非自扩支架与自扩金属支架治疗难治性食管良性狭窄的对照研究

目的 评价非自扩支架及自扩金属支架治疗难治性食管良性狭窄的疗效及其优缺点。方法 按应用食管支架类型的不同,分成非自扩支架组（23例）、自扩金属支架（SEMS）组（16例）,从技术成功率、吞咽功能改善情况、支架的脱落情况、并发症发生率等方面进行临床对照研究。结果 全组随访4－60个月,中位数12个月。全组吞咽功能状态：支架置入术前15、21、3例分别为2、3、4级,支架置入术后27、12例分别为0、1级,吞咽功能明显改善（z=-5.531,P=0.000),取得满意的按期效果。非自扩支架及SEMS均可明显改善患的进食状态。两组的技术成功率均为100％;置支架术后吞咽功能状态两组差异无显性意义（P＝0．107）。非自扩支架组、SEMS组初次置入支架脱落的发生率分别为82．6％（19／23）、6．3％（1／16）,差异有显性意义（P＝0．000）,再狭窄发生率分别为34．6％、31．3％,差异无显性意义（P＝1．000）,但再狭窄的原因不同。结论 对于难治性食管良性狭窄,可采用支架治疗,选用非自扩支架在安全性及远期疗效上均优于SEMS。     

Comparison of plastic prostheses and self-expandable metallic stents in the treatment of malignant esophageal stenosis

OBJECTIVE: We compared the efficacy of plastic prostheses and self-expandable metallic stents in the treatment of malignant esophageal stenosis and/or fistula. SUBJECTS AND METHODS: Subjects were 31 patients with esophageal cancer, 4 with esophagotracheal fistula, and 1 with esophageal stenosis. A plastic prosthesis was inserted in 15 patients (group A) and a self-expandable metallic stent in 21 patients (group B). We evaluated food ingestion improvement, effectiveness, complications, mean survival, food ingestion duration, the percentage of food ingestion capability in total survival time, and inhospital mortality. RESULTS: No differences were seen in food intake improvement or in the effectiveness between groups, whereas fatal complications were higher in Group A. No significant differences were seen in mean survival, food ingestion duration, percentage of food ingestion capability, or inhospital mortality between groups. CONCLUSION: We concluded that a self-expandable metallic stent was safer than a plastic prosthesis because of fewer serious complications such as bleeding, and recommended the use of metallic stents in the treatment of malignant esophageal stenosis and/or fistula.     

Use of self-expandable metal stents for the treatment of esophageal perforations and anastomotic leaks

Background  Esophageal perforations and extensive anastomotic leaks after esophageal resection or gastrectomy are surgical emergencies with high mortality rates. In recent years, the use of self-expanding metallic stents (SEMS) has emerged as a promising treatment alternative for bridging and sealing the damage. This study aimed to evaluate the role of covered SEMS for the management of esophageal perforations and anastomotic leaks. Methods  All esophageal stent placement procedures (174 procedures for 157 patients) at the authors’ unit between January 1999 and April 2008 were assessed by a retrospective chart review. Of the 157 patients, 10 (6.4%) were treated with SEMS for sealing of an iatrogenic esophageal perforation (n = 4), a spontaneous esophageal rupture in Boerhaave’s syndrome (n = 4), or an anastomotic leakage (n = 2). Results  The median time from perforation or anastomotic leak to stent insertion was 13 days (range, 2 h to 48 days). The esophageal leak was totally sealed for 8 (80%) of 10 patients. The overall mortality rate was 50% (n = 5), and three (30%) of the five deaths were related to the perforation (n = 2) or leakage (n = 1). In both of the perforation cases, the diagnosis and treatment were substantially delayed. One patient with an anastomotic leak after gastrectomy died of the complication despite successful operative and SEMS treatment. Two of the deaths were unrelated to the perforation. In both cases, the cause of death was a disseminated malignant disease. Conclusions  Traumatic perforations and anastomotic leaks can be treated effectively with covered SEMS together with adequate drainage of the thoracic cavity even in cases of severely ill patients with inveterate esophageal perforations and leaks.     

Efficacy and safety of covered self-expandable metal stents for management of distal malignant biliary obstruction due to lymph node metastases

Background

Distal malignant biliary obstruction (MBO) due to lymph node metastases (LNM) is a common problem in advanced malignant disease. However, the role of covered self-expandable metal stents (SEMS) in treating MBO has not been studied. The aim of this study was to evaluate the efficacy and safety of covered SEMS for the treatment of distal MBO due to LNM.

Methods

Between November 1994 and December 2009, a total of 65 patients with distal MBO due to LNM underwent covered (n?=?44) and uncovered (n?=?21) SEMS placement.

Results

Successful drainage was achieved in all patients. There was no significant difference in patient survival. The cumulative stent patency of covered SEMS was significantly higher than that of uncovered SEMS (P?=?0.0020). Stent occlusion occurred in 5 patients (11%) with covered SEMS and in 8 (38%) with uncovered SEMS. There was no tumor ingrowth in covered SEMS, but seven in the uncovered SEMS group showed some ingrowth. Cholecystitis was not observed, but mild pancreatitis was observed in 6 (14%) of those with covered SEMS. No stent-insertion-related deaths occurred.

Conclusions

Covered SEMS are safe and effective for treatment of distal malignant biliary obstruction due to LNM.     

Angiosarcomas--clinical profile,pathology and management

Files of 8 patients with primary angiosarcomas treated in the Department of Radiation Oncology at the University of the Witwatersrand from 1982 to 1995 were identified. None of these patients had received prior radiotherapy or chemotherapy which would have predisposed them to the formation of an angiosarcoma. Slides of 6 patients were reviewed. Five of the 6 were confirmed as having angiosarcomas, while 1 patient was found to have a peripheral neuro-epithelial tumour. Four patients had angiosarcomas of the breast, while there was 1 patient each with angiosarcoma of the skin, intestine and brain. Complete excision was the primary modality of management whenever possible. Postoperative radiotherapy was given in cases of incomplete excision, patient refusal of radical surgery or gross tumour. Four patients died within 4 months of diagnosis. Three patients are alive (2 with no evidence of disease) 22-96 months after diagnosis. In 1 patient follow-up details were not available as he did not return for treatment. Angiosarcomas are aggressive malignant tumours arising from the endothelial cells. Complete surgical excision is the treatment of choice in the management of this aggressive disease, which has a poor prognosis.     

Use of Gianturco self-expandable stents in the tracheobronchial tree

Gianturco self-expandable stents were used successfully in the management of 5 patients with tracheobronchial pathology. Placement was performed under endoscopic and fluoroscopic guidance. None of the patients has experienced complications secondary to the stent placement, and in all of them the clinical problems resolved satisfactorily. Longer follow-up is required to determine the place of tracheobronchial stenting in patients with respiratory compromise.     

Covered self-expandable metal stents are more associated with complications in the management of malignant colorectal obstruction

Background

The use of self-expandable metal stents (SEMS) for the treatment of malignant colorectal obstruction is increasing. However, results of risk factors for its complications are inconsistent. This study aimed to examine the clinical effectiveness of the procedure as well as the complications and risk factors associated with the complications.

Methods

Medical records of patients with malignant colorectal obstruction who underwent endoscopic placement of covered or uncovered SEMS were reviewed retrospectively. The procedure was performed by two endoscopists with experience in pancreatobiliary endoscopy.

Results

A total of 152 patients were included (102 men; mean age, 70 ± 12.5 years). The procedure was performed for palliative management in 83 patients and performed as a bridge to surgery in 69 patients. There were 111 uncovered stents and 41 covered stents. The technical success rate was 100 % and the clinical success rate 94.1 %. Overall complications were observed in 49 patients (32.2 %) during the follow-up period (median, 98 days; interquartile range, 19–302 days). Obstruction (17.1 %), migration (7.9 %), perforation (5.2 %), bleeding (1.3 %), and tenesmus (0.7 %) were the causes of the complications. Stage IV disease, carcinomatosis peritonei, complete obstruction of the colon, palliative intention, and covered stents increased the complications based on the univariate analysis. Multivariate analysis revealed that complete obstruction of the colon and covered stents were significantly independent risk factors for complications. In the palliative group, Kaplan–Meier analysis showed significantly shorter median duration to the onset of complications in the covered stent group than in the uncovered stent group.

Conclusions

Although SEMS in patients with malignant colorectal obstruction is effective both as palliative therapy and as a bridge to surgery, one-third of patients experienced complications. Severity of obstruction and stent type can influence outcomes.     

Experience with Ultraflex expandable metallic stents in the management of endobronchial pathology

BACKGROUND: Experience with Ultraflex expandable metallic stents (Micro-invasive, Boston Scientific, Watertown, MA) in the management of endobronchial pathologies leading to airway compromise is reported. METHODS: Between January 1999 and August 2000, twenty-eight expandable metallic stents were inserted into 25 patients (7 men and 18 women; median age, 65 years) who presented with respiratory distress. Each patient had comorbid medical conditions or end-stage malignancy that precluded formal surgical repair. Seventeen patients had intrinsic airway obstruction, 5 had extrinsic compression, 2 had a tracheal tear, and 1 had a tracheoesophageal fistula. Stents were inserted through a bronchoscope under direct vision. Eighteen patients received tracheal stents alone (1 of these patients received two tracheal stents), and 5 patients received bronchial stents only. Two patients received a tracheal and a bronchial stent. Twenty-one stents were covered and seven were uncovered. RESULTS: All patients had successful stents with restoration of airway patency and closure of tracheal defects. One patient developed a respiratory infection early after the operation. Follow-up bronchoscopy confirmed satisfactory stent position in each patient. Late complications included sputum retention, halitosis, and granulation tissue formation. CONCLUSIONS: Ultraflex expandable metallic stents should be considered in the management of airway compromise in selected patients for whom formal surgical repair is inappropriate or contraindicated.     

The management of post-intubation tracheal stenoses with self-expandable stents: early and long-term results in 11 cases

Objective: The optimal management of post-intubation tracheal stenoses is surgical reconstruction of the airway. Stenting of the trachea using silastic T-tubes or one of the various types of tracheal stents are the alternative ways to surgical reconstruction for the management of post-intubation tracheal stenoses. The early and long-term results of 11 patients with post-intubation tracheal stenosis, who underwent tracheal stenting with self-expandable metallic stents (SEMSs), are presented. Methods: Twelve patients (10 men, mean age: 47.8 ± 20.4 years) with post-intubation tracheal stenosis were referred for tracheal stenting with SEMS (2000–2004). In three cases, the upper tracheal stenosis extended within the subglottic larynx. Stenting was successful in 11 patients, while, in one patient with involvement of the subglottic larynx, the attempt to insert the stent failed. Follow-up time varied from 6 to 96 months, and it was made with virtual and fiberoptic bronchoscopy. Results: Immediate relief of obstructive symptoms was observed in all the 11 patients, where an SEMS was successfully inserted. Stent dislodgement occurred shortly after the procedure in two patients, and it was treated with insertion of a new stent in the first case and a stent-on-stent insertion in the second. Good patency of the stent was observed in three patients for 60–96 months. Three patients with good patency of the stent died from other reasons 24–48 months after stent insertion. Four patients developed obstructive granulation tissue at the ends of the stent after 12–43 months, requiring further treatment with thermal lasers and/or tracheostomy. One patient underwent stent removal and successful laryngotracheal reconstruction 6 months after stent insertion. Conclusions: The application of SEMS in post-intubation tracheal stenoses results in immediate improvement of obstructive symptoms without significant perioperative complications. SEMSs have the potential risks of migration and of granulation tissue formation at the end of the stent. SEMS should be applied only in strictly selected patients with post-intubation tracheal stenosis, who are considered unfit for surgery and/or with limited life expectancy.     

Self-expanding metallic stents in the management of advanced esophageal cancer: a review

Palliation of advanced esophageal cancer continues to be a challenge to clinicians. Self expanding metal stents have been used in the esophagus for palliation of advanced esophageal cancer since 1983. They are relatively easy to insert by practicing endoscopists and have low rates of early complications. Delayed complications necessitating reintervention can arise in as many as a third of patients. The majority of stents are placed under sedation using endoscopy and fluoroscopy. Once deployed, they expand in the esophagus causing pressure necrosis on the wall of the esophagus. Several stents are available on the market with newer designs continuing to emerge. Choice of stent seems random among clinicians. Stents have been used for the management of esophageal obstruction including cervical esophageal obstruction and obstruction at the esophagogastric junction, tracheopulmonary fistulae, and mediastinal esophageal compression. Complications include chest pain, deployment and expansion problems, stent migration, tumor overgrowth and ingrowth, gastroesophageal reflux, and stent-related hemorrhage. Despite their high cost, stenting produce better palliation and some cost savings in comparison to conventional methods of palliation. Combination therapy using stenting followed by chemo/radio therapy may increase quality survival.     

Role of self-expandable metal stents in the palliation of malignant duodenal obstruction

Background: Palliative surgical intervention for malignant duodenal obstruction is often associated with a significant morbidity. Endoscopic enteral stenting offers a suitable alternative, that is safe, effective, and less invasive. This study reports our experience with the use of self-expanding metal stents in the palliation of malignant gastric duodenal obstruction. Methods: A retrospective review of all patients who underwent duodenal stenting from November 1998 to February 2001 was performed. All the patients had symptomatic gastric outlet and duodenal obstruction with nausea, vomiting, and decreased oral intake. All of them underwent enteral stenting with self-expandable metal Wallstents 20 or 22 mm in diameter and 6 or 9 cm long. Results: For this study, 33 patients (19 men and 14 women) with a mean age of 62 years (range, 37–81 years) were identified, 32 of whom had successful duodenal stent placement (6 were performed as outpatient surgery). The malignancies were pancreatic 18 (54%), gastric 4 (12%), duodenal 3 (9%), metastatic 6 (18%), and cholangiocarcinoma 2 (6%) disorders. The site of obstruction was pyloric (n = 5; 15%), pyloroduodenal (n = 3; 9%), duodenal bulb (n = 11; 33%), second portion of duodenum (n = 9; 27%), second and third portion of duodenum (n = 3; 9%), C-loop (n = 1; 3%), and anastomotic (n = 1; 3%). A total of 29 patients (91%) had good clinical outcomes, with relief of obstructive symptoms, Two of three patients with no symptomatic relief underwent gastrojejunostomy. One patient refused further treatment. No immediate stent-related complications were noted. During the follow-up period, 20 patients died (none as a result stent-related causes) due to progression of cancer. Median survival was 102 days. Four patients had recurrent obstruction (2 tumor ingrowths, 1 overgrowth, and 1 distally migrated stent) at a mean interval of 82 days. All four had successful restenting without complications. Conclusion: Self-expandable metal stents placed endoscopically provide a safe, less invasive palliative treatment option with good clinical outcome in the management of malignant gastric outlet–duodenal obstruction.     

左半结肠恶性梗阻行自扩张内支架的治疗

目的探讨金属内支架治疗左半结肠恶性狭窄的临床疗效。方法左半结肠恶性狭窄病例38例分成两组。A组24例,B组14例。A组以介入方法植入永久性结肠内支架;B组暂时植入结肠内支架解除梗阻并充分肠道准备后行外科手术。结果A组24例中23例顺利植入结肠支架,其中1例因导丝不能通过植入失败,3例植入2枚支架。B组14例均成功植入支架并顺利接受外科手术。结论自扩张式金属内支架能有效解除左半结肠梗阻,为晚期肿瘤患者提供安全有效的姑息性治疗方法并为临床手术切除创造条件。     

Self-expanding esophageal metallic stents in the treatment of esophageal obstruction

Esophageal obstruction from any cause is debilitating. In patients with malignant obstruction palliation to relieve pain and dysphagia is the primary goal. Conventional endoluminal prostheses allow variable palliation. Covered expandable metallic stents with an 18-mm lumen allow improved deglutition. From December 1994 through December 1998, 59 patients underwent placement of self-expanding silicone-covered esophageal stents for esophageal obstruction. There were 36 men and 23 women ranging in age from 41 to 94. All patients underwent esophageal dilation using a flexible gastroscope and Savary bougies. After dilation placement of the stent was performed under fluoroscopic control. Follow-up was complete in all patients. Technical success was achieved in all patients. There was one postoperative death (bronchopulmonary fistula), one migration of the stent requiring removal, and one recurrent obstruction. The remaining stents were well tolerated even in the cervical region (four patients). All patients returned to a diet of solid foods. We conclude that covered self-expanding esophageal metallic stents are technically simple and safe to insert and appear to provide durable excellent palliation of esophageal obstruction due to either benign or malignant conditions.     

应用自膨胀金属支架治疗梗阻性结直肠癌25例的疗效观察

目的探讨肠镜下自膨胀金属支架(SEMS)置入序贯手术与急诊手术(ES)在梗阻性结直肠癌患者的治疗效果。 方法回顾性分析2014年至2019年接受手术治疗的梗阻性结直肠癌患者55例,其中SEMS组25例,术前接受肠道支架置入,梗阻解除后1周左右行根治性切除;ES组30例接受急诊手术治疗。采用SPSS24.0统计软件处理和分析数据。术中术后各项指标采用( ±s)表示,独立t检验;术后并发症、肿瘤根治性切除率等采用χ²检验。P<0.05为有统计学意义。 结果原发肿瘤根治性切除：ES组22例(73.3%)明显低于SEMS组25例(100%); ES组切除淋巴结为(9.6±5.5)个明显低于SEMS组(18.7±7.7)个;一期手术造口：ES组26例(86.7%),SEMS组11例(44.0%);造口还纳率ES组38.4%,SEMS组90.9%;永久性造瘘率ES组16例(53.3%),SEMS组1例(4.0%);手术切口感染：ES组4例(13.3%),SEMS组0例(0.0%),上述各项指标两组差异均有统计学意义(P<0.05)。 结论肠镜下放置SEMS,然后序贯手术治疗结直肠癌梗阻是安全、有效的备选治疗方案之一。     

Endoscopic treatment of acute colorectal obstruction with self-expandable metallic stents

Background The purpose of this study was to evaluate the efficacy and security of treatment with self-expandable metallic stents for acute colonic obstruction. Methods Retrospectively, we analyzed our experience in placing colonic stents in patients with acute colonic obstruction. Sixty-two patients with malignant colon obstruction were sent to our hospital endoscopic unit from February 1999 through September 2003. The mean age was 75.21 years. A total of 63 self-expandable metallic stents were implanted. All procedures were done under endoscopic and fluoroscopic guidance. Results Technical success was obtained in 58 patients (93.54%). Clinical improvement and resolution of the obstruction were confirmed in 56 of these 58 patients (96.55%) within 48–72 h. Sixteen complications were observed in 11 patients (19%). Twelve cases were minor complications: five patients had pain and rectal tenesmus, and there were seven cases of distal migration of the stent. Four patients (6.9%) had severe complications. Three patients underwent surgery to resolve colonic perforations and one patient developed a colovesical fistula 7 months after stent placement. The stent was used as a bridge to the elective surgery in 22 patients (37.93%). The mean time between stent placement and surgery was 7.66 days (range, 2–20). The stent was used as a definitive palliative treatment in 36 patients (62.07%). Conclusion Stenting was a useful treatment of acute malignant colonic obstruction. The use of stents as a “bridge to the elective surgery” allowed the intestinal preparation, general status restoration, and a one-stage operation with resection and primary reanastomosis. We have also used the stents as a definitive palliative treatment, avoiding surgery in those patients with a very widely metastatic disease or who cannot undergo operation because of comorbid underlying conditions.     

Treatment of acute malignant colorectal obstruction with self-expandable metallic stents

Background: Malignant left‐sided large bowel obstruction from intraluminal and extrinsic causes constitutes a surgical emergency. When conservative measures fail, emergent surgery is usually required, which carries increased morbidity and mortality compared with elective resections. In many situations, a stoma is created and further surgery may be required later to re‐establish bowel continuity. We present an initial series of patients in whom self‐expandable metallic stents (SEMS) were deployed to allow bowel decompression in place of emergency surgery for acute left‐sided colorectal obstruction. Methods: From April 1999 to January 2001, patients who were admitted to the colorectal unit with clinical and radiological features of intestinal obstruction were considered for endolumenal stenting. Stenting was performed under radiological guidance. Results: Sixteen patients underwent endolumenal stenting (age range: 23?90 years, eight men and eight women). There were two technical failures, two delayed perforations and one sealed perforation related to the stent. Three patients underwent elective resection and anastomosis after successful bowel decompression and mechanical bowel preparation. Eight patients with advanced malignancy or multiple medical disease had good bowel decompression after stent deployment and did not undergo any surgery. Conclusion: SEMS is a useful alternative in the management of acute left‐sided colorectal obstruction for a select group of patients. An algorithm for management of acute left‐sided large bowel obstruction incorporating the use of SEMS is proposed.     

自膨支架在颈动脉分叉狭窄成形术中的临床应用

目的探讨自膨支架在颈动脉分叉狭窄支架置入术（CAS）临床应用。方法回顾性分析实施远端过滤脑保护212例CAS患者的临床资料,其中42例患者植入闭环支架（闭环支架组）,170例患者植入开环支架（开环支架组）。观察两组患者的术后24小时内血流动力学变化、远端过滤脑保护装置回收困难的发生率、住院天数和治疗前后美国国立卫生研究院卒中评分量表（NIHSS）评分、治疗后12个月内狭窄处血管超声收缩期最大峰值速度和舒张末期流速评估狭窄程度以及治疗后死亡、脑卒中或心肌梗死等终点事件。结果两组在住院天数和治疗前后NIHSS评分各层次、12个月颈动脉狭窄程度、治疗后30天内及31天至12月终点事件的累计发生率方面比较,差异无统计学意义( P＞0.05);远端过滤脑保护装置回收困难和术后24小时内血流动力学变化差异有统计学意义（P＜0.05）结论经过充分术前准备且合理选择支架,植入自膨式开环支架除术后24小时内血流动力学变化较大和远端过滤脑保护装置回收困难外,两种类型自膨支架在CAS中的疗效和并发症发生率没有明显差别。