内镜结合X线下支架置入术治疗胃出口恶性梗阻38例临床分析

背景：胃出口恶性梗阻的姑息治疗方法较多，但效果不理想，近年支架置入术成为治疗胃出口恶性梗阻的首选方法之一。目的：评价支架置入术治疗胃出口恶性梗阻的疗效以及内镜结合X线操作的优点。方法：取38例胃出口恶性梗阻患者，行内镜检查后经活检孔置入导丝，X线监视下置入并释放自膨式金属肠道支架。结果：38例患者成功置入42枚支架，其中TTS（through the seope）肠道支架3枚。支架置入后内镜和透视造影检查示支架均定位准确、通畅。所有患者均存在少量出血，16例（42．1％）予局部喷洒孟氏液止血，效果良好。37例（97．4％）患者术后3d可进食无渣或少渣食物，1例（2．6％）因远端小肠狭窄仍有呕吐，不能进食。术后随访发现16例（42．1％）患者术后3个月胃出121再次狭窄，其中4例（25．0％）再置入支架解决。38例患者的生存期为1～11个月不等，平均5．5个月。无大出血、穿孔、支架移位等并发症。结论：自膨式金属肠道支架置入术可有效治疗胃出口恶性梗阻，具有简单、创伤小、符合生理腔道和患者易耐受的优点，且对恶性梗阻的姑息治疗疗效优于传统外科手术治疗。内镜结合X线操作具有提高置入成功率、缩短操作时间、支架定位准确以及减少患者痛苦和手术相关并发症的优点。     

胃十二指肠恶性梗阻支架置入后失效原因及处理

经内镜放置膨胀式金属支架，为胃、十二指肠和近端小肠恶性梗阻患者的重要姑息性治疗措施，能有效缓解患者的梗阻症状，增加进食，避免外科手术创伤，提高生存质量。但支架置入后常会出现支架失效，引起再梗阻，必须对此进行处理，维持支架通畅。现总结我院2003年10月-2008年10月胃、十二指肠恶性梗阻支架置入后再梗阻患者内镜处理情况。     

胆肠联合支架置入姑息性治疗恶性胃出口梗阻合并胆总管梗阻22例分析

背景：予恶性胃出口梗阻合并胆总管梗阻者联合置入肠道和胆道支架是首选的姑息性治疗方法之一。目的：观察胆肠联合支架置入治疗恶性胃出口梗阻合并胆总管梗阻的临床疗效。方法：在内镜和X线造影下予22例恶性胃出口梗阻合并胆总管梗阻者放置经内镜活检孔肠道支架,以及从经皮经肝胆管引流（PTCD）途径放置胆道支架,胆道支架穿过肠道支架网孔,远端位于肠道支架内。结果：22例均成功置入肠道支架（24枚）和胆道支架（22枚）。术后造影示肠道和胆道均通畅,无严重并发症发生,平均生存期为124d。结论：胆肠联合支架置入姑息性治疗恶性胃出口梗阻合并胆总管梗阻安全有效,近期疗效较满意。     

记忆合金支架在胃出口和十二指肠恶性梗阻中的应用

目的：探讨胃出口、十二指肠恶性梗阻时镍钛记忆合金支架置入的操作技术及其临床疗效：方法：16例中胃窦癌2例，胃窦癌术后复发伴吻合口狭窄2例，贲门癌术后复发伴幽门梗阻4例，结肠癌晚期伴胆管、十二指肠恶性梗阻1例，胰头癌浸润十二指肠3例，十二指肠癌4例。所有患者均在X线监视下行气囊扩张后进行支架置入。结果：支架一次置入成功15例，成功率93．8％。其中有2例为双支架置入(同时置胆总管支架)。支架置入后1周，患者腹胀消失率为11／15(73．3％)，呕吐消失率为13／15(86．7％)。未发生与操作相关的近期并发症。结论：采用镍钛记忆合金支架治疗胃出口、十二指肠恶性狭窄，能明显改善患者生存质量，是一种安全有效的治疗方法。     

无X线监视内镜下置入幽门支架治疗胃出口恶性梗阻36例

目的:评价无X线监视内镜下置入幽门支架治疗胃出口恶性梗阻的操作技术、临床疗效及并发症.方法:对2007-01/2009-12接受无X线监视内镜下幽门支架置入治疗的36例胃出口恶性梗阻患者的临床资料进行回顾性分析.结果:36例患者共置入39枚支架,其中3例患者为双支架.7例患者因病变狭窄程度高,先行内镜下球囊扩张,再行支...     

三种不同心理测评量表对功能性消化不良患者焦虑、抑郁状态的评估

背景：功能性消化不良（FD）与精神心理因素密切相关,客观评估FD患者的心理状态对理解消化不良症状产生的机制、指导选择综合治疗方案、客观评估疗效均具有重要意义。目的：比较汉密尔顿焦虑/抑郁量表（HAMA/HAMD）、Zung焦虑/抑郁自评量表（SAS/SDS）和罗马Ⅲ心理社会警报问卷（RPAQ）对FD患者焦虑、抑郁状态的检出一致性。方法：纳入2008年11月~2010年4月北京协和医院符合罗马Ⅲ诊断标准的FD患者,同时接受HAMA、HAMD他评以及SAS、SDS和RPAQ自评。结果：共纳入134例FD患者。HAMA对FD患者焦虑检出率为72.4%,明显高于SAS（24.6%）和RPAQ（31.3%）（P〈0.05）;HAMD对FD患者抑郁检出率为47.0%,与SDS无明显差异（44.0%,P〉0.05）,但明显高于RPAQ（20.9%,P〈0.05）。SDS与HAMD检出结果的总符合率为73.1%。HAMA/HAMD较SAS/SDS、RPAQ更易检出重度FD患者合并的焦虑和抑郁;SAS和RPAQ漏检约半数FD患者合并的中重度焦虑。结论：HAMA/HAMD较SAS/SDS、RPAQ更易发现FD患者合并的焦虑、抑郁状态,其检出率差异可能与量表不同的构成有关。     

内镜下金属支架联合射频治疗恶性幽门梗阻的临床探讨

目前由食管恶性肿瘤所致食管梗阻已广泛采用内镜下金属支架置入治疗,但是由胃和十二指肠恶性肿瘤所致的胃窦、幽门及十二指肠球部梗阻患者支架的置入治疗报道不多.由于幽门、十二指肠经口距离远,同时胃底、胃体又有屯积缓冲作用,当这些部位的狭窄出现症状时往往已形成完全性梗阻,这对梗阻部位的球囊导管扩张和内镜下支架置入带来一定的困难.另外,支架置入后再狭窄是影响支架远期疗效的主要原因.     

综合医院住院心血管疾病患者的焦虑抑郁状况调查

目的：了解综合医院住院心血管疾病患者并发焦虑抑郁的状况。方法：对120例心血管疾病患者和100例健康体检者采用焦虑自评量表（SAS）和抑郁自评量表（SDS）进行问卷调查,对其评分进行比较分析。结果：与正常对照组比较,心血管病患者的SAS[（39.13±8.15）分比（56.91±10.39）分]、SDS[（40.21±9.30）分比（59.36±11.42）分]评分均明显高于正常对照组（P均〈0.01）;120例心血管疾病患者中合并焦虑抑郁71例,占59.17%,其中焦虑状态35例（29.17%）,抑郁状态22例（18.33%）,焦虑抑郁状态14例（11.67%）。结论：心血管疾病住院患者中有较高的焦虑、抑郁发病率。     

南京市浦口地区高血压人群抑郁和焦虑状况的病例对照研究

该文了解南京市浦口地区高血压患者的抑郁和焦虑状况。方法：采用病例对照研究，抽取35岁以上高血压患者326例，健康对照组414例；并使用Zung抑郁自评量表（SDS）和焦虑自评量表（SAS）评定调查对象抑郁和焦虑状况。结果：高血压病例组抑郁和焦虑自评量表的总积分及标准分均显著高于健康对照组（P〈0．01）。     

金属自膨胀支架在恶性胃流出道梗阻治疗中的应用

<正>金属自膨胀支架(self-expandable metallic stent,SEMS)是一种金属网状结构组成的支架，常用于治疗食道梗阻、结肠梗阻和胆道梗阻^[1]，近年来也有用于恶性胃流出道梗阻(malignant gastric outlet obstruction,mGOO)姑息治疗的报道。内镜下放置SEMS治疗m GOO是安全有效的，2020年美国胃肠内镜协会指南建议对于肿瘤不可治愈、一般状况差、生存时间短及希望尽早恢复饮食的患者行内镜下放置SEMS治疗^[2]。SEMS主要分为非覆膜型和覆膜型2种，二者各有优缺点，选用何种支架用于mGOO的姑息治疗尚无定论。     

Factors associated with clinical failure of self-expandable metal stent for malignant gastroduodenal obstruction.

Objective. Endoscopic self-expandable metal stent (SEMS) placement has emerged as an effective palliative treatment for inoperable malignant gastric outlet obstruction (GOO). In spite of successful stent placement, some patients complain of ongoing dysphagia and vomiting. Most reported data on SEMS to date are about technical success of different types of stents and low complication rates. The aim of this study was to evaluate the associated factors of clinical failure after endoscopic SEMS placement for inoperable malignant GOO. Methods. A total 122 patients who underwent successful endoscopic SEMS placement for malignant GOO in an academic referral center were included in the analyses. We retrospectively evaluated variables associated with clinical outcomes after successful SEMS placement. Results. The clinical success rate was 81.1%. The common causes of GOO were pancreatic (39%) and gastric cancers (32%). The mean length of the stents (± standard deviation) was 10.06 ± 2.42 cm. Multivariate analysis revealed that gallbladder cancer (p = 0.016, OR 6.486, 95% CI, 1.509–59.655), poor performance status (ECOG ≥3) (p = 0.001, OR 10.200, 95% CI, 2.435–42.721), the presence of carcinomatosis peritonei (p < 0.001, OR 35.714, 95% CI, 5.556–250.000) and the failure of endoscope passage (p = 0.039, OR 6.945, 95% CI, 1.101–43.818) Conclusion. Our results suggest that gallbladder cancer, poor performance status (ECOG ≥3) and the presence of carcinomatosis peritonei related with clinical failure of palliative SEMS placement.     

Fracture of a Self-expandable Metallic Stent Inserted for Malignant Gastric Outlet Obstruction

Duodenal stenting has gradually been established as the first-line treatment for malignant gastric outlet obstruction (GOO). We encountered a case of duodenal stent fracture in a 76-year-old woman with gastric cancer and GOO. She underwent self-expandable metallic stent (SEMS) placement. The SEMS was found to be fractured 4 weeks after its placement. We removed the broken part of the stent and placed a second SEMS. SEMS fracture is a rare and - to the best of our knowledge - unreported complication; hence, clinicians and their patients should be aware of this possibility.     

Cost comparison of gastrojejunostomy versus duodenal stent placement for malignant gastric outlet obstruction

Background  

Gastrojejunostomy (GJJ) and stent placement are the most commonly used palliative treatments for malignant gastric outlet obstruction (GOO). In a recent randomized trial, stent placement was preferred in patients with a relatively short survival and GJJ in patients with a longer survival. As health economic aspects have only been studied in general terms, we estimated the cost of GJJ and that of stent placement in such patients.     

Predictive factors of solid food intake in patients with malignant gastric outlet obstruction receiving self‐expandable metallic stents for palliation

Aim: As for self‐expandable metallic stents (SEMS) for malignant gastric outlet obstruction (GOO), some predictive factors of stent patency have been reported, although re‐canalization of GOO by SEMS does not necessarily lead to favorable food intake. Therefore, we analyzed the predictive factors of oral food intake following SEMS placement. Methods: A total of 97 consecutive patients in whom SEMS were placed for malignant GOO in five hospitals were included in this retrospective study. Clinical outcomes and predictive factors influencing solid food intake were analyzed. Results: The technical and clinical success rates were 97.9% and 87.6%, respectively. The mean gastric outlet obstruction scoring system (GOOSS) improved from 0.39 to 2.24 after SEMS placement (P < 0.01). The median eating period was 2.1 months (95% CI, 1.1–3.0 months), and the median survival time was 3.1 months (95% CI, 2.0–4.2 months). A Karnofsky performance status of ≤50 (odds ratio, 3.65; 95% CI, 1.17–13.1; P = 0.03) and ascites (odds ratio, 3.28; 95% CI, 1.23–9.05; P = 0.02) were identified as statistically significant independent poor predictive factors of solid food intake. Conclusion: SEMS is an effective treatment for patients with malignant GOO. Ascites and a poor performance status were poor predictive factors of solid food intake.     

Gastric emptying in patients with palliative stenting for malignant gastric outlet obstruction

BACKGROUND/AIMS: Palliative stenting for gastric outlet obstruction (GOO) offers a more rapid resumption of oral intake than surgical gastrojejunostomy. Clinically, delayed gastric emptying is observed less frequently in patients with enteral stenting. The aim of this study was to conduct a functional assessment of gastric emptying after stent placement for GOO using isotope scanning. MethodologY: Gastric emptying was assessed in 14 patients with GOO (4 female, 10 male; mean age 67.9 years; 8 with gastric cancer; 4 with pancreatic cancer; 1 with biliary cancer; 1 with metastasis) and 10 healthy volunteers (2 female, 8 male; mean age 31.5 years). None of the patients had undergone previous stomach surgery. The patients were studied 1 week after stent placement. Scintigraphy was performed for 2 hours following the ingestion of a labeled liquid meal. Gastric retention was evaluated at 2 hours in both groups. RESULTS: All patients underwent successful placement of stents and were able to resume an oral diet. All stents were fully deployed and no migration was seen at the time of the investigation. Retained gastric activity at 120 minutes (RGA120) was significantly greater in patients than in controls (65.4% vs. 27.5%, p=0.0128). Median survival time was 179 days in patients with T1/2 of 120 min or less and 75 days in patients with T1/2 of over 120 min. CONCLUSIONS: The results of our study show that although patients with GOO have resumed oral intake 1 week after stent placement, restoration of gastric emptying is often still incomplete.     

Self-expandable metallic stent placement for palliation in gastric outlet obstructions caused by gastric cancer: a comparison with surgical gastrojejunostomy

Background In patients with gastric outlet obstruction (GOO), palliative enteral stenting is a less invasive procedure compared with gastroenterostomy. Most diseases analyzed in previous studies of such stenting were pancreaticobiliary malignancies. Methods We reviewed the medical records of patients with GOO secondary to gastric cancer who were admitted to our institution between September 1994 and September 2004. The outcome of stent placement for GOO was compared with the outcome in patients who underwent palliative open gastrojejunostomy during the same period. Enrolled patients from both groups displayed symptomatic GOO. Patients with recurrent gastric cancer were excluded from this study. Results Twenty-two patients underwent palliative enteral stenting, and 22 patients were subjected to surgical gastrojejunostomy (bypass). There were no significant differences between the two groups regarding patient baseline characteristics. Technical success and clinical success were obtained in 100% and 77.3%, respectively, of both groups. The operating time was shorter in the stent group (30 vs 118 min; P < 0.0001). The time from the procedure to the resumption of food intake was shorter in the stent group than in the bypass group (2 days vs 8 days; P < 0.0001). An improvement in performance score after the procedure was observed in both groups (stent group; P = 0.0264; bypass group; P = 0.0235). No significant differences were observed regarding the possibility of discharge. In patients discharged, the median postoperative hospital stays were 19 days and 28 days (P = 0.0558). The median survival periods were 65 days and 90 days. Minor complications were observed in 1 patient in the stent group and in 4 in the bypass group. No mortality or severe complications were observed for either group. Conclusions Self-expandable metallic stent placement is a safe and efficacious procedure for palliation, with shorter operating time and more prompt restoration of oral intake, compared to surgical alternatives in patients with GOO caused by gastric cancer.     

Feasibility of self-expandable metallic stent plus chemotherapy for metastatic gastric cancer with pyloric stenosis

Background and Aim:  Self-expandable metallic stent placement is accepted as palliative therapy for advanced gastric cancer with gastric outlet obstruction, but data are lacking for chemotherapy after self-expandable metallic stent insertion. This study retrospectively compared results between surgery plus chemotherapy and stenting plus chemotherapy for metastatic gastric cancer with pyloric stenosis.
Methods:  Subjects comprised 26 patients who received chemotherapy after surgery or endoscopic stenting for metastatic gastric cancer with pyloric stenosis between April 2000 and December 2007 in four Japanese hospitals. Patients were categorized into two groups: 15 patients who received chemotherapy after surgery for pyloric stenosis (Surgery group); and 11 patients who received chemotherapy after self-expandable metallic stent placement for pyloric stenosis (Stent group).
Results:  Median survival time and median time to treatment failure were 284 days and 226 days in the Surgery group and 337 days and 247 days in the Stent group, respectively. No significant differences were noted between survival and time to treatment failure. No significant differences were found in median oral intake rate (Surgery, 93.1%; Stent, 93.2%) or median hospital stay rate (Surgery, 24.6%; Stent, 23.7%) during survival. Response rate was 45.5% in the Surgery group and 50% in the Stent group, with no significant difference. Likewise, no significant differences were noted between groups for frequencies of toxicity or complications.
Conclusions:  The present results suggest that chemotherapy after stenting is as effective and safe as chemotherapy after surgery. Stents may replace surgery in combination therapy with chemotherapy for metastatic gastric cancer with gastric outlet obstruction.     

Self-expanding metallic stents for gastric outlet obstruction resulting from stomach cancer: a preliminary study with a newly designed double-layered pyloric stent

BACKGROUND: Although endoscopic stent placement is now generally accepted as a palliative treatment for gastric outlet obstruction resulting from gastric cancer, it carries potential limitations such as tumor ingrowth or migration. OBJECTIVE: Our purpose was to evaluate the technical and clinical efficacy of endoscopic placement of a newly designed double-layered combination pyloric stent. DESIGN: Prospective, uncontrolled, single-center. SETTING: Tertiary referral university hospital. PATIENTS: Eleven patients with gastric outlet obstruction by unresectable stomach cancer. INTERVENTIONS: Eleven patients received a double-layered combination pyloric stent (an outer uncovered stent to reduce migration and an inner polytetrafluoroethylene-covered stent to prevent tumor ingrowth). MAIN OUTCOME MEASUREMENT: To evaluate technical success, clinical success, and complications, especially tumor ingrowth and migration. RESULTS: Technical success was achieved in 11 of 11 (100%) patients. Among 11 patients in whom endoscopic stenting was placed successfully, clinical success was 90.9%, tumor ingrowth 0%, migration 9.1%, and tumor overgrowth 9.1%. Median stent patency period was 121 days. LIMITATIONS: Small number of patients, uncontrolled study, short-term follow-up period. CONCLUSIONS: We have described a technique for endoscopic metal stent placement by using the newly designed double-layered combination stent for gastric outlet obstruction by stomach cancer. This stent seems to be effective and looks promising for technical efficacy, clinical outcome, and preventing tumor ingrowth and migration.     

Enhanced Gastric Ghrelin Production and Secretion in Rats with Gastric Outlet Obstruction

Background and Aim  

Ghrelin has distinct effects on gastrointestinal motility through the vagus nerve and gastric excitatory neural plexus. The objectives of this study were to investigate the dynamics of ghrelin and expression of neuromuscular markers in a newly established surgically manipulated rat model of gastric outlet obstruction (GOO), akin to the pyloric stricture associated with duodenal ulcer, advanced gastric cancer, and other conditions, in the clinical setting.