外科圍手術(shù)期腸內(nèi)營(yíng)養(yǎng)應(yīng)用策略課件

外科圍手術(shù)期腸內(nèi)營(yíng)養(yǎng)應(yīng)用策略上海交通大學(xué)附屬第六人民醫(yī)院外科秦環(huán)龍內(nèi)容提要一、住院病人營(yíng)養(yǎng)篩查二、圍手術(shù)期EN的重要性三、EN實(shí)踐中注意的幾個(gè)問(wèn)題1.營(yíng)養(yǎng)支持應(yīng)用流程圖營(yíng)養(yǎng)評(píng)估胃腸功能有EN胃腸功能特殊配方標(biāo)準(zhǔn)營(yíng)養(yǎng)素受限正常部分PN補(bǔ)充過(guò)渡至EN營(yíng)養(yǎng)素耐受適時(shí)過(guò)渡至經(jīng)口喂養(yǎng)適時(shí)過(guò)渡至全面的配方及經(jīng)口喂養(yǎng)無(wú)PN短期外周PN胃腸功能恢復(fù)中心PN長(zhǎng)期或液體限制無(wú)彌漫性腹膜炎腸梗阻頑固性嘔吐腸麻痹頑固性腹瀉胃腸缺血2.營(yíng)養(yǎng)篩查主觀全面評(píng)定subjectiveglobeassessment,SGA微型營(yíng)養(yǎng)評(píng)估m(xù)ininutritionalassessment,MNA營(yíng)養(yǎng)不良風(fēng)險(xiǎn)篩查2002nutritionriskscreeningNRS2002

疾病嚴(yán)重程度評(píng)分＋營(yíng)養(yǎng)狀態(tài)低減評(píng)分＋年齡評(píng)分（若70歲以上加1分）總評(píng)分

中國(guó)13城市大醫(yī)院營(yíng)養(yǎng)風(fēng)險(xiǎn)調(diào)查2009年8月啟動(dòng)會(huì)，培訓(xùn)外科研究人員2010年1月第一次中期會(huì)議2010年4月第二次中期會(huì)議2011年11月第三次會(huì)議4.我單位篩查分析DepartmentNumberofpatientTheincidenceof

nutritional

deficienciesTheincidenceof

nutritionalrisk＜3分≥3分GeneralSurgery5042509(10.1%)4074(80.8%)968(19.2%)Geriatrics1662187（11.3%）1316(79.2%)346(20.8%)

Neurology1046119（11.4%）589(56.3%)457(43.7%)Neurosurgery923124（13.4%）

513(55.6%)410(44.4%)RespiratoryMedicine67390（13.3%）439(65.2%)

234(34.8%)

Gastroenterology941137（14.6%）571(60.7%)370(39.3%)

Nephrology76682（10.7%）645(84.2%)121(19.8%)

Total110531248（11.3%）8147(73.7%)2906(26.3%)Undernutritionand

nutritionalriskinVariousdepartmentsNRS

ingeneralsurgeryimpactoftheNutritional

riskonthe

clinicaloutcomeNutritionalriskNonutritionalriskp-valueComplicationrate25.9%(251/968)14.8%（604/4074)＜0.01Hospitalstay10.9±4.79.0±3.9＜0.05Hospitalcharges13024.6±4831.29772.6±4001.5＜0.05Riskof

malnutrition

andnutrition

ingeneralsurgeryTypeofdisease

nIncidenceoftheUndernutrition

incidenceof

nutritionalrisk

＜3分≥3分Colorectalcancer603135(22.6%)405(67.3%)198（32.7%）Gastriccancer

358146（40.1%）

182(50.9%)176(49.1%)HepatobiliaryandPancreaticbenigndisease72039（5.4%）573(79.6%)147(20.4%)HepatobiliaryandPancreaticcancer14224(16.7%)84(59.3%)58(40.7%)Thyroid,

herniaand

breastdiseases194693（4.8%）1730(88.9%)216(11.1%)Vasculardisease40621（5.3%）365(89.9%)41(10.1%)Otherdiseases86750（5.7%）735(84.8%)132(15.2%)Total

5042509(10.1%)4074(80.8%)968（19.2%）NRS

ingeneralsurgeryTypeofdiseaseNRSscoreNutritional

supportmethodsPNENPN+ENColorectalcancer＜3152634445≥392382727Gastriccancer＜3144454455≥3152484064HepatobiliaryandPancreaticbenigndisease＜35226206≥34118230HepatobiliaryandPancreaticcancer＜3241248≥32814410Thyroid,

hernia,and

breastdisease＜3122327614≥375392610Vasculardisease＜3154101≥37430Otherdiseases＜382372817≥33617118Total＜3591219226146≥34311781341191022397360265

ImpactofNutritionalsupport

on

complicationsTypeofdiseaseIncidenceofcomplicationsnonutritionalsupportnutritionalsupportp-valueColorectalcancer

39.6%（42/106）

19.6%（18/92）0.0036Gastriccancer

45.8%（11/24）

20.4%（31/152）0.0139HepatobiliaryandPancreaticbenigndisease

19.8%(21/106)

12.2%(5/41)0.3985HepatobiliaryandPancreaticcancer

63.3%(19/30)

32.1%(9/28)0.0346Thyroid,

hernia,and

breastdiseases

17.7%（25/141）

20%（15/75）0.8324Vasculardiseases

29.4%(10/34)

28.6%(2/7）0.6806Otherdiseases

30.2%(29/96)

22.2%(8/36）0.4888Total

29.2%（157/537)

20.4%(88/431)0.0022Impactof

Nutritionalsupporton

hospitalstayTypeofdiseaseHospitalstaynonutritionalsupportnutritionalsupportp-valueColorectalcancer16.1±5.813.7±4.2＜0.05Gastriccancer19.3±6.115.3±4.3＜0.05HepatobiliaryandPancreaticbenigndiseases

8.7±2.9

7.7±2.3＞0.05HepatobiliaryandPancreaticcancer

19.5±3.3

15.4±2.8＜0.05Thyroid,

hernia,and

breastdiseases

5.7±3.0

5.6±2.5＞0.05Vasculardiseases7.1±2.26.6±2.0＞0.05Others8.2±2.97.7±2.4＞0.05Impactof

Nutritionalsupporton

charges

TypeofdiseaseHospitalchargesnonutritionalsupportnutritionalsupportp-valueColorectalcancer19012.3±3728.416011.2±2867.19＜0.05Gastriccancer23628.3±4377.819293.5±3623.7＜0.05HepatobiliaryandPancreaticbenigndiseases

8344.2±1511.2

8065.8±1731.6＞0.05HepatobiliaryandPancreaticcancer24825.9±3711.820924.8±3465.1＜0.05Thyroid,

hernia,and

breastdiseases

4924.2±1009.8

4785.1±985.4＞0.05Vasculardiseases11229.5±2763.1

10825.8±2376.9＞0.05Others

9154.8±3352.7

8996.8±2832.7＞0.05二、圍手術(shù)期營(yíng)養(yǎng)支持的重要性GastriccancerandpostoperativeweightlossRyanAM9913.3%15.5fromdiagnosistofollowup3msBozettiF4418-29spanupto4ysaverage19.1±9.4Kiyama8.9infirst6msandfurther4kginthe2th6msLiedman10%preop40%postopinfirst6msNoccurencewtloss(kg)timeHepatogastroenterology.2008;55(82-83):803-6RyanAMwtloss>10%51.9%11.1%<10%26.2%0%ComplicationmortalitySitges-serra

wtloss>20%23%<20%7%Rey-Ferro

NRI<83.5

severelymalnutrition33%moderatelymalnutrition6.5%MalnutritionandPostoperativecomplicationPutwatanaPSungurtekinHBellantoneRMeguidMWeightlossmorethan10%duringthe6monsbeforesurgeryareatagreatriskfortheoccurrenceofmajorpostoperativecomplicationsinmajorabdominalsurgery1410例胃腸惡性腫瘤患者EN組（ENn=393）免疫增強(qiáng)型EN(IEEN,n=500)TPN組（n=368）標(biāo)準(zhǔn)輸液組（SIFn=149）術(shù)后并發(fā)癥相關(guān)危險(xiǎn)因素的多因素分析非標(biāo)準(zhǔn)輸液組研究設(shè)計(jì)入組患者的基線特征性別年齡腫瘤部位體重丟失手術(shù)持續(xù)時(shí)間失血輸血血紅蛋白水平淋巴細(xì)胞計(jì)數(shù)白蛋白水平入組患者的基線特征與術(shù)后并發(fā)癥嚴(yán)重程度的關(guān)系營(yíng)養(yǎng)支持手段性別年齡腫瘤部位體重丟失手術(shù)持續(xù)時(shí)間失血輸血血紅蛋白水平淋巴細(xì)胞計(jì)數(shù)白蛋白水平入組患者的基線特征與術(shù)后感染與非感染并發(fā)癥的關(guān)系不同營(yíng)養(yǎng)支持類型組的術(shù)后并發(fā)癥發(fā)生概率標(biāo)準(zhǔn)輸液組與非標(biāo)準(zhǔn)組*的術(shù)后并發(fā)癥發(fā)生率*非標(biāo)準(zhǔn)組即TPN、EN及IEEN組所有并發(fā)癥危險(xiǎn)因素的多因素分析結(jié)果主要并發(fā)癥危險(xiǎn)因素的多因素分析結(jié)果年齡、術(shù)前白蛋白及體重水平與術(shù)后并發(fā)癥發(fā)生概率相關(guān)與標(biāo)準(zhǔn)輸液組（SIF）相比：TPN、EN及IEEN組能降低胃腸道惡性腫瘤術(shù)后并發(fā)癥營(yíng)養(yǎng)支持（TPN、EN及IEEN）能降低術(shù)后感染相關(guān)并發(fā)癥的發(fā)生率結(jié)論GianottieL,BragaM.etalPreioperativenutritioninpatientsundergoingcancersurgeryArchSurg.1999;134:428-433邱文才，席時(shí)富等胃腸道疾病術(shù)前及術(shù)后早期腸內(nèi)營(yíng)養(yǎng)的評(píng)價(jià).《四川醫(yī)學(xué)》.2007,28:1257-1258.

3.術(shù)前EN減少術(shù)后感染發(fā)生率、縮短住院時(shí)間14/10231/1048.7±2.2613.5±7.99術(shù)前早期EN可促進(jìn)腸道恢復(fù)，促進(jìn)傷口愈合王毅，王猻等.腸內(nèi)營(yíng)養(yǎng)制劑在大腸癌術(shù)前腸道準(zhǔn)備中的應(yīng)用.天津醫(yī)藥，2006,34:323-333.4.術(shù)后早期EN減少并發(fā)癥、加速康復(fù)可有效減少并發(fā)癥，Pooled分析與傳統(tǒng)術(shù)后禁食比較，并發(fā)癥相對(duì)危險(xiǎn)發(fā)生率減少45%

早期腸內(nèi)營(yíng)養(yǎng)，明顯縮短住院時(shí)間（

7.98±6.6vs12.96±13.4天，P<0.05），加速康復(fù)1.EmmaOsland,.EarlyVersusTraditionalPostoperativeFeedinginPatientsUndergoingResectionalGastrointestinalSurgery:AMeta-Analysis.JPEN,35:473-487.2.MeenaSomanchi.TheFacilitatedEarlyEnteralandDietaryManagementEffectivenessTrialinHospitalizedPatientsWithMalnutrition.JPEN,2011,35:209-216.7.98±6.612.96±13.4薈萃

分析:

胃腸手術(shù)后早期(術(shù)后24小時(shí))與傳統(tǒng)時(shí)間腸內(nèi)營(yíng)養(yǎng)并發(fā)癥：早期腸內(nèi)營(yíng)養(yǎng)優(yōu)于傳統(tǒng)喂養(yǎng)死亡率：早期腸內(nèi)營(yíng)養(yǎng)優(yōu)于傳統(tǒng)喂養(yǎng)吻合口瘺：早期腸內(nèi)營(yíng)養(yǎng)少于傳統(tǒng)喂養(yǎng)鼻胃管重置率：早期腸內(nèi)營(yíng)養(yǎng)多于傳統(tǒng)喂養(yǎng)肛門排氣時(shí)間：早期腸內(nèi)營(yíng)養(yǎng)早于傳統(tǒng)喂養(yǎng)排便時(shí)間：早期腸內(nèi)營(yíng)養(yǎng)早于傳統(tǒng)喂養(yǎng)住院時(shí)間：早期腸內(nèi)營(yíng)養(yǎng)少于傳統(tǒng)喂養(yǎng)5.圍手術(shù)期持續(xù)性營(yíng)養(yǎng)支持對(duì)結(jié)局和轉(zhuǎn)歸積極影響出院后，對(duì)照組體重丟失沒(méi)有有效糾正，而持續(xù)營(yíng)養(yǎng)治療組體重丟失得到有效糾正，營(yíng)養(yǎng)狀況明顯改善

營(yíng)養(yǎng)治療組的生理評(píng)分和心理評(píng)分都高于對(duì)照組，患者生活質(zhì)量明顯提高6.術(shù)后出院口服EN改善營(yíng)養(yǎng)狀態(tài)，提高生活質(zhì)量AHBeattie,ATPrach.Arandomisedcontrolledtrialevaluatingtheuseofenteralnutritionalsupplementspostoperativelyofenteralnutritionalsupplementspostoperatively.Gut2000;46:813–818.結(jié)腸癌術(shù)后患者早期口服營(yíng)養(yǎng)補(bǔ)充（ONS）LobatoDiasConsoliM,etal.Earlypostoperativeoralfeedingimpactspositivelyinpatientsundergoingcolonicresection:resultsofapilotstudy.NutrHosp,2010;25(5):806-9.兩組均術(shù)前12h禁食，早期EN組術(shù)后第1天起即給予500ml口服EN制劑，傳統(tǒng)治療組排氣后才恢復(fù)進(jìn)食POD：術(shù)后天數(shù)結(jié)腸癌術(shù)后早期ONS促進(jìn)腸功能恢復(fù)

縮短住院時(shí)間早期ONS組患者腸蠕動(dòng)恢復(fù)所需時(shí)間顯著縮短（D1排氣，對(duì)照組D2排氣），住院時(shí)間顯著提前（中位數(shù)3天，對(duì)照組5天）；對(duì)照組的腹瀉發(fā)生率是試驗(yàn)組的1.86倍（P<0.05）LobatoDiasConsoliM,etal.Earlypostoperativeoralfeedingimpactspositivelyinpatientsundergoingcolonicresection:resultsofapilotstudy.NutrHosp,2010;25(5):806-9.P<0.05三、臨床實(shí)踐中注意的幾個(gè)問(wèn)題遵循腹部圍手術(shù)期營(yíng)養(yǎng)支持推薦意見(jiàn)2.圍手術(shù)期允許性低熱量低氮量攝入術(shù)后1-3天,1000-1500kcal/d4-5天，2000-2500kcal/d3.術(shù)中建立有效的腸內(nèi)營(yíng)養(yǎng)途徑術(shù)中置管：

賁門癌術(shù)中置管胃大部切除術(shù)中置管胃全切術(shù)中置管胰十二指腸切除術(shù)中置空腸造口管賁門癌術(shù)中置管術(shù)前胃管和十二指腸營(yíng)養(yǎng)管的固定,置入食管腫瘤切除后,拉出胃管及營(yíng)養(yǎng)管,先吻合胃食管后壁放置胃管將營(yíng)