肠外,肠内阶段性营养支持在腹部外科的应用

肠外、肠内阶段性营养支持”（StagenutritionalsupportofPN、EN）是据疾病的不同阶段、胃肠功能状况和／或代谢特征，依次阶段性地施行肠外、肠内营养支持，其中主要指由TPN逐渐过渡为空肠喂养（Je－junalfeeding）的营养支持。这种营养支持方式在腹部外科具有广泛而重要的应用价值。具体地说，在腹部外科某些疾病或为其施行腹腔手术时，于空肠上段施行空肠营养造口备用。术后待病人全身状况稳定（约48～72h），开始施行TPN。一旦全身状况进一步稳定，胃肠功能恢复，肛门排气，及早地过渡为空肠喂养，直至病人能完全经口进食为止。其…     

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目的 研究肠内营养（EN）和肠外营养（PN）支持对外科危重病人的治疗效果。方法 将80例不能进食的研究对象随机分成EN组和PN组,比较营养指标、免疫功能指标、病人耐受性指标的变化。结果在治疗10d后,两组病人均由负氮平衡转为正氮平衡,营养指标及免疫功能指标明显增高,且EN组免疫功能指标增高更显著;病人耐受性指标中,EN组无显著变化而PN组血糖明显增高。结果 EN和PN对外科危重病人均有营养支持和提高机体免疫功能的作用。耐受性强,且EN支持在提高机体免疫功能优于PN支持,病人耐受性较好。     

肝移植病人的营养支持

目的 为提高肝移植病人的手术耐力和促进术后的恢复,制定合理有交的营养支持方法。方法 根据4例肝移植病人术前、术后各自的代谢特点,选择合理的营养支持方式,对状态较好者选用肠内营养支持,状态较差者考虑肠外营养支持;在术后早期（1－3d）采用全肠外营养（TPN）,并辅以人血白蛋白;在术后3－4d肠道功能开始恢复后由肠内营养（EN）结合肠外营养（PN）,逐渐过渡为完全经口饮食。结果 4例病人均顺利度过围手术,基水发生由于营养支持疗法所致的并发症,2例生存超过200d;2例现仍存活,生活质量良好。1例已度过3年,1例现存活3个月。结论 术前应根据病人情况选择合理、适当的营养支持方式。可提高手术耐力,术后视移植肝功能恢复程度,进行肠外营养,适当选择易于移植肝恢复的营养要素和控制营养物质的供给量;当病人胃肠功能恢复后,宜尽早开始EN,辅助PN,并尽快过渡到完全经口饮食。     

胃癌切除术后吻合口瘘的营养支持

目的探讨胃癌切除术后并发吻合口瘘的营养支持,以期提高对胃癌切除术后并发吻合口瘘的防治水平。方法对我科1997年1月-2007年1月间收治的胃癌切除术后并发吻合口瘘28例的临床资料进行回顾性分析。结果全部28例中痊愈25例,因并发多器官功能不全而死亡3例。治愈病人中采用肠外结合肠内营养支持（PN＋EN组）16例,采用全肠外营养支持（TPN组）9例。PN＋EN组的瘘口愈合时间与TPN组相比较无显著性差异（P〉0．05）,但在单日营养费用、血清白蛋白、体温异常日数等方面均较TPN组有显著差异（P〈0．01,P〈0．05,P〈0．01）。结论对于胃癌切除术后并发吻合口瘘的病人,早期应采用肠外营养支持,全身及腹部情况稳定后则应尽早过渡到肠内营养支持。     

胃癌术后早期的肠内营养支持

目的：观察胃癌术后患者早期给予肠内营养（EN）支持治疗的临床疗效.方法：肠外营养支持（PN）组术后每日行完全肠外营养支持直到经口进食.EN组术后第1 d以静脉支持为主,第2 d开始经空肠造瘘管滴入肠内营养制剂能全力,逐步加大支持强度并减少静脉支持.观察术后排气排便时间、并发症发生率、体重、血红蛋白（HGB）、血浆前白蛋白（PALB）和外周血淋巴细胞计数（LY）.结果：EN组术后排气、排便时间和术后平均住院时间均短于PN组.术后第7 d EN组各项指标的恢复速度均优于PN组.EN组术后并发症发生率为27.3%（3/11）,明显低于PN组54.6%（6/11）.结论：胃癌术后早期EN支持可促进小肠运动功能恢复,加快免疫和营养状态改善,降低了并发症的发生率.     

胃肠道恶性肿瘤术后早期肠内营养支持的临床意义

目的 :探讨胃肠道恶性肿瘤术后早期肠内营养支持的可行性及其临床意义。方法 :将 40例胃和大肠癌病人随机分为完全胃肠外营养支持组 (TPN组 )和肠内营养支持组 (EN组 )。TPN组术后行标准的全胃肠外营养支持 7d ;EN组在手术后第 1天 (2 4h内 )经鼻肠管或空肠造口管输入肠内营养液能全力 ;两组提供的热量和氮量完全相同。记录术后并发症 ,肠鸣音恢复时间 ,住院天数和营养支持的总费用情况 ;于术前和术后第 8天检测病人体重、上臂周经、血红蛋白 (Hb)、淋巴细胞 (LC)计数、血浆总蛋白 (TP)和白蛋白 (ALB)。结果 :两组病人无死亡、消化道瘘和腹腔感染等严重并发症。EN组肠动力恢复早于TPN组 ,节约营养支持费用 (P <0 .0 5 ) ;两种方法营养支持疗效相近 ,体重等 6项基本营养指标手术前后和两组间无差异 (P <0 .0 5 )。结论 :胃肠道恶性肿瘤病人术后早期EN的营养支持效果与TPN基本相同 ,具有方便和经济的优点。     

营养支持治疗在外科危重病人中的应用

目的 探讨外科危重病人给予营养支持的效果。方法 对22例外科危重病人实施肠外营养（PN）,早期总热量不超过20Kcal/kg.d,供氮量不超过0.12g/kg.d,脂肪供热不超过40%;应激消退期,相应增加供热、氮量,总热量不超过25Kcal/kg.d,供氮量为0.20g/kg.d,以满足机体全盛代谢的需要,一旦肠道功能恢复逐渐转为肠内营养。结果 本组治愈17例,死亡5例;治疗过程中未出现明显的糖、脂代谢异常和肝酶谱变化的代谢性并发症,EN期间无严重腹泻、腹胀等并发症,使用呼吸机支持者均一次脱机成功。结论 循序渐进、阶段性的肠外营养支持,并适时过渡到EN,可提高危重病人的抢救成功率,降低并发症和死亡率。     

肠外营养在消化道手术患者围手术期应用

近年来肠道外营养在外科临床实践中倍受重视，肠外营养（TPN）已广泛应用于临床，被认为是近代外科的重大进展之一。营养支持方法静脉营养（TPN）在临床上的应用成为外科治疗肠瘘的里程碑。临床实践表明：围手术期患者的营养支持，是减少并发症的有效手段。笔者从1999—2004年对70例消化道手术患者在围手术期应用了肠外营养，现将体会报告如下。     

恶性阻塞性黄疸术后早期肠内营养对肝肾功能影响的临床研究

目的研究恶性阻塞性黄痘手术后早期肠内营养支持（EEN）与全肠外营齐支持（TPN）对肝、肾功能的影响。方法将2003年1月至2004年5月收治的37例恶性阻塞性黄疸病人术后随机分为EEN组（17例）和TPN组（20例），均于术后第2天晨（48h内）开始进行营养支持，EEN液经空肠造口管以肠内营齐输注泵滴入，TPN液经深静脉置管滴入。术前及术后第5、7天监测肝、肾功能，进行统计学分析。结果肝功能检测值EEN组恢复速度较TPN组快，其中血总胆红素（TB）和γ-谷氨酰转肽酶（1-GT）于术后第7天时两组差异有统计学意义。肾功能检测值EEN组术后升高幅度较TPN组低、恢复较快，其中尿转铁蛋白（TRF）、N-乙酰-β-D-氨基葡萄苷酶（NAG）、α1-微球蛋白（α1，mG）于术后第7天两组差异有统计学意义。结论早期肠内营养支持在促进恶性阻塞性黄疸术后肝、肾功能恢复方面优于全肠外营养支持。     

早期放置螺旋型鼻肠营养管治疗重症胰腺炎的应用价值

目的 探讨早期应用螺旋型鼻肠营养管实施肠内营养对于治疗重症急性胰腺炎( SAP)的有效性和实用性.方法 30例SAP患者随机分为肠外营养(TPN)组和肠内营养(EN)组.TPN组进行全肠外营养支持治疗,EN组留置螺旋型鼻肠营养管给予肠内营养支持,两组能量供应相同.观察营养指标、临床效果、平均住院时间及住院费用.结果 EN组7例于置管后24 h内到达空肠上段,2例于48 h内到达预定位置,余6例利用胃镜辅助置管成功.营养管留置时间为(26.7±4.3)d;EN组营养指标较TPN组明显改善,肠道功能恢复时间、住院时间明显缩短,住院费用降低.结论 放置螺旋型鼻肠管给予肠内营养治疗的方法简便、安全、有效,可作为SAP实施早期肠内营养治疗的首选途径.     

急性胰腺炎营养治疗途径的研究进展

营养支持是治疗急性胰腺炎的重要环节,其效果与给予的途径有关,常用的支持途径主要有全肠外营养与肠内营养,近年来有部分学者尝试通过鼻胃管对重症急性胰腺炎患者进行营养支持,为营养治疗重症急性胰腺炎开辟了新的途径,但其效果与安全性有待进一步验证。     

急性坏死性胰腺炎的营养支持

自1985年1月～1992年9月,我们对57例急性坏死性胰腺炎病人的营养支持治疗分三期进行,即术后早期经周围静脉输注高渗糖、脂肪乳剂和氨基酸等营养液行全胃肠外营养(TPN);术后2周左右由TPN逐步过渡到全胃肠内营养(TEN),从空肠造瘘内注入要素饮食;最后逐渐过渡为口服饮食。结果除9例病人在TPN治疗期间死于MOF外,余48例病人的营养状况均有不同程度的改善,并均痊愈出院。实践证明营养支持在急性坏死性胰腺炎的治疗中有着良好效果,是提高治愈率的重要措施。     

Small amount of low-residue diet with parenteral nutrition can prevent decreases in intestinal mucosal integrity

OBJECTIVE: To investigate the suitable combination ratio of low-residue diet (LRD) and parenteral nutrition (PN) for nutritional support of surgical patients. SUMMARY BACKGROUND DATA: Bacterial translocation (BT) is a severe complication of total parenteral nutrition (TPN). However, it is sometimes impossible to supply sufficient amounts of nutrients to surgical patients by the enteral route. The authors reported previously that concomitant use of LRD with PN provided preferable nutritional support for patients undergoing surgery for colorectal cancer. METHODS: Ninety male Donryu rats were used for three experiments. In experiment 1, rats were divided into two groups to receive TPN or total enteral nutrition with LRD. In experiment 2, rats were divided into six groups, receiving variable amounts of LRD. In experiment 3, rats were divided into five groups to receive isocaloric nutritional support with variable proportions of PN and LRD. Intestinal permeability was assessed by monitoring urinary excretion of phenolsulfonphthalein. BT was assessed in tissue cultures of mesenteric lymph nodes and spleen. RESULTS: In experiment 1, increases in intestinal permeability and BT were observed in rats maintained on 7-day TPN, but not in those maintained on total enteral nutrition for up to 14 days. In experiment 2, the changes in body weight of rats were correlated with the dose of LRD. However, the intestinal permeability was increased only in rats receiving LRD at 15 kcal/kg per day. In experiment 3, additive LRD corresponding to 15% of total caloric intake prevented increases in intestinal permeability and BT. CONCLUSION: Combined nutritional therapy consisting of PN and small amounts of LRD can provide better nutritional support than TPN for surgical patients.     

Recent trends in the clinical practice of nutritional support in Japan: results of a national survey carried out in 2001

Nutritional support has advanced and patients can now be given more effective nutritional care. On the other hand, some problems remain, such as inadequate administration of total parenteral nutrition (TPN), catheter-related sepsis, etc. The Committee of the National Survey on Nutritional Support, established under the Japanese Society for Parenteral and Enteral Nutrition, investigated the recent trends in the clinical practice of nutritional support in Japan by mailing a questionnaire containing 90 questions to a total of 6,500 physicians in 10 medical departments. The results showed that: 1) surgeons have more interest in nutritional support than physicians in other fields. 2) More than 90% of physicians in Japan still use intravenous hyperalimentation(IVH) instead of TPN and they place more focus on the central venous catheter and insertion of the central venous catheter than on hyperalimentation in the term IVH. 3) There remains a tendency for surgeons to prefer parenteral nutrition to enteral nutrition. This tendency is supported by data showing that the rate of administering TPN to gastroenterological surgical patients as a postoperative management method is high. To the question, "How did you learn about nutritional support?," only 18.3% of physicians answered that they studied it in medical school. We may conclude this to be the most important problem in nutritional support in Japan.     

Long-term parenteral nutrition in pediatric autoimmune enteropathies

Severe and protracted or persistent diarrhea (SPD) is the most severe form of diarrhea in infancy and has also been defined as intractable diarrhea when it leads to dependence on total parenteral nutrition (TPN). One of the rare causes of SPD is represented by autoimmune enteropathy that is characterized by life-threatening diarrhea mainly occurring within the first years of life, persistent villous atrophy in consecutive biopsies, resistance to bowel rest, and evidence of antigut autoantibodies. We evaluated 10 patients (seven boys, mean age at diagnosis 18 months; range: 0 to 160 months) fulfilling criteria of autoimmune enteropathy to assess dependence on TPN. TPN was first required in all patients to avoid dehydration and electrolytic imbalance. All patients were dependent on immunosuppressive therapy (steroid, azothioprine, cyclosporine, tacrolimus). Three patients died of sepsis: two during TPN while in the hospital, and one at home after he was weaned off TPN. Five patients are weaned off TPN after a mean period of 18 months; they are actually on oral alimentation with a cow milk-free diet after a period of enteral nutrition with elemental formula. One underwent total colectomy and bone marrow transplantation and one developed an IPEX syndrome. One patient is still dependent on TPN for 24 months. She is on home parenteral nutrition. Patients with diagnosis of IPEX syndrome require parenteral support with three or four infusion per week. TPN represents a fixed step in the management of autoimmune enteropathy, but it may be considered as an interim treatment while waiting for intestinal adaptation, at least in some selectioned case of autoimmune enteropathy. Bone marrow transplantation should be considered and reserved for those patients with severe complications due to home parenteral nutrition, or in those that are really dependent on parenteral nutrition.     

全肠外营养及早期肠内营养在胃癌全胃切除术后患者中的对比研究

目的探讨胃癌全胃切除术后的患者分别进行早期肠内营养(EEN)或全肠外营养(TPN)支持对患者术后恢复的影响。方法回顾性分析我院2006年6月至2009年8月期间行全胃切除的患者86例,其中术后行TPN者31例(TPN组),行EEN者55例(EEN组)。TPN组通过上腔静脉(颈内或锁骨下)穿刺置管,经静脉给予营养支持;EEN组术中留置鼻肠管,术后第2天开始逐渐增加肠内营养(瑞素),并逐步减少肠外营养,至术后3～5d达到全肠内营养。检测术后血清白蛋白水平,记录术后通气与排便时间、经口进食时间、住院时间以及各种并发症的发生情况。结果TPN组与EEN组比较,术后血浆白蛋白、术后通气时间、排便时间、并发症发生率及住院时间差异均无统计学意义(P0.05)。在进流质时间上EEN组反而晚于TPN组,差异有统计学意义(P=0.004)。结论经TPN进行营养支持与鼻肠管进行肠内营养均可作为全胃切除术后的营养支持方式,两种方式的恢复情况及并发症发生情况无明显差异,可以根据患者术前营养状态及合并症决定是否行鼻肠管置入。     

Free radical formation in infants: the effect of critical illness, parenteral nutrition, and enteral feeding.

BACKGROUND/PURPOSE: An increase in free radical activity has been observed in patients suffering from a variety of illnesses and has been correlated with disease severity. Free radical production is increased by the administration of total parenteral nutrition (TPN) and may be linked to its adverse effects. Some of the complications of TPN can be ameliorated by partial enteral feeding. The aim of this study was to investigate free radical activity during critical illness and during the administration of parenteral nutrition. METHODS: Three groups of surgical infants were studied: (1) control infants (n = 8) before minor surgery, (2) stable infants on the ward recovering from a major operation (n = 24), (3) critically ill infants in the neonatal intensive care unit (NICU, n = 28). Fourteen patients in the ward and 17 patients in NICU were receiving parenteral nutrition. Of the 31 patients on TPN, 9 were also receiving minimal enteral feeding (3% to 24% of total calorie intake). Plasma malondialdehyde (MDA), an index of free radical activity, was measured in all 60 infants. The Paediatric Risk of Mortality (PRISM) score was obtained on NICU patients. The cytokines tumor necrosis factor (TNF-alpha) and interleukin 6 (IL-6) were measured in 25 patients. RESULTS: Plasma MDA was significantly higher in (1) the stable patients on the ward compared with control patients (P < .001) and (2) patients in NICU compared with stable patients in the ward (P < .001). Parenteral nutrition was associated with higher levels of plasma MDA both in stable patients in the ward and critically ill infants in NICU. There was no correlation between the PRISM score and MDA. In patients not receiving TPN there is a correlation between MDA and TNF-alpha (r = 0.54, P = .02) and between MDA and IL-6 (r = 0.74, P = .001). The level of free radical activity in patients on TPN is not changed by partial enteral feeding. CONCLUSIONS: Critical illness causes a rise in free radical production. Parenteral nutrition causes a significant elevation in free radical activity in both stable infants in the ward and critically ill infants in NICU. The addition of minimal enteral feeding to parenteral nutrition does not reduce free radical activity. We hypothesize that the parenteral nutrition solution directly initiates free radical production.     

肝外伤术后肠内营养对肝功能的影响

目的 探讨肝外伤术后肠内营养对肝功能的影响.方法 将2005年7月至2011年3月收治65例肝外伤患者分成两组,30例术后接受肠内营养(EN组),35例术后行肠外营养(PN组),观察两组患者营养状况和肝功能恢复情况差异.结果 术后第1天两组患者营养状况及急性肝损伤指标差异无统计学意义(P>0.05),但术后第8天EN组各项指标基本达到正常值,而PN组反映肝脏功能的指标ALT、AST和PT检验值偏高,两组间差异有统计学意义(P<0.05),表明肠内营养更有利于肝功能恢复.61例患者得到随访(93.8%),随访时间于术后3～12个月,平均6个月,术后3个月肝功能基本恢复,两组间营养状况及肝功能的差异无统计学意义.结论 肝外伤术后早期使用肠内营养是一种经济、有效的营养支持手段,是改善术后肝损害的重要举措.     

32例十二指肠外瘘的营养支持

目的 总结十二指肠外瘘的营养治疗经验.方法 对1999年1月至2009年12月间收治的32例十二指肠外瘘患者的临床资料进行回顾性分析.结果 32例患者平均接受35.6（8～82） d的营养支持疗法,其中8例接受全肠外营养支持（TPN）,2例接受全肠内营养支持（TEN）,22例接受肠外肠内联合营养支持（PN加EN）.11例患者进行了肠液回输;28例予以谷氨酰胺强化;22例肠瘘初期加用了生长抑素.本组24例十二指肠外瘘患者经非手术治愈,自然愈合率为75.0%;8例接受手术,治愈6例,死亡2例（分别死于严重腹腔感染和多系统器官衰竭）;共计30例患者痊愈出院.结论 肠外肠内营养支持结合肠液回输、强化谷氨酰胺、生长抑素等措施,可促进十二指肠外瘘愈合.