胰十二指腸切除術(shù)后營養(yǎng)方式的選擇

1、胰十二指腸切除術(shù)后營養(yǎng)方式的選擇胰十二指腸切除術(shù)手術(shù)技術(shù)日益成熟（開腹、腹腔鏡、機(jī)器人）相關(guān)疾病的發(fā)病率/檢出率增高胰十二指腸切除術(shù)現(xiàn)狀并發(fā)癥率高（3050%）術(shù)后早期并發(fā)癥的發(fā)生與預(yù)后直接相關(guān)圍術(shù)期營養(yǎng)不良或存在營養(yǎng)風(fēng)險的比例高（88%的患者存在中-重度營養(yǎng)風(fēng)險）重度營養(yǎng)風(fēng)險與術(shù)后并發(fā)癥率相關(guān)（50%）Malnutrition and pancreatic surgery: prevalence and outcomesJ. J Surg Oncol, 2013重視營養(yǎng)篩查和營養(yǎng)治療營養(yǎng)方案多種多樣Oral dietTotal parenteral nutrition (TPN)Jejuno

2、stomy tube Gastrogejunostomy tubeNasojejunal tubeStandard formulaImmunonutritionWith glutamineWith synbioticsSystematic review of five feeding routes after pancreatoduodenectomyJ. Br J Surg, 2013術(shù)后營養(yǎng)方式如何選擇？經(jīng)口腸外管飼經(jīng)口進(jìn)食是最佳途徑？Systematic review of five feeding routes after pancreatoduodenectomyJ. Br J Su

3、rg, 2013Whipple術(shù)后口服營養(yǎng)方式安全，恢復(fù)正常飲食時間短 Guidelines (ERAS society, 2013)經(jīng)口進(jìn)食：現(xiàn)實很骨感Only 61% of patients were able to drink at day 1; 23% took solid food at day 3; and infusions were stopped at day 5 in 32%55%的患者能耐受流質(zhì)飲食，53%的患者能耐受半流質(zhì)或普食Perioperative nutritional support of patients undergoing pancreatic surg

4、ery in the age of ERASJ. Nutrition, 2014Enhanced recovery after surgery pathway in patients undergoing pancreaticoduodenectomyJ. World J Surg, 2014術(shù)后兩周，經(jīng)口進(jìn)食只能達(dá)到30%的目標(biāo)熱量和41%目標(biāo)氮量我們的稀飯、面條？Clinical feasibility and nutritional effects of early oral feeding after pancreaticoduodenectomyJ. Korean J Hepatob

5、iliary Pancreat Surg, 2014術(shù)后胃排空障礙（Delayed Gastric Emptying, DGE）Whipple術(shù)后DGE發(fā)生率高occurred in 340 (44.5 per cent) of 764 patients. 保留幽門術(shù)式DGE比例更高Evaluation of the International Study Group of Pancreatic Surgery definition of delayed gastric emptying after pancreatoduodenectomy in a high-volume centreJ.

6、 Br J Surg, 2010管飼是否普遍需要？Meta-analysis of effect of routine enteral nutrition on postoperative outcomes after pancreatoduodenectomyJ. Br J Surg, 2019結(jié)論：推薦管飼，促進(jìn)胰十二指腸切除術(shù)后的恢復(fù)，減少并發(fā)癥管飼腸內(nèi)營養(yǎng)不是完全的生理過程Eating is “a host of pleasurable phenomena”Food at will after pancreaticoduodenectomies. Re. Perioperative n

7、utritional support of patients undergoing pancreatic surgery in the age of ERASJ. Nutrition, 2015鼻飼管耐受性差43%的患者認(rèn)為鼻飼管和胃管是最不舒適，最無法忍受的管飼增加DGE發(fā)生率Nasogastric tube versus gastrostomy tube for gastric decompression in abdominal surgery: a prospective, randomized trial comparing patients tube-related inconve

8、nienceJ. Langenbecks Arch Surg, 2001Utility of feeding jejunostomy tubes in pancreaticoduodenectomyJ. Am J Surg, 2017腸外營養(yǎng)被拋棄？TPN腸內(nèi)營養(yǎng)補(bǔ)充性腸外營養(yǎng)補(bǔ)充性腸外營養(yǎng)（Supplementary Parenteral Nutrition, SPN）：腸內(nèi)營養(yǎng)不足時，部分能量和蛋白質(zhì)需求由腸外營養(yǎng)來補(bǔ)充的混合營養(yǎng)支持治療方式。合理的SPN能滿足能量和蛋白質(zhì)需求，調(diào)整氮平衡，促進(jìn)蛋白質(zhì)合成，改善患者的營養(yǎng)狀況，降低并發(fā)癥率，改善臨床結(jié)局。消化道重建方式影響術(shù)后營養(yǎng)方式？Nu

9、tritional support and therapy in pancreatic surgery: A position paper of the International Study Group on Pancreatic Surgery (ISGPS)J. Surgery, 2018Pancreaticogastrostomy has advantages over pancreaticojejunostomy on pancreatic fistula after pancreaticoduodenectomy. A meta-analysis of randomized controlled trialsJ. Int J Surg, 2016兩種吻合方式（胰胃/胰腸）術(shù)后胃排空障礙發(fā)生率無差異各種營養(yǎng)方式的特點營養(yǎng)方式優(yōu) 點缺 點口服舒適、符合生理營養(yǎng)供給不足腸外營養(yǎng)營養(yǎng)供給調(diào)節(jié)自由，容易達(dá)到目標(biāo)量并發(fā)癥多（導(dǎo)管相關(guān)性、代謝相關(guān)性、感染等）腸內(nèi)營養(yǎng)（管飼）經(jīng)鼻符合生理，保護(hù)腸道功能，可長期使用舒適性和耐受性差，達(dá)到目標(biāo)量有一定困難造瘺相對舒適，保護(hù)腸道功能手術(shù)相關(guān)并發(fā)癥一般患者：口服+補(bǔ)充性腸外營