食管疾病谢

食 管 疾 病Esophageal Disease,主讲：谢春发 主任医师 赣南医学院第一附属医院胸心外科,Gannan medical university CAI,The First Clinical College of Gannan medical university,讲 授 内 容,The First Clinical College of Gannan medical university,Gannan medical university CAI,食管癌,贲门失弛缓症,食管癌 Esophageal Carcinoma,The First Clinical College of Gannan medical university,Gannan medical university CAI,概 述,流行病学及病因学,解剖及病理,临床表现与诊断,鉴别诊断,预 防,治 疗,Esophageal Carcinoma 概 述 (General discussion),是一种发生于食管上皮的常见消化道恶性肿瘤，在我国其发病率仅次于胃癌，居恶性肿瘤的第二位；全世界每年有30万人死于食管癌，中国每年死亡15万人左右，中国是高发区；发病大多40岁以上，多见于男性，男女发病率之比为3:1；肿瘤发生的部位以食管中段最多见，下段次之，而上段最少。,Gannan medical university CAI,The First Clinical College of Gannan medical university,Esophageal Carcinoma 流行病学(Epidemic discussion),在世界范围内，高发地区为中国、日本、南非、伊朗和俄罗斯；在中国，高发地区分布在河南、广东东部、四川西部、太行山区和苏北地区；我国河北邯郸市发病率为303.37/10万，河南林县为131.79/10万,而云南省的发病率仅为1.05/10万;流调显示人群分布与以下几个因素有关：年龄、性别、职业、种族、地理、生活环境、饮食生活习惯、遗传易感性等有关。,The First Clinical College of Gannan medical university,Gannan medical university CAI,Esophageal Carcinoma 病 因(Etiology),目前确切机制仍不清，与下列因素有关:1.摄入含亚硝胺化合物及被霉菌污染的食物;2.缺乏微量元素如铝、硒、锌、铁、氟等;3.物理因素及饮食习惯，喜食热、粗、硬食物及吸烟、嗜酒者发病率高;4.遗传因素，患者有家族史者占24%60%，美国黑人发病率较白人高56倍;5.食管慢性炎症的刺激，如返流性食管炎、食管裂孔疝、食管憩室、贲门失弛等;6.环境因素，环境污染重、碱性土壤和丘陵地区的发病率高;7) 性别因素，男性发病率相当于女性的3倍,Gannan medical university CAI,The First Clinical College of Gannan medical university,生理侧曲上段偏左:最凸处约在第3胸椎平面,在颈部偏向左侧;中段偏右:凸向右,其最凸处约在第7胸椎平面;下段偏左:食管裂孔处在中线偏左侧.,第一狭窄位于咽与食管交界处,距上门齿约15cm;常处于闭合状态.,第三狭窄为食管通过食管裂孔处,距上门齿约3740cm;常处于闭合状态.,第二狭窄位于胸骨角平面,由主动脉弓和左主支气管跨越食管前面所致;上门齿距食管与主动脉弓交错处约25cm,距左主支气管交错处约27cm;是食管异物易存留处及食管癌的好发部位.,成人食管长约2530cm,直径1.52.5cm,上门齿距贲门约45cm-颈段5cm、胸段17cm、腹段3cm.,起自第6颈椎水平环状软骨下缘至第10胸椎处穿过膈肌与胃相连,Gannan medical university CAI,The First Clinical College of Gannan medical university,食管解剖 (Anatomy),Esophageal Carcinoma 临床分部及分段(Clinic Type),胸上段：胸廓上口至气管分叉平面.,胸中段：气管分叉平面至贲门口全长的上一半.,胸下段：气管分叉平面至贲门口全长的下一半.,食管癌以食管中段最多见,下段次之,而上段最少.,腹段,胸段,颈段,Gannan medical university CAI,The First Clinical College of Gannan medical university,The First Clinical College of Gannan medical university,Gannan medical university CAI,Esophageal Carcinoma 病理分型(Pathological Type),(一)组织学分类：鳞癌：90%腺癌：0.88%未分化癌: 很少见。(二)临床病理分型：1早期(亚临床期):（1）隐伏型（2）糜烂型（3）斑块型（4）乳头型,食管鳞状细胞癌病理图片,The First Clinical College of Gannan medical university,Gannan medical university CAI,Esophageal Carcinoma 病理分型(Pathological Type),(二)临床病理分型： 2中晚期(临床期): A、髓质型：60%. 累及全周,恶行程度高. B、蕈伞型：15%. 累及一侧,外侵少. C、溃疡型：12%. 累及食管周围组织、外侵强. D、缩窄型：10%. 累及全周,环形狭窄、易阻塞. E、腔内型：3%. 有明显的蒂部,恶行程度最低.,食管癌的扩散方式: 直接浸润: 最先侵及粘膜下层,然后向周围扩散,侵及粘膜、肌层、外膜及其邻近器官. 淋巴转移: 癌转移主要经淋巴途径:可以较早经淋巴管转移到食管旁淋巴结,再向远处淋巴结转移. 上段食管癌-气管旁、颈深及锁骨上淋巴结; 中段食管癌-食管旁，肺门、气管及其分叉、主动脉弓下和心包旁淋巴结，向上至胸顶纵隔淋巴结，向下至下段食管引流的淋巴结; 下段食管癌-食管旁、心包旁,肺下韧带及贲门周围淋巴结,可向下转移至贲门癌引流的淋巴结. 纵隔淋巴结与奇静脉及胸导管有交通，癌细胞还可经淋巴管进入血循环. 血行转移: 较晚发生.晚期可以转移到各脏器:肝30%,肺(胸膜)20%,骨8%,还有少数转移到肾、大网膜(腹膜)、肾上腺、脑、心(心包)及脾等.,Esophageal Carcinoma 扩散与转移(Diffusion and Metastasis),Gannan medical university CAI,The First Clinical College of Gannan medical university,Esophageal Carcinoma 病理分期(TNM分期法),Gannan medical university CAI,国际抗癌联盟(UICC)制订： T_ primary tumor Tx: T cannot be assessed T0: No evidence of primary tumor Tis: Ca in situ T1: T Invades lamina propria or submucosa T2: muscularis propria T3: adventitia T4: adjacent structures N_ Regional lymph node Nx: N cannot be assessed N0: No N metastasis N1: N metastasis M_ Distant metastasis M0: NO M M1: M (including positive celiac nodes),The First Clinical College of Gannan medical university,Esophageal Carcinoma 诊断与临床表现(Diagnose and Clinic representation),Gannan medical university CAI,The First Clinical College of Gannan medical university,早期症状: 胸骨后疼痛、特别在吞咽时明显 .进食时有噎感 梗噎可间断出现 .咽部异物感. 下段食管癌患者可有剑突下或上腹部食后饱胀不适、疼痛. 症状可以逐渐加重,也可持续数年而无明显变化.中晚期典型症状: 进行性吞咽困难或伴有胸骨后疼痛,饱胀不适 .癌组织坏死脱落,梗阻症状可暂时减轻.,Esophageal Carcinoma 病理分期(TNM分期法),Gannan medical university CAI,The First Clinical College of Gannan medical university,食管癌TNM分期标准(Tumor stages):Stage 0： TisN0M0 Stage I： T1N0M0 Stage IIa: T2N0M0 , T3N0M0 Stage IIb: T1N1M0，T1N2M0， Stage : T3N1M0，T4 any N、 M0， Stage IV: any T、any N、M1 该分期法的不足之处在于淋巴结转移情况分得不够细，没有区分第一、第二站，有待今后改进。,T:原位癌T1:肿瘤仅侵及粘膜下层 或固有层T2:肿瘤侵及肌层T3:肿瘤侵及食管外膜T4:肿瘤侵及邻近器官N0:无区域淋巴结转移N1:有区域淋巴结转移M0:无远处转移M1:有远处转移,Esophageal Carcinoma 诊断与临床表现(Diagnose and Clinic representation),Gannan medical university CAI,The First Clinical College of Gannan medical university,晚期症状: 呕吐因肿瘤形成梗阻而食管上段扩张.吞咽食物时胸背部疼痛因原发癌的外侵.远处转移:锁骨上淋巴结转移,原发灶可不大.肝脏转移可有多发结节性肿块.骨转移,转移部位有剧痛.癌肿侵犯气管引起咳嗽、呛咳、肺炎等.食管气管瘘表现为进食后呛咳不止,呼吸困难、肺炎、高热.喉返神经受累有声音嘶哑,多发生在左侧.膈神经受累有膈肌麻痹.体重减轻,消瘦,脱水乃至恶病质.,Esophageal Carcinoma 诊断与临床表现(Diagnose and Clinic representation),Gannan medical university CAI,The First Clinical College of Gannan medical university,辅助检查：1、食管拉网检查脱落细胞:用于早期癌的发现,阳性率达80%以上,用于筛选诊断.2、食管(上消化道)造影,无创、首选检查:食管黏膜增粗、中断和紊乱,充盈缺损.梗阻严重时上段食管扩张.3、纤维食管镜检查:可明确梗阻情况,进行病理诊断.食管癌的确诊检查.4、胸部CT检查,可确定食管肿瘤的大小及外侵情况,对手术的选择有参考价值,有助于手术切除的可行性判断.,Esophageal Carcinoma 诊断与临床表现(Diagnose and Clinic representation),Gannan medical university CAI,The First Clinical College of Gannan medical university,对可疑病例,作食管吞稀钡X线双重对比造影.,食管癌(髓质型)中下段不对称充盈缺损,不规则狭窄,管壁僵硬,近侧食管扩张.,Esophageal Carcinoma 诊断与临床表现(Diagnose and Clinic representation),Gannan medical university CAI,The First Clinical College of Gannan medical university,对可疑病例,作食管吞稀钡X线双重对比造影.,食管癌(溃疡型)中段不规则龛影、粘膜皱襞紊乱、粗糙、中断.,Esophageal Carcinoma 诊断与临床表现(Diagnose and Clinic representation),Gannan medical university CAI,The First Clinical College of Gannan medical university,食管镜检查,CT表现,Esophageal Carcinoma诊 断（diagnose),诊断要点: 病史上有明显的进行性吞咽困难;X线上可表现典型的征象;食管镜检查可获得组织学上的确诊.,Gannan medical university CAI,The First Clinical College of Gannan medical university,Esophageal Carcinoma 鉴别诊断(differential diagnosis),Gannan medical university CAI,The First Clinical College of Gannan medical university,无咽下困难，与食管炎、食管憩室和食管静脉曲张鉴别。有咽下困难，与食管良性肿瘤、贲门失弛症和食管良性狭窄鉴别。鉴别方法:吞钡X线食管造影和纤维食管镜检查。,Esophageal Carcinoma 鉴别诊断(differential diagnosis),Gannan medical university CAI,The First Clinical College of Gannan medical university,食管结核 食管结核比较少见,感染途径有:结核菌直接侵入食管粘膜;由喉或咽部结核向下蔓延;血行感染;脊柱结核侵及食管;食管周围的纵隔淋巴结结核干酪性变侵蚀食管壁.其中尤以第项最为常见.临床表现多有进食发噎史.平均年龄小于食管癌患者.X线所见病变部位稍窄发僵有较大溃疡,周围的充盈缺损及粘膜破坏等不如癌那样明显.食管裂孔疝并发反流性食管炎 有长期吞咽疼痛、反酸、烧心等症状,然后由于炎症反复,局部发生瘢痕狭窄而出现吞咽困难.X线可见下段食管管腔轻度狭窄,呈对称性边缘较光滑,有一定扩张度,粗乱胃粘膜经裂孔延入胸内.,Esophageal Carcinoma 鉴别诊断(differential diagnosis),Gannan medical university CAI,The First Clinical College of Gannan medical university,食管平滑肌瘤 典型病例的吞咽困难症状轻进展慢,X线见突向管腔的光滑圆形或“生姜”样壁在性充盈缺损,表面粘膜展平呈“涂抹征”但无溃疡.局部管腔扩张正常,内镜可见隆起于正常粘膜下的圆形肿物,在食管蠕动时可见在粘膜下“滑动”现象.有时和生长在一侧壁,主要向粘膜下扩展的表面粘膜改变轻微的食管癌不易区别,但后者在内镜下见不到“滑动”.食管良性狭窄 一般有吞酸碱史,X线可见食管狭窄、粘膜褶消失、管壁僵硬,狭窄与正常食管段逐渐过渡.临床上要警惕在长期炎症基础上发生癌变的可能.,Esophageal Carcinoma 鉴别诊断(differential diagnosis),Gannan medical university CAI,The First Clinical College of Gannan medical university,食管外压改变 某些疾病如肺癌纵隔淋巴结转移、纵隔肿瘤、纵隔淋巴结炎症等可压迫食管造成部分或严重狭窄，产生严重吞咽困难，有时误诊为食管癌。食管静脉曲张 病人吞咽困难轻，X线可见食管下段粘膜皱褶增粗、迂曲或呈串珠状充盈缺损、管壁柔软,管腔扩张度不受限，食管镜下可见典型的粘膜下迂曲血管。,Esophageal Carcinoma 预 防(Prevention),Gannan medical university CAI,The First Clinical College of Gannan medical university,戒烟. 禁止热吃热饮,避免食用刺激性强及含致癌物的食物. 整治环境污染. 宣教和普及防癌知识. 高发人群定期普查.,Esophageal Carcinoma 治 疗(therapy),Gannan medical university CAI,The First Clinical College of Gannan medical university,坚持以外科手术治疗为主,与放射治疗,化学治疗中医中药治疗等措施相结合的多学科综合性治疗原则。手术治疗(Operation)(首选)放射线治疗（放疗）(Radiotherapy) 化学药物治疗（化疗）(Chemotherapy) 免疫治疗(Immunotherapy)基因治疗(Gene therapy)中医中药治疗(Traditional medicine)预后： 5、10年生存率分别约为:22.536.8%、17.219.7%。,Esophageal Carcinoma外科治疗策略1 (therapy-1),众多临床试验从循证医学的角度证实，外科治疗在食管癌多学科综合治疗中占有极其重要的地位。具备外科治疗条件的食管癌原则上应以手术治疗为首选。现代观点认为：外科治疗食管癌的重要地位不容置疑，根治性切除是食管癌的标准化外科治疗，是手术选择和手术效果评判的金标准。 术前全面准确的评估和及时纠治病人的体质状况、营养状态、脏器功能、内科疾病是确保手术成功与安全必不可少的重要环节。如果无视病人的耐受性，盲目片面的追求手术的成功与创新，是极度危险的，应引起外科医生的高度重视。,Gannan medical university CAI,The First Clinical College of Gannan medical university,Esophageal Carcinoma外科治疗策略2 (therapy-2),化放疗联合治疗与手术治疗一样，同属根治性治疗，是不能耐受手术局限期病变的最佳选择。多学科综合治疗是食管癌的标准化治疗，但并不意味着可盲目随意组合。理想的治疗方案和措施的选择，是基于病人的临床因素和分子生物学机制而制定的个性化治疗。 在食管癌的治疗中为病人提供客观准确的临床诊疗依据，协同相关的专业医生，制定最佳的多学科综合治疗方案，最大限度的延长患者的生存期是我们的职责。,Gannan medical university CAI,The First Clinical College of Gannan medical university,Esophageal Carcinoma外科手术治疗 (Operation),包括根治性手术和姑息性手术。根治性手术适应证： 1.UICC分期中的0、A、B及期中的T3N1M0； 2.放射治疗未控或复发病例,尚无局部明显外侵或远处转移征象; 3.年龄一般不超过70岁,少数高龄接近80岁,但生理年龄较小的病例也可慎重考虑.已知病变长度与治疗预后关系不密切,所以在作选择时仅是一项参考指标.根治性手术禁忌证： 1.恶病体质； 2.UICC分期中的期晚(T4任何NM0)及期； 3.重要脏器有严重合并症如肺功能低下，心脏疾病伴心力衰竭或半年以内的心肌梗死等。,Gannan medical university CAI,The First Clinical College of Gannan medical university,Esophageal Carcinoma外科手术治疗 (Operation),Gannan medical university CAI,The First Clinical College of Gannan medical university,手术径路 消化道重建左胸切口. 胃代食管术.右胸、腹部二切口. 空肠代食管术.颈、胸、腹三切口. 横结肠代食管术.切除范围食管大部：长度距肿瘤上、下58cm.切除广度：肿瘤周围纤维组织及所有淋巴结.,Esophageal Carcinoma外科手术治疗 (Operation),姑息性手术：对晚期食管癌、不能根治或放射治疗、进食困难者.食管腔内置管术.食管胃转流吻合术.食管结肠转流吻合术.胃造瘘术.,Gannan medical university CAI,The First Clinical College of Gannan medical university,Esophageal Carcinoma外科手术治疗 (Operation),食管癌切除术后的并发症:吻合口并发症肺部并发症乳糜胸心律不齐单纯脓胸膈疝胃扭转伪膜性肠炎,Gannan medical university CAI,The First Clinical College of Gannan medical university,Esophageal Carcinoma外科手术治疗 (Operation),Gannan medical university CAI,The First Clinical College of Gannan medical university,左胸切口,Esophageal Carcinoma外科手术治疗 (Operation),Gannan medical university CAI,The First Clinical College of Gannan medical university,右胸、腹部二切口,颈、胸、腹三切口,Esophageal Carcinoma外科手术治疗 (Operation),Gannan medical university CAI,The First Clinical College of Gannan medical university,胃代食管术,横结肠代食管术,Esophageal Carcinoma外科手术治疗 (Operation),Gannan medical university CAI,The First Clinical College of Gannan medical university,食管腔内置管术胃造瘘术空肠造瘘术,食管胃转流吻合术,Esophageal Carcinoma放疗(Radiotherapy)、化疗(Chemotherapy),放射治疗： 鳞癌敏感，适合中上段，与手术联合应用。副作用：放射性肺炎 肺纤维化.重度肺气肿 肺功能不全者慎用.,Gannan medical university CAI,The First Clinical College of Gannan medical university,化学治疗：适用于各种病理类型的食管癌，加用中医中药等，单独效果差。副作用：血像降低，骨髓抑制，脱发，肝肾损害，心肌损害.,综合治疗手段： 1.手术+放疗+药物; 2.放疗+手术+放疗(+药物); 3.放疗+药物.,Esophageal Carcinoma外科诊疗程序,Gannan medical university CAI,The First Clinical College of Gannan medical university,Esophageal Carcinoma 思 考 题 （Question）,简述中、晚期食管癌的临床病理分型.中、晚期食管癌的典型临床表现及鉴别诊断. 简述食管癌手术适应症和禁忌症.,Gannan medical university CAI,The First Clinical College of Gannan medical university,贲门失弛症（Achalasia of Cardia or Cardiospasm）,Gannan medical university CAI,The First Clinical College of Gannan medical university,概 述,指在吞咽动作时，食管体部缺少蠕动，贲门括约肌弛缓不良而继发性食管扩张的一种疾病。多见于中青年患者，女性稍多。,The First Clinical College of Gannan medical university,Gannan medical university CAI,病 因,食管壁的阻滞神经功能失调，使食管括约肌丧失正常的推进作用，同时下食管括约肌的张力增高，严重影响食管的排空。,The First Clinical College of Gannan medical university,Gannan medical university CAI,病 理,失弛缓症可累及胸内食管，并不局限于贲门部。开始时食管解剖学上正常，以后肥厚、扩张，并失去正常蠕动，贲门括约肌不能松弛，异常主要限于层环形肌，而外层纵行肌正常。镜下食管体部及食管下括约肌均有不同程度的肌肉神经丛病变存在。Auerbach丛内单核细胞浸润到整个神经节细胞为纤维组织所替代；迷走神经有Wsllerian变性；食管平滑肌微丝丛表面脱落及细胞萎缩。,The First Clinical College of Gannan medical university,G