针刺导管空肠造口术肠内营养在胰十二指肠切除术病人中的应用

目的探讨针刺导管空肠造口术(NCJ)肠内营养(EN)在胰十二指肠切除术病人中的应用效果。方法32例病人,16例术后肠外营养(PN)(对照组),16例术后行导管空肠造口术(NCJ)肠内营养(EN)治疗(实验组)。结果术后实验组的胃肠动力比对照组的恢复早(P<0.05)。治疗前两组病人血蛋白指标(白蛋白、前白蛋白、转铁蛋白)无明显差异。治疗后两组均升高,而实验组血蛋白指标的水平明显高于对照组(P<0.05),二者差异显著。结论导管空肠造口术(NCJ)肠内营养(EN)应用于胰十二指肠切除术病人中比肠外营养(PN)具有更多的优点。     

肠梗阻导管减压联合肠内营养在结直肠癌性梗阻治疗中的应用研究

目的评价经肛肠梗阻导管减压联合肠内营养在急性结直肠癌性梗阻治疗中的应用价值。方法 47例急性完全性梗阻性结直肠癌患者经肛门置入肠梗阻导管,42例成功置入导管,减压成功后给予肠内营养,肠内营养6～7d后手术。检测入院时、术晨的血清白蛋白、前白蛋白、转铁蛋水平。结果 42例患者术晨的血清前白蛋白,血清白蛋白和转铁蛋白水平,与入院时比较均有明显提高(P<0.05,P<0.01)。全部患者成功行结直肠癌Ⅰ期根治切除吻合术,术后恢复顺利,未发生严重并发症。结论经肛门置入肠梗阻导管减压联合肠内营养可以改善结直肠癌并发肠梗阻患者的术前营养状况,安全可行。     

经肛肠梗阻导管加肠内营养在急性左半结肠恶性梗阻性疾病的临床研究

目的探讨肠梗阻导管加肠内营养在急性左半结肠恶性梗阻性疾病治疗中的作用。方法2006年6月至2008年6月,选择17例肠梗阻患者,按入院时间分为对照组（8例）和导管组（9例）。对照组给予常规治疗方案,导管组在此基础上应用肠梗阻导管和肠内营养治疗。结果经3～5d肠梗阻导管减压和肠内营养支持治疗,8例急性肠梗阻症状均缓解,均可限期行腹腔镜一期切除和吻合,术后随访1～9个月,中位数7个月,未见吻合口漏等并发症。结论经肛门肠梗阻导管和肠内营养用于治疗急性左半结肠恶性梗阻安全有效,同时可减少肠造口和二期手术的风险。     

Early enteral feeding after closure of colostomy in pediatric patients

Background/Purpose

The aim of this study was to determine the benefits and adverse effects of protocolized early postoperative enteral feeding in pediatric patients undergoing a closure of colostomy.

Methods

Pediatric patients, completely treated for anorectal malformation, who underwent a closure of colostomy during September 2000 and May 2002 received early postoperative feeding according to the authors’ protocol (EF group). Retrospective data of consecutive patients operated on from March 1998 to August 2000 who received traditional feeding practice were used as a control (TF group). The protocol began with a small volume of formula or breast feeding within the first postoperative day. Volume allowance was advanced every 4 hours up to the daily maintenance volume. Full feeding was defined as when the patient was able to tolerate at least 80% of daily maintenance volume. TF group received nothing by mouth until documentation of bowel function. The groups were compared with regard to postoperative stay, postoperative hour of full feeding, first bowel movement, and adverse effects. Statistical analyses were performed with χ² test, Student’s t test, and Mann-Whitney U test.

Results

There were 34 and 30 patients in EF and TF groups, respectively. Median age of the patients was 13 months, and median weight was 8.39 kg. Except for the associated anomalies, which were found more in the EF group, there were no differences in the demographic characteristics of the 2 groups. On average, feeding was initiated at 19.7 (16 to 24) hours in the EF group and 51.7 (18 to 92) hours in the TF group (P < .01). Median full feeding hours were 45.5 and 70.5 hours in the EF and TF group, respectively (P < .01). First bowel movement in the EF group was recorded at the average of 4.14 postoperative nurse shifts, compared with 5.96 shifts in the TF group (P < .01). Postoperative stay was significantly reduced from the average of 6.1 days to 4.5 days (P < .01). The overall hospital expenses were not significantly different between the 2 groups. ($203.95 US in TF group and $198.50 US in EF group; P = .75) There was 1 vomiting case in the EF group that was temporary and resolved spontaneously. Septic complications were noted in 8 patients in the EF group and 6 patients in the TF group (P = .27). The majority were uncomplicated urinary tract infections.

Conclusions

Early feeding after a closure of colostomy in pediatric patients stimulated early bowel movement and reduced hospital stay with no increased adverse effects.     

Complications associated with enteral nutrition using catheter jejunostomy after esophagectomy

The present study was conducted on 78 patients, encountered over a 7-year period, who had a catheter-feeding jejunostomy placed at the time of thoracoabdominal esophagectomy for esophageal cancer. A broad-based attachment of the jejunal wall to the peritoneum at the place of entry of the catheter was used. Enteral nutrition was begun an average of 10 days after the operation, the caloric content was increased gradually, and the mean duration was 69 days. There were three patients who suffered from local skin erosion at the site of catheter entry, and seven who developed diarrhea and/or a feeling of abdominal fullness, but none of the patients showed any signs of peritonitis or ileus. The morbidity rates related to enteral nutrients and placement of the catheter jejunostomy were 8.9% and 3.8%, respectively. These findings demonstrate that a broad-based attachment of the jejunal wall to the peritoneum at the place of entry of the catheter is useful for preventing leakage or twisting of the jejunum, and for reducing the incidence and severity of the complications of catheter jejunostomy feeding.     

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目的 从临床经济学角度比较胰十二指肠切除术后肠内营养与肠外营养治疗费用的差别，评价早期肠内营养支持作用。方法 回顾分析1999年7月至2001年6月间32例胰十二指肠切除术后早期营养支持临床资料，其中早期肠内营养（EEN）组11例，术后第1天开始EEN支持；肠外营养组（TPN）21例。结果 术后平均住院日EEN组较TPN组为短（25.0天vs36.3天，P＜0.01），且平均费用明显少于TPN组（28368元vs40494元，P＜0.01）。并发症发生率EEN组虽少于TPN组，但无统计学差异（P＞0.05）。费用效果分析及敏感性分析提示EEN较TPN优越。结论 胰十二指肠切除术后EEN支持可减少并发症，并有更好的费用效果比。     

早期肠道喂养改善烧伤后肠道血液灌流的实验研究

目的 探讨早期肠道喂养改善烧伤大鼠肠血液灌流的机理。方法 采用３０％体表面积Ⅲ度烧伤大鼠模型,分为正常对照（Ｃ）、单纯烧伤（Ｂ）和早期喂养（ＶＩＰ）含量及肠粘膜血流量（ＬＭＢＦ）。结果 烧伤后肠组织中ＥＴ、ＮＯ、ＶＩＰ及ＥＴ／ＶＩＰ比值均呈上升趋势,而ＩＭＢＦ则显著低于伤前。ＥＦ组中ＥＴ含量及ＥＴ／ＮＯ、ＥＴ／ＶＩＰ比值明显低于Ｂ组,而ＮＯ、ＶＩＰ及ＩＭＢＦ则高于Ｂ组,肠道喂养烧伤后肠道缺血状况的     

Postinjury abdominal compartment syndrome does not preclude early enteral feeding after definitive closure

BACKGROUND: Critically injured patients are susceptible to the abdominal compartment syndrome (ACS), which requires decompressive laparotomy with delayed abdominal closure. Previous work by the University of Texas Houston group showed impaired gut function after resuscitation-associated gut edema. The purpose of this study was to determine if enteral nutrition was precluded by the intra-abdominal hypertension and bowel edema of the ACS. METHODS: Patients developing postinjury ACS from January 1996 to August 2003 at our level-I trauma center were reviewed. Patient demographics, time to definitive abdominal closure, and institution and tolerance of enteral nutrition were evaluated. RESULTS: Thirty-seven patients developed postinjury ACS during the study period; 26 men and 11 women with a mean age of 36 +/- 4 and injury severity score of 33 +/- 4. Mean intra-abdominal pressure before decompression was 32 +/- 3 mm Hg, and concurrent mean peak airway pressure was 50 +/- 4 cm oxygen. Enteral feeding was never started in 12 patients; 4 died within 48 hours of admission, 7 required vasoactive agents until their death, and 1 developed an enterocutaneous fistula requiring parenteral nutrition. Enteral feeding was initiated in the remaining 25 patients: 13 had feeds started within 24 hours of abdominal closure; 5 were fed with open abdomens; and 7 had a delay because of vasopressors (n = 2), multiple trips to the operating room (n = 2), paralytics (n = 2), and increased intra-abdominal pressures (n = 1). Once advanced, enteral feeding was tolerated in 23 (92%) of the 25 patients with attainment of goal feeds in a mean of 3.1 +/- 1 days. CONCLUSIONS: Despite the bowel edema and intra-abdominal hypertension related to the ACS, early enteral feeding is feasible after definitive abdominal closure.     

Optimal enteral feeding in children with gastric dysfunction: surgical jejunostomy vs image-guided gastrojejunal tube placement

Purpose

Long-term feeding access in children who fail initial gastrostomy is a management quandary. Although image-guided gastrojejunal feeding tube placement (IGJ) is becoming the access of choice in many centers, few studies have compared long-term results with surgical jejunostomy (SJ). The authors compare outcomes with these 2 techniques.

Method

A retrospective review of 20 children requiring jejunal feeding access after failing initial gastrostomy was done. Procedures were performed at a tertiary referral center by interventional radiologists (IGJ) or board-certified pediatric surgeons (SJ).

Results

Initially, patients underwent IGJ (n = 14) or SJ (n = 6). Image-guided gastrojejunal feeding tube placement patients required gastrostomy at an average age of 23.8 months, with conversion to IGJ an average of 17.2 months later. SJ patients required gastrostomy at average age of 16.2 months, with conversion to SJ 30.7 months later. Of 14 patients undergoing IGJ, 7 (50%) eventually required SJ because of recurring tube management issues. Thus, 13 patients ultimately had SJ, with 11 (85%) Roux-en-Y jejunostomies. Mean operating time for SJ was 158 minutes, with an average of 5.1 days to initiation of feeds, 11 days to full feeds, and 19.9 days to discharge (range, 3-66 days). Image-guided gastrojejunal feeding tube placement patients averaged 4.6 tube adjustments per year requiring fluoroscopic guidance. Surgical jejunostomy averaged 1.5 tube adjustments per year requiring outpatient hospital visits. Image-guided gastrojejunal feeding tube placement patients averaged 3.9 hospital d/y secondary to feeding tube management issues, whereas SJ patients averaged 1.4 hospital days per year.

Conclusion

In this group of children with long-term jejunal feeding access, half of those with IGJ eventually required SJ. Surgical jejunostomy required fewer adjustments and hospitalizations per year. Although initially more invasive than IGJ, SJ may provide more stable feeding access with fewer complications. This represents the first published report comparing long-term outcomes between IGJ and SJ.     

Laparoscopic feeding jejunostomy: A systematic review

Background Enteral feeding devices have gained popularity since the beneficial effects of enteral nutrition have been clarified. Laparoscopic placement of a feeding jejunostomy is the most recently described enteric access route. In order to classify current surgical techniques and assess evidence on safety of laparoscopic feeding jejunostomy, a systematic review was performed.Methods The electronic databases Medline, Cochrane, and Embase were searched. Reference lists were checked and requests for additional or unpublished data were sent to authors. Outcome measures were surgical technique and catheter-related complications.Results Enteral access for feeding purposes can be effectively achieved by laparoscopic jejunostomy. Laparoscopic jejunostomy can be accomplished by either total laparoscopic or laparoscopic-aided techniques. The most experience was obtained with total laparoscopic placement. Which technique to apply should depend on the surgeon’s expertise. Conversion rate is similar to other laparoscopic procedures. Complications can be serious and therefore strict patient selection should be warranted.Conclusion Laparoscopic feeding jejunostomy is a viable method to obtain enteral access with the advantages of minimally invasive surgery.     

早期肠道喂养可降低严重烫伤大鼠肠淋巴液内毒素水平

目的观察早期肠道喂养对严重烫伤大鼠肠淋巴液中内毒素的影响,探讨严重烫伤大鼠早期肠道喂养在保护肠粘膜屏障中的作用。方法采用大鼠肠淋巴瘘模型,随机分为烫伤早期肠道喂养组,烫伤对照组和单纯手术对照组,致伤前和伤后3,6,12,24小时收集肠淋巴液,测定内毒素清除量,光镜、电镜观察回肠粘膜病理改变。结果烫伤后内毒素清除量明显升高;光镜观察表明,回肠绒毛中央乳糜管明显扩张,肠上皮细胞坏死脱落;电镜观察表明,肠上皮细胞间囊性扩张,微绒毛坏死脱落,线粒体空化、嵴断裂,核周间隙扩张。早期肠道喂养组,肠淋巴液内毒素清除量明显低于烫伤对照组;光镜和电镜观察表明,回肠粘膜病理改变有不同程度的减轻。结论早期肠道喂养对大鼠肠粘膜屏障具有保护作用,从而降低了肠淋巴液中内毒素水平。     

术后早期经口肠内营养对结直肠癌患者康复和免疫功能的影响

目的 观察早期进食肠内营养制剂对结直肠癌患者临床结局和免疫功能的影响.方法 88例结直肠癌患者随机分为试验组(43例)和对照组(45例).试验组术后早期少量多次进水和肠内营养制剂,对照组采用传统治疗方案.比较2组患者术前和术后第1、3、7天IgA、IgG、IgM以及CD4+、CD4+/CD8+和C-反应蛋白(C-reactive protien,CRP)水平,记录术后住院天数、并发症及生活质量等指标.结果 试验组术后发热时间[(54±6)h比(65 ±6)h,=8.688,P＜0.01]、排气时间[(58±8)h比(72 ±7)h,t=8.573,P＜0.01]、住院时间[(6.9±1.4)d比(8.5±1.9)d,t=4.277,P＜0.01]以及治疗费用[(41 868 ±3 168)元比(45 950±3 714)元,t=5.536,P＜0.01]明显少于对照组,差异有统计学意义,而2组术后并发症发生[18.6％ (8/43)比22.2％ (10/45),t=0.177,P＞0.05]相比差异无统计学意义;试验组出院时生活质量评分[(18.4±1.7)比(16.4±1.9),t=5.235,P＜0.01]明显高于对照组.术后第7天试验组CD4+、CD4 +/CD8+和IgM水平明显高于对照组(t=3.639,t =2.255,t=2.119,P＜0.05);术后第3天和第7天试验组IgA、IgG明显高于对照组(t=2.035,t =2.961,t=2.060,t =2.108,P＜0.05);术后第3天和第7天试验组CRP水平明显低于对照组(t =7.308,t=3.435,P＜0.05).结论 术后早期进食肠内营养制剂能够改善结直肠癌患者免疫功能,降低应激反应、促进康复.     

早期肠道营养对烧伤后肠道功能的维护

选择平均烧伤面积45%成人21例,随机分为早期喂养(EF 组)和延迟喂养组(DF 组),探讨早期肠道营养对严重烧伤病人肠道功能的维护作用。结果表明内毒素在伤后4,8天 EF 组显著低于 DF组(P<0.05～0.01);而 SOD 则呈相反的变化,在伤后4,8天 EF 组显著高于 DF 组(P<0.01);胃泌素和胃动素除伤后第1天的大多时相点 EF 组显著高于 DF 组(P<0.05～0.01),而炎症介质 TNF 和IL—8则呈相反的变化,两组间差异有显著意义(P<0.05～0.01)。提示早期肠道营养可降低循环内毒素水平,减轻肠道缺血性再灌注损伤,削弱、阻滞“内毒素——炎症介质”对肠粘膜的损伤。     

延长针刺式空肠造口置管肠内营养在胃癌术后辅助化疗中应用

目的 探讨延长针刺式空肠造口置管肠内营养在进展期胃癌术后辅助化疗中应用的可行性及其临床疗效。方法 将72例进展期胃癌术后辅助化疗患者随机分成A、B两组,每组36例;两组病例均于术中放置针刺式空肠造口管,A组延长空肠造口管留置时间至6个化疗疗程结束,每个化疗疗程经空肠造口管给予肠内营养液瑞能,每天1500ml,共7天,B组则于化疗前拔除空肠造口管,每个化疗疗程给予等热量普通饮食;观察A组延长空肠造口管留置及肠内营养并发症的发生率,比较两组化疗期间呕吐发生率及平均每日摄入量,比较两组化疗前后体重、血红蛋白、血清白蛋白、前白蛋白、转铁蛋白及血清白介素-2、NK细胞活性、T淋巴细胞亚群（CD^3＋、CD^4＋、CD^8＋）比例的变化情况。结果 A组延长空肠造口管留置及肠内营养无严重并发症发生;化疗期间A组呕吐发生率显著少于B组,平均每日摄入量显著多于B组;A组化疗前后体重、血红蛋白、血清白蛋白、前白蛋白、转铁蛋白、IL-2、NK细胞活性、CD3＋、CD4＋、CD8＋比例变化显著少于B组（P〈0.001）。结论 进展期胃癌术后辅助化疗期间延长针刺式空肠造口置管肠内营养是安全可行的,并具有减轻化疗呕吐,提高患者摄入量等优点,可以减少化疗药物对患者营养及免疫状况的影响,提高患者术后辅助化疗的耐受性及治疗效果。     

经腹改良Sugiura断流术后早期肠内营养效果观察

目的探讨经腹改良Sugiura断流术后病人早期经鼻饲管实施肠内营养的方法。方法我院于2002年1月～2008年3月对25例肝硬化门静脉高压症病人行经腹改良Sugiura断流术，术后第1d即开始使用肠内营养，8d后检测各营养指标、肝功能及其它生化指标，并进行临床观察。结果病人均顺利耐受肠内营养。血清白蛋白、血红蛋白术后第8d与手术前1d比较，均有显著性差异（P〈0．05）；肝功能及其它生化指标、营养状况等基本同术前。未发生并发症。结论早期肠内营养安全可靠，可有效地应用于肝硬化病人的术后支持治疗。     

早期肠道营养对严重烧伤患者康复的影响

目的通过对早期肠道营养抑制肠内感染的分析探讨对严重烧伤患者康复的影响。方法22例严重烧伤患者随机分组为早期肠道营养组(EF)和延迟肠道营养组(DF)。烧伤后1、3、5d分别测每位患者的血清内毒素水平。结果严重烧伤患者的血清内毒素水平明显高于正常人群(P<0.01)。早期肠道营养组的血清内毒素水平明显低于延迟肠道营养组(P<0.01)。结论早期肠道营养可以减少肠源性感染,有利于营养支持,改善患者体质,增强机体抵抗力,促进损伤组织的修复,有利于烧伤患者的康复。     

Percutaneous replacement jejunostomy after esophagogastrectomy

A surgically placed jejunostomy tube is a safe and effective means of delivering nutritional support for the postesophagogastrectomy patient. We have previously described a method that permits percutaneous replacement of surgically placed jejunostomy feeding tubes, and now present our results with the use of this technique in 350 consecutive esophagogastrectomy patients. Replacement jejunostomy was required in 17 patients (4.9%). M1 patients had successful percutaneous jejunostomy replacement. There were no procedural complications or deaths. The timing of feeding tube replacement following esophagogastrectomy was predictive of the indication. Before 16 weeks, the indication for feeding tube replacement was intubation and inability to eat (1 patient) or anorexia with weight loss and dehydration (7 patients). At or after 16 weeks, the indications for feeding tube replacement were all related to symptoms resulting from recurrent carcinoma. We conclude that the technique of percutaneous jejunostomy allows the surgeon tremendous flexibility in the management of the postesophagogastrectomy patient as it preserves the advantages of an adjuvant surgically placed feeding tube over the lifetime of the patient. The technique is safe, and the success rate is excellent. Supported by the Evelyn Glick Fund for Thoracic Surgery.     

The potential benefits and harms of early feeding post‐surgery: a literature review

The effect of nutrition on wound healing is widely recognized, with many studies highlighting the detrimental effect poor nutrition can have on wound healing. In addition, fasting pre‐, peri‐ and postoperatively can contribute to further protein catabolism, leading to morbidity and mortality. By reviewing the current literature, this work evaluates the potential benefits and harms from early feeding (EF) during the early stages postsurgery. Current randomised control trials suggest that the early introduction of nutrients post‐surgery may be beneficial for wound healing and recovery from surgery. Additionally, this approach does not seem to impose any increased complications post‐operatively. Conversely, although there is ongoing research supporting EF and evidence showing that malnutrition can delay wound healing and recovery, healthcare professionals remain sceptical with a slow uptake in adopting EF protocols.     

Postoperative jejunal feeding and outcome of pancreaticoduodenectomy

Complications following pancreaticoduodenectomy are common, partly because of nutritional debilitation. The aim of this study was to evaluate the impact of early postoperative tube feeding on outcome of pancreaticoduodenectomy and determine the best method for delivering enteral feeding. A retrospective review of 180 consecutive patients undergoing Whipple operations from 1994 to 2000 was performed. Two nonrandomized patient groups were retrospectively studied: those with early postoperative tube feeding vs. those with no planned feeding. Ninety-eight patients (54%) received postoperative jejunal feeding, whereas 82 patients (46%) did not. Jejunal feeding was delivered via a bridled nasojejunal tube in 55 patients (56%) and a gastrojejunal tube in 43 (44%). Vomiting (10% vs. 29%; P = 0.002) and use of total parenteral nutrition (6% vs. 27%; P < 0.0001) were less in the jejunal feeding group as well as rates of readmission (12% vs. 27%; P= 0.022), early (52% vs. 62%; P = 0.223) and late (12% vs. 31%, P = 0.005) complications, and infections (13% vs. 20%, P = 0.014). Tube-related complications occurred in 6 of 98 patients, all of which were associated with gastrojejunal tubes (P = 0.021). Early postoperative tube feeding after pancreaticoduodenectomy is associated with significantly less use of total parenteral nutrition and lower rates of readmission and complications. A bridled nasojejunal feeding tube appears to be a safe and reliable method of short-term enteral feeding. Presented at the 2003 meeting of the Americas Hepato-Pancreato-Biliary Congress, Miami Beach, Florida, February 27–March 2, 2003.