杨宁介入医学网

        传统上良性结肠狭窄主要是应用大直径的球囊扩张，但这种扩张失败较多，其结果令人失望[9，10，12，15，16，20，22~28]。几乎没有多少文献报告应用结肠支撑架治疗良性结肠狭窄[2，3，9~26]。以现有的文献，没有有关结肠良性病变的明确的支撑架适应症的专家共识。主要争论的是结肠良性狭窄病变支撑架长期的耐久性和正常的寿命的预期[2,8]，部分原因由于缺少大样本的资料。Khot等人[1]复习文献报告中近567例，仅有3%的良性结肠狭窄使用结肠支撑架。其安全性和有效性一直被争论[2~5]。

        支撑架植入恶性病变通常仅为短期的外科术前结肠减压，而对于晚期结肠癌的姑息性结肠支撑架的植入也因为病人预期寿命短，对支撑架的耐久性要求差。而对于有正常预期寿命的良性结肠狭窄，则要求支撑架有较长的耐久性。目前良性结肠狭窄支撑架的耐久性差主要由于较高的支撑架移位发生率和并发症[2，8，23]，特别是憩室病的情况下[7]。有些作者建议良性结肠狭窄不是支撑架的适应症，特别是食道和胆道良性狭窄支撑架植入的结果已经令人失望的情况下，这些病人可出现支撑架移位，血管侵入，粘膜生长，支撑架再阻塞[27~29]。

        但是，结肠支撑架可以迅速缓解急性良性狭窄导致的接肠梗阻，似乎一直吸引着部分作者积极地进行尝试，特别是如果能够避免急诊手术，或避免经常需要先进行的结肠造瘘[6]。至2005年全世界英文文献报告有52例良性结肠狭窄病人进行了支撑架治疗。主要适应症包括三个方面

（1）急性结肠梗阻，最常见是憩室性疾病，通过支撑架植入避免急诊结肠手术的并发症[2，13，14，18，19，20]。在大多数病例，狭窄的原因通常在外科术后的的组织学分析中才能得到结果。

（2）顽固性结肠狭窄，包括外科吻合口，放疗后，球囊扩张失败后。

（3）用覆膜支撑架治疗结肠瘘。与狭窄有关的结肠瘘瘘口愈合的成功率较高[11，16，25]，因为支撑架缓解了阻塞，所以瘘口容易愈合。

1. Khot UP, Lang AW, Murali K, Parker MC. Systematic review of the efficacy and safety of colorectal stents. Br J Surg 2002;89:1096–102.

2. Meisner S, Hensler M, Knop FK, West F, Wille-Jorgensen P. Self-expanding metal stents for colonic obstruction: experiences from 104 procedures in a single center. Dis Colon Rectum 2004;47:444–50. 

3. Suzuki N, Saunders BP, Thomas-Gibson S, Akle C, Marshall M, Halligan S. Colorectal stenting for malignant and benign disease: outcomes in colorectal stenting. Dis Colon Rectum 2004;47:1201–7. 

4. Forshaw MJ, Sankararajah D, Stewart M, Parker MC. Self-expanding metallic stents in the treatment of benign colorectal disease: indications and outcomes. Colorectal Dis 2006;8:102–11. 

5. Small AJ, Young-Fadok TM, Baron TH. Expandable metal stent placement for benign colorectal obstruction: outcomes for 23 cases. Surg Endosc 2008;22:454–62. 

6. Ilona Keränen , Anna Lepistö‌, Marianne Udd‌, Jorma Halttunen‌ & Leena Kylänpää‌ Outcome of patients after endoluminal stent placement for benign colorectal obstruction Scandinavian Journal of Gastroenterology
June 2010, Vol. 45, No. 6, Pages 725-731

7. Khot U, Wenk Lang A, Murali K, Parker MC. Systematic review of the clinical evidence on colorectal self-expanding metal stents. Br J Surg 2002; 89: 1096–102.

8. Lo SK. Metallic stenting for colorectal obstruction. Gastrointest Endosc Clin N Am 1999; 9: 459–78.

9. Cascales-Sanchez P, Garcia-Olmo D, Julia-Molla E. Long-term expandable stent as a definitive treatment for benign rectal stenosis. Br J Surg 1997; 84: 840–1.   

10. Salinas JC, Quintana J, De Gregorio MA, Insignares E, Gil I, Lozano R. Management of benign rectal stricture by implantation of a self-expanding prosthesis. Br J Surg 1997; 84: 674.

11. Jeyarajah AR, Shepherd JH, Fairclough PD, Patchett SE. Effective palliation of a colovaginal fistula using a self-expanding metal stent. Gastrointest Endosc 1997; 46: 367–9.

12. Wholey MH, Levine EA, Ferral H, Castaneda-Zuniga W. Initial clinical experience with colonic stent placement. Am J Surg 1998; 175: 194–7.

13. Davidson R, Sweeney WB. Endoluminal stenting for benign colonic obstruction. Surg Endosc 1998; 12: 353–4.

14. Baron TH, Dean PA, Yates 3rd MR, Canon C, Koehler RE. Expandable metal stents for the treatment of colonic obstruction: techniques and outcomes. Gastrointest Endosc 1998; 47: 277–86.

15. Yates 3rd MR, Baron TH. Treatment of a radiation-induced sigmoid stricture with an expandable metal stent. Gastrointest Endosc 1999; 50: 422–6.

16. Fernandez Lobato R, Pinto I, Maillo C, Paul L, Fradejas JM, Moreno Azcoita M. Rectovesical fistula treated by covered self-expanding prosthesis: report of a case. Dis Colon Rectum 1999; 42: 812–5.

17. Camunez F, Echenagusia A, Simo G, Turegano F, Vazquez J, Barreiro-Meiro I. Malignant colorectal obstruction treated by means of self-expanding metallic stents: effectiveness before surgery and in palliation. Radiology 2000; 216: 492–7.

18. Tarquinio L, Zimmerman MJ. Successful treatment of a benign anastomotic stricture despite stent migration. Gastrointest Endosc 2000; 52: 436–8.

19. Tamim WZ, Ghellai A, Counihan TC, Swanson RS, Colby JM, Sweeney WB. Experience with endoluminal colonic wall stents for the management of large bowel obstruction for benign and malignant disease. Arch Surg 2000; 135: 434–8.

20. Matsuhashi N, Nakajima A, Suzuki A, Yazaki Y, Takazoe M. Long-term outcome of non-surgical strictureplasty using metallic stents for intestinal strictures in Crohn's disease. Gastrointest Endosc 2000; 51: 343–5.

21. Adamsen S, Holm J, Meisner S et al. Endoscopic placement of self-expanding metal stents for treatment of colorectal obstruction with long-term follow-up. Dan Med Bull 2000; 47: 225–7.

22. Piccinni G, Nacchiero M. Management of narrower anastomotic colonic strictures. Case report and proposal technique. Surg Endosc 2001; 15: 1227.

23. Odurny A. Colonic anastomotic stenoses and Memotherm stent fracture: a report of three cases. Cardiovasc Intervent Radiol 2001; 24: 336–9.

24. Law WL, Choi HK, Chu KW, Tung HM. Radiation stricture of rectosigmoid treated with self-expanding metallic stent. Surg Endosc 2002; 16: 1106–7.

25. Paul L, Pinto I, Gomez H, Fernandez-Lobato R, Moyano E. Metallic stents in the treatment of benign diseases of the colon: preliminary experience in 10 cases. Radiology 2002; 223: 715–22.

26. Seo TS, Song HY, Sung KB, Ko GY, Yu, CS. A benign colorectal stricture: treatment with a retrievable expandable nitinol stent. Cardiovasc Intervent Radiol 2003; 26: 181–3.

27. Wadhwa RP, Kozarek RA, France RE et al. Use of self-expandable metallic stents in benign GI diseases. Gastrointest Endosc 2003; 58: 207–12.

28. Sandha GS, Marcon JE. Expandable metal stents for benign esophageal obstruction. Gastrointest Endosc Clin N Am 1999; 9: 437–46

29. Raijman I. The Wallstent for benign biliary obstruction. Gastrointest Endosc Clin N Am 1999; 9: 521–31.