| Sažetak | Usporeno pražnjenje želuca je najčešća komplikacija nakon operacije po Whippleu – resekcija glave
gušterače i dvanaesnika, bez obzira na izbor metode, standardna operacija po Whippleu ili resekcija
glave gušterače i dvanaesnika s očuvanim pilorusom. Učestalost komplikacije je 15–40% i predstavlja
polovicu ukupnog morbiditeta operiranih. Za vrijeme trajanja tegoba (2–6 tjedana), peroralna ishrana
nije moguća, enteralna prehrana sondom može izazvati ili pogoršati stanje.
Sve to dovodi do usporenog oporavka bolesnika, produženog bolničkog liječenja i konačno povećanih
troškova liječenja. Brojne modifikacije operacije po Whippleu nisu dale željeni rezultat u smanjenju
učestalosti usporenog pražnjenja želuca, a razlog je što ne postoji jasno definiran uzrok pojavi.
Svim je dosadašnjim modifikacijama u rekonstrukciji probavnog puta zajednička resekcija početnog
segmenta jejunuma i Roux-en-Y metodom izolirana vijuga tankog crijeva.
Slijedom novih saznanja o nervnoj regulaciji motiliteta tankog crijeva, suštinu modificirane metode po
Whippleu čine: očuvanje početnog segmenta jejunuma, novi način rekonstrukcije s omega vijugom
jejunuma i dilatacija pilorusa.
CILJ ISTRAŽIVANJA:
Cilj ovog rada je dokazati da bolesnici operirani modificiranom metodom po Whippleu imaju bolju
gastrointestinalnu funkciju, koja se očituje manjom učestalošću usporenog pražnjenja želuca i većom
mogućnošću rane enteralne prehrane, u odnosu na bolesnike operirane standardnim metodama.
ISPITANICI I METODE:
Rad je prospektivna randomizirana klinička studija 70 bolesnika kojima je izvršena resekcija glave
gušterače i dvanaesnika na Zavodu za digestivnu kirurgiju KBC Rijeka u razdoblju 1.6.1995 –
1.6.2006.
Bolesnici su podijeljeni u dvije grupe ovisno da li je jejunum reseciran ili nije, odnosno da li je
rekonstrukcija ostvarena Roux-en-Y ili omega vijugom jejunuma s dilatacijom pilorusa.
Procjena gastrointestinalne funkcije provedena je na osnovu učestalosti kliničkih pokazatelja
usporenog pražnjenja želuca, brzine želučanog pražnjenja i tolerancije rane enteralne prehrane – kroz
vrijednost ostatnog volumena želuca.
GLAVNI REZULTATI
Učestalost usporenog pražnjenja želuca operiranih modificiranom metodom po Whippleu, u odnosu na
standardne metode, značajno je manja (0% prema 30%; P<0,01).
Primjenom rane enteralne prehrane u svih ispitanika, vrijednost ostatnog volumena želuca je niža u
operiranih modificiranom metodom, nego standardnim metodama, (102±90, prema 328±155 mL;
P<0,05). Vrijeme hospitalizacije je kraće u operiranih modificiranom metodom (12 prema 19 dana;
P<0.05).
ZAKLJUČCI
Na osnovu iznesenih rezultata može se reći kako se primjenom modificirane metode poboljšava
gastrointestinalna funkcija. To se očituje manjom učestalosti usporenog želučanog pražnjenja, većom
mogućnosti rane enteralne prehrane i kraćim vremenom hospitalizacije. |
| Sažetak (engleski) | INTRODUCTION
Delayed gastric emptying is the most common complications after resection of the head of the
pancreas and duodenum, regardless the operation methods – standard Whipple operation or Pylorus
Preserving Pancreatoduodenectomy. The incidence of delayed gastric emptying vary from 15 to 40%,
and represents half of total morbidity. For the duration of the delayed gastric emptying (2-6 weeks), oral
nutrition is not possible, and intragastric feeding may cause or aggravate the condition. All this leads to
a slow recovery of the patient, prolonged hospitalization and increased costs of final treatment.
Despite numerous modifications, the frequency of complications is still remained high. The causative
mechanisms of delayed gastric emptying are still unknown. Up to the present time, however, segmental
resection of the proximal jejunum and Roux-en-Y reconstruction with defunctionalized jejunal loop is
single method of resection and reconstruction and a common feature of various modifications following
resection of the head of the pancreas and duodenum.
Following new insights in the neural regulation and hormonal control of gastrointestinal motility,
especially innervation of proximal jejunum, we altered our standard resection and reconstruction
method, allowing immediate post operative enteral nutrition The essence of a our new method –
Pylorus Jejunum Preserving Pancreatoduodenectomy is preservation of the proximal jejunum, pyloric
dilatation and using omega method of jejunum anastomosis, instead of Roux-en-Y reconstruction
method without pylorus dilatation.
OBJECTIVE
The purpose of the study is to determine if modified method of resection and reconstruction after
pancreaticoduodenectomy may prevent or minimize delayed gastric emptying, the most common
complication after pancreatoduodenectomy, allowing immediate post operative enteral nutrition.
PATIENTS AND METHODS
A prospective, clinical trial included 70 patients who underwent pancreatoduodenectomy from July
1995 to July 2006 at the Department of Digestive Surgery, University Hospital Rijeka.
Patients were randomized into two groups regardless of whether the pylorus and jejunum are
preserved or not, and depending on the method of reconstruction – omega with pyloric dilatation or
Roux-en-Y, without pyloric dilatation.
Assessment of gastrointestinal function was carried out based on the frequency of clinical delayed
gastric emptying manifestations, rate of gastric emptying and tolerance of early enteral nutrition,
through value of a gastric residual volume.
RESULTS
The incidence of delayed gastric emptying in modified Whipple operation group is significantly lower,
none of the patients (0%), compared with those operated by standard methods, 9 (30%).
The difference between the two groups is statistically significant (P<0,01). By applying the early enteral
nutrition in all patients, gastric residual volume is lower in the modified Whipple operation group than
standard methods group, (102 ± 90, v.s. 328 ± 155mL, P <0.05). Finally, earlier return to regular diet
and the median length of postoperative hospital stay was significantly shorter in modified Whipple
operation group (12 v.s.19 days, P<0,05).
CONCLUSIONS
On the basis of the presented results we can conclude that the use of a modified method improves the
gastrointestinal function. It is demonstrated a lower frequency of delayed gastric emptying, increasing
the possibility of early enteral nutrition and shorter hospital stay. |
