婴儿肠吻合术后早期喂养有效性及安全性的随机对照研究

A randomized controlled study on the effectiveness and safety of early feeding after intestinal anastomosis in infants

目的探讨婴儿肠切除和吻合术后早期喂养的有效性及安全性。方法本研究为前瞻性随机对照研究,收集2018年9月至2021年4月深圳市儿童医院胃肠外科、新生儿外科收治的86例行关瘘手术的患儿作为研究对象,其中包括新生儿期因先天性肛门闭锁(congenital anal atresia,CAA)行造瘘手术的患儿(为CAA组)和因新生儿坏死性小肠结肠炎(necrotizing enterocolitis,NEC)行造瘘手术患儿(为NEC组)。将CAA组及NEC组分别按照随机原则划分为早期喂养组(CAA早期喂养组、NEC早期喂养组)及延迟喂养组(CAA延迟喂养组、NEC延迟喂养组)。比较CAA早期喂养组、CAA延迟喂养组与NEC早期喂养组、NEC延迟喂养组患儿的年龄、体重、手术时间、出血量等一般基础信息及术后住院时间、首次肛门排气排便时间、并发症发生率等资料。结果CAA组共44例,其中CAA早期喂养组23例,CAA延迟喂养组21例。CAA早期喂养组较CAA延迟喂养组的平均术后首次肛门排气时间缩短[(2.65±0.65)d比(3.24±0.63)d,t=3.049,P<0.05];术后首次排便时间缩短[(3.17±0.71)d比(4.00±1.00)d,t=3.123,P<0.05];术后住院时间缩短[(8.30±1.66)d比(11.86±3.86)d,t=4.024,P<0.05];平均住院费用减少[15870.68(13536.84,19023.80)元比18001.86(16466.08,23405.25)元,Z=-2.549,P<0.05]。CAA早期喂养组术后发生并发症2例,无一例吻合口瘘发生;CAA延迟喂养组术后发生并发症3例,吻合口瘘1例;两组术后并发症发生率差异无统计学意义(χ2=0.012,P>0.05)。NEC组共42例,其中NEC早期喂养组20例,NEC延迟喂养组22例。NEC早期喂养组较NEC延迟喂养组的术后首次肛门排气时间缩短[(2.45±0.76)d比(3.95±0.72)d,t=6.581,P<0.05];术后首次排便时间缩短[(3.40±0.88)比(4.77±0.42)d,t=6.311,P<0.05];术后住院时间缩短[(9.55±1.67)d比(12.77±2.56)d,t=4.871,P<0.05];住院费用减少[17100.53(14193.25~22249.19)元比25024.26(19887.00~28680.01)元,Z=-3.072,P<0.05]。NEC早期喂养组术后发生并发症1例,无一例吻合口瘘发生;NEC延迟喂养组术后发生并发症4例,吻合口瘘1例;两组术后并发症发生率差异无统计学意义(χ^(2)=0.706,P>0.05);NEC早期喂养组发生喂养不耐受6例,NEC延迟喂养组发生喂养不耐受1例,差异有统计学意义(χ^(2)=4.887,P<0.05)。结论婴儿肠吻合术后早期喂养可缩短住院时间,减少住院费用,且不会增加术后并发症(特别是吻合口瘘)的发生率。因此婴儿行肠吻合术后无需长期禁食,但早期喂养时间应根据患儿具体手术情况制定,以降低术后喂养不耐受的发生率。

Objective To explore the effectiveness and safety of early feeding after intestinal resection and anastomosis in infants.Methods For this prospective randomized controlled study,clinical data were retrospectively reviewed for 86 infants undergoing stoma closure surgery from September 2018 to April 2021.They were assigned into infants with stoma due to congenital anal atresia(CAA)and infants with stoma due to neonatal necrotizing enterocolitis(NEC).And they were randomized into early feeding group(feeding at 24-48 h post-operation,n=20)and delayed feeding group(feeding at Day 5 post-operation,n=22).Age,weight,operation duration,bleeding volume,postoperative hospitalization stay,time to initial flatus/defecation and complication rate were compared between early feeding and delayed feeding groups.Results Forty-four CAA infants underwent colostomy.There were 23 in early feeding group and 21 in delayed feeding group.Mean time to initial postoperative flatus was shorter in early feeding group than that in delayed feeding group[(2.65±0.65)vs.(3.24±0.63)day,t=3.049,P<0.05].Time to initial postoperative defecation was shorter in early feeding group than that in delayed feeding group[(3.17±0.71)vs.(4.00±1.00)day,t=4.024,P<0.05].Average postoperative hospitalization stay became shortened[(8.30±1.66)vs.(11.86±3.86)day,t=4.024,P<0.05];Average hospitalization expense declined[15870.68(13536.84-19023.80)vs.18001.86(16466.08,23405.25)yuan RMB,Z=-3.072,P<0.05].All 42 NEC infants underwent terminal ileostomy.There were 20 in early feeding group and 22 in delayed feeding group;Mean time to initial postoperative flatus was shorter in early feeding group than that in delayed feeding group[(2.45±0.76)vs.(3.95±0.72)day,t=6.581,P<0.05].Time to initial postoperative defecation was shorter in early feeding group than that in delayed feeding group[(3.40±0.88)vs.(4.77±0.42)day,t=6.311,P<0.05].Average postoperative hospitalization stay became shortened[(9.55±1.67)vs.(12.77±2.56)day,t=4.871,P<0.05].Average hospitalization expense decreased[17100.53(14193.25-22249.19)vs.25024.26(19887.00-28680.01)yuan RMB,Z=-3.072,P<0.05].Postoperative complication(n=1)occurred and there was no anastomotic leakage in early feeding group;postoperative complications(n=4)and anastomotic leakage(n=1)in delayed feeding group.Overall incidence of postoperative complications was not statistically significant between two groups(χ^(2)=0.706,P>0.05).Feeding intolerance occurred in early feeding group(n=6)and delayed feeding group(n=1).The difference was statistically significant(χ^(2)=4.887,P<0.05).Conclusion After bowel resection and anastomosis,early feeding can shorten the length of hospitalization stay and lower hospitalization expense.However,it does not increase the incidence of postoperative complications.As a result,long-term postoperative fasting is not required.However,time to start feeding should be formulated according to the specific surgical status of each child so as to lower the incidence of postoperative feeding intolerance.