：比较传统扩张器扩张疗法与放置覆膜可回收食管支架疗法治疗食管术后吻合口良性狭窄的疗效、生物相容性和安全性。方法：纳入54例食管术后吻合口狭窄患者按照自愿原则分为扩张器组和支架组,支架组置入MTN-SE-G-18/60和MTN-SE-G-20/60两种不同型号的镍钛记忆合金支架,便于不同吻合口直径患者的选择;扩张组置入硅胶扩张器。随访观察治疗后1,3,6个月吻合口大小、吞咽困难变化及并发症发生等情况。结果与结论：扩张组因需要反复扩张,咽喉部疼痛及局部渗血的发生率明显高于支架组,且有1例发生食管穿孔。两组患者治疗后1,3,6个月时吻合口的直径均逐渐减小,但较治疗前明显增大。支架组患者治疗后吻合口扩张及吞咽困难改善情况均优于扩张组,6个月时吻合口直径分别为0.94cm和0.63cm（P〈0.01）,能正常进食的比例分别为88%和48%（P=0.005）。提示,相对于扩张器治疗食管术后吻合口狭窄,镜下置入镍钛记忆合金全覆膜可回收食管支架的方法操作简便,并发症少且短暂,安全性高,患者痛苦小,易接受,远期疗效优。     

2种金属支架治疗食管、贲门癌术后吻合口良性狭窄的对比研究

目的 探讨新型不锈钢CZES型(Z型)支架和镍钛记忆合金网状支架治疗食管、贲门癌术后吻合口良性狭窄的疗效和安全性.方法 不锈钢Z型支架置入组13例,置入3个月取出;镍钛记忆合金网状支架置入组13例,置入支架3、4周取出.分析比较2组支架取出后3个月及6个月能正常进食者、吻合口直径及并发症.结果 2组支架均成功放置和取出,2组支架均无严重并发症发生.不锈钢Z型支架组取出支架后3个月和6个月仍能正常进食者分别为92.31%和84.61%;镍钛记忆合金支架组取出支架后3个月和6个月能正常进食者分别为69.23%和46.15%.不锈钢Z型支架组取出后3个月和6个月吻合口平均直径分别为(13.54±2.60)mm和(12.42±1.93)mm;镍钦记忆合金支架组取出后3个月和6个月吻合口平均直径分别为(10.69±3.47)mm和(9.78±2.22)mm,2组3个月和6个月吻合口直径比较,差异有显著性(P＜0.05).结论 不锈钢Z型支架和镍钛记忆合金网状支架在治疗食管、贲门癌术后吻合口良性狭窄上是有效且安全的,不锈钢Z型支架置入组远期疗效明显优于镍钛记忆合金网状支架组.     

内镜下置放记忆合金支架治疗食管狭窄48例分析

目的 探讨内镜下置入记忆合金支架治疗各种良、恶性疾病所致的食管狭窄的疗效.方法 选用富士能电子胃镜,国产镍钛记忆合金支架,Savary-Gilliard扩张器扩张后常规置入支架.结果 48例置入支架病例全部成功,均解除患者吞咽困难,提高患者生活质量.结论 镍钛记忆合金支架对良性、恶性食管狭窄发挥持续扩张作用,是一种操作简便、安全、有效、并发症发生率低的治疗方法,值得临床推广应用.     

全覆膜可回收支架在常见食管狭窄病变中的临床应用

【目的】探讨全覆膜可回收支架治疗常见食管狭窄病变的方法及疗效。【方法】采用全覆膜可回收支架（个性化设计）治疗食管狭窄病变107例,其中食管恶性肿瘤59例,食管恶性肿瘤合并瘘2例,食管癌术后恶性狭窄1例,食管癌术后吻合口良性狭窄12例,镍钛记忆合金支架后上端组织增生致狭窄1例,食管癌术后吻合口狭窄并瘘11例,贲门失弛缓症11例,化学性食管狭窄6例,放疗术后致食管狭窄3例,食管间质瘤致食管狭窄1例。吞咽困难症状按Stooler分级术前、术后30d评分。【结果】所有的食管狭窄病变支架置入后均能顺利恢复进食,生活质量明显提高,吞咽困难症状按Stooler分级评分术后总有效率为95．3％。【结论】全覆膜可回收支架治疗常见食管狭窄病变具有疗效好、创伤小、并发症少等优点,值得临床推广运用。     

食道覆膜支架与扩张治疗食管恶性狭窄的疗效比较

目的比较单纯扩张疗法与放置食管覆膜支架疗法治疗食管恶性狭窄的疗效。方法 68例食管恶性狭窄患者,按照自愿原则分为扩张组36例和支架组32例,扩张组置入沙氏扩张探条,支架组置入镍钛记忆合金食道覆膜支架,随访观察治疗后8周的疗效。结果支架置入组显效28例、有效3例、无效1例;单纯扩张组显效17例、有效8例、无效11例,两组总有效率比较差异有统计学意义(P<0.01)。结论食管恶性狭窄置入覆膜支架的疗效优于单纯扩张。     

置入可回收支架与单纯扩张用于治疗食管癌、贲门癌术后吻合口狭窄的疗效对比研究——附48例报告

目的：比较在内镜下置入可回收支架后再取出与单纯扩张2种治疗方法治疗食管、贲门癌术后吻合口狭窄的疗效。方法：48例食管癌、贲门癌术后吻合口狭窄患者（Stooler分级3～4级）,根椐患者自愿的原则分为单纯扩张组（27例）及支架置入组（21例）,前者依次用不同直径的萨氏扩张探条将狭窄的吻合口扩张至13—15mm;后者在予萨氏扩张探条扩张后置入镍钛记忆合金全覆膜食管支架,2周后取出。比较单纯扩张组术后第4周与支架置入组支架取出后第4周的疗效。结果：支架置入组1次成功置入支架,2周后顺利取出。支架置入组显效18例（86％）、有效2例（10％）、无效1例（5％）;单纯扩张组显效12例（44％）、有效5例（19％）、无效10例（37％）,2组疗效比较差异有统计学意义（P〈0．01）。结论：食管癌、贲门癌术后吻合口狭窄扩张后置入可回收支架的疗效优于单纯扩张,可供临床使用。     

食管胃吻合口良性狭窄的内镜治疗

[目的]探讨食管胃吻合口良性狭窄的两种内镜治疗的效果与经验.[方法]将48例食管癌术后吻合口良性狭窄的患者分别进行内镜下治疗,其中有22例单纯予以球囊扩张术,8例经球囊扩张术后放置食管镍钛记忆金属支架,18例经球囊扩张术后放置全覆膜可取出金属支架(Sigma支架),评价近期厦远期疗效.[结果]单纯球囊扩张术治疗的22例中,吞咽困难改善总有效率为90.9%,其中9例发生再狭窄;8例经球囊扩张术后放置食管镍钛记忆金属支架,其中2例再次出现狭窄;18例经球囊扩张术后放置Sigma支架,无1例出现再狭窄.[结论]全覆膜可取出金属支架是治疗食管胃吻合口术后良性狭窄的较佳方案.     

堵瘘支架结合外固定治疗恶性食管气管瘘35例分析

目的 探讨国产镍钛记忆合金自膨胀双蘑菇头覆膜带堵瘘球头食管支架置入并外固定术对恶性食管气管瘘的疗效.方法 对35例恶性食管气管瘘患者采用国产镍钛记忆合金自膨胀双蘑菇头覆膜带堵瘘球头食管支架置入并外固定术治疗.结果 35例患者治疗后呛咳消失,吞咽困难得到改善.Stooler分级术前术后变化有统计学意义(P＜0.05),半数生存期为189 d,半年生存率为52.0％,未出现严重并发症.结论 国产镍钛记忆合金自膨胀双蘑菇头覆膜带堵瘘球头食管支架置入并外固定术治疗恶性食管气管瘘是安全有效的方法.     

覆膜支架治疗食管瘘26例临床分析

目的 评价覆膜镍钛记忆合金支架在治疗食管瘘中的价值.方法 26例食管瘘患者在胃镜直视下安置食管覆膜支架进行瘘口封堵,术后分别对支架并发症及远期生存率进行随访.结果 支架置入成功率100%,术后瘘口得到有效封堵,17例(65.4%)患者术后出现胸骨后疼痛不适,3例患者出现支架移位,26例患者均治愈出院,治愈率100%.结论 覆膜镍钛记忆合全支架置入治疗食管瘘成功率高,效果好,操作简单,安全,并发症少,有效解除了患者痛苦,宜在临床上推广.     

食管支架临床应用体会

目的 探讨食管支架治疗食管贲门癌晚期及食管贲门癌术后食管狭窄、食管气管瘘或吻合口瘘和食管破裂的疗效。方法 对30例食管贲门癌晚期食管狭窄患者、23例食管贲门癌手术后吻合口狭窄患者、8例食管气管瘘患者、2例吻合口瘘患者和1例食管破裂患者置入镍钛金属自膨胀网状食管支架，根据病变类型采用全覆膜、大部分覆膜和裸支架。结果 63例1次放置成功，立即解除了吞咽困难、呛咳、吻合口瘘或食管破裂的症状。结论 钛金属网状食管支架对器质性食管狭窄、食管气管瘘、吻合口瘘和食管破裂有良好的治疗作用。     

Gene therapy for esophageal cancer

Since surgical resection alone rarely results in long-term survival in esophageal cancer patients, efforts now are focused on combined multi modality treatment in an attempt to improve local control and eliminate micro metastasis present at time of surgery. We have reported that the importance of alteration of p53 gene in progression and prognosis of esophageal cancer. Based on the research of p53 gene therapy for esophageal cancer, we started phase I/II study in 2000. So far, ten patients were enrolled into this clinical study. Six of ten patients were alive more than one-year after initiation of gene therapy. No severe side effects were observed. Although no significant response was observed, seven cases showed stable disease.     

Preoperative therapy in esophageal cancer

Progress has been made in the treatment of locally advanced esophageal cancer. Preoperative and postoperative chemotherapy also appears to improve survival in gastroesophageal junction adenocarcinoma compared to surgery alone. Adding radiotherapy to preoperative chemotherapy enhances rates of curative resection, achieves measurable rates of pathologic complete response, and recent trials indicate a survival benefit for preoperative chemoradiotherapy compared to surgery alone in esophageal cancer. Given the achievement of pathologic complete responses with combined chemoradiotherapy in esophageal cancer, recent trials have evaluated the contribution of surgery after chemoradiotherapy. With currently available systemic therapy for squamous cancers of the esophagus that respond to combined chemoradiotherapy, there is no clear survival benefit for the addition of surgery after chemoradiotherapy despite improvements in local tumor control with the addition of surgery. Surgery may salvage nonresponding patients with biopsy-positive residual disease. For adenocarcinoma of the esophagus, a histology with consistently lower rates of pathologic complete response than squamous cell cancer, surgery appears to play a greater role. Trials are now evaluating the use of newer chemotherapy agents combined with radiotherapy, including taxanes, irinotecan, and oxaliplatin. Response on postiron emission tomography early on during induction chemotherapy may be a strong prognostic measure of outcome. Targeted agents, including monoclonal antibodies that target the epidermal and vascular endothelial growth factor receptors, are in active development in phase II and III trials.     

Photodynamic therapy for obstructive esophageal malignancies

Objectives Determine factors affecting survival rates, benefits and complications of patients with obstructive esophageal cancer treated with photodynamic therapy (PDT). Methods From 1982 to January 1998, we used PDT to treat 140 patients with obstructive adeno or squamous carcinoma and evaluated survival up to November 1998. All patients had failed, refused, or were ineligible for surgery, ionizing radiation or chemotherapy. The effect of different variables on survival was estimated using multivariate analysis. The Karnofsky Performance Status (KPS), weight, diet and complications were recorded and biopsies and brushings were taken at each endoscopy. At the beginning and end of each endoscopy the minimal diameter open of the esophagus, and the length, thickness and color of the tumor were recorded. Edema, exudate, bleeding, and mucositis were evaluated and recorded on an ordinal scale.Results The only significant variable affecting survival was the clinical stage. The median survival after PDT for all patients was 6.5 months (mean = 13.9). Kaplan-Meier survival after PDT curves were statistically significantly different when stratified by the clinical Stage at the time of PDT (p < 0.0001). Median survival (months) were for: Stage I = 56; Stage II = 12; Stage III = 6.5; Stage IV = 3.5. Analysis of each individual stage showed the KPS was the only confounding variable with a statistically significant effect on survival after PDT and this was only for Stages III and IV. The most significant effect occurred when the KPS was >/= 70. For Stage III the median survival when the KPS was >/= 70 was 7.7 months and for a KPS < 70 it was 5.0 months (p = 0.0001). For Stage IV the median survival when the KPS was >/= 70 was 5.5 months and for a KPS < 70 it was 2.5 months (p = 0.0002). The mean minimum diameter open before PDT was 6.2 mm (median 6.0mm) and at the end of the PDT treatment endoscopy 11.1 mm (median 12.0 mm) for a mean increase in the minimum diameter open of 4.9 mm (median 5.0 mm) This was statistically significant using paired t-tests (p < 0.0001).Conclusions Photodynamic therapy for esophageal carcinoma caused minimal complications and procedure related mortality. Complete obstruction can be relieved by the end of the PDT endoscopy. The length of palliation for "non-curative" patients was equal to or better than that reported historically for most other treatment regimens.     

Nifedipine therapy for diffuse esophageal spasm

Although nifedipine therapy resulted in substantial relief of dysphagia in six patients with diffuse esophageal spasm, significant side effects, particularly in young working subjects, precluded prolonged use.     

Delays in diagnosis and therapy of gastric cancer and esophageal adenocarcinoma

BACKGROUND AND STUDY AIMS: In the past, there were long delays in the diagnosis of patients with cancer of the stomach or esophagus. The objective of this study was to describe current delays in the diagnosis and treatment of gastric and esophageal adenocarcinoma and to compare the findings with those from an historical control population treated at the same institutions 10 years earlier. PATIENTS AND METHODS: Patients with biopsy-proven gastric cancer or esophageal adenocarcinoma who were treated at two academic medical centers in Germany between April and October 2003 were consecutively screened for eligibility to take part in the study. Medical charts for each patient were reviewed. Additional data were obtained via structured interviews. Main outcome measures were the total delay, and the delays related to patients themselves, to doctors, and to the hospital. Data were compared with those from a historic control group assessed in 1993. RESULTS: The median total delay for patients with gastric cancer (n = 104) was 3.5 months (range 0.3 - 29.6), and in patients with esophageal adenocarcinoma (n = 22) the total delay was significantly shorter (median 2.2 months, range 1.2 - 11.7; P < 0.05). Comparing these findings with those from an historic cohort of patients with gastric cancer (n = 100) revealed a significant decrease in the total delay (3.5 versus 8.0 months, P < 0.001). CONCLUSIONS: The current findings indicate that delays in the diagnosis and treatment of gastric cancer have become significantly shorter within the last 10 years as our understanding of and ability to treat this form of cancer have improved.     

食管裂孔疝、反流性食管炎合并胆囊结石的腹腔镜治疗

目的探讨腹腔镜手术同时治疗食管裂孔疝、反流性食管炎合并胆囊结石的可行性。方法回顾性分析2004年3月～2006年5月共进行腹腔镜胆囊切除术（LC）合并腹腔镜食管裂孔疝修补、胃底折叠术14例患者的临床资料。采用5孔法。均先行腹腔镜食管裂孔疝修补，再行胃底折叠术，其中9例行Nissen胃底折叠术。5例行Toupet胃底折叠术。最后行LC。结果14例都一次性地顺利完成了手术，术后症状明显改善，无出血、腹腔感染、胆漏等并发症。随访1—29个月，无食管狭窄、切口疝等并发症的发生。结论食管裂孔疝、反流性食管炎合并胆囊结石的患者如无手术禁忌证，一期行腹腔镜手术是可行的。     

Photodynamic therapy for dysplastic Barrett esophagus and early esophageal adenocarcinoma

OBJECTIVE: To evaluate our results using photodynamic therapy (PDT) for the treatment of dysplasia or superficial cancer (T1 N0 M0) in patients with Barrett esophagus. PATIENTS AND METHODS: We retrospectively reviewed our clinical experience with 48 patients (34 patients with high-grade dysplasia and 14 patients with superficial cancer in Barrett esophagus) who had been referred for PDT. Initial evaluation included computed tomography and standard and high-frequency catheter endosonography. Follow-up endoscopy was performed 4 to 6 weeks after PDT with ablation of any residual glandular mucosa, using the argon plasma coagulator. Patients were then followed up indefinitely every 3 to 6 months with computed tomography, endosonography, and endoscopic surveillance. RESULTS: The median series follow-up was 18.5 months (range, 1-56 months). Apparent complete photoablation of Barrett mucosa and/or superficial neoplasm was documented in 47 of 48 cases. Complications included symptomatic strictures (11 patients), photosensitivity (7 patients), atrial fibrillation (1 patient) or recurrent congestive heart failure (1 patient), and self-limited esophageal perforation (1 patient). Failure to ablate T1 N0 M0 adenocarcinoma occurred in 1 patient. CONCLUSIONS: Porfimer sodium PDT appears to eradicate dysplastic Barrett mucosa and neoplasia. These results are promising; however, long-term studies are needed to document the efficacy of PDT in reducing the morbidity and mortality in such patients.