空肠营养性造口与鼻肠管早期肠内营养在胃癌术后的应用比较

目的探讨空肠营养性造口与鼻肠管早期肠内营养在胃癌术后的临床应用效果比较。方法选取延安大学附属医院2011年6月-2013年6月收治的76例行肠内营养的胃癌患者,A组42例采用空肠营养性造口,B组34例采用鼻肠管。分析比较两组患者实施肠内营养后通气时间、术前术后营养状况变化、并发症(呼吸道症状、消化道症状及其他各类不适)、住院时间等。结果73例胃癌术后患者实施肠内营养效果较好,3例患者未完成肠内营养,两组患者在术前术后营养状况变化、住院时间、住院费用上比较差异无统计学意义(P0.05),A组患者在通气时间、并发症发生率上优于B组(P0.05)。结论与鼻肠管比较,空肠营养性造口能减少并发症的发生率,使患者胃肠功能恢复更快,但应根据具体情况合理选择肠内营养方式。     

经胃镜置放鼻空肠营养管治疗重症急性胰腺炎的疗效观察

目的:观察重症急性胰腺炎(SAP)患者经胃镜置放鼻空肠营养管行肠内营养的疗效观察.方法:将50例患者随机分为2组:①全肠外营养(TPN)组26例,行常规治疗:禁食、胃肠减压、抑酸、抗炎、生长抑素、全肠外营养及对症治疗等;②肠内营养(EN)组24例,在常规治疗的基础上,入院后3d左右经胃镜置放鼻空肠营养管,逐渐停止肠外营...     

Enteral nutrition in acute pancreatitis: A review of the current evidence

The use of enteral feeding as part of the management of acute pancreatitis dates back almost two decades.This review describes the indications for and limitations of enteral feeding for the treatment of acute pancreatitis using up-to-date evidence-based data.A systematic review was carried out to analyse current data on the use of enteral nutrition in the management of acute pancreatitis.Relevant literature was analysed from the viewpoints of enteral vs parenteral feeding,early vs delayed enteral nutrition,nasogastric vs nasojejunal feeding,and early oral diet and immunonutrition,particularly glutamine and probiotic supplementation.Finally,current applicable guidelines and the effects of these guidelines on clinical practice are discussed.The latest meta-analyses suggest that enteral nutrition significantly reduces the mortality rate of severe acute pancreatitis compared to parenteral feeding.To maintain gut barrier function and prevent early bacterial translocation,enteral feeding should be commenced within the first 24 h of hospital admission.Also,the safety of nasogastric feeding,which eases the administration of enteral nutrients in the clinical setting,is likely equal to nasojejunal feeding.Furthermore,an earlylow-fat oral diet is potentially beneficial in patients with mild pancreatitis.Despite the initial encouraging results,the current evidence does not support the use of immunoenhanced nutrients or probiotics in patients with acute pancreatitis.     

Nutrition in acute pancreatitis

The majority of patients (80%) admitted with acute pancreatitis recovers after a few days of bowel rest and intravenous fluids. However, some cases progress to a fulminant disease complicated by a severe systemic inflammatory response and multiple organ failure, a condition in which mortality is related to the degree of negative nitrogen balance. The goal of nutrition support in this situation is to cover the increased metabolic demands without stimulating pancreatic secretion and exacerbating the "autodigestion" that characterizes the condition. Although human and animal studies have shown conflicting results regarding the effect of composition and location of feeding on pancreatic enzyme secretion, there is consensus that total parenteral nutrition (TPN), given at moderate infusion rates, does not significantly stimulate secretion in humans and that enteral diets stimulate enzyme secretion unless delivered below the jejunum. Consequently, until recently TPN has been the standard of therapy. The fact that the cost and complications of TPN can often outweigh its benefits (catheter sepsis, hyperglycemia) has led to a series of recent controlled clinical trials of modified enteral diets in which the diet is delivered by nasojejunal tube. Results have demonstrated that enteral nutrition, with either elemental or polymeric formulas, was cheaper, safer, and at the same time more effective in reducing the systemic inflammatory response. The pathophysiologic explanation for these observations needs further investigation.     

Total enteral nutrition vs. total parenteral nutrition in patients with severe acute pancreatitis]

OBJECTIVE: To compare the efficacy of early total enteral nutrition (TEN) vs. total parenteral nutrition (TPN) in patients with severe acute pancreatitis (SAP). METHODS: A total of 22 consecutive patients with SAP were randomized to receive TPN (group I) or TEN (group II). SAP was defined applying APACHE II score, C-reactive protein (CRP) measurements and/or Balthazar CT scan score. Acute inflammatory response (CRP, TNF-a, IL-6), visceral proteins (pre-albumin, albumin), complications (systemic inflammatory response syndrome, multiorgan failure, infections), surgical interventions, length of hospital stay and mortality were evaluated. RESULTS: No significant differences were found between the two groups in the APACHE II score, in CRP, TNF-a and IL-6 concentrations or in pre-albumin and albumin levels over the first 10 days. Seven patients in group I and 4 in group II suffered severe complications. Three patients in group I required surgical intervention. Length of hospital stay was alike in the two groups. Two patients from group I died in the course of the hospitalization. CONCLUSIONS: SAP patients with TEN feeding showed a tendency towards a better outcome than patients receiving TPN.     

Early enteral nutrition after hepatectomy to prevent postoperative infection

BACKGROUND/AIMS: Enteral nutrition helps to prevent septic complications in patients with critical illness, but there are few reports on its use after hepatectomy. To evaluate its benefits, we studied the indications for it. METHODOLOGY: In a retrospective study we reviewed 67 hepatectomized patients, 19 with enteral nutrition after hepatectomy (EN group) and 48 without (TPN group). In the TPN group, the risk factors of postoperative infections were analyzed with discriminant analysis. Then we prospectively selected high-risk patients before surgery and started enteral nutrition soon after surgery. The incidences of postoperative infections were examined in the EN and TPN groups of high-risk patients. RESULTS: In high-risk patients selected using a new discriminant formula, the infection rate was decreased from 73.1% in the TPN group to 53.3% in the EN group (NS). However, in cases in which enteral nutrition was initiated within 4 days after surgery, the infection rate dropped to 30%, a significant decrease (P < 0.03). In this prospective study, the infection rate of high-risk patients was markedly decreased and the overall infection rate was decreased significantly, to 21.4% from 47.4% in the retrospective study (P < 0.02). CONCLUSIONS: We conclude that early enteral nutrition after hepatectomy is helpful for preventing septic complications, especially in patients at high risk of infection as evaluated with our new formula.     

Therapeutic tactics in the treatment of acute necrotizing pancreatitis

BACKGROUND/AIMS: The authors analyze the possibilities for the delay of surgery with special consideration regarding percutaneous peripancreatic drainage in the treatment of acute necrotizing pancreatitis. METHODOLOGY: In addition to intensive care therapy, 61 patients were also given antibiotic prophylaxis, and early nasojejunal enteral feeding was commenced. In a total of 22 cases where peripancreatic fluid was found, percutaneous drainage was performed. Septic necrosis, sepsis, multi-organ failure not resolving with conservative treatment, gastrointestinal perforation, and bleeding were the indications for operation. Only 9 patients underwent surgery within one week and in 40 patients delayed (more than 7 days) necrectomy was performed. Following surgery, closed omental bursa rinsing was performed. RESULTS: Five patients were cured with only conservative therapy and 7 others were cured under the influence of percutaneous drainage. In 15 patients it was possible to delay surgery using percutaneous drainage with combination of conservative treatment. A total of 39 reoperations occurred due to septic focus, bleeding, colonic necrosis and gastric perforation. The average days of nursing care was 43.3 (3-120). Mortality was 16.4% (10/61 patients). CONCLUSIONS: The number of early operations can be reduced with the use of antibiotic prophylaxis, nasojejunal feeding and percutaneous drainage.     

COPD急性呼衰期肠内外营养支持的研究

目的:探讨慢性阻塞性肺疾病合并急性呼吸衰竭患者行机械通气支持治疗时给予早期肠内营养的优点。方法:32例机械通气患者随机分成早期肠内营养(EN)组和早期完全胃肠外营养(TPN)组，在摄入同等热量、同等氮量的条件下对营养及免疫指标、严重感染发生率、感染持续时间、机械通气时间、住院时间、临床营养及相关费用等指标进行比较，研究期为10天。结果：EN组及TPN组给予营养支持治疗后的营养及免疫指标均高于营养支持治疗前；营养支持治疗后EN组营养及免疫指标均高于TPN组；严重感染发生率、感染持续时间、机械通气时间、住院时间、临床营养及相关费用均低于TPN组。结论：慢性呼吸衰竭急性加重期患者行机械通气支持治疗时早期给予高脂低糖肠内营养疗法(EN)较早期完全胃肠外营养(TPN)能更好地提供营养，提高免疫力，减少并发症，缩短机械通气的时间，降低临床营养及相关费用，值得推广。     

鼻肠管肠内营养在重型颅脑损伤患者中的作用

目的探讨经鼻肠管肠内营养在重型颅脑损伤患者中的应用效果。方法回顾性分析2012年6月至2014年12月中山大学附属第三医院重症医学科收治的54例重型颅脑损伤患者的资料。按照肠内营养方式的不同,分为鼻肠管肠内营养支持组(鼻肠组,26例)和鼻胃管肠内营养支持组(鼻胃组,28例)。在两组患者均于入住重症监护室(ICU)第2天开始给予鼻饲整蛋白制剂(瑞代),观察两组患者达到肠内营养支持目标的时间、肠外营养支持时间、营养指标(白蛋白、血红蛋白等)、入住ICU时间、感染及胃肠道并发症等的发生率。结果 (1)按照体质量计算热卡需求量,鼻肠组较鼻胃组更快达到肠内营养支持目标的时间,分别为(3.0±0.8)d和(7.7±2.5)d,两组差异有统计学意义(P0.01)。鼻肠组较鼻胃组联合肠外营养支持的时间明显缩短,分别为(2.0±0.8)d和(6.7±2.5)d,两组差异有统计学意义(P0.01)。(2)治疗第30天时,鼻肠组的血清总蛋白和血红蛋白水平均高于鼻胃组,分别为(64±6)g/L和(61±6)g/L,(120±17)g/L和(106±16)g/L,差异有统计学意义(P0.05)。(4)鼻肠组较鼻胃组平均ICU住院时间明显缩短,分别为(11±5)d和(14±6)d,两组差异有统计学意义(P0.05)。(4)两组患者肺部感染、高血糖、腹泻等发生率差异均无统计学意义(P0.05)。结论经鼻肠管肠内营养支持能更快达到肠内营养支持目标,缩短入住ICU时间。     

重症急性胰腺炎经胃镜放置空肠营养管营养支持的价值

目的 探讨经胃镜放置空肠营养管行肠内营养支持(ENFTP)对重症急性胰腺炎患者的临床价值.方法 回顾性分析经ENFTP及同期行完全胃肠外营养(TPN)支持的重症急性胰腺炎患者47例及50例,比较两组患者营养支持前及支持后1、2、4周血常规、血糖、肝肾功能、血脂、血钙水平变化、各种并发症发生率、死亡率、营养支持时间、营养支持平均每日费用、机械通气时间、重症监护病房(ICU)监护时间及平均住院时间.结果 营养支持4周后,ENFTP组血红蛋白、白蛋白及空腹高血糖较TPN组恢复显著(P值均<0.05);ENFTP组胰周、胆道感染率、导管感染败血症、营养支持时间、营养支持平均每日费用及住院时间均显著低于TPN组(P值均<0.05),此外ENFTP组能更有效改善APACHEⅡ评分(P<0.05).结论 ENFTP在重症急性胰腺炎患者中应用安全经济.     

Endoscopic fibrin sealing of gastrocutaneous fistulas after sleeve gastrectomy and biliopancreatic diversion with duodenal switch

Background and Aim: Gastrocutaneous fistulas (GCF) are uncommon complications accounting for 0.5–3.9% of gastric operations. When their management is not effective, the mortality rate is high. This study reports the conservative treatment of GCF in morbidly obese patients who underwent biliopancreatic diversion with duodenal switch. Methods: Ninety‐six morbidly obese patients were treated in our department with biliopancreatic diversion with duodenal switch (Marceau technique) and, in six of them, a high‐output GCF developed. A general protocol was applied to all patients presenting a GCF. Everyone was treated by total parenteral nutrition (TPN) and somatostatin for at least 7 days after the appearance of the leak. If the leak continued, then fibrin glue was used as a tissue adhesive. Endoscopic application of the sealant was accomplished under direct vision via a double‐lumen catheter passed through a forward‐viewing gastroscope. Results: All patients were treated successfully with conservative treatment (either solely with TPN and somatostatin, or with endoscopic fibrin sealing sessions). No evidence of fistula was observed at gastroscopy 3 and 24 months after therapy. Conclusion: The conservative treatment of GCF following biliopancreatic diversion with duodenal switch is highly effective. All patients should enter a protocol that includes TPN and somatostatin. When the GCF persist, endoscopic sealing glue should be considered before operation because it is simple, safe, effective and, in some cases, life‐saving. Therefore, conservative treatment should be employed as a therapeutic option in GCF developing after bariatric surgery.     

Supportive nutrition on recovery of metabolism, nutritional state, health-related quality of life, and exercise capacity after major surgery: a randomized study.

BACKGROUND & AIMS: The aim of this study was to investigate whether specialized supportive enteral and parenteral feeding have superior effects compared to oral nutrition on recovery during long-term postoperative treatment of cancer patients with preoperative weight loss and reduced maximum exercise capacity. METHODS: One hundred twenty-six patients referred for resection of the esophagus (n = 48), stomach (n = 28), or pancreas (n = 50) were considered to be included before operation. Included patients (n = 80) received supportive enteral or parenteral nutrition postoperatively at home corresponding to 1000 kcal/d until the patients did not wish to continue with artificial nutrition for any reason. Patients randomized to oral nutrition only served as control subjects. Caloric intake, body composition (dual-energy x-ray absorptiometry), and respiratory gas exchanges at rest and during exercise were measured including health-related quality of life. RESULTS: Survival and hospital stay did not differ among the groups, whereas overall complications were higher on artificial nutrition (P < .05). Changes in resting energy expenditure and biochemical tests did not differ during follow-up among the groups. Body weight and whole body fat declined similarly over time in all groups (P < .005), whereas lean body mass was unchanged during follow-up compared to preoperative values. Maximum exercise capacity and maximum oxygen consumption were normalized within 6 months postoperatively in all groups. There was no difference in recovery of food intake among the groups. Parenteral feeding was associated with the highest rate of nutrition-related complications, whereas enteral feeding reduced quality of life most extensively. CONCLUSION: After major surgery, specialized supportive enteral and parenteral nutrition are not superior to oral nutrition only when guided by a dietitian.     

Early enteral nutrition in severe acute pancreatitis: a prospective randomized controlled trial comparing nasojejunal and nasogastric routes

PURPOSE: Enteral nutrition (EN) is effective, easy to provide, cheaper, and associated with fewer complications in comparison with parenteral nutrition in severe acute pancreatitis (SAP). However, the nasogastric (NG) route for enteral supplements still remains to be established, and most studies have used the nasojejunal (NJ) route. The purpose of this study was to compare early NJ with NG feeding in SAP. PATIENTS AND METHODS: A total of 31 patients with SAP were randomized to feeding by either NG (15 patients) or NJ (16 patients). A semi-elemental formula was used through an enteral tube in both groups. Nutritional parameters (anthropometry, serum prealbumin and albumin levels) were recorded at baseline and after 7 days. Recurrence of pain and tolerance of feeding was noted. RESULTS: Recurrence of pain occurred in only 1 patient each in the 2 groups. Diarrhea occurred in 3 and 4 patients in the NJ and NG groups, respectively. There were 4 deaths in the NJ group and 5 in the NG group. Two patients in the NJ group and 1 in the NG group underwent surgery. There was no difference in the outcome measures (ie, discharge, surgery, and death). There was a decline in nutritional parameters in both groups. CONCLUSIONS: EN at a slow infusion is well tolerated by both NJ and NG routes in patients with SAP. Neither NJ nor NG feeding leads to recurrence or worsening of pain in SAP. Nutritional parameters remained unaffected because of inadequate calorie intake during the first week of feeding.     

Endoscopic nasojejunal feeding tube placement in patients with severe hepatopancreatobiliary diseases:a retrospective study of 184 patients

BACKGROUND:Total parenteral nutrition (TPN) has been recognized as the mainstay of nutritional support in patients with severe hepatopancreatobiliary (HPB) diseases for decades.However,recent studies advocate the utilization of endoscopic nasojejunal feeding tube placement (ENFTP),rather than the conventional approach.This study was designed to compare the clinical value of ENFTP and TPN in patients with severe HPB diseases.METHODS:Two groups of patients with severe HPB diseases were analyzed retrospectivel...     

Restoration of energy level in the early phase of acute pediatric pancreatitis

Acute pancreatitis (AP) is a serious inflammatory disease with rising incidence both in the adult and pediatric populations. It has been shown that mitochondrial injury and energy depletion are the earliest intracellular events in the early phase of AP. Moreover, it has been revealed that restoration of intracellular ATP level restores cellular functions and defends the cells from death. We have recently shown in a systematic review and meta-analysis that early enteral feeding is beneficial in adults; however, no reviews are available concerning the effect of early enteral feeding in pediatric AP. In this minireview, our aim was to systematically analyse the literature on the treatmentof acute pediatric pancreatitis. The preferred reporting items for systematic review(PRISMA-P) were followed, and the question was drafted based on participants, intervention, comparison and outcomes: P: patients under the age of twenty-one suffering from acute pancreatitis; I: early enteral nutrition (per os and nasogastric- or nasojejunal tube started within 48 h); C: nil per os therapy; O: length of hospitalization, need for treatment at an intensive care unit, development of severe AP, lung injury (including lung oedema and pleural effusion), white blood cell count and pain score on admission. Altogether, 632 articles (Pub Med: 131; EMBASE: 501) were found. After detailed screening of eligible papers, five of them met inclusion criteria. Only retrospective clinical trials were available. Due to insufficient information from the authors, it was only possible to address length of hospitalization as an outcome of the study. Our mini-meta-analysis showed that early enteral nutrition significantly(SD = 0.806, P = 0.034) decreases length of hospitalization compared with nil per os diet in acute pediatric pancreatitis. In this minireview, we clearly show that early enteral nutrition, started within 24-48 h, is beneficial in acute pediatric pancreatitis. Prospective studies and better presentation of research are crucially needed to achieve a higher level of evidence.     

Nutritional support in acute pancreatitis

Acute pancreatitis is a catabolic condition requiring adequate nutritional support to avoid severe nitrogen loss. Providing nutrition to the patients with acute pancreatitis is, however, limited by the fact that oral feeding may stimulate the pancreas and aggravate the pancreatitis. Hence, total parenteral nutrition (TPN) is recommended for such patients but that too has limitations apart from its prohibitive cost. At the same time, therefore, enteral feeds have been developed, which provide adequate nutrition and are fairly well tolerated by these patients. Based on the available studies, a rational scheme of managing acute pancreatitis has been recommended. Patients with moderately severe acute pancreatitis who are malnourished or are likely to develop complications requiring surgery should be supported with total parenteral nutrition from an early stage. All patients with severe acute pancreatitis should, on the other hand, be supported with total parenteral nutrition from the beginning, but enteral nutrition via a jejunostomy should be commenced as early as possible since such patients often run a protracted course and giving them TPN might become exorbitantly expensive and impractical. Mixed or polymeric feeds are tolerated well from the sixth or seventh postoperative day but in an occasional patient elemental diet via the jejunostomy may become necessary.     

Perioperative immunonutrition ameliorates the postoperative immune depression in patients with gastrointestinal system cancer (prospective clinical study in 42 patients)

Cancer surgery is a major challenge for patients to develop immune depression in postoperative period. Several cytokines can depress immune cell subpopulations. Increased cytokine response after surgery is assumed to arise mainly from lipooxygenase pathway acting on membrane arachidonic acid. Therefore; investigators focused their efforts to alter the membrane fatty acid profile by changing the nutritional regimen with epsilon-3 fatty acid supplementation and encouraging results were obtained after surgery. Despite the theoretical and clinical advantage of enteral nutrition many surgeons remain committed to parenteral nutrition for feeding of patients due to maintain bowel rest and fear of anastomosis leakage at the postoperative period. Several studies investigating role of the postoperative immunonutrition reported that beneficial immunological changes were associated with reduction of infectious complications. Interestingly; these findings were observed at least five days after the surgery in which the highest incidence of complications was seen. In this prospective study including 42 patients eligible for curative gastric or colon cancer surgery; we investigated the beneficial effect of enteral immunonutrition (EEN) compared to total parenteral hyperalimentation (TPN) beginning from the preoperative period. Cortisol and CRP levels as stress parameters significantly increased one day after surgery in both groups but they rapidly returned to (on POD1) preoperative baseline level in EEN group whereas these values remained high in the TPN group. Additionally a significant decrease in natural killer (NK) cells and CD8+ levels were observed in both groups. However they recovered on POD3 in EEN group and on POD6 in TPN group. CD4+ subset remained almost same as preoperative value in the TPN group whereas it increased from (%) 40.14 to 46.40, 51.29 and 54.7 on PO 6th hr, POD3 and POD6 in the EEN group. Our findings suggest that preoperative nutrition via the enteral route provided better regulation of postoperative immune system restoration than parenteral nutrition. On the basis of our findings we recommend enteral immunonutrition to be started at the preoperative period rather than postoperatively before a major operation whenever the enteral route is feasible.     

Aspirin concurrently administered with ranitidine does not delay healing of duodenal ulcer

Sixty-nine patients with endoscopically diagnosed duodenal ulcer were randomised to either Group I or Group II. Group I patients (n= 35) received tablet ranitidine 150 mg twice daily along with tablet aspirin 600 mg three times a day while Group II patients received only tablet ranitidine 150 mg twice daily. Eight patients (four in each group) dropped out of the trial but were included in the final analysis as failure of treatment. At the end of four weeks 51.4% ulcers healed in Group I compared to 58.8% in Group II. The difference between the two groups was not significant. There was also no statistical difference in the time required for relief of pain, number of patients relieved of pain and the complication rate. It is concluded that aspirin concurrently administered with ranitidine is safe and does not delay the healing of uncomplicated duodenal ulcers.     

Clinical Outcomes Comparing Parenteral and Nasogastric Tube Nutrition After Laryngeal and Pharyngeal Cancer Surgery

Nasogastric tube-assisted enteral feeding and parenteral feeding are utilized for nutritional support after major surgery. Although these nutritional supports have been compared before, there have been no comparative trials following surgery for laryngeal and pharyngeal cancer. In this study, 81 patients were randomized to total parenteral nutrition (TPN) or nasogastric tube nutrition (NGTN) after laryngopharyngeal cancer surgery. The two groups were well-matched demographically and clinically. Clinical outcomes such as time of commencement of oral feeding and hospital stay and complications such as fistula were similar in both groups. One case in the TPN group had catheter-related sepsis, whereas aspiration pneumonia occurred in four cases (9.8%) in the NGTN group. The daily cost of NGTN was $11.81 cheaper than that of TPN. Subjective symptoms of nasal and pharyngeal discomfort and scores on subjective swallowing were more severe in the NGTN group within the first postoperative week but became similar thereafter. Although there was no difference in objective postoperative outcomes between both groups, these results imply that each method had particular advantages and disadvantages. Nutritional support after laryngopharyngeal cancer surgery should be determined after full consideration of each patient’s conditions and surgical details along with economics.     

Nutritional support in acute pancreatitis: an update on management issues

About 20% of acute pancreatitis cases develop necrosis and have a high risk of inflammatory and infectious complications and a high mortality rate. Acute pancreatitis has a variety of causes and despite years of research its pathogenesis remains complex and obscure. Both local and systemic inflammatory responses play key roles in the pathophysiology of this disorder. Treatment plans continue to rely on supportive care without proven specific therapies. Pancreatic rest and use of total parenteral nutrition (TPN) were the gold standard for nutritional support of these challenging patients. Because numerous studies in other critically ill patients demonstrated benefits of enteral nutrition, recent investigations compared TPN to enteral nutrition in acute pancreatitis. These studies indicated that enteral nutrition delivered into the jejunum was tolerated well, even in patients with severe acute pancreatitis. "Mild' cases of pancreatitis should improve and tolerate oral nutrition within a few days. In contrast, "severe' cases of pancreatitis or those with a protracted clinical course require nutritional support to aid in preventing adverse effects of starvation and nutrient deficiencies. Current recommendations are to attempt enteral nutrition in patients with acute pancreatitis prior to instituting TPN. Further studies to determine optimal nutrient composition are warranted and should investigate the possibility of modulating the inflammatory response induced by pancreatitis to improve outcomes.