无痛内镜下胆道金属支架置入治疗胆道恶性梗阻

目的探讨无痛内镜下胆道金属支架置入术治疗胆道恶性梗阻的临床意义。方法对20例胆道恶性梗阻患者进行无痛内镜下胆道金属支架置入术,并观察其疗效。结果 20例患者均成功放置胆道金属支架,同时行左右肝管双胆道金属支架置入术7例;伴有远端胰管扩张7例,均成功放置胰管支架,术后黄疸消失,症状明显缓解。结论无痛内镜下胆道金属支架置入治疗胆道恶性梗阻是一种确切有效的方法,可以提高患者生存质量。     

经内镜支架置入术在左侧结直肠癌梗阻中的应用

目的探讨经内镜金属支架置入术治疗左侧结直肠癌性梗阻的临床价值。方法在X线透视下经肠镜将导丝插入狭窄近端,沿导丝导入造影管造影了解狭窄情况,根据病变情况选择并放置支架。结果 1例因肠管几乎完全闭塞放弃支架置入,1例因病灶较长而中止支架置入;20例放置支架成功,成功率90.9%,术后1~7 d梗阻症状均得到缓解或消除。2例术后2~3 d粪块堵塞支架,以探条及网篮疏通后缓解;1例术后7 d肿瘤增殖堵塞支架,经肠镜切除后缓解。术后7~10 d限期行肿瘤根治术、一期吻合。结论经内镜放置金属支架治疗左侧结直肠癌性梗阻,能够有效缓解患者的梗阻症状,提高病人的生活质量。     

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。     

金属支架治疗恶性梗阻性黄疸伴十二指肠梗阻47例

目的:探讨经内镜置入十二指肠金属支架治疗恶性梗阻性黄疸合并十二指肠梗阻的作用.方法:恶性梗阻性黄疸合并十二指肠梗阻病例47例.经内镜置入47个十二指肠自膨式金属支架,观察临床疗效.结果:47例病人十二指肠金属支架置入均成功,随访期间,病人术后均能正常进半流质事物,黄疸基本消退,疗效满意,本组未发生严重并发症发生.结论:内镜置入金属内支架是一种简单、有效的治疗方法,对不能手术的恶性梗阻性黄疸合并十二指肠梗阻有很好的缓解作用.     

金属支架治疗恶性梗阻性黄疸伴十二指肠梗阻47例

目的:探讨经内镜置入十二指肠金属支架治疗恶性梗阻性黄疸合并十二指肠梗阻的作用.方法:恶性梗阻性黄疸合并十二指肠梗阻病例47例.经内镜置入47个十二指肠自膨式金属支架,观察临床疗效.结果:47例病人十二指肠金属支架置入均成功,随访期间,病人术后均能正常进半流质事物,黄疸基本消退,疗效满意,本组未发生严重并发症发生.结论:内镜置入金属内支架是一种简单、有效的治疗方法,对不能手术的恶性梗阻性黄疸合并十二指肠梗阻有很好的缓解作用.     

金属内支架置入治疗胃十二指肠恶性梗阻

目的评价金属内支架置入术治疗胃或十二指肠恶性梗阻的效果. 方法 2002年10月～2004年11月,24例恶性肿瘤(胃癌19例,胰腺癌4例,胆管癌术后1例)引起的胃或十二指肠梗阻的患者,在X线透视下,用内镜将金属内支架置入胃或十二指肠狭窄部位. 结果 24例金属支架均置入预定的部位.术后第1天进流质,第3天开始进半流质.无置入支架引起的消化道穿孔、出血等并发症.21例在1～24个月的随访期间,仅2例出现梗阻.无金属支架移位. 结论在胃或十二指肠恶性梗阻部位置入金属内支架,是一种安全有效的治疗胃或十二指肠恶性梗阻方法.     

胆道支架介入治疗恶性胆道梗阻136例临床分析

目的探讨胆道支架(金属支架、塑料支架)介入治疗恶性胆道梗阻的应用价值。方法2005年8月～2008年5月,对136例不宜行手术治疗的恶性胆道梗阻患者,通过内镜途径或经皮经肝途径行胆道支架置入术。结果内镜成功128例,不成功的8例行经皮经肝穿刺。放置金属支架71例,塑料支架65例。放置胆道内支架1周后,血清总胆红素、ALT、AST均明显下降(P0.01),临床症状显著改善。71例放置胆道金属支架者中,11例术后2个月内支架阻塞,再次放置塑料支架后引流通畅;余60例支架通畅时间270～286d,平均275d。65例放置塑料内支架者中,9例术后1～4周支架移位和梗阻,重新置入塑料支架;余56例支架通畅时间110～128d,平均118d。经皮经肝途径术后发生胆汁性腹膜炎1例,经保守治疗治愈。其余病例无严重并发症。随访生存时间1.5～28个月,存活3个月以上者92例。结论胆道支架介入治疗恶性胆道梗阻疗效确切,适用于不宜手术者,对于解除晚期恶性胆道梗阻性黄疸、缓解症状、提高患者生存质量具有满意效果。估计生存期3个月者,宜选择金属支架;估计生存期3个月或经济条件不充许者,可选用塑料支架。     

内镜介入治疗胃肠道癌性梗阻

目的 探讨经内镜介入治疗胃肠道癌性梗阻的可行性与临床疗效。方法 总结分析在X线辅助下经内镜介入治疗32例胃肠道癌性梗阻患者的临床资料。结果 32例患者梗阻部位分别为胃出口8例、十二指肠7例、直肠13例、乙状结肠4例。30例（93．7％）放置支架成功，术后1—3d梗阻症状均得到缓解或消除。其中15例胃出口及十二指肠梗阻均为永久性姑息治疗；15例结直肠梗阻中，12例为姑息治疗，3例经内镜治疗解除梗阻后行Ⅰ期肿瘤切除术。1例直肠癌术后复发伴盆腔广泛转移者治疗失败，1例乙状结肠癌广泛转移者术中穿孔而急诊行Hartmann术。随访期间，未发现支架移位；有1例放置十二指肠支架者，术后2个月肿瘤浸润支架远端导致梗阻复发，置入第2根支架后缓解。结论 经内镜介入治疗胃肠道癌性梗阻是一种简单可行、经济有效、并发症少的方法。     

胆肠吻合术后吻合口狭窄的非手术治疗

目的：探讨胆肠吻合口狭窄非手术治疗的方法和疗效。方法：8例经皮下盲袢、13例经T管窦道进入胆道镜，先气囊扩张狭窄，再取狭窄上方结石，瘢痕性狭窄置硬塑管支撑3-6个月；恶性狭窄胆道镜引导置金属支架。12例行PTCD；恶性狭窄不伴结石，放射介入置金属支架；如有结石或瘢痕狭窄，先扩张窦、后经PTCS取石或置金属支架、硬塑管。全组气囊扩张19例、置硬塑管5例、置金属支架9例。结果：33例中24例良性狭窄，扩张19例、置硬塑管5例均解除梗阻，9例恶性狭窄8例置金属支架解除梗阻。15例伴有结石取净结石。全组无严重并发症。结论：借助胆道镜的非手术方法在治疗胆肠吻合术后吻合口狭窄中创伤小、副损伤少、疗效确切。     

无痛内镜下胆道金属支架联合胰管支架治疗壶腹周围癌

目的 探讨胆道金属支架联合胰管支架置入治疗壶腹周围癌的临床价值。方法 3例患者经临床或病理诊断为壶腹周围癌,其中1例经病理学诊断为（十二指肠乳头）腺癌,2例临床诊断为胰头癌。影像学表现为胰管和胆管均有狭窄,经内镜先在胰管内置入塑料胰管支架,后胆道内置入可膨胀式金属支架,观察支架置放前后患者的临床表现及胆红素、血尿淀粉酶等生化指标变化。结果 3例均顺利置入胆道金属支架及胰管支架,支架置放后总胆红素、血尿淀粉酶均有明显的下降,症状缓解。结论 胆道金属支架联合胰管支架可以解除壶腹周围癌患者的胆、胰管恶性狭窄与梗阻,安全有效。     

Clinical outcome of simultaneous self-expandable metal stents for palliation of malignant biliary and duodenal obstruction

Background: Previous studies have shown that self-expanding metal stents are an effective method for palliation of malignant biliary or duodenal obstruction. We present our experience with the use of simultaneous self-expandable metal stents for palliation of malignant biliary and duodenal obstruction. Methods: We performed a retrospective review of all patients undergoing simultaneous biliary and duodenal self-expandable metal stent placement between November 98 and May 2001. All the patients had documented evidence of biliary obstruction and symptomatic duodenal obstruction. The patients received endoscopic biliary stenting with biliary Ultraflex or Wallstents, and endoscopic duodenal stenting using enteral Wallstents. They were followed until their death. Results: We identified 18 patients (11 men and 7 women) whose mean age was 65 years, (range, 46–85 years). Malignancies included pancreatic 14 (78%), biliary 2 (11%), lymphoma 1 (5%), and metastatic 1 (5%) disorders. Ten patients previously had plastic biliary stents placed for past malignant biliary obstruction (4 patients had recurrent biliary obstruction). All the patients had evidence of duodenal obstruction. Combined metal stenting was successful in 17 patients. One procedure failed due to a tortuous duodenal stricture. All the patients had effective palliation of biliary obstruction, as evidenced by a decrease in the level of total bilirubin and alkaline phosphatase. Of the 17 patients with successful duodenal stenting, 16 had a good clinical outcome, with relief of obstructive symptoms. No immediate stent-related complications were noted. During the follow-up period, 12 patients died of progression of the underlying malignancy. None of the deaths were stent related. Median survival time was 78 days. Two patients had recurrent biliary obstruction from tumor ingrowth at 45 and 68 days, respectively. Both underwent restenting: one by endoscopic retrograde cholangiopancreatography (ERCP) and the other by percutaneous transhepatic cholangiography (PTC). Two other patients had recurrent duodenal obstruction, respectively, 36 and 45 days after the initial stenting. One obstruction was secondary to tumor ingrowth, and the other was caused by distal stent migration. Both patients had successful duodenal restenting. Conclusion: Combined self-expandable metal stenting for simultaneous palliation of malignant biliary and duodenal obstruction may provide a safe and less invasive alternative to surgical palliation with an acceptable clinical outcome. Simultaneous self-expandable metal stents should be considered as a treatment option for patients who are poor candidates for surgery.     

Ureteral Obstruction: Is the Full Metallic Double-Pigtail Stent the Way to Go?

Background

The Resonance metallic ureteral stent (Cook Medical, Bloomington, Indiana, USA) has been introduced for the management of extrinsic-etiology ureteral obstruction for time periods up to 12 mo.

Objective

The current study aims to determine short- and medium-term effectiveness of the Resonance stent in malignant and benign ureteral obstruction.

Design, setting, and participants

In total, 50 patients with extrinsic malignant obstruction (n = 25), benign ureteral obstruction (n = 18), and previously obstructed mesh metal stents (n = 7) were prospectively evaluated.

Intervention

All patients were treated by Resonance stent insertion. Twenty stents were inserted in antegrade fashion, and the remaining stents were inserted in a retrograde approach. No patient dropped out of the study. The follow-up evaluation included biochemical and imaging modalities.

Measurements

We evaluated the technical success rate, stricture patency rate, complications, and the presence and type of encrustation.

Results and limitations

The technical success rate of transversal and stenting of the strictures was 100%. In 19 patients, balloon dilatation was performed prior to stenting. The mean follow-up period was 8.5 mo. The stricture patency rate in patients with extrinsic malignant ureteral obstruction was 100% and in patients with benign ureteral obstruction 44%. Failure of Resonance stents in all cases of obstructed metal stents was observed shortly after the procedure (2–12 d). In nine cases, stent exchange was demanding. Encrustation was present in 12 out of 54 stents.

Conclusions

The Resonance stent provides safe and sufficient management of malignant extrinsic ureteral obstruction. Resonance stent use in benign disease needs further evaluation, considering the untoward results of the present study.     

Self-expandable metal stent in the treatment of obstructive cancer of the left colon. Preliminary results and review of the literature

AIM: To report our preliminary experience with self-expandable metal stent in the treatment of acute malignant obstruction of the left colon and to review the literature on this specific subject. PATIENTS AND METHODS: From March to September 1999, 8 consecutive patients with a mean age 71 were admitted as an emergency for acute malignant obstruction of the left colon. A self-expandable metal stent was inserted under radioscopic and, in 4 cases, endoscopic guidance. The patients then underwent bowel preparation before operation, if required. RESULTS: There was no mortality. Bowel preparation was satisfactory in 6 cases. Complications occurred in 1 patient, who was operated on day one for peritonitis due to perforation of the tumour by the prosthesis inserted after dilatation. Another six patients were operated: 2 had resection followed by anastomosis; 3 had resection and anastomosis protected by ileostomy; 2 had Hartmann's procedure. The last patient retained the prosthesis as palliation. In the literature, self-expandable metal stent application in obstructed carcinoma of the left colon gives satisfactory results. CONCLUSION: Based on our experience and a review of the literature, we provide practical recommendations when inserting self-expandable metal stents for acute malignant left colonic obstruction.     

Colonic perforations after self-expandable metallic stenting: two case reports

The use of self-expandable metallic stents in colorectal stenoses, both benign and malignant, is a recently born treatment, quickly widespread because of its simplicity and therapeutic efficacy. It is particulary useful, like emergency temporany treatment, in malignant colonic obstruction; in these cases the temporary endoprosthesis positioning allows the intestinal transit and to overcame the emergengy phase. After patient conditions improvement, he can be operated and the endoprosthesis removed within operating specimen. In some particularly serious cases, when only a derivative intervention is mandatory because of the general conditions of the patient or the advanced stadium of the illness, stenting can also represent definitive palliative treatment. In fact, it allows contemporary resolution of the occlusion and of the physiopathologic alterations, with hospital cost reduction and a quality life imprevement for the patient thanks to the colestomy absence. In benign pathologies, self-expandable stents are used for a long time in the superior gastrointestinal and biliary tract; now stents have found employment also for the treatment of the post-operative fistula, intestinal diverticular occlusion and for the treatment of post-anastomotic or radiotherapy strictures. The Authors report two cases observed in emergency with complication determinated by positioning of colonic endoprosthesis for previous occlusive episode. The first case, a 56 year-old woman with a decubitus perforation occurred by stent, previously positioned with only palliative intent for a sigma-rectal metastatic cancer: in the second case, a 75 year-old man, the endoprosthesis had been positioned for a postoperative benign stricture of colorectal anastomosis for neoplasm: in this case the stent had determined a vescico-rectal fistula and after a new intestinal occlusion.     

Endoscopic stenting for malignant gastric outlet obstruction

BACKGROUND AND AIMS: Obstruction often gives rise to disabling symptoms in non curable malignant upper gastrointestinal disease. Surgical relief is associated with high morbidity and mortality. We report outcomes of 24 patients palliated with endoscopic inserted stents. PATIENTS STUDIED: Thirteen females and 11 males, median age 66 years (range 24 to 88) suffered from gastroduodenal obstruction because of non curable malignant disease. All patients had nausea, repeated vomiting, and weight loss. The obstruction was localized in the stomach (n=5), gastrojejunostomy (n=3), or the duodenum (n=16). Self-expanding metal stents were delivered endoscopically under fluoroscopic control. RESULTS: All patients got an improved quality of life and could eat at least semisolid food. All the patients were followed until they died. The median survival time after the procedure was 6.4 (range 0.5 to 23) months. In 1 patient stenting was complicated by perforation leading to death 2 weeks later. In another patient the stent migrated during the initial placement, but a secondary stent could be placed during the same procedure. Due to a long duodenal stenosis 2 patients got 2 stents under the primary procedure. During the follow-up period, 6 patients had supplementary gastroduodenal stents placed. Nine patients had biliary stents placed before the placement of the gastroduodenal stents, 2 after. CONCLUSIONS: Our data suggest that endoscopic stenting for disabling symptoms due to gastroduodenal obstruction from non curable malignant disease, gives good symptomatic improvement with only few complications.     

恶性梗阻性黄疸合并十二指肠梗阻治疗中内支架的应用

目的探讨经口置入十二指肠支架、后经皮肝穿刺置入胆道内支架的方法,评价金属支架在治疗恶性梗阻性黄疸合并十二指肠梗阻的作用。方法恶性梗阻性黄疸合并十二指肠梗阻病例12例。在透视监视下,使用介入放射学方法经口置入12个十二指肠自膨式金属支架,经皮肝穿通过十二指肠支架网眼置入11个胆道自膨式金属支架、单纯置入外引流1个。结果12例病人十二指肠支架置入均成功、同时11例胆道支架置入成功,1例导管不能通过胆道阻塞段仅放置胆道外引流管,随访期间,病人术后均能正常进半流质事物,黄疸基本消退,疗效满意,本组无严重并发症发生。结论介入放射学置入金属内支架是一种简单、有效的治疗方法,对不能手术的恶性梗阻性黄疸合并十二指肠梗阻有很好的缓解作用。     

Stenting for obstructing colorectal malignancy: an interim or definitive procedure

Background: The purpose of this paper is to review and report our experience with colorectal stenting in the management of malignant large bowel obstruction. Methods: Twelve consecutive patients with malignant left‐sided large bowel obstruction between June 1998 and January 2001 underwent insertion of self‐expanding metallic stents. One patient required two stents. Eight stents were inserted under fluoroscopic guidance, and five were inserted with combined fluoroscopic and endoscopic guidance. Patients were followed up until death, stent removal or the time of publication. Results: Thirteen stents were inserted. Eleven patients with acute large bowel obstruction had relief of obstruction with stenting, and one of these patients required a second stent because relief had been incomplete. One patient was stented in order to sub­sequently close a problematic stoma. Technical success was 92.9% and clinical success was 100%. Three patients proceeded to surgical resection. In nine patients, the stent was left as the definitive procedure. Of these, six patients have died within 4 months. Complications included one case of migration, one case of reobstruction, one intestinal haematoma and one case of cheesewiring. Conclusions: Colorectal stenting is an important treatment modality for malignant large bowel obstruction. It may be definitive treatment alone, or a bridge to elective surgical resection.     

Ureteral metal stents: a tale or a tool?

There are four types of ureteral metal stents: self expandable, balloon expandable, covered, and thermoexpandable shape-memory. Insertion of metal stents requires expertise with transurethral and percutaneous techniques. The stricture is traversed with the aid of a guidewire via a percutaneous nephrostomy, and the stenotic segment is dilated using a high-pressure balloon catheter. The stent is then inserted over the guidewire, such that the upper end bypasses the obstruction by at least 3 to 4 cm, while the lower end extends intravesically for 0.5 to 1 cm from the ureteral orifice. If necessary, two or more stents are placed in sequence, overlapping by at least 2 to 3 cm. Metal stents were initially used for the relief of end-stage malignant disease, and their role in the treatment of benign ureteral strictures is still undefined. Patients often complain of abdominal discomfort and mild pain after stent insertion, which soon resolve spontaneously. Hematuria usually stops after a few days and does not necessitate any treatment. Mild urothelial hyperplasia in the stent lumen is common but usually regresses after 4 to 6 weeks. Many authors suggest the use of a double-pigtail catheter for the first 4 to 6 weeks to avoid narrowing of the ureteral lumen. The influence of stents on ureteral peristalsis is a major but poorly documented issue. Encrustation is a significant problem that needs to be addressed. The characteristics of both the patient and the stent influence its likelihood. Migration of coated metal stents was seen in 81% of patients at our center. Virtual endoscopy has recently been introduced as a tool for the follow-up of patients with stented ureters. Further design development is necessary to obtain the ideal ureteral metal stent. In a recent study in female pigs, paclitaxel-eluting metal stents engendered less inflammation and hyperplasia of the surrounding tissues.