125Ⅰ粒子覆膜支架对正常兔食管组织的放射性损伤实验研究

目的 观察125I粒子覆膜食管支架对于正常兔食管组织的放射性损伤.方法 将实验用兔分两组,每组各6只,实验组置入125I粒子支架(单颗粒子剂量22.2MBq ×3颗粒子),对照组植入无放射粒子的支架.于支架植入后2、4、8周分别取实验组和对照组兔2只,行食管造影,观察支架、粒子移位情况,处死后取标本行肉眼、显微镜观察.结果 支架释放过程及术后随访未发现125I粒子脱落.所有动物未发现穿孔等严重并发症.实验组术后2周,食管中部仅为轻微的病理学损伤,鳞状上皮明显增生.黏膜卜炎性细胞浸润.术后4周,出现肉芽组织增生,少量纤维组织增生.术后8周,肉芽组织、纤维结缔组织进一步增生.粒子相对处的食管组织损伤程度明显轻于粒子接触处食管组织.对照组支架中间部分食管与正常食管组织相似,可见食管鳞状卜皮轻增生.支架两端实验组和对照组局部增生食管组织覆盖支架,可见肉芽组织、纤维结缔组织明显增牛.结论 125I粒子支架置人正常兔食管壁组织造成病理性改变,主要表现为肉芽组织、纤维结缔组织增生,无出血、穿孔.     

食管支架置入后良性增生性狭窄动物模型的建立及观察

目的探讨犬食管支架良性增生性狭窄模型的建立方法。方法采用补片外固定法建立模型。按照正交设计表确定2种类型的支架与6种规格的聚四氟乙烯补片的不同组合,支架采用头端杯口状、尾端蘑菇状设计。模型采用比格犬,术后观察犬进食情况,8周后处死实验犬观察支架段食管黏膜增生J隋况。按照进食情况和大体标本组织增生情况,对动物模型效果进行评分。结果正交设计提供8类组合方式。3类组合模型失败：1只犬完全不能进食,行支架回收;1只犬支架吐出;1只犬术后1周死于补片与支架之间的食管缺血坏死。4类组合模型实现食管黏膜肉芽增生,但存在缺陷。1类组合模型术后实验犬正常进食,透视随访支架位置固定,8周后大体标本可见食管黏膜炎症反应和肉芽增生显著。8类组合间在模型效果评价上差异有统计学意义（F=14．7000,P=0．031）。结论采用体质量10—12kg比格犬,总长度50mm、主体直径20mm、头端外径30mm、尾端外径25mm、头尾长度10mm的裸支架,长度60mm、宽度15mm的补片可以获得组织增生良好的动物模型。     

X线联合内镜下食管支架置入术治闻食管癌性狭窄

将有癌性狭窄的食管癌或贲门癌的患者(118例)随机分为A、B、C三组,A组采用C臂X线监视结合内镜直视置入食管支架,B组采用单纯内镜直视下置入,C组单纯采用X线监视置入.对三组置入支架的一次性成功率,并发症发生率,术后1个月再狭窄和畅通率进行对比分析.结果A组一次性成功率100%,B组84%,C组78%;术后1个月复查疗效,A组畅通率100%,B组84%,C组83%.认为C臂X线监视结合内镜直视经口置入食管支架安全,定位准确,支架覆盖病变完全,具有临床推广应用价值.     

X线联合内镜下食管支架置入术治疗食管癌性狭窄

将有癌性狭窄的食管癌或贲门癌的患者（118例）随机分为A、B、C三组，A组采用C臂X线监视结合内镜直视置入食管支架，B组采用单纯内镜直视下置入，C组单纯采用X线监视置入。对三组置入支架的一次性成功率，并发症发生率，术后1个月再狭窄和畅通率进行对比分析。结果；A组一次性成功率100％，B组84％，C组78％；术后1个月复查疗效，A组畅通率100％，B组84％，C组83％。认为C臂X线监视结合内镜直视经口置入食管支架安全，定位准确，支架覆盖病变完全，具有临床推广应用价值。     

覆膜食管支架敷贴放射性粒子对食管癌患者生存质量的影响

目的 探讨覆膜食管支架敷贴放射性粒子对食管癌患者生存质量的影响.方法 将76例食管癌患者按数字表法随机分为两组,对照组38例采用传统食管支架置入治疗,观察组38例采用覆膜食管支架敷贴放射性粒子置入治疗.两组术后均随访6个月.结果 两组置入支架后吞咽困难改善率均达100％,均未发生穿孔、大出血或感染等严重并发症.术后随访6个月,对照组发生再狭窄21例（55.3％）,观察组发生再狭窄15例（39.5％）,两组比较有统计学差异（P＜0.05）;对照组死亡5例,观察组死亡3例.两组术后生存质量均提高,但以观察组提高更明显（P＜0.05）.结论 覆膜食管支架敷贴放射性粒子可明显提高食管癌患者的生存质量.     

"Z"型及网状食管支架置入后的病理学比较研究

目的探讨Z型及网状支架置入实验犬食管后局部的形态学变化特点.方法选择成年健康实验犬,均分为Z型组和网状组,采取自体阔筋膜移植固定法置入Z型或网状食管支架,分别于术后1,2,4,8 wk分批处死每组动物,取出置架部位的食管组织,进行大体、光镜、电镜分析,并比较两组的差异.结果自体阔筋膜移植固定法能有效地固定食管支架.支架术后1,2 wk局部食管粘膜炎症反应显著,成纤维细胞处于旺盛的增殖及分泌状态,有广泛肉芽组织形成及部分纤维化,食管组织开始向管腔内生长;术后4,8 wk增生组织已完全覆盖支架结构,并连接成片,管腔明显狭窄,局部大量的纤维结缔组织形成,炎症反应缓解.两组实验标本病理形态基本相似,仅"网状"组于术后1,2 wk炎症反应明显,粘膜广泛出现溃疡.结论支架术后食管组织主要表现为肉芽组织形成及纤维化,术后4,8 wk随着炎性反应的减弱,纤维化过程渐趋稳定.网状及Z型支架术后的病理过程基本一致,网状支架术后局部炎性反应显著加重.     

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。     

被膜食管支架治疗食管贲门良性狭窄32例

目的:评价被膜食管支架治疗食管贲门良性狭窄的疗效和安全性.方法:选择食管贲门良性狭窄患者32例,根据不同患者选择合适的被膜食管支架置入狭窄段.观察操作成功率、吞咽困难改善情况、术中术后并发症的发生及其处理等.结果:32例均一次性成功置入支架,支架置入后吞咽困难症状均得到持续改善.所有患者未出现食管穿孔、出血等严重并发症,但均出现不同程度的胸骨后闷胀隐痛不适,其中4例患者胸痛较明显,肌注止痛荆后缓解:3例出现支架脱落:1例出现支架近端肉芽组织增生.支架置入后可有效封闭食管气管瘘、食管纵隔瘘等.术后6 mo可经内镜成功取出支架.结论:内镜下置入被膜食管支架是治疗食管贲门良性狭窄的一种安全、有效的方法.     

食管支架的临床应用及前景

本世纪60年代,外科医生在食管内置入塑料管或树胶管,以解除食管梗阻,开始了食管支架的临床应用.80年代又出现了镍钛合金网状食管支架.近年来,随着覆膜支架、防反流支架和可回收支架等新型食管支架的出现,进一步扩大了食管支架的应用范围,为良性食管狭窄和各种食管瘘口的治疗解决了许多难题,取得了显著效果.     

不同形状食管支架术后病理形态变化观察

目的通过食管再狭窄动物模型的制作，研究实验犬食管支架术后不同时间局部组织的病理形态，并比较“喇叭状”和“酒杯状”支架术后再狭窄形成有无不同。方法选择健康成年实验犬6条，随机分成2组，采取自体阔筋膜移植固定法分别置人“喇叭状”或“酒杯状”支架，术后第1、3、8周分别处死，取出置架部位的食管组织，进行大体标本观察、光学显微镜检查，并比较2组的差异。结果肉眼观察：随着时间的延长，支架上下端增生越显严重，食管壁厚度相应增加，局部肉芽组织形成及纤维化。术后第1、3、8周2组支架上下端未覆膜处食管组织、食管管腔、支架金属丝被增生组织覆盖情况等表现基本一致，只是在第8周“酒杯状”支架下端金属丝多处断裂，食管组织增生明显较上端轻。结论再狭窄均发生于支架两端未覆膜处，“喇叭状”和“酒杯状”2种形状食管支架术后病理学变化基本没有差异。     

An internally covered (lined) self-expanding metal esophageal stent: tissue response in a porcine model

BACKGROUND: Self-expandable metal stents (SEMS) palliate malignant dysphagia but may embed in tissue, produce granulation tissue, and prevent removal. OBJECTIVE: Our purpose was to evaluate in a porcine model the tissue response induced by a new esophageal SEMS completely coated internally rather than externally. DESIGN: Eight Yucatan pigs were studied. Each animal underwent placement of 2 stents: 1 study stent and 1 control stent. SEMS were placed proximally or distally by random assignment. Follow-up endoscopy was performed 1, 2, 3, and 4 weeks after implantation. Ease of stent removal was assessed at 2 weeks and 4 weeks after placement. SETTING: Animal laboratory. INTERVENTIONS: Endoscopic placement of study stents (Alveolus ES-STS, Alveolus, Inc, Charlotte, NC; 18 mm diameter, fully covered internally) and control stents (Ultraflex stent, Boston Scientific, Natick, Mass; microvasive, 18 mm midbody, subtotally covered externally). MAIN OUTCOME MEASUREMENTS: Extent of granulation tissue and stent-induced esophageal injury. RESULTS: The tissue hyperplasia response of the study stents was endoscopically graded as mild to moderate. All study stents were endoscopically removed easily and atraumatically. Control stents produced severe granulation tissue formation with complete embedding of the uncovered stent ends; endoscopic removal was possible but resulted in trauma and endoscopically visible bleeding. Histopathologic findings revealed minimal tissue response at the ends of the study stents and severe pseudopolyps in the embedded portion of the control stent. Stent migration occurred in 7 of 8 study stents and 4 of 8 control stents. LIMITATIONS: Animal model lacks stricture. CONCLUSIONS: Fully internally lined SEMS may resist tissue embedding and hyperplasia and may be removable. Human studies are needed to assess applicability to treatment of benign and malignant esophageal disease.     

多支架植入治疗难治性胆总管结石的随机对照研究

目的评价不同方法胆道支架植入术对难治性胆总管结石的疗效。方法将137例难治性胆管结石患者随机分成4组,单根支架组（A组）32例;单根支架加药物治疗组（B组）35例;双根支架组（C组）33例;双根支架加药物治疗组（D组）37例。在ERCP成功后植入1根或2根支架,药物治疗组在病情平稳后应用熊去氧胆酸和（或）茴三硫,对所有患者进行密切随访。结果所有患者3个月后胆石均有缩小,C组、D组缩小的幅度显著超过A组、B组（P〈0．05）;支架通畅时间平均7．6个月,最长为20．0个月,其中D组的支架通畅时间最长,4组间两两比较均有统计学差异（P〈0．05）;对72例（52．6％）进行了第2次ERCP,其中84．7％患者（61／72）取净了结石;本组发生高淀粉酶血症41例（29．9％）,以双支架组为多（P〈0．05）。结论对于难治性性胆总管结石,支架植入术是一种安全、有效的姑息疗法,尤以双支架加溶石药物疗效最佳。     

Fluoroscopically guided insertion of self-expandable metal esophageal stents for palliative treatment of patients with malignant stenosis of esophagus and cardia: comparison of uncovered and covered stent types

The aim of this retrospective study was to present and compare the results of using two different types of esophageal self-expanding stents (uncovered and covered) for palliative treatment of patients with inoperable malignant stenosis of the esophagus and cardia. Over a period of 8 years, 152 patients underwent fluoroscopically guided insertion of metal esophageal stents. We inserted uncovered esophageal nitinol Strecker stents in 54 patients (group I) and covered esophageal Ultraflex stents in the remaining 98 patients (group II). The stent insertion procedure was successively performed in all patients. Closure of esophageal fistula by covered stents was achieved in 8/8 patients. Mean dysphagia score was significantly decreased in both patient groups at 4 weeks follow-up: from 2.73 before stent insertion to 0.15 in group I, and from 2.67 to 0.05 in group II (on 0-4 scale). Eighty-eight per cent of patients with covered stents and 54% with uncovered type were free of symptoms during follow-up. Complications occurring during follow-up and their comparative frequency in the two groups of patients were as follows (group I: group II%): stent migration (0:10%); tumor or granulation tissue ingrowth (100:53%); overgrowth at the ends of stents (17:30%); restenosis causing recurrent dysphagia (37:8%); and appearance of esophageal fistulas (8:6%). In conclusion, fluoroscopically guided insertion of self-expandable esophageal stents is a safe and comfortable method of palliation for patients suffering with malignant dysphagia. In selection of a stent, covered types should be given priority for prevention of restenosis.     

Esophageal stent placement without fluoroscopy

BACKGROUND: Access to fluoroscopic equipment is limited in some regions where esophageal cancer is common. This report describes a simple method for placement of expandable esophageal stents without fluoroscopy. METHODS: Patients with dysphagia due to unresectable esophageal cancer underwent esophageal stent placement under endoscopic control alone. A colored mark on the stent delivery catheter was used to properly position the undeployed stent with respect to the proximal end of the tumor. RESULTS: Stent placement was attempted in 70 patients and was successful in every case. There were no immediate complications of stent placement. Mean dysphagia score decreased from 3.3 before stent placement to 0.5 at follow-up. There was a trend toward lower dysphagia scores in patients who received coated stents. CONCLUSION: Expandable esophageal stents can be accurately and safely placed under direct endoscopic control, without fluoroscopy.     

预防良性再狭窄食管支架的动物实验研究

目的于普通食管支架上口捆绑^125I粒子,通过动物实验探索其预防食管良性再狭窄的可行性及效果。方法于普通食管支架上口均匀捆绑8颗^125I粒子,制成预防食管良性再狭窄支架并进行动物实验。取32只比格犬,分为对照组、实验组,其中对照组（16只）置人捆绑空粒子的支架;实验组（16只）置入捆绑^125I粒子（33．3MBq×8）的支架。术后1、2、4、8周分别取各组犬4只,处死前行相关影像学检查及胃镜检查;处死后取各组支架上端2cm范围内的食管组织行病理学等检查。结果所有食管支架均释放到位,ECT复查未发现放射源泄漏。测量支架上口管腔内径,结果显示随着时间延长管腔逐渐变窄,4、8周时对照组较实验组更为狭窄,差异有统计学意义（P〈0．05）;免疫组化结果示平均光密度值4周时实验组较对照组减低,差异有统计学意义（P〈0．05）;羟脯氨酸及总氨基酸含量随时间延长逐渐上升并且术后4、8周时实验组较对照组含量减低,差异有统计学意义（P〈0．05）。实验观察期间内实验组支架周围的气管与大血管等与对照组肉眼、光镜所见基本一致。结论该新型支架用于食管良性狭窄的预防是可行的、安全的,并具有一定的预防和减轻支架术后良性再狭窄的效果。     

Morbidity and mortality after self-expandable metallic stent placement in patients with progressive or recurrent esophageal cancer after chemoradiotherapy

BACKGROUND: Placemet of self-expandable metallic stents in patients with advance esophageal cancer improves dysphagia and occludes tracheoesophageal fistulas. However, the safety of self-expandable metallic stents for patients who have undergone chemoradiotherapy is controversial. This study evaluated the morbidity and modality after self-expandable metallic stent placement in patients with progressive or recurrent esophageal cancer after chemoradiotherapy. METHODS: A total of 22 patients in whom self-expandable metallic stents were placed because of progressive or recurrent esophageal cancer after chemoradiotherapy were studied. RESULTS: All 22 patients had dysphagia, and 13 had a tracheoesophageal fistula. After self-expandable metallic stent placement, the mean dysphagia grade improved from 3.5 to 0.9, and tracheoesophageal fistula was successfully managed in all cases. Seventeen patients had T4 stage disease, and among 8 of them with invasion to the aorta, 6 (75%) died of sudden massive hemorrhage. Median survival for these 6 patients was 31 days (range 13-63 days) compared with 67 days (range 4-262 days) for all patients after self-expandable metallic stent placement. CONCLUSION: Self-expandable metallic stent placement improved dysphagia and was useful for treatment of tracheoesophageal fistula. However, for patients with T4 lesions that invade to the aorta, self-expandable metallic stent placement after chemoradiotherapy should be considered carefully.     

Successful Closure of Pharyngo-cutaneous and Phayryngo-tracheal Fistulas using Removable Hypopharyngeal Stent after Laryngectomy for Laryngeal Carcinoma

Placement of removable stents to close pharyngo-cutaneous and tracheo-pharyngeal fistulas after laryngectomy has not been reported before. This case presents the feasibility of removable esophageal stent in closing pharyngo-cutaneous and tracheo-pharyngeal fistulas after laryngectomy for laryngeal cancer. Consecutive patients who underwent placement of removable esophageal stent for closing pharyngo-cutaneous and tracheo-pharyngeal fistulas after laryngectomy for laryngeal cancer. Three patients underwent successful stent placement in the hypopharynx. The stents were well tolerated. Patient one had the stent for 14 months, leading to complete healing of the fistula. Removal was successful. The second patient was palliated but died 8 weeks after stent placement. The third patient has successful palliation of his tracheo-esophageal fistula and the stent is being exchanged every 3-4 months to palliate his fistula. Closure of pharyngo-cutaneous and tracheo-esophageal fistulas is feasible with esophageal removable stents. These stents provide alternative options when dealing with these challenging problems.     

镁合金可降解的肝素及bFGF支架在心肌血运重建中的应用研究

目的:探讨镁合金可降解联合肝素及碱性成纤维细胞生长因子(bFGF)支架改善心肌缺血区灌注情况。方法: 对18只小猪通过结扎前降支冠状动脉建立急性心肌梗死模型,然后随机分为3组(每组6只),A组为对照组,B组为心肌打孔+镁合金复合缓释肝素可降解支架植入组,C组为心肌打孔+镁合金可降解复合缓释肝素和bFGF支架植入组。在B和C组中,于心肌梗死区采用自制高速钻孔器由心外膜打两个直径为2 mm的透壁孔道,每个孔道内植入1枚支架。6周后,用Image Pro Plus 6.0软件量化各组新生血管的密度。于治疗前和治疗后6周,用SPECT结合软件Emory Cardiac Toolbox分析心肌灌注缺损区域质量百分率,超声学指标左室舒张末直径(LVEDD)、右室收缩末直径(LVESD)、左心室射血分数(LVEF)评价心脏的功能。结果: 治疗后6周,B组和C组LVEF及心肌灌注质量缺损较A组明显改善（P<0.05）;C组中新生血管密度百分率较A组和B组显著改善（P<0.01）。结论: 镁合金复合肝素及bFGF可降解支架能够显著增加缺血心肌新生血管的密度,改善缺血部位心肌的血流灌注,进而提高心脏功能。