ω-3多不饱和脂肪酸对腹部创伤术后应激和肠道功能恢复的影响

Effect ofω-3 polyunsaturated fatty acids on stress and intestinal function recovery after abdominal trauma

目的观察添加ω-3多不饱和脂肪酸(PUFAs)的肠外营养对急性腹部创伤患者的影响。方法前瞻性研究2017年1月—2019年6月陆军军医大学第一附属医院急诊医学科收治的急性腹部创伤患者84例,肝损伤17例、脾损伤30例、单纯十二指肠损伤4例、回肠损伤15例、胰腺合并十二指肠损伤9例、胃合并空肠损伤9例。随机数字表法将上述患者分为脂肪酸组和常规对照组各42例,其中脂肪酸组男性37例,女性5例;平均年龄(39.82±11.43)岁,平均BMI(24.14±2.28)kg/m^(2);常规对照组男性34例,女性8例;平均年龄(40.17±12.38)岁,平均BMI(24.03±1.86)kg/m^(2)。急救手术后两组均给予常规肠外营养支持,脂肪酸组加用ω-3PUFAs乳剂0.2g/(kg·d),连续使用7d。观察两组术前即刻及术后7d血清炎性因子、免疫因子和热休克蛋白70(HSP70)水平,以及血浆D-乳酸、血清肠型脂肪酸结合蛋白(I-FABP)等肠黏膜功能相关指标和术后住院天数、肠鸣音恢复及肛门排气时间等手术相关指标,同时记录两组患者术后2个月内并发症(谵妄、全身炎性症反应综合征、吻合口或残端瘘、手术切口感染、肺炎等)发生情况。结果两组术前白细胞介素-1(IL-1)、白细胞介素-6(IL-6)、肿瘤坏死因子(TNF-α)、转化生长因子(TGF-β)、I-FABP、D-乳酸、HSP70和辅助淋巴细胞计数(CD4+)、T杀伤淋巴细胞计数(CD8+)、CD4+/CD8+比值等指标较术后7d明显较低,差异有统计学意义(P<0.05);两组对比,术前上述所有指标未见显著差异(P>0.05),但术后7d脂肪酸组TGF-β、HSP70、CD4+、CD4+/CD8+水平(54.47±6.08)ng/L、(18.89±0.91)g/L、(39.45±2.43)%、(1.66±0.10)较常规对照组(44.39±5.76)ng/L、(17.13±0.64)g/L、(35.08±2.26)%、(1.45±0.08)更高,而IL-1、IL-6、TNF-α、I-FABP、D-乳酸、CD8+水平(44.02±10.45)ng/L、(18.55±3.37)ng/L、(46.84±6.13)ng/L、(36.70±5.22)μg/L、(17.80±1.75)mg/L、(23.58±1.27)%较常规对照组(58.53±9.67)ng/L、(24.94±3.45)ng/L、(55.44±6.89)ng/L、(41.47±5.35)μg/L、(19.69±1.58)mg/L、(24.25±1.22)%更低,且脂肪酸组术后肠鸣音恢复时间,肛门排气时间及术后住院天数(44.35±8.60)h、(53.24±7.73)h、(10.39±1.65)d等均明显少于常规对照组(54.97±9.44)h、(70.61±8.38)h、(12.43±1.58)d,上述差异均有统计学意义(P<0.05);术后2个月内脂肪酸组并发症总发生率26.2%(11/42)显著低于常规对照组47.6%(20/42),差异有统计学意义(P<0.05)。结论添加ω-3PUFA的肠外营养方式对急性腹部创伤患者具有抑制炎性水平和应激反应、保护肠道黏膜功能和调节免疫功能的作用,能降低手术并发症发生率。

Objective To observe the effect of parenteral nutrition supplemented with omega-3 polyunsaturated fatty acids(PUFAs)on patients with acute abdominal trauma.Methods A prospective study was conducted in 84 patients with acute abdominal trauma admitted to the First Affiliated Hospital of the ArmyMedical University from Jan.2017 to Jun.2019.There were 17 cases of liver injury,30 cases of spleen injury,4 cases of simple duodenal injury,15 cases of ileum injury,9 cases of pancreas combined with duodenal injury,and 9 cases of stomach combined with jejunum injury.The above patients were randomly divided into fatty acid group and control group,with 42 cases in each group.In the fatty acid group,there were 37 males and 5 females,with an average age of(39.82±11.43)years,and an average BMI of(24.14±2.28)kg/m^(2);in the control group,there were 34 males and 8 females,with an average age of(40.17±12.30)years,and an average BMI of(24.03±1.86)kg/m^(2).After emergency surgery,both groups were given conventional parenteral nutrition support,and the fatty acid group was supplemented withω-3PUFAs emulsion 0.2g/(kg·d)for 7 days.The serum levels of inflammatory factors,immune factors and heat shock protein 70(HSP70)immediately before surgery and 7 days after surgery,as well as plasma D-lactic acid,serum intestinal fatty acid binding protein(I-FABP)and other intestinal mucosal functions were observed.Also,postoperative hospital stays,bowel sounds recovery and anal exhaust time and other related surgical indicators were recorded.The complications such as delirium,SIRS,anastomotic or stump fistula,surgical incision infection and pneumonia within 2 months after surgery were recorded.Results The preoperative levels of interleukin-1(IL-1),interleukin-6(IL-6),tumor necrosis factor(TNF-α),transforming growth factor(TGF-β),I-FABP,D-Lactic acid,HSP70,lymphocyte count(CD4+),T-killer lymphocyte count(CD8+),CD4+/CD8+ratio and other indicators were significantly lower than those at 7 days after surgery in both groups,and the difference was statistically significant(P<0.05).There was no significant difference in all the above indexes between the two groups before operation(P>0.05),but TGF-β,HSP70,CD4+,CD4+/CD8+[54.47±6.08)ng/L,(18.89±0.91)g/L,(39.45±2.43)%,(1.66±0.10)]in the fatty acid group at 7 days after operation were higher than those of the control group[(44.39±5.76)ng/L,(17.13±0.64)g/L,(35.08±2.26)%,(1.45±0.08)],while the levels of IL-1,IL-6,TNF-α,I-FABP,D-lactic acid,CD8+[(44.02±10.45)ng/L,(18.55±3.37)ng/L,(46.84±6.13)ng/L,(36.70±5.22)μg/L,(17.80±1.75)mg/L,(23.58±1.27)%]were lower than those of the control group[(58.53±9.67)ng/L,(24.94±3.45)ng/L,(55.44±6.89)ng/L,(41.47±5.35)μg/L,(19.69±1.58)mg/L,(24.25±1.22)%].The postoperative bowel sound recovery time,anal exhaust time and postoperative hospitalization days[(44.35±8.60)hours,(53.24±7.73)hours,(10.39±1.65)days]in the fatty acid group were significantly shorter than those in the control group[(54.97±9.44)hours,(70.61±8.38)hours,(12.43±1.58)days)],with statistically significant differences(P<0.05).The total incidence of complications in the fatty acid group within 2 months after surgery was 26.2%(11/42),which was significantly lower than that of the control group(47.6%,20/42),and the difference was statistically significant(P<0.05).Conclusion The parenteral nutrition supplemented with omega-3PUFA can inhibit the inflammatory level and stress response,protect the intestinal mucosal function and regulate the immune function in patients with acute abdominal trauma,and can reduce the incidence of surgical complications.