胰腺切除术后胰腺外分泌功能不全的诊治现状
DOI: 10.3969/j.issn.1001-5256.2023.12.003
利益冲突声明:本文不存在任何利益冲突。
作者贡献声明:浦宁、安燕飞负责资料收集,撰写论文;浦宁、楼文晖负责修改论文;楼文晖负责拟定写作思路,指导撰写文章并最后定稿。
Current status of the diagnosis and treatment of pancreatic exocrine insufficiency after pancreatectomy
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摘要: 胰腺外分泌功能不全引起的消化不良是胰腺切除术后常见并发症,但目前仍缺乏简单、高效、统一的诊断方法和规范化的治疗手段,且外科医师缺乏对其认识程度,导致其难以得到充分诊治。因此,本文对胰腺切除术后胰腺外分泌功能不全的定义、发病原因、不同胰腺手术方式后发生率、现有诊断方法与治疗预防策略等几个方面的相关研究进展进行了归纳总结,以期为进一步改善胰腺切除术后胰腺外分泌功能不全的诊治提供参考。Abstract: Dyspepsia due to pancreatic exocrine insufficiency is a common complication after pancreatectomy; however, due to the lack of simple, efficient, and unified diagnostic methods, standardized treatment standards, and awareness of this disease among surgeons, it is difficult to get adequate diagnosis and treatment. Therefore, this article summarizes the research advances in the definition and pathogenesis of pancreatic exocrine insufficiency, the incidence rate of pancreatic exocrine insufficiency after different surgical procedures, and current diagnostic methods and treatment strategies, in order to provide a reference for further improving the diagnosis and treatment of pancreatic exocrine insufficiency after pancreatectomy.
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Key words:
- Exocrine Pancreatic Insufficiency /
- Pancreatectomy /
- Dyspepsia /
- Diagnosis /
- Therapeutics
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[1] KUSAKABE J, ANDERSON B, LIU JX, et al. Long-term endocrine and exocrine insufficiency after pancreatectomy[J]. J Gastrointest Surg, 2019, 23( 8): 1604- 1613. DOI: 10.1007/s11605-018-04084-x. [2] DIMAGNO EP, GO VLW, SUMMERSKILL WHJ. Relations between pancreatic enzyme outputs and malabsorption in severe pancreatic insufficiency[J]. N Engl J Med, 1973, 288( 16): 813- 815. DOI: 10.1056/nejm197304192881603. [3] Editorial Board of the Chinese Journal of Pancreatic Diseases. Diagnostic and therapeutic criteria for pancreatic exocrine insufficiency in China(draft)[J]. Chin J Pancreatol, 2013, 13( 1): 45- 48. DOI: 10.3760/cma.j.issn.1674-1935.2013.01.016.《中华胰腺病杂志》编委会. 中国胰腺外分泌功能不全诊治规范(草案)[J]. 中华胰腺病杂志, 2013, 13( 1): 45- 48. DOI: 10.3760/cma.j.issn.1674-1935.2013.01.016. [4] SABATER L, AUSANIA F, BAKKER OJ, et al. Evidence-based guidelines for the management of exocrine pancreatic insufficiency after pancreatic surgery[J]. Ann Surg, 2016, 264( 6): 949- 958. DOI: 10.1097/sla.0000000000001732. [5] Study Group of Pancreatic Surgery in Chinese Society of Surgery of Chinese Medical Association, Pancreatic Disease Committee of Chinese Research Hospital Association. A consensus statement on the diagnosis and treatment of pancreatic exocrine insufficiency after pancreatic surgery(2018)[J]. Chin J Surg, 2018, 56( 9): 641- 645. DOI: 10.3760/cma.j.issn.0529-5815.2018.09.001.中华医学会外科学分会胰腺外科学组与中国研究型医院学会胰腺疾病专业委员会. 胰腺术后外分泌功能不全诊治的中国专家共识(2018)[J]. 中华外科杂志, 2018, 56( 9): 641- 645. DOI: 10.3760/cma.j.issn.0529-5815.2018.09.001. [6] TRAN TC KHE, van LANSCHOT JJB, BRUNO MJ, et al. Functional changes after pancreatoduodenectomy: Diagnosis and treatment[J]. Pancreatology, 2009, 9( 6): 729- 737. DOI: 10.1159/000264638. [7] NORDBACK I, PARVIAINEN M, PIIRONEN A, et al. Obstructed pancreaticojejunostomy partly explains exocrine insufficiency after pancreatic head resection[J]. Scand J Gastroenterol, 2007, 42( 2): 263- 270. DOI: 10.1080/00365520600849174. [8] NAKAMURA H, MURAKAMI Y, UEMURA K, et al. Predictive factors for exocrine pancreatic insufficiency after pancreatoduodenectomy with pancreaticogastrostomy[J]. J Gastrointest Surg, 2009, 13( 7): 1321- 1327. DOI: 10.1007/s11605-009-0896-5. [9] GOESS R, CEYHAN GO, FRIESS H. Pancreatic exocrine insufficiency after pancreatic surgery[J]. Panminerva Med, 2016, 58( 2): 151- 159. [10] NØJGAARD C, BENDTSEN F, BECKER U, et al. Danish patients with chronic pancreatitis have a four-fold higher mortality rate than the Danish population[J]. Clin Gastroenterol Hepatol, 2010, 8( 4): 384- 390. DOI: 10.1016/j.cgh.2009.12.016. [11] MIYAMOTO R, INAGAKI Y, IKEDA N, et al. Three-dimensional remnant pancreatic volume ratio indicates postoperative pancreatic exocrine insufficiency in pancreatic cancer patients after distal pancreatectomy[J]. Pancreatology, 2020, 20( 5): 867- 874. DOI: 10.1016/j.pan.2020.06.018. [12] NAKAMURA H, MURAKAMI Y, UEMURA K, et al. Reduced pancreatic parenchymal thickness indicates exocrine PancreaticInsufficiency after pancreatoduodenectomy[J]. J Surg Res, 2011, 171( 2): 473- 478. DOI: 10.1016/j.jss.2010.03.052. [13] OKANO K, MURAKAMI Y, NAKAGAWA N, et al. Remnant pancreatic parenchymal volume predicts postoperative pancreatic exocrine insufficiency after pancreatectomy[J]. Surgery, 2016, 159( 3): 885- 892. DOI: 10.1016/jsurg.2015.08.046. [14] BUDIPRAMANA VS, WITARTO AP, WITARTO BS, et al. Risk factors for exocrine pancreatic insufficiency after pancreatic surgery: A systematic review and meta-analysis[J]. Can J Surg, 2022, 65( 6): E770- E781. DOI: 10.1503/cjs.010621. [15] HARTMAN V, ROEYEN E, BRACKE B, et al. Prevalence of pancreatic exocrine insufficiency after pancreatic surgery measured by 13C mixed triglyceride breath test: A prospective cohort study[J]. Pancreatology, 2023: S1424-S3903(23)00174- 6. DOI: 10.1016/j.pan.2023.05.012. [16] REDDY MS, SINGH S, SINGH R, et al. Morphological and functional outcome after pancreatic necrosectomy and lesser sac lavage for necrotizing pancreatitis[J]. Indian J Gastroenterol, 2007, 26( 5): 217- 220. [17] SELIGSON U, IHRE T, LUNDH G. Prognosis in acute haemorrhagic, necrotizing pancreatitis[J]. Acta Chir Scand, 1982, 148( 5): 423- 429. [18] ANGELINI G, PEDERZOLI P, CALIARI S, et al. Long-term outcome of acute necrohemorrhagic pancreatitis[J]. Digestion, 1984, 30( 3): 131- 137. DOI: 10.1159/000199097. [19] van SANTVOORT HC, BESSELINK MG, BAKKER OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis[J]. N Engl J Med, 2010, 362( 16): 1491- 1502. DOI: 10.1056/NEJMoa0908821. [20] LÖHR JM, DOMINGUEZ-MUNOZ E, ROSENDAHL J, et al. United European Gastroenterology evidence-based guidelines for the diagnosis and therapy of chronic pancreatitis(HaPanEU)[J]. United European Gastroenterol J, 2017, 5( 2): 153- 199. DOI: 10.1177/2050640616684695. [21] SIKKENS ECM, CAHEN DL, de WIT J, et al. Prospective assessment of the influence of pancreatic cancer resection on exocrine pancreatic function[J]. Br J Surg, 2014, 101( 2): 109- 113. DOI: 10.1002/bjs.9342. [22] STOOP TF, ATEEB Z, GHORBANI P, et al. Impact of endocrine and exocrine insufficiency on quality of life after total pancreatectomy[J]. Ann Surg Oncol, 2020, 27( 2): 587- 596. DOI: 10.1245/s10434-019-07853-3. [23] KROON VJ, DAAMEN LA, TSENG DSJ, et al. Pancreatic exocrine insufficiency following pancreatoduodenectomy: A prospective bi-center study[J]. Pancreatology, 2022, 22( 7): 1020- 1027. DOI: 10.1016/j.pan.2022.08.002. [24] LIN JH, HU LH, LIAO Z, et al. Clinical application of pancreatic exocrine function examination[J]. Acad J Second Mil Med Univ, 2017, 38( 10): 1298- 1303. DOI: 10.16781/j.0258-879x.2017.10.1298.林金欢, 胡良皞, 廖专, 等. 胰腺外分泌功能检测方法应用现状[J]. 第二军医大学学报, 2017, 38( 10): 1298- 1303. DOI: 10.16781/j.0258-879x.2017.10.1298. [25] DOMÍNGUEZ MUÑOZ JE. Diagnosis of chronic pancreatitis: Functional testing[J]. Best Pract Res Clin Gastroenterol, 2010, 24( 3): 233- 241. DOI: 10.1016/j.bpg.2010.03.008. [26] CONWELL DL, ZUCCARO G, VARGO JJ, et al. An endoscopic pancreatic function test with cholecystokinin-octapeptide for the diagnosis of chronic pancreatitis[J]. Clin Gastroenterol Hepatol, 2003, 1( 3): 189- 194. DOI: 10.1053/cgh.2003.50028. [27] BIAN Y. Quantification of pancreatic exocrine function of chronic pancreatitis with secretin-enhanced MRCP[J]. World J Gastroenterol, 2013, 19( 41): 7177. DOI: 10.3748/wjg.v19.i41.7177. [28] MENSEL B, MESSNER P, MAYERLE J, et al. Secretin-stimulated MRCP in volunteers: Assessment of safety, duct visualization, and pancreatic exocrine function[J]. Am J Roentgenol, 2014, 202( 1): 102- 108. DOI: 10.2214/ajr.12.10271. [29] SUGIYAMA M, HARADOME H, ATOMI Y. Magnetic resonance imaging for diagnosing chronic pancreatitis[J]. J Gastroenterol, 2007, 42( 17): 108- 112. DOI: 10.1007/s00535-006-1923-x. [30] SUGAI E, SRUR G, VAZQUEZ H, et al. Steatocrit: A reliable semiquantitative method for detection of steatorrhea[J]. J Clin Gastroenterol, 1994, 19( 3): 206- 209. DOI: 10.1097/00004836-199410000-00007. [31] ROBERTS IM, POTURICH C, WALD A. Utility of fecal fat concentrations as screening test in pancreatic insufficiency[J]. Dig Dis Sci, 1986, 31( 10): 1021- 1024. DOI: 10.1007/BF01300253. [32] VANGA RR, TANSEL A, SIDIQ S, et al. Diagnostic performance of measurement of fecal elastase-1 in detection of exocrine pancreatic insufficiency: Systematic review and meta-analysis[J]. Clin Gastroenterol Hepatol, 2018, 16( 8): 1220- 1228.e4. DOI: 10.1016/j.cgh.2018.01.027. [33] LANKISCH PG, SCHMIDT I, KONIG H, et al. Faecal elastase 1: Not helpful in diagnosing chronic pancreatitis associated with mild to moderate exocrine pancreatic insufficiency[J]. Gut, 1998, 42( 4): 551- 554. DOI: 10.1136/gut.42.4.551. [34] HUTA Y, ASHOROV O, HAMOUDA D, et al. A novel fecal elastase assay for the detection of pancreatic exocrine insufficiency[J]. Clin Lab, 2022, 68( 7). DOI: 10.7754/Clin.Lab.2021.211206. [35] VANTRAPPEN GR, RUTGEERTS PJ, GHOOS YF, et al. Mixed triglyceride breath test: A noninvasive test of pancreatic lipase activity in the duodenum[J]. Gastroenterology, 1989, 96( 4): 1126- 1134. DOI: 10.1016/0016-5085(89)91632-6. [36] NAKAMURA H, MURAKAMI Y, MORIFUJI M, et al. Analysis of fat digestive and absorptive function after subtotal gastrectomy by a 13C-labeled mixed triglyceride breath test[J]. Digestion, 2009, 80( 2): 98- 103. DOI: 10.1159/000220098. [37] SIUKA D, KUMER K, STABUC B, et al. Abbreviated 13C-mixed triglyceride breath test for detection of pancreatic exocrine insufficiency performs equally as standard 5-hour test in patients after gastrectomy performed for gastric cancer[J]. Radiol Oncol, 2022, 56( 3): 390- 397. DOI: 10.2478/raon-2022-0034. [38] HOPSON P, SMADI Y, MEHTA V, et al. Assessment of exocrine pancreatic function in children and adolescents with direct and indirect testing[J]. Front Pediatr, 2022, 10: 908542. DOI: 10.3389/fped.2022.908542. [39] LINDKVIST B, DOMÍNGUEZ-MUÑOZ JE, LUACES-REGUEIRA M, et al. Serum nutritional markers for prediction of pancreatic exocrine insufficiency in chronic pancreatitis[J]. Pancreatology, 2012, 12( 4): 305- 310. DOI: 10.1016/j.pan.2012.04.006. [40] SIKKENS ECM, CAHEN DL, KOCH AD, et al. The prevalence of fat-soluble vitamin deficiencies and a decreased bone mass in patients with chronic pancreatitis[J]. Pancreatology, 2013, 13( 3): 238- 242. DOI: 10.1016/j.pan.2013.02.008. [41] TIGNOR AS, WU BU, WHITLOCK TL, et al. High prevalence of low-trauma fracture in chronic pancreatitis[J]. Am J Gastroenterol, 2010, 105( 12): 2680- 2686. DOI: 10.1038/ajg.2010.325. [42] SAFDI M, BEKAL PK, MARTIN S, et al. The effects of oral pancreatic enzymes(Creon 10 capsule) on steatorrhea[J]. Pancreas, 2006, 33( 2): 156- 162. DOI: 10.1097/01.mpa.0000226884.32957.5e. [43] THORAT V, REDDY N, BHATIA S, et al. Randomised clinical trial: The efficacy and safety of pancreatin enteric-coated minimicrospheres(Creon 40000 MMS) in patients with pancreatic exocrine insufficiency due to chronic pancreatitis: A double-blind, placebo-controlled study[J]. Aliment Pharmacol Ther, 2012, 36( 5): 426- 436. DOI: 10.1111/j.1365-2036.2012.05202.x. [44] TRANG T. Pancreatic enzyme replacement therapy for pancreatic exocrine insufficiency in the 21st century[J]. World J Gastroenterol, 2014, 20( 33): 11467. DOI: 10.3748/wjg.v20.i33.11467. [45] GIANOTTI L, BESSELINK MG, SANDINI M, et al. Nutritional support and therapy in pancreatic surgery: A position paper of the International Study Group on Pancreatic Surgery(ISGPS)[J]. Surgery, 2018, 164( 5): 1035- 1048. DOI: 10.1016/j.surg.2018.05.040. [46] SIKKENS ECM, CAHEN DL, VAN EIJCK C, et al. Patients with exocrine insufficiency due to chronic pancreatitis are undertreated: A Dutch national survey[J]. Pancreatology, 2012, 12( 1): 71- 73. DOI: 10.1016/j.pan.2011.12.010. [47] DOMINGUEZ-MUNOZ JE, IGLESIAS-GARCIA J, IGLESIAS-REY M, et al. Effect of the administration schedule on the therapeutic efficacy of oral pancreatic enzyme supplements in patients with exocrine pancreatic insufficiency: A randomized, three-way crossover study[J]. Aliment Pharmacol Ther, 2005, 21( 8): 993- 1000. DOI: 10.1111/j.1365-2036.2005.02390.x. [48] REGAN PT, MALAGELADA JR, DIMAGNO EP, et al. Comparative effects of antacids, cimetidine and enteric coating on the therapeutic response to oral enzymes in severe pancreatic insufficiency[J]. N Engl J Med, 1977, 297( 16): 854- 858. DOI: 10.1056/nejm197710202971603. [49] KURDI B EL, BABAR S, ISKANDARANI M EL, et al. Factors that affect prevalence of small intestinal bacterial overgrowth in chronic pancreatitis: A systematic review, meta-analysis, and meta-regression[J]. Clin Transl Gastroenterol, 2019, 10( 9): e00072. DOI: 10.14309/ctg.0000000000000072. [50] WONG BS, CAMILLERI M, CARLSON PJ, et al. Pharmacogenetics of the effects of colesevelam on colonic transit in irritable bowel syndrome with diarrhea[J]. Dig Dis Sci, 2012, 57( 5): 1222- 1226. DOI: 10.1007/s10620-012-2035-5. [51] TOOULI J, BIANKIN AV, OLIVER MR, et al. Management of pancreatic exocrine insufficiency: Australasian pancreatic club recommendations[J]. Med J Aust, 2010, 193( 8): 461- 467. DOI: 10.5694/j.1326-5377.2010.tb04000.x. [52] GULLO L, BARBARA L, LABÒ G. Effect of cessation of alcohol use on the course of pancreatic dysfunction in alcoholic pancreatitis[J]. Gastroenterology, 1988, 95( 4): 1063- 1068. DOI: 10.1016/0016-5085(88)90184-9. [53] YADAV D, LOWENFELS AB. The epidemiology of pancreatitis and pancreatic cancer[J]. Gastroenterology, 2013, 144( 6): 1252- 1261. DOI: 10.1053/j.gastro.2013.01.068. [54] LAW R, PARSI M, LOPEZ R, et al. Cigarette smoking is independently associated with chronic pancreatitis[J]. Pancreatology, 2010, 10( 1): 54- 59. DOI: 10.1159/000225927. [55] HOHWIELER M, ILLING A, HERMANN PC, et al. Human pluripotent stem cell-derived acinar/ductal organoids generate human pancreas upon orthotopic transplantation and allow disease modelling[J]. Gut, 2017, 66( 3): 473- 486. DOI: 10.1136/gutjnl-2016-312423. [56] ELLIS C, RAMZY A, KIEFFER TJ. Regenerative medicine and cell-based approaches to restore pancreatic function[J]. Nat Rev Gastroenterol Hepatol, 2017, 14( 10): 612- 628. DOI: 10.1038/nrgastro.2017.93. [57] ITO K, MATSUURA K, MIHARA Y, et al. Delivery of pancreatic digestive enzymes into the gastrointestinal tract by pancreatic exocrine tissue transplant[J]. Sci Rep, 2019, 9: 5922. DOI: 10.1038/s41598-019-42362-z. -
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