黏膜下激素注射联合内镜扩张治疗儿童难治性食管良性狭窄的临床分析

发布时间：2018-01-18 04:17

本文关键词：黏膜下激素注射联合内镜扩张治疗儿童难治性食管良性狭窄的临床分析　出处：《大连医科大学》2014年硕士论文　论文类型：学位论文

【摘要】：背景与目的：儿童食管良性狭窄是由化学腐蚀性烧伤、术后吻合口狭窄等多种原因引起的且不伴有恶性病变的食管狭窄，不同程度的吞咽困难为常见伴随症状，由于狭窄管腔无法扩张至理想直径或短期内复发需要频繁治疗，严重影响儿童的正常生长发育，甚至危及患儿生命。目前常用的治疗方法主要有食管扩张术、支架置入术、食管重建术等，由于其远期疗效较差或并发症较多，故目前尚无统一有效的治疗措施。近年来糖皮质激素开始用于治疗食管良性狭窄，它通过抑制狭窄处毛细血管及纤维母细胞增生而延缓肉芽组织生成。尽管已有研究显示于食管良性狭窄患者中行糖皮质激素注射治疗可有效延缓复发时间并减少复发频率，但其多为针对成人患者的小样本非随机对照研究。由于引起儿童食管良性狭窄的病因较为特殊且儿童机体损伤修复能力较强，故再狭窄的发生率及难治率较成人为高，同时由于糖皮质激素在儿童中用药的特殊性，黏膜下糖皮质激素注射治疗对于儿童难治性食管良性狭窄的疗效尚不确定，同时其在儿童中的最佳注射频率和注射剂量尚无文献报道。因此，本研究主要针对5岁以下儿童难治性食管良性狭窄患者，采用扩张联合激素注射治疗前后自身对照及与单纯扩张组随机对照的研究方法，通过一系列疗效观察，旨在探讨激素联合扩张治疗对儿童难治性食管良性狭窄的疗效。方法：采用前瞻性研究方法依据纳入标准选取北京军区总医院消化内镜中心2010年12月至2013年6月收治的38例难治性食管良性狭窄患儿，根据临床表现及胃镜或上消化道钡餐检查明确患儿病因、狭窄部位、范围及程度。研究随机分为对照组与实验组：对照组26例患儿采用单一接受沙式探条扩张的方法治疗；实验组12例患儿采用探条扩张后随即于狭窄部位分象限注射5mg/ml地塞米松的方法治疗，激素注射剂量严格依据儿童实际公斤体重计算，患儿依个体差异接受一至三疗程注射治疗（第一疗程每周注射1次连续4次，第二疗程每两周注射1次连续2次，第三疗程每四周注射一次连续2次）。观察记录所有患者扩张次数、随访时间、症状缓解时间、进食积分、并发症及不良反应发生情况，并通过计算患者周期扩张指数（PDI指数=扩张次数/随访时间）及治疗3月后复发率来进一步评估黏膜下注射糖皮质激素对于探条扩张治疗是否有辅助效果。结果：实验组与对照组患儿在性别、年龄、病因、狭窄部位、狭窄程度、吞咽困难程度及扩张疗效等方面均无明显差异（P＞0.05）。两组患儿均进行了有效扩张，实验组共进行111次（平均9.25±2.14次/人）扩张，对照组共进行345次（平均13.27±6.77次/人）扩张（t=1.999,P=0.007）；实验组平均PDI指数为1.22±0.30，对照组平均PDI指数为1.62±0.68（t=1.909,P=0.007）。实验组中12名患儿共接受68次（平均5.50±1.51次/人）激素注射治疗，接受激素注射治疗前平均扩张11.17±5.78次/人，治疗结束后平均扩张3.75±1.66次/人（t=3.712,P=0.035）；注射前平均PDI指数为2.18±0.59，注射后平均PDI指数为0.52±0.17（t=8.132,P=0.025）。实验组患儿接受扩张联合激素注射治疗后进食积分下降3.17±0.72级，对照组进食积分下降1.81±0.40级（t=7.500,P=0.030）；平均症状缓解时间在实验组为92.67±18.49天，在对照组为17.42±11.12天（t=15.633,P=0.042）。研究中共有6例患儿发生反流性食管炎，1例少量渗血，1例发生肺部感染，1例出现颈部皮下气肿，上述并发症经内科保守治疗后均已好转，无使用激素不良反应事件发生。随访3月内复发者共21人，其中实验组复发率为16.7%（2/12），对照组复发率为73.1%（19/26）（x2=10.290,P=0.001）。结论：在儿童难治性食管良性狭窄患者中采用黏膜下注射糖皮质激素联合探条扩张治疗可有效减少扩张次数，降低重复扩张需要，延长症状缓解时间，改善吞咽困难症状并降低近期复发频率；可将黏膜下局部注射糖皮质激素作为内镜扩张治疗的有效辅助方法应用于临床。
[Abstract]:BACKGROUND & OBJECTIVE : This study is mainly aimed at the treatment of benign esophageal stenosis in children due to its poor long - term curative effect or complication . Methods : A prospective study was conducted to determine the etiology , stenosis site , range and extent of 38 cases of refractory esophageal benign stenosis from December 2010 to June 2013 in Beijing Military Region General Hospital . The study was divided into control group and experimental group . All patient dilatation times , follow - up time , symptom relief time , eating integration , complications and adverse reactions occurred were observed and evaluated by calculating the patient ' s cycle expansion index ( PDI index = expansion number / follow - up time ) and the recurrence rate after treatment for 3 months . Results : There was no significant difference between the experimental group and the control group ( P > 0.05 ) . In the experimental group , there was no significant difference between the two groups ( P > 0.05 ) . There were 111 ( mean 9.25 卤 2.14 times / person ) expansion in the experimental group . The average PDI of the experimental group was 1.22 卤 0.30 , the average PDI of the control group was 1 . 62 卤 0.68 ( t = 1.909 , P = 0.007 ) . There were 68 ( mean 5.50 卤 1 . 51 times per person ) hormone injection in 12 children in the experimental group . The average dilation before injection was 11.17 卤 5.78 times / person ( t = 3.712 , P = 0.035 ) . The average PDI index before injection was 2.18 卤 0.59 , and the mean PDI index after injection was 0.52 卤 0.17 ( t = 8.132 , P = 0.025 ) . In the experimental group , the feeding score decreased by 3 . 17 卤 0 . 72 , and that of the control group was 1 . 81 卤 0 . 40 ( t = 7 . 500 , P = 0.030 ) . The mean symptom response time was 92.67 卤 18.49 days in the experimental group and 17.42 卤 11.12 days in the control group ( t = 15.633 , P = 0.042 ) . There were 6 children with reflux esophagitis , 1 case with small bleeding , 1 case of pulmonary infection , 1 case with cervical subcutaneous emphysema , and the complications were improved after internal conservative treatment . There were 21 patients with recurrence in the follow - up period . The recurrence rate in the experimental group was 16.7 % ( 2 / 12 ) , and the recurrence rate in the control group was 73.1 % ( 19 / 26 ) ( x2 = 10.290 , P = 0.001 ) . Conclusion : Submucous injection of glucocorticoid in patients with refractory esophageal benign stricture can effectively reduce the number of dilatation , reduce the need of repeated dilatation , prolong the time of symptom relief , improve the symptoms of swallowing difficulty and reduce the recurrence frequency in the near term , and can be used for clinical application of local injection of glucocorticoid as an effective auxiliary method for endoscopic dilation therapy .

【学位授予单位】：大连医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R726.5

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