肝移植后近期并发胃肠道漏营养支持经验

目的探讨肝移植受者术后近期并发胃肠道漏应用三阶梯热量递减方案营养支持的经验。方法 2000年1月至2010年12月中山大学附属第一医院器官移植中心1173例次尸体肝移植中术后近期并发胃肠道漏15例（1.2%）,确诊后给予禁食、腹腔引流、抗感染、手术和营养支持相结合的综合治疗。其中营养支持采用三阶梯热量递减方案。第一阶：禁食状态下使用全营养混合液提供患者每日所需热量。总热量为167～209kJ.kg-1.d-1,其中蛋白质为1.3～1.95g.kg-1.d-1,碳水化合物占总热量的50%～55%,脂肪占总热量的30%～35%,碳水化合物与脂肪热量比约为2：1。第二阶：经口进食流质后直至恢复正常饮食。所给肠外营养的总热量减为125～146kJ.kg-1.d-1,蛋白质为1.0～1.2g.kg-1.d-1;碳水化合物、脂肪所占总热量的比例维持不变。第三阶：患者恢复正常饮食后,继续给予口服肠内营养素（瑞素）500mL/d,持续5～7d。结果 8例康复出院,随访12～48个月,无胃肠道漏再发;感染较重的7例（46.6%）综合治疗后仍死亡。结论肝移植后近期并发胃肠道漏的发生率低,但病死率高。三阶梯热量递减营养支持方案对治愈胃肠道漏有重要作用。

Experience of nutritional support for gastrointestinal fistula after orthotopic liver transplantation

Objective To share an experience of nutritional support for gastrointestinal fistula after orthotopic liver transplantation(OLT).Methods Fifteen liver transplant recipients who were among 1173 patients receiving OLT from January 2000 to December 2010 had gastrointestinal fistula at an early stage postoperation.Thirteen patients were male and 2 were female,from 38 to 59 years old,with a median age of 44.Ten of them had history of abdominal surgeries before OLT.The treatment composed of fasting,drainage from the abdominal cavity,anti-inflammatory,surgical operations,and nutritional support.The nutritional support contained protocol of spiral decrease of calorie with 3 different stages after diagnosis.At the first stage,a total calorie of 167 to 209 kJ·kg-1·d-1 from total nutrition admixture was given while fasting,including protein(1.3-1.95 g·kg-1·d-1),carbohydrate accounting for 50%-55% of total calorie,fat accounting for 30%-35%,with a 2 to 1 ratio of calories from carbohydrate to fat.At the second stage,a total calorie of 125 to 146 kJ·kg-1·d-1 was given from parenteral nutrition,including protein(1.0-1.2 g·kg-1·d-1),with the same ratio of calories from carbohydrate to fat as that at the first stage.At the last stage,enteral nutrition of 500 mL/d was given for 5 to 7 days after resuming normal diet.Results After treatment,8 cases discharged uneventfully with no reoccurrence of gastrointestinal fistula in 12-48 months follow up;other 7 cases(46.6%) with serious infections died.Conclusion The morbidity of gastrointestinal fistula at the early stage after OLT was low,but the mortality was high.The protocol of spiral decrease of calorie with 3 stages was crucial for recovery of gastrointestinal fistula.