食管胃吻合术后胃食管反流的诊断和治疗进展

食管癌或贲门癌切除食管胃吻合术后存在胃食管反流。食管癌或贲门癌术后患者进行食管胃的压力测定，结果显示吻合口上方的静息压高于吻合口下方的静息压。食管24小时pH监测表明术后胃食管反流是客观存在的。内镜检查和病理检查，患者有异常现象及食管炎征象。胃食管反流的发生不因机械吻合或手工吻合而异。反流的发生与术后时间的长短无关。食管24小时pH监测是最敏感的观察方法。半卧位睡眠是预防反流的有效方法。反流的治疗主要应用促动力药和粘膜保护剂．     

和胃降逆汤治疗食管贲门癌术后反流性食管病的疗效

目的观察和胃降逆汤对食管贲门癌术后反流性食管病的临床疗效。方法将90例食管贲门癌术后反流性食管病患者随机分为治疗组和对照组,分别给予和胃降逆汤和奥美拉唑、吗丁啉治疗,疗程8周。观察治疗后两组患者的疗效。结果治疗组总有效率为86.7%;对照组总有效率为71.1%,治疗组总有效率优于对照组(P<0.05)。结论和胃降逆汤能明显改善食管贲门癌术后食管反流病患者的临床症状及粘膜损伤,疗效优于对照组。     

食管贲门癌切除术中CDH型吻合器吻合的术后转化过程

目的 动态观察食管贲门癌切除行食管胃机械吻合患者的术后转化过程，探讨其形成和处理方法。方法 在68例食管贲门癌根治性切除术中，以CDH-25或29型吻合器行食管胃吻合术，动态观察患者的术后转化过程。结果 68例随访3～29个月，发生胃食管反流和反流性食管炎者，经使用制酸剂和胃动力药后症状缓解。发生吻合口轻度狭窄56例（82.4%）其中37例做了扩张治疗，24例（64.9%)治愈，13例（35.1%）疗效欠佳。通过进一步随访，发现手术后5个月，钛钉自吻合口完全脱落，56例患者出现的胃食管反流、反流性食管炎和吻合口狭窄症状自然缓解。结论 CDH型吻合器吻合具有快捷、安全和易掌握等优点。在食管胃吻合中完全可取代手工操作。多数患者术后通常经历反流、反流性食管炎和吻合器狭窄到吻合口再通畅的转化过程。这一转化过程与吻合口区钛钉的存在密切相关。制酸剂、胃动力药和扩张术在转化过程中起着重要作用。     

贲门癌切除术后胃食管反流病的诊断和治疗

目的　探讨贲门癌切除术后胃食管反流病的诊断和治疗方法。方法　对 2 7例贲门癌术后患者定期行2 4小时食管 p H监测 ,并给予西沙必利、抑酸剂、思密达等药物治疗。结果　 (1)治疗前 ,食管 p H各项指标明显高于正常值 (P<0 .0 1) ;(2 )治疗 3个月后复查 ,各项指标接近正常 (P>0 .0 5 ) ;停药 3个月后 ,各项指标又明显高于正常(P<0 .0 1) ;(3)维持治疗 1年时复查 ,各项指标接近正常 (P>0 .0 5 )。结论　 2 4小时食管 p H监测是检测胃食管反流病最敏感的方法 ;药物治疗贲门癌切除术后胃食管反流病 ,疗效满意 ,应终身维持治疗。     

胃粘膜瓣成型预防食管胃吻合术后反流的观察

目的:介绍胃粘膜瓣成型预防食管胃吻合术后反流的临床应用.方法:食管、贲门癌50例,行部分食管部分胃切除,用吻合器作食管胃吻合后行胃粘膜瓣成型.结果:成型组术后无反流症状,上消化道造影及放射性核素显像表明该手术方法抗反流作用明显.食管镜检查示胃粘膜瓣成型组吻合口粘膜充血、水肿、糜烂、溃疡较常规手术组明显减轻.结论:胃粘膜瓣成型术可有效预防食管胃吻合术后胃食管反流.     

贲门癌切除机械吻合术后的胃食管反流

目的:探讨贲门癌切除食管胃机械吻合术后重建食管与胃食管反流之间的关系.方法:对30例术后患者进行食管胃压力测定,其中16例行24h食管pH监测,12例行内镜检查和病理学检查.结果:测压结果显示:吻合口与吻合口下方的静息压相似,比较差异无显著性(P＞0.05),而吻合口上方静息压增高,平均为3.42mmHg,经比较吻合口上方和吻合口下方差异有显著性(P＜0.05).值得注意的是其压力值(3.42mmHg)远低于正常括约肌的静息压(10～45mmHg),因此其抗反流作用的程度是有限的.本组16例术后食管24h pH监测表明食管的酸暴露时间延长,食管酸暴露时间百分比平均为13.78%,为正常人的11倍,反流次数增加,最长反流时间达43min,说明手术后的胃食管反流是客观存在的.内镜检查和病理检查,83.3%有异常现象及食管炎征象,进一步证实术后患者有不同程度的反流性食管炎.结论:1)贲门癌切除食管胃吻合术后存在胃食管反流.2)反流的发生不因机械吻合或手工吻合而异.3)反流的发生与术后时间长短无关.4)24h食管pH监测是最敏感的观察方法.5)半卧位睡眠是预防反流的有效方法.6)反流的治疗主要应用促动力药和粘膜保护剂.     

食管支架置入术后并发症及防治

目的 探讨食管支架置入术后的并发症及预防处理措施.方法 对140例给予食管支架治疗的患者进行术后临床观察、影像学检查和随访.结果 支架置入全部成功,成功率100.0％.术后主要并发症为:胸骨后疼痛及异物感126例(90.0％),胃食管反流23例(16.4％),支架移位15例(10.7％),食管再狭窄13例(9.3％),...     

人工胃底折叠重建His角的抗反流作用——附食管胃连接部癌102例分析

目的探讨人工胃底折叠重建His角预防食管胃连接部癌根治术后吻合口反流的价值。方法食管胃连接部癌根治术中利用人工胃底折叠重建His角，使其接近恢复食管胃连接部的生理解剖。术后通过上消化道造影及胃镜检查来评定其抗反流效果。结果实验组51例，无手术死亡，无吻合口狭窄及吻合口瘘，上下切缘均无癌残留。其中6例有反流症状，反流发生率11．8％；对照组51例，有反流者22例，反流发生率43．1％。两组反流发生率差别有统计学意义（P〈0．001）。结论该术式具有较好的抗反流作用，且具有操作简单、安全等优点。     

金属内支架治疗食管恶性狭窄并发症的分析

为探讨食管支架置入术后的并发症和对策，对126例严重食管狭窄及食管癌合并有瘘的患者给予食管内支架治疗，术前先扩张狭窄部位，术后部分患者辅以放疗。126倒惠者均置入成功，近期疗效良好，术后主要并发症有胸骨后疼痛、胃食管反流、食管气管瘘、支架置入后再狭窄、支架移位脱落和心律失常，这些症状经治疗后大都得到缓解或消失。初步研究结果提示，食管支架是治疗食管狭窄的有效方法，其并发症可采取防范措施，术后给予辅助治疗可减少或防止再狭窄的产生，对放疗后食管狭窄的病例放置支架应有所选择。     

金属内支架治疗食管恶性狭窄并发症的分析

为探讨食管支架置入术后的并发症和对策,对126例严重食管狭窄及食管癌合并有瘘的患者给予食管内支架治疗,术前先扩张狭窄部位,术后部分患者辅以放疗。126例患者均置入成功,近期疗效良好,术后主要并发症有胸骨后疼痛、胃食管反流、食管气管瘘、支架置入后再狭窄、支架移位脱落和心律失常,这些症状经治疗后大都得到缓解或消失。初步研究结果提示,食管支架是治疗食管狭窄的有效方法,其并发症可采取防范措施,术后给予辅助治疗可减少或防止再狭窄的产生,对放疗后食管狭窄的病例放置支架应有所选择。     

Possible association between gastrectomy and subsequent development of esophageal cancer

To clarify the possible association between gastrectomy and the subsequent development of esophageal cancer, we studied the incidence of subjective gastroesophageal reflux in 287 patients and analyzed the nutritional status and results of endoscopic examination of the esophagus in 62 patients who had survived for a long period after gastrectomy for nonmalignant diseases. The incidence of postoperative reflux was 22.6%. None of the patients had severe deterioration of blood parameters or nutritional status. Endoscopic observation revealed esophagitis in 24.2% of patients, mainly in the lower esophagus. Histologically, there was a high incidence of infiltration of neutrophils and lymphocytes, enlarged papillae, and basal cell hyperplasia. Epithelial dysplasia was detected in 41.9% of patients, and of these there were more patients in whom the degree of dysplasia was more severe in the lower esophagus than in other areas. These data suggest that postgastrectomy gastroesophageal reflux is more likely than postgastrectomy changes in nutritional status to be a possible contributory factor to the development of subsequent esophageal cancer.     

不均等黏贴包盖吻合口法食管癌抗反流手术256 例

目的:解决中下段食管癌手术的反流问题,分析不均等黏贴包盖吻合口法重建小胃底的抗反流效果。方法:随机选择不均等黏贴包盖吻合口法抗反流组（A 组）256 例,与同期未行抗反流包埋的对照组（B 组）240 例做术后随访对比,分析两组吻合口反流情况。结果:不均等黏贴包盖吻合口法包埋吻合口,重建小胃底,行胸内食管胃吻合在防止吻合口反流方面效果明显,优于单纯吻合者,经Ridit分析有显著性差异（P<0.01）。 结论:不均等黏贴包盖吻合口法包埋吻合口,重建小胃底,行胸内食管胃吻合在防止食管胃吻合口反流方面效果良好。      

Cyclin D1 polymorphism (G870A) and risk for esophageal adenocarcinoma

BACKGROUND: To investigate individual susceptibility to gastroesophageal reflux disease, Barrett esophagus, and esophageal adenocarcinoma, the authors studied the frequency of the common G870A polymorphism of CCND1, which encodes cyclin D1, a key cell cycle regulatory protein. METHODS: The study population included 307 patients who were enrolled in a prospective case-control study to evaluate lifestyle risk factors and molecular alterations in gastroesophageal reflux disease (n = 126 patients), Barrett esophagus (n = 125 patients), and esophageal adenocarcinoma (n = 56 patients). A control group included 95 strictly asymptomatic individuals. Genomic DNA was extracted from cases and controls, and polymerase chain reaction was used to amplify exon 4 of CCND1. After digestion with BsrI, acrylamide gel electrophoresis was used to identify the wild type and common G870A polymorphic alleles. The frequency of alleles (G/G, G/A, A/A) was compared between cases and controls. Immunohistochemistry was used to study cyclin D1 distribution in among patients in the case group. RESULTS: Compared with the asymptomatic control group, and adjusted for age and gender, increasing frequencies were seen for the A/A genotype in patients with gastroesophageal reflux disease (odds ratio [OR], 2.83; 95% confidence interval [95% CI], 1.09-7.34), Barrett esophagus (OR, 3.69; 95% CI, 1.46-9.29), and esophageal adenocarcinoma (OR, 5.99; 95% CI, 1.86-18.96). No association was seen between genotype and cyclin D1 overexpression. CONCLUSIONS: The CCND1 A/A genotype was associated with increased risk for gastroesophageal reflux disease, Barrett esophagus, and esophageal adenocarcinoma. The contribution of this polymorphism to susceptibility of defined stages of progression to esophageal adenocarcinoma suggested potential application in endoscopic Barrett surveillance programs.     

Identification of intestinal-type Barrett's metaplasia by using the intestine-specific protein villin and esophageal brush cytology

Villin is an actin-binding cytoskeletal protein required for brush-border formation in the normal small intestinal and renal proximal tubule epithelium. Villin is a marker of cell differentiation in small intestinal and renal cell lineages, and recent studies have shown villin to be highly expressed in 100% of intestinal-type Barrett's metaplasias. This epithelium is the single greatest risk factor for developing esophageal adenocarcinoma and arises when the normal esophageal squamous epithelium is replaced by a small intestine-like columnar epithelium after damage by chronic gastroesophageal reflux. In intestinal-type Barrett's metaplasia, the villin protein exhibits a highly characteristic staining pattern in which strong apical, brush-border staining of columnar epithelial cells is observed. In this study, the ability to identify intestinal metaplastic cells by using this distinct villin staining pattern was examined in endoscopic esophageal brushings from patients with confirmed Barrett's metaplasia. Esophageal brushings from 81% (17 of 21) of patients with Barrett's metaplasia demonstrated individual columnar cells with the characteristic villin staining pattern, whereas all normal esophageal squamous cells, blood cells, and gastric columnar cells were negative for villin expression. Northern blot analysis demonstrated villin mRNA expression in Barrett's metaplasia but not in the normal squamous esophagus or gastric mucosa from the same patients. The combined use of villin immunohistochemical analysis and esophageal brush cytology may provide a simple and effective method of detecting intestinal-type Barrett's metaplasia in patients at higher risk for developing this epithelium, such as those experiencing chronic gastroesophageal reflux symptoms.     

食管癌切除术后反流性食管炎

 食管癌切除后食管炎是一个十分普遍的问题,主要是食管与胃之间的抗反流屏障遭到破坏和胃食管反流所致,食管不能清除反流物是另一致病原因。作者对30例食管癌切除术后一年左右的病人进行了食管镜检查,发现患者取右侧卧位比左侧卧位更易发生反流。病理组织学检查表明,全部患者均存在不同程度的食管炎症。睡眠时取半卧位是有效的防治方法。作者提出了食管炎的病理组织学分级标准。     

Pathologic risk factors of adenocarcinoma of the gastric cardia and gastroesophageal junction

Available evidence supports the existence of two major pathways of neoplastic development in the gastroesophageal region: the Barrett pathway, related to gastroesophageal reflux disease, and the gastric pathway, related to Helicobacter pylori infection. The existence of an independent junctional pathway is questionable, and gastroesophageal junction adenocarcinomas share features of esophageal and gastric adenocarcinomas. It has been impossible to accommodate all data that are provided by different levels and tools of observation in tumors that develop in the gastroesophageal region in a single, coherent classification. That is why the stratification of pathologic risk in such tumors, and their respective precursors, incorporates features from topography, histology, immunohistochemistry, and molecular pathology.     

Multimodality therapy for esophageal cancer

Recent developments in the epidemiology, staging, and treatment of esophageal and gastroesophageal junction cancers have led to significant changes in the way these malignancies are managed. Although a relationship between gastroesophageal reflux disease and esophageal cancer has been demonstrated, antireflux surgery has been shown to have no preventive effect with regard to the development of esophageal adenocarcinoma. The newly modified staging system of the World Esophageal Cancer Consortium has helped define the optimal number of lymph nodes to dissect during an esophagectomy. Incorporating modern techniques, such as esophageal ultrasound, fine needle aspiration, and positron emission tomography, can improve the prognostic value of staging. Use of higher-volume centers and higher-volume surgeons for the performance of procedures in upper gastrointestinal cancers is associated with better outcomes. Neoadjuvant chemoradiation using a wide variety of chemotherapy regimens appears to have become the new standard of care for stage II and III esophageal cancer.     

经食管床食管粘膜胃弓上吻合和胃斜形包套缝合治疗食管癌

目的减少食管癌术后胸胃对患者肺功能的影响和其他常见并发症的发生。方法采用经食管床食管粘膜胃弓上吻合和胃斜形包套缝合治疗食管癌１１８例。结果全组术后无吻合口瘘和胃食管返流,吻合口狭窄的发生率为２．５％,手术切除死亡率为０．９％,心肺并发症发生率为１１．０％。结论本吻合方法比食管胃经胸内弓上吻合更符合人体的正常解剖生理功能,并且可有效地减少术后其他并发症的发生。