食管esd術(shù)后狹窄防治

1、ESD術(shù)后食管狹窄的防治,中國人民解放軍陸軍軍醫(yī)大學新橋醫(yī)院重慶市消化疾病臨床醫(yī)學研究中心趙曉晏2018-11-10,ESD適應(yīng)癥,,,Techniques in Gastrointestina lEndoscopy 19(2017)159–169,,Risk of stricture formation in patients undergoing extensive ER/ESD.,Study

2、 N. Diagnosis Extent of the circumference Stricture rate van Vilsteren FG4* 25 BE, AC or HGD ≥75% 88% Park JS8* 5 SCC ≥75%

3、 83% Ono S7* 10 SCC ≥75% 90% Katada C6* 19 SCC, HGD and AC ≥75% Wen J9* 7 SCC ≥75%

4、 71% *No preventive strategy used.,,1.對抗炎藥的系統(tǒng)性用藥；2.局部注射消炎或抗纖維原物質(zhì)；3.單純的內(nèi)鏡方法（支架、擴張）；4.組織工程方法--細胞治療；5.胃粘膜移植到食管；6.各種其他辦法,post-ESD 食管狹窄防治方法,預(yù)防性系列擴張腔內(nèi)注射內(nèi)固醇藥物/局部類固醇凝膠全覆膜金屬支架聚乙醇酸（PGA）片和纖維蛋白膠放射狀切開/環(huán)狀

5、切除組織工程及再生醫(yī)學自體粘膜移植,,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 eve

6、nts2、Local injection of steroids? Easy to do? RCT available? Partially effective? Drawback: a delayed perforation was reported3、Stenting? Only fully covered metallic stents appropriate? Easy to do? RCT available

7、? Limited efficacy? Drawback: no clear data on stent removal, the need for fixation to decrease migration rate,Minerva Chirurgica 2018;73(4):394-409,球囊擴張術(shù)/內(nèi)固醇藥物,,Characteristics of steroid refractory caseResected circ

8、umference: 9/10 or moreResected longitudinal diameter: 50 mmLocation of esophagus: cervical esophagusHistory of chemo-radio therapy,GIE 2011;74(6):1389-1393,全身使用皮質(zhì)類固醇,長期使用導(dǎo)致感染、骨質(zhì)疏松癥、糖尿病、視力下降等不良反應(yīng),,,抗炎抗肉芽組織抗纖維化,抗炎抗肉

9、芽組織抗纖維化,抑制纖維母細胞 活化與增生,抗纖維化,重癥感染消化性潰瘍高血糖精神癥狀骨質(zhì)疏松,注射部位潰瘍形成風險延緩傷口愈合,,局部使用皮質(zhì)類固醇,注射開始于其基部潰瘍的遠端邊緣，并在10毫米處向近端邊緣均勻重復(fù)注射（0.5毫升/點，濃度10毫克/毫升）,其他具有消炎或抗纖維作用的物質(zhì)局部應(yīng)用,肉毒桿菌毒素小干擾RNA(CHST15)止血粉(TC.325, Hemospray®)絲裂霉素

10、CN-乙酰半胱氨酸氨甲酯（治療支氣管哮喘、瘢痕和肥厚疤痕的抗過敏藥物）,預(yù)防性擴張策略,降低狹窄發(fā)生率（59% vs. 92%）減輕狹窄程度縮短治療時間9%穿孔率,食管支架,自膨式全覆膜金屬支架18.2% vs72.8%2-8w固定/移位（金屬夾、錨定、縫合）組織生長次生梗阻生物降解支架（Walterova et al., presented at DDW 2018）質(zhì)量問題多二惡英肉眼炎癥降解顆粒和食物梗阻

11、高塑組織反應(yīng)其他材料或藥物支架,移植,人羊膜移植：羊膜由無血管間質(zhì)和單層柱狀細胞上皮組成，表達很少的組織相容性抗原（免疫排斥不太可能）豬表皮的脫細胞基質(zhì)移植Xe-Derma®Walterova et al., presented at DDW 2018藥物洗脫支架,組織工程方法--細胞、組織療法,促進上皮愈合支持上皮重建抗炎抑制膠原形成,組織細胞工程與再生醫(yī)學,Techniques in Gastrointes

12、tinal Endoscopy, 2011; 13(1):105-109Gastroenterolgy,2012;143:582–588Annals of Translational Medicine, 2017;5(8):5-7,膠原蛋白玻璃膠（動物試驗）,2 cm,,GIE 2017;85:1076-85,去細胞皮膚基質(zhì)(動物試驗),GIE 2017；86（6）:1160-1167,Dig Dis Sci. 2018 May

13、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,Clinica

14、l 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.

15、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

16、 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: preli

17、minary humanexperience.He K#1, Zhao L#1, Bu S2, Liu L1, Wang X1, Wang M1, Fan Z1.Author informationAbstract?Esophageal caustic stricture is a stubborn disease and postoper

18、ative 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

19、 after extensive mucosal resection. We aimed to use mucosal autografting performed endoscopically to treat refractory esophageal stricture. METHODS?: Three patients with intractable corrosiv

20、e esophageal stricture were treated endoscopically by combining dilation with autologous mucosal transplantation. RESULTS?: All procedures were successful with no severe complications. Mucosal

21、60;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 improv

22、ed in another two patients. CONCLUSIONS?: Mucosalautografting can achieve esophageal re-epithelialization, inhibit undesired fibrosis, prevent restenosis, and promote functional regeneration.,Endoscopy. 20

23、18 Oct;50(10):1017-1021,其它,胃粘膜移植到食管支架輔助粘膜切除術(shù)聚乙醇酸片和纖維蛋白膠,,,,World J Gastroenterol. 2018 Mar 7; 24(9): 1046–1055,新橋醫(yī)院臨床實踐,Gut and Liver（已接受）,環(huán)狀切除+氣囊擴張,,Background?The feasibility and safety of endoscopic submucosal disse

24、ction (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?Thi

25、s 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

26、 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 s

27、tricture 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 (EB

28、D) in two and EBD being required for more than 1 year in the other two.Conclusions?ESD including the cervical esophagus is technically feasible. Circumferential resection may cause refractory postoperative stricture or

29、 post-EBD perforation, so needs to be avoided where possible.,GIE 2018;88(4) : 784,he stent itself has been demonstrated to be effective to prevent post-ESD esophageal stricture.that technique is not adequate to demonst

30、rate the advantage of autologous esophageal mucosa transplantation,RCTnotice any adverse events,小結(jié),近環(huán)周食管ESD術(shù)后狹窄發(fā)病率高、特別是難治性術(shù)后狹窄，需要干預(yù)干預(yù)方式、方法尚未得到共識，目前臨床應(yīng)用成熟技術(shù)有預(yù)防性系列擴張、全身/局部應(yīng)用內(nèi)固醇藥物、全覆膜金屬支架尚有許多方式有待進一步臨床驗證,謝謝聆聽！,XINQIAO H