Immediate enteral nutrition following multisystem trauma: a decade perspective.

Metabolic support is an integral component of surgical critical care. Although prompt restoration of oxygen availability is clearly essential, the timing, composition, and route of nutritional support may also be decisive factors. The ensuing discussion will focus on: (a) timing of substrate delivery and (b) route of administration based on our clinical investigation over the past decade. The acutely injured patient was selected as a model of ICU hypermetabolism because of relative homogeneity with respect to age, comorbid factors, and stress level. Our first study hypothesis was that early nutritional support would improve outcome in the severely injured, but previously well-nourished patient. During an 18-month period, all patients undergoing laparotomy with a abdominal trauma index (ATI) greater than 15 were randomized to a control or total enteral nutrition (TEN) group. The control patients were given total parenteral nutrition (TPN) after POD 5, whereas the TEN cohort had a needle catheter jejunostomy (NCJ) inserted at laparotomy and received an elemental diet within 12 hours. The control (n = 31) and TEN (n = 32) groups were otherwise comparable with respect to risk stratification. The TEN patients, of course, shared improved nitrogen balance (p less than 0.001), but also had significantly (p less than 0.025) less septic morbidity. Nine (29%) of the controls developed major infections, contrasted to three (9%) of the TEN patients. Acknowledging the benefit of early nutrition, the next issue we addressed was the optimal route of substrate delivery; i.e., TEN vs TPN. The hypothesis was that TEN, compared to TPN, would reduce the injury stress response as reflected by the prioritization of hepatic protein synthesis. TEN given via NCJ and a nutritionally matched TPN solution were administered during the same postoperative period. Indeed, the TEN patients (n = 23) had significantly (p less than 0.05) higher constitutive proteins and lower acute-phase proteins, whereas the TPN patients manifested the opposite protein profile as measured by crossed immunoelectrophoresis. In view of these findings, we continued the study to ascertain clinical impact. Ultimately, 75 patients were randomized, providing groups with equivalent risk factors. Eleven (37%) of the TPN patients developed septic complications compared to five (17%) of the TEN group, and the incidence of major infection was six (20%) following TPN vs one (3%) with TEN. Thus, immediate TEN provided an additional clinical benefit compared to early TPN in these high-risk surgical patients.     

消化道肿瘤-T-术后早期肠内营养疗效研究

目的评价消化道肿瘤手术后早期肠内营养的安全性,比较手术后短期应用要素制剂爱伦多的肠内营养与标准肠外营养支持的疗效。 方法62例消化道恶性肿瘤手术患者,随机分为对照组、肠外营养组和肠内营养组。手术后第一天开始等热卡、等氮量的肠外或肠内营养支持一周。检测体重、机体测量指标、血浆各内脏蛋白浓度及氮平衡等营养指标,外周血T细胞亚群、NK细胞和NK细胞活性等免疫指标及血清氨基酸谱。 结果三组病人术后体重下降分别为4．26±1．03ks、2．04±0．65ke和2．12±o．72kg,对照组与肠外营养组、肠内营养组之间差异有显著性(P<0．05),后两组之间无差异。术后各内脏蛋白浓度均低于术前,对照组降低最明显,与肠外或肠内营养组之间差异有显著性(P<0．05),而后两组之间无差异。三组病人平均氮平衡为—8．6±3．12g／d,—4．22±2．02g／d及—3．88±2．35g／d,对照组与肠外或肠内营养组之间差异有显著性(P<0．05),而后两组之间无差异。手术后各组病人外周血T细胞亚群、NK细胞和NK细胞活性均不同程度下降,但三组之间差异无显著性意义。三组病人血清谷氨酰胺水平明显下降,术后1周对照组和肠外营养组血清谷氨酰胺水平仍处于低水平,而肠内营养组却有一定程度恢复。 结论消化道肿瘤手术后早期肠内营养支持是安全、有效的方法,短期肠内营养和肠外营养支持的临床效果基本相同。     

肠外瘘病人肠内营养支持临床应用研究

目的：观察肠内营养在肠外瘘病人应用的时机、条件、途径及肠内营养制品的选择,研究肠内营养在肠外瘘病人中的作用。方法：收集１７０例肠外瘘病人诊断、住院总天数及全肠外营养（ＴＰＮ）、全肠内营养（ＴＥＮ）、肠内＋肠外营养（ＰＮ＋ＥＮ）、经口饮食的天数,计算不同营养支持方法期间,非蛋白质热量、蛋白质的供给量和并发症的发生率。收集ＴＰＮ、ＴＥＮ支持前和支持后满１５天病人的血清白蛋白浓度。另对４０例肠外瘘病人进行为期１５天的前瞻性观察,了解肠内营养对白蛋白、前白蛋白、转铁蛋白、纤维连结蛋白、总蛋白、球蛋白和肝酶谱的影响。结果：１７０例病人的总住院天数为１３５５３天,其中１６４人曾使用ＴＰＮ６０４０天（４４．６％）;１２９人使用ＴＥＮ３６７６天（２７．１％）;８３人使用肠内＋肠外营养４８９天（３．６％）;１２８人经口饮食２３３     

Liver function tests abnormalities in patients with inflammatory bowel disease receiving artificial nutrition: a prospective randomized study of total enteral nutrition vs total parenteral nutrition

Liver and biliary abnormalities are well-known complications of inflammatory bowel disease (IBD). It has been suggested that using total parenteral nutrition (TPN) may further impair liver function in these patients; this seems not to be so with total enteral nutrition (TEN). However, prospective trials comparing the incidence of liver function test (LFT) abnormalities with either TPN or TEN have not been carried out. Twenty-nine IBD inpatients with normal LFT, randomized to receive either TEN with a polymeric diet or isocaloric, isonitrogenous "all-in-one" TPN because of protein-energy malnutrition and/or severe disease, were included in the study. Sixteen patients (five with ulcerative colitis and 11 with Crohn's disease) received TEN, and 13 patients (eight ulcerative colitis and five Crohn's disease) were on TPN. All patients were on systemic steroids, and nine of them were on oral metronidazole. Both groups were homogeneous regarding age, sex, diagnosis, disease activity, nutritional status, daily nutrient supply, and days on artificial nutrition. Serum albumin levels significantly increased with TEN (32 +/- 1 to 38.2 +/- 1.6 g/liter, p less than 0.01), but not with TPN (32.1 +/- 2.2 to 33.9 +/- 1.4 g/liter, NS). Clinical improvement occurred in both groups of patients as shown by the change in the disease activity indexes. In all cases, measurements of serum alkaline phosphatase, serum bilirubin, aspartate aminotransferase, alanine aminotransferase, and gamma-glutamyltransferase were performed weekly. There were no significant differences in the initial LFT between both groups.(ABSTRACT TRUNCATED AT 250 WORDS)     

全肠外营养在腹部外科围手术期的应用体会

目的自1998年12月以来对53例腹部大、中手术的病人,在围手术期辅以全肠外营养支持治疗(TPN)的作用。     

肝胰十二指肠器官簇移植围手术期营养支持疗法探讨

目的探讨肝胰十二指肠器官簇移植围手术营养支持疗法的合理方案。方法我中心自2004年5月至2010年9月共实施了10例肝胰十二指肠器官簇移植手术,其中5例为上腹部肿瘤伴腹腔多发转移病灶患者,行肝脏、胰腺及上消化道全切除术后进行器官簇移植,5例为乙型肝炎后肝硬化失代偿期合并2型糖尿病患者,予以单纯肝切除后行器官簇移植。对这10例患者进行围手术期营养支持疗法,术前经口进食辅以口服营养液改善患者营养状况,术后先给予全肠外营养（total parenteral nutrition,TPN）,后转为肠外联合肠内营养,逐渐过渡至肠内营养（enteralnutrition,EN）。观察患者术后肠道功能恢复情况、患者营养状况、各项实验室指标及并发症情况。结果10例患者手术顺利,术后肝脏、胰腺及十二指肠功能恢复良好。3例患者出现肠瘘,经TPN营养支持,2例死于感染致多器官功能衰竭,1例痊愈;其余7例患者均顺利由TPN过渡至EN,营养状况良好。5例肿瘤患者最长存活326d,3例死于多器官功能衰竭,2例死于肿瘤复发。5例肝硬化合并糖尿病患者除1例于术后4周死于移植物抗宿主病外,其余4例均存活,最长生存时间已超过24个月。结论合理的围手术期营养支持疗法对肝胰十二指肠器官簇移植成功有一定作用。     

全胃切除术后早期肠内肠外营养的对比研究

目的：探讨全胃切除术后早期肠内营养（EEN）与全肠外营养（TPN）对患者营养状况的改善及并发症发生率的影响。方法：将86例接受根治性全胃切除的胃癌患者随机分为EEN组和TPN组。EEN组手术后第1天开始分别给予营养支持,于术前1天、术后8天检测体重、血常规、肝功能、前白蛋白和C-反应蛋白,并观察并发症的发生率和平均住院费用。结果：EEN组体重、白蛋白、前白蛋白下降幅度和白细胞、转氨酶、C-反应蛋白升高幅度均少于TPN组。EEN组患者吻合口瘘、肺部感染、切口愈合不良等并发症发病率低于TPN组。EEN组的平均住院费用低于TPN组。结论：术后EEN较TPN能改善全胃切除术后患者的营养状况,降低并发症发生率,减少经济费用。     

肠内和肠外联合阶段性营养对重症急性胰腺炎患者治疗效果的影响

目的观察肠内和肠外联合阶段性营养对重症急性胰腺炎患者治疗效果的影响。方法重症急性胰腺炎患者45例分为完全胃肠外营养组（TPN组，n=25）和肠内营养加肠外阶段性营养组（PN＋EN组，n=20）。观察两组治疗结果以及临床指标的变化。结果营养支持后PN＋EN组的APACHEⅡ评分和CT评分均显著低于TPN组（P〈0．01）。营养支持两周后两组患者的血糖、血清淀粉酶和血肌酐水平均较营养支持前显著下降（P〈0．01），血清白蛋白、总蛋白、血钙水平均较营养支持前显著升高（P〈0．01），但是两组的各项指标比较无显著性差异（P〉0．05）。PN＋EN组患者的感染并发症发生率显著低于TPN组（P〈0．01），平均住院天数也显著短于TPN组（P〈0．01）。结论肠内和肠外联合阶段性营养支持方式的疗效优于完全胃肠外营养，对重症急性胰腺炎的治疗起了积极作用。     

Perioperative nutrition: parenteral versus enteral

Malnutrition has been shown to have an adverse effect on the clinical outcome of surgical patients. During the past 25 years, investigators have sought to determine whether clinical outcome can be improved by the administration of pre- or postoperative (perioperative) nutritional support. We conclude that the clinical outcome of severely malnourished surgical patients is improved by perioperative nutritional support and that this should be administered whenever possible via the enteral route. The clinical outcome of less severely malnourished surgical patients, including those who are normally nourished, can be improved by the administration of oral dietary supplements at a time in the postoperative period when patients are ingesting free fluids. Some of these patients may also benefit from early postoperative enteral tube feeding, but further work is required to determine the effects following different types of surgery before this is adopted for routine use. Parenteral nutrition is only indicated in the postoperative period when major complications occur in association with intestinal failure.     

急性重症胰腺炎经鼻空肠置管早期肠内营养的疗效观察

目的探讨及评价区域性动脉灌注(RAI)治疗急性重症胰腺炎(SAP)过程中,经鼻空肠置管早期肠内营养的方法及疗效。     

Perioperative nutritional support: a randomised clinical trial

Ever since methods of artificial nutritional support became available, attempts have been made using this form of treatment to reduce mortality and morbidity in surgical patients. Many trials have addressed this question, but very few have given a meaningful answer because of conceptual and methodological flaws. We therefore undertook a prospective randomised trial investigating the effects of at least 10 days pre-operative total parenteral nutrition (TPN) (n = 51) or total enteral nutrition (TEN) (n = 50) providing 150% basal energy expenditure (BEE) non-protein energy, to reduce major postoperative complications and mortality in a homogeneous patient group with signs of depletion. 50 patients served as a depleted control group (D) and 49 patients served as a non-depleted reference group (ND) and were operated upon without delay. Depleted control patients suffered significantly more septic complications than did patients in the non-depleted reference group (p < 0.05). There was no significant difference, however, in septic complications between either of the nutritional support groups and the non-depleted control group. In high risk patients, with weight loss >10% of body weight and over 500 ml blood loss during operation, a significant decrease in major complications was observed (p < 0.05) as a result of nutritional support. We conclude that pre-operative nutritional support, in patients with severe depletion, results in a reduction in major complications to a degree that justifies its routine use in this selected group of patients.     

结肠穿孔致急性腹膜炎病人术后营养支持的临床研究

目的:比较急性结肠穿孔病人术后早期肠内营养(EEN)和全肠外营养(TPN)支持治疗对机体恢复和营养状态的效果,探讨急性结肠穿孔术后合适的营养支持治疗方法。方法:回顾性研究分析60例急诊手术的急性结肠穿孔病人,根据所给予的营养支持治疗方式的不同将所有病人分为EN+PN组和TPN组。对比两组病人的临床治疗效果。结果:EN+PN组治疗效果明显优于TPN组,且差异有显著性统计学意义(P0.05)。结论:结肠穿孔术后EEN支持可改善病人的营养状态,加速病人康复,减少术后并发症。     

Changes in liver function tests in patients with inflammatory bowel disease on enteral nutrition

Morphologic and functional hepatic changes occur in inflammatory bowel disease (IBD). Patients with this disease often require the administration of artificial nutritional support. Liver function tests (LFT) derangement is a widely recognized side-effect of total parenteral nutrition (TPN). Therefore, the use of this modality of nutritional support may be an additional factor to cause hepatic damage in IBD patients. However whether or not the same occurs in patients receiving total enteral nutrition (TEN) is not well-established. The aim of the present study was to evaluate the effect of TEN upon LFT in patients with moderate to severe acute attacks of IBD, by means of a prospective, controlled, and nonrandomized design. Forty-nine patients were included; 29 (11 patients with ulcerative colitis and 18 with Crohn's disease) received TEN, and 20 (11 with ulcerative colitis and 9 with Crohn's disease) did not. Both groups were homogeneous regarding age, sex, disease activity index, nutritional status, and length of the study (24.8 +/- 1.3 vs 23.9 +/- 16.8 days). In all cases, weekly measurements of serum alkaline phosphatase, GOT, and GPT were performed. There were no significant differences in LFT at the beginning of the study between groups. The percentage of patients showing derangement of some LFT during the study did not differ between both groups: six of 29 (20.6%) in TEN group vs three of 20 (15%) in control group. Six out of the nine patients (in both groups) who developed LFT derangement had one or more causes, other than TEN for explaining hepatic dysfunction.(ABSTRACT TRUNCATED AT 250 WORDS)     

Prise en charge nutritionnelle périopératoire en chirurgie de l'adulte

Over the past ten years, perioperative nutritional support has adapted with the preferential use of the oral and enteral route, earlier introduction of the postoperative enteral nutrition, using adapted digestive accesses, and the evidence of the additional benefits provided by the use of perioperative immunonutrition during surgery for cancer. In the case of severe trauma, the use of glutamine-supplemented enteral nutrition provides the best clinical outcome. In the case of postoperative complications handled in the intensive care unit, the nutritional support can also be optimized by the supplementation with glutamine and the use of antioxydant micronutrients. Several meta analysis and cost-effectiveness studies indicate that the intensification and the optimization of the perioperative nutrition, in particular by the use of a pharmaconutrients, favourably influences clinical outcome and can be cost-efficient. Finally, with the new concept of the metabolic conditioning, it appears that even in the absence of malnutrition or major surgery, an immediate preoperative pharmaconutritional conditioning, the reduction of the preoperative fast or a post-operative oral supplementation can significantly improve functional recovery and reduce the rate of post-operative complications.     

食管癌术后早期肠内营养的临床研究

目的 :探讨食管癌术后早期肠内营养的可行性、安全性和临床疗效。　方法 :食管癌病人 4 0例随机分为早期肠内营养组 (EEN)和传统肠内营养组 (TEN) ,每组 2 0例。所有病例在术后第 1、5、9天分别测定血清白蛋白(Alb)、前白蛋白 (PA)、转铁蛋白 (TF)和淋巴细胞计数 (TLC) ,临床观察生命体征、胃肠道功能恢复情况以及各种不良反应。　结果 :所有病人在研究期无死亡 ,无严重并发症 ,无明显肝肾功能改变。EEN组较TEN组PA和TF水平以及外周血TLC都明显升高 (P <0 .0 5 ) ;血清Alb水平未见明显改变 ;肛门排气时间较TEN组早 (P <0 .0 5 )。结论 :食管癌术后早期应用肠内营养支持安全可行 ,既能改善营养状态 ,维护和促进胃肠道功能 ,又能提高机体免疫功能     

Effect of perioperative nutrition, with and without arginine supplementation, on nutritional status, immune function, postoperative morbidity, and survival in severely malnourished head and neck cancer patients

BACKGROUND: Malnourished head and neck cancer patients are at increased risk of postoperative complications. OBJECTIVE: We studied the effect of perioperative, arginine-supplemented nutritional support on nutritional status, immune status, postoperative outcome, and survival in severely malnourished (weight loss >10% of body weight) head and neck cancer patients undergoing major surgery. DESIGN: Forty-nine patients were randomly assigned to receive 1) no preoperative and standard postoperative tube feeding, 2) standard preoperative and postoperative tube feeding, or 3) arginine-supplemented preoperative and postoperative tube feeding. RESULTS: Patients in both prefed groups received approximately 9 d of preoperative tube feeding, resulting in energy intakes of 110% and 113% of calculated needs (compared with 79% in the control group; P = 0.007). Compared with no preoperative feeding, preoperative enteral nutrition did not significantly improve nutritional status or any of the studied biochemical or immunologic indexes. Major postoperative complications occurred in 53%, 47%, and 59% of patients in study groups 1, 2, and 3 (NS). A trend was seen toward better survival in the arginine-supplemented group (P = 0.15). Secondary analysis showed that survivors had better human leukocyte antigen-DR expression on monocytes (P = 0.05) and higher endotoxin-induced cytokine production (P = 0.010 for tumor necrosis factor alpha and P = 0.042 for interleukin 6) at the start of the study than did patients who died. CONCLUSIONS: Nine days of preoperative tube feeding, with or without arginine, did not significantly improve nutritional status, reduce the surgery-induced immune suppression, or affect clinical outcome in severely malnourished head and neck cancer patients. Patients supplemented with arginine-enriched nutrition tended to live longer. Some markers of immune function may distinguish patients with good or bad prognoses.     

重症急性胰腺炎的营养支持治疗

目的：探讨营养支持在重症急性胰腺炎病人治疗中的价值及特点。方法;通过对１７例重症急性胰腺炎营养支持治疗,观察其应用的必要性。采取低热量,高氮量的营养配方,糖脂比例为１：１,热氮比４１８．４（ｋＪ）：１（ｇ）。全肠外营养全部自中心静脉供给。分阶段逐渐由ＴＰＮ过渡到全肠内营养或口服饮食。     

糖预处理联合肠内营养对胃癌手术病人的治疗意义

目的:探讨在围手术期用糖预处理联合EN治疗胃癌病人的临床意义.方法:将胃癌手术病人随机分为三组,即术前常规禁食+术后EN(A组)、术前糖预处理+术后TPN(B组)和术前糖预处理+术后EN(C组).比较三组病人术后胰岛素敏感性、营养状况、免疫水平和临床恢复的差异.结果:C组病人胰岛素敏感性、营养状况、免疫水平和临床恢复等均优于A组和B组,差异有显著性意义(P＜0.05).结论:术前糖预处理和术后EN具有协同作用,对胃癌手术病人的恢复和预后有着积极的治疗意义.     

小肠移植围手术期的营养支持

目的:改进小肠移植围手术期的营养支持方法,并总结3例小肠移植病人的营养支持疗效. 方法:3例病人均接受全小肠移植.病人手术前先接受TPN支持,术后便开始TPN支持.随着移植肠功能的恢复,在对EN支持耐受和有效地维持营养状态的前提下,尽快实现PN向EN过渡,恢复经口进食,并最终摆脱PN支持.应用Gln、甘氨酰谷氨酰二肽和生长激素,以促进移植肠功能的恢复. 结果:3例病人分别于移植术后21、14和24 d摆脱TPN,体质量和血浆ALB水平明显改善. 结论:改进小肠移植围手术期的营养支持方法,能促进移植肠功能恢复,使病人尽快适应EN支持.     

围手术期营养支持在胃肠手术病人中的应用

目的:应用主观全面评价(SGA)法对外科病人进行营养评定,并观察围手术期营养支持对胃肠手术病人的效果.方法:回顾性总结了76例胃肠手术病人,应用SGA法进行营养状况评定,统计各组围手术期营养支持情况,观察围手术期营养支持对病人血红蛋白、清蛋白、前清蛋白、转铁蛋白、纤维连接蛋白等的影响以及手术并发症等情况.结果:应用SGA法评定,34例(44.7%)存在营养不良;与入院时相比,术后血红蛋白明显下降,清蛋白在术后2周内明显下降,前清蛋白在术后2周时明显上升,术后1周转铁蛋白明显下降;各组手术并发症发生率分别为19%、29.6%和14.3%.结论:SGA法可对手术病人进行初步营养评定;围手术期营养支持可改善营养不良的胃肠外科病人的营养状况,但对营养良好的病人效果不明显.