围手术期营养支持在胰十二指肠切除术病人的临床应用

A clinical study of perioperative nutritional support in patients with pancreaticoduodenectomy

目的:比较胰十二指肠切除术病人围手术期肠内营养(EN)与肠外营养(PN)支持的效果。方法:60例胰十二指肠切除捆绑式胰肠吻合术后病人随机分为全肠内营养(TEN)组和完全胃肠外营养(TPN)两组,每组各30例。手术前3 d开始给予营养支持,TEN组口服百普素,术后24 h内开始经空肠造口管输注;TPN组术前3 d开始经腔静脉置管行PN支持,术后24 h恢复TPN支持,两组营养支持时间均为14 d。结果:两组病人均完成营养支持计划,未发生吻合口瘘和腹腔感染。两组病人术后的体质量、体质指数、上臂周径均较术前略低,但组间比较无显著性差异(P>0.05)。两组病人血清蛋白水平在手术后均有明显下降,TPN组下降更明显,组间比较有显著性意义(P<0.05)。TPN组术后谷酰转肽酶和乳酸脱氢酶高于TEN组。术后监测氮平衡1周,两组均表现为负氮平衡。TEN、TPN组肠功能恢复时间分别为(2.5±0.5)d和(3.0±0.5)d(P<0.05)。术后排便时间分别为(4.0±1.0)d和(6.0±1.0)d(P<0.01)。两组病人住院天数无显著性差异(P>0.05),但TEN组伤口愈合情况优于TPN组(P<0.05),平均住院费用/药物费用TEN、TPN组分别为11 206/4 502元、15 430/7 500元(P<0.05)。结论:对胰十二指肠切除术病人,术前3 d及术后早期行EN,可改善营养状况,降低蛋白质分解,促进肠功能恢复,符合生理需求。

Objective：To compare the effect of perioperative enteral nutrition with parenteral nutrition in patients receiving pancreaticoduodenectomy. Methods： Sixty patients after pancreaticoduodenectomy with binding pancreaticojejunostomy were randomly divided into two groups：TEN group （n = 30） and TPN group （n = 30）. All these patients began nutritional support 3 days before the operation. Peptisorb was given to TEN group patients by mouth before operation and enteral feeding were given via jejunal feeding tube within the first 24 hours postoperatively. Parenteral nutrition were given to TPN group patients by catheterization of superior vena cava before the operation, and TPN was resumed in the first 24 hours postoperatively. All the patients received nutritional support for 14 days. Results： All patients completed the nutritional suppot plan, with no enterocutaneous fistula or abdominal infection. Postopera-tive nutritional indexes changed after the operation, but there were no significant difference between the two groups （P 〉 0.05 ）. Postoperative plasma proteins were also decreased after the operation, and patients in TPN group decreased more obviously, the differences between the two groups were statistically significant （P 〈 0.05 ）. The postoperative γ-GT and LDH in TPN group were higher than TEN group. Both groups showed negative nitrogen balance after the operation. Intestinal movement was （2.5 ± 0.5 ） days in TEN group and （ 3.0 ±0.5 ） days in TPN group （ P 〈 0.05 ） and defecation time was （4.0 ± 1.0） days and （6.0 ± 1.0）days in TEN and TPN group（P 〈0.01）. There was no difference in hospital stay between the two groups （ P 〉 0.05 ）, but wound healing was better in TEN group than TPN group （ P 〈 0.05）. The average cost of hospitalization/drug in TEN and TPN group was 11 206/4 502 yuan and 15 430/7 500 yuan respectively （P 〈 0.05 ）. Conclusion： In patients receiving pancreaticoduodenec- tomy, it is a safe and feasible treatment to give early enteral nutritional support 3 days before operation and resume as early as possible after the operation （in 24 hours）. Both TPN and TEN can improve the nutritional state and reduce protein catabolism. TEN can promote the recovery of GI function, decrease the cost of hospitalization, and improve the liver function.