惡性腸梗阻專家共識(shí)課件

1、1. Anthony T, Baron T, Mercadante S, et al. Report of the clinical protocol committee: development of randomized trials for malignant bowel obstruction. J Pain Symptom Manage2007;34:S49591. Ripamonti C, Bruera E. Palliative management of malignantbowel obstruction. Int J Gynecol Cancer 2002;12:13543

2、.2. Krouse RS. The international conference on malignant bowel obstruction: a meeting of the minds to advance palliative care research. J Pain Symptom Manage 2007;34:S16.3。Ali sidgiqui，et al：desease and sciences 2007 52（1）276281EJC癥癥 狀狀胃或近端小腸胃或近端小腸遠(yuǎn)端小腸或大腸遠(yuǎn)端小腸或大腸嘔吐嘔吐膽汁樣，稀薄，量大，膽汁樣，稀薄，量大，無(wú)或稍有氣味無(wú)或稍有氣味 顆

3、粒狀，體積小，惡臭，也可顆粒狀，體積小，惡臭，也可能無(wú)嘔吐能無(wú)嘔吐腹痛腹痛 出現(xiàn)早，集中在臍周，出現(xiàn)早，集中在臍周，痙攣性痛，發(fā)作間隔痙攣性痛，發(fā)作間隔短短出現(xiàn)晚，局限，深部?jī)?nèi)臟性痛，出現(xiàn)晚，局限，深部?jī)?nèi)臟性痛，痙攣性痛發(fā)作間隔長(zhǎng)，患者痙攣性痛發(fā)作間隔長(zhǎng)，患者多描述為絞痛多描述為絞痛 腹脹腹脹可能不出現(xiàn)可能不出現(xiàn)出現(xiàn)出現(xiàn)食欲減退食欲減退經(jīng)常出現(xiàn)經(jīng)常出現(xiàn)可能不出現(xiàn)可能不出現(xiàn) 有腫瘤病史的患者有腫瘤病史的患者出現(xiàn)腸梗阻癥狀出現(xiàn)腸梗阻癥狀影像學(xué)檢查影像學(xué)檢查CT/MRI 臨床評(píng)估臨床評(píng)估患者因素患者因素臨床決策臨床決策技術(shù)因素技術(shù)因素 與患者及家屬商定最終治療方案與患者及家屬商定最終治療方案 數(shù)周數(shù)

4、日數(shù)周數(shù)日（瀕臨死亡）（瀕臨死亡）l與手術(shù)相比，藥物治與手術(shù)相比，藥物治療是更適宜的選擇療是更適宜的選擇l評(píng)估治療目標(biāo)有助于評(píng)估治療目標(biāo)有助于指導(dǎo)干預(yù)方案（例如：指導(dǎo)干預(yù)方案（例如：減少惡心、嘔吐，允減少惡心、嘔吐，允許患者進(jìn)食，減輕疼許患者進(jìn)食，減輕疼痛，允許患者回家或痛，允許患者回家或接受家庭護(hù)理）接受家庭護(hù)理）l藥物治療藥物治療l靜脈或者皮下補(bǔ)液靜脈或者皮下補(bǔ)液l內(nèi)鏡治療鼻胃管引流內(nèi)鏡治療鼻胃管引流 僅當(dāng)其他措施無(wú)法減輕嘔吐僅當(dāng)其他措施無(wú)法減輕嘔吐時(shí)方考慮時(shí)方考慮預(yù)計(jì)生存期預(yù)計(jì)生存期1 .Lowe AS, Beckett CG, Jowett S, et al. Self-expanda

5、ble metal stent placement for the palliation of malignant gastroduodenal obstruction: experience in a large, single, UK centre. Clin Radiol 2007;62:73844.2. Telford JJ, Carr-Locke DL, Baron TH, et al. Palliation of patients with malignant gastric outlet obstruction with the enteral Wallstent: outcom

6、es from a multicenter study.Gastrointest Endosc 2004;60:91620.3. Dormann A, Meisner S, Verin N, et al. Self-expanding metal stents for gastroduodenal malignancies: systematic review of their clinical effectiveness. Endoscopy 2004;36:54350.4. Nassif T, Prat F, Meduri B, et al. Endoscopic palliation o

7、f malignant gastric outlet obstruction using self-expandable metallic stents: results of a multicenter study. Endoscopy 2003;35:4839.5. Espinel J, Sanz O, Vivas S, et al. Malignant gastrointestinal obstruction: endoscopic stenting versus surgical palliation. Surg Endosc 2006;20:10837.6. Lillemoe KD,

8、 Cameron JL, Hardacre JM, et al. Is prophylactic gastrojejunostomy indicated for unresectable periampullary cancer? A prospective randomized trial. Ann Surg 1999;230:3228. discussion 328-30.7. Jeurnink SM, Steyerberg EW, Hof GV, et al. Gastrojejunostomy versus stent placement in patients with malign

9、ant gastricoutlet obstruction: a comparison in 95 patients. J Surg Oncol 2007.1. Holt AP, Patel M, Ahmed MM. Palliation of patients with malignant gastroduodenal obstruction with self-expanding metallic stents: the treatment of choice? Gastrointest Endosc 2004;60:101072. Jeurnink SM, Steyerberg EW,

10、Hof GV, et al. Gastrojejunostomy versus stent placement in patients with malignant gastricoutlet obstruction: a comparison in 95 patients. J Surg Oncol 2007.3. Wong YT, Brams DM, Munson L, et al. Gastric outletobstruction secondary to pancreatic cancer: surgical vs endoscopic palliation. Surg Endosc

11、 2002;16:3102.1. Holt AP, Patel M, Ahmed MM. Palliation of patients with malignant gastroduodenal obstruction with self-expanding metallic stents: the treatment of choice? Gastrointest Endosc 2004;60:10107.Khot et al. 1 Sebastian et al.2成功應(yīng)用技術(shù) 551（92%）1198（94%）臨床成功 525（88%）1198（91%）姑息治療成功 301/336（90

12、%）791（93%）死亡 3（1%）7（0.6%）穿孔 22（4%）45（3.8%）支架移位 54（10%）132（11.8%）再梗阻 53（10%）82（7.3%）1. Khot UP, Wenk Lang A, Murali K, et al. Systematic review of the efficacy and safety of colorectal stents. Br J Surg 2002;89:1096102.2. Sebastian S, Johnston S, Geoghegan T, et al. Pooled analysis of the efficacy an

13、d safety of self-expanding metal stenting in malignant colorectal obstruction. Am J Gastro 2004;99:20517.1 . Camunez F, Echenagusia A, Simo G, et al. Malignant colorectal obstruction treated by means of self-expanding metallic stents: Effectiveness before surgery and in palliation. Radiology 2000;21

14、6:4927.2 . Law WL, Chu KW, Ho JW, et al. Self-expanding metallic stent in the treatment of colonic obstruction caused by advancedmalignancies. Dis Colon Rectum 2000;43:15227.3. Nash CL, Markowitz AJ, Schattner M, et al. Colorectal stents for the management of malignant large bowel obstruction. Gastr

15、ointest Endo 2002;55:AB216.4. Pothuri B, Guiguis A, Gerdes H, et al. The use of colorectal stents for palliation of large bowel obstruction due to recurrent gynecologic cancer. Gynecol Oncol 2004;95:5137.1. Campagnutta E, Cannizzaro R, Gallo A, Zarrelli A, Valentini M, De Cicco M, et al. Palliative

16、Treatment of Upper Intestinal Obstruction by Gynecological Malignancy: The Usefulness of Percutaneous Endoscopic Gastrostomy. Gynecologic Oncology1996;62:1035.2. Pothuri B, Montemarano M, Gerardi M, Shike M, Ben-Porat L, Sabbatinin P, et al. Percutaneous endoscopic gastrostomy tube placement in pati

17、ents with malignant bowel obstruction due to ovarian carcinoma. Gynecologic Oncology 2005;96:3304.鎮(zhèn)痛藥根據(jù)WHO指南強(qiáng)烈推薦抗膽堿能藥物丁溴東莨菪堿氫溴酸東莨菪堿持續(xù)疼痛絞痛給藥方式n持續(xù)皮下給藥（CSI）l持續(xù)靜脈給藥CIV）l經(jīng)皮膚給藥減少胃腸道分泌1、抗膽堿能藥物丁溴東莨菪堿（40-120mg/d）甘羅溴銨（0.1-0.2mg，tid，sc或iv）氫溴酸東莨菪堿（0.8-2.0mg/d） 和/或2、生長(zhǎng)抑素類似物奧曲肽0.2-0.9 mg/d，civ或csi止吐治療l胃復(fù)安（僅用于不全腸梗

18、阻及沒(méi)有絞痛的患者） 氟哌啶醇（5-15mg/dCSI） 甲氧異丁嗪 （50-150mg/dCSI）l鎮(zhèn)靜藥 氯吡嗪（25-75mg/d直腸給藥） 氯丙嗪 （50-100mg/d直腸給藥/皮下）l抗組胺藥鹽酸嗎嗪（100-150mg/d皮下或直腸 給藥）惡心嘔吐1. World Health Organization. Cancer Pain Relief. Second ed. Geneve: WHO; 1996.2. Hofmann B, Haheim LL, Soreide JA. Ethics of palliative surgery in patients with cancer.

19、 Br J Surg 2005;92:8029.3. Pothuri B, Guiguis A, Gerdes H, et al. The use of colorectal stents for palliation of large bowel obstruction due torecurrent gynecologic cancer. Gynecol Oncol 2004;95:5137.4.Fainsinger RL, Spachynski K, Hanson J, et al. Symptom control in terminally ill patients with mali

20、gnant bowel obstruction. J Pain Symptom Manage 1994;9:128.5. Ventafridda V, Ripamonti C, Caraceni A, et al. The management of inoperable gastrointestinal obstruction in terminal cancer patients. Tumouri 1990;76:38993.6. Mercadante S. Pain in inoperable bowel obstruction. Pain Digest 1995;5:913.7. De

21、 Conno F, Caraceni A, Zecca E, Spoldi E, Ventafridda V. Continuous subcutaneous infusion of hyoscine butylbromide reduces secretions in patients with gastrointestinal obstruction. J Pain Sympt Manage 1991;6:4846.Ventafridda V, Ripamonti C, Caraceni A, et al. The management of inoperable gastrointest

22、inal obstruction in terminal cancer patients. Tumouri 1990;76:38993.2. De Conno F, Caraceni A, Zecca E, Spoldi E, Ventafridda V. Continuous subcutaneous infusion of hyoscine butylbromide reduces secretions in patients with gastrointestinal obstruction. J Pain Sympt Manage 1991;6:4846.3. Ripamonti C,

23、 Mercadante S, Groff L, Zecca E, De Conno F, Casuccio A. Role of octreotide, scopolamine butylbromide and hydration in symptom control of patients with inoperable bowel obstruction having a nasogastric tube. A prospective, randomized clinical trial. J Pain Symptom Manage 2000;19:2334.4. Mercadante S

24、, Ripamonti C, Casuccio A, Zecca E, Groff L. Comparison of octreotide and hyoscine butylbromide in controlling gastrointestinal symptoms due to malignant inoperable bowel obstruction. Supportive Care in Cancer 2000;8:18891.1. Ripamonti C, Panzeri C, Groff L, Galeazzi G, Boffi R. The role of somatost

25、atin and octreotide in bowel obstruction: pre-clinical and clinical results. Tumouri 2001;87:19.2. Anthone GJ, Bastidas JA, Orlandle MS, Yeo CJ. Direct proabsorptive effect of octreotide on ionic transport in the small intestine. Surgery 1990;108:113642.1. Ripamonti C, Mercadante S, Groff L, Zecca E

26、, De Conno F, Casuccio A. Role of octreotide, scopolamine butylbromide and hydration in symptom control of patients with inoperable bowel obstruction having a nasogastric tube. A prospective, randomized clinical trial. J Pain Symptom Manage 2000;19:2334.2. Mercadante S, Ripamonti C, Casuccio A, Zecc

27、a E, Groff L. Comparison of octreotide and hyoscine butylbromide in controlling gastrointestinal symptoms due to malignant inoperable bowel obstruction. Supportive Care in Cancer 2000;8:18891.1. Mercadante S, Avola G, Maddaloni S, et al. Octreotide prevents the pathological alterations of bowel obst

28、ruction in cancer patients. Support Care Cancer 1996;4:3934.Mercadante S, Kargar J, Nicolosi G. Octreotide may prevent definitive intestinal obstruction. J Pain Symptom Manage 1997;13:3525.3. Sun X, Li X, Li H. Management of intestinal obstruction in advanced ovarian cancer: an analysis of 57 cases

29、in Chinese. Zhonghua Zhong Liu Za Zhi 1995;17:3942.1. Cozzaglio L et al. Outcome of cancer patients receiving home parenteral nutrition. J Parenteral Enteral Nutrition 1997;21:33942.2. Hoda D, Jatoi A, Burnes J, Loprinzi C, Kelly D. Should patients with advanced, incurable cancers ever be sent home with Total parenteral nutrition? Cancer 2005;103:8638.1. Ripamonti C, Twycross R, Bai