胰十二指肠切除术后营养方式的选择

1、胰十二指肠切除术后营养方式的选择胰十二指肠切除术手术技术日益成熟（开腹、腹腔镜、机器人）相关疾病的发病率/检出率增高胰十二指肠切除术现状并发症率高（3050%）术后早期并发症的发生与预后直接相关围术期营养不良或存在营养风险的比例高（88%的患者存在中-重度营养风险）重度营养风险与术后并发症率相关（50%）Malnutrition and pancreatic surgery: prevalence and outcomesJ. J Surg Oncol, 2013重视营养筛查和营养治疗营养方案多种多样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术后营养方式如何选择？经口肠外管饲经口进食是最佳途径？Systematic review of five feeding routes after pancreatoduodenectomyJ. Br J Su

3、rg, 2013Whipple术后口服营养方式安全，恢复正常饮食时间短 Guidelines (ERAS society, 2013)经口进食：现实很骨感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%的患者能耐受流质饮食，53%的患者能耐受半流质或普食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术后两周，经口进食只能达到30%的目标热量和41%目标氮量我们的稀饭、面条？Clinical feasibility and nutritional effects of early oral feeding after pancreaticoduodenectomyJ. Korean J Hepatob

5、iliary Pancreat Surg, 2014术后胃排空障碍（Delayed Gastric Emptying, DGE）Whipple术后DGE发生率高occurred in 340 (44.5 per cent) of 764 patients. 保留幽门术式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管饲是否普遍需要？Meta-analysis of effect of routine enteral nutrition on postoperative outcomes after pancreatoduodenectomyJ. Br J Surg, 2019结论：推荐管饲，促进胰十二指肠切除术后的恢复，减少并发症管饲肠内营养不是完全的生理过程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鼻饲管耐受性差43%的患者认为鼻饲管和胃管是最不舒适，最无法忍受的管饲增加DGE发生率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肠外营养被抛弃？TPN肠内营养补充性肠外营养补充性肠外营养（Supplementary Parenteral Nutrition, SPN）：肠内营养不足时，部分能量和蛋白质需求由肠外营养来补充的混合营养支持治疗方式。合理的SPN能满足能量和蛋白质需求，调整氮平衡，促进蛋白质合成，改善患者的营养状况，降低并发症率，改善临床结局。消化道重建方式影响术后营养方式？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, 2016两种吻合方式（胰胃/胰肠）术后胃排空障碍发生率无差异各种营养方式的特点营养方式优 点缺 点口服舒适、符合生理营养供给不足肠外营养营养供给调节自由，容易达到目标量并发症多（导管相关性、代谢相关性、感染等）肠内营养（管饲）经鼻符合生理，保护肠道功能，可长期使用舒适性和耐受性差，达到目标量有一定困难造瘘相对舒适，保护肠道功能手术相关并发症一般患者：口服+补充性肠外营