三种不同营养支持方式对急性重症胰腺炎的疗效评估

Evaluation of three different nutritional supports in patients with severe acute pancreatitis

目的探讨不同营养支持方式对重症急性胰腺炎（SAP）的治疗效果。方法将SAP患者分为肠内营养对照组（EN组）、肠外营养组（TPN组）和肠内联合肠外营养组（EN＋TPN组）。三组均给予常规治疗，EN组在此基础上通过鼻空肠管给予早期肠内营养，TPN组在此基础上静脉给予卡文，EN＋TPN组在肠内营养支持的同时加用肠外营养。比较入院时及入院后7、14、21天各组急性生理与慢性健康（APACHE）Ⅱ评分、Ranson评分、腹内压（IAP）、白蛋白、总胆红素、白细胞（WBC）计数、C-反应蛋白（CRP）和血清淀粉酶的变化。于出院时比较各组的多脏器功能不全（MODS）和死亡例数、平均住院时间及并发症发生例数。结果入院后7天，TPN组和EN＋TPN组的Ranson评分与同期EN组相比均升高，差异有统计学意义（P〈0．05）。人院后14天和21天，TPN组和EN＋TPN组的APACHEⅡ评分、Ranson评分、IAP值、总胆红素和CRP水平与同期EN组相比均更高，白蛋白水平均降低，差异均有统计学意义（P〈0．05或P〈0．01）。出院时，与EN组相比，TPN组及EN＋TPN组的MODS和死亡例数均增加，平均住院时间延长，消化道出血、胰周感染的发生例数增加，但腹胀、返流和误吸的发生例数降低，差异均有统计学意义（P〈0．05或P〈0．01）。EN组患者中，65岁以上者出现并发症的人数多于65岁以下者，男女之间的差异无统计学意义。结论给予早期肠内营养可以显著改善SAP患者的营养状况，缩短病程，降低MODS发生率、病死率，但有腹胀及返流风险。

Objective To assess the effectiveness of different nutritional supports in patients with severe acute pan- creatitis （SAP）. Methods SAP patients were divided into three groups： an enteral nutrition group （Group EN group）, a parenteral nutrition group （ Group TPN） and a combined enteral and parenteral nutrition group （ Group EN ＋ TPN）. Three groups were given routine therapy of pancreatitis. Meanwhile, patients in Group EN also enterally received nutri- ents at early stage through a nasal jejunal tube. Those in Group TPN were intravenously injected with Kabiven？. Group EN ＋ TPN underwent both enteral nutrition support and Kabiven injection simultaneously. Then, all groups were com- pared for the changes of APACHE II score, Ranson score, intra- abdominal pressure （IAP）, albumin, total bilirubin, white blood cell （WBC） count, C -reactive protein （CRP） and serum amylase immediately after admission and 7, 14 and 21 days after admission. The number of patients with MODS and complications were recorded, while the mortality and average duration of hospitalization were observed. Results Seven days after admission, Groups TPN and EN ＋ TPN presented remarkably increased Ranson scores than Group EN at the same period （ P 〈 0.05 ）. Then, 14 and 21 days af- ter admission, compared with Group EN, marked increases in APACHE II score, Ranson score, IAP, total bilirubin and C -reactive protein （CRP） as well as decreases in albumin level were found in Groups TPN and EN ＋ TPN （P 〈 0.05 or P 〈 0.01 ）. Before discharge, Groups TPN and EN ＋ TPN reported extended average duration of hospitalization as well assignificantly more MODS, death, gastrointestinal bleeding and peripancreatic infection but less abdominal distension and regurgitation （P 〈 0.05 or P 〈 0.01 ）. Among patients in Group EN, those beyond 65 years old manifested more compli- cations than those below 65 years old, and the incidence of complications were not related with gender. Conclusion Early enteral nutrition can significantly improve the condition of SAP patients, shorten disease course and reduce MODS rate and mortality. However, the risk of abdominal distension and regurgitation may exist.