临床研究 Open Access
Copyright ©The Author(s) 2003. Published by Baishideng Publishing Group Inc. All rights reserved.
世界华人消化杂志. 2003-10-15; 11(10): 1528-1530
在线出版日期: 2003-10-15. doi: 10.11569/wcjd.v11.i10.1528
自膨胀金属支架治疗晚期食管癌吞咽困难26例
张朋彬, 赵晓晏, 李宜辉, 达四平
张朋彬, 赵晓晏, 李宜辉, 达四平, 中国人民解放军第三军医大学附属新桥医院消化内科 重庆市 400037
张朋彬, 男, 1966-04-13生, 河北省宁晋县人, 汉族, 医学博士, 主治医师, 讲师.
通讯作者: 张朋彬, 400037, 重庆市, 中国人民解放军第三军医大学附属新桥医院消化内科.
电话: 023-68755604
收稿日期: 2002-10-08
修回日期: 2002-10-15
接受日期: 2002-10-21
在线出版日期: 2003-10-15

目的

回顾分析覆膜自膨胀金属支架(self-expandable metal stent, SEMS)对晚期食管癌吞咽困难患者的治疗效果及并发症的防治.

方法

对26例晚期食管癌吞咽困难患者, 行食管狭窄扩张术后, 在内镜直视下置入覆膜SEMS, 观察其对吞咽困难的治疗效果及并发症的防治.

结果

26例患者均顺利安放SEMS, 吞咽困难症状得到缓解, 吞咽困难计分由治疗前的3.08分下降至1.38分(P<0.01), 主要并发症为胸痛、胃食管反流及SEMS阻塞.

结论

SEMS能明显改善晚期食管癌患者的吞咽困难, 提高生存质量, 延长生存时间.

关键词: N/A
引文著录: 张朋彬, 赵晓晏, 李宜辉, 达四平. 自膨胀金属支架治疗晚期食管癌吞咽困难26例. 世界华人消化杂志 2003; 11(10): 1528-1530
Self-expandable metal stents for dysphagia in 26 patients with advanced esophageal cancer
Peng-Bin Zhang, Xiao-Yan Zhao, Yi-Hui Li, Si-Ping Da
Peng-Bin Zhang, Xiao-Yan Zhao, Yi-Hui Li, Si-Ping Da, Department of Gastroenterology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
Corresponding author: Peng-Bin Zhang, Department of Gastroenterology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China.
Received: October 8, 2002
Revised: October 15, 2002
Accepted: October 21, 2002
Published online: October 15, 2003

AIM

To evaluate the therapeutic effect of self-expandable metal stents for dysphagia in 26 patients with advanced esophageal cancer.

METHODS

Twenty-six patients with inoperable esophageal cancer had dysphagia and were treated with self-expandable stents. After esophageal dilation, a covered self-expandable metal stent was inserted and released on the site of stenosis.

RESULTS

The stent was placed successfully in all of the 26 patients. Immediate relief of dysphagia was observed, the dysphagia score decreased from 3.08 to 1.38 (P<0.01).The main complications of this procedure were chest pain, gastroesophageal reflux and obstruction of the stent.

CONCLUSION

Self-expandable mental stent is a safe and effective method to palliate the dysphagia in inoperable esophageal cancer.

Key Words: N/A
0 引言

晚期食管癌患者由于失去了手术机会, 食管狭窄日益加重, 进食困难, 严重了影响了患者的生活质量及生存时间. 我们通过给患者置入自膨胀金属支架(self-expandable metal stent, SEMS), 以改善患者的生存质量, 延长生存时间, 取得了较好的效果.

1 材料和方法
1.1 材料

晚期食管癌患者共26例, 男18例, 女8例, 年龄35-79(平均59.4)岁; 其中鳞癌18例, 腺癌8例. 食管上段狭窄2例, 中段15例, 下段7例, 中下段均累及者2例. 采用Vakil et al [1]计分方法对患者进行吞咽困难进行计分(0: 无吞咽困难; 1: 能进食固体食物, 但存在吞咽困难; 2: 能进食软食; 3: 能进食液体; 4: 不能进食), 其中4分4例, 3分20例, 2分2例, 平均计分3.08分. SEMS及支架置入器均为常州智力医疗器械公司产品, 其中SEMS为覆膜镍钛记忆合金支架, 规格18-20 mm×60-140 mm (直径×长度); Savary-Gilliard扩张器及引导钢丝(Wilson-Cook Medical Inc, USA); Olympus GIFXQ-230及Fujinon EG-410HR电子胃镜.

1.2 方法

术前患者均应行食管吞钡(稀钡)或泛影葡胺检查并摄片, 了解食管癌狭窄的部位、程度及病变范围; 并常规胃镜检查活检以明确肿瘤诊断. 常规进行咽喉局部麻醉, 并给予安定针及654-2针各10 mg肌注. 胃镜检查至病变狭窄口, 直视下将引导导丝通过狭窄段至胃腔, 退出胃镜. 根据狭窄程度选择合适外径的扩张器, 然后渐增大扩张器至12 mm以上, 以利于胃镜进一步检查及确定病变范围. 重新胃镜检查明确病变上缘及下缘距门齿的距离, 判断病变的长度. 根据病变长度选择合适长度SEMS (病变长度+4 cm以上), 将SEMS装入置入器, 沿引导导丝将SEMS远端置于病变下缘以下2 cm处, 逐渐释放. 一般SEMS两端应超过病变上下缘的2 cm. 若病变长度超出SEMS时, 可重叠置放两根支架. 复查胃镜, 观察支架位置及释放程度(图1-3). SEMS放置后, 即可进食流质饮食, 次日即可进食软食, 并逐渐过渡到正常食物. 对于较粗糙食物, 应完全嚼烂, 最好和水吞咽. 术后有6例患者接受了化疗, 另20例患者未再接受进一步化疗或放疗.

图1
图1 食管中段癌并狭窄, 扩张前.
图2
图2 食管中段癌并狭窄, 扩张后.
图3
图3 自膨胀支架置入后.

统计学处理 术前术后吞咽困难计分比较采用Wilcoxon检验.

2 结果

共置放SEMS 28根, 其中2例患者病变长度分别为12.5 cm和13 cm, 各置放2根SEMS (20×120 mm及20×60 mm). 所有患者均成功置放SEMS, 置放位置准确. 在置放SEMS后吞咽困难即得到缓解, 吞咽困难计分由治疗前的3.08分降至治疗后的1.38分, 治疗效果明显(P<0.01). 有19例在SEMS置放后均出现了不同程度的胸痛, 应用多瑞吉透皮剂后症状可缓解, 一般1 wk内症状基本消失. 共有11例患者出胃食管反流, 其中以病变位于下段者最多见(9例下段狭窄者中, 有8例发生反流; 15例中段狭窄中, 有3例发生反流; 2例上段未发生反流). 有7例次(其中1例患者出现2次)SEMS放置后出现阻塞, 均为食物所至, 内镜下治疗后得到畅通. 未发生SEMS移位及食管穿孔、出血等现象. 共随访19例(7例失访), 随访时间1-18 mo, 生存时间2-13.5 mo, 平均7.2±3.2 mo. 死亡原因主要为肿瘤转移及全身衰竭.

3 讨论

SEMS与其他治疗晚期食管癌吞咽困难的姑息性方法相比, 具有安全, 简单, 经济的特点, 在临床得到广泛推广[2-12].

SEMS多用不锈钢或镍钛合金制作, 有较强的柔韧性及较大的内径, 优于以前应用的塑料支架[13]. 植入SEMS时, 可在X线监视下和/或内镜直视下进行[14]. 内镜直视下安放SEMS效果与X线监视下相仿, 而且操作简便、省时[15,16]. SEMS置入食管后, 依靠自身的张力, 其直径扩张至10-15 mm, 保证了患者食管的通畅, 使患者的正常饮食能够维持. 覆膜SEMS是在支架表面覆有聚亚氨脂(polyurethane), 后者能够有效地阻止肿瘤向腔内生长, 防止了再狭窄的产生[1,17-20].

安置SEMS后的主要并发症包括胸痛、胃食管反流、支架移位等[15,16]. 胸痛几乎发生于任何患者, 可为新出现, 也可为原有症状的加重, 可能与SEMS对食管壁的扩张有关, 给预麻醉药品或加大麻醉品用量可得到缓解[21]. Christie et al [22]对100例SEMS置放者观察发现, 85 %的患者置放后吞咽困难即刻得到缓解, 未发生与安放SEMS相关的死亡. 其主要并发症为食管气管瘘, 纵隔脓肿, SEMS移位. 其他观察与此相似[23]. 此外, 并发症还包括食管穿孔、出血、再狭窄、硬膜外脓肿、心室纤颤等[24-27]. 造成食管穿孔的原因可能与SEMS的压迫及病变食管的抵抗力下降有关[28,29]. 安置SEMS前后进行的化疗、放疗也可诱发穿孔、出血、食管气管瘘[30,31]. 我们在内镜直视下对晚期食管癌患者置放覆膜SEMS后, 患者吞咽困难均得到明显的缓解, 主要并发症为胸痛、胃食管反流, 及食物阻塞, 未发生食管气管瘘、出血等, 也未发生SEMS移位. SEMS置放前扩张食管狭窄很重要, 尽量扩至12 mm以上, 这样可使SEMS能够得到充分释放扩张. 本组观察中有12例明显的胃食管反流, 主要发生于在食管下段置放SEMS者, 可能与食管下段及贲门口部位的SEMS, 使贲门区不能正常闭合有关.

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