加速康复外科围术期营养管理对胃切除术后肠黏膜屏障的影响

目的: 探讨加速康复外科(enhanced recovery after surgery,ERAS)围术期营养管理对胃切除术后肠黏膜屏障的影响。方法: 选择22例胃癌胃切除术患者实施ERAS围术期营养管理(ERAS组)，另选择20例胃癌胃切除术患者按传统围术期营养管理(传统组)，比较两组患者术前及术后1、3、5 d血浆中二胺氧化酶(DAO)、D-乳酸及肠脂肪酸结合蛋白(IFABP)水平。同时建立SD大鼠胃切除术模型，其中20只按ERAS围术期营养管理模式并行肠内营养(ERAS组)，20只实施传统围术期营养管理模式并行肠外营养(传统组)，并以10只大鼠作对照(对照组)；于术后24、72 h每组各处死10只，比较各组回肠标本的肠黏膜病理评分及肠黏膜超微结构变化。结果： 两组患者术后1 d血浆DAO、D-乳酸及IFABP水平均明显高于术前(P均<0.01)。与传统组相比，ERAS组术后1、3、5 d DAO水平，术后3、5 d D-乳酸水平，术后1、3 d血浆IFABP水平均明显降低(P<0.01或0.05)。动物实验显示，ERAS组术后24、72 h肠黏膜病理评分均明显低于传统组(P均<0.05)，肠上皮细胞超微结构损伤程度较传统大鼠减轻。结论： 胃切除术可导致肠屏障结构及功能受损，实施ERAS围术期营养管理可促进肠屏障结构及功能较早恢复。

Effect of perioperative nutrition management of enhanced recovery after surgery on intestinal mucosa barrier after gastrectomy

Objective: To investigate the effect of perioperative nutrition management of enhanced recovery after surgery (ERAS) on the intestinal barrier after gastrectomy. Methods: Twenty-two patients with gastric cancer and gastrectomy were treated with perioperative nutrition management according to the ERAS protocol (ERAS group), while 20 cases were only given traditional nutrition management(traditional group). Plasma diamine oxidase (DAO), D-lactic acid (D-LA), and intestinal fatty acid binding protein (IFABP) levels before operation and on the 1st, 3rd and 5th postoperative day were compared between the two groups. In addition, the gastrectomy model of SD rat was established, in which 20 rats underwent perioperative nutrition management according to the ERAS protocol by the enteral route (ERAS group), while the other 20 rats were given traditional perioperative nutrition management by the parenteral route (tradition group), and 10 normal rats were used as control group. Ileal specimens of 10 rats in each group were harvested at 24 h and 72 h after operation, and the pathological scores and microstructures of intestinal mucosa in each group were compared. Results: The plasma DAO, D-lactic acid and IFABP levels of the two group patients on the 1st postoperative day were significantly higher than preoperative level (P<0.01). Compared with the tradition group, in the ERAS group, the DAO level at 1st, 3rd and 5th postoperative day, the D-lactic acid level at 3rd and 5th postoperative day, and the plasma IFABP level on the 1st and 3rd postoperative day were all significantly reduced (P<0.01 or 0.05). Animal experiments showed that pathological scores of intestinal mucosa in the ERAS group were lower than those in the tradition group at 24 h and 72 h after surgery(P<0.05), and ERAS group had less ultrastructural damage of the intestinal epithelial cells compared with the tradition group. Conclusion: Gastrectomy could cause damage to the structure and function of intestinal barrier. The implementation of perioperative nutrition management of ERAS may promote the earlier recovery of structure and function of intestinal barrier.［Key words］enhanced recovery after surgery; nutrition management; gastrectomy; intestinal barrier; diamine oxidase; D-lactic acid; intestinal fatty acid binding protein