肝移植术后早期肠内营养支持治疗效果评估:同期对照比较

背景:国肝移植术后早期开始肠内营养的主要目的是恢复和保护肠道功能,保证正常的胃肠道功能对术后的免疫抑制治疗有极其重要意义.目的:对肝移植患者术后采用早期肠内营养支持治疗,观察患者肠道功能的恢复情况.设计:病例分析.单位:解放军八一医院.对象:选择20(13-04/2006-06解放军八一医院肝移植中心进行肝脏移植患者86例,男57例,女29例,年龄21～68岁,平均48岁.其中原发性肝癌37例,肝炎后肝硬化49例;Child A级8例(均为肝癌患者),Child B级34例,Child C级44例.其中重症肝炎肝功能衰竭伴肝昏迷5例.所有患者家属均对治疗知情同意,移植手术经过医院伦理委员会批准许可.方法:患者手术方式主要采取腔静脉成形的原位肝移植术80例,4例行非转流原位经典手术;2例行背驮式.供肝热缺血时间平均(4.8±2.4)min,冷缺血时间平均(8.6±3.2)h.无肝期(84±28)min.术后常规三联免疫抗排斥治疗:他克莫司(Fujisawa产品) 吗替麦考酚酸酯(美国罗氏产品) 强的松(Pred).根据术中有无放置鼻饲管将患者分为对照组(n=49)及早期肠内营养组(n=37),两组患者性别、年龄及一般情况差异无统计学意义.对照组术后早期以肠外营养为主,早期肠内营养组患者术中置入鼻肠营养管建立肠道喂养的通道,术后24 h开始使用短肽肠内营养制剂,如百普素.用量从63～126 g/d开始,逐渐增加至372 g/d.两组患者根据胃肠功能恢复情况术后3～5 d可酌进流质饮食.主要观察指标:①观察术后患者临床症状恢复及并发症情况.②术后1,3,5 d检测包括血清总蛋白、白蛋白、前臼蛋白水平等肝功能恢复指标及c反应蛋白水平.③术后7 d检测血清免疫球蛋白水平.结果:纳入患者86例均进入结果分析.①临床症状恢复及并发症情况:早期肠内营养组10例患者术后并发腹胀,5例患者表现为腹泻,3例患者喂养导管堵塞或滑脱,未见呕吐、返流及吸入性肺炎等并发症.对照组胆漏2例,早期肠内营养组无胆漏发生.②肝功能恢复指标检测结果:早期肠内营养组术后3,5 d前白蛋白水平高于对照组,C反应蛋白水平低于对照组.差异均有统计学意义(P＜0.05).③血清免疫球蛋白水平:早期肠内营养组术后7 d 血IgA,IBM均高于对照组,差异有统计学意义(P＜0.05).结论:肝移植术后早期肠内营养支持.能降低机体应激反应,加快分解代谢向合成代谢的转变.促进肝细胞的修复,减少感染的机会.

Early enteral nutrition following liver transplantation A concurrent controlled study

BACKGROUND: Early enteral nutrition (EEN) following liver transplantation can benefit to recover and guarantee the normal gastrointestinal tract function,which plays an important role on post-operational immunosuppressive therapy.OBJECTIVE: To conduct EEN on the patients undergoing liver transplantation,and observe the post-operation recovery of intestinal function.DESIGN: Case analysis.SETTING: The 81 Hospital of Chinese PLA.PARTICIPANTS: From April 2003 to June 2006,86 patients undergoing liver transplantation in Liver Transplantation Center at the 81 Hospital of Chinese PLA were enrolled,including 57 males and 29 females.They aged 21-68 years,with a mean of 48 years.Among them,there were 37 cases of primary hepatic carcinoma and 49 cases of posthepatitic cirrhosis; 8 cases graded in Child A (all hepatic carcinoma),34 cases in Child B,and 44 cases in Child C.And 5 cases were complicated with serious hepatitis liver function failure and hepatic coma.Informed consents were obtained from all the patients and relatives.Transplantation operation was approved by the hospital ethical committee.METHODS: Surgical approach was orthotopic liver transplantation through caval vein in 80 cases,typical orthotopie liver wansplantation without veno-venous bypass in 4 cases,and piggyback orthotopic liver transplantation in 2 cases.The average warm ischemia time was (4.8±2.4) minutes,and average cold ischemia time was (8.6±3.2) hours.Anhepatic phase was (84±28)minutes.Post-operational trigeminy immunity and anti-rejection therapy consisted of tacrolimus (Fujisawa product) +mycophenolate mofetil (Roche product) + prednisone (Pred).According to the presence of nasogastric feeding tube,the patients were divided into control group (n=49) and EEN group (n =37).There were no significant differences in the sex,age and general data of patients between the two groups.Control group adopted EEN mainly,while EEN group was fed with EEN via a nose-intestine nutritional tube,and they received short-peptide enteral nutrition (Pepti-2000) at 24 hours post-operation at the initial dose of 63-126 g/d,which was gradually increased to 372 g/d.Liquid diet was allowable by 3-5 days.MAIN OUTCOME MEASURES: ①Clinical recovery and complications of patients.②Liver function recovery indices such as total serum protein,albumin and prealbumin,as well as C reactive protein at days 1,3,5 post-operation.③Level of serum immune globulin at day 7 post-operation.RESULTS: Totally 86 patients were involved in the result analysis.①Clinical recovery and complications: In EEN group,abdominal distension occurred in 10 cases,diarrhea in 5 cases,and blocking or slippage of feeding tube in 3 cases; No emesia,back flow or aspirated pneumonia was found; In control group,2 cases appeared bile leakage,which was not detected in the EEN group.②Indices of liver function recovery: Compared with control group,the prealbumin level was significantly rised and C reactive protein was significantly decreased in the EEN group at days 3 and 5 (P ＜ 0.05).③Levels of serum immune globulin: Blood IgA and IgM of EEN group were significantly higher than those of control group at day 7 (P ＜ 0.05).CONCLUSION: EEN in post-operation patients can reduce stress,promote synthesize metabolism,improve the recovery of liver cells,and decrease the infection rate.