胰腺术后胃排空延迟：国际胰腺外科学组(ISGPS)的推荐-…

PAGEPAGE4遵守CreativeCommonsAttribution-NonCommercial-NoDerivatives4.0International(CCBY-NC-ND4.0)，引用请注明出处。本文翻译自：MoritzN.Wente,etal.Delayedgastricemptying(DGE)afterpancreaticsurgery:AsuggesteddefinitionbytheInternationalStudyGroupofPancreaticSurgery(ISGPS).Surgery,2007,vol142:761-768.译文权利所有：彭泉，杨桂元，钱祝银翻译时间：2010-04译文发表于：胰腺术后胃排空延迟（DGE）：国际胰腺外科学研究小组（ISGPS）的推荐定义翻译：彭泉，解放军105医院，安徽，合肥杨桂元，南京中医药大学附属医院暨江苏省中医院，江苏，南京审校：钱祝银，南京医科大学第一附属医院暨江苏省人民医院，江苏，南京背景：胃排空延迟（delayedgastricemptying,DGE）是胰腺切除术后最常见的并发症之一。由于没有一个国际统一的DGE定义标准，不同的外科中心报道的胰腺术后DGE发病率有很大差异。由于各个外科中心采用的DGE定义不同，也就无法对不同的研究报告和手术技术进行有效合理地比较。方法：通过对有关胰腺术后DGE的文献进行回顾总结，国际胰腺外科学研究小组（ISGPS）制定了一个客观的、普遍适用的DGE定义标准，并根据严重程度及对临床的影响进行分级。结果：DGE是指术后第一周末未能恢复正常饮食，包括需要延长鼻胃管减压时间的情况。按照对患者病程及术后处理的影响将其划分为三个等级（A，B，C级）。结论：本次制定的DGE定义及临床分级标准，能保障对以后的临床试验结果进行客观、准确的比较，并且有助于对胰腺外科领域采用新的干预治疗和手术方式进行客观的评价。(Surgery2007;142:761-8)功能性胃瘫可发生于糖尿病，中枢或周围神经功能紊乱，肾功能不全的病人，也可以表现为某些药物的副作用，也可能在无明确诱因的情况下出现。1-3不伴机械梗阻的胃排空延迟（DGE）可发生于上消化道术后，如胃迷走神经切断术后，食管切除术后等。4-9胰腺术后DGE尤为常见，导致患者住院时间延长。10，11目前，胰腺术后的主要并发症如胰瘘，胰腺术后出血的共识性定义已经被提出和达成。12，13但重大胰腺手术后DGE的定义目前仍未有一个广为接受的、客观、统一的标准；实际上，不同的临床研究采用了为数众多的不同的标准，使得无法对这些研究成果进行比较（如REF_Ref258362231\h表1）；这种不一致性也限制了对临床采用新的手术方法，手术技术，以及临床试验产生的并发症发病率和结果数据进行比较分析。表SEQ表\*ARABIC1已报道的胰腺切除术后DGE的定义。研究定义Miedema（1992）18术后14天以后无法耐受全量经口进食Yeo（1993）29(1)术后胃肠减压超过10天加以下其中一条：（a）胃管拔除后呕吐，（b）术后10天仍需应用胃动力药物，（c）需要再次置入胃管，（d）无法过渡到正常饮食；（2）术后胃肠减压小于10天加上（a）~（d）其中两项Patel（1995）67术后7天无法耐受流质饮食VanBergeHenegouwen（1997）38术后胃肠减压超过10天或术后14天内无法恢复正常饮食Sadowski（1997）39术后胃肠减压超过5天，每天引流量>500mlFabre(1999)56术后胃肠减压超过10天或因呕吐需再次置入胃管Horstmann（1999）42术后胃肠减压超过7天或术后14天仍不能恢复正常饮食Jimenez(2000)40术后14天无法正常进食，需要全肠外营养Martignoni（2000）25胃肠减压超过术后10天，术后第5天以后连续超过3天呕吐，X线检查发现胃部造影剂残留Goei（2001）50胃肠减压超过术后10天或术后14天仍无法耐受正常饮食Balcom（2001）41术后14天无法耐受经口进食Buchler（2003）20术后胃肠减压超过10天或术后10天以后需要再次置入胃管Niedergethmann（2006）46术后胃肠减压超过3天，需要重新置入胃管，或因DGE而需要应用胃动力药物如胃复安，新斯的明，红霉素Tani（2006）48（a）术后10天以后胃肠减压>500ml/d；（b）再次置入胃管；（c）术后14天无法全量经口进食DGE，胃排空延迟；POD，术后天；NGT，鼻胃管。在过去的二十年间，随着手术技术，重症监护医学，介入放射学的进展，以及更好的病例选择和术前准备，一些大手术量医疗中心报道的胰腺手术围手术期死亡率已经显著下降到<5%。14-17但尽管术后死亡率已明显下降，胰腺术后并发症的发病率依然很高（30%-50%）。14-22除了胰瘘和术后出血，DGE也是胰腺术后常见的主要并发症之一，发病率在19%-57%之间。18,19,23-27术后胃瘫，胃潴留，胃排空延迟的发生机制目前仍未阐明。使用促胃动力药，如胃动素受体激动剂红霉素可以减少DGE的发生率，支持说明十二指肠切除，残留十二指肠的长度以及术后血液促胃动素浓度下降可能是DGE的诱因之一的假说。28-33远端胰腺切除术后的患者很少发生DGE的现象同样支持这一假说。另外，对照研究也表明：保留十二指肠的胰头切除与胰十二指肠手术相比，前者的DGE发病率较低。23,34-37经典的（包括胃窦切除）与保留幽门的的胰十二指肠切除术均会发生DGE。一些研究表明，保留幽门的胰十二指肠切除术后的DGE发生率比采用经典术式的发病率要高，35,38-41而另一些研究则得出了相反的结论。42-46其他手术因素也会影响DGE的发生率，如消化道重建的方法（结肠前或结肠后）47,48以及其它特殊操作（BillrothI与BillrothII重建方法，或幽门机械扩张术）49-52和治疗小组采用的临床路径上的细节。25保留幽门的胰十二指肠切除术后DGE曾被部分归咎于幽门部去血管化和去神经化后继发的幽门痉挛。53-55支持这一理论的是，最近的研究将标准的保留幽门的胰十二指肠切除术与附加了幽门扩张或幽门肌切开的保留幽门的胰十二指肠切除术进行了比较，发现采用上述改良措施的术后DGE发病率明显降低（分别为26%：7%，25%：2%）。16,52,55一些报告指出其它的术后并发症会增加DGE的发病率。38,52,56-59DGE常常，但也不都是，伴随有胰瘘、胰周液体积聚或腹腔脓肿。对大多数患者而言，DGE本身并不是一个危及生命的并发症；但它可引起患者不适，延长术后住院时间，增加治疗费用，降低患者的术后生活质量。目前，由于进行胰腺手术的病人采用快速康复外科，缩短住院时间的情况变得越来越普遍，DGE与住院时间延长的直接联系使其具有显著地经济影响。在谈论这个话题时，必须要考虑到辅助诊断无可能需要（内窥镜检查，上消化道造影，ＣＴ）需要（内窥镜检查，上消化道造影，ＣＴ）介入治疗否否可能是（如脓肿引流，因并发症二次手术，因DGE二次手术）住院时间延长可能是是是辅助治疗延期否否是CT，计算机断层扫描；DGE，胃排空延迟；GI，胃肠道；NGT，鼻胃管。讨论DGE的发病原因目前仍不清楚，且很有可能是多因素造成。18,25,28,70-72胰腺切除手术后DGE，特别是胰十二指肠切除术后DGE可能的原因包括：十二指肠切除后血液胃动素浓度降低；沿肝总动脉的扩大淋巴结清扫使得支配胃窦区域的迷走神经和交感神经受损；保留幽门的胰十二指肠切除术后幽门区相关的相对去血管化或去神经化；以及胰肠吻合口瘘或一过性胰腺炎等。DGE之所以缺乏一个普遍接受的定义主要有几个原因。报告胰腺手术的病人通常年龄，性别各异，且更重要的是需要进行胰腺切除的病因有良性或恶性之分。此外，胰十二指肠切除术作为导致DGE最常见的胰腺手术存在多种实施方法。消化道重建所致的各种解剖变异情况，如十二指肠残留长度，胃切除的范围，胃-空肠、十二指肠-空肠吻合位于结肠前或结肠后，以及迷走神经切断与否都会影响到DGE的发生率。在一份报告中指出，DGE的发生率在十年间从17%下降到了6%。41研究者把这种下降归因于医生经验的增加和保留幽门的胰十二指肠切除术式应用的减少。除外胰瘘，DGE的发生与否是预测胰十二指肠术后患者住院时间的一个独立指标；在十年间，胰腺术后患者的平均住院时间从14天下降到８天。最近，Kurosaki和Hatakeyama51在连续55名行保留幽门的胰十二指肠切除术的患者中对现有的３种DGE定义进行了比较分析。采用Fabre等56、vanBergeHenegouwen等38、和Yeo等29的定义，DGE的发病率分别为6%,29%和18%，这也再次证明迫切需要制定一个客观的、可被广泛接受的DGE定义共识。缺少统一的定义，同时没有循证医学支持的处理方法以及缺少广为接受的何时移除胃管的标准，导致无法对胰腺手术后DGE的各种研究进行比较。日前，国际胰腺外科学研究小组（ISGPS）已就胰腺术后胰瘘12和术后出血13的定义达成共识，并且最近胰瘘的定义又做了更新。73相应的，此处制定的DGE定义标准也需要不断地在大型胰腺外科中心进行验证，以明确其临床适用性。这里提出的胰腺切除手术后重大并发症的定义，应该能够满足对以后的临床试验进行更有效的比较和评估。参考文献1.HornbuckleK,BarnettJL.Thediagnosisandwork-upofthepatientwithgastroparesis.JClinGastroenterol2000;30:117-24.2.JonesMP,MagantiK.Asystematicreviewofsurgicaltherapyforgastroparesis.AmJGastroenterol2003;98:2122-9.3.SyedAA,RattansinghA,FurtadoSD.Currentperspectivesonthemanagementofgastroparesis.JPostgradMed2005;51:54-60.4.KungSP,LuiWY,P’engFK.Ananalysisofthepossiblefactorscontributingtothedelayedreturnofgastricemptyingaftergastrojejunostomy.SurgToday1995;25:911-5.5.BemelmanWA,TaatCW,SlorsJF,vanLanschotJJ,ObertopH.Delayedpostoperativeemptyingafteresophagealresectionisdependentonthesizeofthegastricsubstitute.JAmCollSurg1995;180:461-4.6.BurtM,ScottA,WilliardWC,etal.Erythromycinstimulatesgastricemptyingafteresophagectomywithgastricreplacement:arandomizedclinicaltrial.JThoracCardiovascSurg1996;111:649-54.7.Bar-NatanM,LarsonGM,StephensG,MasseyT.Delayedgastricemptyingaftergastricsurgery.AmJSurg1996;172:24-8.8.ChangTM,ChenTH,TsouSS,LiuYC,ShenKL.Differencesingastricemptyingbetweenhighlyselectivevagotomyandposteriortruncalvagotomycombinedwithanteriorseromyotomy.JGastrointestSurg1999;3:53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