免疫强化肠内营养在老年全胃切除术后患者中的临床应用

Clinical Evaluation of Immune-Enhanced Enteral Nutrition in The Elderly Patients after Total Gastrectomy

目的探讨谷氨酰胺强化肠内营养支持对老年患者全胃切除术后营养及免疫功能的影响。方法选择我院普外科2008年2月至2010年8月期间接受全胃切除术的84例进展期胃癌老年患者作为研究对象,平均分为谷氨酰胺强化肠内营养(Gln)组、肠内营养(EN)组和肠外营养(PN)组。观察肛门排气恢复时间、术后并发症发生率、住院时间等,分别于术前、术后第2和第10天检测血清总蛋白、白蛋白、前白蛋白和转铁蛋白水平,并于术前和术后第10天检测外周血CD4和CD8 T细胞百分数、CD4/CD8以及免疫球蛋白IgM和IgG水平。结果 3组患者均按计划完成治疗。Gln组和EN组患者术后肛门排气时间和住院时间均显著短于PN组(P<0.05)。3组患者术后并发症和消化道症状发生率差异均无统计学意义(P>0.05),仅PN组1例患者在术后6d发生吻合口漏,经引流、抗感染、抑制消化液分泌等治疗后于术后54d痊愈出院。3组患者术前总蛋白、白蛋白、前白蛋白及转铁蛋白水平的差异均无统计学意义(P>0.05),术后第2天各组患者上述各指标均较术前明显下降(P<0.05),但各组之间比较差异无统计学意义(P>0.05);术后第10天时各项指标不同程度恢复,且Gln组和EN组患者术后10d各指标均显著高于术后2d(P<0.05);除转铁蛋白之外,Gln组与EN组患者术后第10天总蛋白、白蛋白、前白蛋白水平明显高于PN组(P<0.05),Gln组与EN组之间比较差异无统计学意义(P>0.05)。术前3组患者各项免疫学指标之间的差异无统计学意义(P>0.05);术后第10天Gln组患者CD4和CD8T细胞百分数、CD4/CD8比值以及血清IgM和IgG水平均已基本恢复甚至略超过术前水平,且除IgM以外均明显高于EN组和PN组相应结果(P<0.05);术后第10天EN组和PN组各项指标除EN组IgG以外仍明显低于术前水平(P<0.05)。结论老年胃癌患者行全胃切除术后早期应用谷氨酰胺强化肠内营养是安全可行的。在恢复和改善营养及免疫功能同时,可更好地促进患者术后恢复、缩短住院时间,是此类患者术后营养支持治疗的最佳选择之一。

Objective To evaluate the effect of glutamine-enhanced enteral nutritional support on elder patients after total gastrectomy.Methods A total of eighty-four cases of elder patients receiving total gastrectomy were included in this study from February 2008 to August 2010.The patients were randomly divided into three groups： glutamine-enhanced enteral nutrition（Gln） group,enteral nutrition（EN） group and parenteral nutrition（PN） group.The complications and hospital stay after operation were compared,and the levels of serum total protein,albumin,proalbumin,and transferrin of patients were measured before operation,on 2 d and 10 d after operation,respectively.Furthermore,the percentage of CD4 and CD8 T cells,CD4/CD8 ratio,and the levels of serum IgM and IgG of patients in peripheral blood before and after operation were detected.Results Nutritional therapy was successfully performed in patients of three groups.The anal exhaust time and hospital stay after operation of patients in Gln group and EN group were significantly lower than those in PN group（P0.05）.The difference of postoperative complications and digestive tract symptoms of patients in three groups was not obvious（P0.05）.Anastomotic fistula occurred in one patient of PN group on 6 d after operation and was cured by conservative treatment for 54 d.The difference of total protein,albumin,proalbumin,and transferrin levels of patients in three groups before operation was not significant（P0.05）,and these indexes fell dramatically on 2 d after operation and lower than before operation（P0.05）,although the inter-group difference was not statistically significant（P0.05）.On 10 d after operation,all indexes recovered in different extent,while those data in Gln group and EN group were significantly higher than those on 2 d after operation（P0.05）.The levels of total protein,albumin,and proalbumin of patients in Gln group and EN group were markedly higher than those in PN group（P0.05）,although there was no difference between the former groups（P0.05）.The difference of several immunological parameters of patients in three groups before operation was not significant（P0.05）.On 10 d after operation,the percentage of CD4 and CD8 T cells,CD4/CD8 ratio,and the levels of serum IgM and IgG of patients in Gln group returned and even exceeded the preoperative results,which were significantly higher than those in EN group and PN group other than IgM（P0.05）.The postoperative results of all parameters except IgG in EN group were significantly lower than preoperative results in patients of EN group and PN group（P0.05）.Conclusions It is safe and feasible to elder patients who had received total gastrectomy and perioperative glutamine-enhanced nutritional support,which can improve nutrition and immune status,promote the recovery and reduce the duration of hospital stay,and nutritiional support after total gastrectomy is one of the optimal choices for these patients.