肝癌合并肝硬化患者术后不同剂型肠内营养的临床效果

Effects of different enteral nutrition formulas in postoperative hepatocarcinoma patients with cirrhosis

目的比较氨基酸型和整蛋白型肠内营养制剂用于肝癌合并肝硬化患者术后营养治疗的临床效果。方法肝癌合并肝硬化术后患者207例，等热量等氮肠内联合肠外营养连续至少5d，按肠内营养剂型分为氨基酸型制剂组（氨基酸为氮源，104例）和整蛋白型制剂组（整蛋白为氮源，103例）。观察肠道通气时间、术后住院时间、腹泻发生率、术后并发症发生率等临床结果，以及电解质、肝功能相关生化指标。结果2组患者术前及术中资料差异无统计学意义（P〉0．05）；氨基酸型制剂组较整蛋白型制剂组腹泻发生率高（23．08％比8．74％，P=0．005），肠道通气时间早[（55．87±10．12）h比（68．27±9．07）h，P=0．000）]；两组患者腹胀发生率（10．58％比13．59，P=0．506）、术后住院时间[（10．30±3．50）d比（10．12±4．26）d，P=0．738]、并发症发生率（43．27％比33．98％，P=0．170）及术后7d钾f（4．02±0．50）mmol/L比（3．98±0．55）mmo]/L，P=0．644]、钠[（136．29±3．55）mmol/L比（136．23±2．74）mmol/L，P=0．913]、丙氨酸氨基转移酶[（90．22±64．29）U/LI比（96．01±59．74）U/L，P=0．556]、天门冬氨酸氨基转移酶[（36．01±19．68）u/L比（39．00±18．88）U/L，P=0．329]、总胆红素[（15．39±8．64）μmol/L比（15．43±8．33）Ixmol/L，P=0．978]差异均无统计学意义（P〉0．05）；氨基酸型制剂组较整蛋白型制剂组白蛋白水平高[（32．87±3．54）g/L比（31．37±3．50）g/L，P=0．008]、前白蛋白水平高[（11．41±4．32）mg/dl比（9．84±3．64）mg/dl，P=0．014]，但凝血酶原时间活动度水平低[（66．94±7．24）s比（70．634-8．49）s，P=0．017）]。结论两种制剂均有利于肝癌合并肝硬化患者术后肝功能恢复，氨基酸型制剂更有助于肠功能恢复和蛋白质合成，整蛋白型制剂肠道耐受性较好并促进凝血功能恢复。

Objective To compare the efficacy of elemental formula （amino acid-based） with polymer ic formula （protein-based） in postoperative hepatocarcinoma patients with cirrhosis. Methods A non-ran domized controlled trial was performed from August 2010 to March 2013. A total of 207 hepatocareinoma pa tients with cirrhosis who had undergone hepatectomy were recruited. Enteral combining parenteral nutritional support was administrated at least 5 days postoperatively, and all the patients were divided into 2 groups accord ing to the enteral nutrition formulas： elemental formula group （amino acid-based, n = 104） and polymeric for mula group （protein-based, n = 103）. The first passage of flatus, hospital stay, incidence of diarrhea, and postoperative morbidity were recorded. The postoperative biochemical indicators were also observed. Results The preoperative characteristics and intraoperative condition of two groups were not significant differences （ P 〉0. 05）. No postoperative mortality happened within 30 days. Compared with polymeric formula group, the ele mental formula group was associated with significantly more diarrhea （23.08% vs. 8.74% , P = 0. 005 ） and earlier first passage of flatus [ （55.87±10.12） h vs. （68.27±9.07） h, P=0.000]. But the 2 groups showed a similar incidence of abdominal distension （ 10. 58% vs. 13. 59, P = 0. 506）. No significant differ ences were found among the two groups in hospital stay [ （10.30±3.50） d vs. （10.12±4.26） d, P= 0. 738 ] or postoperative morbidity （43.27% vs. 33.98% , P = 0. 170） including hepatic insufficiency, infec tion, and ascites. Elemental formula group had a significant higher level of albumin [ （ 32. 87 ± 3.54） g/L vs. （31.37±3.50） g/L, P=0.008） and prealbumin [ （11.41±4.32） mg/dl vs. （9.84±3.64） mg/dl, P =0. 014], but a significantly lower level of prothrombin time activity [ （66. 94 ± 7.24） s vs. （70. 63 ± 8.49） s, P = 0. 017 ] on the 7th postoperative day. No significant difference were found among the two groups regarding serum electrolytes [ K ： （ 4. 02 ± 0. 50 ） mmol/L vs. （ 3.98 ± 0. 55 ） mmo]/L, P = 0. 644 ; Na ： （ 136. 29 ± 3.55） mmol/L vs. （ 136. 23 ± 2. 74） mmot/L, P = 0. 913 ] , aminotransferase [ alanine aminotrans ferase ： （90. 22 ± 64. 29） U/L vs. （96. 01 ± 59. 74） U/L, P = 0. 556 ; aspartate amino transferase ： （ 36.01 ± 19. 68） U/Lvs. （39.00±18.88） U/L, P=0.329]; and total bilirubin [ （15.39±8.64） p.mol/L vs. （ 15.43 ± 8.33 ） Ixmol/L, P = 0. 978 ] on the 7th postoperative day （ P 〉 0. 05 ）. Conclusions Either ele mental formula or polymeric formula is safe and efficacious, but no one has absolute advantage over the other. Elemental formula contributes to earlier recovery of gastrointestinal function and promotes protein synthesis, whereas polymeric formula has better intestinal tolerance and improves coagulation function.