1、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2018-11-10ESD适应症Techniques in Gastrointestina lEndoscopy 19(2017)159169Risk 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
2、 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u预防性系列扩张u腔内注射内固醇药物 /局部类固醇 凝胶u全覆膜金属支架u聚 乙醇酸（ PGA）片和纤维蛋白 胶u放射状切开 /环状切除u组织工程
3、及再生医学u自体粘膜移植Minerva Chir 2018;73:394-409.List of methods, which could be, at present, considered in clinical practice1、 Oral steroids Partially effective, easy to do No RCT available Drawback: adverse events2、 Local injection of steroids Easy to do RCT available Partially effective Drawback: a delay
4、ed perforation was reported3、 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 rateMinerva Chirurgica 2018;73(4):394-409球囊扩张术 /内固醇药物Characteristics of steroid refrac
5、tory case Resected circumference: 9/10 or more Resected longitudinal diameter: 50 mm Location of esophagus: cervical esophagus History of chemo-radio therapyGIE 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Action Administration Advantages Disadvantages and limitationsClinical studyCor
6、ticosteroids Steroidal Oral intake Strongly inhibits the infiltration of inflammatory cells, the hyperplasia associated with granulation, and the fibrosis of the remaining submucosal layerGeneral side effects (severe infection, peptic ulcer, hyperglycemia, psychiatric symptoms, and osteoporosis)Dela
7、yed wound healingTriamcinolone acetonide Steroidal Local injection Inhibits the infiltration of inflammatory cells, the hyperplasia associated with granulation, and the fibrosis of the remaining submucosal layerRisk of ulcer formation due to accidental injection into the muscularisDelayed wound heal
8、ingPre-clinical studyMMC Inhibition of DNA synthesis Local injectionInhibits the proliferation and activation of fibroblastsAn effect has not been shown for the prevention of esophageal strictures, although MMC improves recurrent dysphagia or restenosis after the dilatation of esophageal stricturesT
9、he risks of perforation and secondary malignancyN-acetylcysteine Antioxidant molecule Oral intake Antifibrotic effect without the inhibition of wound healingInsufficient effect in an animal model of severe esophageal stricture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
