【作者】 吴刚；

【导师】 韩新巍；

【作者基本信息】 郑州大学 ， 影像医学与核医学， 2004， 硕士

【摘要】 背景和目的 高位食管疾病是指颈段和胸上段食管的良恶性病变，包括食管-胃吻合口瘘、食管癌弓上或颈部吻合术后复发和高位食管-气管瘘、食管-纵隔瘘、食管癌性狭窄、放射性食管狭窄、腐蚀性食管炎等。此类疾病或导致食管严重狭窄不能进食，或因进食后气道误咽剧烈呛咳而不敢进食，病人进食障碍，直接危及生命。内科治疗效果差，外科治疗缺乏有效方法。 所有失去手术机会或不愿接受手术治疗的良恶性食管病变采取食管内支架置入治疗，操作简单安全、创伤小，能迅速有效地解除狭窄或瘘所致的吞咽困难，其良好的治疗效果使之在食管瘘或狭窄性疾病的治疗中得到越来越广泛的应用，但是高位食管疾病的内支架置入治疗仍属于盲区，原因在于对食管入口和上段解剖结构认识存在极大的偏差。对于高位食管病变内支架置入，大多采用骨性标志一颈椎来定位支架最上界，部分学者认为支架上缘最高不能超过第七颈椎上缘水平或第1胸椎水平。食管入口随体位、头部活动变化相对于椎体位置变化较大，X线以椎体作为解剖标志既不能准确显示食管入口的位置，又不能反映食管入口的动态变化。 为了详细了解食管入口的毗邻关系及其影响因素，充分利用上段正常食管，准确、合理放置支架，减少支架置入后下滑、移位等并发症，扩大食管内支架置入治疗高位食管疾病的适应症，本研究旨在进行梨状隐窝下极和食管入口位置关系的解剖学研究，寻找和探索一条切实可行的食管入口定位法，指导临床准确置入食管内支架治疗高位食管疾病。 材料与方法 ①随机、自愿的原则对257例健康体检志愿者，年龄5～86郑州大学2004年硕士研究生毕业论文高位食管疾病内支架置入治疗的解剖学研究与临床应用斌淤争介屯砂盛书淤淤犷几奈粉讲飞移称仁溺犷介君‘旦~杂犷诵艺二绍;矛~魏拔卫么弃飞欲梦‘淤介势姗盛韶忙石需匕舒尹护夯照若户宝纷行咬必佗簇宁缺睽嚣笋七溺产丫奋留‘押了求沙货珍于呀经先沸;褪梦‘绷，~冷黔必泛藻粉形了泌二溯梦端少潇职‘口二由盼‘奋欲岁，平均46.1士15.6岁，记录其姓名、年龄、身高、体重等，并在胃肠造影机下口服钡剂进行咽腔及食道造影。180位被检查者使用n xl4寸X线胶片四分格拍片，分别摄直立仰头位、平头位、低头位和仰卧仰头位咽腔食管造影片;77位被检查者只摄直立平头位咽腔食管造影片(4位用一张胶片)。随机抽出10位被测者进行X线造影片放大率校正。通过X线片将椎体平分三等份、椎间盘一份，分别记录梨状隐窝下极对应的椎体位置;以第五颈椎(C5)下缘平面为基线，利用两脚规和游标卡尺测量梨状隐窝下极与C5下缘基线的距离。在直立平头位图片上测量颈5、6高度，利用两脚规和游标卡尺测量C5上缘中点和第六颈椎(C6)下缘中点间的距离。 ②福尔马林固定的头颈部尸体标本61例，正中矢状断面切开，用1/50Inm游标卡尺和两脚规测量梨状隐窝下极与环状软骨板下缘平面之间距离、梨状窝下极与CS下缘的垂直距离和相对椎体位置关系、环状软骨板下缘与C5下缘平面的垂直距离和相对椎体位置关系。 ③26例高位食管疾病患者，男性20例，女性6例，年龄2~78岁，平均52.0士22.3岁。食管癌或责门癌根治性切除食管一胃弓上吻合或颈部吻合术后形成食管一胃吻合口痰10例、吻合口癌性复发狭窄4例、吻合口狭窄合并气管痰2例和高位食管一气管屡6例、腐蚀性食管炎4例。根据病变性质、长度、部位个体化选择食管内支架。患者仰卧于手术台上，头尽量抬高后仰，X线监视下置入食管内支架。支架置入后食管造影，了解支架位置、膨胀程度，观察食管通畅和痰口封堵情况，感染控制效果。 结果X线片梨状隐窝下极位置测量:①梨状隐窝下极随着体位的变化而相对椎体位置变化。②四种体位下男女之间梨状隐窝下极位置均有显著性差异 (户0.000)，且女性梨状隐窝下极位置高于男性。③男性或者女性直立仰头位、平头位、低头位和仰卧仰头位四种体位之间均有显著性差别，且直立仰头位高于仰卧仰头位、仰卧仰头位高于直立平头位、直立平头位又高于直立低头位。④将被测试者以蕊30岁、31一60岁、)61岁年龄段分组，四种体位下梨状隐窝下极位置年龄段间均有显著性差异。⑤将被测试者体重指数分为<18.5、18.5~22.99和>2.99三组，分析显示四种体位下各体重指数段间均无显著性差异。⑥梨状隐窝下极活动度不受性别、年龄、体型的影响。⑦颈5、6高度与身高呈正相关郑州大学2004年硕士研究生毕业论文高位食管疾病内支架置入治疗的解剖学研究与临床应用欲绝J犷令舀叮扁岁命犷房甲理期护汤犷笼狱说卖今凌男货势汉鲜浦尹彩r袱峨凭黔届路舅臼多诬户篇祝弱娜全斜洲彩洲蛇翎群必一~拐广飞罗，涛男协洲韶尹;游峪韶黔苏尹佗诫照谈笋扩矛螃诀比蔑赞卜洲货抖裕筑分留哟今磅，」死华炭仁属粉宝砰卜浦尸拼架几淤哪歼屯甲李拼勺盼口谈、徽礴粉减汹气面绷护产线性关系。 尸体标本测量:梨状隐窝下极与环状软骨下缘相距约2.ocm，而与C5下缘相距约1.Icm，环状软骨下缘与C5相距约一0.scm。尸体标本梨状隐窝下极多位于C4一CS一6水平(94.8%)，环状软骨板下缘多位于C5一C6刃之间(97.4%)。 临床高位食更多还原

【Abstract】 Background and objective: The upper esophageal disease refers to the benign/malignant esophageal disease in the cervical segment and upper thoracic segment of esophagus, including gastroesophageal anastomosis fistula or carcinous stricture, esophageal carcinous stenosis with tracheal fistula, mediastinoesophageal fistula,esophageal carcinous stricture, esophageal radioactive stricture, corrosive esophagitis,etc. In these diseases, esophagus is so severely constricted that the patient can’t take food or choked after meal that patient does not dare to eat food. Because the barrier of taking food, the patient is dying. There is a bad result in the internal medicine or non-efficient method in surgery.It is simple and safe, non-invasive method to treat esophageal disease and eliminate dysphagia after implanting stent successfully, which results in an extensive application. But stent is not popularly used in upper esophageal disease because of the enormous deviation in knowing the esophageal entrance and cervical anatomic structure. Cervical vertebra is mostly used as bony marker to locate the upper edge of stent in upper esophageal disease, some scholars thought the highest edge of stent can’t surpass C7 or T1. The esophageal entrance changes greater with the movement of the head than that of the vertebra. Moreover, the position of the esophageal entrance can’t be demonstrated accurately on X-ray according to the anatomic marker(vertebra).In order to study the adjacent structure and influence of esophageal entrance,make use of normal upper segment of esophagus, place stent accurately and reasonably, reduce the complication such as stent shifting and expand the indication of placing stent, the purpose of research is to study the anatomic relation of piriform recess and esophageal entrance, explore a practically feasible locating way of esopheal entrance, direct implanting esophageal stent in upper esophageal disease accurately and reasonably.Material and method:(1)On the basis of random trial and voluntary principle, 257 healthy people were registered about the name, age, height, weight, etc. The barium meal was given and radiography of the pharynx and esophagus was taken. 180 patients’ pharynx and esophageal radiography were taken in 11X 14inch films and a patient’extension, normal, flexion, prone extension position were taken in a film separately. The flat head position was shot in 77 patients. The maginificant rate of X-ray was adjusted in 10 cases with random trial. The vertebra was divided into three equal parts and the intervertibral disc was regarded as one part according to X-ray films. The position of vertebra corresponding to the extreme of the piriform recess was recorded separately. Taking the inferior level of C5 as a baseline, calliper and vernier caliper were used to measure the distance between the inferior piriform recess and the baseline. On the film of normal position, caliper and vernier caliper were used to measure the distance between the midpoint of the superior edge of C5 and the midpoint of the inferior edge of C6.(2)The anatomical relationships between inferior piriform recess and inferior cricoid cartilage, inferior piriform recess and inferior level of C5, inferior cricoid cartilage and inferior level of C5 were measured with caliper and vernier caliper with l/50mm.(3)26 patients with upper esophageal disease(male 20 cases, female 6 cases), average age 52.0 + 22.3 years old. In this group,there were 10 patients with gastroesophageal anastomosis fistula, 4 with gastroesophageal carcinous stricture, 2 with gastroesophageal carcinous stricture and tracheal fistula, 6 with upper esophageal carcinous stenosis with tracheal fistula and 4 with corrosive esophagitise. The esophageal stent was selected on the bases of the character, length, position ofesophageal disease. The patient lay on the operating table, lifting his head and facing forward as much as possible, Stent was placed under the fluoroscopic guidance. Re-radiography was taken after the placement of esophageal stent to know t更多还原