摘要
目的关于食管支架置入术(ESP)和内镜下切开术(EIM)治疗难治性食管癌术后吻合口狭窄的疗效比较研究较少。文中旨在评价ESP和EIM治疗难治性食管癌术后吻合口狭窄的疗效。方法回顾性分析2012年1月至2018年12月南京医科大学附属第二医院消化医学中心收治的50例难治性食管癌术后吻合口狭窄的患者临床资料。根据治疗方式分为:食管支架组(狭窄段长度>5 cm或无明显环周狭窄者,接受ESP治疗,n=32),内镜切开组(狭窄长度≤5 cm且有明显环周狭窄者,接受ESP治疗,n=18)。患者术后随访开始时间2012年1月,结束时间2018年12月。统计手术前后吞咽困难评分,手术并发症及随访结果。结果食管支架组吞咽困难评分改善程度小于内镜切开组[(1.0±0.0)分vs(1.4±0.5)分],差异有统计学意义(P<0.001)。食管支架组扩张直径明显大于内镜切开组[(19.9±1.8)mm vs(11.0±1.9)mm],差异有统计学意义(P<0.001)。食管支架组住院时间、轻微胸痛及严重胸痛发生率大于内镜切开组(P=0.022)。食管支架组术后12个月狭窄缓解率大于内镜切开组(P<0.05)。结论 EIM能迅速缓解吻合口狭窄引起的进食梗阻症状,而ESP则能提供较长的缓解时间。2种手术对难治性食管吻合口狭窄患者均比较安全。
Objective Few reports are seen comparing esophageal stent placement(ESP)and the endoscopic incision method(EIM)in the treatment refractory esophageal anastomotic strictures(EAS)following esophageal carcinoma resection(ECR). This study was to evaluate the effect ESP versus that of EIM in the treatment of refractory EAS after ECR.Methods We retrospectively analyzed the clinical data on 50 cases of post-ECR refractory EAS treated by ESP(n = 32)or EIM(n = 18)in our Center of Digestive Medicine between January 2012 and December 2018. We recorded and compared the pre-and post-operative dysphagia scores,postoperative complications and follow-up results between the two groups of patients.Results Compared with the EIM group,the patients of the ESP group had a remarkably lower dysphagia score post-operatively(1.4±0.5 vs 1.0±0.0,P<0.01),a smaller diameter of the dilated esophagus([19.9±1.8]vs[11.0±1.9]mm,P<0.01),higher incidence rates mild and severe chest pain(P=0.022),and a higher rate of relief of esophageal stricture at 12 months after surgery(P<0.05).Conclusion EIM can rapidly relieve the symptoms of esophageal anastomotic stricture,while ESP may achieve a longer duration of relief. Both of the procedures are safe for patients with refractory esophageal anastomotic stricture.
引文
[1]Enzinger PC,Mayer RJ.Esophageal cancer[J].New Engl JMed,2003,349(23):2241-2252.
[2]Tanaka Y,Yoshida K,Suetsugu T,et al.Recent advancements in esophageal cancer treatment in japan[J].Ann Gastroenterol Surg,2018,2(4):253-265.
[3]Sundelof M,Ye W,Dickman PW,et al.Improved survival in both histologic types of oesophageal cancer in sweden[J].Int JCancer,2002,99(5):751-754.
[4]邓立春,曹向明,盛华明,等.窄带成像技术评价食管癌放疗的近期疗效[J].医学研究生学报,2018,31(7):722-725.
[5]姚圣,刘灿辉,王康.四管法在食管癌术后吻合口胸腔瘘治疗中的疗效观察[J].医学研究生学报,2016,29(8):845-848.
[6]Briel JW,Tamhankar AP,Hagen JA,et al.Prevalence and risk factors for ischemia,leak,and stricture of esophageal anastomosis:Gastric pull-up versus colon interposition[J].J Am Coll Surgeons,2004,198(4):536-541;discussion 541-532.
[7]Rice TW.Anastomotic stricture complicating esophagectomy[J].Thorac Surg Clin,2006,16(1):63-73.
[8]van Heijl M,Gooszen JA,Fockens P,et al.Risk factors for development of benign cervical strictures after esophagectomy[J].Ann Surg,2010,251(6):1064-1069.
[9]王敏,张银,范志宁.食管良性狭窄内镜下治疗的研究进展[J].中国微创外科杂志,2016,16(4):365-369.
[10]Committee ASoP,Pasha SF,Acosta RD,et al.The role of endoscopy in the evaluation and management of dysphagia[J].Gastrointest Endosc,2014,79(2):191-201.
[11]Spaander MC,Baron TH,Siersema PD,et al.Esophageal stenting for benign and malignant disease:European society of gastrointestinal endoscopy(esge)clinical guideline[J].Endoscopy,2016,48(10):939-948.
[12]Minamino H,Machida H,Tominaga K,et al.Endoscopic radial incision and cutting method for refractory esophageal stricture after endoscopic submucosal dissection of superficial esophageal carcinoma[J].Digest Endosc,2013,25(2):200-203.
[13]Fuccio L,Hassan C,Frazzoni L,et al.Clinical outcomes following stent placement in refractory benign esophageal stricture:A systematic review and meta-analysis[J].Endoscopy,2016,48(2):141-148.
[14]Burdick JS,Venu RP,Hogan WJ.Cutting the defiant lower esophageal ring[J].Gastrointest Endosc,1993,39(5):616-619.
[15]DiSario JA,Pedersen PJ,Bichis-Canoutas C,et al.Incision of recurrent distal esophageal(schatzki)ring after dilation[J].Gastrointest Endosc,2002,56(2):244-248.
[16]Muto M,Ezoe Y,Yano T,et al.Usefulness of endoscopic radial incision and cutting method for refractory esophagogastric anastomotic stricture(with video)[J].Gastrointest Endosc,2012,75(5):965-972.
[17]Tan Y,Wang X,Lv L,et al.Comparison of endoscopic incision and endoscopic balloon dilation for the treatment of refractory colorectal anastomotic strictures[J].Int J Colorectal Dis,2016,31(7):1401-1403.
[18]Tan Y,Liu D.Endoscopic incision for the treatment of refractory esophageal anastomotic strictures:Outcomes of 13 cases with a minimum follow-up of 12 months[J].Rev Esp Enferm Dig,2016,108(4):196-200.
[19]Jain D,Sandhu N,Singhal S.Endoscopic electrocautery incision therapy for benign lower gastrointestinal tract anastomotic strictures[J].Ann Gastroenterol,2017,30(5):473-485.
[20]Hordijk ML,Siersema PD,Tilanus HW,et al.Electrocautery therapy for refractory anastomotic strictures of the esophagus[J].Gastrointest Endosc,2006,63(1):157-163.
[21]Kochman ML,McClave SA,Boyce HW.The refractory and the recurrent esophageal stricture:A definition[J].Gastrointest Endosc,2005,62(3):474-475.
[22]Dan DT,Gannavarapu B,Lee JG,et al.Removable esophageal stents have poor efficacy for the treatment of refractory benign esophageal strictures(rbes)[J].Dis Esophagus,2014,27(6):511-517.
[23]Yano T,Yoda Y,Nomura S,et al.Prospective trial of biodegradable stents for refractory benign esophageal strictures after curative treatment of esophageal cancer[J].Gastrointest Endosc,2017,86(3):492-499.
[24]Shenfine J,McNamee P,Steen N,et al.A pragmatic randomised controlled trial of the cost-effectiveness of palliative therapies for patients with inoperable oesophageal cancer[J].Health Technol Asses,2005,9(5):iii,1-121.
[25]Kawasaki R,Sano A,Matsumoto S.Long-term outcomes and complications of metallic stents for malignant esophageal stenoses[J].Kobe J Med Sci,2003,49(5-6):133-142.
[26]Sarper A,Oz N,Cihangir C,et al.The efficacy of self-expanding metal stents for palliation of malignant esophageal strictures and fistulas[J].Eur J Cardio Thorac,2003,23(5):794-798.
[27]Acunas B,Rozanes I,Akpinar S,et al.Palliation of malignant esophageal strictures with self-expanding nitinol stents:Drawbacks and complications[J].Radiology,1996,199(3):648-652.
[28]Turkyilmaz A,Eroglu A,Aydin Y,et al.Complications of metallic stent placement in malignant esophageal stricture and their management[J].Surg Laparosc Endosc Percutan Tech,2010,20(1):10-15.
[29]程相方.食管床低负压引流在食管癌术后胸内吻合口瘘早期诊断及治疗中的应用[J].医学研究生学报,2017,30(1):88-90.
[30]Sabharwal T,Morales JP,Irani FG,et al.Quality improvement guidelines for placement of esophageal stents[J].Cardiovasc Inter Rad,2005,28(3):284-288.
