2092例肠内营养置管方法分析

目的比较不同肠内营养置管方法的优缺点。方法1996年9月-2008年6月,共有2092例患者接受肠内营养支持。肠内营养置管方法包括床旁经鼻置螺旋型鼻肠管、X线引导下经鼻置鼻肠管、胃镜引导下经鼻置鼻肠管、术中经鼻置鼻肠管、空肠切开造口置空肠管、空肠穿刺造口置空肠管、胃切开造口术及内镜引导下经皮胃穿刺造口术。结果床旁经鼻置肠管32例,第2天23例鼻肠管的远端通过幽门到达小肠,另9例鼻肠管盘曲在胃腔内。X线引导下直接经鼻置鼻肠管61例,顺利通过幽门57例,另4例鼻肠管盘曲胃腔内。胃镜引导下经鼻置鼻肠管186例,术后经x线检查显示177例鼻肠管的远端位于小肠。腹部手术时,经鼻放置鼻肠管1628例,7例鼻肠管远端离开手术时放置的位置。空肠切开术放置空肠营养管56例,术后出现不全性肠梗阻2例、肠瘘1例。空肠穿刺造口术98例,2例空肠穿刺管移位脱出小肠。传统胃切开造口术19例,出现胃瘘1例。胃穿刺造口术12例,无并发症。结论肠内营养置管的方法有多种,具体采取哪种方法,需根据患者的原发病以及营养支持的时间决定。经鼻置鼻肠管是一种安全、简便、实用的方法。经皮穿刺胃造口术、空肠穿刺造口术将逐步替代传统的造口方法。     

肠梗阻导管治疗肠梗阻的105例临床分析

目的：探讨肠梗阻导管治疗肠梗阻的临床疗效,以供参考。方法：将本院2010年3月-2013年2月收治的肠梗阻患者105例纳入本研究,均置入肠梗阻导管治疗。观察置管后症状缓解情况,并对比置管前后患者腹部周径、腹腔内压力、梗阻近端肠管最大横径等指标的变化。结果：置管3 d后所有患者腹痛、腹胀症状均缓解或消失,肠鸣音恢复正常。与置管前对比,置管后第3天患者腹部周径、腹腔内压力、梗阻近端肠管最大横径等指标明显减小,比较差异有统计学意义（P〈0.05）。结论：将肠梗阻导管应用于急性肠梗阻的治疗中,可迅速缓解梗阻症状,有利于后期手术治疗的实施,具有安全有效、创伤小等,值得临床推广应用。     

经颈外静脉行中心静脉置管后经C型臂X线机定位在老年患者中的临床应用

目的 对老年患者经颈外静脉行中心静脉置管后经C型臂X线机定位,以判断最适置管长度及安全性.方法 80例ASA分级Ⅰ-II级老年患者,将中心静脉导管经颈外静脉穿刺留置于上腔静脉末端后,保留导丝,在C型臂X线机下定位,调整至最适长度.结果 穿刺置管成功率为98.75%(79/80).最佳置管长度右侧为(13.15 ±2.04)cm,左侧为(15.14±1.64)cm.结论 经颈外静脉行中心静脉置管后经C型臂X线机定位方法应用于老年患者能提高穿刺成功后置管位置的准确率,减少穿刺的并发症.     

胃肠超声造影技术联合气体灌注定位鼻肠管的方法学研究

目的:探讨利用胃肠超声造影技术联合气体灌注对危重症病人鼻肠管进行定位的方法。方法:随机选择符合鼻肠管留置指征的危重症病人60例,采用床旁盲插法,置管过程中均常规采用传统气体灌注听诊法对鼻肠管进行初步定位,并记录结果。置管完成后,先通过超声扫查鼻肠管走行利用气体灌注法辅助定位,直至可疑头端位置,采用气体冲击灌注,若该处肠腔内出现瞬间气体强回声充盈,再将胃窗声学造影剂注入鼻肠管。若肠腔内出现造影剂充盈并清晰显示鼻肠管头端可予以明确。以胸腹部X线检查为判断鼻肠管定位的金标准,幽门后置管为置管成功的标准,将胃肠超声造影技术联合气体灌注法与传统气体灌注听诊法进行比较。比较两种方法进行鼻肠管定位的敏感性、特异性、阳性预测值、阴性预测值和准确度。结果:在60例行胃肠超声造影技术联合气体灌注法定位鼻肠管的病人中,定位成功58例(96.7%),其中56例位于幽门后,2例位于胃内,定位失败2例(3.3%),敏感性为96.6%,特异性为100%,阳性预测值为100%,阴性预测值为50%,准确度为96.7%。传统气体灌注听诊法的敏感性为74.1%,特异性为50%,阳性预测值为97.7%,阴性预测值为6.3%,准确度为73.3%。经统计学分析,除阳性预测值外,其余均高于传统气体灌注听诊法(P0.05)。结论:胃肠超声造影技术联合气体灌注法具有较高的敏感性、特异性、阴性预测值和准确度,可成为一种准确、实时、便捷、安全的鼻肠管定位方法。     

经颈外静脉行中心静脉置管后经C型臂X线机定位在老年患者中的临床应用

目的对老年患者经颈外静脉行中心静脉置管后经C型臂X线机定位，以判断最适置管长度及安全性。方法80例ASA分级Ⅰ～Ⅱ级老年患者，将中心静脉导管经颈外静脉穿刺留置于上腔静脉末端后，保留导丝，在C型臂X线机下定位，调整至最适长度。结果穿刺置管成功率为98．75％（79／80）。最佳置管长度右侧为（13．15±2．04）cm，左侧为（15．14±1．64）cm。结论经颈外静脉行中心静脉置管后经C型臂X线机定位方法应用于老年患者能提高穿刺成功后置管位置的准确率，减少穿刺的并发症。     

多导丝置管法床边盲插鼻肠喂养管

目的：评价多导丝置管法床边盲插鼻肠喂养管的有效性、安全性。方法：为39例住院患行多导丝法盲插鼻肠喂养管44次。该方法在鼻肠管腔内预置三条导丝以增加刚度。置管时保持轻柔推力，随患呼吸缓慢进管；如遇阻力增加或阻力突然消失，退管后重新进管。最后行美蓝回抽试验及床边X线造影腹部摄片明确管端位置。结果：置管成功率为95％。2次置管失败改在X线透视下成功置管。无呼吸道内置管或消化道穿孔等并发症。结论：多导丝置管法床边盲插鼻肠喂养管是成功率高、安全的置管方法。     

重症急性胰腺炎病人在X线及内镜辅助下放置鼻空肠管的比较

目的:比较重症急性胰腺炎(SAP)病人在X线及内镜辅助下放置鼻空肠管的方法. 方法: 选取52例SAP病人分别采用X线辅助超滑导丝法和内镜辅助下放置鼻空肠管,记录置管成功率,置管时间,置管相关并发症的发生率,置管前、置管中、置管后舒适度(VAS评分)以及留置时间. 结果: X线辅助下超滑导丝法较内镜辅助法的置管时间短,VAS评分低,置管相关并发症(腹痛、腹胀)的发生率低(P＜0.05);两种方法在置管成功率,其他置管相关并发症(鼻咽部出血、上消化道出血、穿孔、误吸、呼吸困难)以及远期并发症(导管移位、咽炎、鼻窦炎、肺部感染)的发生率、留置时间等差异无显著性意义(P＞0.05). 结论: X线辅助下超滑导丝法和内镜辅助法均是SAP病人早期非手术放置鼻空肠管有效、安全、易行的方法.X线辅助下超滑导丝法可作为一般病人的首选方法;对需要机械通气、持续血液滤过治疗以及并发胰性脑病、十二指肠狭窄的SAP病人,内镜辅助法则更合适.     

螺旋CT和腹部X线平片用于机械性肠梗阻诊断的价值

目的比较在机械性肠梗阻诊断中使用螺旋CT和腹部X线平片的临床价值。方法选取2018年2月至2019年2月诊治的62例疑似机械性肠梗阻患者作为研究对象,所有对象经螺旋CT、腹部X线平片诊断后,均接受手术治疗,将手术确诊结果作为“金标准”,分析螺旋CT、腹部X线平片诊断的灵敏度、特异度、准确度。结果62例疑似机械性肠梗阻患者经手术治疗得知,48例确诊为机械性肠梗阻,占77.42%。依据手术确诊结果,螺旋CT诊断的灵敏度、特异度、准确度均较腹部X线平片高,差异有统计学意义(P<0.05)。结论相较于腹部X线平片,螺旋CT对机械性肠梗阻诊断的灵敏度、特异度、准确度更高,值得临床推广应用。     

床边B超判断重症急性胰腺炎病人鼻肠管位置的应用评价

目的:介绍床边B超判断鼻空肠营养管位置的方法,并评价该方法的可行性和准确性. 方法:结合前期研究成果,执行床边放置鼻肠管操作规范,连续为51例重症急性胰腺炎(SAP)病人放置鼻肠管,并使用床边B超判断鼻肠管位置,记录操作时间、评价置管耐受性、管端位置及相关并发症.然后每例病人再行影像学检查作为判断鼻肠管位置的金标准,确定鼻肠管位置.评价使用B超判断鼻肠管位置的正确率、敏感性、特异性以及与影像学方法的一致性. 结果:51例病人均在入院后采用床边放置鼻肠管的操作流程放置鼻肠管.B超验证提示鼻肠管在位的42例,不在位9例;影像学(x线片与腹部CT)判断尖端在位46例,不在位5例.B超判断鼻肠管位置的正确率为92.2％(47 例/51例);敏感性为91.3％(42例/46例);特异性为100％;kappa分析判断两种方法的一致性,kappa值为0.673. 结论:床边B超验证鼻肠管技术,在SAP病人实施床边鼻肠管盲置后特异性验证其尖端位置的敏感性较高,具有良好的可行性和安全性.     

腹部X线平片与64排螺旋CT对胃后壁穿孔患者游离气体检出率的对比研究

目的研究腹部X线平片与64排螺旋CT对胃后壁穿孔患者游离气体检出率。方法笔者于2012年2月-2014年2月,共收集了46例被诊断为胃后壁穿孔的病患。所有患者在手术前均采用腹部X线平片以及64排螺旋CT进行扫描检查,对比观察两种方法对游离气体的检出率以及扫描准确率。结果 64排螺旋CT对游离气体的检测率显著高于X线的检出率,且正确率显著高于X线;同时64排螺旋CT还可以准确检测出穿孔部位;以上差异均有统计学意义(均P0.05)。结论 64排螺旋CT对胃后壁患者游离气体检出率显著高于腹部X线平片,且准确率高,值得临床推广使用。     

Bedside placement of nasojejunal tubes: a randomised-controlled trial of spiral- vs straight-ended tubes

BACKGROUND AND AIMS: The success rate of unguided nasojejunal feeding tube insertion is low, thus often requiring endoscopic or radiological assistance. The spiral end of the Bengmark nasojejunal tube is supposed to aid post-pyloric placement, but no comparative trial has been performed. METHODS: Patients requiring nasojejunal feeding were randomised to have either Medicina (straight) or Bengmark (spiral) nasojejunal tube placed after stratification into those with normal gastric emptying or clinical evidence of delayed gastric emptying. Nasojejunal tubes were placed at the bedside in a standard fashion without radiological guidance by the same person for pre- and/or post-operative feeding. Bolus intravenous metaclopromide (10mg) was given prior to insertion in the abnormal gastric emptying group. Abdominal radiographs were obtained at 4 and 24h, and the primary end-point was jejunal placement at 24h. RESULTS: Forty-seven patients were randomised of which 17 (11 straight, 6 spiral) could not tolerate the nasojejunal tube. Of the 30 remaining patients, 16 had normal gastric emptying. In patients with normal gastric emptying, successful placement at 24h was achieved in 78% (spiral tube), vs 14% (straight tube) (P=0.041). In the abnormal gastric emptying group, success rates were 57% and 0%, respectively (P=0.07). CONCLUSION: Spiral nasojejunal tubes are preferable to straight tubes for bedside unguided post-pyloric feeding in patients with normal gastric emptying.     

重型颅脑损伤后早期肠内营养相关并发症分析

目的:观察重型颅脑损伤后早期肠内营养(EN)相关并发症的发生特点、相关因素及防治措施.方法:360例接受早期肠内营养支持的重型颅脑损伤病人,入住ICU后进行GCS评分,置鼻胃(肠)管,48 h后开始EN,观察伤后第7 d EN最大输注量(mL/d)、过渡至完全肠内营养(TEN)的时间(d)、伤后第7 d实现TEN的病例数及血糖和血清清蛋白(ALB)和谷丙转氨酶变化,记录各种肠内营养并发症的发生率.结果:颅脑损伤后早期EN并发症发生特点:伤后1周内以腹胀、呕吐、反流和误吸为主,1周后以腹泻为主;腹胀和呕吐的发生与鼻饲管所在位置有关,腹泻发生与GCS评分和ALB水平呈负相关;GCS评分越低,EN耐受的最大输注量越低、过渡至TEN的时间越长、相关并发症的发生率亦增加.结论:重型颅脑损伤后早期肠内营养相关并发症与其损伤程度、血清清蛋白水平等因素呈负相关;使用鼻肠管可降低腹胀和呕吐的发生率.     

鼻胃管肠内营养对中—重度急性胰腺炎的临床疗效研究

目的 :探讨鼻胃管肠内营养(NGEN)在中-重度急性胰腺炎(M-SAP)治疗中的临床疗效、安全性及耐受性。方法 :收集2013年11月至2014年8月我院消化科住院病人中符合诊断标准的M-SAP病人60例,其中30例使用鼻胃管予以肠内营养(EN),30例使用鼻空肠管进行EN,比较两组病人在肠道通透性(内毒素、D-乳酸)、炎症反应指标(CRP、IL-6、TNFα)、营养情况、管饲副作用(反流误吸、腹痛加重、腹泻)的发生率及病人病情评估(APACHE II评分、MCTSI评分)、预后(感染并发症发生率、病死率、住院时间、住院费用)等方面差异是否存在统计学意义。结果 :在肠道通透性、炎症反应指标、营养状况评价、整体病情评估、预后等方面,两组差异无统计学意义(P0.05),但在反流误吸上,鼻胃管肠内营养组(NG组)发生率为20%,鼻空肠管肠内营养组(NJ组)为3.3%,差异有统计学意义(P0.05)。结论:M-SAP患者行NGEN治疗与鼻空肠管肠内营养(NJEN)在SAP病情变化、营养情况、肠道通透性、预后等方面作用相当,NGEN方法简便,值得临床重视。NGEN发生反流误吸风险较NJEN大,其在M-SAP应用的安全性方面,尚需更多大样本随机对照实验加以研究。     

Comparative Analysis of the Efficacy and Complications of Nasojejunal and Jejunostomy on Patients Undergoing Pancreaticoduodenectomy

Background: The efficacy and feeding‐related complications of a nasojejunal feeding tube and jejunostomy after pancreaticoduodenectomy (PD) was investigated with a randomized, controlled clinical trial at the Affiliated Drum Tower Hospital. Methods: Sixty‐eight patients who underwent PD in the Department of Hepatobiliary Surgery were randomly divided into 2 groups: 34 patients received enteral feeding via a nasojejunal tube (NJT group) and 34 patients received enteral feeding via a jejunostomy tube (JT group). The assessment of clinical outcome was based on postoperative investigation of complications. The second part of the assessment included tube related complications and an index on catheter efficiency. Results: There were 15 cases with infectious complications in the JT group and 13 cases in the NJT group, and there was no significant difference in the rate of infectious complications between the 2 groups. The rate of intestinal obstruction and delayed gastric emptying was significantly decreased in the NJT group (P < .05). Catheter‐related complications were more common in the JT group as compared with the NJT group (35.3% vs 20.6%, P < .05). The time for removal of the feeding tube and nasogastric tube was significantly decreased in the NJT group. The postoperative hospital stay in the NJT group was significantly decreased (P < .05), and there was no hospital mortality in this study. Conclusion: Nasojejunal feeding is safer than jejunostomy, and it is associated with only minor complications. Nasojejunal feeding can significantly decrease the incidence of delayed gastric emptying and shorten the postoperative hospital stay.     

超声辅助四步法鼻空肠管置入在ICU中的应用

目的:探讨超声辅助四步法鼻空肠管置入在ICU重症病人中的应用价值。方法:33例拟行肠内营养支持的ICU重症病人采用超声引导四步法进行鼻空肠管置入,即通过超声判断鼻空肠管置入食道内、鼻空肠管置入胃内、鼻空肠管置入幽门后、最后确认鼻空肠管位置。结果:成功置入28例,失败3例,失败原因为通过幽门之假象及病人胃蠕动消失,鼻空肠管末端贴于胃大弯处,无法弯曲进入胃窦、幽门。结论:超声辅助四步法床旁鼻空肠管置入技术是一种新的鼻空肠管置入技术,操作简单,有效、无创,可重复性且成功率较高,可预防或减少并发症的发生。     

胃镜辅助下放置空肠营养管的方法

目的:探讨内镜下放置空肠营养管的方法.方法:给148例病人放置空肠营养管,116例病人在胃镜下用异物钳钳夹胃腔内空肠营养管,推送胃镜将其送至Treitz韧带以下.32例经鼻超细胃镜放置导丝后,再经导丝放入空肠营养管.结果:两种空肠营养管放置成功率均为100%,其中鼻肠管126例,三腔鼻肠管22例.两组均无严重并发症,1例病人置管后出现血淀粉酶升高.结论:两种空肠营养管放置的方法成功率均高,不良反应小,操作简单安全.     

Feasibility of self-propelling nasojejunal feeding tube in patients with acute pancreatitis

BACKGROUND & AIMS: To assess the success rate of a self-propelling nasojejunal feeding tube in patients with acute pancreatitis. METHODS: All patients admitted for acute pancreatitis were included. A self-propelling nasojejunal feeding tube was introduced into the stomach, and gastrointestinal motility was stimulated using metoclopramide. If the tube failed to advance to the ligament of Treitz, a nasojejunal tube was placed endoscopically. RESULTS: A total of 108 patients, 94 with necrotizing pancreatitis (Balthazar D/E) and 14 with nonnecrotizing pancreatitis (Balthazar B/C), were referred for artificial nutrition. In 11 cases, ileus persisted and parenteral nutrition was initiated. Among the remaining 97 patients, 5 refused tube placement. The self-propelling feeding tube was inserted in 92 patients with successful migration to the ligament of Treitz in 61% (n = 56) and failure in 39% (n = 36). Of the 36 patients with an initial failed placement, endoscopic placement of a nasojejunal tube was successful 80% of the time (29 patients). The success rate of a nasojejunal self-propelling feeding tube placement correlated directly with the severity of the acute pancreatitis (92% in B/C vs 61% in D vs 48% in E; P < .05). CONCLUSIONS: Use of a self-propelling nasojejunal tube is a simple technique that can be successfully performed in the majority of patients with acute pancreatitis. The utility of this procedure in the most severe cases of acute pancreatitis continues to pose a challenge.     

The evolving role of post-ligament of Trietz nasojejunal feeding in enteral nutrition and the need for improved feeding tube design and placement methods

Nutrition support is an important link in the chain of therapy for intensive care unit patients. The early institution of nutrition support significantly reduces the incidence of septic complications, reduces mortality, and shortens hospital stay. Unfortunately, impaired gastrointestinal function, particularly gastric atony, restricts the use of nasogastric enteral tube feeding, and the use of this route of administration in these patients can lead to regurgitation, aspiration, and the development of pneumonia. Postpyloric enteral feeding was heralded as a means of overcoming many of these problems. Overall, the results of controlled studies do not support a role of postpyloric duodenal feeding in reducing the incidence of aspiration pneumonia. As a consequence, post-ligament of Treitz nasojejunal enteral feeding is proposed as the technique of choice in these patients. Feeding tube design must incorporate a gastric aspiration port to overcome problems of gastroesophageal acid reflux, duodenogastric bile reflux, and increased gastric acid secretion, problems that occur during "downstream" jejunal feeding. Tube placement technique will need to be refined and patients will need to receive a predigested enteral diet. In postoperative surgical patients in the intensive care unit, there is also a need for a newly designed dual-purpose nasogastric tube capable initially of providing a means of undertaking gastric aspiration and decompression and subsequently a means of initiating nasogastric enteral feeding.     

Nasojejunal feeding in hyperemesis gravidarum--a preliminary study

Hyperemesis gravidarum is a severe form of nausea and vomiting during the first trimester of pregnancy. Our objective was to assess the feasibility of nasojejunal feeding in our patients. Eleven pregnant women aged 23-46 years with hyperemesis gravidarum, persisting in spite of an in-hospital treatment of 2-15 days by intravenous fluids and antiemetic drugs and accompanied by weight loss, consented to have a nasojejunal feeding tube inserted endoscopically. Mean in-hospital weight loss prior to tube insertion was 2.2+/-1.1 kg (range 0.9-5.1 kg). A clear reduction in the extent of vomiting was already apparent within the first 48 h after tube insertion, but vomiting ceased completely after a mean of 5+/-4 days (range 1-13 days). Weight gain was recorded in six patients who stayed on tube feeding for more than 4 days. Patients were encouraged to start drinking and eating along tube feeding after 3-4 days. Ceasing vomiting and a concomitant sufficient oral intake of at least 1000 kcal/day resulted in the decision to remove the tube after 4-21 days. In three cases, however, the tube was expelled by recurrent vomiting after 1-4 days, or was blocked as in one case. The tube was not reintroduced and patients did not resume vomiting. There were no complications associated with this feeding approach in this population. Only one patient was readmitted. None of the rest resumed vomiting after tube withdrawal.The above suggests that nasojejunal enteral feeding can be an effective option in hyperemesis gravidarum persisting despite intravenous fluids and antiemetic drugs.     

三种肠内进食方法对吸入性肺炎的影响

目的：研究经鼻胃管、鼻空肠管和经口进食三种人工肠内营养方法对吸入性肺炎的影响，为临床工作提供理论依据。方法：纳入118例人工肠内营养患者，其中38例接受鼻胃管进食（A组），34例接受鼻空肠管进食（B组），46例接受经口进食（C组），比较6个月以后三种进食途径患者吸入性肺炎发生率的差异。结果：6个月后经鼻胃管、鼻空肠管及经口三种进食途径吸入性肺炎的发生率分别为76.3%、55.9%、89.1%，差异有统计学意义（P〈0.05）。结论：对于长期需要人工肠内营养的患者，留置鼻空肠管可有效降低吸入性肺炎的发生率。