恶性肠梗阻营养制剂的选择

晚期恶性肿瘤合并恶性肠梗阻 （MBO）的发生率为5%～43%。MBO的常规治疗方法有药物治疗、手术治疗、营养治疗、支架置入、胃肠减压及中医治疗。但是,由于消化道梗阻的存在,大多数MBO患者无法进食或仅能进食少量食物,尽早予以营养治疗,对于提高患者生存质量、延长生存期非常重要。只要肠道有功能,就尽量采用肠内营养。营养不良治疗的基本原则应该是满足患者能量需求、蛋白质需求、液体量目标需求及微量营养素需要量。营养治疗主要采用第四阶梯部分肠内营养+部分肠外营养（PEN+PPN）或第五阶梯全肠外营养（TPN）。本文就患者可使用的肠内营养制剂类型及肠外营养制剂类型进行分别阐述。     

恶性肠梗阻的营养治疗策略

恶性肠梗阻是晚期肿瘤患者频发的终末期事件,常伴随重度营养不良和恶液质,严重影响患者治疗疗效和生存质量。合理的肠外肠内营养治疗可以使恶性肠梗阻患者的肠道功能得到一定程度恢复,水、电解质、酸碱平衡紊乱得到纠正,一般状况得到明显好转,从而获得再次姑息性手术或者造瘘的机会,提高生活质量。因此,开展规范化的营养治疗对恶性肠梗阻患者具有重要意义。然而,迄今为止,尚无专门针对恶性肠梗阻患者的营养治疗策略。因此,本文拟通过对恶性肠梗阻患者营养治疗最新国内外文献的全面检索与分析,从恶性肠梗阻患者的营养诊断、营养治疗肠内肠外营养治疗适应证、治疗途径、治疗通路、营养素和疗效评价六个方面分别进行证据论述和意见推荐,以期指导临床营养的治疗。     

恶性肠梗阻的整合治疗

恶性肠梗阻（malignant bowel obstruction,MBO）是由恶性肿瘤导致的肠梗阻,最常见于卵巢、胃和结直肠肿瘤。MBO的病理生理与良性疾病所致的肠梗阻既有相似之处,也有显著不同,其治疗既遵循肠梗阻的一般原则,也遵循恶性肿瘤的一般原则。尽管MBO总体预后差,但是MBO并非不治之症。MBO的治疗是一种整合疗法,包括如下11个方面：抑制分泌、制止呕药、抑制炎症、控制疼痛、抗击肿瘤、液体管理、促进排空、改善体能、减压引流、改善营养、肠腔再通。MBO目前没有一个适用于所有患者的金科玉律,也没有一把可以确切解决所有问题的万能钥匙。理想的MBO治疗只能是个体化基础上的综合治疗。组建跨专业的多学科MBO诊疗团队,制订平衡理想与现实的MBO诊疗规范,确立以解决主要矛盾——提高生活质量为导向的治疗目标,充分听取患者本人及亲属的意见,积极有效的综合治疗仍然可以显著改善肿瘤患者生活质量、延长生存时间。     

恶性肠梗阻患者的代谢紊乱

恶性肠梗阻是由恶性肿瘤引起的小肠或大肠梗阻,常见于卵巢癌及胃肠道肿瘤患者。恶性肠梗阻是由于肿瘤压迫、肿瘤细胞浸润自主神经、副肿瘤综合征或药物因素导致的急性或慢性肠道梗阻,是晚期肿瘤患者常见的致死性并发症之一。本文综合国内外进展探讨恶性肠梗阻患者的代谢紊乱情况及其机制,得出以下提示:恶性肠梗阻不仅引起葡萄糖、蛋白质、脂肪酸等宏量营养素的代谢紊乱,还会引起微量营养素代谢异常等。造成代谢紊乱的机制主要有肠道功能紊乱,肠道局部甚至全身发生炎性反应,肠道菌群紊乱及缺乏有效的营养治疗等因素。恶性肠梗阻患者发生代谢紊乱可能加剧肠梗阻的发展,更与患者的预后显著相关。临床决策中医生应重视患者的代谢情况,认识到代谢紊乱对恶性肠梗阻患者预后的影响,积极纠正代谢紊乱,提高患者的预后及生活质量。     

恶性肠梗阻的诊治进展

恶性肠梗阻是晚期癌症患者常见的并发症之一,患者预后较差,平均生存期4~9个月。影像学检查除腹部立卧位平片、CT扫描外,无肠道准备磁共振成像对于恶性肠梗阻检查简便、诊断准确。恶性肠梗阻的治疗包括手术、药物治疗、置入扩张式支架,以及经皮内镜下胃造口和鼻胃管引流等。本文就目前恶性肠梗阻的诊断及治疗作一综述。     

恶性机械性肠梗阻临床诊疗

恶性机械性肠梗阻是晚期肿瘤常见并发症之一,通常以内科综合治疗为主。了解其病理生理机制（包括“不协调蠕动-组织水肿-不协调蠕动”及“分泌-扩张-分泌”恶性循环）,明确梗阻的分类、亚型和完善肿瘤内科的系统评估（包括一般情况、脏器功能、肿瘤学评估、营养代谢及肠屏障功能）是其有效治疗的前提。治疗原则和目的是尽量减少,甚至解除机体肿瘤负荷,改善或根治肠梗阻所致不良症状、体征及肠功能异常,纠正水、电解质紊乱及营养代谢紊乱状态,最终改善患者生活质量及总生存。具体措施包括基础治疗、营养治疗和代谢调节、抗炎、减轻肠壁水肿、抑制消化道腺体分泌、修复肠道屏障及防治感染、抗肿瘤病因治疗及运动疗法、心理治疗。其中抗肿瘤病因治疗是临床中的难点,因恶性肠梗阻多伴随营养不良、一般情况差,难以耐受常规抗肿瘤治疗,抗肿瘤治疗上需兼顾肿瘤因素、营养状况及患者一般情况等,有效的抗肿瘤治疗是肠梗阻再通的基本保障。     

大肠癌合并恶性肠梗阻18例的非手术治疗

目的探讨胃肠减压，相关药物联合肠外营养支持（PN）的非手术措施，治疗完全性恶性肠梗阻患者的疗效。方法对18例晚期大肠癌所致的完全性肠梗阻患者，采取胃肠减压，并以生长抑素、止吐药、止痛药及糖皮质激素药物为主，联合肠外营养支持（PN）进行治疗，观察治疗前后的KPS评分与梗阻症状及胃液引流量的变化情况。结果18例患者中7例疗效良好，11例症状缓解明显，继续肠外营养（PN）支持治疗，生活质量明显改善。结论采取胃肠减压，并以生长抑素、止吐药、止痛药及糖皮质激素药物为主，联合肠外营养支持（PN）的非手术治疗，对大肠癌并恶性肠梗阻患者的疗效好，患者生活质量明显改善，无毒副反应。     

晚期肿瘤合并恶性肠梗阻的预后分析

目的：探讨晚期不可手术的Ⅳ期恶性肿瘤患者合并恶性肠梗阻（MBO）的预后因素。方法：选取70例随访资料完整的合并MBO的晚期肿瘤患者,并记录患者的人口统计学、临床特点、实验室检查、影像学检查及ECOG评分等特征。随访结束至2012年12月。单因素生存分析采用Kaplan—Meier生存曲线,多因素分析采用COX比例风险回归模型。结果：是否伴有腹膜转移和腹水、梗阻部位、ECOG评分、白蛋白水平、MBO诊断后治疗模式（后续治疗vs支持治疗）均可影响MBO患者的预后,但仅ECOG评分、MBO诊断后治疗模式可作为影响MBO患者预后的独立危险因素。结论：MBO受各种因素影响。     

1例恶性肠梗阻患者的镇痛治疗

患者女性,70岁,2010年2月因腹痛就诊。经检查诊为乙状结肠腺癌,左侧卵巢转移,予姑息性手术及术后辅助化疗。2010年10月再次因腹痛就诊,发现对侧卵巢转移,再行姑息手术,术后口服卡培他滨5日(早1.5 g,晚1.0 g),因胃肠道反应严重而终止化疗。此后腹痛间断出现,予羟考酮缓释片止痛,VAS评分4～5分。2011年2月腹痛加重,诊为不完全肠梗阻,腹腔广泛转移癌,收住本科,予胃肠外营养、生长抑素     

Management of malignant bowel obstruction

Malignant bowel obstruction (MBO) is a common and distressing outcome particularly in patients with bowel or gynaecological cancer. Radiological imaging, particularly with CT, is critical in determining the cause of obstruction and possible therapeutic interventions. Although surgery should be the primary treatment for selected patients with MBO, it should not be undertaken routinely in patients known to have poor prognostic criteria for surgical intervention such as intra-abdominal carcinomatosis, poor performance status and massive ascites. A number of treatment options are now available for patients unfit for surgery. Nasogastric drainage should generally only be a temporary measure. Self-expanding metallic stents are an option in malignant obstruction of the gastric outlet, proximal small bowel and colon. Medical measures such as analgesics according to the W.H.O. guidelines provide adequate pain relief. Vomiting may be controlled using anti-secretory drugs or/and anti-emetics. Somatostatin analogues (e.g. octreotide) reduce gastrointestinal secretions very rapidly and have a particularly important role in patients with high obstruction if hyoscine butylbromide fails.A collaborative approach by surgeons and the oncologist and/or palliative care physician as well as an honest discourse between physicians and patients can offer an individualised and appropriate symptom management plan.     

Surgical management of malignant bowel obstruction

MBO is a common but difficult problem for surgeons caring for cancer patients. Nonsurgical interventions should be considered in all patients with MBO, especially inpatients with limited survival or for whom surgery will have little effect on disease control. Although there is no algorithm for all patients with MBO, decision-making is based on reasonable expectations of survival and treatment-related success. Surgical options can be helpful in the setting of MBO as long as reasonable goals and realistic outcomes are clear.     

Surgical approaches to malignant bowel obstruction

The management of patients with malignant bowel obstruction (MBO) can be one of the most challenging aspects of advanced cancer care, and as a result, their symptoms are often palliated poorly, especially near the end of life.The term MBO encompasses a heterogeneous clinical syndrome,defined as obstructive symptoms due to the presence of intra-abdominal neoplastic disease. Radiological imaging, particularly with computed tomography, is critical in determining the cause of obstruction and possible therapeutic interventions. Options include laparotomy with or without a stoma, decompression with a stent, or aggressive medical therapy. Surgical decision-making involves the selection of the intervention most likely to relieve symptoms and improve quality of life for a particular patient at that particular point along his or her disease course. Although MBO is a relatively common dilemma encountered in clinical practice, there are no simple treatment guidelines or algorithms to follow. Instead, each patient must be assessed individually to devise a treatment plan that best balances the advantages and disadvantages of the intervention, considering the patient's prognosis, tumor biology, and-most importantly-his or her goals of care, as determined through an honest discourse between physician and patient.This review outlines a surgical framework for clinicians managing patients with MBO.     

Current concepts in malignant bowel obstruction management

Malignant bowel obstruction (MBO) is a challenging complication of advanced cancer. Several pathophysiologic mechanisms are responsible for the syndrome, including mechanical compression, motility disorders, gastrointestinal secretion accumulation, decreased gastrointestinal absorption, and inflammation. The treatment of related symptoms requires a collaborative approach of surgical, interventional, and medical specialists. The surgical approach proves beneficial in selected patients with operable lesions, life expectancy greater than 2 months, and good performance status. Interventionalists place self-expanding metallic stents as a minimally invasive palliative method either as a definitive treatment or as a bridge to surgery. However, most patients with MBO are not candidates for surgery or stent placement. Medical management with opioids, antispasmodics, anti-emetics, antisecretory agents, and corticosteroids is effective in controlling the symptoms associated with MBO. This article discusses the current understanding of MBO pathophysiology and emphasizes current MBO management concepts; it then reviews surgical, interventional, and medical approaches.     

Endoscopic therapy for malignant bowel obstruction

Mechanical obstruction is common in advanced gastrointestinal malignancies and may be associated with significant morbidity. Patients with malignant bowel obstruction are often poor surgical candidates due to advanced disease, malnutrition, hypoalbuminemia, and dehydration. Recent advances in endoscopy have led to a variety of highly efficacious, nonsurgical treatment options that relieve mechanical bowel obstruction. This articles reviews endoscopic techniques to treat malignant small bowel and colonic obstruction including decompression tubes, enteral stents, and ablative methods such as laser therapy and argon plasma coagulation.     

Interventional palliative strategies for malignant bowel obstruction

Malignant bowel obstruction is the luminal narrowing of the small bowel or colon due to direct or indirect cancer growth. Small bowel obstruction usually occurs at the level of the duodenum. Interventional, nonoperative strategies for palliation of malignant bowel obstruction include endoscopic and radiologic techniques. The latter are performed by interventional radiologists. Palliation of luminal small bowel and colonic obstruction primarily is achieved through the use of endoscopically or radiologically placed self-expandable metal stents. Gastrostomy and jejunal tubes also may be placed to provide palliative decompression when other palliative methods are not possible.