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浙江大学学报（医学版）
浙江大学学报（医学版）  2018, Vol. 47 Issue (6): 643-650    DOI: 10.3785/j.issn.1008-9292.2018.12.13
原著     
无X射线监视内镜下消化道支架置入治疗消化道狭窄的疗效和安全性
沈宏(),季峰*()
浙江大学医学院附属第一医院消化内科, 浙江 杭州 310003
Efficacy and safety of digestive tract stent placement under direct visual endoscopy without X-ray monitoring in treatment of digestive tract stricture
SHEN Hong(),JI Feng*()
Department of Gastroenterology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
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摘要：

目的: 评价无X射线监视内镜下消化道支架置入治疗消化道狭窄的疗效及安全性。方法: 回顾性分析浙江大学医学院附属第一医院2003年3月至2017年11月所有无X射线监视全程内镜直视下消化道支架置入治疗消化道狭窄患者的资料库，详细记录手术经过、疗效、术后并发症及随访情况，比较恶性肿瘤患者与同期未行支架置入的消化道恶性狭窄患者的生存时间。结果: 562例患者中，食管、贲门狭窄310例，胃、十二指肠狭窄40例，结、直肠狭窄212例，其中合并食管气管狭窄、食管纵隔瘘、吻合口瘘共63例。成功置入支架560例（99.64%），症状缓解有效率达100%。术后胸骨后不适、胸痛、腹痛26例（4.64%），消化道出血18例（3.21%），食管支架移位后再调整9例（1.61%），支架再次狭窄15例（2.68%），均再次成功放置支架。术后7 d无患者死亡。食管、贲门狭窄组术后胸/腹痛、出血、支架移位的发生率高于结、直肠狭窄组（均P < 0.05）。284例恶性狭窄中，食管、贲门狭窄组，胃、十二指肠狭窄组，结、直肠狭窄组的中位生存时间分别为（13.40±0.71）、（11.00±1.78）、（27.50±1.94）个月，其中直肠恶性狭窄组的中位生存时间明显长于食管、贲门恶性狭窄组及胃、十二指肠恶性狭窄组（均P < 0.05）。与同期未行支架置入术的上消化道恶性狭窄患者比较，食管、贲门狭窄组及胃、十二指肠狭窄组置入支架术后患者生存时间明显提高（均P < 0.05）。结论: 无X射线监视全程内镜直视下消化道支架置入治疗消化道良恶性狭窄及封堵瘘口简便、准确、安全、有效。
关键词： 内窥镜检查, 胃肠道;  消化系统肿瘤/治疗;  消化系统瘘/治疗;  缩窄, 病理性/治疗;  支架;  治疗结果;  安全;  回顾性研究    
Abstract:

Objective: To evaluate the efficacy and safety of digestive tract stent implantation under direct visual endoscopy without X-ray monitoring in the treatment of digestive tract stricture. Methods: The clinical data of patients undergoing digestive tract stent placement under direct visual endoscopy without X-ray monitoring in the First Affiliated Hospital of Zhejiang University School of Medicine from March 2003 to November 2017 were retrospectively analyzed. The process of procedures, the postoperative complications and the postoperative follow-up data were documented. The survival time of patients with malignant gastrointestinal stricture was compared between those with and without stent implantation. Results: Among 562 patients, there were 310 cases of esophagus and cardia stricture, 40 cases of gastroduodenus stricture, 212 cases of colorectum stricture, and 63 cases with esophagus-tracheal fistula, esophagus-mediastinal fistula or anastomotic fistula. The stents were implanted successfully in 560 cases (99.64%) and the symptoms were alleviated in all patients after stent implantation (100%). Postoperative substernal discomfort, chest pain or abdominal pain occurred in 26 cases (4.64%), bleeding in 18 cases (3.21%), displacement of esophageal stents in 9 cases (1.61%), and restenosis in 15 cases (2.68%), in whom the stents were successfully placed again. None of the patients died within 7 days after the procedure. The incidence of postoperative abdominal pain, bleeding and stent displacement in esophageal/cardiac stricture patients was higher than that in the colorectal stricture patients (P < 0.05). In 284 cases of malignant stenosis, the median survival time of colorectal stricture patients[(27.5±1.94) months] was significantly higher than that of esophagus/cardia stricture patients[(13.40±0.71) months] and gastroduodenal stricture patients[(11.00±1.78) months]. The survival time of stenting patients with upper gastrointestinal malignant stenosis was significantly longer than that of the non-stenting patients (P < 0.05). Conclusion: Stent implantation under direct visual endoscopy without X-ray monitoring is safe and effective for the treatment of benign and malignant stricture of digestive tract and closure of fistula.
Key words: Endoscopy, gastrointestinal    Digestive system neoplasms/therapy    Digestive system fistula/therapy    Constriction, pathologic/therapy    Stents    Treatment outcome    Safety    Retrospective studies
收稿日期: 2018-04-05 出版日期: 2019-03-15
:  R57  
通讯作者: 季峰     E-mail: 158767328@qq.com;jifeng@zju.edu.cn
作者简介: 沈宏(1984-), 男, 硕士研究生, 主治医师, 主要从事消化系统疾病诊治工作; E-mail:158767328@qq.com; https://orcid.org/0000-0002-4264-386X
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引用本文:

沈宏,季峰. 无X射线监视内镜下消化道支架置入治疗消化道狭窄的疗效和安全性[J]. 浙江大学学报（医学版）, 2018, 47(6): 643-650.

SHEN Hong,JI Feng. Efficacy and safety of digestive tract stent placement under direct visual endoscopy without X-ray monitoring in treatment of digestive tract stricture. J Zhejiang Univ (Med Sci), 2018, 47(6): 643-650.

链接本文:

http://www.zjujournals.com/med/CN/10.3785/j.issn.1008-9292.2018.12.13    或    http://www.zjujournals.com/med/CN/Y2018/V47/I6/643

图 1  食管支架置入操作过程
图 2  十二指肠支架置入操作过程
图 3  结肠支架置入操作过程
[n(%)或($\bar x \pm s$)]
组别 n 吞咽困难分级 平均级数
0级 1级 2级 3级 4级
与术前比较, *P < 0.05, **P < 0.01.
食管、贲门狭窄 术前 310 0 0 0 256 54 3.17±0.38
术后 310 9 224 75 2 0 1.23±0.50**
胃、十二指肠狭窄 术前 40 0 0 0 8 32 3.68±0.47
术后 40 16 21 3 0 0 0.62±0.59*
表 1  食管、贲门狭窄与胃、十二指肠狭窄患者支架置入前后吞咽困难分级比较
[n(%)]
与食管、贲门狭窄组比较, *P < 0.05.
组别 n 胸/腹痛 消化道出血 支架移位 再狭窄 呃逆 咳嗽 气急 合计
食管、贲门狭窄组 310 19(6.1) 6(1.9) 9(2.9) 11(3.6) 3(1.0) 4(1.3) 1(0.3) 53(17.1)
胃、十二指肠狭窄组 40 3(7.5) 1(2.5) 0(0.0)* 2(5.0) 0(0.0) 0(0.0) 0(0.0) 6(15.0)
结、直肠狭窄组 210 4(1.9)* 11(5.2)* 0(0.0)* 2(1.0) 0(0.0) 0(0.0) 0(0.0) 17(8.1)*
合计 560 26(4.6) 18(3.2) 9(1.6) 15(2.7) 3(0.5) 4(0.7) 1(0.2) 76(13.6)
表 2  三组支架置入术后不良反应及并发症发生比较
图 4  消化道恶性狭窄支架置入与未置入患者生存曲线比较
1 袁娟, 叶楠, 冯凯祥 et al. 胃镜-X线联合金属内支架置入治疗胃、十二指肠恶性梗阻的临床价值[J]. 中国内镜杂志, 2017, 23 (12): 73- 76
YUAN Juan , YE Nan , FENG Kaixiang et al. Clinical observation of endoscopic X-ray combined with metal stent implantation in treatment of gastroduodenal malignant obstruction[J]. China Journal of Endoscopy, 2017, 23 (12): 73- 76
doi: 10.3969/j.issn.1007-1989.2017.12.015
2 朱新影, 杜娟, 刘改芳 et al. 食管支架置入术治疗食管良恶性疾病:2016年欧洲胃肠道内镜学会临床指南介绍[J]. 中华消化内镜杂志, 2017, 34 (11): 817- 818
ZHU Xinying , DU Juan , LIU Gaifang et al. Esophageal stenting for benign and malignant disease:European Society of Gastrointestinal Endoscopy(ESGE) clinical guideline in 2016[J]. Chinese Journal of Digestive Endoscopy, 2017, 34 (11): 817- 818
doi: 10.3760/cma.j.issn.1007-5232.2017.11.017
3 石磊, 赵伟, 周宇 et al. 肠道支架置入术与急诊手术治疗急性梗阻性结直肠癌疗效的Meta分析[J]. 中国全科医学, 2016, 19 (8): 941- 945
SHI Lei , ZHAO Wei , ZHOU Yu et al. Curative effect on acute obstructive colorectal cancer by stent implantation in intestinal tract and emergency operation:a meta analysis[J]. Chinese General Practice, 2016, 19 (8): 941- 945
doi: 10.3969/j.issn.1007-9572.2016.08.016
4 蒋波涛, 李桂红, 李荣华 et al. 内镜下覆膜食管支架治疗食管癌性狭窄及食管气管瘘的临床应用价值[J]. 现代消化及介入诊疗, 2014, 19 (4): 222- 225
JIANG Botao , LI Guihong , LI Ronghua et al. The value of clinical application of covered esophageal stent in the treatment of malignant esophageal; stenosis and esophago-tracheal fistula under endoscope[J]. Modern Digestion & Intervention, 2014, 19 (4): 222- 225
doi: 10.3969/j.issn.1672-2159.2014.04.06
5 张功霖, 姜永能, 赵卫 . 全覆膜食管支架治疗食管癌术后吻合口瘘的临床应用[J]. 介入放射学杂志, 2013, 22 (3): 211- 215
ZHANG Gonglin , JIANG Yongneng , ZHAO Wei . Fully covered stents for the treatment of esophageal cancer with anastomotic fistula occurring after esophagectomy:its clinical application[J]. Journal of Interventional Radiology, 2013, 22 (3): 211- 215
doi: 10.3969/j.issn.1008-794X.2013.03.009
6 张雪梅, 马洪升 . 食管支架置入术后并发症[J]. 国际消化病杂志, 2013, 33 (4): 230- 233
ZHANG Xuemei , MA Hongsheng . Complications after esophageal stent implantation[J]. International Journal of Digestive Diseases, 2013, 33 (4): 230- 233
doi: 10.3969/j.issn.1673-534X.2013.04.005
7 DEL PIANO M , BALLARè M , MONTINO F et al. Endoscopy or surgery for malignant GI outlet obstruction?[J]. Gastrointest Endosc, 2005, 61 (3): 421- 426
doi: 10.1016/S0016-5107(04)02757-9
8 GHAZAL A H , EL-SHAZLY W G , BESSA S S et al. Colonic endolumenal stenting devices and elective surgery versus emergency subtotal/total colectomy in the management of malignant obstructed left colon carcinoma[J]. J Gastrointest Surg, 2013, 17 (6): 1123- 1129
doi: 10.1007/s11605-013-2152-2
9 LEE G J , KIM H J , BAEK J H et al. Comparison of short-term outcomes after elective surgery following endoscopic stent insertion and emergency surgery for obstructive colorectal cancer[J]. Int J Surg, 2013, 11 (6): 442- 446
doi: 10.1016/j.ijsu.2013.04.010
10 SAIDA Y , SUMIYAMA Y , NAGAO J et al. Long-term prognosis of preoperative "bridge to surgery" expandable metallic stent insertion for obstructive colorectal cancer:comparison with emergency operation[J]. Dis Colon Rectum, 2003, 46 (10 Suppl): S44- S49
11 HUANG X , LV B , ZHANG S et al. Preoperative colonic stents versus emergency surgery for acute left-sided malignant colonic obstruction:a meta-analysis[J]. J Gastrointest Surg, 2014, 18 (3): 584- 591
doi: 10.1007/s11605-013-2344-9
12 李弼民, 朱萱, 舒徐 et al. 内镜下肠道支架置入术在治疗结直肠癌并肠梗阻中的应用和价值[J]. 世界华人消化杂志, 2016, 24 (7): 1113- 1116
LI Bimin , ZHU Xuan , SHU Xu et al. Value of endoscopic intestinal stent placement in treatment of colorectal cancer complicated with intestinal obstruction[J]. World Chinese Journal of Digestolog, 2016, 24 (7): 1113- 1116
13 王国鑫, 刘香, 王晟 et al. 内镜下肠道金属支架置入术在结直肠恶性梗阻中的近期疗效评估[J]. 中华消化内镜杂志, 2015, 32 (8): 549- 552
WANG Guoxin , LIU Xiang , WANG Sheng et al. Short-term safety and efficacy of endoscopic self-expandable metal stent implantation for malignant colonic obstruction[J]. Chinese Journal of Digestive Endoscopy, 2015, 32 (8): 549- 552
doi: 10.3760/cma.j.issn.1007-5232.2015.08.011
14 李德春, 徐元顺, 杜洪涛 et al. 透视下金属支架置入术在结肠癌急诊手术中的应用价值[J]. 中华消化外科杂志, 2014, 13 (11): 891- 894
LI Dechun , XU Yuanshun , DU Hongtao et al. Clinical value of emergent perspective stent implantation for left-side obstructive colonic cancer[J]. Chinese Journal of Digestive Surgery, 2014, 13 (11): 891- 894
doi: 10.3760/cma.j.issn.1673-9752.2014.11.013
15 孙杰, 刘文天, 王邦茂 et al. 内镜下支架置入术治疗消化道狭窄273例[J]. 世界华人消化杂志, 2011, 19 (6): 644- 649
SUN Jie , LIU Wentian , WANG Bangmao et al. Endoscopic stent placement for stenosis of the digestive tract:an analysis of 273 cases[J]. World Chinese Journal of Digestology, 2011, 19 (6): 644- 649
16 SELINGER C P , ELLUL P , SMITH P A et al. Oesophageal stent insertion for palliation of dysphagia in a district general hospital:experience from a case series of 137 patients[J]. QJM, 2008, 101 (7): 545- 548
doi: 10.1093/qjmed/hcn045
17 WAIDMANN O , TROJAN J , FRIEDRICH-RUST M et al. SEMS vs cSEMS in duodenal and small bowel obstruction:high risk of migration in the covered stent group[J]. World J Gastroenterol, 2013, 19 (37): 6199- 6206
doi: 10.3748/wjg.v19.i37.6199
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