Pankreas Cerrahisi Sonrası Gastrik Disfonksiyon Yönetimi
Özet
Gecikmiş mide boşalması (DGE), üst gastrointestinal sistem cerrahileri ve özellikle pankretikoduodenektomi (Whipple) operasyonları sonrasında en sık gözlenen ikinci komplikasyon olarak klinik yönetimde önemli bir yer tutmaktadır. Mekanik bir tıkanıklık olmaksızın midenin nörohumoral aktivitelerindeki yetersizlik sonucu gelişen bu disfonksiyon, hastanede kalış süresini uzatmakta, malnütrisyona yol açmakta ve adjuvan tedavileri geciktirerek mortaliteyi artırmaktadır. Patofizyolojisinde, motilin hormonu ve migrating motor kompleks (MMK) mekanizmalarının cerrahi rezeksiyon nedeniyle bozulması temel rol oynamaktadır. Uluslararası Pankreas Cerrahisi Çalışma Grubu (ISGPS) kriterlerine göre DGE; nazogastrik tüp ihtiyacı ve katı gıda toleransına bağlı olarak A, B ve C olmak üzere üç klinik dereceye sınıflandırılmaktadır. Derece A genellikle hafif ve geçici seyrederken; B ve C dereceleri prokinetik ajanlar, enteral/parenteral beslenme desteği ve batın içi enfeksiyon veya fistül gibi altta yatan diğer cerrahi komplikasyonların radyolojik olarak dışlanmasını gerektirmektedir. Günümüze kadar pilor koruyucu yaklaşımlar, subtotal mide koruyucu teknikler ile antekolik/retrokolik rekonstrüksiyon tipleri gibi birçok cerrahi yöntem karşılaştırılmış olsa da hiçbir tekniğin birbirine kesin üstünlüğü kanıtlanamamıştır. Sonuç olarak DGE, hasta konforunu ve maliyetleri doğrudan etkileyen, önlenmesi ve tedavisi için daha fazla klinik çalışmaya ihtiyaç duyulan kritik bir postoperatif problemdir.
Delayed gastric emptying (DGE) stands as the second most common complication following upper gastrointestinal surgeries, particularly pancreaticoduodenectomy (Whipple procedure), presenting a significant challenge in clinical management. Characterized by the impairment of gastric motility due to deficient neurohumoral activities without mechanical obstruction, DGE significantly prolongs hospital stay, causes severe malnutrition, and increases mortality by delaying adjuvant therapies. Its pathophysiology is driven by the disruption of the migrating motor complex (MMC) and motilin hormone pathways resulting from surgical resection. According to the International Study Group of Pancreatic Surgery (ISGPS), DGE is classified into Grades A, B, and C based on the duration of nasogastric tube dependence and solid food intolerance. While Grade A presents a mild, self-limiting course, Grades B and C necessitate prokinetic agents, enteral or parenteral nutritional support, and diagnostic imaging to rule out associated complications like pancreatic fistulas or intra-abdominal abscesses. Various surgical modifications—including pylorus-preserving, subtotal stomach-preserving techniques, and antecolic versus retrocolic reconstructions—have been extensively researched, yet no single approach has proven definitively superior in preventing DGE. Consequently, DGE remains a major postoperative challenge affecting patient quality of life and healthcare costs, demanding further targeted clinical research.
Referanslar
Kung SP, Lui WY, P’eng FK. An analysis of the possible factors contributing to the delayed return of gastric emptying after gastrojejunostomy. Surg Today 1995;25:911-5.
Bemelman WA, Taat CW, Slors JF, Delayed postoperative emptying after esophageal resection is dependent on the size of the gastric substitute. J Am Coll Surg 1995;180:461-4.
Burt M, Scott A, Williard WC, et al. Erythromycin stimulates gastric emptying after esophagectomy with gastric replacement:a randomized clinical trial. J Thorac Cardiovasc Surg 1996;111:649-54.
Bar-Natan M, Larson GM, Stephens G, Massey T. Delayed gastric emptying after gastric surgery. Am J Surg 1996; 172:24-8.
Chang TM, Chen TH, Tsou SS, et al. Differences in gastric emptying between highly selective vagotomy and posterior truncal vagotomy combined with anterior seromyotomy. J Gastrointest Surg 1999;3:533-6.
Lee HS, Kim MS, Lee JM, et al. Intrathoracic gastric emptying of solid food after esophagectomy for esophageal cancer. Ann Thorac Surg 2005;80:443-7.
Hornbuckle K, Barnett JL. The diagnosis and work-up of the patient with gastroparesis. J Clin Gastroenterol 2000;30: 117-24.
Jones MP, Maganti K. A systematic review of surgical therapy for gastroparesis. Am J Gastroenterol 2003;98:2122-9.
Syed AA, Rattansingh A, Furtado SD. Current perspectives on the management of gastroparesis. J Postgrad Med 2005;51:54-60
Gangavatiker R, Pal S, Javed A. et al. Effect of antecolic or retrocolic reconstruction of the gastro/duodenojejunostomy on delayed gastric emptying after pancreaticoduodenectomy: a randomized controlled trial. J Gastrointest Surg. 2011;15(5):843–52.
Warshaw AL, Torchiana DL. Delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy. Surg Gynecol Obstet. 1985;160(1):1–4.
Parmar AD, Sheffield KM, Vargas GM, et al. Factors associated with delayed gastric emptying after pancreaticoduodenectomy. HPB (Oxford). 2013;15(10):763–72.
Fabre JM, Burgel JS, Navarro F, et al. Delayed gastric emptying after pancreaticoduodenectomy and pancreaticogastrostomy. Eur J Surg. 1999;165:560-565.
Horstmann O, Becker H, Post S, et al. Is delayed gastric emptying following pancreaticoduodenectomy related to pylorus preservation? Langenbecks Arch Surg. 1999;384:610- 618.
Ehrlein HJ, Schemann M. Gastrointestinal Motility. Technische Universitat Munchen, Munich, Germany. 2005. http://humanbiology. wzw.tum.de/motvid01/tutorial.pdf. Accessed August 6 2015.
Hansen MB: Neurohumoral control of gastrointestinal motility. Physiol Res 2003;52:1–30.
Itoh Z, Aizawa I, Takeuchi S, TakayanagiR: Diurnal changes in gastric motor activity in conscious dogs.AmJ Dig Dis 1977;22:117–124.
Poitras S, Brosseau L: Evidence-informed management of chronic low back pain with transcutaneous electrical nerve stimulation, interferential current, electrical muscle stimulation, ultrasound, and thermotherapy. Spine J 2008;8:226–233.
Kollmar O, Sperling J, Moussavian MR, et al. : Delayed gastricemptying after pancreaticoduodenectomy: influence of the orthotopic technique of reconstruction and intestinal motilin receptor expression. J Gastrointest Surg 2011;15:1158–1167.
Miller P, Roy A, St-Pierre S, et al.: Motilin receptors in the human antrum. Am J Physiol Gastrointest Liver Physiol 2000;278:G18-23.
Mochiki E, Asao T, Kuwano H: Gastrointestinal motility after digestive surgery. Surg Today 2007;37:1023–1032.
Tanaka M, SarrMG: Role of the duodenum in the control of caninegastrointestinal motility. Gastroenterology 1988;94:622–629.
Tanaka M, SarrMG: Effects of exogenousmotilin and morphine oninterdigestive gastrointestinal motor activity after total duodenectomy in dogs. Surgery 1988;104:317–325.
McLeod RS, Taylor BR, O’Connor BI, et al.: Quality of life, nutritional status, and gastrointestinal hormone profile following the Whipple procedure. Am J Surg 1995;169:179–185.
Naritomi G, Tanaka M, Matsunaga H. et al.: Pancreatic head resectionwith and without preservation of the duodenum: different postoperative gastric motility. Surgery 1996;120:831–837.
Murakami Y, Uemura K, Sudo T, et al.: An antecolic Roux-en Y type reconstruction decreased delayed gastric emptying after pyloruspreserving pancreatoduodenectomy. J Gastrointest Surg 2008;12: 1081–1086.
Nikfarjam M, Kimchi ET, Gusani NJ, et al.: A reduction in delayed gastric emptying by classic pancreaticoduodenectomy with an antecolic gastrojejunal anastomosis and a retrogastric omental patch. J Gastrointest Surg 2009;13:1674–1682.
Fischer CP, Hong JC: Method of pyloric reconstruction and impact upon delayed gastric emptying and hospital stay after pyloruspreserving pancreaticoduodenectomy. J Gastrointest Surg 2006;10:215–219.
Hayashibe A, KameyamaM, Shinbo M: The surgical procedure and clinical results of subtotal stomach preserving pancreaticoduodenectomy (SSPPD) in comparison with pylorus preserving pancreaticoduodenectomy (PPPD). J Surg Oncol 2007;95:106–109.
KawaiM, Tani M, Hirono S: Pylorus ring resection reduces delayed gastric emptying in patients undergoing pancreatoduodenectomy: a prospective, randomized, controlled trial of pylorus-resecting versus pyloruspreserving pancreatoduodenectomy. Ann Surg 2011;253:495–501.
Kurahara H, Shinchi H, Maemura K : Delayed gastric emptying after pancreatoduodenectomy. J Surg Res 2011;171:e187-192.
Ogata Y, Hishinuma S: The impact of pylorus-preserving pancreatoduodenectomy on surgical treatment for cancer of the pancreatic head. J Hepatobiliary Pancreat Surg 2002;9:223–232.
Ohtsuka T, Tanaka M, Miyazaki K: Gastrointestinal function and quality of life after pylorus-preserving pancreatoduodenectomy. J Hepatobiliary Pancreat Surg 2006;13:218–224.
Traverso LW, Longmire WP, Jr.: Preservation of the pylorus in pancreaticoduodenectomy. Surg Gynecol Obstet 1978;146:959–962.
Pastorino G, Ermili F, Zappatore F: Multiparametric evaluation of functional outcome after pyloruspreserving duodenopancreatectomy. Hepatogastroenterology 1995;42:62–67.
Izbicki JR, Bloechle C, Broering DC. Extended drainage versus resection in surgery for chronic pancreatitis: a prospective randomized trial comparing the longitudinal pancreaticojejunostomy combined with local pancreatic head excision with the pylorus-preserving pancreatoduodenectomy. Ann Surg 1998;228:771-9
Witzigmann H, Max D, Uhlmann D, et al. Outcome after duodenum-preserving pancreatic head resection is improved compared with classic Whipple procedure in the treatment of chronic pancreatitis. Surgery 2003;134:53-62
Van Berge Henegouwen MI, van Gulik TM, DeWit LT, et al. Delayed gastric emptying after standard pancreaticoduodenectomy versus pylorus-preserving pancreaticoduodenectomy: an analysis of 200 consecutive patients. J Am Coll Surg 1997;185:373-9
Balcom JH, Rattner DW, Warshaw AL:Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization. Arch Surg 2001;136: 391-8
Kim DK, Hindenburg AA, Sharma SK, et al. Is pylorospasm a cause of delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy? Ann Surg Oncol 2005;12:2227.
Hanna M., Gadde , Sleeman D., et al. Delayed gastric emptying after pancreaticoduodenectomy: Is subtotal stomach preserving better or pylorus preserving? Journal of Gastrointestinal Surgery. 2015;19(8):1542–1552.
Matsumoto I., Shinzeki M., Asari S., et al. A prospective randomized comparison between pylorus- and subtotal stomach-preserving pancreatoduodenectomy on postoperative delayed gastric emptying occurrence and long-term nutritional status. J Surg Oncol. 2014;109(7):690–696.
Qian D., Lu Z.P., Jackson R., et al. Effect of antecolic or retrocolic route of gastroenteric anastomosis on delayed gastric emptying after pancreaticoduodenectomy: A meta-analysis of randomized controlled trials. Pancreatology. 2016;16(1):142–150.
Mamura M., Kimura Y., Ito T., et al. Effects of antecolic versus retrocolic reconstruction for gastro/duodenojejunostomy on delayed gastric emptying after pancreatoduodenectomy: a systematic review and meta-analysis. J Surg Res. 2016;200(1):147–157.
Shimoda M., Kubota K., Katoh M. . Effect of Billroth II or Roux-en-Y Reconstruction for the Gastrojejunostomy on Delayed Gastric Emptying After Pancreaticoduodenectomy. Ann Surg. 2013;257(5):938–942
Barakat O., Cagigas M.N., Bozorgui S. . Proximal Roux-en-y Gastrojejunal Anastomosis with Pyloric Ring Resection Improves Gastric Emptying After Pancreaticoduodenectomy. Journal of Gastrointestinal Surgery. 2016;20(5):914–923.
