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儿童食管良性狭窄的临床分析

摘要: 　目的　总结治疗儿童食管良性狭窄的临床经验, 以提高治疗效果。　方法　2000 年2 月至2006 年2 月我科治疗食管良性狭窄15 例, 早期采用食管扩张术9 例, 胃代食管术1 例, 食管端端吻合2 例; 后期应用结肠代食管术3例。　结果　15 例患者全部治愈。术后1 例发生胃食管反流, 经增强胃动力药物治疗痊愈; 1 例食管穿孔, 经胃造瘘和胸腔引流, 静脉应用“全合一”高价营养液保守治疗3 周治愈。15 例分别随访3 个月～ 4 年, 食管X 线钡餐造影显示: 钡剂通过顺利, 无狭窄表现, 均恢复普通饮食, 生长发育良好。　结论　对儿童食管良性狭窄患者早期采用食管机械扩张是较为有效的方法, 可回收性金属支架治疗食管狭窄可替代反复食管扩张, 当扩张无效时应积极手术治疗; 在食管重建术中以结肠代食管为好; 下段食管狭窄可采用食管切除胃代食管重建术; 对气管软骨食管异位症引起的食管狭窄宜作软骨切除食管吻合术。

带膜网状镍钛合金支架治疗恶性病变引起的食管狭窄

目的 通过使用带膜网状镍钛合金支架治疗恶性病变引起的食管狭窄，评价该支架的临床应用价值。方法对38例食管狭窄患者行食管支架植入，其中晚期食管癌引起食管狭窄23例（1例上段食管癌合并食管-气管瘘），晚期贲门癌4例，食管、贲门癌术后吻合口复发6例，肺癌侵及食管4例，纵隔淋巴结转移癌压迫食管1例。全部病例均在X线电视监视下经口食管扩张后放入带膜网状镍钛合金支架，术后全身静脉化疗并进行随访。 结果 本组无手术死亡。38例共进行39次支架植入，均一次性放置成功，其中1例因肿瘤生长超过原支架上缘引起再堵塞，而于首次支架植入2.5个月后第2次放置，1例15cm长食管癌患者同时放置2根支架。支架植入后静脉化疗（卡铂+5-氟脲嘧啶，共4个疗程）。随访观察35例,26例平均生存4.5个月后死亡；6例生存11～19个月，平均16个月；3例生存超过24个月。死前1～7d均可进食，无严重并发症发生。 结论 带膜网状镍钛合金支架治疗恶性病变引起的食管狭窄，可较好地改善患者的进食状况，提高生活质量。

应用带膜镍钛记忆合金支架治疗晚期食管癌

目的总结应用带膜镍钛记忆合金支架治疗晚期食管癌的临床经验。方法53例晚期食管癌患者在食管X线钡餐透视下采用介入法、内镜法或术中植入法在食管内放置带膜镍钛记忆合金支架。术后进食困难程度用Neuhaus分级评估，并随访观察所有患者近期和远期疗效。结果所有患者支架均一次放置成功，无操作引起的严重并发症，术后患者吞咽困难症状明显改善，置入支架后患者吞咽困难分级较置入支架前明显降低（P〈0．01），能顺利进半流质或普通食物。狭窄食管段直径由2～4mm扩张至16～20mm。随访49例（92．5%），随访时间3～24个月。术后近期并发症主要为胸骨后异物感、疼痛、恶心和少量消化道出血，发生率为96．2％（51／5a）。26例患者（53．1％，26／49）于术后3～15个月内死亡，平均生存7．8个月，死亡原因多为肿瘤转移、全身衰竭。结论食管内放置带膜镍钛记忆合金支架治疗晚期食管癌患者的食管狭窄、食管瘘简单易行、损伤小，近期疗效明显，是一种有效的姑息性非手术治疗方法。

The Prevention of Stricture Formation with Esophageal Intraluminal Stenting in Patients with Corrosive Esophageal Burns

Objective To introduce the technique of esophageal intraluminal stenting and assess its effect on the prevention of development of stenosis in patients with esophageal burns. Methods Thirty-three patients were admitted less than 3 weeks after ingestion of caustic agents. The second-or third-degree injuries were confirmed by esophogoscopy in all cases, but one with esophageal perforation at admission. Esophageal stenting was performed in all patients and these stents were kept in place for 4 to 6 months. Results There was no death in the series. All patients had a normal intake of food after removal of the stents, and stricture was not found on barium swallow test. Follow-up from 1 to 60 months five cases developed esophageal stenosis from 2 to 3 months after extracting the stents. One of them responded to esophageal bougienage, the remaining 4 patients required esophageal reconstruction and took a normal diet postoperatively. The other 28 patients have a normal diet after the stent removal. Conclusion The esophageal intraluminal stenting is able to prevent the formation of stricture in the aftermath of esophageal burns and its effect will be enhanced plus administering isoniazid.

食管腐蚀伤的外科治疗

目的总结食管腐蚀伤的外科治疗经验。方法149例食管腐蚀伤患者，除7例行保守治疗外，其余142例采用外科手术治疗（其中11例在我科行2次手术）。采用改良食管腔内置管28例，于腐蚀伤后6个月行食管重建术96例（结肠代食管71例、胃代食管25例），颈阔肌皮瓣修复颈段食管局限性狭窄或吻合口狭窄17例，其他手术12例。结果7例保守治疗的患者中死亡2例，余5例1度烧伤患者未形成瘢痕狭窄。手术治疗142例中，行结肠代食管术患者死亡5例，发生颈部吻合口瘘14例，颈部吻合口狭窄8例，脓胸1例。改良食管腔内置管28例，23例成功，再狭窄5例经再次手术或食管扩张治愈。存活患者均恢复正常进食。结论改良食管腔内置管可预防食管瘢痕狭窄；食管狭窄位于主动脉弓平面及以上时，旷置瘢痕食管行结肠代食管术，而位于主动脉弓平面以下时，切除瘢痕食管采用胃代食管术重建食管；颈阔肌皮瓣可用于修复颈段食管狭窄或吻合口狭窄。

颈阔肌皮瓣修复或重建颈部食管缺损术后并发症探讨

目的 探讨颈阔肌皮瓣重建或修复颈部食管缺损术后常见并发症的预防和治疗。方法 对我科1989年6月至2001年6月采用双侧颈阔肌皮瓣重建颈段食管缺损15例，单侧颈阔肌皮瓣修复颈段食管缺损23例进行回顾性分析。结果 全组无手术死亡，肌皮瓣全部成活，6例发生吻合口瘘，更换敷料后愈合；吻合口狭窄2例，1例经扩张后治愈，另1例经再次手术恢复，所有患者均能正常经口进食。结论 颈阔肌皮瓣重建或修复下咽及颈段食管缺损，具有创伤小、转移就近方便、能一期完成手术、术后并发症少等优点，值得在临床推广应用。

带蒂空肠移位修复小儿食管狭窄一例

The Clinical Application of Nasal Endoscopy in patients with Esophageal Stenosis Stent Expansion

【摘要】 目的 探讨经鼻胃镜在食管狭窄扩张和支架置入术中的作用。 方法 2007年10月-2009年3月对28例癌性食管狭窄以及并发食管-气管瘘的患者行PENTAX（EG-1580K）超细经鼻电子胃镜检查，计算插入深度，并进行扩张和支架治疗，在胃镜直视下调节输送器内支架上端的位置，观察扩张效果、支架放置成功率、定位的准确性以及并发症情况。 结果 全部患者均行扩张治疗，效果良好，支架一次性放置全部成功，定位准确，自膨满意，最狭窄处的内径由（4.8±1.2）mm扩至（12.5±1.5）mm，食管气管瘘被覆盖治疗效果好，患者的吞咽困难评级由3.25±0.58降至0.94±0.59。 结论 在食管狭窄扩张和支架置入术中应用经鼻超细胃镜患者依从性好，方法简便，安全有效。【Abstract】 Objective To explore the role of nasal endoscopy in the esophagostenosis expansion and esophageal stent. Methods PENTAX (EG-1580K) ultrafine nasal endoscopy was used in 28 patients (October 2007-March 2009) with esophageal cancer complicated with esophagostenosis and fistula to check the e-calculated insertion depth, stent expansion and the average diameter expansion. The endoscopy was carried under the direct vision with the location of the top bracket in order to ensure the accurate stent placement, all without X-ray assist. The success rates of stent placement, positioning accuracy, as well as complications were evaluated. Results The expansion treatments were successful in all patients with one-off operation. The narrowest part increased from (4.9±1.6) mm to (12.7±1.5) mm, and the esophageal fistula was covered. The rating of dysphagia decreased from 3.15±0.68 to 0.91±0.49. Conclusion Nasal endoscopy is simple, safe and effective in the treatment of ultrafine expansion for esophagostenosis and stent implantation with good compliance.

The Clinical Aplication and Efficacy of Domestic Self-expanding Nickel-titanium Memorial Alloying Covered Stent

目的：探讨国产自膨式镍钛记忆合金食管支架在食管、贲门良恶性狭窄及食管瘘中的临床应用并观察疗效。方法:收集我院2005年11月～2008年8月采用胃镜辅助置入镍钛记忆合金食管支架的患者108例，其中男90例，女18例，年龄37~88岁；包括食管癌性狭窄41例，贲门癌性狭窄5例，放疗后狭窄1例，肺癌压迫致食管狭窄1例，食管、贲门癌术后吻合口顽固性狭窄21例，食管癌术后复发致狭窄6例，食管瘘33例。结果：108例患者共置入食管支架116枚，一次性置入成功率100%，置入后患者吞咽梗阻的症状有不同程度的改善，呛咳的症状基本消失。结论：食管支架置入操作简单、安全，成功率高，是治疗食管良恶性狭窄及封堵瘘口的有效方法。

Preliminary verification of animal model of benign esophageal stricture caused by gastroesophageal reflux in rats

ObjectiveTo develop an experimental model of gastroesophageal reflux-induced esophageal stricture in rats and explore the mechanism of esophageal stricture. MethodsA total of 30 male Sprague-Dawley (SD) rats by random number table method were randomly divided into three groups as follows: an operation+acid perfusion group, first the models of lower esophageal sphincter relaxation and hiatal hernia were made, and then the rats’ esophagus were perfused with hydrochloric acid-pepsin; acid perfusion group, the rats’ esophagus were directly perfused with hydrochloric acid-pepsin; and control group, rats’ esophagus were perfused with normal saline. After 4 weeks of continuous perfusion, the esophageal mucosal injury of SD rats in each group were observed, and the concentrations of inflammatory cytokines [tumor necrosis factor-α (TNF-α), interleukin (IL)-1β and IL-18] in esophageal tissues were detected by enzyme-linked immunosorbent assay. ResultsIn the operation+acid perfusion group, esophageal stricture was formed in 2 SD rats, but no esophageal stenosis was found in the acid perfusion group and the control group. The body weight of rats in the operation+acid perfusion group and the acid perfusion group were lower than that in the control group (P<0.05). The esophageal mucosal injury scores of rats in the operation+acid perfusion group and the acid perfusion group were higher than that in the control group (P<0.001), and the operation+acid perfusion group was higher than that in the acid perfusion group (P=0.014). The concentrations of TNF-α, IL-1β and IL-18 in esophageal tissues were higher in the operation+acid perfusion group and the acid perfusion group than that in the control group (P<0.001), and the operation+acid perfusion group was higher than that in the acid perfusion group (P<0.001). ConclusionsThe anti-reflux barrier is an important part of preventing gastroesophageal reflux disease. The destruction of anti-reflux barrier, hydrochloric acid-pepsin perfusion and inflammatory cytokines jointly induced esophageal inflammation and injury, and even caused esophageal stricture.