鼻胃管减压并鼻空肠管营养在重型脑出血患者中的应用价值

目的比较经鼻胃管减压联合经鼻空肠管营养与单纯经鼻空肠管营养2种肠内营养方式在重型脑出血患者中的应用效果。方法将56例重型脑出血患者分成两组进行肠内营养,一组采用经鼻胃管减压联合经鼻空肠管营养,另一组采用单纯经鼻空肠管营养。记录两组置管前及置管后第8天、第15天的营养情况,包括血清总蛋白、前白蛋白、血红蛋白含量。记录两组置管15d内并发症发生率,包括腹泻、反流、误吸及吸入性肺炎。用格拉斯哥预后评分表评定两组患者的预后情况。结果置管后第15天经鼻胃管减压联合经鼻空肠管营养组的总蛋白、前白蛋白的含量均高于单纯经鼻空肠管营养组(P<0.05)。经鼻胃管减压联合经鼻空肠管营养组15d内并发症发生率低于单纯经鼻空肠管营养组(P<0.05),两组的格拉斯哥预后评分显示经鼻胃管减压联合经鼻空肠管肠内营养组预后优于单纯经鼻空肠管营养组,差异均有统计学意义(P<0.05)。结论在重型脑出血患者中使用经鼻胃管减压联合经鼻空肠管肠内营养更能改善其营养状况,减少并发症,更有利于患者康复。     

肠内营养支持在80岁以上反复肺部感染患者中的应用

目的 探讨肠内营养支持在≥80岁反复肺部感染患者中的临床应用效果. 方法 对34例≥80岁反复肺部感染患者肠内营养支持情况进行分析.采用经皮内镜下胃造瘘术(PEG/J)治疗组18例,采用鼻胃管治疗组16例,摄入同等热量和同等氮量,营养支持时间＞2月. 结果 经肠内营养支持后,全部患者的营养状况得到改善,2组各指标差异无显著性.PEG/J治疗组反流、误吸、吸入性肺炎的发生次数均明显少于鼻胃管组,对比差异均有统计学意义(P＜0.05). 结论 在≥80岁反复肺部感染患者中选择合适的肠内营养支持方式,不仅可以改善病人的营养状况,还可以减少肺部感染的发生,提高机体免疫功能,促进病人的康复.     

经皮内镜下胃造口空肠置管术在良性食管瘘患者中的应用

目的研究经皮内镜下胃造口空肠置管术(PEJ)在良性食管瘘患者中应用的可行性、疗效和并发症。方法观察18例良性食管瘘患者接受PEJ的置管时间、成功率、并发症和导管留置时间。结果平均置管时间为(21.75±5.9)min,成功率为94.44%,未发生置管相关性并发症,置管后并发症的发生率为11.11%,平均导管留置时间为(76.88±21.13)d。结论 PEJ是一项安全有效的治疗方法,具有操作简便、快捷、易于护理、患者痛苦少、易于耐受等优点,适合良性食管瘘患者应用。     

经皮内镜下胃/空肠造口术在胃大部切除术后患者中的应用

经皮内镜下胃造口（ percutaneous endoscopic gastrostomy, PEG）于1980年开始应用于临床，目前主要适用于建立长期肠内营养支持的途径或进行姑息性胃肠减压。经皮内镜下空肠造口 （ percutaneous endoscopic jejunostomy, PEJ ）则是在PEG基础上，通过PEG管将空肠营养管送入空肠近端，应用于胃排空障碍、幽门不全梗阻等患者中，既可通过空肠营养管进行肠内营养，又可以通过胃管进行胃内减压引流。     

内镜介入肠内营养管置入术临床应用

恶性肿瘤患者由于疾病本身或治疗要求，短时或长期内患者不能主动进食或不宜经口饮食时，内镜下鼻胃肠管置入术(endoscopic nasogastric tube，ENGT／endoscopic nasoentera ltube，ENET)和经皮内镜胃空肠造瘘术(percutaneous endoscopic gastrostomy，PEG／percutaneous endoscopic jejunostomy，PEJ)可有效地避免胃肠外营养的缺点。     

PEG和PEJ在临床营养支持中的应用进展

肠内营养支持是临床营养支持的首选途径,鼻胃管、鼻肠管、胃造口和空肠造口等途径均可实施肠内营养。鼻胃管法因其简便易操作,在临床上使用最广泛,但它容易引发反流、误吸,因此有时不能很好地实现肠内营养支持。1979年,Ponsky和Gauderer首次报道了经皮内镜下空肠造口术（percutaneousendoscopicgastrostomy,PEG）,随后又进一步开展了经皮内镜下空肠造口术（percutaneousendos—copicjejunostomyPEJ）,     

鼻空肠与鼻胃管管饲的急性重症卒中患者的肺炎

目的 探讨鼻空肠管与鼻胃管肠内营养支持对重症急性卒中患者卒中相关性肺炎(stroke associated pneumonia,SAP)以及其他并发症的影响.方法 共纳入60例需要管饲的重症急性卒中患者,随机分为鼻空肠管组和鼻胃管组进行肠内营养支持,观察2周内SAP、腹泻、呕吐、消化道出血和低钠血症的发生,记录置管前以及置管后7d和14 d时的营养指标(总蛋白、前白蛋白、血红蛋白)并进行比较.结果 鼻空肠管组和鼻胃管组各30例,2组人口统计学和基线临床资料均无显著差异.鼻空肠管组SAP(43.3％对70.0％;x2=4.340,P=0.037)、呕吐(13.3％对43.3％x2 =6.648,P=0.010)和低钠血症(16.7％对40.0％;x2 =4.022,P=0.045)发生率显著低于鼻胃管组,但腹泻和消化道出血发生率无显著差异.鼻空肠管组置管后14 d时的血浆总蛋白和前白蛋白浓度与置管前无显著差异,但血红蛋白浓度显著降低(P=0.001);相比之下,鼻胃管组置管后14 d时血浆总蛋白(P=0.001)、前白蛋白(P=0.036)和血红蛋白(P=0.001)浓度与置管前相比均显著降低.结论 重症急性卒中患者鼻空肠肠内营养能有效预防SAP以及呕吐和低钠血症的发生,并且有助于维持患者的营养状况.     

经皮内镜下胃肠造口行肠内营养在术后胃瘫中的应用

腹部术后出现胃瘫并非少见，以往给予禁食、胃减压、应用胃动力药及静脉插管输液以及经鼻肠管行肠内营养等，但疗效欠佳且存在诸多并发症与不便。近年来，随着经皮内窥镜下胃造口（PEG）及经皮内窥镜下空肠造口（PEJ）术的日益成熟和推广，经PEJ管行肠内营养后，极大地提高疗效并减轻了病人的痛苦。现将我们开展此项治疗的情况总结报告如下。     

胃镜拖线法在大肠癌术后胃瘫患者空肠营养管置入术中的应用

目的观察胃镜拖线法在大肠癌术后胃瘫患者空肠营养管置入术中的应用效果。方法选取10例结肠癌术后发生胃瘫的患者,均行空肠营养管置入术。置管前在鼻胃管的顶部预先用7号慕丝线打好麻线结,助手将鼻胃管放入食管内,胃镜下用活检钳夹住鼻胃管前端预留线结拖入空肠。结果本组均置管成功,置管时间平均15 min,送入鼻胃空肠管总长约85 cm,置管后均无严重并发症;与置管前比较,置管后2周患者体质量增加、血清白蛋白升高、KPS评分增加,P均〈0.05。拔管后3周内,患者均恢复胃肠功能。结论胃镜拖线法用于空肠营养管置入术操作简单、无并发症,可明显改善大肠癌术后胃瘫患者的营养及生活质量。     

吞咽功能障碍的老年重症患者经鼻肠管和鼻胃管肠内营养的比较

目的 比较经鼻肠管和鼻胃管两种途径在伴有吞咽功能障碍的老年重症患者中的肠内营养（EN）支持的效果及并发症情况,以选择更安全有效的EN途径。方法 选取2012年1月至2014年11月在南京市市级机关医院重症医学科住院的伴有吞咽功能障碍的老年患者共53例进行EN,将患者随机分为留置鼻胃管组（31例）和留置鼻空肠管组（22例）。EN 2周后观察两组的营养指标情况、并发症发生率及预后,进行比较及统计分析。结果 两组患者中鼻空肠管组前白蛋白升高更显著,胃肠道并发症及吸入性肺炎发生率均显著下降,差异存在统计学意义（P＜0.05）。但机械通气率和病死率两组相比差异无统计学意义（P＞0.05）。结论 伴有吞咽功能障碍的老年重症患者应用鼻空肠管给予EN更为安全、有效。     

Tube dysfunction following percutaneous endoscopic gastrostomy and jejunostomy

Percutaneous endoscopic gastrostomy (PEG) and jejunostomy (PEJ) have supplanted their surgical counterparts in many institutions. Previous reports have claimed advantages in placing PEJ tubes because of reduced gastroesophageal reflux, prevention of aspiration, and improved tube anchoring distally. We reviewed the records of 191 patients who underwent placement of PEG/J tubes. Data collected included incidence of tube dysfunction, need for tube replacement or removal, and aspiration after PEG or PEJ tube placement. Tube dysfunction, defined as peritube leakage, plugging, fracture, or migration, occurred in 36% of patients over a mean follow-up period of 275 days and was significantly more common and likely to necessitate tube replacement in PEJ patients. Tube trade-out or removal and aspiration within a 30-day period after tube placement occurred in 28% and 10% of patients, respectively. These complications were significantly more common in PEJ patients than in PEG patients. Because of the increased incidence of tube dysfunction and the failure to prevent aspiration in predisposed patients, PEJ tube placement is not routinely indicated in patients requiring tube feedings.     

Unsedated transnasal percutaneous endoscopic gastrostomy carried out by a single physician

Aim: The present prospective observational study investigates the safety of transnasal percutaneous endoscopic gastrostomy (T‐PEG) carried out by a single physician using an ultrathin endoscope. Methods: A single endoscopist attempted the unsedated transnasal insertion of a 20‐Fr PEG tube using a pull‐method in 31 dysphagic patients: 11 females and 20 males aged 76.5 ± 10.6 (46–96) years, using a 5‐mm‐diameter endoscope. The indications for PEG, cardiopulmonary function before and after T‐PEG, operation time, success or failure, and any immediate adverse events that occurred during each procedure were recorded. Complications, including peristomal infection, systemic infection, tube lifespan, and patient mortality were monitored throughout the post‐T‐PEG follow‐up period. Results: Thirty (96.8%) of the transnasal PEG insertions were successful. The mean operation time was 14.7 ± 2.9 (10–20) min, and cardiopulmonary function did not change before and after T‐PEG. Complications included three (10%) cases of epistaxis, eight (26.6%) cases of minor Pseudomonas wound infection and two cases of Foley‐related urinary tract infection (UTI). No self‐extubation was observed, and the mean lifespan of the PEG tubes was 10.7 ± 2.2 months. Four patients died from pneumonia 10 months after T‐PEG insertion. Conclusion: Unsedated T‐PEG insertion carried out by a single physician is a feasible and safe procedure. No major complications or mortality were observed following the procedures; only minor Pseudomonas aeruginosa wound infections were noted. It is an alternative method for dysphagic patients when transoral insertion of endoscopy is impossible.     

A 94-year-old woman with nontuberculous mycobacterium who developed small intestinal intussusception associated with a percutaneous endoscopic jejunostomy tube

We report a 94-year-old woman, who underwent percutaneous endoscopic Jejunostomy (PEJ) tube feeding for enteral nutrition, developed the intussusception of the small intestine. She suffered from nontuberculous mycobacterium (NTM), and her lung inflammation deteriorated due to aspiration pneumonia and malnutrition. Because of old age, dysphagia, esophageal hiatus hernia, gastro-esophageal reflux and her bedridden condition due to severe osteoporosis, oral nutritional supplementation is nearly impossible. To reduce the aspiration risk, we chose PEJ instead of percutaneous endoscopic gastrostomy (PEG) as the route of tube feeding. Six months after the placement of a PEJ tube, aspiration pneumonia was diagnosed and she was readmitted to our hospital. During hospitalization, she had sudden diarrhea, vomiting, and lower abdominal pain. Abdominal CT scan and radiographs using contrast medium showed small intestinal intussusception related to the PEJ tube. We observed the clinical course without performing surgery, pulling it back towards the stomach and placing an ileus tube, because the small intestine was not completely obstructed. Two months later, although she suffered from aspiration pneumonia once more, she remained in a stable condition without further intervention so that she could move to aother hospital. Recently PEJ has been expected to prevent aspiration pneumonia, but we believe that it can be a risk factor for intussusception. Although the PEJ can be a good parenteral nutrition route for frail elderly with dysphagia, we need to consider possible complications including intussusception.     

Percutaneous endoscopic gastrostomy placement without a skin incision: results of a prospective pilot study

Percutaneous endoscopic gastrostomy (PEG) tube placement may result in substantial skin site complications. Standard PEG (SPEG) placement involves performing a skin incision, which in our experience is not necessary. In a prospective pilot study, we examined the need for this incision with respect to placement success and stomal complications. Twenty consecutive patients underwent 20 Fr PEG tube placement by a modified technique, involving skin incision omission (IOPEG). Stoma evaluations were performed at 2 and 7 days after placement to record infection and bleeding scores. Mean infection scores were compared with published historical SPEG data obtained from this institution using the identical scoring system. In 12 cases, a digital force gauge measured peak pull-forces (pounds) required to pull the IOPEG through the abdominal wall and were compared with published SPEG pull-force data. Successful IOPEG placement was achieved in 20/20 (100%). No infectious or bleeding complications occurred. Mean 2 and 7-day infection scores were significantly lower than historical SPEG scores. Mean pull-forces were greater than published SPEG forces. A skin incision is not required for successful PEG placement. Incision omission likely increases PEG pull-forces, but may possibly lead to reduced infection complications.     

肠内营养在高龄多器官功能障碍综合征患者中的应用

目的 探讨不同途径营养支持治疗对高龄多器官功能障碍综合征(MODS)患者脏器功能恢复及预后的影响.方法 将确诊为MODS高龄患者85例随机分组为2组,肠内营养组43例,通过鼻饲管或内镜下经皮胃/肠造瘘术(PEG/PEJ)给予营养支持,全胃肠外营养组(对照组)42例,经中心静脉治疗,总疗程至少2个月;比较两组患者治疗前后体质指数(BMI)、血红蛋白(Hb)、肝肾功能、电解质、血糖、血脂、血清白蛋白(ALB)、转铁蛋白(TRF)及前白蛋白(PA)、免疫球蛋白(IgA、IgG、IgM)、T淋巴细胞亚群(CD3+,CD4+、CD4+/CD8+)等指标.结果 在摄入同等热量和氮量的条件下,两组患者血Hb、BMI、血清ALB、TRF及PA水平在营养支持治疗后第1个月(t1EN=2.672、2.440、2.209、3.331和5.025,t1TPN=2.720、2.337、2.179、3.418和2.221)、第2个月(t2EN =2.279、3.021、2.337、3.005和5.779,t2TPN=2.118、2.956、3.018、3.310和2.119)较治疗前均有明显改善(均为P＜0.05),肠内营养组PA水平较对照组变化更明显(t=2.336,P＜0.05).对照组治疗后第1、2个月都出现高脂血症(t1TPN=3.609,P＜0.05;t2TPN =3.114,P＜0.05).肠内营养组治疗第1、2个月后血IgG、IgA较治疗前均明显升高(t1 EN=2.664、2.437,P＜0.05;t2 EN=2.983、3.005,P＜0.05),血CD3+、CD4+、CD8+、CD4+/CD8+水平在治疗2个月后改变明显(t=2.399、3.478、2.579和3.995,P＜0.05),IgM于治疗后第2个月有明显升高(t=3.886,P＜0.05).肠内营养组中34例PEG/PEJ术前反复发生吸入性肺炎,术后2个月内仅发生5例(x2=51.12,P＜0.05);术后2个月反流性食管炎发生率减少、严重程度较术前明显减轻(x2=13.53,P＜0.05).结论 及时、充分的胃肠内营养支持治疗,可有效改善高龄MODS患者全身状况及营养;PEG/PEJ术可减少因鼻饲管引发的吸入性肺炎和反流性食管炎的发生.     

Complications of percutaneous endoscopic gastrostomy in the elderly: local skin infection and respiratory infection

We investigated post-operative management of acute complications of percutaneous endoscopic gastrostomy (PEG) which often caused respiratory infections and local skin infections. The subjects were a total of 341 patients (male 131, female 210, and the mean age was 80.3), they were classified into six groups by method of feeding and use of antibiotics. Patients were divided into three groups based on the time that feeding was started. In Group I, enteral feeding was not started within the first five days. In Group II, sterilized enteral feeding (lactated Ringer's solution for intravenous infusion) using sterilized intravenous infusion kit started within 24 hours after the procedure, and in Group III, feeding of the usual enteral formula started within 24 hours after the procedure. And as for the using of antibiotics, they were also divided into two groups, antibiotics administered[AB (+)] and no antibiotics administered[AB (-)]. Thus, the patients were divided into six groups according to the time of starting nutrition and the use of antibiotics. The rates of incidence of acute respiratory infections and local skin infections in the six groups were compared by the chi-square test and differences in the rates of incidence of complication were also compared between two PEG methods; the Pull/Push method and the Introducer method. The frequency of local skin infection in Group III was significantly higher than in Group I and Group II. As for the PEG methods, the frequency of local skin infection in the Pull/Push method was significantly higher than Introducer methods. Acute respiratory infections occurred significantly less in the AB (+) group than in the AB (-) group. Postoperative administration of antibiotics would seem to be appropriate for prophylaxis of respiratory infection in elderly patients after PEG. On the other hand, local skin infections are not related to administration of antibiotics, and are highly related to the method of feeding. We concluded that nutrition of sterilized enteral feeding immediately after operation using a sterilized intravenous infusion kit and administration of antibiotics are advisable to prevent major complications in elderly patients.     

Percutaneous Endoscopic Gastrostomy,Duodenostomy and Jejunostomy for Alimentation in Gastrectomized Patients

Percutaneous Endoscopic Gastrostomy (PEG) which can be accomplished with local anesthesia and without the necessity for laparotomy is now gaining popularity as a clinical treatment for patients who have difficulties in swallowing and require long term nutritional support but have an intact gut. A total of 40 patients underwent percutaneous endoscopic placement of a feeding tube in our clinic. They included 37 patients who had had PEG, 1 Percutaneous Endoscopic Duodenostomy (PED) and 2 Percutaneous Endoscopic Jejunostomy (PEJ). Of these patients, 3 had previously had a partial gastrectomy and 1 had had an esophagectomy with esophago-jejunostomy. Three patients who had undergone a previous partial gastrectomy received different procedures; 1 PEG, 1 PED and 1 PEJ, which were considered to be most appropriate for each patient. One patient with a previous esophagectomy had a PEJ. PEG, PED and PEJ for the patients who had previously undergone a gastrectomy were successfully done with great care. Our experience suggests that PEG, PED or PEJ are rapid, safe and useful procedures for patients who are a poor anesthetic or poor operative risk and can be used even for patients who have undergone previous surgery.     

Percutaneous endoscopic gastrostomy in elderly patients. A prospective study in a geriatric hospital

OBJECTIVES: The purpose of this work was to search for prognostic factors after percutaneous endoscopic gastrostomy (PEG) for enteral nutrition in geriatric patients by studying complications, nutritional benefits, and impact on quality of life.METHODS: In this prospective study, 59 elderly patients referred for PEG were followed for 1 year or until tube removal or death. Complications, tolerance to enteral nutrition, nutritional status, infection, bedsores and quality of life were assessed by a questionnaire at tube insertion, at 1 month and every 3 months. Multivariate analysis was performed to look for factors predictive of early mortality before one month.RESULTS: Insertion of the PEG tube was always successful. Pneumonia in the week before tube insertion was predictive of early mortality (odds-ratio: 8.77 [1.63-47.2], P=0.01). Thirty-day mortality was 25%, but was never related to PEG tube insertion. During follow up, no local complication was observed and enteral feeding was well tolerated. After 3 months, serum albumin and prealbumin levels increased (P<0.001). There were fewer infections (P<0.001) and bedsores remained unchanged. Quality-of-life scores were not modified. At one year, the PEG tube was removed in 16 patients who resumed normal oral nutrition, and 6 other patients were able to return to their home.CONCLUSION: In a cohort of aged institutionalized patients, PEG for enteral nutrition was well tolerated and not definitive in more than one-quarter of them. Active lung infection is a risk factor of early mortality.     

腹腔镜下"无管化"结直肠手术的临床研究

目的通过改善围手术期处理实现腹腔镜下结直肠手术"无管化";将腹腔镜下"无管化"结直肠手术与传统术后留置鼻胃管、腹腔引流管和导尿管腹腔镜下的结直肠手术在术后恢复和并发症方面进行对照研究,进一步论证腹腔镜下"无管化"结直肠手术的可行性和安全性。 方法将49例结、直肠恶性肿瘤患者随机分为常规留置"三管"手术组（对照组）（23例）、"无管化"手术组（TF组）（26例）。比较患者基线特征指标、术后恢复指标、生活质量量表（QoR-40）评估、术后安全性指标。 结果"无管化"手术组有3人术后发生尿潴留;"无管化"手术组与对照组相比,其术后阿片类镇痛药物的使用天数（Z=5.241,P<0.001）和住院天数明显缩短（t=3.21,P=0.002）,差异均有统计学意义。两组患者在吻合口漏、肠梗阻、切口感染、肺部感染、心力衰竭、深静脉血栓和心脑血管意外等并发症的发生率方面差异无明显统计学意义（均P>0.05）。"无管化"手术组术后48 h QoR-40总分明显高于对照组（Z=5.774,P<0.01）;其中"无管化"手术组在身体舒适度、自理能力和疼痛方面的评分明显优于对照组（P<0.01）。 结论在结直肠手术后常规留置鼻胃管、导尿管和腹腔引流管并不能使患者获益;而"无管化"结直肠手术通过减少患者术后不适,明显改善患者术后恢复质量,且不增加术后短期并发症的发生;是一种安全、可行的治疗措施。