谷氨酰胺、胆囊收缩素预防完全胃肠外营养期间胆汁淤积的作用

目的 探讨谷氨酰胺（ＧＬＮ）和胆囊收缩素（ＣＣＫ）在完全胃肠外营养（ＴＰＮ）期间预防胆汁淤积的作用。方法 用白兔制成ＴＰＮ模型,随机分成４组,每组１０只,即Ⅰ组（ＴＰＮ组）,Ⅱ组（ＴＰＮ＋ＧＬＮ组）,Ⅲ组（ＴＰＮ＋ＣＣＫ组）,Ⅳ组（ＴＰＮ＋ＧＬＮ＋ＣＣＫ组）。分别在第４周和第８周时检测动物胆汁成分,并用光镜和电镜观察肝、胆组织结构变化。结果 Ⅰ、Ⅲ组早期出现直接胆红素及胆固醇升高,Ⅲ组于晚期升高,     

谷氨酰胺预防幼兔全肠外营养相关肝损害的实验研究

目的:探讨谷氨酰胺对幼兔全肠外营养相关肝脏损害的保护作用。方法:将43只幼兔分为正常对照组(n=12)、PN-10d组(n=18)和Gln-PN组(n=13)等3组,对各PN组动物连续24h输注营养液,10d后比较各组的肝功能、光镜和电镜下的病理变化。结果:Gln-PN组血胆汁酸和直接胆红素水平较PN-10天组显著下降;肝脏无胆汁淤积样改变。结论:谷氨酰胺可以减轻全肠外营养相关的肝脏损害。     

TPN-associated hyperbilirubinemia: a common problem in newborn surgical patients

TPN-associated cholestasis (TPNAC) is a common problem in neonatal surgical patients. Of the 222 infants admitted to the neonatal surgical intensive care unit between January 1982 and June 1983, 46 patients received parenteral nutrition for over 14 days. Cholestasis occurred in 16 of these patients (35%), while 30 patients remained jaundice-free. Clinical characteristics associated with the development of TPNAC, included primary diagnosis, low birth weight, duration of TPN administration, the interval before enteral feeding was initiated, sepsis, central venous catheter infection, and the number of operative procedures. Factors which did not appear significant in the development of conjugated hyperbilirubinemia were prematurity, sex, gestational age, average daily weight gain, and the specific components of the nutritional intake. Mortality was high in the children with cholestasis (31%) as compared to the "normal" neonates (3%) and two of the five deaths were directly related to progressive hepatic dysfunction. This report confirms the high incidence of TPNAC in the newborn surgical population and discusses the critical risk factors associated with development of the syndrome.     

Home total parenteral nutrition: an alternative approach to the management of children with severe chronic small bowel disease.

A home program of total parenteral nutrition (HTPN) has been developed for managing patients with severe chronic small bowel disease who would otherwise be unable to leave the hospital. Six such children were treated by this program using a Broviac catheter to shorten hospitalization, to decrease the cost of care, and to normalize their lives as much as possible. They ranged in age from 2 1/4-17 yr and received HTPN for periods of from 1-11 mo. Criteria for instituting this therapy were the inability to maintain fluid and nutritional balance on therapeutic diet or oral formula, or a need for 30 or more days of conventional TPN. The 6 patients had a total of 1139 days on HTPN with 1 episode of catheter sepsis and 1 localized infection at the catheter site. None of the catheters clotted but 1 was accidentally dislodged. Small bowel adaptation occurred in 4 of the 6 patients. This allowed gradual discontinuous of HTPN and reinstitution of total oral alimentation.     

Changes in total body water and extracellular fluid volume in infants receiving total parenteral nutrition

The nature of weight gain seen in infants receiving total parenteral nutrition continues to be controversial. The debate centers around whether or not the weight gain represents an increase in body mass or water retention. The following study was carried out to answer this question. Eighteen infants receiving peripheral or central intravenous nutrition following major surgery were studied for periods ranging from 1 to 17 weeks. The following studies were carried out after receiving informed consent from the parents and in accordance with the standards established by the Human Use Committee. Total body water was measured using the nonradioactive isotope, deuterium oxide; extracellular fluid volume was assayed using the nonradioactive isotope, sodium bromide. Both body fluid compartments were calculated using the Fick principle of dye dilution. Following double vacuum distillation, serum deuterium oxide was assayed using the falling drop technique. Serum bromide was measured by a technique developed in our laboratory that involves the complexing of bromide with gold chloride and the measurement of this chemical complex colorimetrically. Weight gain was observed in all patients. Total body water percent body weight was 82% +/- 15% prior to the initiation of intravenous nutrition; it decreased within the first week to 71% +/- 12% and then stabilized for the remainder of the study period at 75% +/- 7%. The extracellular fluid volume percent body weight was 56% +/- 15% prior to the start of intravenous nutrition; it fell to 47% +/- 10% during the first week of parenteral nutrition, and then stabilized at 40% +/- 9%.(ABSTRACT TRUNCATED AT 250 WORDS)     

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目的研究富含支链氨基酸的肠外营养液对危重病人营养状况和临床转归的影响。方法按随机、对照、单盲的原则,将2003年10月至2004年4月入住中山大学第一附属医院SICU,符合入选标准的40例病人分为研究组和对照组,两组使用等热量、等氮量的全肠外营养(TPN),检测血浆氨基酸谱的变化和测定氮平衡。结果治疗后,研究组缬氨酸、亮氨酸、异亮氨酸和精氨酸的浓度较对照组显著提高(P=0.008,P=0.02,P=0.01,P=0.007)。治疗后两组均未达到正氮平衡,但研究组显示出较对照组更快达到正氮平衡的趋势。治疗后研究组APACHⅡ评分较对照组下降更为明显(P<0.01)。两组平均住院时间和病死率差异无显著性(P>0.05)。结论富含支链氨基酸的肠外营养液可改善危重病人血浆氨基酸谱的构成,促进蛋白质合成,抑制蛋白质分解;大样本的研究有助于评估支链氨基酸对危重病人临床转归的影响。     

Resolution of intractable cholestasis associated with total parenteral nutrition following biliary irrigation

Although the protracted use of total parenteral nutrition (TPN) in infants is known to predispose to cholestasis, which in certain instances may not be reversible, failure to understand the pathogenesis of this condition has hindered the development of an effective medical treatment. That surgical treatment may reverse this process in selected patients is the subject of the present report. Two premature infants and one term infant, with short bowel syndrome acquired in infancy, developed conjugated hyperbilirubinemia following institution of balanced TPN. Infectious and metabolic etiologies for the jaundice were ruled out. No excretion of 99mTc-labeled DISIDA from the biliary tree was demonstrable 24 hours following injection by nuclear scintigraphy, despite the absence of extrahepatic biliary obstruction by abdominal sonography. When all conventional medical methods of managing the problem failed, exploration was performed. Intraoperative cholangiography showed normal intrahepatic and extrahepatic biliary ducts in each instance. Irrigation of the biliary tree with normal saline solution was then performed. In all cases, liver biopsies were obtained that were consistent with TPN-associated cholestasis and in all cases, jaundice resolved promptly following operation. We conclude that intractable cholestasis associated with TPN, regardless of its etiology, is a functional abnormality of biliary excretion that may respond in selected patients to irrigation of the biliary tree with radiographic dye and/or normal saline solution.     

Combined endoscopic and surgical approach to primary gallstone disease

Summary Over a 5-year period, 443 patients were treated for primary gallstone disease. There were 333 patients with negative preoperative findings in the common bile ducts (CBD) on sonography and liver enzymes estimation who underwent cholecystectomy without endoscopic retrograde cholangiography (ERC). Thirty-eight surgical explorations of the choledochus were necessary, and in 11 patients a second intervention (endoscopically) had to be performed. There were 110 patients with signs of stone formation in the bile ducts. These patients were submitted to examination of the CBD by ERC. Choledocholithiasis was found in 67 patients; in 47, endoscopic papillotomy and stone extraction were successful. On 7 occasions it was insufficient and in 13 patients it was not attempted due to the size of the stone. One second intervention (endoscopically) had to be performed in this group of patients. The sonographical and laboratory suspicion of bile ductstones could be disproved in 43 patients. In these cases, the preoperative ERC was negative. We therefore had information on the bile duct system preoperatively and no surgical bile duct exploration was necessary for diagnosis. Thirty-eight of 333 patients (11.4%) had a false-negative and 43 of 110 (39%) a false-positive sonographical or laboratory diagnosis. This shows that there is no other preoperative diagnostic test other than ERC for the precise preoperative evaluation of common bile duct stones. Morbidity, mortality and the rate of choledochus revision (especially negative explorations) can be reduced by preoperative endoscopic bile duct stone removal. In cases where bile duct stones are suspected, we recommend endoscopic retrograde cholangiography for clarification and, if stones are verified, endoscopic papillotomy and stone extraction followed by simple cholecystectomy for therapy, thus avoiding surgical bile duct explorations.     

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。     

合理营养支持对重症急性胰腺炎治疗作用的研究

目的　探讨合理营养支持对重症急性胰腺炎治疗的作用。方法　将 96例重症急性胰腺炎病人随机分为全胃肠外营养组和肠内与肠外营养结合组。分别检测血清内毒素、尿L/M值、CD4 /CD8比值和IgG水平以监测肠黏膜通透性和免疫状态的改变 ,同时观察TNF α和IL 6血清病人感染率和死亡率。结果　肠内与肠外结合营养组病人血清IgG和CD4 /CD8明显高于全胃肠外营养组 (P <0 0 5 ) ,而内毒素、尿L/M值以及TNF α、IL 6水平则明显低于全胃肠外营养组 (P <0 0 5 ) ,病人感染率和死亡率亦明显降低 (P <0 0 5 )。结论　合理应用肠外与肠内营养相结合的营养支持方式可缓解炎性细胞因子及炎性介质的释放 ,从而对重症急性胰腺炎具有积极的治疗作用。     

TPN联合生长激素对胃肠道恶性肿瘤患者术后应激反应的抑制作用

目的 探讨胃肠道恶性肿瘤患者术后完全胃肠外营养（TPN）基础上给予生长激素（GH）促进机体合成代谢的机理。方法 将94例胃肠道恶性肿瘤手术患者按随机数字表法随机均分为TPN组和TPN＋GH组，术后第1、3及7d分别测定其TNF-α、IL-1、IL-6及C反应蛋白（CRP）值。结果 TPN＋GH组的TNF-α、IL-1、IL-6及CRP值在术后第1、3及7d均低于TPN组相应时相。结论 外源性GH可抑制胃肠道恶性肿瘤患者术后TNF-α、IL-1、IL-6及CRP的产生．进而阻断炎症因子诱导的GH不敏感反应所致的高分解代谢为特征的合成代谢障碍，促进机体合成代谢。     

苏南地区胆石病临床特征的分析

目的了解苏南地区胆石病的临床特征。方法收集2000年8月至2002年3月经手术确诊的胆石病病人671例作为研究对象。结果30岁及以下年龄组胆石病病人占所有病例的21．46％；胆囊结石占85．99％，单纯胆管结石仅占4．92％；胆固醇结石占66．17％，胆色素结石占33．83％；66．32％病人同时伴有一种或多种并发症，其中合并胆囊周围炎者占60．36％。结论苏南地区胆石病的发病年龄、部位和类型呈现不同的特点。     

Trophic enteral nutrition increases hepatic glutathione and protects against peroxidative damage after exposure to endotoxin

Background

During total parenteral nutrition (TPN), hepatic concentration of the important intracellular antioxidant glutathione (GSH) is decreased. This study sought to determine whether enteral trophic (small quantity) feeding of GSH precursors would increase hepatic GSH levels during TPN and result in decreased peroxidative injury after endotoxin exposure.

Methods

Sprague-Dawley rats received full TPN for 7 days with postpyloric infusions of either (1) amino acid GSH precursors (cysteine, 60 mg/d; glycine, 86 mg/d; glutamate, 31 mg/d; F1); (2) iso-nitrogenous alanine (132 mg/d; F2); or (3) normal saline (SA). Hepatic GSH concentration was measured by gas chromatography/mass spectrometry. In a parallel study, animals were given TPN and either F1 or SA for 7 days, and endotoxin was administered intravenously before death. Hepatic lipid peroxidation and histology were assessed.

Results

Hepatic GSH concentration measured 11.7 ± 0.6 μmol/g in F1. This was significantly higher (P < .001) than in F2 (7.0 ± 0.8 μmol/g) or SA (5.0 ± 0.4 μmol/g). F2 and SA were not significantly different. Hepatic malondialdehyde concentration after exposure to endotoxin was significantly higher in SA (10.36 μmol/g ± 0.65) than in F1 (7.38 μmol/g ± 0.77; P < .01). All SA animals had histologic evidence of hepatic necrosis, whereas none of the F1 group showed these changes.

Conclusions

Targeted trophic feeding of GSH amino acid precursors during parenteral nutrition markedly increased hepatic GSH concentration. This was associated with decreased lipid peroxidation and enhanced hepatocellular protection after endotoxin challenge. Thus, targeted trophic feedings may aid in the prevention of TPN-related liver disease.     

谷氨酰胺对短肠综合征大鼠残留小肠代偿作用的影响

目的观察谷氨酰胺对短肠综合征大鼠残留小肠代偿作用的影响.方法23只雄性SD大鼠切除80%小肠,随机分三组饮食组(n=8)术后自由进食;全胃肠外营养(TPN)组(n=8)输TPN标准液;谷氨酰胺(Gln)组(n=7)输TPN+Gln;正常大鼠8只,作为正常对照组.术后第7天,称体重,取回盲部淋巴结和门静脉血作细菌培养,取残留空肠和回肠进行组织学检查(包括光镜和电镜).结果饮食组和Gln组术后体重有明显差异饮食组、TPN组和Gln组回盲部淋巴结和门静脉血细菌培养阳性率无明显差别,但TPN组细菌培养阳性率高于Gln组;饮食组空肠粘膜绒毛高度(VH)和粘膜厚度(MT)、回肠粘膜VH均明显大于正常组;正常组空肠粘膜VH、MT明显大于TPN组,正常组回肠粘膜隐窝深度(CD)、MT明显大于TPN组;Gln组空肠和回肠粘膜VH、CD和MT明显大于TPN组.结论80%小肠切除后,残留小肠发生代偿性改变,食物刺激是残留小肠代偿的重要因素;但这种代偿不完全,补充TPN可维持机体生理平衡,TPN引起残留小肠粘膜萎缩;Gln可阻止TPN引起残留小肠粘膜萎缩,促进残留小肠代偿.     

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。     

Isolated liver and multivisceral transplantation for total parenteral nutrition-related end-stage liver disease

Purpose

Total parenteral nutrition (TPN) has prolonged survival in children with intestinal failure; however, end-stage liver disease owing to TPN-induced cholestasis (ESLD-TPN) may preclude its use. ESLD-TPN is an indication for isolated liver transplantation (ILT) or multivisceral transplantation (MVT). Isolated liver transplantation for ESLD-TPN should only be considered in patients who have the potential for enteral autonomy.

Methods

We retrospectively reviewed the records of patients with ESLD-TPN who underwent ILT (n = 7) or MVT (n = 5) between 1994 and 2005. The median age at the time of transplantation was 10.0 months. Intestinal failure followed necrotizing enterocolitis (n = 3), gastroschisis (n = 3), gastroschisis with volvulus (n = 3), gastroschisis with atresia (n = 1), malrotation (n = 1), and megacystis microcolon intestinal hypoperistalsis syndrome (n = 1).

Results

Isolated liver transplant patients had a median length of small bowel of 70 cm and tolerated a median of 50% of enteral calories. The median length of small bowel in patients who underwent MVT was 29 cm, and none tolerated more than 30% of goal enteral feeds. Reduced-size (n = 5) and whole-liver (n = 2) allografts were used for patients undergoing ILT. Patients undergoing MVT received liver-small bowel-pancreas (n = 4) or liver-small bowel-pancreas-colon (n = 1). Overall patient survival was 57% in ILT (median follow-up = 25.1 months); 3 survivors are TPN independent, and the fourth patient requires TPN 3 days/wk. Patient survival was 40% after MVT (median follow-up = 13.0 months); 1 MVT patient died of abuse 16.9 months after transplant and was TPN independent at the time of death. Both survivors are TPN independent. Bilirubin levels are within normal range in all survivors.

Conclusion

Isolated liver transplantation for ESLD-TPN in the setting of intestinal failure is a viable option in patients who have the potential for enteral autonomy. Multivisceral transplantation is the only alternative in patients without the potential for intestinal recovery. Survival can be achieved in patients with ESLD-TPN, but mortality remains high for both procedures.     

The effects of total parenteral nutrition on gastrointestinal growth and development

Total parenteral nutrition (TPN) is vital for the nutritional support of infants with disorders of the gastrointestinal tract that prevent adequate enteral intake. Studies in adult rodents maintained on TPN have demonstrated intestinal atrophy and decreased activity of the brush border enzymes of the small bowel mucosa. We studied the effects of TPN during the phase of rapid intestinal growth and development in piglets. Matched groups of three 6-week-old weaned piglet littermates received a glucose (45 g/kg/d), amino acid (8 g/kg/d), and fat (2.5 g/kg/d) solution intravenously (IV) or by gastrostomy (GF), or were given hog chow (Chow) at an equivalent caloric value for three weeks. No differences were noted in the mean weight gain (13-15 g/kg/d), total serum protein (4.5-4.8 g/dL), BUN (9-12 mg/dL), or Hct (25% to 30%). The IV and GF animals, compared to the Chow animals, had decreased growth of the stomach, small bowel, and pancreas with decreased small bowel mucosal disaccharidase activity. The IV group, compared to Day 0 animal measurements, had decreased small bowel length and weight and pancreatic weight. Histology of the proximal small bowel mucosa in the IV animals showed decreased mucosal depth, villus height, crypt depth, and epithelial cell number from the crypt base to the midvillus. These findings suggest that stomach, small bowel, and pancreatic growth are dependent on the route of administration and/or the composition of the diet, the small bowel mucosa and the pancreas atrophies in young piglets maintained on TPN, the activity of some intestinal brush border disaccharidases are decreased in the small bowel in piglets maintained on either an intravenous or an intragastric infusion of a TPN solution.     

Rapid intravenous administration of amino acids prevents biliary sludge induced by total parenteral nutrition in humans

The aim of this study was to evaluate whether daily rapid intravenous administration of amino acids (IVAA) prevented the formation of biliary sludge in humans receiving long-term total parenteral nutrition (TPN). Thirty adult patients receiving TPN for more than 28 consecutive days were studied. They were randomized to receive either saline solution (placebo) intravenously (15 patients) or 6.9% branched chain amino acid (BCAA)-enriched amino acid (15 synthetic amino acids; Freamine HBC) solution given by administration rapid intravenous (15 patients). The groups were similar with respect to age, sex, diagnosis, liver function test results, amylase levels, TPN time, and time of study. All patients underwent weekly ultrasound studies. Volume and emptying studies of the gallbladder in response to the study drug were performed after 1 week. As a result, none of the patients receiving rapid IVAA had sludge, whereas 11 of the 15 patients receiving placebo had sludge (P < 0.01). Results of emptying studies showed significant contraction of the gallbladder in those in the rapid IVAA group, but not in the placebo group. Consequently, the data suggest that rapid IVAA given daily prevents TPN-induced stasis and sludge in the gallbladder. We conclude that rapid IVAA should be used as routine prophylaxis against biliary sludge and formation of gallstones in patients receiving long-term TPN. Received: May 8, 2000 / Accepted: August 8, 2000