胰腺癌围手术期营养治疗的策略

Strategy of perioperative nutrition therapy for pancreatic cancer

胰腺癌患者围手术期易发生营养不良。术前营养不良因素包括胰腺功能不全与肿瘤引起的代谢改变,术后应激与炎症等因素增加了短期内营养不良风险,围手术期营养不良是导致整体预后不良的独立危险因素,因此有必要开展全程化营养管理。入院后患者常规进行营养筛查,应用量化的营养筛查工具可以判断营养风险,对于营养风险较高的患者需进一步行营养评估,加速康复外科建议术前出现体重丢失>15%或体质指数<18.5 kg/m^(2)的患者行营养治疗,营养治疗遵循阶梯递升式原则,术前营养状态将影响手术时机的选择。单一指标无法完整描述术后患者的营养状态,建议采用多种方式动态监测营养状况并综合分析。术后营养治疗需结合患者病情与营养状况制订个体化方案,合理选择营养治疗途径能避免为患者带来额外的痛苦与经济负担。早期经口进食被认为是安全有效的,但对于口服耐受不佳的患者应及时启动人工营养。肠内营养具有维持肠道功能等优势,但全肠外营养在严重肠瘘、胃排空延迟等并发症治疗中具有巨大价值。

Patients with pancreatic cancer are susceptible to perioperative malnutrition.Preoperative malnutrition factors include pancreatic insufficiency and tumor-induced metabolic changes,postoperative stress and inflammation increase the risk of short-term nutritional deterioration,and perioperative malnutrition is an independent risk factor for overall poor prognosis,so it is necessary to carry out a comprehensive nutritional management.Nutritional screening is routinely performed after admission,and quantitative nutritional screening tools can be used to determine the nutritional risk.Further nutritional assessment is required for patients with higher nutritional risk.Enhanced recovery after surgery suggests that nutritional therapy should be performed for patients who have lost more than 15%of their body weight or have a body mass index of less than 18.5 kg/m^(2) before surgery,and nutritional therapy should be based on the principle of stepwise escalation.The preoperative nutritional status will affect the timing of surgery.A single indicator cannot completely describe the nutritional status of postoperative patients,and it is recommended to use multiple methods to dynamically monitor the nutritional status and analyze it comprehensively.Postoperative nutritional therapy should be individualized in accordance with the patient's condition and nutritional status,and a reasonable choice of nutritional support pathway can avoid additional pain and economic burden for patients.Early oral feeding is considered to be safe and effective,but artificial nutrition should be initiated in time for patients with poor oral tolerance.Enteral nutrition has advantages such as maintaining intestinal function,but total parenteral nutrition is of great value in the treatment of severe intestinal fistula,delayed gastric emptying and other complications.