可回收食管覆膜支架治疗良性食管瘘的疗效分析

The effectiveness of retrievable covered-stent for the treatment of benign esophageal fistulas: a clinical analysis

目的分析总结置入可回收食管覆膜支架治疗由于多种原因引起的良性食管瘘的疗效及堵漏失败后的治疗策略。方法收集苏州大学附属第一医院自2006年1月至2011年6月经食管碘水造影确诊的21例良性食管瘘患者,在DSA监视下置入可回收食管覆膜支架,支架在体内放置28～250 d后取出并行食管造影检查评估瘘口封闭情况,对堵漏失败的病例,尝试胃镜下钛夹夹闭、DSA下生物胶堵漏及永久食管覆膜支架堵漏后进行成功补救治疗。结果入组所有病例中,可回收食管覆膜支架均一次性置入,技术成功率100%,术中无严重并发症。14例支架取出术后复查食管造影显示瘘口完全封闭,首次支架治愈率66.7%,未成功患者中5例取出支架复查食管造影见对比剂外溢,提示瘘口未完全封闭,其中2例各放置永久性覆膜食管支架1枚,6个月后食管造影复查成功堵漏。2例在用钛夹夹闭瘘口;1例用生物胶堵漏后未成功。2次支架治疗成功率为76.2%,通过其他微创方式补救治疗后成功率85.7%。所有堵漏成功的患者支架取出后或微创补救堵漏成功后行上消化道造影证实无对比剂外溢。支架相关并发症包括不同程度胸骨后疼痛不适或异物感21例(100%),支架移位3例(14.3%);严重并发症为迟发性支架所致大出血、休克、死亡2例(9.5%)。结论应用可回收食管覆膜支架封堵由多种病变引起的良性食管瘘技术成功率及回收率高,封堵瘘口疗效确切,严重并发症少,对堵漏失败者可尝试永久支架或钛夹夹闭方法治疗。

Objective To analyze the effectiveness of retrievable covered stent in treating esophageal fistulas and to discuss the management of complications occurred after stenting. Methods Twenty-one patients with esophogography-proved esophageal fistulas, who were encountered in authors＇ hospital during the period from Jan. 2006 to June 2011, were enrolled in this study. Guided by DSA, retrieval esophageal eovered-stent implantation was carried out in all patients. The stent was removed within 28-250 days after the procedure. Esophogography was employed to observe the seal of the fistulas. Gastroscopic titanium clipping, DSA-guided biological glue injection and permanent esophageal coveredstent were selectively used to close the fistulas for patients who failed to respond to stent implantation. The results were analyzed. Results Stent implantation was successfully accomplished in all patients with a technical success rate of 100%. No serious complications occurred. Esophogography performed after the stent was removed showed that the fistula was completely sealed in 14 patients, and the initial cure rate was 66.7%. Esophogography in five patients, who failed to respond to stent implantation, showed contrast extravasation, indicating the fistulas were not completely closed. Of the five patients, two received permanent esophageal covered-stent implantation, two were treated with titanium clips and the remaining one underwent the injection of biological glue. The secondary cure rate was 76.2%. And the cure rate after remedial treatment with micro-invasive techniques was 85.7%. Minor perioperative complications included mild to moderate chest pain （n = 21, 100% ） and stent migration （n = 3, 14.3%）. Severe complications included delayed massive bleeding and shock leading to death （n = 2, 9.5% ）. Conclusion Retrievable covered-stent is easily to be placed and removed from the esophagus with fewer complications, and it is very effective for the treatment of benign esophageal fistulas caused by various disorders. （J Intervent Radiol, 2012, 21： 314-317）