消化道狹窄的內(nèi)鏡治療

消化道狹窄的內(nèi)鏡治療第1頁/共52頁病理類型我國鱗癌為主 97.6% 上1/3段 8.8%

中1/3段65.9%

下1/3段 25.3%西方國家以下段食管為主、主要為腺癌（60％以上）第2頁/共52頁食管癌的治療

（強(qiáng)調(diào)早期發(fā)現(xiàn)、早期診斷、早期治療）手術(shù)治療

-姑息性手術(shù)

-根治性手術(shù)內(nèi)鏡下治療-食管擴(kuò)張，食管支架取代傳統(tǒng)的旁路手術(shù)

-內(nèi)鏡下電灼切除、Nd:YAG激光切除、光動(dòng)力療法等化療：5-Fu和順鉑為主放療：外放射為主以手術(shù)為主的綜合治療第3頁/共52頁手術(shù)適應(yīng)證早期食管癌中期（Ⅱ）、中下段食管癌病變在5cm內(nèi)，上段在3cm內(nèi)，全身情況好者中期（Ⅲ）、病變在5cm以上，無明顯遠(yuǎn)處轉(zhuǎn)移，全身?xiàng)l件允許，可采用術(shù)前放化療與手術(shù)綜合療法放射治療后復(fù)發(fā)，病變范圍尚不大，無遠(yuǎn)處轉(zhuǎn)移，全身情況良好者

第4頁/共52頁手術(shù)禁忌證食管癌病變廣泛或累及鄰近器官如氣管、肺、縱隔等者已有鎖骨上窩淋巴結(jié)等遠(yuǎn)處轉(zhuǎn)移者有嚴(yán)重心、肺或肝功能不全者嚴(yán)重惡病質(zhì)者第5頁/共52頁Surgicalresectionistheonlycurativetreatmentoptionforinvasiveesophagealcancer.However,despitecarefulstagingandadvancesinadjuvanttherapyandsurgicaltechniques,5-yearsurvivalratesrarelyexceed40%.1,2Manypatientspresentwithlocoregionalrecurrenceanddistantmetastasiswithin2yearsaftercurativeesophagectomy.3Treatmentofpatientswithlocaldiseaserecurrenceaimsatrelievingdysphagia第6頁/共52頁第7頁/共52頁第8頁/共52頁第9頁/共52頁第10頁/共52頁第11頁/共52頁第12頁/共52頁第13頁/共52頁第14頁/共52頁第15頁/共52頁食管氣管瘺金屬支架置放術(shù)第16頁/共52頁復(fù)查碘油造影未見造影劑瘺出。第17頁/共52頁EsophagealdiseasesandtypesofSEMSusedUUCUEGZWEsophagealcarcinomaCervical(n=14)77–––Thoracic(n=93)3147735G-Ejunction(n=79)44262–7Locallyrecurrentcarcinoma1236–––(n=48)Achalasia(n=8)–44––UU,UncoveredUltraflex(BostonScientific,Boston,Mass.);CU,coveredUltraflex(BostonScientific);E,Esophacoil(InstentInc.,EdenPrarie,Minn.);GZ,GianturcoZ-stent(CookInc.,Bloomington,Ind.);W,Wallstent(BostonScientific).第18頁/共52頁Factorsthatmaypredisposetoesophagealstentmigration:multivariateanalysis

NMigration(%)pvalueGenderFemale588/13(61.5)0.0038StrictureTC802/13(15.4)0.954GEJ679/13(11.4)0.017EAC82/13(25)0.625PrevioustherapyS+B42/13(15.4)0.997R102/13(15.4)0.997Dilation<10mm393/13(23.0)0.047>10mm246/13(46.1)0.000StentGZ32/13(15.4)0.719E124.13(30.7)0.104UU874/13(30.7)0.169CU953/13(23.0)0.166TC,Esophagealthoraciccarcinoma;GEJ,carcinomaofthegastroesophagealjunction;EAC,esophagealachalasia;S+B,surgery&balloondilation;R,radiotherapy;GZ,GianturcoZ-stent;E,Esophacoil;UU,uncoveredUltraflex;CU,coveredUltraflex(GastrointestEndosc2001;53:96-97.)第19頁/共52頁第20頁/共52頁Esophagealstentsformalignantstricturescloseto

theupperesophagealsphincter第21頁/共52頁第22頁/共52頁GastrointestEndosc2007;66:1082-90第23頁/共52頁第24頁/共52頁Esophagealstentsforthepalliationof

malignantdysphagiaandfistularecurrenceafteresophagectomy第25頁/共52頁Luminalpatency.Themediansurvivaltimeafterstentingforallpatientswithstenosiswas70days(range1dayto34months).Stentinsertionwastechnicallysuccessfulinallbut1patient(98%)(Fig.1).Mediandurationofprimarystentpatencywas56days(range1dayto33months)(Fig.2).Atotalof20episodesofstentdysfunctionoccurredin18(27%)of66patientsatamedianof38dayspost-SEMSinsertion(range2-406days).Stentdysfunctionwascausedbytissuein-orovergrowth(n8),stentmigration(n9),andfoodimpaction(n3).Tissuein-andovergrowthoccurredatamedianof119dayspost-SEMSinsertion(range33–297days);5patientsweresuccessfullytreatedwithasecondSEMS.Six(24%)of25fullycoveredstentsversus3(7%)of41partiallycoveredSEMSmigrated(P.07)atamediantimeintervalof66daysafterSEMSinsertion(range12-406days).Ofthesepatients,6patientsrequiredasecondSEMS.Foodbolusimpactionoccurredin3(20%)patientsatamediantimeintervalof11daysafterSEMSinsertion;all3weresuccessfullyclearedendoscopically.InsertionofasecondSEMSwassuccessfulinallpatients(100%).Medianpatencyofthesestentswas59days(range5–286days)第26頁/共52頁Fistulasealing.Themediansurvivaltimeofpatientswithmalignantfistulacausedbytumorrecurrencewas73days(range10daysto91months).Thecoatedsegmentofthestenteffectivelysealedfistulaeinallbut1patient(93%).Thispatientwassuccessfullytreatedwithasecondstent.Stentdysfunctionoccurredin6(40%)of15patients.In5(33%)patients,additionalstentsweresuccessfullyinsertedtomanagestentmigration(n4)andpersistentleakageduringstenttreatment(n1).Two(22%)of9fullycoveredstentsversus2(33%)of6partiallycoveredSEMSsmigratedatamediantimeintervalof5monthspost-SEMSinsertion(range5daysto11months).Foodbolusimpactionoccurredin1patient17dayspost-SEMSinsertion,thispatientwasalsosuccessfullytreatedendoscopicallybystentclearance.第27頁/共52頁OverallcomplicationsMildcomplicationsafterstentplacementoccurredin7(9%)patientsincludingretrosternalpainandsymptomaticgastroesophagealreflux.Majorcomplicationsoccurredin9(11%)patients.Stridordevelopedimmediatelyafterinsertionin3patientswithalesionwithin4cmoftheupperesophagealsphincter.Inall3patients,thestentwasremoved,andtheyweremanagedconservatively.ThreepatientshadanupperGIhemorrhagefromthetumorsiteatamediantimeintervalof26daysafterSEMSinsertion(range11daysto10months).Thebleedingsubsidedspontaneouslyin1ofthesepatients;theother2patientsdiedofthepersistentbleeding.Anesophagealfistuladevelopedduringstenttreatmentin2patients,bothofwhichwerelocatedatthedistalfunnelofthepartiallycoveredstentatamediantimeintervalof48dayspost-SEMSinsertion.Thesewalldefectsweresuccessfullysealedwithanadditionalstent.Onepatienthadstent-inducedulcerationafterstentmigrationat7monthsafterSEMSinsertionandrequiredendoscopicstentextraction.第28頁/共52頁SEMSplacementinrecurrentesophagealcanceraftersurgicalresectionoffersadequatepalliationbyrelievingdysphagiaandsealingoffesophagealrespiratoryfistula.Therefore,inthesepatientswhohavearelativelyshortlifeexpectancy,theimplantationofSEMSstoshouldbeconsideredthetreatmentofchoice第29頁/共52頁Esophagealrespiratoryfistulaeoccurin5%to10%ofpatientswithesophagealcancer.Inourseries,19%ofpatientswithrecurrentcanceraftergastrictubeinterpositionpresentedwithafistula.Thisrepresentsadevastatingcomplicationleadingtorecurrentpulmonaryinfectionsandtheinabilitytoeatorevenswallowsaliva.Thisconditionisassociatedwithaveryhighshort-termmortalityrate.ThetechnicalsuccessoffistulasealingbySEMSswas93%,whichiswithintherangeofthe80%to100%reportedbyotherseries.Inthemajorityofpatientswithcancerrecurrenceafteresophagectomy,thefistulaorstenosisislocatedclosetotheupperesophagealsphincter.Atthislocation,SEMSplacementmaycauseforeign-bodysensation,trachealcompression,orrespiratoryfistula.Ithasbeenhypothesizedthatstentsshouldhaveabodydiameterof18mmorlesstoavoidthesecomplications.Inourseries,however,stridordevelopedin3(4%)patientsandafistuladevelopedin2(2%)patientsafterstentplacement,despitetheuseofsmall-diameterstentsin4ofthem.Noneofthepatientsreportedglobussensation第30頁/共52頁GastrointestEndosc2010;72:249-54第31頁/共52頁第32頁/共52頁第33頁/共52頁ComparisonofTemporaryandPermanentStent

PlacementwithConcurrentRadiationTherapy

inPatientswithEsophagealCarcinomaJVascIntervRadiol2005;16:67–74第34頁/共52頁第35頁/共52頁MATERIALSANDMETHODS:Coveredretrievableexpandablenitinolstentswereplacedin47patientswithesophagealcarcinoma1weekbeforestartingradiationtherapy;thestentswereelectivelyremoved4weeksafterplacementin24patients(groupA),whilenotelectivelyremovedintheother23patients(groupB).Incasesofcomplications,thestentswerealsoremovedfrompatientsingroupsAandB.Thedysphagiascore,complications(severepain,granulationtissueformation,stentmigration,esophagorespiratoryfistula,andhematemesis),tumorovergrowth/regrowth,reinterventionrates,anddysphagia–progression-freeandoverallsurvivalrateswerecomparedinthetwogroups.第36頁/共52頁RESULTS:Stentplacementorremovalwastechnicallysuccessfulandwelltoleratedinallpatients.Thedysphagiascorewassignificantlyimprovedinbothgroupsafterstentplacement(P<.01).Eachofthestent-relatedcomplicationswaslessingroupAthaningroupBbuttherewasnosignificantdifference.However,thetotalnumberofpatientswithoneormorethanonecomplicationsandwhoneededrelatedreinterventionswassignificantlylessingroupAthaningroupB(P

.042and.030,respectively).Tumorovergrowth/regrowthandthetotalnumberofpatientswhorequiredrelatedreinterventionswasnotsignificantlydifferent(P1.00and.517,respectively).Dysphagia–progression-freeandoverallsurvivalratesweresignificantlylongeringroupAthaningroupB(P

.005and.001,respectively).第37頁/共52頁CONCLUSION:Temporaryplacementofacoveredretrievableexpandablemetallicstentwithconcurrentradiationtherapyforpatientswithesophagealcarcinomaisbeneficialforreducingcomplicationsandrelatedreinterventionsandforincreasingresultantsurvivalratescomparedwithpermanentesophagealstentplacement.第38頁/共52頁Useofself-expandablemetalstentsforthetreatment

ofesophagealperforationsandanastomoticleaksSurgEndosc(2009)23:1526–1530第39頁/共52頁EsophagorespiratoryFistula:

Long-termResultsofPalliativeTreatmentwith

CoveredExpandableMetallicStentsin61PatientsRadiologyVol232

,253-259第40頁/共52頁MATERIALSANDMETHODS:SixtypatientswithERFsduetoesophagealorbronchogeniccarcinomaandonepatientwithERFduetopressurenecrosiscausedbyinitialesophagealstentplacementforesophagealcarcinomaweretreatedwithcoveredexpandableesophagealortracheobronchialmetallicstents.Informationabouttechnicalsuccessofstentplacement,initialclinicalsuccessandfailure,fistulareopening,andcomplicationswasobtained.SurvivalcurvesforbothpatientgroupswithinitialclinicalsuccessandfailurewereobtainedandcomparedwithKaplan-Meiermethodsandlog-ranktest.第41頁/共52頁RESULTS:Stentplacementwastechnicallysuccessfulinallpatients,withnoimmediateproceduralcomplications.Thestentcompletelysealedoffthefistulain49(80%)of61patientssothattheyhadnofurtheraspirationsymptoms(initialclinicalsuccess).Twelve(20%)of61patientshadpersistentaspirationsymptomsduetoincompleteERFclosure(initialclinicalfailure).Duringfollow-up,thefistulareopenedin17(35%)of49patientswithinitialclinicalsuccess:Ineightpatients,thereopenedERFwassealedoffsuccessfullywithstentplacementorballoondilation.IntwopatientswithreopenedERFcausedbyfoodimpaction,thereopenedfistularesolvedspontaneously.Sevenpatientsdidnotundergofurthertreatment.Allpatientsdiedduringfollow-up,andmeansurvivalwas13.4weeks(range,1–56weeks)afterstentplacement.Meansurvivalinpatientswithinitialclinicalsuccesswassignificantlylongerthanthatinpatientswithinitialclinicalfailure(15.1vs6.2weeks,P.05).第42頁/共52頁CONCLUSION:Coveredexpandablemetallicstentswereplacedin61patientswithERFs,buttheinitialclinicalsuccessratewaspoorandtherateofreopeningwashigh;however,interventionaltreatmentwaseffectiveforsealingoffreopenedERFs.第43頁/共52頁Useofself-expandablemetalstentsforthetreatment

ofesophagealperforationsandanastomoticleaksP.SalminenSurgEndosc(2009)23:1526–1530第44頁/共52頁10(6.4%)weretreatedwithSEMSforsealingofaniatrogenicesophagealperforation(n=4),aspontaneousesophagealruptureinBoerhaave’ssyndrome(n=4),orananastomoticleakage(n=2).ResultsThemediantimefromperforationoranastomoticleaktostentinsertionwas13days(range,2hto48days).Theesophagealleakwastotallysealedfor8(80%)of10patients.Theoverallmortalityratewas50%(n=5),andthree(30%)ofthefivedeathswererelatedtotheperforation(n=2)orleakage(n=1).Inbothoftheperforationcases,thediagnosisandtreatmentweresubstantiallydelayed.OnepatientwithananastomoticleakaftergastrectomydiedofthecomplicationdespitesuccessfuloperativeandSEMStreatment.Twoofthedeathswereunrelatedtotheperforation.Inbothcases,thecauseofdeathwasadisseminatedmalignantdisease.第45頁/共52頁ConclusionsTraumaticperforationsandanastomoticleakscanbetreatedeffectivelywithcoveredSEMStogetherwithadequatedrainageofthethoraciccavityevenincasesofseverelyillpatientswithinveterateesophagealperforationsandleaks.第46頁/共52頁P(yáng)ostoperativeesophagealleakmanagementwiththe

PolyflexesophagealstentJThoracCardiovascSurg2007;133:333-8第47頁/共52頁Objective:Leakafteresophagealanastomosisorperforationrepairprolongshospitalization,preventsoralhydrationandnutrition,andcanproducelocalizedinfectionorsepsis.ThisinvestigationreviewsourexperiencetreatingpostoperativeesophagealleakswiththePolyflexesophagealstent(BostonScientific,Natick,Mass).第48頁/共52頁