结构脂肪乳和中长链脂肪乳对年龄≥70岁胃癌患者全胃切除联合食管空肠Roux-en-Y吻合术后疗效的影响

Effects of structured triglyceride and medium and long chain triglyceride on postoperative efficacies of elderly patients （ ≥ 70 years old） after total gastrectomy for gastric cancer

目的 探讨结构脂肪乳和中长链脂肪乳对年龄≥70岁胃癌患者全胃切除＋食管空肠Roux-en-Y吻合术后疗效的影响。 方法：采用回顾性队列研究方法。收集2014年9月至2015年9月江苏省肿瘤医院收治的42例行全胃切除术＋食管空肠Roux-en-Y吻合术年龄≥70岁胃癌患者的临床病理资料。22例术后肠外营养剂中脂肪乳为结构脂肪乳患者设为试验组，20例术后肠外营养剂中脂肪乳为物理混合的中长链脂肪乳患者设为对照组。两组患者行全胃切除＋食管空肠Roux-en-Y吻合术，试验组患者给予20%结构脂肪乳；对照组患者给予物理混合的20%中长链脂肪乳。观察指标：（1）术后恢复情况：肠道通气时间，术后5 d体质量，术后吻合口瘘、腹腔感染。（2）肝功能指标检测结果：患者分别于术前1 d，术后1、5 d抽取清晨空腹外周血检测肝功能（AST、ALT、TBil、DBil）。（3）营养学指标检测结果：术前1 d，术后1、5 d取清晨空腹外周血检测TP、Alb、前清蛋白。（4）免疫学指标检测结果：术前1 d，术后1、5 d取清晨空腹外周血检测IgG、IgA水平以及CD3、CD4、CD4/CD8比值。正态分布的计量资料以±s表示。重复测量数据采用重复测量的方差分析，计数资料采用x2检验或Fisher确切概率法。 结果：（1）术后恢复情况：两组患者在行肠外营养支持治疗过程中无特殊不良反应。试验组患者术后肠道通气时间、术后5 d体质量、术后吻合口瘘、术后腹腔感染分别为（46±12）h、（60±8）kg、0、0；对照组患者分别为（50±14）h、（58±9）kg、0、1例。两组患者上述指标比较，差异均无统计学意义（t=0.86，0.65，P〉0.05）。（2）肝功能指标检测结果：试验组患者AST、ALT分别由术前的（24±9）U/L和（31±12）U/L变化为术后5 d的（22±6）U/L和（20±8）U/L，对照组患者上述指标分别由术前的（23±8）U/L和（30±9）U/L变化为术后5 d的（30±10）U/L和（32±7）U/L，两组患者的AST、ALT变化趋势比较，差异均有统计学意义（F=92.87，87.92，P〈0.05）；试验组患者TBil和DBil分别由术前1 d的（21±4）μmol/L和（7.0±2.0）μmol/L变化为术后5 d的（19±4）μmol/L和（6.0±2.0）μmol/L，对照组患者上述指标分别由术前1 d的（19±3）μmol/L和（7.0±2.0）μmol/L变化为术后5 d的（20±4）μmol/L和（8.0±3.0）μmol/L，两组患者的变化趋势比较，差异均无统计学意义（F=1.48，0.81，P〉0.05）。（3）营养学指标检测结果：试验组患者TP、Alb由术前1 d的（52±6）g/L和（34±3）g/L变化为术后5 d的（56±5）g/L和（37±4）g/L，对照组患者上述指标分别由术前1 d的（53±7）g/L和（33±3）g/L变化为术后5 d的（52±4）g/L和（31±3）g/L，两组患者TP、Alb指标变化趋势比较，差异均无统计学意义（F=0.47，0.54，P〉0.05）；试验组患者前清蛋白由术前1 d的（230±32）mg/L变化为术后5 d的（245±30）mg/L，对照组患者由术前1 d的（228±28）mg/L变化为术后5 d的（222±26）mg/L，两组患者前清蛋白变化趋势比较，差异均有统计学意义（F=16.81，P〈0.05）。（4）免疫学指标检测结果：试验组患者血清IgG、IgA以及CD3、CD4、CD4/CD8比值术前1 d的（12±4）g/L、（2.20±0.20）g/L、52%±4%、30%±4%、1.30±0.20变化为术后5 d的（18±5）g/L、（2.80±0.30）g/L、59%±4%、33%±4%、1.50±0.20，对照组患者上述指标由术前1 d的（12±3）g/L、（2.10±0.10）g/L、52%±4%、27%±4%、1.30±0.10变化为术后5 d的（13±4）g/L、（2.30±0.20）g/L、51%±4%、26%±4%、1.20±0.20，两组患者血清IgG、IgA以及CD3、CD4、CD4/CD8比值变化趋势比较，差异均有统计学意义（F=25.07，29.42，33.53，22.19，33.47，P〈0.05）。 结论：术后早期、短程使用结构脂肪乳或中长链脂肪乳，均能较好地促进年龄≥70岁胃癌患者术后恢复，而对肝功能的影响较小。使用结构脂肪乳可更好地改善免疫功能和营养状态。

Objective：To investigate the effects of structured triglyceride and long chain triglyceride/medium chain triglyceride （LCT/MCT） on postoperative efficacies of elderly patients （≥70 years old） after total gastrectomy for gastric cancer. Methods：The retrospective cohort study was conducted. The clinical data of 42 elderly patients who underwent total gastrectomy for gastric cancer in the Jiangsu Cancer Hospital between Sepember 2014 and September 2015 were collected. Twenty-two patients using structured triglyceride in postoperative parenteral nutrition and 20 using LCT/MCT in postoperative parenteral nutrition were allocated into the case and control groups, respectively. All the patients underwent total gastrectomy＋Roux-en-Y esophago-jejunostomy. Patients in the case and control groups received respectively 20% structured triglyceride and 20% LCT/MCT. Observation indicators： （1） postoperative recovery situation： time of gut exsufflation, changes of body mass at postoperative 5 days, postoperative anastomotic leakage and abdominal infection; （2） test of liver function indexes： aspartate transaminase （AST）, alanine transaminase （ALT）, total bilirubin （TBil）, direct bilirubin （DBil） of liver function in fasting peripheral blood were tested at preoperative day 1 and at postoperative day 1 and 5; （3） test of nutritional indexes： serum total protein （TP）, albumin （Alb） and prealbumin in fasting peripheral blood were tested at preoperative day 1 and at postoperative day 1 and 5; （4） test of immunological indexes： levels of IgG and IgA, CD3, CD4 and ratios of CD3/CD8 in fasting peripheral blood were tested at preoperative day 1 and at postoperative day 1 and 5. Measurement data with normal distribution were represented as ±s. Repeated measures data were evaluated with the repeated measures ANOVA. Count data were analyzed using the chi-square test and Fisher exact probability. Results：（1） Postoperative recovery situation： there was no special adverse reaction during support treatment of parenteral nutrition. Time of gut exsufflation, changes of body mass at postoperative 5 days, incidences of postoperative anastomotic leakage and abdominal infection were （46±12）hours, （60±8）kg, 0, 0 in the case group and （50±14）hours, （58±9）kg, 0, 1 in the control group, respectively, with no statistically significant difference between the 2 groups （t=0.86, 0.65, P〉0.05）. （2） Test of liver function indexes： levels of AST and ALT from preoperation to postoperative day 5 were respectively from （24±9）U/L to （22±6）U/L, from （31±12）U/L to （20±8）U/L in the case group and from （23±8）U/L to （30±10）U/L, from （30±9）U/L to （32±7）U/L in the control group, respectively, with statistically significant differences between the 2 groups （F=92.87, 87.92, P〈0.05）. Levels of TBil and DBil from postoperative day 1 to postoperative day 5 were respectively from （21±4）μmol/L to （19±4）μmol/L , from （7.0±2.0）μmol/L to （6.0±2.0）μmol/L in the case group and from （19±3）μmol/L to （20±4）μmol/L, from （7.0±2.0）μmol/L to （8.0±3.0）μmol/L in the control group, respectively, with no statistically significant difference between the 2 groups （F=1.48, 0.81, P〉0.05）. （3） Test of nutritional indexes： levels of serum TP and Alb from postoperative day 1 to postoperative day 5 were respectively from （52±6）g/L to （56±5）g/L, from （34±3）g/L to （37±4）g/L in the case group and from （53±7）g/L to （52±4）g/L, from （33±3）g/L to （31±3）g/L in the control group, respectively, with no statistically significant difference in changing trends between the 2 groups （F=0.47, 0.54, P〉0.05）. Levels of prealbumin from postoperative day 1 to postoperative day 5 were respectively from （230±32）mg/L to （245±30）mg/L in the case group and from （228±28）mg/L to （222±26）mg/L in the control group, respectively, with a statistically significant difference in changing trend between the 2 groups （F=16.81, P〈0.05）. （4） Test of immunological indexes： levels of IgG and IgA, CD3, CD4 and ratios of CD4/CD8 from postoperative day 1 to postoperative day 5 were respectively from （12±4）g/L, （2.20±0.20）g/L, 52%±4%, 30%±4%, 1.30±0.20 to （18±5）g/L, （2.80±0.30）g/L, 59%±4%, 33%±4%, 1.50±0.20 in the case group and from （12±3）g/L, （2.10±0.10）g/L, 52%±4%, 27%±4%, 1.30±0.10 to （13±4）g/L, （2.30±0.20）g/L, 51%±4%, 26%±4%, 1.20±0.20 in the control group, respectively, with statistically significant differences in changing trends between the 2 groups （F=25.07, 29.42, 33.53, 22.19, 33.47, P〈0.05）. Conclusions： The short-term usage of structured triglyceride or LCT/MCT in early period after operation can effectively improve postoperative recovery of elderly patients with gastric cancer, with a small impact on liver function. Structured triglyceride can improve immunologic function and nutrition status more effectively.