Said Adnan, Brust Donald J, Gaumnitz Eric A, Reichelderfer Mark
Section of Gastroenterology and Hepatology, Department of Medicine, The University of Wisconsin Hospital, Madison, Wisconsin, USA.
Am J Gastroenterol. 2003 Jun;98(6):1252-6. doi: 10.1111/j.1572-0241.2003.07490.x.
In the era of liberal proton pump inhibitor (PPI) use, benign esophageal strictures remain a significant management problem, with 30-40% of patients experiencing symptomatic recurrence within 1 yr of successful dilation. We therefore sought to examine predictors of early recurrence of benign esophageal strictures after endoscopic dilation.
Predictors for stricture recurrence were examined in 87 consecutive outpatients undergoing initial dilation over a 1-yr period. Patients with symptomatic recurrence of dysphagia requiring repeat dilation within 1 yr of initial successful dilation (cases) were compared to patients who did not require redilation (controls). Predictors were assessed by univariate and multivariate analysis. Kaplan-Meier analysis of significant predictors using time to first redilation was also performed.
Of the patients, 36 required repeat dilation within 1 yr, whereas 51 did not (median follow-up, 33 months). Of all strictures, 67 (77%) were peptic, with the remainder caused by radiation, drug-related injury, or congenital stenosis, among other causes. In multivariate analysis, nonpeptic strictures were significant predictors for early recurrence, as was a narrower stricture diameter. For peptic strictures, the persistence of heartburn after dilation and the presence of a hiatal hernia were significant predictors. Of all peptic strictures, 84% of patients were on PPIs after dilation, with no difference between cases and controls. Of all patients with persistent heartburn after dilation, 90% were on PPIs.
The persistence of heartburn after dilation is a strong predictor for early symptomatic recurrence of benign esophageal peptic strictures, despite a high rate of PPI use. This may suggest persistent acid reflux requiring optimization of acid reduction therapy. Alternatively, combined acid and alkaline reflux may account for progressive injury despite PPI therapy. Esophageal pH studies may be invaluable in making the distinction between acid and non-acidic (alkaline) reflux. Nonpeptic strictures are also more likely to have early recurrences and are therefore more difficult to manage.
在质子泵抑制剂（PPI）广泛使用的时代，良性食管狭窄仍然是一个重要的治疗难题，30%-40%的患者在成功扩张后1年内出现症状复发。因此，我们试图研究内镜扩张后良性食管狭窄早期复发的预测因素。
对87例在1年期间接受初次扩张的连续门诊患者的狭窄复发预测因素进行了研究。将初次成功扩张后1年内出现吞咽困难症状复发需要再次扩张的患者（病例组）与不需要再次扩张的患者（对照组）进行比较。通过单因素和多因素分析评估预测因素。还使用首次再次扩张时间对显著预测因素进行了Kaplan-Meier分析。
在这些患者中，36例在1年内需要再次扩张，而51例不需要（中位随访时间为33个月）。在所有狭窄中，67例（77%）为消化性狭窄，其余由放疗、药物相关损伤或先天性狭窄等其他原因引起。在多因素分析中，非消化性狭窄是早期复发的显著预测因素，狭窄直径较窄也是如此。对于消化性狭窄，扩张后烧心持续存在和存在食管裂孔疝是显著的预测因素。在所有消化性狭窄患者中，84%在扩张后使用PPI，病例组和对照组之间无差异。在所有扩张后烧心持续存在的患者中，90%使用PPI。
尽管PPI使用率很高，但扩张后烧心持续存在是良性食管消化性狭窄早期症状复发的有力预测因素。这可能表明存在持续的酸反流，需要优化抑酸治疗。或者，尽管进行了PPI治疗，但酸和碱反流共同作用可能导致进行性损伤。食管pH研究对于区分酸反流和非酸性（碱性）反流可能具有重要价值。非消化性狭窄也更有可能早期复发，因此更难处理。
