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消化道肿瘤患者运动干预专家共识

1.北京体育大学 运动人体科学学院，北京 100084；

Expert Consensus on Exercise Interventions for Patients with Digestive System Neoplasm

School of Sport Science，Beijing Sport University，Beijing 100084 , China；

作者简介:

《消化道肿瘤患者运动干预专家共识》工作组：

共识指导委员：倪国新（厦门大学附属第一医院），郭建军（首都体育学院），李然（北京体育大学）

共识专家组成员（以姓氏汉语拼音排序）：

白震民（北京体育大学），陈和木（安徽医科大学第一附属医院），黄彩华（厦门理工学院），黄琰菁（海南省人民医院），李嘉（空军军医大学），李雪（成都体育学院），刘忠良（吉林大学第二医院），苏国强（厦门大学附属第一医院），王育斌（泉州市第一医院），吴霜（贵州医科大学附属医院），吴文（南方医科大学珠江医院），肖京（中国中医科学院西苑医院），谢贤和（福建医科大学附属第一医院），许建文（广西医科大学第一附属医院），杨远滨（中国中医科学院望京医院），虞乐华（重庆医科大学附属第二医院），张善纲（武汉科技大学附属天佑医院），张杨（山东大学齐鲁医院）

共识执笔者：刘慧钰，李然

通讯作者:

李然（1979—），男，内蒙古赤峰人，副教授，博士，研究方向为体质测评与运动处方、运动促进健康的循证医学。

中图分类号:G804.5

文献标识码:A

文章编号:1008-3596(2024)02-0001-07

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目录contents

    摘要

    流行病学调查发现，我国的消化道肿瘤的发病和死亡病例数占全肿瘤的比例均高于世界平均水平。随着消化道肿瘤患者对自身生活质量要求的日益提高，运动干预逐渐受到医师和患者的广泛关注。运动干预相比传统药物治疗，更加侧重通过改善患者的身体机能和运动能力来减少术后并发症，提高总体生存率。目前我国尚未形成消化道肿瘤患者运动干预的相关指南，基于国内外相关证据和我国临床实践，制定《消化道肿瘤患者运动干预专家共识》，内容包括消化道肿瘤患者有氧运动和抗阻运动相关推荐，上消化道癌手术患者、食管癌手术患者、胃肠道癌手术患者、结直肠癌手术患者和肝胆癌手术患者运动干预时间和方式的相关推荐，旨在帮助临床医师基于循证研究证据开展消化道肿瘤患者的运动干预。

    Abstract

    Epidemiological survey found that the incidence and mortality of digestive system neoplasm in China accounted for the proportion of total tumors were higher than the world average. With the increasing demand for the quality of life of patients with digestive system neoplasm, exercise intervention has gradually attracted the attention of doctors and patients. Compared with traditional drug therapy, exercise intervention focuses more on reducing postoperative complications and improving overall survival rate by improving patients’ physical function and exercise ability. At present, China has not yet formed relevant guidelines for exercise intervention in patients with digestive system neoplasm. Based on relevant evidence at home and abroad and clinical practice in China, the Expert Consensus on Exercise Interventions for Patients with Digestive System Neoplasm was formulated, including recommendations for aerobic exercise and resistance exercise in patients with digestive system neoplasm, and recommendations for exercise intervention time and methods in patients with upper gastrointestinal cancer surgery, esophageal cancer surgery, gastrointestinal cancer surgery, colorectal cancer surgery, and hepatobiliary cancer surgery. The purpose of this study is to help clinicians to carry out exercise intervention for patients with gastrointestinal cancer based on evidence-based research evidence.

  • 0 前言

  • 伴随社会的发展，人们的生活方式特别是饮食习惯也在不断变化，消化道肿瘤的发病率和死亡率不断攀升。2020年发布的全球癌症统计数据显示，在全球十大最常见的癌症中，结直肠癌、胃癌、肝癌、食管癌的发病率分别位于第三、五、六、七名，死亡率分别位于第二、四、三、六名[1]。2020年我国4种消化道肿瘤（结直肠癌、肝癌、胃癌和食管癌）的发病和死亡病例数占全肿瘤的比例（38.71%、45.03%）均高于世界平均水平（23.48%、30.91%）[2]，消化道肿瘤已经成为我国人民生命健康和生活质量的主要威胁，给社会造成了巨大的负担。

  • 近代肿瘤学科认为，癌症患者的生存质量比生存期和死亡率更能代表病人的康复效果[3]。在术后的生活中，消化道肿瘤患者依然会出现一系列的症状，如疲乏、抑郁、焦虑、厌食等，严重影响其生活质量。运动干预作为一种非药物干预方式，为提升癌症患者的生活质量提供了切实有效的方法[4]。有研究认为，增加体力活动可以降低消化道肿瘤患病风险，在一定程度上改善消化道肿瘤远期预后[5-6]，缓解癌症相关疼痛、癌因性疲乏、睡眠障碍、焦虑、抑郁等症状[7]，减少消化道肿瘤患者的术后并发症并降低死亡率。

  • 随着生存率的提升，消化道肿瘤患者对自身生活质量的要求也越来越高，运动干预的方式逐渐受到医师和患者的广泛关注，目前国内针对消化道肿瘤患者的运动干预主要集中在术前、术后和围手术期的康复训练，干预方式较为杂乱，缺乏可供参考的临床指南或共识。因此，亟须在总结和综合国内外现有最佳证据的基础上，制定适合国内消化道肿瘤患者的运动干预共识，给医师和患者提供更加明确和规范的运动干预依据。本共识依据国内外相关文献，并在广泛征求我国相关领域专家学者意见的基础上进行编写修改，最终形成《消化道肿瘤患者运动干预专家共识》。

  • 1 共识制定方法

  • 《消化道肿瘤患者运动干预专家共识》以运动干预18岁及以上的消化道肿瘤患者为目标，采用证据质量和推荐意见分级的评估、制定与评价（Grading of Recommendations Assessment，Development and Evaluations，GRADE）标准制定[8]，专家共识的形成步骤如下。

  • 1.1 专家共识工作组的成立

  • 本共识的指导组和专家组由临床医学、运动医学、循证医学和运动人体科学等多领域专家组成。

  • 1.2 临床问题的确定

  • 本共识工作组通过文献调研法和专家访谈法，依据PICO模式（population，interventions，comparisons，outcomes），针对研究对象、干预手段、对照因素和诊疗效果，筛选临床实验和实践中发现的相关问题后，进一步构建并确定与消化道肿瘤有关的临床问题。

  • 1.3 文献的检索

  • 本共识数据均来源于Pubmed、Embase、The Cochrane Library、Web of Science、PEDro、CINAHL、WanFang Data、CNKI、SinoMed和维普等中英文数据库，利用运动、消化道肿瘤、exercise、physical activity、digestive system neoplasm、esophageal neoplasm、biliary tract neoplasm、gastrointestinal neoplasm、liver neoplasm、pancreatic neoplasm和peritoneal neoplasm等中英文检索词进行系统检索，检索时间为建库到2023年11月5日，语种限制为中文和英文。检索范围包括国内外公开发表的临床实践指南、专家共识、系统评价、Meta分析或网状Meta分析等二次研究文献。如果检索到3年内的高质量系统评价，则直接使用。如果检索到的系统评价质量低、需要更新或没有相关系统评价，则对临床对照试验和观察性研究进行检索。其中临床对照试验包括随机对照试验（randomized controlled trial，RCT）、半随机对照试验（quasi-RCT）和非随机对照试验，观察性研究包括队列研究、病例对照研究和横断面研究。

  • 1.4 证据的质量评价

  • 本共识采用明确界定了证据质量和推荐强度的GRADE证据分级评价，对证据质量的分级有详细的标准，而且对推荐意见的强弱也有清晰的解释。证据质量和推荐意见分级见表1。

  • 表1 证据质量和推荐意见分级

  • 1.5 推荐意见的形成

  • 本共识工作组基于检索到的国内外证据，并结合我国消化道肿瘤患者的临床表现，评估各种运动干预的可行性后，初步拟定了针对我国消化道肿瘤患者的运动干预推荐意见，依据两轮德尔菲调查结果进行修改，经讨论后达成一致。

  • 2 消化道肿瘤患者运动干预推荐

  • 2.1 推荐意见1

  • 推荐消化道肿瘤患者进行短期（≤12周）有氧运动，以缓解患者的疼痛和疲劳，改善心理健康，提高功能状态。（证据级别：高；专家共识度：强）

  • 美国癌症协会2022年发布的《癌症幸存者营养和运动指南》表明，癌症患者在治疗期间和治疗后进行运动，可以减少心理困扰，提高身体机能，改善与健康相关的生活质量[9]。证据表明，短期有氧运动可以促进胃肠道蠕动，减少病原体与胃肠黏膜的接触，防止消化道肿瘤患者病情恶化，有效改善患者的整体健康状况[10]。短期有氧运动可以通过提高体温和脑血流量改善自我效能[11]，是促进消化系统肿瘤患者心理健康和角色功能健康最有效的运动类型，男性有氧运动30 MET-小时/周的获益最大[12]。长期有氧运动会降低患者的心理健康和角色功能健康水平。短期有氧运动和短期有氧结合抗阻运动都可以改善消化道肿瘤患者的预后情况，缓解疲劳的症状[13]，体现为患者失眠、抑郁和焦虑的减少以及住院时间的缩短[14-15]。

  • 2.2 推荐意见2

  • 推荐消化道肿瘤患者进行短期（≤12周）渐进性抗阻运动，强度从1次重复最大力量的30%~40%开始逐渐递增，包括上肢和下肢力量训练，每周2次，每次30分钟，以降低患者的胃食管反流发生率，提高生活质量和身体功能水平。（证据级别：中；专家共识度：强）

  • 短期抗阻运动有助于减轻治疗的副作用，提高肌肉力量，增加骨密度，抑制进行性肌肉萎缩[16]。对于消化系统肿瘤患者而言，长期运动可能会限制其他娱乐和社交活动时间，对患者生活质量的角色情感方面产生负面影响[17-18]，不利于患者对运动积极性的保持。证据表明[14，19-20]，与无运动干预相比，短期渐进性抗阻运动可以促进消化系统肿瘤患者身体健康，缩短住院时间，降低胃食管反流的发生率，是缓解疲劳最有效的干预方式；但长期抗阻运动会导致患者整体健康状况和角色功能的降低，且运动的有利影响可能随疾病的发展而逐渐抵消，患者的依从性也逐渐减弱。

  • 2.3 推荐意见3

  • 推荐上消化道癌手术患者术前进行有氧结合抗阻运动，具体为每周3次有氧运动结合1次抗阻运动，每次运动时间为30分钟，以改善患者的胰岛素抵抗指数和功能能力。（证据级别：中；专家共识度：强）

  • 上消化道癌手术患者常表现为体重减轻和生理储备减少，可能会导致患者产生更多的术后并发症、更长的住院时间，术后发病率也会升高[12，21]。证据表明，在术前对上消化道癌患者进行有监督的有氧结合抗阻运动——每周3次、每次30分钟的快走、慢跑或骑行，以及使用弹力带进行每周1次、每次30分钟、主观疲劳程度RPE 12~13的抗阻运动[22]，可以有效提高患者的有氧运动能力，增强机体免疫力，加快术后恢复，体现为患者功能能力的显著改善，术后并发症的明显减少和死亡率的明显降低[23-25]。

  • 2.4 推荐意见4

  • 推荐食管癌手术患者在围手术期开展运动，并至少在术前1周进行低强度和高强度相间的运动，术后进行12周步行和八段锦等有氧运动，以改善患者的心肺功能和运动能力。（证据级别：中；专家共识度：强）

  • 证据表明，食管癌患者术前出现肌肉疏松症、肌力下降和运动能力下降，与术后较高死亡率和更多并发症的风险有关[26-28]，高强度间歇运动可以降低患者的血清肿瘤标志物水平，降低术后发病率，缩短住院时间[29]，延长中位生存期[30]。食管切除手术患者在术前2~4周进行有监督的有氧结合抗阻运动，在术后4~12周运动能力会有明显恢复，通过提高患者术前的心肺耐力，改善其情绪健康。同时，有氧结合抗阻运动还可能有助于预防呼吸系统并发症的发生[31-32]。食管切除手术患者在术前进行1~2周呼吸训练，术后持续12周有氧运动结合营养补充，患者的运动能力可以得到恢复，降低胃食管反流发生率，在呼吸训练的基础上进行体能练习还能够减少术后肺部并发症的发生[33-34]。因此，建议临床医师在应用证据进行运动指导时，鼓励食管癌患者积极参与运动锻炼，以提高术后康复效果，降低并发症发生和死亡风险。

  • 2.5 推荐意见5

  • 推荐胃肠道癌手术患者在术前2~4周进行预康复的运动干预，并按照每周2次、每次30分钟进行中等强度抗阻或有氧运动，以辅助降低患者的血浆胰岛素水平和血清TNF-α水平。（证据级别：高；专家共识度：弱）

  • 实施预康复干预的目的是利用患者的术前等待时间来优化术前身体状态，提高身体的耐受能力和术后恢复能力。证据表明[35]，胃肠道癌患者在手术前2~4周进行每周2次、每次30分钟有监督的中等强度抗阻或有氧训练，可以显著提高患者术前和术后4~8周的运动能力[36-37]。与常规组相比，有运动干预的患者血浆胰岛素水平和血清TNF-α水平显著下降[38-39]。预康复运动干预的有效实施关键在于患者的依从性，以往研究表明，对于参加预康复运动干预的癌症患者来说，剧烈运动时依从性会大幅降低[40]。因此，在患者入院时，临床医师应对其进行健康宣教及运动指导，以提高术前运动能力，减少术后运动的不适感，提升患者的依从性。同时，督促患者手术后尽早下床活动，在术后8周内持续进行每周3次及以上、每次30分钟的家庭运动干预[36]，可以根据患者的身体情况做出适当调整，以改善术后恢复能力。

  • 2.6 推荐意见6

  • 推荐结直肠癌手术患者在围手术期开展运动干预，进行每周至少3次、每次30分钟的有氧结合抗阻运动，以提高患者身体机能，改善胰岛素抵抗指数和功能能力。（证据级别：中；专家共识度：弱）

  • 结直肠癌手术患者容易呈现身体疲惫、身体活动水平下降和体重减轻的状态，进而导致术后并发症发病率、再住院率和死亡率提高，住院时间延长[41]。美国癌症协会发布的第3版《癌症幸存者营养和运动指南》指出，更多的运动与结直肠癌患者特异性生存率提高有关[9]。结直肠癌手术患者术前每周进行至少3次有氧结合抗阻运动——每次最多50分钟、中等强度（主观疲劳程度RPE 12）的有氧运动，或15 RM的抗阻练习，临床医师可根据患者情况适当调整训练强度，充分提高患者的术前功能和身体机能，以承受手术压力并促进术后恢复，缩短住院时间[25，42]。证据表明，大部分在术后继续运动的患者可以恢复到术前水平。同时，临床医师也需要对患者进行营养干预，保证患者运动干预过程中所需的蛋白质和能量[37]。

  • 2.7 推荐意见7

  • 推荐肝胆癌手术患者在术前进行4周间歇性有氧运动干预，每周3次，每次30分钟，以改善患者的心肺功能和生活质量。（证据级别：中；专家共识度：强）

  • 肝胆癌手术患者在术前进行运动干预可以明显缩短住院时间，减少术后并发症并保留胃的功能，其原因可能是运动提高了患者的有氧能力，改善了患者的潜在生理机能[25，43-44]。证据表明，与无运动干预相比，肝胆癌手术患者进行运动强度为60%~90% VO2 max、为期4周的间歇训练，其最大摄氧量和无氧阈值都会显著提高，肺部并发症的发生率明显降低，住院时间明显缩短，患者的生活质量得到改善[45-46]。临床医师对肝胆癌患者进行运动指导时，需要同时注意对患者进行营养干预，增加蛋白质和糖类的摄入，减少胃的排空延迟，促进患者身体机能恢复[47]。

  • 3 结束语

  • 本共识总结了目前有关消化道肿瘤的运动干预证据，旨在为临床医师给消化道肿瘤患者制定具有科学性和个性化的运动干预方案提供循证依据。本共识仅纳入了中文和英文文献，可能会因遗漏其他语种的文献而产生一定的偏倚。此外，与运动干预方案相关的部分证据存在异质性，这可能是因患者个体的身体状况、肿瘤的部位和分期存在差异，运动的强度和形式不能完全一致造成的。虽然目前对于消化道肿瘤患者通过运动获益的最佳运动干预方案存在许多未知，但随着该领域研究的不断发展，更多的临床应用证据的出现，共识内容会不断更新和丰富。未来可以为消化道肿瘤患者制定更加具有针对性的运动干预方案，为临床实践提供更多支持。

  • 利益冲突声明：所有作者均声明不存在利益冲突。

  • 本共识已在国际实践指南注册平台（Inter-national Practice Guideline Registry Platform，IPGRP，http://www.guidelines-registry.cn/）上进行注册，注册号为IPGRP-2022CN219。

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  • 基本信息

    中图分类号: G804.5
    文献标识码: A
    文章编号: 1008-3596(2024)02-0001-07

    基金信息

    国家重点研发计划课题（2020YFC2006703）；

    引用信息

    稿件历史

    收稿日期: 2023-12-13

  • 参考文献

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    • [2] 周家琛，郑荣寿，王少明，等.2020年中国和世界部分国家主要消化道肿瘤负担比较[J].肿瘤综合治疗电子杂志，2021，7（2）：26.

    • [3] 肖益萍，李琼.癌症症状管理的研究进展[J].解放军护理杂志，2016，33（17）：34.

    • [4] HOJAN K,PROCYK D,HORYŃSKA-KESTOWICZ D,et al.The preventive role of regular physical training in ventricular remodeling,serum cardiac markers,and exercise performance changes in breast cancer in women undergoing trastuzumab therapy-an REH-HER study[J].Journal of Clinical Medicine,2020,9(5):1379.

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