【作者】 王庆良；

【导师】 李传福；

【作者基本信息】 山东大学 ， 影像医学与核医学， 2004， 博士

【摘要】 目的:回顾性分析食管支架放置对食管疾病的治疗并由此带来的生存质量的提高、生存期的延长以及食管支架放置过程中、术后出现的并发症及其相关因素、并发症的处理原则及食管支架治疗各种食管疾病存在的弊端。临床材料:本组326例不同食管疾病患者,男202例,女124例,年龄5～94岁,平均62.6岁,其中良性食管疾病72例(包括术后吻合口狭窄41例,食管腐蚀性损伤16例,全身性疾病累及食管3例,食管自发性破裂7例,手术后吻合口瘘5例),恶性食管疾病254例(食管、贲门癌232例,纵隔转移淋巴结压迫食管狭窄15例,恶性纵隔肿瘤直接浸润食管7例)。临床症状主要有吞咽困难、胸骨后不适及疼痛、呛咳、消瘦、发热、消化道出血。所有患者在支架放置之前均有钡餐或者口服其他造影剂的X光片以及CT或者MRI等影像学检查资料,106例患者接受开胸食管切除术;66例患者经内镜检查病理证实;7例纵隔肿瘤中2例患者行手术肿瘤切除,另外5例行纵隔肿瘤穿刺获得细胞学证据;3例全身性疾病患者食管明显受累及并且内镜检查排除了食管恶性病变的可能性;16例食管腐蚀性损伤患者均有明确的腐蚀物吞入史。本组326例患者共放置369枚食管支架,其中37例患者放置了第二枚食管支架,3例患者放置了3枚食管支架。根据支架的制作材料不同,所用的食管支架可分为两种:镍钛合金支架,由0.2mm的镍钛合金丝编织成网格状,支架的形状对温度有记忆功能,其上、下两端或上端呈膨大的喇叭口状,体部贴覆一层硅胶膜,一端或两端距支架1cm范围没有覆膜来增加支架的稳定性,支架的直径18～20mm,长度60～140mm;不锈钢丝编织而成的“Z”型支架,为分节状、全覆膜支架,两节之间为软连接,支架体部的相对两侧有1～2对倒刺来增加支架的稳定性,用来防止支架滑脱,支架直径13～19mm,长度55～190mm。 支架放置、回收方法:摘除活动义齿,咽部利多卡因喷雾麻醉,常规肌注654—2 10～20mg或者阿托品0.5mg,让患者右侧(或仰卧、左侧)卧于手术床上,8F大腔导管与超滑导丝一同经口腔过咽部进入更多还原

【Abstract】 Objective:To evaluate the clinical efficacy and complications of the covered esophageal stents in the treatment of esophageal stricture resulted from benign or malignant diseases and esophageal rupture,retrospectively. Materials:Under fluoroscopic guidance,369 stents were placed in 326 patients (202 men, 124 women,age ranged from 5 to 94 years ,mean 62.6 years),314 patients with dysphagia due to benign (including 41 cases of stricture at the site of anastomosis, 16 cases with caustic erosion,3 cases of systemic disease )or malignant (including 254 cases of carcinoma of esophagus or cardia)obstruction,and 12 patients with esophageal rupture were treated with covered stents.The main symptoms included progressive dysphagia or aphagia,chest pain,choking,emaciation and bleeding.All patients came with their X—ray,CT or MRI films. 108 patients had undergone surgical resection of esophagus ,66 patients were diagnosed with endoscopy,5 patients were punctured percutanuously .All those patients who were diagnosed as benign lesions had unequivocal history or had endoscopic corroboration.An additional stent was necessary to be placed in 37 patients(8 benign cases and 29 malignant cases),the third one was placed in 3 patients (all were benign cases).In our study,two kinds of stents were used :one was nitinol stent(NTS),the other was stainless steel "Z"stent(SSZS).NTS was made of 0.2mm nitinol wire,woven in a crisscross fashion to form a cylindrical mesh,which had a shape memory that allowed the stent to assume the proper configuration once released from its constraining delivery assembly. 112 NTS were placed in our study.The stent was 18—20mm in diameter and 60—140mm in length.One or both ends ofthe stent about 10mm were flared and bared to prevent the stent’s migration,while the body of the stent was covered with silicone membrance to prevent ingrowth.The other kind of stent was made of stainless steel wire,woven in a zigzag fashion,with a soft connection between two "Z"bodies and one or two pairs of inversus thorns to prevent stents migration.This kind of stent was 13—19mm in diameter and 55—190mmin length. 257 SSZS were placed in our study.Methods of stentplacement and removal:All of the stent insertion were performedunder fluoroscopic guidance.An aerosol spray for topical anesthesia(spray and gel lidocaine) was applied to the mouth and pharynx.Drugs such as 10—20mg 654—2 or 0.5mg atropine was administered routinely before the procedure.Picked out the patients’movable false—tooth.With the patient in the right lateral or supine position and in full extension of the neck,a 8F big lumen catheter with a super smooth guidewire was passed into the esophagus perorally.Let the patient swallow when the guidewire passed through the pharynx.The catheter was passed over the guidewire as far as the distal portion of the stricture. Withdrew the guidewire and injected some water—soluble contrast while pulling the catheter upward to show the range of the lesion to verify the diagnosis made previously.Then the location of the lesion in the esophagus was marked on the patients’ skin under fluoroscopic guidance both in supine and lateral position.Let the catheter with super smooth guidewire go through the lesion,exchanged the super smooth guidewire with a super stiff steel wire until its distal spring end was kept in stomach to be used.Savry—Gilliard dilator,whose distant part was lubricated with paraffin oil ,was passed over the kept guidewire into the esophagus and advanced until the dilator reached the spring part of the wire to dilate the stricture(if necessary) from 5mm to 9mm,one by one.In this procedure,if the resistance from the tight stricture was magnificent,dilated it with the next thicker dilator. Without massive bleeding,the stent assemblywas introduced into the esophagus until the distal tip of the stent reached about 2cm beyond the stricture marked before. Locating the stent carefully,released the stent under fluoroscopic guidance on end.Withdrew the stent assembly together with the guidewire.If patients had no obvious complications,let them have fluid food in 3 days,soft food 3—6 days and ordinary food 1 week later.For those patients with split esophagus,kept a good drainage and gave sufficient antiphlogistic and nutritional supplement.Stent removal:Inserted an 8F big lumen cathether with a super smooth guidewire as above—mentioned in stent placement.The catheter should be confirmed with contrast in the lumen of the stent which would be removed .A steel wire with a hook on its distal end was introduced into the lumen of catheter.When the hook appeared beyond the catheter,withdrew the catheter together with the hook until the kook neared the upper inner edge of the stent.Tried to hook the removal string.When the stent shrinked,withdrew the hook while pushing the catheter to tighten up the string.Pulled the hook and the catheter out of the mouth fast.Then the stentwas removed successfully.ResultS:369 stents(112 NTS,254 SSZS) were placed in 326patients.343 stents (92.9%)were placed one time ,23 stents(6.2%) at the second time and 3 stents(0.9%) at the third time.lt was satisfactory of immediate location in 337 stents(91.3%) and 32 stents (8.7%) after adjustment.Patients condition improved in a short time.X2 test showed that there was significant difference (P<0.001) of swallow after placement of stent.Esophagus—trachea(or bronchus) fistula or esophagus rupture or fistula at the site of anastomosis in 74 and 76 cases diappeared 24 and 72 hours after stent placement ,accounting for 91.3% and 93.8%,respectively.In our group,complications included chest pain(118 cases),restenosis(61 cases),stent migration(83 cases),esophagus reflux(67 cases),bleeding(52 cases,one patient died of massive bleeding 30 hours later),stent blockage(46 cases) and eructation(12 cases).X2 test showed thatstent in CE resulted in much more severe pain(P<0.01) and stent migration(P<0.05) than in other regions.NTS resulted in more restenosis than SSZS(PO.Ol) while SSZS had higher rate of stent migration than NTS(P<0.01).There were no significant difference (P>0.05) both about bleeding resulted from different stents in different regions of esophagus and esophagus reflux resulted from two kinds of non—antiruflux.Stents Adjustment (6cases),an additional stent (25cases) and only dialation(30cases) palliated 61 restenosis patients effectively.Conclusion:l.Esophageal stent placement was a safe,simple and relatively cheap and dependable management with microtrauma for those who had lost the chance of surgical resection or refused to undergo operation.2.Clinical application of retrieavable stent set up a new way to treat benign esophagus stricture or rupture.Of course,patients needed a series of treatment such as endoscopy,medical supporting,surgical drainage,life rescue and so on.3.It was necessary to have an ample dilation in advance if the stent was placed in CE.SSZS was intensely recommended when the scope of the lesion was higher than T2,while antireflux stent should be used at the site of anastomosis or when striding cardiaAFor malignant lesions,placement of stent was only a pallative measure because the stent had no use in treating tumor. When permitted,these patients should undergo one or more other treatment such as chemotherapy,radiation or immunization therapy.5.Stent removal was easy to do,but it would be impossible,despite the aid of endoscopy,to remove the stent when the removal string was covered deeply by tumor or other tissue .6.During and after the placement of stent ,there existed some unavoidable complications such as chest pain,stent migration,restenosis,bleeding,stent blockage,esophagus reflux and eructation.If the stricture was too stiff and narrow to pass the guidewire through,we can do nothing about the procedure.7.Long term observation of the cytological and histological更多还原