早期肠内营养对重症肝炎肝移植患者术后恢复的影响

Effect of early enteral nutrition on recovery of patients with severe hepatitis after liver transplantation

目的 探讨早期肠内营养对重症肝炎肝移植患者术后恢复的影响.方法 本前瞻性研究对象为2012 年6 月至2014 年4 月在中山大学附属第三医院行同种异体原位肝移植的32 例重症肝炎患者.所有患者均签署知情同意书,符合医学伦理学规定.采用随机数字表法将患者随机分为肠内营养组和肠外营养组.其中肠内营养组14 例,均为男性;平均年龄（42±9）岁.肠外营养组16 例,男14 例,女2 例;平均年龄（44±10）岁.肠内营养组术后1 d 经胃空肠管注入温水、乳果糖,术后2 d开始使用肠内营养混悬液,并逐渐加量至1 000 ml/d,同时逐步减少肠外营养;肠外营养组术后即给予肠外营养,两组均待肠道功能完全恢复后开始正常饮食.分别于术前、术后1、10 d 抽取静脉血检测两组患者肝肾功能.观察患者术后2 周内胃肠道功能恢复情况、肝肾功能及感染发生情况.两组观察指标比较采用t 检验或秩和检验,率的比较采用Fisher 确切概率法.结果 肠内营养组患者术后胃肠道功能恢复时间为（6.1±1.4）d,明显短于肠外营养组的（10.6±3.8）d（t=-4.21,P〈0.05）.肠内营养组患者术后10 d 的ALT、AST、TB、前白蛋白、尿素氮（BUN）中位数分别为106（50～163） U/L、62（27～135） U/L、67（35～116） μmol/L、201（105～389） mg/L、12.5（6.4～18.8）mmol/L,与肠外营养组的276（46～716）U/L、119（33～447）U/L、131（89～391）μmol/L、162（103～238）mg/L、26.1（12.9～37.6）mmol/L 比较差异有统计学意义（Z=-3.76,-3.15,-4.01,2.93,-3.79;P〈0.05）.术后2 周内肠内营养组感染发生率为43%（6/14）,明显低于肠外营养组的69%（11/16）（ P〈0.05）.结论与肠外营养相比,肝移植术后早期肠内营养能促进患者胃肠道功能恢复、改善肝肾功能和营养状态,降低术后感染发生率,有利于术后恢复.

Objective To investigate the effects of early enteral nutrition on the recovery of patients with severe hepatitis after liver transplantation(LT).Methods Thirty-two patientswith severe hepatitis undergoing allogeneic orthotopic LT in the Third Affiliated Hospital of Sun Yat-sen University between June 2012 and April 2014 were included in this prospective study.The informed consents of all patients were obtained and the local ethical committee approval had been received.The patients were randomized into the enteral nutrition group and the parenteral nutrition group according to the random number table method.Among the 14 patients in the enteral nutrition group,all patients were males with the average age of(42±9) years old.Among the 16 patients in the parenteral nutrition group,14 were males and 2 were females with the average age of(44±10) years old.Patients in the enteral nutrition group were given warm water and lactulose through gastro-jejunal tube 1 d after LT.Enteral nutritional suspension was offered 2 d after LT and gradually increased to 1 000 ml/d,meanwhile,parenteral nutrition was reduced gradually.Patients in the parenteral nutrition group were given parenteral nutrition.Patients in both groups started normal diet after full recovery of the intestinal function.Venous blood was collected before LT and 1,10 d after LT to examine hepatic and renal function.The recovery of g a s t r o e n t e r i c f u n c t i o n,h e p a t i c a n d r e n a l f u n c t i o n a n d i n c i d e n c e o f i n f e c t i o n w e r e o b s e r v e d 2 weeks after LT.The comparison of the observed indexes of two groups was conducted using t test or rank-sum test and the rate comparison was conducted using Fisher's exact test.Results The postoperative recovery time of gastroenteric function of the enteral nutrition group was(6.1±1.4) d,which was significantly shorter than(10.6±3.8) of the parenteral nutrition group(t=-4.21,P<0.05).The median ALT,AST,TB,prealbumin and blood urea-nitrogen(BUN) in the enteral nutrition group 10 d after LT were respectively 106(50-163) U/L,62(27-135) U/L,67(35-116) μmol/L,201(105-389) mg/L and 12.5(6.4-18.8) mmol/L,and those in the parenteral nutrition group were respectively 276(46-716) U/L,119(33-447) U/L,131(89-391) μmol/L,162(103-238) mg/L and 26.1(12.9-37.6) mmol/L.Significant difference was observed(Z=-3.76,-3.15,-4.01,2.93,-3.79;P<0.05).The incidence of infection of the enteral nutrition group 2 weeks after LT was 43%(6/14),which was significantly lower than 69%(11/16) of the parenteral nutrition group(P<0.05).Conclusion Compared with parenteral nutrition,early enteral nutrition after LT may promote the recovery of gastroenteric function,improve the hepatic and renal function and nutritional situation and reduce the incidence of postoperative infection,which is beneficial to postoperative recovery.