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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。     

Stenting for malignant ureteral obstruction: Tandem,metal or metal‐mesh stents

Extrinsic malignant compression of the ureter is not uncommon, often refractory to decompression with conventional polymeric ureteral stents, and frequently associated with limited survival. Alternative options for decompression include tandem ureteral stents, metallic stents and metal‐mesh stents, though the preferred method remains controversial. We reviewed and updated our outcomes with tandem ureteral stents for malignant ureteral obstruction, and carried out a PubMed search using the terms “malignant ureteral obstruction,” “tandem ureteral stents,” “ipsilateral ureteral stents,” “metal ureteral stent,” “resonance stent,” “silhouette stent” and “metal mesh stent.” A comprehensive review of the literature and summary of outcomes is provided. The majority of studies encountered were retrospective with small sample sizes. The evidence is most robust for metal stents, whereas only limited data exists for tandem or metal‐mesh stents. Metal and metal‐mesh stents are considerably more expensive than tandem stenting, but the potential for less frequent stent exchanges makes them possibly cost‐effective over time. Urinary tract infections have been associated with all stent types. A wide range of failure rates has been published for all types of stents, limiting direct comparison. Metal and metal‐mesh stents show a high incidence of stent colic, migration and encrustation, whereas tandem stents appear to produce symptoms equivalent to single stents. Comparison is difficult given the limited evidence and heterogeneity of patients with malignant ureteral obstruction. It is clear that prospective, randomized studies are necessary to effectively scrutinize conventional, tandem, metallic ureteral and metal‐mesh stents for their use in malignant ureteral obstruction.     

Initial experience with full-length metal stent to relieve malignant ureteral obstruction

Ureteral obstruction caused by extrinsic compression by a malignancy generally can be overcome initially with a ureteral stent. However, the long-term failure rate is high, usually necessitating placement of a nephrostomy tube. Herein, we present the initial case, in this country, of intractable ureteral obstruction managed successfully with the newly developed all-metal Resonance stent (Cook Ireland Ltd., Limerick, Ireland) constructed of MP35N alloy, a composite of nonmagnetic nickel-cobalt-chromium-molybdenum. The patient is a 64-year-old woman with metastatic breast cancer causing retroperitoneal fibrosis and ureteral obstruction diagnosed laparoscopically. The obstruction failed to respond to placement of a single 7F double-J stent and then of two 6F double-J stents in the left ureter. As a last resort, in order to avoid nephrostomy-tube placement, the 6F metal stent was placed; this provided unobstructed flow of urine, as documented on a subsequent Whitaker test and, most recently, on a renal scan, 4 months after initial stent placement.     

金属支架管在解除恶性输尿管梗阻中的疗效评价

目的 评估金属支架管在解除恶性肿瘤所致输尿管梗阻中的临床疗效及影响因素分析.方法 回顾性分析2012年10月至2015年4月在本院留置金属支架管患者47例,根据治疗结果将47例患者分成成功组(n=39)与失败组(n=8),其中采用经尿道逆行留置金属支架管40例,经皮肾顺行留置金属支架管7例,通过术后并发症、血清肌酐、肾盂分离程度、支架管留置的时间及失败率来评估支架管的有效性,通过两组之间的比较分析性别、手术方式及恶性肿瘤类别与失败率之间的相关性.结果 47例患者共留置金属支架管54根,留置后输尿管梗阻解除率100％,患者支架相关并发症发生率为59％(28/47),失败率为17％ (8/47),术后并发症与失败发生率存在一定相关性,与性别、手术方式及恶性肿瘤类别无相关性(P＞0.05).平均随访时间为8个月,支架管平均留置时间为6个月左右,留置时间最长1年半.结论 金属支架管能有效的解除恶性肿瘤所致的输尿管梗阻并防止肾功能进一步恶化,是目前解除恶性输尿管梗阻的一种有效的治疗方案.     

Success of ureteral stents for intrinsic ureteral obstruction

PURPOSE: Previous reports suggest a high success rate for retrograde ureteral stenting for intrinsic ureteral obstruction, but few preoperative predictors of success have been offered. We reviewed our experience to look for factors that suggest failure of stents for intrinsic ureteral obstruction. MATERIALS AND METHODS: We retrospectively reviewed the outcome of retrograde ureteral stent placement for intrinsic ureteral obstruction without concurrent or intended definitive management of the obstruction. RESULTS: Thirty-eight patients treated for intrinsic ureteral obstruction, representing 41 ureteral units (UUs), were monitored for an average of 25.5 months. The overall success rate was 88%. Of the successes, 13 UUs had definitive therapy to permanently remove the cause of obstruction, obstruction resolved in 12 UUs after stent placement, and 11 UUs were managed with indwelling stents. Therapy failed in five UUs, with a median time to failure of 1.9 months. Of the UUs in which failure occurred, three failures were caused by misdiagnosis; in the remaining two, the stent did not correct the obstruction. On univariate analysis, male sex (P = 0.006), increased creatinine level as a presenting symptom (P = 0.002), and more severe preoperative hydronephrosis (P = 0.042) were predictive of failure. Adverse events were low, with complications from stenting occurring on only four of 41 UUs. CONCLUSION: If initial stent placement was possible, intrinsic ureteral obstruction was managed successfully in 88% of patients. Given high success and minimal complications, retrograde placement of ureteral stents can be performed to treat patients with intrinsic ureteral obstruction. Treatment failure is more likely to occur in men and patients with severe hydronephrosis or an elevated creatinine level.     

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.     

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。     

Tannenbaum and metal stents in the palliative treatment of malignant distal bile duct obstruction: a comparative study of patency and cost effectiveness

Background Stent clogging is the major limitation of palliative treatment for malignant biliary obstruction. Metal stents have much better patency than plastic stents, but are more expensive. Preliminary data suggest that the recently designed plastic (Tannenbaum) stent has better duration of patency than the polyethylene stent. This study aimed to compare the efficacy and cost effectiveness between the Tannenbaum stent without side holes and the uncovered metal stent for patients with malignant distal common bile duct obstruction. Methods In this study, 47 patients (median age, 73 years, range, 56–86 years) with inoperable malignant distal common bile duct strictures were prospectively randomized to receive either a Tannenbaum stent (n = 24) or an uncovered self-expandable metal stent (n = 23). The patients were clinically evaluated, and biochemical tests were analyzed if necessary until their death or surgery for gastric outlet obstruction. Cumulative first stent patency and patient survival were compared between the two groups. Cost-effectiveness analysis also was performed for the two study groups. Results The two groups were comparable in terms of age, gender, and diagnosis. The median first stent patency was longer in the metal group than in the Tannenbaum stent group (255 vs 123.5 days; p = 0.002). There was no significant difference in survival between the two groups. The total cost associated with the Tannenbaum stents was lower than for the metal stents (17,700 vs 30,100 euros; p = 0.001), especially for patients with liver metastases (3,000 vs 6,900 euros; p < 0.001). Conclusions Metal stent placement is an effective treatment for inoperable malignant distal common bile duct obstruction, but Tannenbaum stent placement is a cost-saving strategy, as compared with metal stent placement, especially for patients with liver metastases and expected short survival time.     

联合应用胆道支架与十二指肠支架植入术治疗恶性胆管梗阻合并十二指肠梗阻

目的评价联合应用胆道支架与十二指肠支架植入术治疗恶性梗阻性黄疸合并十二指肠梗阻的疗效。方法 18例恶性梗阻性黄疸合并十二指肠梗阻患者接受双管腔内支架植入术,其中胰腺癌12例,胆管癌3例,十二指肠癌2例,腹腔淋巴结转移1例。14例患者首先出现胆管梗阻症状,然后出现十二指肠梗阻症状;4例患者同时表现为胆管及十二指肠梗阻症状。对所有患者均先行经皮肝穿刺植入胆管支架解决胆管梗阻,再经口植入十二指肠支架治疗十二指肠梗阻。结果 18例患者均成功植入胆道及肠道支架。所有患者血清总胆红素均明显下降,1例十二指肠支架植入后5天死于吸入性肺炎,未出现其他严重并发症。17例患者消化道梗阻症状缓解,生存期为3~17个月,中位生存期8.6个月。结论管腔内双支架植入术是治疗恶性梗阻性黄疸合并十二指肠梗阻的有效治疗方法。     

Endoscopic methods (other than stents) for palliation of rectal carcinoma

Patients with unresectable or metastatic rectal cancer may have symptoms of obstruction, bleeding, pain or tenesmus. Insertion of a self-expandable metal stent is the most durable nonsurgical method for relieving obstruction and has been reviewed in the previous article. Other endoscopic methods of palliating obstruction have been largely replaced by expandable metal stent placement. However, laser ablation is still a useful therapy for some patients, particularly when the predominant symptom is rectal bleeding. The indications and results of endoscopic laser therapy along with other endoscopic treatments for the palliation of rectal cancer will be reviewed here.     

Palliation of malignant rectal obstruction with self-expanding metal stents

BACKGROUND: Surgical management of patients with metastatic or recurrent rectal cancer remains controversial. Self-expanding metal stents are increasingly used for palliative treatment of advanced tumors, although long-term results are not yet available. METHODS: Between 1996 and 2003, 521 patients underwent surgery for rectal neoplasms. In the same time period, self-expanding metal stents were used for palliation of 34 patients with malignant rectal obstruction and incurable disease. The outcome of the patients was analyzed retrospectively. RESULTS: Rectal stents were successfully placed in 33 of 34 patients (97%) without major complications. Early failure occurred in 7 patients (21%) because of stent migration, pain, or incontinence. Long-term success with a mean patency of 5.3 months was observed in 26 patients (79%), but restenting was required in 2 patients. Despite the initial success of stenting, a colostomy was created in 2 other patients after 3.4 months and 9.2 months because of incontinence and rectovesical fistula. Overall, 6 of 33 patients (18%) underwent palliative surgery because of early complications (n = 4) or long-term failure of stent treatment (n = 2). CONCLUSIONS: Self-expanding metal stents are useful to avoid a colostomy in selected patients with incurable rectal cancer and limited life expectancy. Nonetheless, a considerable number (18%) of patients will require surgical palliation because of failure of stent treatment.     

胆道支架植入加介入化疗方法治疗高位恶性胆道梗阻的体会

目的:评估胆道支架植入结合介入化疗在高位恶性胆道梗阻病人中的疗效。方法:对49例植入胆道支架并辅以选择性动脉插管化疗的病人,回顾性分析血清总胆红素(SB)和碱性磷酸酶(AKP)的变化,及支架阻塞发生率和存活时间。结果:术后2周,血清总胆红素和碱性磷酸酶水平较术前明显下降。在39例植入(33.3%)可膨式金属支架病人中,13例(33.3%)发生阻塞,中位阻塞时间为10个月;10例塑料支架均在术后4个月内出现阻塞。本组病人的中位生存时间为12个月,1年生存率为55%,2年生存率为20%。结论:对高位恶性胆道梗阻病人,植入胆道支架同时辅以选择性动脉化疗是合适的治疗方法。可膨式金属支架较塑料支架的效果更好。     

Predicting the success of retrograde stenting for managing ureteral obstruction

PURPOSE: Retrograde ureteral stenting is often considered the first line option for relieving ureteral obstruction when temporary drainage is indicated. Several retrospective studies have implied that in cases of extrinsic obstruction retrograde ureteral stenting may fail and, therefore, percutaneous nephrostomy drainage is required. We examined the efficacy of retrograde ureteral stenting for resolving ureteral obstruction and identified clinical and radiological parameters predicting failure. MATERIALS AND METHODS: Enrolled in our prospective study were 92 consecutive patients with ureteral obstruction, which was bilateral in 8. Retrograde ureteral stenting was attempted in all cases by the urologist on call. When stent insertion failed, drainage was achieved by percutaneous nephrostomy. Patients were followed at 3-week intervals for 3 months. Each followup visit included a medical interview, blood evaluation, urine culture and ultrasound. Stent malfunction was defined as continuous flank pain manifesting as recurrent episodes of acute renal colic, 1 or more episodes of pyelonephritis, persistent hydronephrosis or elevated creatinine. Preoperative data and outcomes were compared in cases of intrinsic and extrinsic obstruction. Univariate and multivariate analysis was done to identify predictors of the failure of ureteral stent insertion and long-term function. RESULTS: The etiology of obstruction was intrinsic in 61% of patients and extrinsic in 39%. Extrinsic obstruction, which was associated with a greater degree of hydronephrosis, was located more distal. Retrograde ureteral stenting was successful in 94% and 73% of patients with intrinsic and extrinsic obstruction, respectively. At the 3-month followup stent function was maintained in all patients with intrinsic obstruction but in only 56.4% with extrinsic obstruction. On multivariate logistic regression the type of obstruction, level of obstruction and degree of hydronephrosis were the only predictors of stent function at 3 months. Stent diameter and preoperative creatinine had no predictive value. CONCLUSIONS: Retrograde ureteral stenting is a good solution for most acutely obstructed ureters. In patients with extrinsic ureteral obstruction a more distal level of obstruction and higher degree of hydronephrosis are associated with a greater likelihood of stent failure. These patients may be better served by percutaneous drainage.     

经内镜金属支架治疗胃出口梗阻的疗效评价

目的评价经内镜金属支架治疗胃出口梗阻的临床价值。方法1999年3月至2009年7月,我院内镜中心采用内镜金属支架治疗胃出口梗阻77例,评价手术成功率、并发症和远期疗效。结果共77例患者,男43例,女34例,年龄24—90（65±14）岁。其中晚期胃窦癌24例,胃癌术后复发19例（其中毕Ⅰ式吻合10例）,十二指肠癌7例,壶腹周围癌7例,转移性肿瘤20例。支架置入成功率为93．5％（72,77）,59例（81．9％）在支架置入1．3d后开始流质饮食,进食半流质的时间为4～9（5±3）d,其中52例（72．2％）患者在支架置入10～16（13±3）d后开始普通饮食。并发症包括疼痛（15.3％）、支架移位（2．8％）、出血（22．2％）。截至2009年8月30日,获随访率94．8％（73／77）,中位生存期135（13～336）d。7例患者出现了再狭窄,支架通畅率90．3％（65／72）,再次置入金属支架后好转。结论内镜下金属支架引流术是治疗胃出口梗阻的一种微创且安全有效的方法。     

Expandable metal stents for tracheal obstruction: permanent or temporary? A cautionary tale.

An expandable metal stent inserted via a long term tracheostomy successfully relieved life threatening respiratory obstruction due to benign tracheal stenosis. Later the patient's tracheostomy suction catheter became stuck on the stent and dislodged it. The stent was removed electively, without damaging the trachea, with a rigid biopsy forceps.     

Use of a self-expanding stent in the palliation of rectal cancer recurrences

BACKGROUND: Patients with nonresectable rectal cancer recurrences and elderly high risk patients are currently given a colostomy as a palliative therapy. To improve the quality of life in these patients, we inserted a self-expanding metal stent to relieve the symptoms of obstruction caused by a rectal cancer recurrence. METHODS: Three patients (two male, one female; ages 61, 69, and 59), all suffering from a rectal cancer pelvic recurrence and diffuse metastases, had a stent inserted. Using fluoroscopic and endoscopic control, a metal guidewire was passed through the obstruction. A mild dilatation of the stenosis was carried out before positioning of the expandable metal stent. RESULTS: The procedure was successful at the first attempt in all the patients, and stool evacuation was immediate. Patients complained of rectal tenesmus during the first 48 h, which was treated with nonsteroid anti-inflammatory drugs. However, there were no serious complications related to the procedure. Regular endoscopic and clinical follow-up were carried out. No patient had any evidence of recurrent obstruction. CONCLUSION: In cases of inoperable rectal cancer recurrence, the placement of self-expanding metal stents is technically feasible and safe, and it avoids a permanent colostomy.     

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。     

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.     

Feasibility of prosthesis insertion by laparotomy as palliative treatment for malignant duodenal stenosis

The authors report a preliminary series assessing the feasibility of duodenal stenting using a surgical approach. The study included 16 patients with a malignant duodenal outlet obstruction for whom a biliaryobstruction necessitated a laparotomyor following an endoscopic stenting failure.The stent was efficient in 15 patients with a complete relieve of obstruction. These patients could have oral intake at the end of the first postoperative week. No stent obstruction occurred. The duodenal stenting by laparotomy could be a good alternative to palliative gastroenteral anasotomosis.     

胆管恶性梗阻内镜引流术的疗效观察

目的 比较塑料内置管及金属内支架在胆管恶性梗阻引流中的疗铲。方法 全组患者１０５例,行鼻胆管或塑料内置管引流８７例次,放置金属内置管３１例次。结果 鼻胆管或塑料内置管引流组,引流有效率８２．８％,３０天死亡率１０．３％,平均通畅时间２．４月,平均生存期２．５月;金属内支架组,引流有效率９０．３％,３０天死亡率６．５％,平均通畅时间６．８月,平均生存期７．２月。结论对于胆管恶性梗阻,内镜引流术是一种