UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

良性食管狭窄的治疗

Author
Moises Guelrud, MD
Section Editor
John R Saltzman, MD, FACP, FACG, FASGE, AGAF
Deputy Editor
Anne C Travis, MD, MSc, FACG, AGAF
Translators
李渊, 副主任医师

引言

多数良性食管狭窄是由长期存在的胃食管反流引起的[1,2]。治疗通常包括扩张结合抑酸治疗。 (参见“成人胃食管反流病的并发症”)

约25%的良性食管狭窄病例与胃食管反流无关，这些病例的治疗可能更困难。例如，继发于外照射、食管硬化疗法、摄入腐蚀性物质(参见“成人腐蚀性食管损伤”)、外科吻合术及罕见皮肤病(如营养不良型大疱性表皮松解症)等情况的狭窄。由肺结核导致的纵隔纤维化或特发性纤维性纵隔炎导致的食管外部受压也可能导致狭窄。这种情况导致的食管狭窄长又细，难以扩张，扩张可能导致较高的并发症发生率。嗜酸细胞性食管炎是食管狭窄的一种更常见的病因，尤其是在年轻男性中。由于扩张可导致黏膜撕裂及穿孔，识别出嗜酸细胞性食管炎很重要。 (参见“嗜酸细胞性食管炎的临床表现和诊断”)

良性食管狭窄的治疗目标是缓解吞咽困难并预防狭窄复发[3]。在多数患者中，通过食管扩张可实现该目标；但对于难治性狭窄的患者，可能需其他治疗。

本专题将总结良性食管狭窄的治疗，包括患者选择、扩张方法及难治性食管狭窄的治疗。扩张的并发症、(食管)失弛缓症时下食管括约肌的气囊扩张、食管环和食管蹼的扩张及恶性食管梗阻的治疗将单独讨论。 (参见“内镜下食管狭窄扩张术的并发症”和“气囊扩张与肉毒毒素注射治疗贲门失驰缓症”，关于‘气囊扩张’一节和“食管环与食管蹼”，关于‘治疗’一节和“可膨式食管支架的应用”和“食管癌的内镜下姑息治疗”)

扩张前评估

食管狭窄的基本特征是吞咽困难。然而，除食管狭窄外，其他可导致食管狭窄的情况包括胃食管反流病、运动性障碍、感染、恶性肿瘤、食管蹼或食管环等。虽然其中某些情况的治疗可能包含食管扩张，但使用的具体治疗方法不同。因此，在确定一个治疗疗程前，有必要对食管狭窄进行内镜和/或放射影像学评估。 (参见“成人吞咽困难概述”)

                          

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: 2017-06 . | This topic last updated: 2017-01-30.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
References
Top
  1. Patterson DJ, Graham DY, Smith JL, et al. Natural history of benign esophageal stricture treated by dilatation. Gastroenterology 1983; 85:346.
  2. Marks RD, Richter JE. Peptic strictures of the esophagus. Am J Gastroenterol 1993; 88:1160.
  3. Standards of Practice Committee, Egan JV, Baron TH, et al. Esophageal dilation. Gastrointest Endosc 2006; 63:755.
  4. Shemesh E, Czerniak A. Comparison between Savary-Gilliard and balloon dilatation of benign esophageal strictures. World J Surg 1990; 14:518.
  5. Cox JG, Winter RK, Maslin SC, et al. Balloon or bougie for dilatation of benign esophageal stricture? Dig Dis Sci 1994; 39:776.
  6. Saeed ZA, Winchester CB, Ferro PS, et al. Prospective randomized comparison of polyvinyl bougies and through-the-scope balloons for dilation of peptic strictures of the esophagus. Gastrointest Endosc 1995; 41:189.
  7. Scolapio JS, Pasha TM, Gostout CJ, et al. A randomized prospective study comparing rigid to balloon dilators for benign esophageal strictures and rings. Gastrointest Endosc 1999; 50:13.
  8. Abele JE. The physics of esophageal dilatation. Hepatogastroenterology 1992; 39:486.
  9. McLean GK, LeVeen RF. Shear stress in the performance of esophageal dilation: comparison of balloon dilation and bougienage. Radiology 1989; 172:983.
  10. Kozarek RA. Esophageal dilation. Mayo Clin Proc 1992; 67:299.
  11. Piotet E, Escher A, Monnier P. Esophageal and pharyngeal strictures: report on 1,862 endoscopic dilatations using the Savary-Gilliard technique. Eur Arch Otorhinolaryngol 2008; 265:357.
  12. Jones MP, Bratten JR, McClave SA. The Optical Dilator: a clear, over-the-scope bougie with sequential dilating segments. Gastrointest Endosc 2006; 63:840.
  13. Wesdorp IC, Bartelsman JF, den Hartog Jager FC, et al. Results of conservative treatment of benign esophageal strictures: a follow-up study in 100 patients. Gastroenterology 1982; 82:487.
  14. Atkinson M, Robertson CS. Benign oesophageal stricture in Barrett's columnar epithelialised oesophagus and its responsiveness to conservative management. Gut 1988; 29:1721.
  15. Hernandez LV, Jacobson JW, Harris MS. Comparison among the perforation rates of Maloney, balloon, and savary dilation of esophageal strictures. Gastrointest Endosc 2000; 51:460.
  16. Jacobs JW Jr, Spechler SJ. A systematic review of the risk of perforation during esophageal dilation for patients with eosinophilic esophagitis. Dig Dis Sci 2010; 55:1512.
  17. Saeed ZA. Balloon dilatation of benign esophageal stenoses. Hepatogastroenterology 1992; 39:490.
  18. Pereira-Lima JC, Ramires RP, Zamin I Jr, et al. Endoscopic dilation of benign esophageal strictures: report on 1043 procedures. Am J Gastroenterol 1999; 94:1497.
  19. Kozarek RA, Patterson DJ, Ball TJ, et al. Esophageal dilation can be done safely using selective fluoroscopy and single dilating sessions. J Clin Gastroenterol 1995; 20:184.
  20. Ho SB, Cass O, Katsman RJ, et al. Fluoroscopy is not necessary for Maloney dilation of chronic esophageal strictures. Gastrointest Endosc 1995; 41:11.
  21. Kozarek RA. To stretch or to shear: a perspective on balloon dilators. Gastrointest Endosc 1987; 33:459.
  22. Boyce HW, Palmer ED. Techniques of Clinical Gastroenterology, Charles C Thomas, Springfield, IL 1975.
  23. Tulman AB, Boyce HW Jr. Complications of esophageal dilation and guidelines for their prevention. Gastrointest Endosc 1981; 27:229.
  24. Barkin JS, Taub S, Rogers AI. The safety of combined endoscopy, biopsy and dilation in esophageal strictures. Am J Gastroenterol 1981; 76:23.
  25. Saeed ZA, Ramirez FC, Hepps KS, et al. An objective end point for dilation improves outcome of peptic esophageal strictures: a prospective randomized trial. Gastrointest Endosc 1997; 45:354.
  26. Glick ME. Clinical course of esophageal stricture managed by bougienage. Dig Dis Sci 1982; 27:884.
  27. Marks RD, Richter JE, Rizzo J, et al. Omeprazole versus H2-receptor antagonists in treating patients with peptic stricture and esophagitis. Gastroenterology 1994; 106:907.
  28. Smith PM, Kerr GD, Cockel R, et al. A comparison of omeprazole and ranitidine in the prevention of recurrence of benign esophageal stricture. Restore Investigator Group. Gastroenterology 1994; 107:1312.
  29. Jaspersen D, Schwacha H, Schorr W, et al. Omeprazole in the treatment of patients with complicated gastro-oesophageal reflux disease. J Gastroenterol Hepatol 1996; 11:900.
  30. Silvis SE, Farahmand M, Johnson JA, et al. A randomized blinded comparison of omeprazole and ranitidine in the treatment of chronic esophageal stricture secondary to acid peptic esophagitis. Gastrointest Endosc 1996; 43:216.
  31. Swarbrick ET, Gough AL, Foster CS, et al. Prevention of recurrence of oesophageal stricture, a comparison of lansoprazole and high-dose ranitidine. Eur J Gastroenterol Hepatol 1996; 8:431.
  32. Katzka DA, Paoletti V, Leite L, Castell DO. Prolonged ambulatory pH monitoring in patients with persistent gastroesophageal reflux disease symptoms: testing while on therapy identifies the need for more aggressive anti-reflux therapy. Am J Gastroenterol 1996; 91:2110.
  33. Dakkak M, Hoare RC, Maslin SC, Bennett JR. Oesophagitis is as important as oesophageal stricture diameter in determining dysphagia. Gut 1993; 34:152.
  34. Said A, Brust DJ, Gaumnitz EA, Reichelderfer M. Predictors of early recurrence of benign esophageal strictures. Am J Gastroenterol 2003; 98:1252.
  35. Holder TM, Ashcraft KW, Leape L. The treatment of patients with esophageal strictures by local steroid injections. J Pediatr Surg 1969; 4:646.
  36. Kirsch M, Blue M, Desai RK, Sivak MV Jr. Intralesional steroid injections for peptic esophageal strictures. Gastrointest Endosc 1991; 37:180.
  37. Zein NN, Greseth JM, Perrault J. Endoscopic intralesional steroid injections in the management of refractory esophageal strictures. Gastrointest Endosc 1995; 41:596.
  38. Lee M, Kubik CM, Polhamus CD, et al. Preliminary experience with endoscopic intralesional steroid injection therapy for refractory upper gastrointestinal strictures. Gastrointest Endosc 1995; 41:598.
  39. Miyashita M, Onda M, Okawa K, et al. Endoscopic dexamethasone injection following balloon dilatation of anastomotic stricture after esophagogastrostomy. Am J Surg 1997; 174:442.
  40. Samanta J, Dhaka N, Sinha SK, Kochhar R. Endoscopic incisional therapy for benign esophageal strictures: Technique and results. World J Gastrointest Endosc 2015; 7:1318.
  41. Simmons DT, Baron TH. Electroincision of refractory esophagogastric anastomotic strictures. Dis Esophagus 2006; 19:410.
  42. Guelrud M, Villasmil L, Mendez R. Late results in patients with Schatzki ring treated by endoscopic electrosurgical incision of the ring. Gastrointest Endosc 1987; 33:96.
  43. Kochhar R, Makharia GK. Usefulness of intralesional triamcinolone in treatment of benign esophageal strictures. Gastrointest Endosc 2002; 56:829.
  44. Russell SB, Trupin JS, Myers JC, et al. Differential glucocorticoid regulation of collagen mRNAs in human dermal fibroblasts. Keloid-derived and fetal fibroblasts are refractory to down-regulation. J Biol Chem 1989; 264:13730.
  45. Ramage JI Jr, Rumalla A, Baron TH, et al. A prospective, randomized, double-blind, placebo-controlled trial of endoscopic steroid injection therapy for recalcitrant esophageal peptic strictures. Am J Gastroenterol 2005; 100:2419.
  46. Hirdes MM, van Hooft JE, Koornstra JJ, et al. Endoscopic corticosteroid injections do not reduce dysphagia after endoscopic dilation therapy in patients with benign esophagogastric anastomotic strictures. Clin Gastroenterol Hepatol 2013; 11:795.
  47. Bhutani MS, Usman N, Shenoy V, et al. Endoscopic ultrasound miniprobe-guided steroid injection for treatment of refractory esophageal strictures. Endoscopy 1997; 29:757.
  48. Morikawa N, Honna T, Kuroda T, et al. High dose intravenous methylprednisolone resolves esophageal stricture resistant to balloon dilatation with intralesional injection of dexamethasone. Pediatr Surg Int 2008; 24:1161.
  49. Fuccio L, Hassan C, Frazzoni L, et al. Clinical outcomes following stent placement in refractory benign esophageal stricture: a systematic review and meta-analysis. Endoscopy 2016; 48:141.
  50. Song HY, Jung HY, Park SI, et al. Covered retrievable expandable nitinol stents in patients with benign esophageal strictures: initial experience. Radiology 2000; 217:551.
  51. Repici A, Conio M, De Angelis C, et al. Temporary placement of an expandable polyester silicone-covered stent for treatment of refractory benign esophageal strictures. Gastrointest Endosc 2004; 60:513.
  52. Evrard S, Le Moine O, Lazaraki G, et al. Self-expanding plastic stents for benign esophageal lesions. Gastrointest Endosc 2004; 60:894.
  53. Holm AN, de la Mora Levy JG, Gostout CJ, et al. Self-expanding plastic stents in treatment of benign esophageal conditions. Gastrointest Endosc 2008; 67:20.
  54. Dua KS, Vleggaar FP, Santharam R, Siersema PD. Removable self-expanding plastic esophageal stent as a continuous, non-permanent dilator in treating refractory benign esophageal strictures: a prospective two-center study. Am J Gastroenterol 2008; 103:2988.
  55. Oh YS, Kochman ML, Ahmad NA, Ginsberg GG. Clinical outcomes after self-expanding plastic stent placement for refractory benign esophageal strictures. Dig Dis Sci 2010; 55:1344.
  56. Repici A, Hassan C, Sharma P, et al. Systematic review: the role of self-expanding plastic stents for benign oesophageal strictures. Aliment Pharmacol Ther 2010; 31:1268.
  57. Fry SW, Fleischer DE. Management of a refractory benign esophageal stricture with a new biodegradable stent. Gastrointest Endosc 1997; 45:179.
  58. Saito Y, Tanaka T, Andoh A, et al. Novel biodegradable stents for benign esophageal strictures following endoscopic submucosal dissection. Dig Dis Sci 2008; 53:330.
  59. van Boeckel PG, Vleggaar FP, Siersema PD. A comparison of temporary self-expanding plastic and biodegradable stents for refractory benign esophageal strictures. Clin Gastroenterol Hepatol 2011; 9:653.
  60. Hirdes MM, Siersema PD, van Boeckel PG, Vleggaar FP. Single and sequential biodegradable stent placement for refractory benign esophageal strictures: a prospective follow-up study. Endoscopy 2012; 44:649.
  61. Canena JM, Liberato MJ, Rio-Tinto RA, et al. A comparison of the temporary placement of 3 different self-expanding stents for the treatment of refractory benign esophageal strictures: a prospective multicentre study. BMC Gastroenterol 2012; 12:70.
  62. ASGE Technology Committee, Tokar JL, Banerjee S, et al. Drug-eluting/biodegradable stents. Gastrointest Endosc 2011; 74:954.
  63. van Hooft JE, van Berge Henegouwen MI, Rauws EA, et al. Endoscopic treatment of benign anastomotic esophagogastric strictures with a biodegradable stent. Gastrointest Endosc 2011; 73:1043.
  64. Repici A, Vleggaar FP, Hassan C, et al. Efficacy and safety of biodegradable stents for refractory benign esophageal strictures: the BEST (Biodegradable Esophageal Stent) study. Gastrointest Endosc 2010; 72:927.
  65. Stivaros SM, Williams LR, Senger C, et al. Woven polydioxanone biodegradable stents: a new treatment option for benign and malignant oesophageal strictures. Eur Radiol 2010; 20:1069.
  66. McCain S, McCain S, Quinn B, et al. The role of biodegradable stents in the management of benign and malignant oesophageal strictures: A cohort study. Surgeon 2016; 14:322.
  67. Sandha GS, Marcon NE. Expandable metal stents for benign esophageal obstruction. Gastrointest Endosc Clin N Am 1999; 9:437.
  68. Eloubeidi MA, Lopes TL. Novel removable internally fully covered self-expanding metal esophageal stent: feasibility, technique of removal, and tissue response in humans. Am J Gastroenterol 2009; 104:1374.
  69. Bakken JC, Wong Kee Song LM, de Groen PC, Baron TH. Use of a fully covered self-expandable metal stent for the treatment of benign esophageal diseases. Gastrointest Endosc 2010; 72:712.
  70. Senousy BE, Gupte AR, Draganov PV, et al. Fully covered Alimaxx esophageal metal stents in the endoscopic treatment of benign esophageal diseases. Dig Dis Sci 2010; 55:3399.
  71. Eloubeidi MA, Talreja JP, Lopes TL, et al. Success and complications associated with placement of fully covered removable self-expandable metal stents for benign esophageal diseases (with videos). Gastrointest Endosc 2011; 73:673.
  72. Buscaglia JM, Ho S, Sethi A, et al. Fully covered self-expandable metal stents for benign esophageal disease: a multicenter retrospective case series of 31 patients. Gastrointest Endosc 2011; 74:207.
  73. Thorsen G, Rosseland AR. Endoscopic incision of postoperative stenoses in the upper gastrointestinal tract. Gastrointest Endosc 1983; 29:26.
  74. Moretó M, Zaballa M, Ibáñez S. Endoscopic incision as an alternative to bougienage in the treatment of peptic esophageal stricture. Endoscopy 1990; 22:105.
  75. Shah JN. Benign refractory esophageal strictures: widening the endoscopist's role. Gastrointest Endosc 2006; 63:164.
  76. Spier BJ, Sawma VA, Gopal DV, Reichelderfer M. Intralesional mitomycin C: successful treatment for benign recalcitrant esophageal stricture. Gastrointest Endosc 2009; 69:152.
  77. Machida H, Tominaga K, Minamino H, et al. Locoregional mitomycin C injection for esophageal stricture after endoscopic submucosal dissection. Endoscopy 2012; 44:622.