食管ESD术后狭窄防治.ppt

ESD术后食管狭窄的防治,中国人民解放军陆军军医大学新桥医院 重庆市消化疾病临床医学研究中心 赵晓晏 2018-11-10,ESD适应症,Techniques in Gastrointestina lEndoscopy 19(2017)159169,Risk of stricture formation in patients undergoing extensive ER/ESD.,Study N. Diagnosis Extent of the circumference Stricture rate van Vilsteren FG4* 25 BE, AC or HGD 75% 88% Park JS8* 5 SCC 75% 83% Ono S7* 10 SCC 75% 90% Katada C6* 19 SCC, HGD and AC 75% Wen J9* 7 SCC 75% 71% *No preventive strategy used.,1.对抗炎药的系统性用药； 2.局部注射消炎或抗纤维原物质； 3.单纯的内镜方法（支架、扩张）； 4.组织工程方法-细胞治疗； 5.胃粘膜移植到食管； 6.各种其他办法,post-ESD 食管狭窄防治方法,预防性系列扩张 腔内注射内固醇药物/局部类固醇凝胶 全覆膜金属支架 聚乙醇酸（PGA）片和纤维蛋白胶 放射状切开/环状切除 组织工程及再生医学 自体粘膜移植,Minerva Chir 2018;73:394-409.,List of methods, which could be, at present, considered in clinical practice,1、Oral steroids Partially effective, easy to do No RCT available Drawback: adverse events 2、Local injection of steroids Easy to do RCT available Partially effective Drawback: a delayed perforation was reported 3、Stenting Only fully covered metallic stents appropriate Easy to do RCT available Limited efficacy Drawback: no clear data on stent removal, the need for fixation to decrease migration rate,Minerva Chirurgica 2018;73(4):394-409,球囊扩张术/内固醇药物,Characteristics of steroid refractory case Resected circumference: 9/10 or more Resected longitudinal diameter: 50 mm Location of esophagus: cervical esophagus History of chemo-radio therapy,GIE 2011;74(6):1389-1393,全身使用皮质类固醇,长期使用导致感染、骨质疏松症、糖尿病、视力下降等不良反应,抗炎 抗肉芽组织 抗纤维化,抗炎 抗肉芽组织 抗纤维化,抑制纤维母细胞 活化与增生,抗纤维化,重症感染 消化性溃疡高血糖 精神症状 骨质疏松,注射部位溃疡形成风险 延缓伤口愈合,局部使用皮质类固醇,注射开始于其基部溃疡的远端边缘，并在10毫米处向近端边缘均匀重复注射（0.5毫升/点，浓度10毫克/毫升）,其他具有消炎或抗纤维作用的物质局部应用,肉毒杆菌毒素 小干扰RNA(CHST15) 止血粉(TC.325, Hemospray) 丝裂霉素C N-乙酰半胱氨酸 氨甲酯（治疗支气管哮喘、瘢痕和肥厚疤痕的抗过敏药物）,预防性扩张策略,降低狭窄发生率（59% vs. 92%） 减轻狭窄程度 缩短治疗时间 9%穿孔率,食管支架,自膨式全覆膜金属支架 18.2% vs72.8% 2-8w 固定/移位（金属夹、锚定、缝合） 组织生长次生梗阻 生物降解支架（Walterova et al., presented at DDW 2018） 质量问题 多二恶英 肉眼炎症 降解颗粒和食物梗阻 高塑组织反应 其他材料或药物支架,移植,人羊膜移植：羊膜由无血管间质和单层柱状细胞上皮组成，表达很少的组织相容性抗原（免疫排斥不太可能） 猪表皮的脱细胞基质移植Xe-Derma Walterova et al., presented at DDW 2018 药物洗脱支架,组织工程方法-细胞、组织疗法,促进上皮愈合 支持上皮重建 抗炎 抑制胶原形成,组织细胞工程与再生医学,Techniques in Gastrointestinal Endoscopy, 2011; 13(1):105-109 Gastroenterolgy,2012;143:582588 Annals of Translational Medicine, 2017;5(8):5-7,胶原蛋白玻璃胶（动物试验）,2 cm,GIE 2017;85:1076-85,去细胞皮肤基质(动物试验),GIE 2017；86（6）:1160-1167,Dig Dis Sci. 2018 May 8. doi: 10.1007/s10620-018-5094-4. Autologous Flap Transfer for Esophageal Stricture Prevention After Endoscopic Submucosal Dissection in a Porcine Model. Tang A1, Ma C1, Deng P1, Zhang H1, Xu Y1, Min M1, Liu Y2,Clinical outcomes,Am J Gastroenterol. 2018 May 1:938. doi: 10.1038/s41395-018-0142-4. Autologous Skin-Grafting Surgery for the Prevention of Esophageal Stenosis After Complete Circular Endoscopic Submucosal Tunnel Dissection. Chai N1, Zhang W1, Linghu E2, Han Y3, Chai M1, Li Z1, Zou J1, Li L1, Xiong Y1,Endoscopy. 2018 Oct;50(10):1017-1021. doi: 10.1055/a-0622-8019. Epub 2018 Jun 11. Endoscopic mucosal autograft for treating esophageal caustic strictures: preliminary human experience. He K#1, Zhao L#1, Bu S2, Liu L1, Wang X1, Wang M1, Fan Z1,Endoscopic mucosal autograft for treating esophageal caustic strictures: preliminary humanexperience. He K#1, Zhao L#1, Bu S2, Liu L1, Wang X1, Wang M1, Fan Z1. Author information Abstract Esophageal caustic stricture is a stubborn disease and postoperative restenosis limits the clinical efficacy of endoscopic dilation. Autologous mucosal grafts have been successfully applied in the treatment of urethral stricture and in the prevention of stricture after extensive mucosal resection. We aimed to use mucosal autografting performed endoscopically to treat refractory esophageal stricture. METHODS : Three patients with intractable corrosive esophageal stricture were treated endoscopically by combining dilation with autologous mucosal transplantation. RESULTS : All procedures were successful with no severe complications. Mucosal regeneration was shown at the transplanted segments. One patient was able to maintain a normal diet with complete remission after 1 year of follow-up. Intraluminal stenosis and dysphagia were significantly improved in another two patients. CONCLUSIONS : Mucosalautografting can achieve esophageal re-epithelialization, inhibit undesired fibrosis, prevent restenosis, and promote functional regeneration.,Endoscopy. 2018 Oct;50(10):1017-1021,其它,胃粘膜移植到食管 支架辅助粘膜切除术 聚乙醇酸片和纤维蛋白胶,World J Gastroenterol. 2018 Mar 7; 24(9): 10461055,新桥医院临床实践,Gut and Liver（已接受）,环状切除+气囊扩张,Background The feasibility and safety of endoscopic submucosal dissection (ESD) for superficial esophageal neoplasms extending to the cervical esophagus currently remain unknown because of the limited number of cases. We aimed to clarify the clinical outcomes of these cases. Methods This was a case series study conducted at a single institution that enrolled 26 consecutive patients with superficial esophageal neoplasms extending to the cervical esophagus who underwent ESD between July 2003 and December 2015. Results En bloc and complete resection rates were both 100 % and no major intraprocedural complications occurred. Thirteen patients were treated with prophylactic steroid therapy. The incidence of postoperative stricture in patients with a circumferential mucosal defect of more than three-quarters was 72.7 %. Four patients required entire circumferential resection, with perforation occurring after endoscopic balloon dilation (EBD) in two and EBD being required for more than 1 year in the other two. Conclusions ESD i