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.     

Parenteral and enteral nutrition and the enterocutaneous fistula treatment. I. Investigations on fistula output, nutritional status complications.

Prospective evaluation were made of 45 patients with postoperative small bowel fistulas treated with total parenteral nutrition (TPN) and enteral nutrition (EN) between 1971-1988. The administration of TPN in the early treatment of enteric fistulas decreased the mean fistula output significantly (p < 0.05-0.001) and provided an effective tool in the control of high-output fistulas. The electrolyte contents of different fistula secretions were unchanged and the losses through the fistulas depended on the daily output. In patients with high-output fistulas acid-base balance disturbances had to be corrected. When comparing two parenteral nutrition regimens (carbohydrate+amino acids /CH + AA/ versus carbohydrate + amino acids + fat /CH + AA + F/) both facilitated the reduction of fistula secretion (in high-output fistulas. CH + AA = -50.2%; CH + AA + F = -49%). Positive nitrogen balance was achieved in non septic patients after 13 days of treatment. Improvement of serum protein and albumin occurred by the time of fistula healing. In non surviving patients significant decrease in protein synthesis was observed. Out 7 of 75 central venous catheters yielded positive bacterial cultures (9.3%). In 5 patients autopsy proved generalized sepsis. The use of parenteral and enteral nutrition proved to be a powerful method for controlling the enterocutaneous fistulas and maintaining the nutritional integrity of patients.     

Serum albumin level in the management of postoperative enteric fistula for gastrointestinal cancer patients.

Postoperative enteric fistula is a serious complication and cause of death following gastrointestinal (GI)-tract surgery. Many reports have demonstrated the effectiveness of parenteral nutrition in the spontaneous closure of enteric fistula. Our study was aimed at analyzing the prognostic factors of parenteral nutritional support in the treatment of enteric fistula for patients with GI-tract cancer following surgery. GI-tract cancer patients receiving surgical interventions, which then unfortunately developed enteric fistula, were included in our study. All of them had to have received parenteral nutrition soon after leakages were recognized, and they were subsequently divided into successful and unsuccessful (classified as "failure") groups according to spontaneous closure of fistula or not, respectively. The studied patients' laboratory data were collected to identify the clinically relevant prognostic factors. Fifty-three primary GI-tract cancer patients with postoperative enteric fistulas were enrolled into our study. Of these, 33 patients were considered as successful parenteral nutritional therapy (successful group) and the other 20 patients (failure group) were not. After a period of parenteral nutritional therapy, serum total bilirubin, creatinine, C-reactive protein (CRP), hemoglobin, and albumin were significantly different between these two groups (all p < .05). Using a multivariate logistic regression analysis, it was determined that increased serum albumin level was an independent predictive factor of successful management for enteric fistula (p = .029), in addition to the well-known lower drainage amount (< 500 mL/day) from the enteric fistula (p = .013). Our observations show that both serum albumin levels and drainage amounts from the enteric fistula can be potentially used as important prognostic predictors of healing enteric fistula under total parenteral nutrition in patients following surgery for GI-tract malignancies.     

Fistuloclysis can successfully replace parenteral feeding in the nutritional support of patients with enterocutaneous fistula

BACKGROUND: Use of total parenteral nutrition (TPN) in patients with acute intestinal failure due to enteric fistulation might be avoided if a simpler means of nutritional support was available. The aim of this study was to determine whether feeding via an intestinal fistula (fistuloclysis) would obviate the need for TPN. METHODS: Fistuloclysis was attempted in 12 patients with jejunocutaneous or ileocutaneous fistulas with mucocutaneous continuity. Feeding was achieved by inserting a gastrostomy feeding tube into the intestine distal to the fistula. Infusion of enteral feed was increased in a stepwise manner, without reinfusion of chyme, until predicted nutritional requirements could be met by a combination of fistuloclysis and regular diet, following which TPN was withdrawn. Energy requirements and nutritional status were assessed before starting fistuloclysis and at the time of reconstructive surgery. RESULTS: Fistuloclysis replaced TPN entirely in 11 of 12 patients. Nutritional status was maintained for a median of 155 (range 19-422) days until reconstructive surgery could be safely undertaken in nine patients. Two patients who did not undergo surgery remained nutritionally stable over at least 9 months. TPN had to be recommenced in one patient. There were no complications associated with fistuloclysis. CONCLUSION: Fistuloclysis appears to provide effective nutritional support in selected patients with enterocutaneous fistula.     

Serum Albumin Level in the Management of Postoperative Enteric Fistula for Gastrointestinal Cancer Patients

Postoperative enteric fistula is a serious complication and cause of death following gastrointestinal (GI)-tract surgery. Many reports have demonstrated the effectiveness of parenteral nutrition in the spontaneous closure of enteric fistula. Our study was aimed at analyzing the prognostic factors of parenteral nutritional support in the treatment of enteric fistula for patients with GI-tract cancer following surgery. GI-tract cancer patients receiving surgical interventions, which then unfortunately developed enteric fistula, were included in our study. All of them had to have received parenteral nutrition soon after leakages were recognized, and they were subsequently divided into successful and unsuccessful (classified as “failure”) groups according to spontaneous closure of fistula or not, respectively. The studied patients' laboratory data were collected to identify the clinically relevant prognostic factors. Fifty-three primary GI-tract cancer patients with postoperative enteric fistulas were enrolled into our study. Of these, 33 patients were considered as successful parenteral nutritional therapy (successful group) and the other 20 patients (failure group) were not. After a period of parenteral nutritional therapy, serum total bilirubin, creatinine, C-reactive protein (CRP), hemoglobin, and albumin were significantly different between these two groups (all p <. 05). Using a multivariate logistic regression analysis, it was determined that increased serum albumin level was an independent predictive factor of successful management for enteric fistula (p =. 029), in addition to the well-known lower drainage amount (< 500 mL/day) from the enteric fistula (p =. 013). Our observations show that both serum albumin levels and drainage amounts from the enteric fistula can be potentially used as important prognostic predictors of healing enteric fistula under total parenteral nutrition in patients following surgery for GI-tract malignancies.     

消化道瘘12例临床分析

目的　探讨有关术后消化道瘘的原因 ,提高其治疗水平。方法　回顾 12例术后肠外瘘胆瘘的临床资料。胆瘘 3例 ,十二指肠瘘 2例 ,小肠瘘 5例 ,结肠瘘 2例 ,其中吻合口瘘 3例。平均术后至瘘时间 5 .3d。采用有效引流、肠外加肠内营养、控制感染、纠正水电解质及酸碱平衡紊乱、扩创换药先吸后堵等治疗。结果　除 3例死亡 (病死率 2 5 % ) ,其余均治愈 ,平均治愈时间 5 5 .3d。结论　有效充分引流及营养支持是治疗消化道瘘成功的关键。     

Enteral and parenteral nutrition in patients with enteric fistulas and short bowel syndrome

Significant advances in the use of enteral and parenteral nutrition in patients with either enteric fistulas or short bowel syndrome include increased usage of enteral nutrition because of its trophic effects on the gut and increased usage of both enteral and parenteral nutrition in the home setting. Current investigations are directed toward identifying gut-specific fuels and dietary and pharmacologic enhancement of nutrient utilization.     

Parenteral and enteral nutrition and the enterocutaneous fistula treatment. II. Factors influencing the outcome of treatment.

An 18-year review of 64 patients treated with 71 postoperative enterocutaneous fistulas of the stomach /4/, duodenum /21/, jejunum /9/ and ileum /37/ was carried out to identify the factors affecting morbidity and mortality. Age, localization, output, inflammatory or malignant bowel disease, nutritional status and associated sepsis were analysed. The administration of total parenteral nutrition (TPN) or/and enteral nutrition (EN) as adjuvant therapy in the management of gastrointestinal fistulas increased the fistula closure rate (64%) and decreased mortality (33%). In patients over 65 years a rise in mortality rate (69%) was found. TPN and EN support yielded the best results in duodenal and jejunal fistula patients (closure rate 83% and 71%; respectively). In patients with high-output fistulas, inflammatory bowel disease and malignancy good results could be achieved with nutritional treatment. The presence of malnutrition had an adverse effect on the outcome in the non-TPN group with a mortality rate of 49%. In 43 patients severe septic complications occurred and 21 died due to septic multiple organ failure proved by autopsy. The overall mortality rate was 39%. Timing of fistula surgery had little impact on the fistula closure rate, but better results were obtained when reconstructive surgery was deferred beyond 6 weeks from fistula onset. Mortality has decreased since 1980. While many factors influence the outcome of fistula disease, adequate antiseptic treatment is assumed of primary importance. The nutritional therapy facilitated the spontaneous fistula healing and allowed the elective intestinal reconstruction to be scheduled at an optimal time.     

肠内营养对长期禁食肠瘘患者肠黏膜上皮内淋巴细胞及黏液屏障功能的研究

目的研究肠内营养对长期禁食的肠外瘘患者肠黏膜上皮内淋巴细胞（iIEL）及黏液屏障功能的影响。方法对2003年7月至2004年5月收治的10例唇状小肠外瘘病例，分别于实施肠内营养支持前和实施第5天及第10天，在肠镜下经小肠外瘘口距瘘口15～20cm以活检钳取检肠黏膜，行常规苏木精-伊红染色计数iIEL，免疫组织化学染色测定CD8阳性淋巴细胞比例和黏蛋白基因2阳性细胞比例，特殊染色阿利新蓝（Alcian Blue，AB）结合法检测黏液层厚度。结果肠内营养实施5d后，各活检标本黏蛋白基因2阳性细胞比例及黏液层厚度较实施前显著增高（P〈0．05）；10d后，iIEL及CD8阳性淋巴细胞比例也较肠内营养实施前显著增多（P〈0．05）。结论实施肠内营养对于长期禁食的肠外瘘患者的肠道黏膜具有保护作用，并可增强肠黏膜的免疫功能。     

Reconstructive operations for enteric and colonic fistulas: Low mortality and recurrence in a single-surgeon series with long follow-up

BackgroundThe aim of the study was to evaluate the outcomes of 100 consecutive patients undergoing reconstructive operation for enteric and colonic fistulas. These fistulas cause dramatic morbidity and profoundly diminish quality of life. Fistula takedown has been associated with high rates of recurrence.MethodsConsecutive patients undergoing definitive fistula reconstruction by a single surgeon were reviewed retrospectively. Major adverse outcomes included bowel leak, fistula recurrence, death, total parenteral nutrition dependence, and incidence of new stomas.ResultsAmong the 100 patients, median follow-up was 2.7 years. A total of 11 patients had postoperative leaks that evolved to 5 fistula recurrences. Of these patients 3 underwent successful secondary or tertiary takedown. The 30-day mortality rate was 1%, and the combined postoperative and fistula-related mortality rate at follow-up was 3%. New postoperative total parenteral nutrition dependence occurred in 2 patients (2%), and 9 (9%) had placement of a new stoma. Leaks were more frequent for patients who had a history of open abdomen than for patients who did not.ConclusionsWith minimal patient selection and a methodic approach to evaluation and management, we achieved a 96% fistula-free survival rate. Few patients acquired new total parenteral nutrition dependence or a new stoma. These results compare favorably with outcomes published elsewhere.     

营养支持对消化道瘘患者高代谢状态的作用

消化道瘘多继发于手术后并发症,由于消化道瘘自身特点．多伴有多系统的感染．由于感染的存在．必然导致机体的高分解代谢。持续的高分解代谢延长机体的治疗病程。甚至影响预后。抑制机体高分解代谢状态．首要控制感染．由于消化道瘘感染的复杂性,其治疗措施是综合性的,而其中营养支持是重要治疗手段之一。多数临床医生近年也逐渐认识到了营养支持在消化道瘘治疗中的重要性。     

Small bowel necrosis related to enteral nutrition after duodenal surgery

Nutritional support is the key to the successful recovery of any patient. Small bowel necrosis is described in patients being fed with enteral nutrition after surgery. Five patients with small bowel necrosis after surgery will be discussed and an etiology proposed. A retrospective review of patient data was performed. Data was collected on the type of surgical procedures performed, the enteral nutrition given to the patient, basic laboratory data, the length of stay, and discharge status. A total of five patients' charts were reviewed. Three patients had pancreaticoduodenectomy for a pancreatic mass and two required pyloric exclusion secondary to gunshot wounds. All five patients were fed with a fiber-based enteral nutrition. All patients subsequently had small bowel necrosis requiring reoperation. Four of the five patients had inspissated tube feeding within the necrotic small bowel. Two patients died and three survived with prolonged hospital courses. We propose that the combination of duodenal surgery and fiber-based enteral nutrition contribute to the development of small bowel necrosis postoperatively.     

Enterocutaneous fistulas of the small bowel in children (25 cases).

During the past 5 yr, 25 children ranging in age from 10 days to 14 yr have been treated for single or multiple severe enterocutaneous fistulas. There were two deaths. In 24 cases out of 25, initial treatment was nonsurgical and consisted of nutritional support (by total parenteral nutrition in 20, and constant rate enteral feeding in 4) and was associated with local treatment. Successful closure was achieved without surgery in 13 cases, and 11 secondary operations were performed, with success in 9. The addition of nutritional methods has completely changed the prognosis of enterocutaneous fistula.     

食管癌合并糖尿病的围手术期营养支持

目的 比较围手术期肠内与肠外营养支持对于合并糖尿病的食管癌患者的治疗效果.方法 前瞻性入组2012年9-11月间福建省肿瘤医院胸外科收治的30例合并糖尿病的食管癌患者,按随机数字表法将其随机分为肠内营养组（15例）和肠外营养组（15例）.两组于术前3d至术后8d期间分别给予肠内营养素（安素）和肠外营养支持.每日动态监测血糖;术前1d和术后8d检测患者的营养指标（白蛋白和前白蛋白）;观察术后胃肠道功能恢复时间和营养支持相关并发症发生率;统计营养支持总费用.结果 两组患者围手术期血糖控制情况均较为满意：3餐前手指末梢血糖为5.0～9.0 mmol/L,3餐后2h手指末梢血糖为7.0～10.0 mmol/L,晚10时和凌晨3时的血糖波动于4.0～8.0 mmol/L;所有患者均未出现低血糖（末梢血糖小于3.5 mmol/L）.肠内营养组术后首次排气时间为（62.4±15.7）h,明显快于肠外营养组的（90.8±22.4） h（P＜0.01）.两组患者术后营养指标及营养支持相关并发症方面的差异均无统计学意义（均P＞0.05）.肠内营养组营养支持费用为 （650.8±45.8）元,明显低于肠外营养组的（3016.5±152.6）元（P＜0.01）.结论 在合并糖尿病的食管癌患者中,围手术期营养支持能在有效调控血糖的同时明显改善其营养状况.与肠外营养相比,使用安素进行肠内营养能加快胃肠功能恢复,并降低营养支持的费用.     

Current trends of artificial enteral nutrition in acute pancreatitis

During recent years, there has been considerable debate as to the nutritional supply that needs to be established for a patient with acute pancreatitis. The main problem is still infection of the pancreatic necrosis, which has a decisive bearing on the indication for surgery and is the main cause of mortality. Infection stems from bacterial translocation from the patient's gut. Enteral nutrition with its known potential for reducing this type of infection constitutes an attempt to prevent it by preserving the enteric mucosal barrier. Today, the concept of pancreatic rest is no longer considered mandatory in the guidelines of many Surgical and Nutritional Societies, whilst enteral nutrition is the gold standard for acute pancreatitis. Assuring an integrated parenteral and enteral supply before reaching the full regimen of enteral nutrition is the most reliable policy during the early days of the disease. Moreover, outcomes being equal, enteral nutrition is cheaper than parenteral nutrition, as has been extensively demonstrated in many clinical trials in severe acute pancreatitis.     

急性坏死性胰腺炎并发多器官功能不全综合征患者的营养支持治疗

目的 总结急性坏死性胰腺炎并多器官功能不全综合征患者的营养支持治疗经验。方法 营养支持分全胃肠外营养(TPN),肠外加肠内营养及全胃肠内营养三个阶段。结果 6例病人,1例死亡,其余5例均痊愈出院。结论 急性坏死性胰腺炎并发多器官功能衰竭的营养支持是其它治疗的基础,并与其它治疗同步进行。分三阶段进行,效果较好。     

A systematic review of the benefit of total parenteral nutrition in the management of enterocutaneous fistulas

Enterocutaneous fistulas (ECFs) most commonly occur as a complication of abdominal surgery but can also occur spontaneously in inflammatory bowel disease, diverticulitis, radiation, trauma and sepsis. Although mortality and morbidity have reduced in recent years they are still a major cause of concern in patients with ECF. Nutritional support is a challenging issue in these patients and a major cause of mortality and morbidity. Total parenteral nutrition (TPN) is widely used in the management of ECF. In this review the authors examined the evidence of the use of TPN in ECF with the aim of determining the indications, benefits and outcome of this type of nutritional support in these.     

The Role of Surgery and Hyperalimentation in Therapy of Gastrointestinal-Cutaneous Fistulae

Thirty-eight patients with external gastrointestinal fistulas arising from different levels of the gastrointestinal tract, observed and treated at the Massachusetts General Hospital, from December 1970 to April 1973, are analyzed. Surgical complications were the causes of fistulization in 77% of the cases. The treatment program included parenteral nutrition through a subclavian line in all cases. The 38 patients were fed parenterally for a total of 2311 days. Spontaneous fistula closure occurred in only 11 of the 38 patients. Surgical procedures were necessary in 71.05% of the cases to control fistula complications or persistent fistula drainage. Operative success rate was 70.4%. Parenteral nutrition effects on metabolic parameters, fistula secretion, nutritional status, morbidity and mortality of fistulas are discussed. Parenteral nutrition hazards are also presented. Overall mortality in this series was 21%. Roles of parenteral nutrition and surgery in the total management of external gastrointestinal fistulas are suggested.     

Perioperative enteral nutrition

Enteral nutrition, as demonstrated by the many published papers, is not only safer and cheaper than parenteral supply of nutrients, but modulates an exaggerated cytokine response related to surgical trauma that leads to an increase in intestinal permeability, bacterial translocation and infection. The aim of enteral nutrition is to reduce the impact of cytokines on surgical patients and the related infectious complications. Via the enteral route the nutrients can reach the bowel lumen where enterocytes draw upon their fuel, preserving the barrier effect and modulating the cytokine response. Parenteral supply does not achieve this target since the blood supply of nutrients is not as important as the luminal supply. It is only via the enteral supply route that we can preserve the barrier effect. Since the cytokine response sets in immediately after a trauma such as surgery, we implement uninterrupted enteral nutrition, which means before, during and after surgery, plus parenteral support till the full calorie intake is achieved. In a hepatic resection study, we have demonstrated that enteral nutrition modulates the interleukin-6 immunological response and shortens both the period to bowel movement resumption and the duration of hospital stay. Aggressive enteral nutrition has also been implemented in severe pancreatitis, allowing control of the disease without the onset of septic complications. The most important target is not to achieve full calorie intake rapidly, but to supply the enteric mucosa continuously with useful immuno-nutrients, such as glutamine and fibres, to preserve the barrier effect, the mucus layer, and immunological status of the mucosa. In this way we have obtained significant results in the surgical treatment of these patients, reducing the infection rate and hospital stay. New prospects may be,possible in the fight against surgical infections by adding probiotics to enteral nutrition in order to improve the microenvironment of the colon.     

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.