胃切除加速康复外科围手术期营养相关问题探讨

Perioperative nutrition in patients undergoing gastrectomy with enhanced recovery after surgery

ERAS的核心理念是减少创伤和应激,目的是促进器官功能早期康复、有效改善患者的预后和生活质量。近年来,国内外相关组织及专家共同探索胃切除术ERAS的研究,并先后发布了相关指南和共识,倡导建立由外科医师、麻醉医师、护士等共同参与的规范化管理团队,在遵循循证医学证据的基础上,尊重患者的客观实际,制订个性化的ERAS方案。本文针对ERAS临床实践中争论的焦点问题,如术前与术后营养实施的时机及方案选择、免疫营养制剂及ONS的临床应用等,结合国内外多中心最新的研究进展深入地剖析及总结,得出如下结论:术前有效的营养评估和营养治疗是改善胃癌患者围手术期的营养状况及机体功能的重要内容。应根据患者术前的营养状况水平,选择相应的术前营养治疗方案如口服、ONS、免疫营养疗法、肠外营养或多途径联合营养疗法。术后应尽早恢复经口进食及饮水,尽量减少术后肠麻痹的发生。在患者不能经口进食或经口摄入不足的情况下,通过肠内或肠外途径进行补充。同时,我们详细阐述了本课题组在胃癌切除手术ERAS各阶段营养相关问题的处理措施,旨在促进胃癌患者术后的快速、安全康复,为我国胃癌胃切除手术ERAS在临床实践中广泛地开展提供了重要依据。

The core idea of ERAS is to reduce trauma and stress, its aim is to promote early rehabilitation of organ function and to improve the patient prognosis and the quality of life effectively. In recent years, domestic and foreign relevant organizations and experts who explore the research of gastrectomy and ERAS have released the relevant guidelines and consensus, advocating the establishment of a standardized management team, including surgeon, anesthesiologists and nurses. On the basis of evidence-based medicine, we should respect patients＇ objective reality and work out individualized ERAS program. This paper focuses on the issues of controversy in the ERAS clinical practice, such as the timing of the preoperative and postoperative nutritional implementation, scheme selection and immune nutrition preparation and clinical application of ONS. Combining with the latest research progress at home and abroad that has been thoroughly analyzed and summarized, we came to the following conclusions. Preoperative nutrition assessment and nutritional therapy are important contents for improving perioperative nutrition and body function of gastric cancer patients. According to the preoperative nutrition status of the patients, the corresponding preoperative nutrition treatment plans, such as the oral administration, ONS, immunotherapy, parenteral nutrition or multi-channel combined nutrition therapy, should be selected. After operation, the patients should resume eating and drinking water as soon as possible, to minimize the occurrence of postoperative enteroplegia. For patients with no oral intake or insuffcient oral intake, they can be supplemented through enteral or parenteral pathways. At the same time, this paper elaborates the treatment measures of the nutrition related issues at all stages in the ERAS of gastrectomy, aiming at promoting postoperative gastric cancer patients recover quickly and securely and providing an important basis to carry out ERAS widely in clinical practice for gastrectomy in China.