富含单不饱和脂肪酸的肠外营养对老年肝切除术后患者脂质过氧化肝脏功能及临床结局的影响

Impact of the monounsaturated fatty acid-rich parenteral nutrition on lipid peroxidation, liver function and clinical outcomes in elderly patients undergoing liver resection

目的评价富含单不饱和脂肪酸的肠外营养对老年肝切除手术后患者脂质过氧化反应、免疫功能和临床结局指标的影响。方法采用前瞻、随机、双盲和对照的方法。44例老年患者接受肝切除手术的患者进人本研究；术后2～6d给予全肠外营养，其中葡萄糖3g·kg-1·d-1，脂肪1．2g·kg-1·d-1，氮入量0．2g·kg-1·d-1研究组（22例）肠外营养中应用橄榄油脂肪乳；对照组（22例）给予大豆油长链脂肪乳。检测脂质过氧化指标丙二醛、C反应蛋白（CRP）、白介素-6（IL-6）和肿瘤坏死因子-α（TNF-α）的变化；检测丙氨酸氨基转移酶（ALT）、天门冬氨酸氨基转移酶（AST）、总胆红素（TBIL）和碱性磷酸酶（ALP）以及血浆蛋白（白蛋白和前白蛋白）变化；记录系统性炎症反应综合征（SIRS）和临床结局指标并发症、感染性并发症、住院天数和费用等。结果44例患者均完成研究，无脱落病例。术后接受5d的肠外营养后，将术后7d与术后1d的丙二醛、CRP、IL-6和TNF-α差值结果进行比较，研究组丙二醛的下降幅度为（4．9±1．0）μmol／L，显著多于对照组（4．0±1．3）μmol／L，（P=0．014）；IL-6下降幅度为（33．5±8．4）ng／L，显著多于对照组（28．7±6．3）ng／L（P=0．038）；两组CRP[（34．8±9．2）mg／L比（31．0±6．8）mg／L，P=0．182）]和TNF-α[（30．3±6．2）ng／L比（33．6±8．1）ng／L，P=0．1363的下降幅度相似。白蛋白和前白蛋白术后均出现下降，后逐渐升高，两组变化值差异无统计学意义（P=0．314、0．143）；研究组AST和TBIL降幅优于对照组（P=0．037、0．040）；而ALT和ALP两组间差异统计学意义（P=0．094、0．193）；研究组术后感染性并发症2例，少于对照组5例，（P=0．409）；研究组术后SIRS8例，少于对照组11例，（P=0．362）；总并发症、住院时间和总医疗费用两组结果相似（均P〉0．05）。结论富含单不饱和脂肪酸的肠外营养能改善老年患者肝脏术后的肝脏功能、减轻脂质过氧化及炎症反应，可能减少术后感染并发症。

Objective To evaluate the impact of the monounsaturated fatty acid-rich parenteral nutrition on lipid peroxidation, immunologic function and clinical outcomes in elderly patients undergoing liver resection surgery. Methods A prospective, randomized, double-blind and controlled study of 44 elderly patients undergoing liver resection surgery were conducted. All patients were given total parenteral nutrition with glucose 3 g·kg-1·d-1 , trig[yceride 1.2 g·kg-1·d-1, nitrogen intake0.2 g·kg-1·d-1. 2-6 days after operation, 22 cases in the control group were given soybean oil - based fat emulsion （long-chain fatty acid）, and the other 22 cases in the study group were given olive oil-based fat emulsion. The changes in lipid peroxidation indicator of malondialdehyde （MDA）, inflammation cytokines including C-reactive protein （CRP）, interleukin （IL） - 6 and tumor necrosis factor （TNF）-alpha, liver enzymes including alanine aminotransferase （ALT）, aspartate aminotransferase （AST）, total bilirubin （TBIL） and alkaline phosphatase （ALP） and plasma proteins such as albumin and prealbumin （PA） were observed. The systemic inflammatory response syndrome （SIRS）, clinical outcomes, complications, infections, length of hospitalization and the medical expense were recorded. Results 44 patients completed the trial with no case quitting. Baseline data were comparable between the two groups （all P〈0.05）. After 5 days of parenteral nutrition, the decreases of MDA and IL-6 from POD7 to POD1 were more significant in the study group than in the controlgroupE（4.9±1. 0） vs. （4.0±1. 3）μmol/L, （33. 5±8.4）ng/L w （28.7±6.3）ng/L, P= 0. 014 and 0. 0383. The decreases of CRP and TNF-a from 7 d to 1 d of postoper ation were similar between two groups E（34.8±9.2） vs （31.0±6.8）, （30.3±6.2） w （33.6±8.1）, P=0. 182 and 0. 1363. The mean differences of ALB and PA from POD7 to POD1 were decreased, then increased in the two groups, which had no significant differences between the two groups （P= 0. 314 and 0. 314）. The decreases of AST and TBIL from POD7 to POD1 were higher in the study group than in the control group （P=0. 037 and 0. 040）, but the decreases of ALT and ALP from 7 d to 1 d of postoper ation had no significant difference （P= 0. 094 and 0. 193）. The patients with infectious complications or SIRS were less in the study group than in the control group （2 cases vs. 5 cases, 8 cases v~ 11 cases, P=0. 409 and 0. 362）. Total postoperative complications, hospital stay and total postoperative medical costs had no significant difference between the two groups （all P~ O. 05）. Conclusions Olive oil-based lipid emulsion-supplemented parenteral nutrition？ can improve liver function, alleviate lipid peroxidation and inflammatory reaction, and may reduce postoperative infection complications in elderly patients undergoing liver resection surgery.