术后胃瘫的治疗进展
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摘要
术后胃瘫延长住院时间、增加医疗费用并造成很多不良后果。对胃正常生理运动功能的研究有助于指导术后胃瘫的治疗。很多机制参与术后胃瘫的发生发展,如神经-化学因素、炎症反应、阿片类麻醉药物、部分胃切除、补液过多、低血压和缩血管药物等等。术后胃瘫治疗应采取综合性的治疗,包括术前、术中和术后的一系列预防性措施。针对性治疗主要是药物治疗,目前新的治疗方法如内镜下内毒素及支架治疗、胃电起搏治疗的效果尚需进一步研究。腔镜下幽门成形术可用来治疗内科保守治疗无效的胃瘫。而以经口内镜下胃幽门肌切开术(gastric peroral endoscopic pyloromyotomy, G-POEM)为代表的微创治疗在难治性胃瘫中的作用日益受到推崇。
Postoperative gastroparesis increases hospitalization time, medical expenses and caused many adverse consequences. The study of the normal physiological motor function of the stomach helps to guide the treatment of postoperative gastroparesis. Many mechanisms are involved in the development of postoperative gastroparesis, such as neuro-chemical factors, inflammatory reactions, opioid anesthetics, partial gastrectomy,excessive fluid replacement, hypotension, and vasoconstrictor drugs. Postoperative gastroparesis should be treated in a comprehensive manner, including a series of preventive measures before, during and after surgery. Targeted treatment is mainly drug treatment. At present, the effects of new treatment methods such as endoscopic endotoxin, stent placement and gastric pacing therapy need further investigation. Endoscopic py-loric angioplasty can be used to treat stomach cramps that are ineffective in conservative medical treatment.The role of minimally invasive treatment represented by gastric peroral endoscopic pyloromyotomy(G-POEM) in refractory gastric fistula is increasingly recognized as an efficient treatment.
Postoperative gastroparesis increases hospitalization time, medical expenses and caused many adverse consequences. The study of the normal physiological motor function of the stomach helps to guide the treatment of postoperative gastroparesis. Many mechanisms are involved in the development of postoperative gastroparesis, such as neuro-chemical factors, inflammatory reactions, opioid anesthetics, partial gastrectomy,excessive fluid replacement, hypotension, and vasoconstrictor drugs. Postoperative gastroparesis should be treated in a comprehensive manner, including a series of preventive measures before, during and after surgery. Targeted treatment is mainly drug treatment. At present, the effects of new treatment methods such as endoscopic endotoxin, stent placement and gastric pacing therapy need further investigation. Endoscopic py-loric angioplasty can be used to treat stomach cramps that are ineffective in conservative medical treatment.The role of minimally invasive treatment represented by gastric peroral endoscopic pyloromyotomy(G-POEM) in refractory gastric fistula is increasingly recognized as an efficient treatment.
引文
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[2] Vantrappen G, Janssens J, Hellemans J, et al:The interdigestive motor complex of normal subjects and patients with bacterial overgrowth of the small intestine[J]. J Clin Invest, 1977, 59(6):1158-1166.
[3] Minami H, Mccallum R W:The physiology and pathophysiology of gastric emptying in humans[J]. Gastroenterology, 1984, 86(6):1592-1610.
[4] Azpiroz F, Malagelada J R:Vagally mediated gastric relaxation induced by intestinal nutrients in the dog[J]. Am J Physiol,1986, 251(6 Pt 1):G727-G735.
[5] Parkman H P, Hasler W L, Fisher R S:American Gastroentero-logical Association technical review on the diagnosis and treatment of gastroparesis[J]. Gastroenterology, 2004,127(5):1592-1622.
[6] Kendall B J, Mccallum R W:Gastroparesis and the current use of prokinetic drugs[J]. Gastroenterologist, 1993, 1(2):107-114.
[7] Ramkumar D, Schulze K S:Gastroduodenal motility[J]. Curr Opin Gastroenterol, 2003, 19(6):540-545.
[8] Berend K R, Lombardi A J, Mallory T H, et al:Ileus following total hip or knee arthroplasty is associated with increased risk of deep venous thrombosis and pulmonary embolism[J]. J Arthroplasty, 2004, 19(7 Suppl 2):82-86.
[9] Malinzak L E, Long G W, Bove P G, et al:Gastrointestinal complications following infrarenal endovascular aneurysm repair[J]. Vase Endovascular Surg, 2004, 38(2):137-142.
[10] Fruhwald S, Holzer P, Metzler H:Intestinal motility disturbances in intensive care patients pathogenesis and clinical impact[J]. Intensive Care Med, 2007, 33(1):36-44.
[11] Wente M N, Bassi C, Dervenis C, et al:Delayed gastric emptying(DGE)after pancreatic surgery:a suggested definition by the International Study Group of Pancreatic Surgery(ISGPS)[J]. Surgery, 2007, 142(5):761-768.
[12] Fruhwald S, Holzer P, Metzler H:Gastrointestinal motility in acute illness[J]. Wien Klin Wochenschr, 2008, 120(1-2):6-17.
[13] Lobo D N:Fluid, electrolytes and nutrition:physiological and clinical aspects[J]. Proc Nutr Soc, 2004, 63(3):453-466.
[14] Eh L:Stomach and duodenum, Surgery:Basic Science and Clinical Evidence[J]. New York:Springer-Verlag, 2001,489-516.
[15] Johnson M D, Walsh R M:Current therapies to shorten postoperative ileus[J]. Cleve Clin J Med, 2009, 76(11):641-648.
[16] Cowley D J, Vernon P, Jones T,et al:Gastric emptying of solid meals after truncal vagotomy and pyloroplasty in human subjects[J]. Gut,1972, 13(3):176-181.
[17] Hinder R A, Kelly K A:Human gastric pacesetter potential.Site of origin, spread, and response to gastric transection and proximal gastric vagotomy[J]. Am J Surg, 1977, 133(I):29-33.
[18] Akkermans L M, Hendrikse C A:Post-gastrectomy problems[J]. Dig Liver Dis, 2000, 32 Suppl 3:S263-S264.
[19] Sun W M, Doran S M, Jones K L, et al:Long-term effects of pyloromyotomy on pyloric motility and gastric emptying in humans[J]. Am J Gastroenterol, 2000, 95(1):92-100.
[20] Luckey A, Livingston E, Tache Y:Mechanisms and treatment of postoperative ileus[J]. Arch Surg, 2003, 138(2):206-214.
[21] De Winter B Y, Boeckxstaens G E, De Man J G, et al:Effect of adrenergic and nitrergic blockade on experimental ileus in rats[J]. Br J Pharmacol, 1997, 120(3):464-468.
[22] Kalff J C, Schraut W H, Billiar T R, et al:Role of inducible nitric oxide synthase in postoperative intestinal smooth muscle dysfunction in rodents[J]. Gastroenterology, 2000,118(2):316-327.
[23] Stengel A, Tache Y:Ghrelin:new insight to mechanisms and treatment of postoperative gastric ileus[J]. Curr Pharm Des, 2011,17(16):1587-1593.
[24] Kalff J C, Schraut W H, Simmons R L, et al:Surgical manipulation of the gut elicits an intestinal muscularis inflammatory response resulting in postsurgical ileus[J]. Ann Surg, 1998, 228(5):652-663.
[25] Schwarz N T, Kalff J C, Turler A, et al:Prostanoid production via COX-2 as a causative mechanism of rodent postoperative ileus[J]. Gastroenterology,2001,121(6):1354-1371.
[26] Kaufman P N, Krevsky B, Malmud L S, et al:Role of opiate receptors in the regulation of colonic transit[J]. Gastroenterology,1988, 94(6):1351-1356.
[27] Eagon J C, Miedema B W, Kelly K A:Postgastrectomy syndromes[J]. Surg Glin North Am, 1992, 72(2):445-465.
[28] Fich A, Neri M, Camilleri M, et al:Stasis syndromes following gastric surgery:clinical and motility features of 60 symptomatic patients[J]. J Clin Gastroenterol, 1990, 12(5):505-512.
[29] Le Blanc-Louvry I, Savoye G, Maillot C, et al:An impaired accommodation of the proximal stomach to a meal is associated with symptoms after distal gastrectomy[J]. Am J Gastroenterol,2003, 98(12):2642-2647.
[30] Lobo D N:Fluid, electrolytes and nutrition:physiological and clinical aspects[J]. Proc Nutr Soc, 2004, 63(3):453-466.
[31] Tougas G, Eaker E Y, Abell T L, et al:Assessment of gastric emptying using a low fat meal:establishment of international control values[J]. Am J Gastroenterol, 2000, 95(6):1456-1462.
[32] Dong K, Yu X J, Li B, et al:Advances in mechanisms of postsurgical gastroparesis syndrome and its diagnosis and treatment[J]. Chin J Dig Dis, 2006, 7(2):76-82.
[33] Lobo D N, Bostock K A, Neal K R, et al:Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection:a randomised controlled trial[J]. Lancet,2002, 359(9320):1812-1818.
[34] Kehlet H:Future perspectives and research initiatives in fasttrack surgery[J]. Langenbecks Arch Surg, 2006, 391(5):495-498.
[35] Nisanevich V, Felsenstein I, Almogy G, et al:Effect of intraoperative fluid management on outcome after intraabdominal surgery[J]. Anesthesiology, 2005, 103(1):25-32.
[36] Hasler W L, Soudah H C, Dulai G, et al:Mediation of hyperglycemia-evoked gastric slow-wave dysrhythmias by endogenous prostaglandins[J]. Gastroenterology, 1995, 108(3):727-736.
[37] Horowitz M,O'Donovan D, Jones K L,et al:Gastric emptying in diabetes:clinical significance and treatment[J]. Diabet Med,2002, 19(3):177-194.
[38] Weber F J, Richards R D, Mccallum R W:Erythromycin:a motilin agonist and gastrointestinal prokinetic agent[J]. Am J Gastroenterol, 1993,88(4):485-490.
[39] Larson J M, Tavakkoli A, Drane W E, et al:Advantages of azithromycin over erythromycin in improving the gastric emptying half-time in adult patients with gastroparesis[J]. J Neuro-gastroenterol Motil, 2010, 16(4):407-413.
[40] Ramirez B, Eaker E Y, Drane W E, et al:Erythromycin enhances gastric emptying in patients with gastroparesis after vagotomy and antrectomy[J]. Dig Dis Sci,1994,39(11):2295-2300.
[41] Kendall B J, Chakravarti A, Kendall E, et al:The effect of intravenous erythromycin on solid meal gastric emptying in patients with chronic symptomatic post-vagotomy-antrectomy gastroparesis[J]. Aliment Pharmacol Ther, 1997, 11(2):381-385.
[42] Yeo C J, Barry M K, Sauter P K, et al:Erythromycin accelerates gastric emptying after pancreaticoduodenectomy. A prospective, randomized, placebo-controlled trial[J]. Ann Surg,1993, 218(3):229-237, 237-238.
[43] Thompson J S, Quigley E M:Prokinetic agents in the surgical patient[J]. Am J Surg, 1999, 177(6):508-514.
[44] Chapman M J, Fraser R J, Kluger M T, et al:Erythromycin improves gastric emptying in critically ill patients intolerant of nasogastric feeding[J]. Crit Care Med, 2000, 28(7):2334-2337.
[45] Ray W A, Murray K T, Meredith S, et al:Oral erythromycin and the risk of sudden death from cardiac causes[J]. N Engl J Med, 2004, 351(11):1089-1096.
[46] Booth C M, Heyland D K, Paterson W G:Gastrointestinal promotility drugs in the critical care setting:a systematic review of the evidence[J]. Crit Care Med, 2002, 30(7):1429-1435.
[47] Delaney C P:Clinical perspective on postoperative ileus and the effect of opiates[J]. Neurogastroenterol Motil, 2004, 16 Suppl2:61-66.
[48] Administration U F A D:FDA requires boxed warning and risk mitigation strategy for metoclopramide-containing drugs, 2009,(Accessed 8/24/2009):Agency warns against chronic use of these products to treat gastrointestinal disorders.
[49] Soykan I, Sarosiek I, Shifflett J, et al:Effect of chronic oral domperidone therapy on gastrointestinal symptoms and gastric emptying in patients with Parkinson's disease[J]. Mov Disord,1997, 12(6):952-957.
[50] Fraser R J, Horowitz M, Maddox A F, et al:Postprandial antropyloroduodenal motility and gastric emptying in gastroparesis--effects of cisapride[J]. Gut,1994, 35(2):172-178.
[51] Braden B, Enghofer M, Schaub M, et al:Long-term cisapride treatment improves diabetic gastroparesis but not glycaemic control[J]. Aliment Pharmacol Ther, 2002, 16(7):1341-1346.
[52] Jones M P:Access options for withdrawn motility-modifying agents[J]. Am J Gastroenterol, 2002, 97(9):2184-2188.
[53] Aljarallah B M:Management of diabetic gastroparesis[J]. Saudi J Gastroenterol, 2011, 17(2):97-104.
[54] Gupta P, Rao S S:Attenuation of isolated pyloric pressure waves in gastroparesis in response to botulinum toxin injection:a case report[J]. Gastrointest Endosc,2002, 56(5):770-772.
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