Morita Yoshifumi, Sakaguchi Takanori, Ida Shinya, Muraki Ryuta, Kitajima Ryo, Furuhashi Satoru, Takeda Makoto, Kikuchi Hirotoshi, Hiramatsu Yoshihiro, Takeuchi Hiroya
Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan.
Department of Surgery, Iwata City Hospital, Japan.
Asian J Surg. 2022 Jan;45(1):172-178. doi: 10.1016/j.asjsur.2021.04.022. Epub 2021 Apr 28.
BACKGROUND/OBJECTIVE: Pancreaticoduodenectomy (PD) is highly invasive with unsatisfactory postoperative complication rates. Nutritional and fluid management after major surgery attracts much attention with regard to the reduction in severe postoperative complications. We retrospectively analyzed PD cases and proposed a novel strategy for perioperative fluid and nutritional therapy according to the risk stratification by pancreatic fistula (PF) and delayed gastric emptying (DGE).
Between 2003 and 2018, 140 patients underwent PD at our institute of which 134 patients were enrolled. We evaluated the clinicopathological factors affecting severe (≥10%) body weight loss (BWL), factors affecting the incidence of PF and intraabdominal complications (IAC), and factors related to DGE.
Multivariate analysis indicated that male sex, severe PF, and DGE are significant risk factors for BWL ≥10%. PF and IAC were predominantly observed in male patients and those with non-pancreatic cancer. A fluid balance ≥6000 ml on postoperative day 2 was the sole risk factor for primary DGE. Secondary DGE significantly correlated with stomach preserving PD. Importantly, the average BWL was around 15% in grade B or C secondary DGE.
Severe postoperative complications resulted in significant BWL. Enteral feeding is unnecessary in cases with a hard pancreas and dilated pancreatic duct if appropriate perioperative fluid management is performed. Secondary DGE followed by PF or IAC is unavoidable to some extent, especially in the case of soft pancreas with a fine pancreatic duct. In such cases, enteral feeding with tube ileostomy should be considered, and stomach preserving PD is likely to be harmful.
背景/目的：胰十二指肠切除术（PD）具有高度侵袭性，术后并发症发生率不尽人意。大手术后的营养和液体管理对于降低严重术后并发症备受关注。我们回顾性分析了PD病例，并根据胰瘘（PF）和胃排空延迟（DGE）的风险分层提出了一种围手术期液体和营养治疗的新策略。
2003年至2018年期间，我院有140例患者接受了PD手术，其中134例患者被纳入研究。我们评估了影响严重（≥10%）体重减轻（BWL）的临床病理因素、影响PF和腹腔内并发症（IAC）发生率的因素以及与DGE相关的因素。
多因素分析表明，男性、严重PF和DGE是BWL≥10%的显著危险因素。PF和IAC主要见于男性患者和非胰腺癌患者。术后第2天液体平衡≥6000 ml是原发性DGE的唯一危险因素。继发性DGE与保留胃的PD显著相关。重要的是，B级或C级继发性DGE患者的平均BWL约为15%。
严重的术后并发症导致显著的BWL。如果进行适当的围手术期液体管理，对于胰腺坚硬且胰管扩张的病例无需进行肠内喂养。继发性DGE随后出现PF或IAC在一定程度上是不可避免的，尤其是在胰腺柔软且胰管纤细的情况下。在这种情况下，应考虑行回肠造口管饲肠内喂养，而保留胃的PD可能有害。
