恶性肠梗阻PPT课件

恶性肠梗阻专家共识,恶性肠梗阻（Malignant Bowel Obstruction，简称MBO）是指原发性或转移性恶性肿瘤造成的肠道梗阻，是晚期癌症患者的常见并发症。对于常规手术无法解除梗阻及去除病因的晚期及终末期癌症的恶性肠梗阻患者，不仅要承受呕吐、腹痛、腹胀、无法进食等病痛的折磨，而且可能还要承受因临床放弃治疗，或持消极态度所致的精神痛苦。,重要观点,以患者为中心评价姑息治疗，重视患者的感受对原来认为外科治疗是首选的观点有所转变，趋向更谨慎地采用手术治疗药物治疗，尤其是阿片类和奥曲肽药物治疗的选择有重要地位,内容,MBO的决策MBO的外科治疗胃十二指肠梗阻的内镜治疗恶性结直肠梗阻的内镜治疗药物对症治疗,相关共识对 MBO 的界定1,肠梗阻的临床表现（病史/查体/影像学检查）难治性腹腔内肿瘤或非腹腔内原发肿瘤伴有明确腹膜内病灶，出现 Treitz 韧带以下部位的肠梗阻,1. Anthony T, Baron T, Mercadante S, et al. Report of the clinical protocol committee: development of randomized trials for malignant bowel obstruction. J Pain Symptom Manage2007;34:S4959,导致 MBO 的常见恶性肿瘤,结直肠癌患者中有10%28%会在病程中出现MBO1卵巢癌患者中有20%50%有肠梗阻症状1乳腺癌或黑色素瘤是引起恶性肠梗阻的最常见的非肠道肿瘤2 另据报道胃癌引发恶性肠梗阻约占30 3,1. Ripamonti C, Bruera E. Palliative management of malignantbowel obstruction. Int J Gynecol Cancer 2002;12:13543.2. Krouse RS. The international conference on malignant bowel obstruction: a meeting of the minds to advance palliative care research. J Pain Symptom Manage 2007;34:S16.3。Ali sidgiqui，et al：desease and sciences 2007 52（1）276281EJC,MBO 的病生理机制,机械性肠梗阻肠腔外占位性病变导致梗阻：原发肿瘤增大或复发，肠系膜和网膜肿物，腹腔或盆腔粘连、放疗后纤维化等压迫肠壁。 肠腔内占位性病变导致梗阻：肿瘤在肠腔内生长所致。肠壁内占位性病变导致梗阻：皮革肠，肿瘤在肠壁内生长导致肠运动障碍。,MBO 的病生理机制,动力性肠梗阻/功能性肠梗阻肿瘤浸润肠系膜或肠壁肌肉和神经、或恶性累及腹腔神经丛假性肠梗阻（CIP）: 化疗药物所致的神经损害、副癌综合征性神经病变（尤其多见于肺癌患者）、副癌性假性肠梗阻,MBO 的临床表现,腹部痉挛性痛、恶心、呕吐和腹胀 症状渐进性的加重：频率渐增，持续时间渐长排便或排气后缓解,MBO 初步判断和治疗,仔细排除急腹症的可能初步判断梗阻的部位和性质补液治疗鼻胃管引流减压,根据病史和症状判断肠梗阻的部位,影像学检查,腹部平片：直立位+仰卧位胃肠道对比造影：建议使用泛影葡胺腹部CT内镜检查,评价和治疗恶性肠梗阻患者的流程图,有肿瘤病史的患者出现肠梗阻症状,影像学检查CT/MRI,临床评估,患者因素,临床决策,技术因素,与患者及家属商定最终治疗方案,MBO 临床决策 影响治疗效果的因素,梗阻程度病变类型肿瘤临床分期及总体预后之前和未来可能进行的抗肿瘤治疗患者的健康和体力状况,MBO 临床决策强调以患者为中心评价姑息治疗,症状的缓解：腹痛、腹胀、恶心、呕吐生活质量的改善：有限进食、营养状态改善、不良心理状态改善、回归社会家庭等临终前的生活质量：家庭护理负担减轻等,MBO 临床决策通常并非急症,医生有必要也有条件以提高患者的生存质量为目标，权衡各种治疗方案的利弊对症治疗手术治疗胃十二指肠梗阻的内镜治疗 结直肠梗阻的内镜治疗 经皮内镜下胃造瘘引流术治疗肠梗阻,内容,MBO的决策MBO的外科治疗胃十二指肠梗阻的内镜治疗恶性结直肠梗阻的内镜治疗药物对症治疗,MBO 手术治疗 是否选择手术,患者、家属和医生首先应建立实际的治疗预期，避免无用的和可能伤害患者的治疗手段告知患者所有可以选择的治疗方案：手术 vs 非手术治疗告知患者手术治疗现实的预期收益和相关风险,MBO 手术治疗 严格把握适应症,粘连引起的机械性梗阻局限肿瘤造成的单一部位梗阻 对进一步化疗可能会有较好疗效的患者（化疗敏感者）,MBO 手术治疗 绝对禁忌症,近期开腹手术证实无法进一步手术既往腹部手术显示肿瘤弥漫性转移累及胃近端影像学检查证实腹腔内广泛转移，并且造影发现严重的胃运动功能障碍触及弥漫性腹腔内肿物大量腹水，引流后复发,MBO 手术治疗 相对禁忌症,高龄一般情况差有腹腔外转移产生难以控制的症状（如呼吸困难）腹腔外疾病（如广泛转移、胸水）营养状态较差（如体重明显下降，甚至出现恶液质，明显低蛋白血症）既往腹腔或盆腔放疗,MBO 手术治疗 - 手术方案,松解粘连肠段切除肠段吻合肠造瘘,NCCN肿瘤实践指南2009年版,数周数日（濒临死亡）,与手术相比，药物治疗是更适宜的选择评估治疗目标有助于指导干预方案（例如：减少恶心、呕吐，允许患者进食，减轻疼痛，允许患者回家或接受家庭护理）,药物治疗静脉或者皮下补液内镜治疗鼻胃管引流 仅当其他措施无法减轻呕吐时方考虑,MBO 手术治疗小结：应更加慎重地选择手术治疗，手术治疗只对某些有选择的MBO患者有益,MBO 手术治疗的指征、方法选择等并无定论，存在高度的经验性和选择性 手术存在很多禁忌 手术未必是最好的选择消除肿瘤，降低肿瘤负荷是手术的首要目标，对患者生存预期、生活质量的判断尚缺乏客观标准应更加慎重地选择手术治疗，手术治疗只对某些有选择的MBO的患者有益。,内容,MBO的决策MBO的外科治疗胃十二指肠梗阻的内镜治疗恶性结直肠梗阻的内镜治疗药物对症治疗,胃十二指肠恶性梗阻的内镜治疗,胃出口梗阻（GOO）和近端小肠梗阻 腹腔、盆腔恶性肿瘤：胰腺癌、远端胃癌、胆囊癌、胆管癌、卵巢癌 腹腔外恶性肿瘤：肺癌、乳腺癌,用于胃和小肠近段梗阻治疗的内镜技术,植入自张性金属支架（SEMS）来解除梗阻，缓解患者的症状 经皮行胃造瘘（PEG）引流术 适于预后不佳、生存时间有限的患者,循证医学 内镜治疗的优势,支架植入技术的成功率 90%，支架植入后恶心、呕吐的缓解率和耐受经口进食的成功率大于75% 1-4 内镜下支架植入技术能缩短胰腺癌继发胃出口梗阻患者的住院时间，减低围手术期死亡率 5,6 内镜术后开始经口进食的时间短于胃肠旁路手术 5,7,1 .Lowe AS, Beckett CG, Jowett S, et al. Self-expandable metal stent placement for the palliation of malignant gastroduodenal obstruction: experience in a large, single, UK centre. Clin Radiol 2007;62:73844.2. Telford JJ, Carr-Locke DL, Baron TH, et al. Palliation of patients with malignant gastric outlet obstruction with the enteral Wallstent: outcomes from a multicenter study.Gastrointest Endosc 2004;60:91620.3. Dormann A, Meisner S, Verin N, et al. Self-expanding metal stents for gastroduodenal malignancies: systematic review of their clinical effectiveness. Endoscopy 2004;36:54350.4. Nassif T, Prat F, Meduri B, et al. Endoscopic palliation of malignant gastric outlet obstruction using self-expandable metallic stents: results of a multicenter study. Endoscopy 2003;35:4839.5. Espinel J, Sanz O, Vivas S, et al. Malignant gastrointestinal obstruction: endoscopic stenting versus surgical palliation. Surg Endosc 2006;20:10837.6. Lillemoe KD, Cameron JL, Hardacre JM, et al. Is prophylactic gastrojejunostomy indicated for unresectable periampullary cancer? A prospective randomized trial. Ann Surg 1999;230:3228. discussion 328-30.7. Jeurnink SM, Steyerberg EW, Hof GV, et al. Gastrojejunostomy versus stent placement in patients with malignant gastricoutlet obstruction: a comparison in 95 patients. J Surg Oncol 2007.,循证医学 内镜治疗的并发症,再梗阻：食物嵌顿导致的支架梗阻和肿瘤生长造成1支架移位：可能由治疗过程中肿瘤体积减小造成1再次行介入治疗的比例高于手术治疗的患者2,3,1. Holt AP, Patel M, Ahmed MM. Palliation of patients with malignant gastroduodenal obstruction with self-expanding metallic stents: the treatment of choice? Gastrointest Endosc 2004;60:101072. Jeurnink SM, Steyerberg EW, Hof GV, et al. Gastrojejunostomy versus stent placement in patients with malignant gastricoutlet obstruction: a comparison in 95 patients. J Surg Oncol 2007.3. Wong YT, Brams DM, Munson L, et al. Gastric outletobstruction secondary to pancreatic cancer: surgical vs endoscopic palliation. Surg Endosc 2002;16:3102.,内镜治疗胃十二指肠恶性梗阻的适应症,肿瘤累及肠段长度短梗阻部位单一位于幽门或近端十二指肠一般状况中等或良好预期生存时间大于30天,胃十二指肠支架植入术后再梗阻的处理1,植入另外一枚支架 激应用Nd:YAG激光清扫氩等离子凝固器治疗,1. Holt AP, Patel M, Ahmed MM. Palliation of patients with malignant gastroduodenal obstruction with self-expanding metallic stents: the treatment of choice? Gastrointest Endosc 2004;60:10107.,内容,MBO的决策MBO的外科治疗胃十二指肠梗阻的内镜治疗恶性结直肠梗阻的内镜治疗药物对症治疗,恶性结直肠梗阻的内镜治疗,疗效及安全性的系统性回顾,1. Khot UP, Wenk Lang A, Murali K, et al. Systematic review of the efficacy and safety of colorectal stents. Br J Surg 2002;89:1096102.2. Sebastian S, Johnston S, Geoghegan T, et al. Pooled analysis of the efficacy and safety of self-expanding metal stenting in malignant colorectal obstruction. Am J Gastro 2004;99:20517.,结直肠支架植入术后再梗阻的处理1-4,植入另外一枚支架 内镜下行扩张术 激应用Nd:YAG激光清扫,1 . Camunez F, Echenagusia A, Simo G, et al. Malignant colorectal obstruction treated by means of self-expanding metallic stents: Effectiveness before surgery and in palliation. Radiology 2000;216:4927.2 . Law WL, Chu KW, Ho JW, et al. Self-expanding metallic stent in the treatment of colonic obstruction caused by advancedmalignancies. Dis Colon Rectum 2000;43:15227.3. Nash CL, Markowitz AJ, Schattner M, et al. Colorectal stents for the management of malignant large bowel obstruction. Gastrointest Endo 2002;55:AB216.4. Pothuri B, Guiguis A, Gerdes H, et al. The use of colorectal stents for palliation of large bowel obstruction due to recurrent gynecologic cancer. Gynecol Oncol 2004;95:5137.,经皮内镜下胃造瘘（PEG）引流术,长期留置鼻胃管引流的缺点： 干扰咳嗽，患者无法通过咳嗽排出肺内分泌物 长期留置患者会越来越不舒服 影响美观，使患者无法外出,PEG置管的优势,安全快捷地缓解症状避免手术风险避免留置鼻胃管的不便,PEG 置管术的相关研究,Campagnutta等1报道了34 名应用PEG引流术姑息治疗妇科肿瘤所致肠梗阻的患者，使用15号和20号胃管，94%患者PEG置管成功，84.4%患者症状缓解，耐受经口进流质或软食的中位时间为术后74天。Pothuri等2的回顾性研究显示，98%进展期复发性卵巢癌患者留置28号PEG胃管是可行的，即使肿瘤已包裹胃、广泛播散和形成腹水。,1. Campagnutta E, Cannizzaro R, Gallo A, Zarrelli A, Valentini M, De Cicco M, et al. Palliative Treatment of Upper Intestinal Obstruction by Gynecological Malignancy: The Usefulness of Percutaneous Endoscopic Gastrostomy. Gynecologic Oncology1996;62:1035.2. Pothuri B, Montemarano M, Gerardi M, Shike M, Ben-Porat L, Sabbatinin P, et al. Percutaneous endoscopic gastrostomy tube placement in patients with malignant bowel obstruction due to ovarian carcinoma. Gynecologic Oncology 2005;96:3304.,内容,MBO的决策MBO的外科治疗胃十二指肠梗阻的内镜治疗恶性结直肠梗阻的内镜治疗药物对症治疗,欧洲姑息治疗协会工作组晚期肿瘤患者MBO药物治疗建议,镇痛药根据WHO指南强烈推荐,抗胆碱能药物丁溴东莨菪碱氢溴酸东莨菪碱,持续疼痛,绞痛,给药方式持续皮下给药（CSI）持续静脉给药CIV）经皮肤给药,减少胃肠道分泌1、抗胆碱能药物丁溴东莨菪碱（40-120mg/d）甘罗溴铵（0.1-0.2mg，tid，sc或iv）氢溴酸东莨菪碱（0.8-2.0mg/d） 和/或2、生长抑素类似物奥曲肽0.2-0.9 mg/d，civ或csi,止吐治疗胃复安（仅用于不全肠梗阻及没有绞痛的患者） 氟哌啶醇（5-15mg/dCSI） 甲氧异丁嗪 （50-150mg/dCSI）镇静药 氯吡嗪（25-75mg/d直肠给药） 氯丙嗪 （50-100mg/d直肠给药/皮下）抗组胺药盐酸吗嗪（100-150mg/d皮下或直肠 给药）,恶心呕吐,MBO的药物对症治疗控制腹痛、减少恶心呕吐、改善临终生存质量,缓解持续性的腹痛和肠绞痛在不使用鼻胃管的情况下将患者的呕吐减轻到可接受程度（如12次/24小时）减轻恶心呕吐能够出院，以便在家里或临终关怀医院接受治疗,阿片类、奥曲肽和莨菪碱类药物被重点强调,镇痛药的应用,根据WHO指南1应用镇痛药，主要为强效阿片类药 阿片类药物的剂量须根据需要滴定调节，通常肠外给药 若使用阿片类药物后绞痛依然存在，应考虑联用丁溴东莨菪碱或氢溴东莨菪碱2-7,1. World Health Organization. Cancer Pain Relief. Second ed. Geneve: WHO; 1996.2. Hofmann B, Haheim LL, Soreide JA. Ethics of palliative surgery in patients with cancer. Br J Surg 2005;92:8029.3. Pothuri B, Guiguis A, Gerdes H, et al. The use of colorectal stents for palliation of large bowel obstruction due torecurrent gynecologic cancer. Gynecol Oncol 2004;95:5137.4.Fainsinger RL, Spachynski K, Hanson J, et al. Symptom control in terminally ill patients with malignant bowel obstruction. J Pain Symptom Manage 1994;9:128.5. Ventafridda V, Ripamonti C, Caraceni A, et al. The management of inoperable gastrointestinal obstruction in terminal cancer patients. Tumouri 1990;76:38993.6. Mercadante S. Pain in inoperable bowel obstruction. Pain Digest 1995;5:913.7. De Conno F, Caraceni A, Zecca E, Spoldi E, Ventafridda V. Continuous subcutaneous infusion of hyoscine butylbromide reduces secretions in patients with gastrointestinal obstruction. J Pain Sympt Manage 1991;6:4846.,阿片类药物治疗MBO的多种适宜的给药途径,皮下给药静脉给药经皮给药,恶心、呕吐的药物治疗,能够减少胃肠道（GI）分泌的药物：如抗胆碱药（丁溴东莨菪碱、氢溴东莨菪碱、格隆溴铵）和/或生长抑素类似物（奥曲肽）1-4中枢性止吐药：可单用，也可与减少GI分泌的药物联用,Ventafridda V, Ripamonti C, Caraceni A, et al. The management of inoperable gastrointestinal obstruction in terminal cancer patients. Tumouri 1990;76:38993.2. De Conno F, Caraceni A, Zecca E, Spoldi E, Ventafridda V. Continuous subcutaneous infusion of hyoscine butylbromide reduces secretions in patients with gastrointestinal obstruction. J Pain Sympt Manage 1991;6:4846.3. Ripamonti C, Mercadante S, Groff L, Zecca E, De Conno F, Casuccio A. Role of octreotide, scopolamine butylbromide and hydration in symptom control of patients with inoperable bowel obstruction having a nasogastric tube. A prospective, randomized clinical trial. J Pain Symptom Manage 2000;19:2334.4. Mercadante S, Ripamonti C, Casuccio A, Zecca E, Groff L. Comparison of octreotide and hyoscine butylbromide in controlling gastrointestinal symptoms due to malignant inoperable bowel obstruction. Supportive Care in Cancer 2000;8:18891.,关于奥曲肽：是一种合成的生长抑素类似物，特异性较强，作用时间长,奥曲肽抑制恶心呕吐的作用机制,抑制GI激素的释放和活性通过减少胃酸分泌、减缓肠蠕动、减少胆汁量、增加粘膜分泌量和减少内脏血流量调控GI功能减少GI内容物，提高细胞间隙内水和电解质的吸收量,1. Ripamonti C, Panzeri C, Groff L, Galeazzi G, Boffi R. The role of somatostatin and octreotide in bowel obstruction: pre-clinical and clinical results. Tumouri 2001;87:19.2. Anthone GJ, Bastidas JA, Orlandle MS, Yeo CJ. Direct proabsorptive effect of octreotide on ionic transport in the small intestine. Surgery 1990;108:113642.,奥曲肽有效缓解部分性肠梗阻的机制,降低肠腔内的高张力 阻断高张力状态所造成的“扩张-分泌-扩张”的恶性循环,奥曲肽和丁溴东莨菪碱药效比较,两项前瞻性随机研究结果显示1,2：奥曲肽能显著减少GI分泌量和每天呕吐的次数，缓解恶心，效果优于丁溴东莨菪碱 当两种药物之一无法奏效，联合用药可能改善GI分泌,1. Ripamonti C, Mercadante S, Groff L, Zecca E, De Conno F, Casuccio A. Role of octreotide, scopolamine butylbromide and hydration in symptom control of patients with inoperable bowel obstruction having a nasogastric tube. A prospective, randomized clinical trial. J Pain Symptom Manage 2000;19:2334.2. Mercadante S, Ripamonti C, Casuccio A, Zecca E, Groff L. Comparison of octreotide and hyoscine butylbromide in controlling gastrointestinal symptoms due to malignant inoperable bowel obstruction. Supportive Care in Cancer 2000;8:18891.,其他奥曲肽相关研究结果,最近一项进展期癌症患者的研究显示1：奥曲肽与甲氧氯普胺、地塞米松和早期推注泛影酸联合应用。绝大部分患者在15天内即可恢复胃肠道通畅并预防肠梗阻再发生，直到死亡 肠梗阻患者可在围手术期应用奥曲肽来改善患者的一般状况，然后联合静脉补充水和电解质、留置鼻胃管和使用抗生素2,3,1. Mercadante S, Avola G, Maddaloni S, et al. Octreotide prevents the pathological alterations of bowel obstruction in cancer patients. Support Care Cancer 1996;4:3934.Mercadante S, Kargar J, Nicolosi G. Octreotide may prevent definitive intestinal obstruction. J Pain Symptom Manage 1997;13:3525.3. Sun X, Li X, Li H. Management of intestinal obstruction in advanced ovarian cancer: an analysis of 57 cases in Chinese. Zhonghua Zhong Liu Za Zhi 1995;17:3942.,奥曲肽在 MBO 治疗中的意义,用于术前肠道准备，缩短准备时间，提高准备质量用于围手术期管理，减少术后并发症保守治疗，减轻或缓解不完全性梗阻的症状用于丧失手术机会的患者，缓解梗阻症状，提高其生活质量,全胃肠外营养（TPN）,无法手术的肠梗阻患者中 TPN 的作用，须从多方面认真考虑，应避免常规使用 需要根据其可能给患者带来的收益而作出判断1TPN 只能选择性使用2,1. Cozzaglio L et al. Outcome of cancer patients receiving home parenteral nutrition. J Parenteral Enteral Nutrition 1997;21:33942.2. Hoda D, Jatoi A, Burnes J, Loprinzi C, Kel