1 Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA ; 2 Department of Food and Nutrition Management, 3 Department of Medicine (Medical Nutrition), 4 Department of Surgery, New York-Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA.
Hepatobiliary Surg Nutr. 2015 Feb;4(1):59-71. doi: 10.3978/j.issn.2304-3881.2014.08.07.
Surgery remains the only curative treatment for pancreaticobiliary tumors. These patients typically present in a malnourished state. Various screening tools have been employed to help with preoperative risk stratification. Examples include the subjective global assessment (SGA), malnutrition universal screening tool (MUST), and nutritional risk index (NRI). Adequate studies have not been performed to determine if perioperative interventions, based on nutrition risk assessment, result in less morbidity and mortality. The routine use of gastric decompression with nasogastric sump tubes may be unnecessary following elective pancreatic resections. Instead, placement should be selective and employed on a case-by-case basis. A wide variety of feeding modalities are available, oral nutrition being the most effective. Artificial nutrition may be provided by temporary nasal tube (nasogastric, nasojejunal, or combined nasogastrojejunal tube) or surgically placed tube [gastrostomy (GT), jejunostomy (JT), gastrojejunostomy tubes (GJT)], and intravenously (parenteral nutrition, PN). The optimal tube for enteral feeding cannot be determined based on current data. Each is associated with a specific set of complications. Dual lumen tubes may be useful in the presence of delayed gastric emptying (DGE) as the stomach may be decompressed while feeds are delivered to the jejunum. However, all feeding tubes placed in the small intestine, except direct jejunostomies, commonly dislodge and retroflex into the stomach. Jejunostomies are associated with less frequent, but more serious complications. These include intestinal torsion and bowel necrosis. PN is associated with septic, metabolic, and access-related complications and should be the feeding strategy of last-resort. Enteral feeds are clearly preferred over parental nutrition. A sound understanding of perioperative nutrition may improve patient outcomes. Patients undergoing pancreatic cancer surgery should undergo multidisciplinary nutrition screening and intervention, and the surgical/oncological team should include nutrition professionals in managing these patients in the perioperative period.
手术仍然是治疗胰胆肿瘤的唯一方法。这些患者通常处于营养不良状态。各种筛选工具已被用于帮助术前风险分层。例如主观全面评估（SGA）、营养不良通用筛选工具（MUST）和营养风险指数（NRI）。尚未进行充分的研究来确定基于营养风险评估的围手术期干预是否会降低发病率和死亡率。在选择性胰腺切除术后，胃减压可能不需要常规使用鼻胃管。相反，应根据具体情况选择性放置。有多种不同的喂养方式，口服营养是最有效的。人工营养可以通过临时鼻管（鼻胃管、鼻空肠管或联合鼻胃空肠管）或手术放置的管（胃造口术[GT]、空肠造口术[JT]、胃空肠造口术管[GJT]）以及静脉内（肠外营养，PN）提供。根据目前的数据，无法确定最适合的肠内喂养管。每种方法都与一组特定的并发症相关。在存在胃排空延迟（DGE）的情况下，双腔管可能会很有用，因为在向空肠输送喂养物的同时可以对胃进行减压。然而，除了直接空肠造口术外，放置在小肠中的所有喂养管都经常脱落并反流到胃中。空肠造口术与不太频繁但更严重的并发症相关，包括肠扭转和肠坏死。PN 与感染、代谢和通路相关的并发症有关，应作为最后的营养支持策略。肠内喂养显然优于肠外营养。对围手术期营养有一个清晰的了解可以改善患者的预后。接受胰腺癌手术的患者应接受多学科营养筛查和干预，手术/肿瘤学团队应包括营养专业人员，以在围手术期管理这些患者。
