补充性肠外营养对食管癌患者术后营养状态、免疫功能和炎症反应的影响

Effects of supplemental parenteral nutrition on the postoperative nutritional status, immune function, and inflammatory response in patients with esophageal cancer after operation

目的探讨补充性肠外营养对食管癌患者术后营养状态、免疫功能和炎症反应的影响。方法选取2018年6月至2020年6月于莆田学院附属医院胸心外科就诊的72例食管癌患者进行前瞻性研究。按新药数据统计处理软件随机表随机分为试验组(补充性肠外营养组)和对照组(完全肠内营养组),每组36例。试验组,术后第1天开始,予以肠内营养,术后第4~8天,予以肠内营养+肠外营养。对照组,术后第1天,开始予以肠内营养。对比两组患者围手术期营养状态、免疫功能和炎症指标的变化。不符合正态性标准的计量资料进行Mann-Whitney U检验,符合正态性标准的计量资料组间比较采用t检验。营养指标、炎症指标和免疫指标采用重复测量方差分析。计数资料中,等级分类资料进行Mann-Whitney U检验,无序多分类资料采用χ^(2)检验进行分析。结果术后第1天,试验组和对照组患者的前白蛋白浓度[(95.34±37.93)mg/L与(81.60±37.68)mg/L]较术前[(144.86±46.79)mg/L与(130.39±50.91)mg/L]降低,差异均有统计学意义(均P<0.05),两组间比较差异无统计学意义(均P>0.05);试验组和对照组免疫球蛋白(immunoglobulin,Ig)A[(0.48±0.39)g/L与(0.41±0.30)g/L]、IgG[(4.21±3.44)g/L与(4.08±2.98)g/L]、IgM[(0.32±0.26)g/L与(0.30±0.27)g/L]较术前[(0.55±0.45)g/L与(0.47±0.39)g/L、(5.16±3.36)g/L与(5.48±3.30)g/L、(0.38±0.32)g/L与(0.35±0.30)g/L]降低,差异均无统计学意义(均P>0.05),两组间比较差异均无统计学意义(均P>0.05);试验组和对照组CD3[(31.75±11.81)%与(28.03±9.30)%]较术前[(40.86±12.50)%与(42.31±8.09)%]降低、CD4[(14.19±5.39)%与(16.06±9.08)%]较术前[(21.69±8.54)%与(24.11±12.09)%]降低、CD4/CD8[(0.24±0.09)与(0.29±0.18)]较术前[(0.42±0.16)与(0.50±0.28)]降低,CD8[(59.03±8.14)%与(56.39±7.42)%]较术前[(51.25±6.64)%与(49.14±6.53)%]升高,差异均有统计学意义(均P<0.05);两组C3、C4和C反应蛋白(C reactive protein,CRP)与术前比较差异均无统计学意义(均P>0.05),两组间比较差异均无统计学意义(均P>0.05)。术后第7天,试验组前白蛋白浓度[(186.70±40.88)mg/L]较术前和术后第1 d升高,差异均有统计学意义(均P<0.05),高于对照组[(131.62±53.37)mg/L],差异有统计学意义(P<0.05);对照组前白蛋白浓度[(131.62±53.37)mg/L]较术后第1 d升高,差异有统计学意义(P<0.05);试验组IgA[(0.88±0.42)g/L]、IgG[(10.70±4.39)g/L]较术前升高,差异均有统计学意义(均P<0.05),较术后第1 d升高,差异均有统计学意义(均P<0.05),低于对照组[(0.59±0.44)g/L、(4.08±2.98)g/L],差异有统计学意义(均P<0.05);试验组CD3[(45.92±14.31)%]、CD4[(27.06±10.53)%]、CD4/CD8(0.66±0.33)较术后第1 d升高,CD8[(43.64±11.34)%]较术后第1 d降低,差异均有统计学意义(均P<0.05),其中CD4和CD4/CD8升高水平,与对照组比较差异均有统计学意义(均P<0.05)。术后第7 d试验组CRP[(8.90±7.56)mg/L]较术前和术后第1 d降低,差异均有统计学意义(均P<0.05),低于对照组[(16.24±13.53)mg/L],差异有统计学意义(P<0.05)。试验组术后肺部感染发生率[22.22%(8/36)]、吻合口瘘发生率[5.56%(2/36)]、术后住院时间[(14.17±4.79)d]低于对照组[44.44%(16/36)、25.00%(9/36)、(18.47±6.34)d],试验组住院总费用[(71261.94±11503.50)元]高于对照组[(65226.81±10106.43)元],差异均有统计学意义(统计量值分别为χ^(2)=4.00、χ^(2)=5.26、t=3.74、t=2.37;P值分别为0.046、0.022、<0.001、0.021)。结论围手术期食管癌患者予以补充性肠外营养能有效地维持营养状态、改善免疫功能和减轻炎症应激反应及预后。

Objective To investigate the effects of supplemental parenteral nutrition on postoperative nutritional status,immune function and inflammatory response in patients with esophageal cancer after operation.Methods A prospective study was performed on 72 patients with esophageal cancer who visited the Department of Thoracic and Cardiovascular Surgery of the Affiliated Hospital of Putian University from June 2018 to June 2020.According to the random table of new drug data statistics and processing software,they were randomly divided into experimental group(supplementary parenteral nutrition group)and the control group(complete enteral nutrition group),with 36 cases in each group.The experimental group was given enteral nutrition(EN)from the first day after operation,and EN and parenteral nutrition(PN)was given on the 4th to 8th day after operation.In the control group,EN was started on the first day after operation.The changes of nutritional status,immune function and inflammatory indexes in the perioperative period were compared between the two groups.Mann-Whitney U test was used for measurement data that did not meet the normality standard,and t test was used to compare measurement data that met the normality standard between groups.Nutrition indicators,inflammatory indicators and immune indicators used repeated measures analysis of variance.For enumeration data,Mann-Whitney U test was used for hierarchical classification data,andχ^(2) test was used for unordered multi-classification data.Results On the 1st day after operation,the prealbumin concentration((95.34±37.93)mg/L and(81.60±37.68)mg/L)in the experimental group and the control group was significantly higher than that before the operation((144.86±46.79)mg/L and(130.39±50.91)mg/L),and the differences were statistically significant(all P<0.001),and there was no significant difference between the two groups(all P>0.05).Immunoglobulin(Ig)A((0.48±0.39)g/L and(0.41±0.30)g/L),IgG((4.21±3.44)g/L and(4.08±2.98)g/L),IgM((0.32±0.26)g/L and(0.30±0.27)g/L)in the experimental group and the control group were compared with preoperative((0.55±0.45)g/L and(0.47±0.39)g/L,(5.16±3.36)g/L and(5.48±3.30)g/L,(0.38±0.32)g/L and(0.35±0.30)g/L),and the difference was not statistically significant(all P>0.05),and there was no significant difference between the two groups(all P>0.05).In the experimental group and the control group,CD3((31.75±11.81)%and(28.03±9.30)%)were lower than those before operation((40.86±12.50)%and(42.31±8.09)%),CD4((14.19±5.39)%and(16.06±9.08)%)were lower than those before operation((21.69±8.54)%and(24.11±12.09)%),CD4/CD8((0.24±0.09)and(0.29±0.18))were lower than those before operation((0.42±0.16)and(0.50±0.28)),and CD8((59.03±8.14)%and(56.39±7.42)%)were lower than those before operation((51.25±6.64)%and(49.14±6.53)%),the differences were statistically significant(all P<0.05).There was no significant difference in C3,C4 and C reactive protein(CRP)compared with preoperatively(all P>0.05),and there was no significant difference between the two groups(all P>0.05).On the 7th day after operation,the prealbumin concentration((186.70±40.88)mg/L)in the experimental group was higher than that before operation and on the 1st day after operation,and the difference was statistically significant(all P<0.05),which was higher than that in the control group((131.62±53.37)mg/L),the difference was statistically significant(all P<0.05);the prealbumin concentration in the control group((131.62±53.37)mg/L)was higher than that on the 1st day after operation,and the difference was statistically significant(all P<0.05).IgA((0.88±0.42)g/L),IgG((10.70±4.39)g/L)in the experimental group was higher than that before operation,and the difference was statistically significant(all P<0.05),and it was higher than that on the 1st day after operation,and the difference was statistically significant(all P<0.05),lower than those in the control group((0.59±0.44)g/L and(4.08±2.98)g/L),the difference was statistically significant(all P<0.05).In the test group,CD3((45.92±14.31)%),CD4((27.06±10.53)%),CD4/CD8(0.66±0.33)increased and and CD8(43.64±11.34%)decreased compared with the first day after operation,with statistically significant differences(all P<0.05).The elevated levels of CD4 and CD4/CD8 were statistically significant compared with the control group(all P<0.05).The CRP((8.90±7.56)mg/L)in the experimental group on the 7th postoperative day was lower than that before operation and on the 1st postoperative day,and the difference was statistically significant(all P<0.05),which was lower than the control group((16.24±13.53)mg/L),the difference was statistically significant(all P<0.05).The incidence of postoperative pulmonary infection(22.22%(8/36)),the incidence of anastomotic leakage(5.56%(2/36)),and the postoperative hospital stay((14.17±4.79)d)in the experimental group were lower than those in the control group(44.44%(16/36),25.00%(9/36),(18.47±6.34)d),the total hospitalization expenses in the experimental group((71261.94±11503.50)yuan)were higher than those in the control group((65226.81±10106.43)yuan),the difference was statistically significant(the statistical values wereχ^(2)=4.00,χ^(2)=5.26,t=3.74,t=2.37;P values were 0.046,0.022,<0.001 and 0.021,respectively).Conclusion Supplemental parenteral nutrition for perioperative esophageal cancer patients can effectively maintain nutritional status,improve immune function,and reduce the inflammatory stress response.