不同营养支持方式对食管切除术后体液免疫及结局的影响

Effect of different nutritional support modes on humoral immunity and outcomes after esophagectomy

目的探讨不同营养支持方式对食管切除术后体液免疫及结局的影响。方法46例行Ivor．Lewis食管切除术的食管鳞癌患者按抽签随机法分为肠内营养（EN）组和肠内＋肠外营养（EN＋PN）组，于术前1d、术后第18小时、术后第3、7天检测血清免疫球蛋白IgG、IgA、IgM、IgE、K和入轻链、补体C3、C4的含量。比较两组围手术期感染相关性并发症及住院时间。结果手术前后各时点两组患者血清中IgG、IgA、IgM、IgE、K和入轻链、补体c3、C4的含量差异均无统计学意义（均P〉0．05）。术后18h、术后第3天EN和EN＋PN组IgG[（8．90±1．75）、（7．53±1．41）g／L和（8．64±2．44）、（7．48±2．16）g／L]、K轻链[（2．14±0．46）、（1．78±0．41）g／L和（2．15±0．63）、（1．86±0．62）g／L]和入轻链[（1．34±0．45）、（1．11±0．31）g／L和（1．20±0．32）、（1．08±0．35）g／L]的含量均较术前1d[（12．15±2．86）和（11．11±2．96）g／L、（2．90±0．77）和（2．77±0．79）g／L、（1．79±0．57）和（1．56±0．41）g／L]明显降低（P=0．000，P=0．000；P=0．004，P=0．000；P=0．000，P=0．000；P=0．011，P=0．000；P=0．004，P=0．000；P=0．008，P=0．000），除EN组患者中K轻链术后第7天[（2．42±0．69）g／L]仍明显低于术前[（2．90±0．77）g／L]（P=0．027）外，其他指标均在术后第7天接近术前水平（均P〉0．05）；在手术前后各时点，两组患者血清中IgA、IgE和C3的含量差异均无统计学意义（均P〉0．05）；EN组患者血清中IgM的含量手术前后各时点差异无统计学意义（P〉0．05），EN＋PN组患者术后第3天[（1．00±0．53）g／L]明显低于术前[（1．47±0．76）s／L]（P=0．031），其余各时点与术前相比差异无统计学意义（均P〉0．05）；EN组患者血清中C4的含量在术后18h[（0．24±0．08）g/L]明显低于术前[（0．37±0．36）g／L]（P=0．030），其余各时点与术前比较差异均无统计学意义（均P〉0．05），而EN＋PN组患者手术前后各时点差异均无统计学意义（P〉0．05）。两组患者感染相关性并发症发生率和住院时间的差异均无统计学意义（P=0．300，P=0．371）。结论EN和EN＋PN支持方式对食管切除术后体液免疫及结局的影响无差异。两种营养支持方式均不能完全改善术后体液免疫损害，EN方式更经济。

Objective To explore the effect of different nutritional support mdoes on humoral immunity and outcomes after esophagectomy in patients with esophageal carcinoma. Methods Forty-six patients with middle or low thoracic esophageal carcinoma underwent Ivor Lewis esophagectomy. The patients were randomized into en- teral nutrition group （ EN, n = 23 ） and enteral combined parenteral nutrition group （ EN ＋ PN, n = 23 ） based on the nutrition support modes. Serum levels of immunoglobulin （IgG, IgA, IgM, IgE, κ/λ. light chain） and complements （C3/CA） were assayed and compared on the 1st pre-operative day and at 18 hours as well as 3rd and 7th day after operation. The clinical outcomes including infection-related complications and hospital stay were com- pared between two groups. Results There was no significant difference in all humoral immunity indicators between two groups at the each pest-operative time peinL In beth two groups, the levels of IgG [ （ 8.90 ±1.75 ）, （ 7.53 ± 1.41） g/Land （8.64±2.44）, （7.48 ±2. 16） g/L], K [ （2. 14±0.46）, （1.78 ±0.41） g/L, and （2. 15 ±0.63）, （1.86±0.62） g/L] and k light chain [ （1.34±0.45）, （1.11±0.31） g/Land （1.20±0.32）, （ 1.08 ± 0. 35 ） g/L] were significantly lower 18 hours and 3rd day after operation than the pre-operative levels [ （12. 15 ±2.86） and （11.11±2.96） g/L, （2.90 ±0.77） and （2.77 ±0.79） g/L, （1.79 ±0.57） and （1.56±0.41） g/L] （P=0. 000, P=0. 000, and P=0.004, P=0. 000, and P=0. 000, P=0.000, and P= 0. 011, P = 0. 000, and P = 0. 004, P = 0. 000, and P = 0. 008, P = 0. 000 ）, and returned to the preoperative levels by the postoperative 7th day （P〉0. 05）, except for the level of K light chain 7th day after operation in EN group [ （2.42 ±0. 69） g/L] （P =0. 027）. The levels of IgA, IgE, and C3 were not significantly different during the perioperative period （ P 〉 0. 05 ）. The level of IgM was not significantly different during the perioperative period in EN group （P 〉 0. 05 ）, and was significantly lower on the 3rd pest-operative day [ （ 1.00±0.53 ） g/L] than the pre-operative level [ （ 1.47 ±0. 76） g/L] in the EN ＋ PN group （P =0. 031 ）, and were not significantly different on the other time points （P 〉 0.05 ）. In the EN group, the C4 level was significandy lower at the postopera- tive 18 hours [ （0. 24 ~0. 08） g/L] than the pre-operative level [ （0. 37 ~0. 36） g/L] （P =0. 030）, and were not significantly different at the other time points （ P 〉 0. 05 ）. In the EN ＋ PN group, the C4 level was not signifi- cantly different during the perioperative period （ P 〉 0. 05 ）. There was no significant difference in the infection-re- lated complications and hospital stay between these two groups （ P = 0. 300, P = 0. 371 ）. Conclusions The effects of EN or EN ＋ PN on humoral immunity and outcomes after esophagectomy in patients with esophageal carcinoma are not different. Both these two nutritional support modes can not completely alleviate the harm to the humor- al immunity. The EN is more cost-effective.