覆膜支架在食管疾患治疗中的临床应用研究
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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
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 of
the 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 assembly
was 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 that
stent 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
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
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 of
the 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 assembly
was 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 that
stent 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
引文
1. Muller JM, Erasmi H, Stelzner M, et al. Surgical therapy of esophageal carcinoma. Br J Surg, 1990; 77: 845～857
2.邵令芳,王其彰。2002。新编食管外科学。石家庄:河北科学技术出版社,1～22,465～494,697～736
3.李文华,杨仁杰,赵廷常。2002。食管影像学。北京:人民卫生出版社
4. Earlam R, Cunha—Melo JR. Malignant esophageal strictures: a review of techniques for palliative intubation. Br J Surg, 1982; 69: 61～68
5.李树铭,黄如川,王恩升,等。内镜—微波灼扩术治疗食管癌术后吻合口狭窄的经验。中国肿瘤临床,1993;20:500～501
6.辛育龄,刘德若,赵凤瑞,等。电化学治疗晚期食管癌梗阻和术后吻合口狭窄。中华胸心血管外科杂志,1998;14:14～17
7. Song, HY, Han, YM, Kim HN, et al. Corrosive esophageal stricture: safety and effectiveness of balloon dilation. Raiology, 1992; 184: 373～378
8. Fleischer D, Sivak M. Endoscopic Nd: YAG laser therapy as palliation for esophagogastric carcinoma. Gastroenterology, 1985; 89: 827～831
9. Atkinson M, Ferguson R. Fibrioptic endoscopic pallative intubation of inoperable esophagogastric neoplasms. Br Med J, 1977; 1: 266～277
10. Frimberger E. Expanding spiral: a new tupe of prosthesis for the palliative treatment of malignant esophageal stenosis. Endoscopy, 1983; 15: 213～214
11. Dmschke W, Foerter EC, Matek W, et al. Self—expanding mdsh stent for esophageal cancer stenosis. Endoscopy, 1990; 22: 134～136
12. Song, HY, Choi KC, Kwon HC, et al. Esophageal strictures: treatment with a modified Gianturco stent.. Raiology, 1991; 180: 349～354
13. Cwikiel W, Stridbeck H, Tranberg KG, et al. Malignant esophageal strictures: treatment with a self—expanding Nitinol stent. Radiology, 1993; 187: 661～665
14. Song, HY, Choi KC, Kwon HC, et al. Esophageal strictures: treatment with a modified Gianturco stent.. Work in progress. Raiology, 1992; 184: 729～734
15.董宗俊,薛祥禄,许庆生。镍钛合金食管支撑物的初步临床应用。中华外科杂志,1993;31:26
16.杨仁杰,张宏志,黄俊,等。被覆支架成形术在食管癌姑息治疗中的应用。中华放射学杂志,1995;29:461～464
17.翟仁友,戴定可。食管支架治疗食管良恶性狭窄。中华放射学杂志,1995;29:465～468
18.崔进国,孙兴旺,王秀英,等。金属内支架在良性食管狭窄中的应用。中华放射学杂志,1999;33:553～557
19.吴雄,葛荣,李培基,等。防反流食管支架的临床应用。中华放射学杂志,1999;33:185～187
20.崔进国,孙兴旺,王秀英,等。食管恶性狭窄内支架治疗和良性狭窄球囊扩张后的随访评价。中华放射学杂志,1999;33:625～628
21. Earlam R, Cunha—melo JR. Esophageal squamous cell carcinoma: a critical review of surgery. Br J Surg, 1980; 67: 381～390
22. Eigler NL, Khorsandi, MJ, Forrester JS, et al. Implantation and recovery of temporary metallic stents in canine coronary arteries. J Am Coll Cardiol 1993; 22: 1207
23.王如文,蒋耀光,范士志,等。瘢痕食管切除胃代食管治疗腐蚀伤后瘢痕狭窄。中华胸心血管外科杂志,1996;12:204～205
24.马富锦,李厚文,杨志山,等。食管良性狭窄的外科治疗。中华外科杂志,1984;22:749～752
25.孙玉鹏,徐启明,黄孝迈,等。食管化学性烧伤后狭窄的外科治疗。中华外科杂志,1992;30:481～482
26.孙耀昌,答作为,徐志飞,等。食管化学性烧伤后狭窄的手术与并发症治疗。中华创伤杂志,1996;12:312～314
27.施巩宁,柴大森,周伯俊,等。横结肠移植咽下食管吻合在高位食管瘢痕狭窄中的应用。中华胸心血管外科杂志,1993;9:40～41
28.姚宪章,王伯杰。食管胃双吻合术在食管烧伤瘢痕狭窄中的应用。中华外科杂志,1995;33:76～772.
29. Cardona JC, Daly JF. Current management of corrosive esophagitis. Ann Otol Rhinol Larngol, 1971; 80: 521～527
30. Estrera A, Taylor W, Millis LJ, et al. Corrosive burns of the esophagus and stomach: a recommendation for an aggressive surgical approach. Ann Thorc Surg, 1986; 41: 276～283
31.程邦昌,高尚志,涂仲凡,等。自发性食管破裂各种外科治疗选择的探讨。中华胸心血管外科杂志,1989;5:160～161
32. Abbott OA, Mansour KA, Logan WD Jr, et al. Atraumatic so—called "spontaneous" rupture of the esophagus. A review of 47personal cases with comments on a new method of surgical therapy. J Thorac Cardivasc Surg, 1970; 59: 67～83
33.刘正津,陈尔瑜。1989。临床解剖学丛书(胸部和脊柱分册)。北京:人民卫生出版社
34. Belleguic C, Lena H, Briens E, et al.Tracheobronchial stenting in patients with esophagus cancer involving the central airways. Endoscopy. 1999; 31: 232
35. Freitag L, Tekolf E, Steveling H, et al. Management of malignant esophagotracheal fistulas with airway stenting and double stenting. Chest, 1996; 110: 1155
36. Watkinson AF, Ellul J, Entwisle K. Esophageal carcinoma: initial results of palliative treatment with covered self—expanding endoprostheses. Radiology, 1995; 195: 821～827
37. Richard RS, Katherine EM, Paul CL, et al. Malignant esophageal obstruction and esophagorespiratory fistula: palliation with a polyethylene covered Z—stent. Radiology, 1997; 202: 349～354
38. Hong Suk Park, Yong Soo Do, Soo Won Wuh, et al. Upper gastrointestinal tract malignant obstruction: initial results of palliation weth a flexible covered stent. Radiology, 1999; 210: 865～870
39. Song, HY, Do, YS, Han, YM, et al. Covered, expandable esophageal metallic stent tubes: experiences in 119 patients. Radiology, 1994; 193: 689～695
40. Rafanan AL,Mehta AC. Stenting of the tracheobuonchial tree. Interventional Chest Radiology, 2000; 38: 395～408
41. Dev V, Eigler N, Litvack F. Current status and prospects for the use of temporary stents. Coron Artery Dis. 1994; 5: 597
42. Fan Z, Dai N, Chen L. Expandable thermal—shaped memory metal esophagus stents: Experiences with a new nitinol stent in 129 patients. Gastrointest Endosc, 1997; 46: 352
43. Nesitt J, Carrasco H. Expandable stents.Thorae Endosc 1996; 6: 305.
44. Nicholson DA. Tracheal and esophageal stenting for carcinoma If the upper esophagus involving the tracheo—branchial tree. Clin Radiol. 1998; 53: 760
45. Schmassmann A, Meyenbarger C, Knuchel J, et al. Self—epanding metal stents in malignant esophageal obstmction: A comparison between two stent types. Am J Gestroenterol, 1997; 92: 400
46.仇学明,孟凯,王震。CZES型食管支架硬式改软式的临床意义。中国生物医学工程报,2002;21:367～369
47.吴雄,葛荣,李培基,等。三种自行设计和改进的食管支架的临床应用。中华放射学杂志,1997;31:172～175
48.吴雄,葛荣,李培基,等。弯曲型食管支架的临床应用。实用放射学杂志,2000;16.669～671
49.CZES型食管支架202例临床应用。中华胸心血管外科杂志,2000:16:264～265
50. Shimi SM. Self—expanding metallic stents in the management of advanced esophageal cancer: a review. Semin Laparosc Surg, 2000; 7: 9～21
51. Davies AP, Vaughan R. Expanding metal stent in the emergency treatment of Boerhaave's syndrome. Ann Thorc Surg, 1999; 67: 1482～1483
52. K. E. Grund, Storek, H. D. Becker, et al. Highly flexible self—expanding meshed metal stents for palliation of malignant esophagogastric obstruction. Endoscopy, 1995; 27: 486～494
53.金东升,刘光元,梁定,等。带膜支架在食管狭窄中的临床应用。放射学实践,2001;16:325～327
54. Loizou LA, Rampton D, Bown SG. Treatment of malignant strictures of the cervical esophagus by endoscopic intubation using modified endoprostheses. Gastrointest Endosc, 1992; 38: 158～164
55. Thierry de Baere, Ducreux M, Elias D, et al. Self—expanding metallic stents as palliative treatment of malignant gastroduodenal stenosis. AJR, 1997; 169: 1079～1083
56.严子才,李玉,张海波,等。金属支架治疗恶性食管狭窄26例。放射学实践,2003;18:56～58
57.吕维富,季学兵,张行明,等。覆膜内支架在食管癌术后吻合口瘘中的应用。医学影像学杂志,2003;13:20～22
58.王志纯,张生昌,马贵,等。国产镍钛合金支架在食管良恶性狭窄应用中的进一步研究。医学影像学杂志,2001;11:208～210
59.贾广志,尹华,张子东,等。加膜支架对食管气管瘘的临床应用。放射学实践,2002;17:219～221
60. Acunas B, Rozanes I, Akpinar S, et al. Palliation of malignant esophageal strictures with self—expanding Nitinol stents: drawbacks and complications. Radiology, 1996; 199: 6448～652
61. Song HY, Jung HY, Kim SB, et al. Covered retrievable expandable Nitinol stents in patients with benign esophageal strictures: initial experience. Radiology, 2000; 217: 551～557
62. Park KB, D1 YS, Kang WK, et al. Malignant obstruction of gastric outlet and duodenum: palliation with flexible covered metallic stents. Radiology, 2001; 219: 679～683 陈平有,徐霖,夏进东,等。食管内支架置入术并发症分析。放射学实践,2000;15:422～424
63.潘元海。带膜金属支架治疗高位食管-气管瘘8例报告。中华放射学杂志,2000;34:86～87
64.程贵余,张汝刚,方德康。金属支架治疗食管狭窄的价值。中华胸心血管外科杂志,2000;16:258～260
65.张伯生,姬曙光,刘阳晨,等。应用带膜支架治疗晚期食管贲门癌。中华胸心血管外科杂志,2000;16:261～263
66.林庆胜,张保中,侯伟,等。带膜支架治疗恶性食管呼吸道瘘。中华胸心血管外科杂志,2000;16:266
67. Mayoral W, Fleischer D, Salcedo J, et al. Nonmalignant obstruction is a common problem with metal stents in the treatment of esophageal cancer. Gastrointest Endosc, 2000; 51: 556～559
68.范士志。食管腐蚀伤外科治疗进展。中华胸心血管外科杂志,1996;12:124～126
69.蒋耀光,范士志,王如文,等。食管腐蚀性瘢痕狭窄的预防治疗。中华创伤杂志,1996;12:213～214
70. Andreoni B, Farina ML, Biffi R, et al. Esophageal perforation and caustic injury: Emergency management of caustic ingestion. Dis Eso, 1997; 10: 95～100
71. Appelvist P, Salmo M. Lye corrosion carcinoma of the esophagus. A review of 63 cases. Cancer, 1980; 45: 2655～2658
72. Chih—Yi chen, Chung—Ping Hsu, Sen—Ei Shai, et al. Caustic injury of the esophagus—emphasis on management of high level stricture. Can J Gastroenterol, 1998; 12: 167
73.严嘉顺,金旦年,郭介基,等。自发性食管破裂。中华外科杂志,1980;18:526～529
74. B; looki H, Anderson I, Garcia—Rivera C, et al. Spontaneous rupture of the esophagus: Berhaave's syndrome analysis of the literature and report of 18 new cases. Dis Eso, 1997; 10: 64～68
2.邵令芳,王其彰。2002。新编食管外科学。石家庄:河北科学技术出版社,1～22,465～494,697～736
3.李文华,杨仁杰,赵廷常。2002。食管影像学。北京:人民卫生出版社
4. Earlam R, Cunha—Melo JR. Malignant esophageal strictures: a review of techniques for palliative intubation. Br J Surg, 1982; 69: 61～68
5.李树铭,黄如川,王恩升,等。内镜—微波灼扩术治疗食管癌术后吻合口狭窄的经验。中国肿瘤临床,1993;20:500～501
6.辛育龄,刘德若,赵凤瑞,等。电化学治疗晚期食管癌梗阻和术后吻合口狭窄。中华胸心血管外科杂志,1998;14:14～17
7. Song, HY, Han, YM, Kim HN, et al. Corrosive esophageal stricture: safety and effectiveness of balloon dilation. Raiology, 1992; 184: 373～378
8. Fleischer D, Sivak M. Endoscopic Nd: YAG laser therapy as palliation for esophagogastric carcinoma. Gastroenterology, 1985; 89: 827～831
9. Atkinson M, Ferguson R. Fibrioptic endoscopic pallative intubation of inoperable esophagogastric neoplasms. Br Med J, 1977; 1: 266～277
10. Frimberger E. Expanding spiral: a new tupe of prosthesis for the palliative treatment of malignant esophageal stenosis. Endoscopy, 1983; 15: 213～214
11. Dmschke W, Foerter EC, Matek W, et al. Self—expanding mdsh stent for esophageal cancer stenosis. Endoscopy, 1990; 22: 134～136
12. Song, HY, Choi KC, Kwon HC, et al. Esophageal strictures: treatment with a modified Gianturco stent.. Raiology, 1991; 180: 349～354
13. Cwikiel W, Stridbeck H, Tranberg KG, et al. Malignant esophageal strictures: treatment with a self—expanding Nitinol stent. Radiology, 1993; 187: 661～665
14. Song, HY, Choi KC, Kwon HC, et al. Esophageal strictures: treatment with a modified Gianturco stent.. Work in progress. Raiology, 1992; 184: 729～734
15.董宗俊,薛祥禄,许庆生。镍钛合金食管支撑物的初步临床应用。中华外科杂志,1993;31:26
16.杨仁杰,张宏志,黄俊,等。被覆支架成形术在食管癌姑息治疗中的应用。中华放射学杂志,1995;29:461～464
17.翟仁友,戴定可。食管支架治疗食管良恶性狭窄。中华放射学杂志,1995;29:465～468
18.崔进国,孙兴旺,王秀英,等。金属内支架在良性食管狭窄中的应用。中华放射学杂志,1999;33:553～557
19.吴雄,葛荣,李培基,等。防反流食管支架的临床应用。中华放射学杂志,1999;33:185～187
20.崔进国,孙兴旺,王秀英,等。食管恶性狭窄内支架治疗和良性狭窄球囊扩张后的随访评价。中华放射学杂志,1999;33:625～628
21. Earlam R, Cunha—melo JR. Esophageal squamous cell carcinoma: a critical review of surgery. Br J Surg, 1980; 67: 381～390
22. Eigler NL, Khorsandi, MJ, Forrester JS, et al. Implantation and recovery of temporary metallic stents in canine coronary arteries. J Am Coll Cardiol 1993; 22: 1207
23.王如文,蒋耀光,范士志,等。瘢痕食管切除胃代食管治疗腐蚀伤后瘢痕狭窄。中华胸心血管外科杂志,1996;12:204～205
24.马富锦,李厚文,杨志山,等。食管良性狭窄的外科治疗。中华外科杂志,1984;22:749～752
25.孙玉鹏,徐启明,黄孝迈,等。食管化学性烧伤后狭窄的外科治疗。中华外科杂志,1992;30:481～482
26.孙耀昌,答作为,徐志飞,等。食管化学性烧伤后狭窄的手术与并发症治疗。中华创伤杂志,1996;12:312～314
27.施巩宁,柴大森,周伯俊,等。横结肠移植咽下食管吻合在高位食管瘢痕狭窄中的应用。中华胸心血管外科杂志,1993;9:40～41
28.姚宪章,王伯杰。食管胃双吻合术在食管烧伤瘢痕狭窄中的应用。中华外科杂志,1995;33:76～772.
29. Cardona JC, Daly JF. Current management of corrosive esophagitis. Ann Otol Rhinol Larngol, 1971; 80: 521～527
30. Estrera A, Taylor W, Millis LJ, et al. Corrosive burns of the esophagus and stomach: a recommendation for an aggressive surgical approach. Ann Thorc Surg, 1986; 41: 276～283
31.程邦昌,高尚志,涂仲凡,等。自发性食管破裂各种外科治疗选择的探讨。中华胸心血管外科杂志,1989;5:160～161
32. Abbott OA, Mansour KA, Logan WD Jr, et al. Atraumatic so—called "spontaneous" rupture of the esophagus. A review of 47personal cases with comments on a new method of surgical therapy. J Thorac Cardivasc Surg, 1970; 59: 67～83
33.刘正津,陈尔瑜。1989。临床解剖学丛书(胸部和脊柱分册)。北京:人民卫生出版社
34. Belleguic C, Lena H, Briens E, et al.Tracheobronchial stenting in patients with esophagus cancer involving the central airways. Endoscopy. 1999; 31: 232
35. Freitag L, Tekolf E, Steveling H, et al. Management of malignant esophagotracheal fistulas with airway stenting and double stenting. Chest, 1996; 110: 1155
36. Watkinson AF, Ellul J, Entwisle K. Esophageal carcinoma: initial results of palliative treatment with covered self—expanding endoprostheses. Radiology, 1995; 195: 821～827
37. Richard RS, Katherine EM, Paul CL, et al. Malignant esophageal obstruction and esophagorespiratory fistula: palliation with a polyethylene covered Z—stent. Radiology, 1997; 202: 349～354
38. Hong Suk Park, Yong Soo Do, Soo Won Wuh, et al. Upper gastrointestinal tract malignant obstruction: initial results of palliation weth a flexible covered stent. Radiology, 1999; 210: 865～870
39. Song, HY, Do, YS, Han, YM, et al. Covered, expandable esophageal metallic stent tubes: experiences in 119 patients. Radiology, 1994; 193: 689～695
40. Rafanan AL,Mehta AC. Stenting of the tracheobuonchial tree. Interventional Chest Radiology, 2000; 38: 395～408
41. Dev V, Eigler N, Litvack F. Current status and prospects for the use of temporary stents. Coron Artery Dis. 1994; 5: 597
42. Fan Z, Dai N, Chen L. Expandable thermal—shaped memory metal esophagus stents: Experiences with a new nitinol stent in 129 patients. Gastrointest Endosc, 1997; 46: 352
43. Nesitt J, Carrasco H. Expandable stents.Thorae Endosc 1996; 6: 305.
44. Nicholson DA. Tracheal and esophageal stenting for carcinoma If the upper esophagus involving the tracheo—branchial tree. Clin Radiol. 1998; 53: 760
45. Schmassmann A, Meyenbarger C, Knuchel J, et al. Self—epanding metal stents in malignant esophageal obstmction: A comparison between two stent types. Am J Gestroenterol, 1997; 92: 400
46.仇学明,孟凯,王震。CZES型食管支架硬式改软式的临床意义。中国生物医学工程报,2002;21:367～369
47.吴雄,葛荣,李培基,等。三种自行设计和改进的食管支架的临床应用。中华放射学杂志,1997;31:172～175
48.吴雄,葛荣,李培基,等。弯曲型食管支架的临床应用。实用放射学杂志,2000;16.669～671
49.CZES型食管支架202例临床应用。中华胸心血管外科杂志,2000:16:264～265
50. Shimi SM. Self—expanding metallic stents in the management of advanced esophageal cancer: a review. Semin Laparosc Surg, 2000; 7: 9～21
51. Davies AP, Vaughan R. Expanding metal stent in the emergency treatment of Boerhaave's syndrome. Ann Thorc Surg, 1999; 67: 1482～1483
52. K. E. Grund, Storek, H. D. Becker, et al. Highly flexible self—expanding meshed metal stents for palliation of malignant esophagogastric obstruction. Endoscopy, 1995; 27: 486～494
53.金东升,刘光元,梁定,等。带膜支架在食管狭窄中的临床应用。放射学实践,2001;16:325～327
54. Loizou LA, Rampton D, Bown SG. Treatment of malignant strictures of the cervical esophagus by endoscopic intubation using modified endoprostheses. Gastrointest Endosc, 1992; 38: 158～164
55. Thierry de Baere, Ducreux M, Elias D, et al. Self—expanding metallic stents as palliative treatment of malignant gastroduodenal stenosis. AJR, 1997; 169: 1079～1083
56.严子才,李玉,张海波,等。金属支架治疗恶性食管狭窄26例。放射学实践,2003;18:56～58
57.吕维富,季学兵,张行明,等。覆膜内支架在食管癌术后吻合口瘘中的应用。医学影像学杂志,2003;13:20～22
58.王志纯,张生昌,马贵,等。国产镍钛合金支架在食管良恶性狭窄应用中的进一步研究。医学影像学杂志,2001;11:208～210
59.贾广志,尹华,张子东,等。加膜支架对食管气管瘘的临床应用。放射学实践,2002;17:219～221
60. Acunas B, Rozanes I, Akpinar S, et al. Palliation of malignant esophageal strictures with self—expanding Nitinol stents: drawbacks and complications. Radiology, 1996; 199: 6448～652
61. Song HY, Jung HY, Kim SB, et al. Covered retrievable expandable Nitinol stents in patients with benign esophageal strictures: initial experience. Radiology, 2000; 217: 551～557
62. Park KB, D1 YS, Kang WK, et al. Malignant obstruction of gastric outlet and duodenum: palliation with flexible covered metallic stents. Radiology, 2001; 219: 679～683 陈平有,徐霖,夏进东,等。食管内支架置入术并发症分析。放射学实践,2000;15:422～424
63.潘元海。带膜金属支架治疗高位食管-气管瘘8例报告。中华放射学杂志,2000;34:86～87
64.程贵余,张汝刚,方德康。金属支架治疗食管狭窄的价值。中华胸心血管外科杂志,2000;16:258～260
65.张伯生,姬曙光,刘阳晨,等。应用带膜支架治疗晚期食管贲门癌。中华胸心血管外科杂志,2000;16:261～263
66.林庆胜,张保中,侯伟,等。带膜支架治疗恶性食管呼吸道瘘。中华胸心血管外科杂志,2000;16:266
67. Mayoral W, Fleischer D, Salcedo J, et al. Nonmalignant obstruction is a common problem with metal stents in the treatment of esophageal cancer. Gastrointest Endosc, 2000; 51: 556～559
68.范士志。食管腐蚀伤外科治疗进展。中华胸心血管外科杂志,1996;12:124～126
69.蒋耀光,范士志,王如文,等。食管腐蚀性瘢痕狭窄的预防治疗。中华创伤杂志,1996;12:213～214
70. Andreoni B, Farina ML, Biffi R, et al. Esophageal perforation and caustic injury: Emergency management of caustic ingestion. Dis Eso, 1997; 10: 95～100
71. Appelvist P, Salmo M. Lye corrosion carcinoma of the esophagus. A review of 63 cases. Cancer, 1980; 45: 2655～2658
72. Chih—Yi chen, Chung—Ping Hsu, Sen—Ei Shai, et al. Caustic injury of the esophagus—emphasis on management of high level stricture. Can J Gastroenterol, 1998; 12: 167
73.严嘉顺,金旦年,郭介基,等。自发性食管破裂。中华外科杂志,1980;18:526～529
74. B; looki H, Anderson I, Garcia—Rivera C, et al. Spontaneous rupture of the esophagus: Berhaave's syndrome analysis of the literature and report of 18 new cases. Dis Eso, 1997; 10: 64～68