Parenteral and enteral nutrition and translational medicine T3: discussion on clinical study design for standardized application and patient benefit / 中华临床营养杂志

The ultimate goal of the development of parenteral and enteral nutrition is to achieve T3 transfer of translational medicine in this field. This study is an international cooperative, multicenter and observational clinical study conducted by CSPEN-NUSOC cooperative group for 15 years which is aimed to observe the effect of standardized nutritional support on clinical outcome and cost/ effect and verify the clinical value parenteral and enteral nutrition through investigating the prevalence of nutritional risk and malnutrition and the application of nutritional support in adult in-patients.

Nutritional support therapy during treatment of chronic critical illness / 中华胃肠外科杂志

Chronic critical illness (CCI) refers to a group of critically ill patients who survive the acute phase of intensive care, but with persistent organ dysfunction, thus entering a chronic period of continuous dependence on life support system, and still need to stay in intensive care unit (ICU) for a long time. Persistent inflammatory response-immunosuppression-catabolic syndrome (PICS) is the main pathophysiological feature of CCI. Three factors interact to form a vicious circle, leading to poor prognosis. Nutritional support therapy is a key link in the comprehensive treatment of CCI. Enteral nutrition (EN) should be started as soon as possible if conditions permit. If EN can not be implemented, temporary or transitional parenteral nutrition (PN) should be used, and EN should be added gradually in time. At the same time, the amount of PN should be gradually reduced. When EN meets more than 60% of patients’ energy and protein requirements, PN can be considered to be discontinued. The main strategies and functions of CCI nutritional support therapy are as follows: strengthening high protein supply to correct negative nitrogen balance and inhibit catabolism, selecting branched chain amino acids (BCAA) to promote anabolism, using immunomodulators (arginine, ω3 polyunsaturated fatty acids) to improve immune suppression and inflammatory response, supplementing micronutrients (vitamins and trace elements) to counteract the decrease in intake and the increase in consumption, and adding probiotics to maintain the intestinal microecological balance, and so on. Reasonable nutritional support therapy not only improve malnutrition of CCI patients, but also help to reduce complications, thus speeding up rehabilitation, improving prognosis, shortening ICU hospitalization time, and even reducing mortality.

Parenteral and enteral nutrition and translational medicine T3: discussion on clinical study design for standardized application and patient benefit / 中华临床营养杂志

The ultimate goal of the development of parenteral and enteral nutrition is to achieve T3 transfer of translational medicine in this field. This study is an international cooperative, multicenter and observational clinical study conducted by CSPEN-NUSOC cooperative group for 15 years which is aimed to observe the effect of standardized nutritional support on clinical outcome and cost/effect and verify the clinical value parenteral and enteral nutrition through investigating the prevalence of nutritional risk and malnutrition and the application of nutritional support in adult in-patients.

Literature Analysis of Vitamins Utilization in Parenteral Nutrition Prescription in China during 2006-2015 / 中国药房

OBJECTIVE:To investigate the application of vitamins in parenteral nutrition (PN) prescription,and to provide reference for rational use of vitamins in PN. METHODS:Usingparenteral nutritionintravenous nutritionprescription analy-sisrational drug useanalysis of medical orderas keywords,the literatures about the rationality analysis of PN prescriptions were retrieved from CNKI and Wanfang database during 2006-2015,and the utilization of vitamin included in literatures were ana-lyzed and summarized. RESULTS:A total of 34 literatures were included. There were 158874 prescriptions,among which vitamin was used in 145400 prescriptions (91.52%). 12 or 13 kinds of vitamin were used in 73508 prescriptions (46.27%);over-dose drug use was found in 53388 prescriptions(33.60%),and vitamin was not completely added into 18504 prescriptions(11.65%);no vitamin was added into 1663 prescriptions (1.05%). The proportion of the prescriptions including 12 or 13 kinds of vitamin was the highest in northern China (52.00%). 12 or 13 kinds of vitamin were added into the prescriptions and the author believed that the proportion of excessive use of vitamin,incomplete addition of water-soluble vitamin and fat-soluble vitamin in class three grade A hospitals were all lower than hospitals below class three grade A. The prescriptions including 12 or 13 kinds of necessary vi-tamin were adopted in oncology department(97.72%),internal medicine department(86.62%),intensive care unit(77.99%)and surgery department(52.83%). CONCLUSIONS:The standardized use of vitamin PN prescriptions occupies low proportion in Chi-na. It is necessary to enhance the conception that multiple recommended vitamins should be added into PN.

A prospective study of early enteral nutrition and combined enteral nutrition and parenteral nutrition in patients with hepatocellular carcinoma after precise hepatectomy / 中华消化外科杂志

Objeetive To compare the clinical value of early enteral nutrition (EEN) and combined enteral nutrition (EN) and parenteral nutrition (PN) in patients with hepatocellular carcinoma (HCC) after precise hepatectomy.Methods The prospective study was conducted.The clinical data of 60 HCC patients who underwent precise hepatectomy in the Affiliated Drum Tower Hospital of Nanjing University Medical School between January 2013 and December 2014 were collected.All patients were allocated into the EN group and combined EN+PN group by random number table method.Patients in the EN group and combined EN+PN group respectively received EEN and early combined EN+PN at 24 hours postoperatively for 7 days,total nutrient intakes between groups were consistent,with an average daily intake of nitrogen-feeding of 0.2 g/(kg · d) and an average daily intake of nonprotein calories of 25 kcal/(kg · d).Observation indicators:(1) comparison of nutritional indexes between groups;(2) comparison of liver function between groups;(3) comparison of postoperative conditions between groups.Measurement data with normal distribution were represented as-x±s.Comparisons at the same time between groups were respectively analyzed using the group-design t test.Comparisons of count data were analyzed using the chi-square test.Ordinal data were analyzed by the nonparametric test.Comparison of repeated measurement data were done using the repeated measures ANOVA.Results Sixty patients were screened for eligibility,and 30 in each group.(1) Comparison of nutritional indexes between groups:levels of albumin (Alb),globulin,prealbumin and hemoglobin (Hb) and lymph nodes count in the EN group were respectively (41±4)g/L,(28±4) g/L,(188±37) mg/L,(139± 17) g/L,(1.6±0.6) × 109/L before operation and (32±4) g/L,(23±5)g/L,(114±41)mg/L,(121±19)g/L,(1.1±0.7) ×109/L at 1 day postoperative1y and (34±5)g/L,(26±4) g/L,(169± 41) mg/L,(113 ± 16) g/L,(1.9 ± 1.1) × 109/L at 8 days postoperatively,with statistically significant differences in above indexes (F=2.23,4.45,8.96,5.21,2.18,P＜0.05).There were statistically significant differences in above indexes between pre-operation and 1 day postoperatively (t =9.79,8.53,9.81,4.56,5.77,P＜0.05) and between 1 and 8 days postoperatively (t =5.55,6.31,4.69,3.99,8.26,P＜0.05).There were statistically significant differences in levels of Alb,globulin,prealbumin and Hb between pre-operation and 8 days postoperatively (t=3.48,5.12,6.37,8.20,P＜0.05) and no statistically significant difference in lymph nodes count (t =2.48,P＞0.05).Levels of Alb,globulin,prealbumin and Hb and lymph nodes count in the combined EN+PN group were respectively (42±4)g/L,(28±6)g/L,(188±29)g/L,(142±16)g/L,(1.6±0.6)×109/L before operation and (31±5)g/L,(20±5) g/L,(96±31) g/L,(124± 16) g/L,(0.9±0.4) × 109/L at 1 day postoperatively and (34±4)g/L,(24±4)g/L,(143±18)g/L,(115±18)g/L,(1.4±0.7)×109/L at 8 days postoperatively,with statistically significant differences in above indexes (F=3.21,7.35,4.36,7.78,3.19,P＜0.05).There were statistically significant differences in above indexes between pre-operation and 1 day postoperatively (t =11.95,5.38,9.91,4.84,6.22,P＜0.05) and between 1 and 8 days postoperatively (t =9.45,7.66,4.98,3.15,4.79,P＜ 0.05).There were statistically significant differences in levels of Alb,globulin,prealbumin and Hb between pre-operation and 8 days postoperatively (t=9.31,8.44,6.57,5.25,P＜0.05).There were no statistically significant difference in lymph nodes count (t =3.11,P＞ 0.05) and in changing trends of Alb,globulin,prealbumin,Hb and lymph nodes count (F=8.54,3.83,7.21,6.33,3.91,P＞0.05).Levels of prealbumin at 8 days postoperatively were statistically different between groups (t =3.00,P＜0.05).(2) Comparison of liver function between groups:levels of alanine transaminase (ALT),aspartate transaminase (AST),alkaline phosphatase (ALP),glutamyl-transpeptidase (GGT),total bilirubin (TBil),direct bilirubin (DBil) and C-reactive protein (CRP) in the EN group were respectively (44±37)U/L,(44±30) U/L,(90± 29) U/L,(85 ± 49) U/L,(15.7± 5.4) μmol/L,(4.6± 2.3) μmol/L,(4.5 ± 3.2) mg/L before operation and (411±375)U/L,(379±323)U/L,(68±26)U/L,(55±49)U/L,(20.3±10.7)μmol/L,(7.8±5.5) μmol/L,(47.9± 30.6) mg/L at 1 day postoperatively and (107± 58) U/L,(43± 21) U/L,(100± 42) U/L,(111±71)U/L,(19.7±10.6) μmol/L,(8.8±5.9) μmol/L,(28.3±23.0) mg/L at 8 days postoperatively,with statistically significant differences in above indexes among pre-operation,1 and 8 days postoperatively (F=5.48,9.44,1.73,5.03,8.42,6.09,6.69,P＜0.05) and between pre-operation and 1 day postoperatively (t=5.12,5.36,5.35,0.45,2.88,3.82,6.95,P＜ 0.05).There were statistically significant differences in levels of ALT,TBil,DBil and CRP between pre-operation and 8 days postoperatively (t =6.71,4.14,5.96,6.33,P＜0.05) and in levels of ALT,AST,ALP,GGT and CRP between 1 and 8 days postoperatively (t =6.23,5.55,3.14,3.56,4.99,P＜0.05).There were no statistically significant difference in levels of AST,ALP and GGT (t =0.13,0.98,1.11,P＞0.05) and in levels of TBil and DBil (t =0.08,0.23,P＞0.05).Levels of ALT,AST,ALP,GGT,TBil,DBil and CRP in the combined EN+PN group were respectively (41±38) U/L,(43±25) U/L,(100±89) U/L,(106±46) U/L,(17.9±9.8) μmol/L,(6.2±3.6) μmol/L,(3.7±2.3)mg/L before operation and (462±409)U/L,(494±162)U/L,(73±53)U/L,(75±57)U/L,(28.1±18.8)μmol/L,(9.1±6.1) μmol/L,(40.7±26.2) mg/L at 1 day postoperatively and (90±47) U/L,(42± 16) U/L,(95±40) U/L,(110±66) U/L,(22.5± 14.5) μmol/L,(8.2±8.1) μmol/L,(26.9±24.6) mg/L at 8 days postoperatively,with statistically significant differences in above indexes among pre-operation,1 and 8 days postoperatively (F=5.96,3.73,6.94,3.88,7.97,4.14,5.25,P＜0.05) and between before operation and 1 day postoperatively (t=5.72,4.96,3.95,0.88,2.83,4.13,6.11,P＜0.05).There were statistically significant differences in levels of ALT and CRP between pre-operation and 8 days postoperatively (t =4.22,6.77,P＜0.05) and in levels of ALT,AST,ALP and GGT between 1 and 8 days postoperatively (t=7.01,5.21,4.38,6.15,P＜0.05).There were no statistically significant difference in levels of AST,ALP,GGT,TBil and DBil (t =0.29,1.65,1.92,0.33,P＞0.05) and in levels of TBil,DBil and CRP (t =0.09,0.37,0.58,P＞0.05).There was no statistically significant difference in changing trends of ALT,AST,ALP,GGT,TBil,DBil and CRP of 2 groups (F=7.18,2.23,3.94,5.88,4.72,2.17,6.53,P＞0.05) and in above indexes among pre-operation,1 and at 8 days postoperatively (t=0.27,0.42,0.91,0.12,0.96,0.24,0.59,0.32,0.49,1.27,0.88,0.07,1.07,1.45,0.23,1.11,0.88,0.32,0.35,0.93,0.21,P＞0.05).(3) Comparison of postoperative conditions between groups:times of initial defecation were respectively (3.2± 1.0) days and (4.2± 1.2) days in the EN group and combined EN +PN group,showing a statistically significant difference (t =3.21,P＜ 0.05).Conclusion EEN and combined EN+PN are safe and feasible in HCC patients after precise hepatectomy,and also can improve liver function recovery,but EEN has advantages of promoting protein synthesis and gastrointestinal function recovery.

Advances of nutritional support therapy in critical illness / 中华消化外科杂志

In recent years,the scientific literatures have revealed exponential advances in the understanding of molecular basis of nutritional support therapy and evolution of clinical protocols aimed at treating artificial nutritional support as a therapeutic intervention,preventing loss of lean body mass and metabolic deterioration to improve clinical outcomes in the critical illness.According to the evidence-based medicine,this review will summarize recent findings,highlight areas of consensus and controversy and define priorities for further researches.

Overall management of perioperative nutritional support treatment in the enhanced recovery after surgery period / 中华消化外科杂志

Only scientific and reasonable nutritional support treatment,can reduce complications to the maximum extent,so that patients will rehabilitate faster and more stably.Authors integrate bundles of care from enhanced recovery after surgery,combined with the latest research progress domestic and overseas,to discuss nutritional status and nutritional risk screening,focus of perioperative nutrition support therapy,key issues on the pre-,intra-and post-operative periods of nutritional support treatment,and strategy of throughout nutritional management during perioperative period.These includes the following aspects:integrating nutrition management into perioperative period management;avoiding fasting before surgery;resuming oral feeding early;early nutritional support therapy for high nutritional risk patients;metabolic control,such as positive control of blood glucose;reducing stress related catabolism or factors affecting gastrointestinal function recovery;decreasing postoperative anesthesia drug use for ventilator management;early activity to promote protein synthesis and muscle function recovery.

Nutritional support therapy in complicated intra-abdominal infection / 中华消化外科杂志

Complicated intra-abdominal infections (cIAIs) are common clinical conditions but difficult to manage in abdominal surgical practice.Since usually combined with gastrointestinal dysfunction,nutritional support therapy plays a key role in the long-term treatment.Early enteral nutrition could maintain intestinal barrier function,regulate immune function,and reduce gut permeability and bacterial translocation.Enteral combined with supplement parenteral nutrition could provide full-energy support to improve negative nitrogen balance and physiological function.Underlying pathophysiological changes should be understood,and appropriate mode of nutritional support should be chose carefully during disease course which can reduce incidence of complications and improve patients' prognoses.

Clinical value of preoperative nutritional support therapy in the hepatectomy of patients with nutritional risk: a prospective study / 中华消化外科杂志

Objective To investigate the clinical value of preoperative nutritional support (PNS) therapy in the hepatectomy of patients with nutritional risk.Methods The prospective study was conducted.The clinical data of 133 patients with nutritional risk who were admitted to the Drum Tower Hospital Affiliated to Nanjing University Medical School from August 2012 to June 2016 were collected.All the patients undergoing PNS and traditional therapy were divided into the PNS group and the control group by random number table method,respectively.Observation indicators:(1) comparisons of laboratory indexes between groups;(2) comparisons of postoperative situations between groups;(3) comparisons of postoperative complications between groups.Measurement data with normal distribution were represented as-x±s.Comparisons between groups were evaluated with the independent-sample t test.Comparisons of count data were analyzed using the chi-square test,and repeated measures data were analyzed by the repeated measures ANOVA.Results All the 133 patients were screened for eligibility,including 68 in the PNS group and 65 in the control group.(1) Comparisons of laboratory indexes between groups:alanine transaminase (ALT),aspartate transaminase (AST),total bilirubin (TBil),cholinesterase,albumin (Alb),prealbumin,transferrin and C-reactive protein (CRP) in the PNS group were respectively (36± 13) U/L,(29± 10) U/L,(18.5±2.4) mmol/L,(5 738± 1 824) U/L,(37.4±5.1) g/L,(155±48) mg/L,(2.2±0.5)g/L,(10±4) g/L at admission and (33 ± 9) U/L,(27 ± 8) U/L,(17.9± 1.8) mmol/L,(5 796± 2 016) U/L,(38.5 ± 4.7) g/L,(181 ± 40) mg/L,(2.4± 0.5) g/L,(8± 4) g/L before operation and (285±100)U/L,(218±93)U/L,(33.5±6.3)mmol/L,(4 847±1 044)U/L,(32.6±3.8)g/L,(105±34)mg/L,(1.3±0.4) g/L,(55±28) g/L at 1 day postoperatively and (149±84) U/L,(76±42) U/L,(22.7±4.9) mmol/L,(3 866±893) U/L,(34.2±2.4) g/L,(125±30) mg/L,(1.6±0.4) g/L,(51±34) g/L at 3 days postoperatively and (64±33) U/L,(44±18) U/L,(19.4±2.8) mmol/L,(4 257± 1 032) U/L,(37.0±2.1) g/L,(148±42) mg/L,(1.9±0.4)g/L,(16±11)g/L at 7 days postoperatively;ALT,AST,TBil,cholinesterase,Alb,prealbumin,transferrin and CRP in the control group were respectively (36± 15)U/L,(31± 12)U/L,(18.3±2.9)mmol/L,(5 762±1 693)U/L,(37.3±6.1)g/L,(162±51)mg/L,(2.3±0.5)g/L,(10±4)g/L at admission and (36±11)U/L,(30±11)U/L,(18.2±2.8)mmol/L,(5 789±1 673)U/L,(37.8±7.1)g/L,(166±57) mg/L,(2.3±0.6) g/L,(9±5) g/L before operation and (305±127) U/L,(246± 104) U/L,(34.2±7.8) mmol/L,(4 842±1 173)U/L,(32.0±4.1) g/L,(83±32) mg/L,(1.2±0.4) g/L,(61 ±31) g/L at 1 day postoperatively and (163±104)U/L,(82±62)U/L,(23.1±6.0)mmol/L,(3 672±937) U/L,(33.8±3.6) g/L,(106±30)mg/L,(1.4±0.4)g/L,(61±40)g/L at 3 days postoperatively and (77±48) U/L,(52±27) U/L,(20.2±3.5) mmol/L,(3 925±987) U/L,(36.6±2.8) g/L,(125±40) mg/L,(1.7±0.4) g/L,(22± 12) g/L at 7 days postoperatively,showing no statistically significant difference in changing trends of above indicators between groups (F =1.007,2.223,0.579,0.014,0.235,3.533,2.970,2.143,P＞0.05).Results of further analysis showed that there were statistically significant differences in the levels of ALT,AST and cholinesterase at 7 days postoperatively between groups (t=1.832,2.073,1.899,P＜0.05),and in the levels of prealbumin before operation and at 1,3 and 7 days postoperatively between groups (t =1.698,3.738,3.625,3.178,P＜0.05) and in the levels of transferrin and CRP at 3 and 7 days postoperatively between groups (t=2.917,2.709,1.667,2.990,P＜0.05).(2) Comparisons of postoperative situations between groups:time to initial exsufflation,time of initial defecation,infused volume of exogenous albumin and duration of postoperative hospital stay were respectively (46± 15)hours,(64±16)hours,(23±10)g,(9.2±2.6)days in the PNS group and (55±18)hours,(78±21)hours,(39±25)g,(11.7±5.3) days,with statistically significant differences in the above indicators between groups (t =2.830,4.157,5.044,3.497,P＜0.05).(3) Comparisons of postoperative complications between groups:23 and 33 patients in the PNS and control groups had postoperative complications,showing a statistically significant difference between groups (x2=3.915,P＜0.05).Eight and 17 patients in the PNS and control groups were respectively complicated with peritoneal effusion,with a statistically significant difference between groups (x2 =4.508,P＜ 0.05).Conclusion PNS therapy in the hepatectomy of patients with nutrition risk can effectively improve pre-and post-operative nutrition statuses,reduce liver damage,accelerate recoveries of liver and gastrointestinal functions,reduce complications,shorten duration of postoperative hospital stay and accelerate patients' recovery.

Application of double-tube gastrostomy in the repair of duodenal rupture / 中华消化外科杂志

Objective To investigate the application value of double-tube gastrostomy in the duodenal rupture repair.Methods The retrospective cohort study was adopted.The clinical data of 41 patients who underwent duodenal rupture repair at the Chongqing Emergency Medical Center from January 2005 to January 2015 were collected.Twenty-five patients using Hassan triple-tube gastrostomy technique between January 2005 and December 2009 were divided into the triple-tube (TT) group and 16 patients using double-tube gastrostomy technique between January 2010 and January 2015 were divided into the double-tube (DT) group.Duodenal rupture repair included suture repair,pedicled ileal flap to repair duodenal defect and end to end anastomosis.Patients underwent the regular treatments of anti-infection,antishock,somatostatin inhibition,nutritional support and complications prevention.Patients were injected with 500 mL/d nutrient solution using enteral nutritional tube from 48 hours after operation,and then dosage was gradually increased to total enteral nutrition and digestive juices collected from drainage fluid were transfused to enteral nutritional tube.The postoperative complications (duodenal fistula,intraperitoneal infection,incision infection,pulmonary infection and intestinal obstruction),operation method,operation time,volume of blood loss,euteral nutritional tube removal time and duration of hospital stay were observed.Measurement data with normal distribution were presented as x ± s and comparison between groups was analyzed using an independent sample t test.Comparison of count data was analyzed using chi-square test or Fisher exact probability.Results All the 41 patients underwent duodenal rupture repair,including 28 using suture repair of duodenal rupture,8 using pedicled ileal flap to repair duodenal defect and 5 using end to end anastomosis,with the intraoperative duodenal decompression and placement of intestinal feeding tube.The operation time was (184 ± 38)minutes in the TT group and (153 ± 37)minutes in the DT group,with a significant difference between the 2 groups (t =2.566,P ＜0.05).The volume of intraoperative blood loss was (1 112 ± 707)mL in the TT group and (1 011 ± 595)mL in the DT group,with no significant difference between the 2 groups (t =0.476,P ＞ 0.05).The proportions of duodenal fistula,intraperitoneal infection,incision infection and pulmonary infection in the TT and DT groups were 3/25 and 1/16,8/25 and 5/16,9/25 and 4/16,10/25 and 6/16,respectively,showing no significant difference between the 2 groups (x2=0.003,0.545,0.026,P ＞ 0.05).Eleven patients were complicated with postoperative early intestinal obstruction,including 10 (3 with partial duodenal stenosis and 7 with incomplete small intestinal obstruction) in the TT group and 1 (partial duodenal stenosis) in the DT group,showing a significant difference in the incidence of postoperative early intestinal obstruction between the 2 groups (P ＜ 0.05).Patients with early intestinal obstruction had remission after conservative treatment of gastrointestinal decompression and fasting.The time of intestinal feeding tube indwelling and duration of hospital stay were (25 ±9)days and (29 ± 9)days in the TT group,(19 ± 9)days and (23 ± 8) days in the DT group,with significant differences between the 2 groups (t =2.188,2.120,P ＜ 0.05).Conclusion Double-tube gastrostomy technique for duodenal rupture repair can simplify the operation procedures and reduce operation time,recovery time and risk of postoperative intestinal obstruction,with a reliable efficacy.

Effects of different types of triglycerides on hepatic and renal function and lipometabolism of patients with acute necrotizing pancreatitis: a prospective study / 中华消化外科杂志

Objective To investigate the effects of structured triglyceride (STG) and physical mixed medium chain/long chain triglycerides (MCT/LCT) on hepatic and renal function and lipometabolism of patients with acute necrotizing pancreatitis (ANP).Methods The clinical data of 30 patients with ANP who were admitted to the PLA General Hospital between January 2012 and June 2014 were prospectively analyzed.A double-blind,randomized,controlled study was performed in 30 patients who were allocated into the experimental group (15 patients received STG) and the control group (15 patients received physical mixed MCT/LCT).All the patients received isometrical nitrogen and isocaloric parenteral nutrition more than 5 days.The levels of alanine transaminase (ALT),aspartate transaminase (AST),glutamyl-transpeptidase (GGT),alkaline phosphatase (ALP),creatinine (Cr),blood urea nitrogen (BUN),triglyceride (TG) and total cholesterol (TC) were assayed before nutritional support treatment and at day 1,3 and 5 after nutritional support therapy.The measurement data with normal distribution was presented as (x) ± s.The skew distribution data were described as M (range).The comparison between groups were evaluated with an independent sample t test or one-way ANOVA.The count data were analyzed using the chi-square test.Results A total of 30 patients were screened for eligibility.The levels of ALT,AST,GGT,ALP,Cr,BUN,TG and TC were changed within a certain range at day 1,3 and 5 after nutritional support treatment.The levels of ALT,AST,GGT,ALP,Cr,BUN and TC before treatment and at day 5after treatment were changed from 29.0 U/L,25.4 U/L,83.2 U/L,(193 ± 115) U/L,(124 ± 97) μmol/L,(8±6)mmol/L and (2.4±1.1)mmol/L to 29.4 U/L,33.0 U/L,77.7 U/L,(172±74)U/L,(117 ±103)μmol/L,(8 ± 5) mmol/L and (2.3 ± 1.0) mmol/L in the experimental group,and from 23.8 U/L,22.9 U/L,96.2 U/L,(148 ± 108) U/L,(82 ± 57) μmol/L,(9 ± 7) mmol/L and (2.5 ± 0.7) mmol/L to 21.3 U/L,24.5 U/L,127.4 U/L,(179 ± 126) U/L,(80 ± 54) μmol/L,(10 ± 6) mmol/L and (2.4 ±0.8) mmol/L in the control group,respectively.There were no significant differences in the changing trends of the levels of ALT,AST,GGT,ALP,Cr,BUN and TC between the 2 groups (F =0.647,1.186,0.282,0.553,0.862,0.182,0.369,P＞0.05).The level of TG in the experimental group from pre-treatment to day 5 after treatment was changed from (1.5 ± 0.6) mmol/L to (1.5 ± 0.7) mmol/L,with increasing trend from pre-treatment to day 1 after treatment and reaching the normal level at day 3 and 5 after treatment.The level of TG in the control group from pre-treatment to day 5 after treatment was changed from (1.5 ± 0.6) mmol/L to (2.4 ± 0.6) mmol/L,with increasing trend from pre-treatment to day 1,3 and 5 after treatments.There were significant differences in the changing trends of TG before and after nutritional support therapy between the 2 groups (F =7.940,P ＜ 0.05).Conclusion STG and physical mixed MCT/LCT don't influence the hepatic and renal function of patients with ANP undergoing parenteral nutritional support therapy,while STG has a better effect of lipometabolism compared with physical mixed MCT/LCT.Registry This study was registered with the UMIN Clinical Trial Registry with the registry number of UMIN000016958

Effects of structured triglyceride on postoperative recovery of patients with primary liver cancer after hepatectomy: a prospective study / 中华消化外科杂志

Objective To investigate the effects of structured triglyceride on hepatic function,nutritional status,inflammatory reaction and immunologic function of patients with primary liver cancer after hepatectomy.Methods A prospective,double-blind,randomized,controlled clinical trial was conducted based on the clinical data of 80 patients with primary liver cancer who underwent hepatectomy at the Drum Tower Hospital from January 2011 to December 2012.All the 80 patients were allocated into the testing group (40 patients) and the control group (40 patients) based on a random number table,and received isometrical nitrogen and isocaloric parenteral nutritional support therapy for 7 days after operation.Structured triglyceride (STG) and physical mixed medium chain/long chain triglycerides (MCT/LCT) were applied to the patients in the testing group and the control group,respectively.The hepatic function,nutritional status,inflammatory reaction,immunologic function and prognosis of patients were compared between the 2 groups.The measurement data with normal distribution were presented as (x) ± s.The comparision between groups was evaluated with an independent sample t test.The trend analyses for variables were done using the repeated measures ANOVA.The measurement data with skew distribution were described as M(P25,P75) and analyzed by the analysis of variance.The count data were analyzed using the chi-square test.Results All the 80 patients who were screened for eligibility were randomly divided into the testing group (40 patients) and the control group (40 patients).The alanine transaminase (ALT),aspartate transaminase (AST),prealbumin,choline esterase,C-reactive protein,IgG,IgM,IgA,CD3 +,CD4 +,CD8 + and CD4 +/CD8 + in the 2 groups showed a range of variations before operation and at postoperative day 5 and 7.The ALT,AST,prealbumin,choline esterase,C-reactive protein,IgG,IgM,IgA,CD3 +,CD4 +,CD8 + and CD4+/CD8 + from preoperation to postoperative day 7 were from (36 ± 10)U/L,(37 ± 13)U/L,(233 ±42)mg/L,(154±32)U/L,(8.1 ±1.6)mg/L,(14±5)g/L,(3.2±1.3)g/L,(2.1 ±1.3)g/L,55.6％±6.8％,37.5％±2.0％,25.9％±2.9％ and 1.5 ±0.5 to (83 ±33)U/L,(63 ±42)U/L,(208 ±37)mg/L,(145 ±26)U/L,(30.3 ±8.6)mg/L,(12 ±3)g/L,(2.8 ±1.6)g/L,(2.0 ±1.2)g/L,46.2％±3.9％,33.4％±3.1％,27.9％±3.0％ and 1.2 ±0.4 in the control group,and from (36 ± 12)U/L,(36 ± 14)U/L,(231 ±45)mg/L,(149 ±25)U/L,(7.6 ± 1.8)mg/L,(13 ±5)g/L,(3.3 ±0.7)g/L,(2.1 ± 1.1)g/L,54.2％±6.3％,37.6％±3.5％,24.8％±3.4％ and 1.5 ±0.4 to (43 ±30)U/L,(40 ±33)U/L,(255 ±44)mg/L,(153 ±27)U/L,(21.7 ±11.2)mg/L,(17 ±4)g/L,(4.1 ± 1.7)g/L,(2.4 ± 1.9)g/L,57.9％±3.2％,39.2％ ± 2.9％ 22.7％ ± 3.4％ and 1.7 ± 0.4 in the testing group,respectively,showing significant differences between the 2 groups (F =94.71,86.40,64.22,16.77,8.18,37.23,11.52,22.58,50.30,26.44,13.16,44.84,P ＜ 0.05).There were no significant differences in the level of ALT,AST,prealbumin,choline esterase,C-reactive protein,IgA,CD8 + and CD4 +/CD8 + at postoperative day 5 between the 2 groups (t =1.24,1.03,0.91,1.02,0.53,0.68,1.61,0.98,P＞0.05).There were significant differences in the IgG,IgM,CD3+and CD4 + at postoperative day 5 between the 2 groups (t =2.58,3.15,3.87,2.46,P ＜ 0.05).There were significant differences in the levels of ALT,AST,prealbumin,choline esterase,C-reactive protein,IgG,IgM,IgA,CD3 +,CD4 +,CD8 + and CD4 +/CD8 + at postoperative day 7 between the 2 groups (t =4.83,2.79,5.58,2.12,3.10,2.53,4.17,2.35,3.45,2.98,3.12,3.75,P ＜0.05).The body weight of patients at postoperative day 7 and duration of hospital stay in the control group were (57 ± 6) kg and (9.9 ± 1.5) days,which were significantly different from (61 ± 8) kg and (8.8 ± 1.3) days in the testing group (t =3.67,2.71,P ＜ 0.05).Conclusion Structured triglyceride can effectively improve the recovery of hepatic function,nutrition status and immunologic function and reduce inflammatory reaction for the patients with primary liver cancer after hepatectomy.

Strategy of standardized nutritional support therapy in the perioperative period / 中华消化外科杂志

In recent years,nutritional support therapy has been increasingly paid attention to scientific and reasonable using for patients.Based on the recent researches,the hot topics on the nutritional risk screening,nutritional status assessment and preoperative and postoperative nutritional support therapy were analyzed,and the strategies and progresses of nutritional support therapy for the postoperative critically ill patients,obese patients and short bowel syndromes or bowel failure patients were summarized,meanwhile,hot issues on the standardized nutritional support therapy in the perioperative period were explored in this article.

Research progress of nutritional support therapy in the perioperative period / 中华消化外科杂志

Standardized nutritional support therapy can improve the nutrition status and surgical tolerance as well as reducing postoperative complications.The enteral nutritional support therapy is recommended as the first choice,while supplementary parenteral nutrition will be applied to the patients when enteral nutritional support therapy cannot achieve target supplement for more than 3 days.Enhanced recovery after surgery (ERAS) focuses on the optimization of preoperative managements,which also greatly update the strategy of nutritional support therapy.Risk assessment of nutrition in patients with surgery and correction of preoperative malnutrition are becoming important parts of ERAS.Preoperative nutritional support therapy not only emphasizes the energy supplement,but also regulates pathophysiologic changes of patients with surgery.It has been regarded as a mandatory method to enhance postoperative recovery and optimize preoperative managements.

Effects of timing of enteral nutrition in the severe acute pancreatitis / 中华消化外科杂志

Objective To explore the effects of timing of enteral nutrition (EN) in the severe acute pancreatitis (SAP).Methods The rabbit model of SAP was constructed,and 40 experimental rabbits were divided randomly into the experimental group (20 rabbits) and the control group(20 rabbits).(1) The parenteral nutrition (PN) was administered to rabbits in the experimental group,and then EN was administered after bowel sound restoration.(2) EN was administered to the rabbits in the control group at hour 12 after PN.The values of TNF-α,IL-6 and IL-8 on post-modeling day 1,3 and 7 and intra-abdominal pressures at hour 1 before EN and on post-modeling day 1 and 3 were respectively examined.The experimental animals were sacrificed on post-modeling day 7 and 10.The expression of nuclear factor-kappa B (NF-κB) was detected by immunohistochemistry and bacteria from mesenteric lymph nodes were cultured.The measurement data with normal distribution were presented as (x) ± s.The trend comparison between groups and pairwise comparison were analyzed using the repeated measures ANOVA and t test.Results The 40 rabbit models of SAP were constructed successfully.(1) The results of serum test showed that the values of TNF-α,IL-6 and IL-8 in the experimental group on post-modeling day 1,3and 7 were (6.9 ±2.1)ng/L,(5.9 ± 1.8) ng/L,(5.3 ± 1.8) ng/L and (109 ± 17) ng/L,(96 ± 16) ng/L,(83 ± 17)ng/L and (89 ±20)ng/L,(78 ±21)ng/L,(70 ± 19)ng/L,respectively.The values of TNF-α,IL-6 and IL-8 in the control group on post-modeling day 1,3 and 7 were (7.4 ± 1.5) ng/L,(7.1 ± 1.6) ng/L (6.8 ±1.7) ng/L and (101 ± 19) ng/L,(98 ± 18) ng/L,(93 ±20) ng/L and (91 ± 14) ng/L,(91 ± 16) ng/L,(83 ±19)ng/L,respectively.There were significant differences in the changing trends of TNF-α and IL-6 between the 2 groups (F =7.947,19.386,P ＜ 0.05),with no significant difference in the changing trend of IL-8 between the 2 groups (F =2.756,P ＞ 0.05).(2)The intra-abdominal pressures in the experimental group at hour 1 before EEN and on post-modeling day 1 and 3 were (3.5 ± 1.6) cmH2O (1 cmH2O =0.098 kPa),(4.3 ± 1.7) cmH2Oand (3.6 ± 1.8) cmH2O,which were significantly different from (4.9 ± 1.9) cmH2O,(5.7 ± 2.2) cmH2O and (4.5 ± 1.6)cmH2O in the control group (F =7.042,P ＜0.05).(3) The expression of NF-κB in the tissues of pancreas was localized mainly in the cell nucleus.The expression of NF-κB in the experimental group on postmodeling day 7 was 5.0 ± 2.7,which was significantly different from 7.0 ± 2.9 in the control group (t =2.236,P ＜ 0.05).(4) The amount of bacteria culture from mesenteric lymph nodes in the experimental group on postmodeling day 7 and 10 were (4.7 ±0.9) × 103 cfu/g and (4.1 ±0.7) × 103 cfu/g,which were significantly different from (5.5 ± 1.0) × 103 cfu/g and (4.6 ± 0.7) × 103 cfu/g in the control group (t =2.382,2.126,P ＜0.05).Conclusion The selective timing of EN can effectively improve the recovery of rabbits with SAP,and the efficacy of EN administering based on the recovery of bowel function may be better than immediate EN administering.

Effects of total nutrient admixture on the recovery of patients with gastric cancer after radical gastrectomy / 中华消化外科杂志

Objective To investigate the effects of total nutrient admixture (TNA) on the recovery of patients with gastric cancer after radical gastrectomy.Methods The clinical data of 50 patients with gastric cancer who were admitted to the Affiliated Hospital of Luzhou Medical College between March 2013 and March 2014 were retrospectively analyzed.Among 50 patients receiving radical gastrectomy,26 patients receiving TNA were allocated to the experimental group and 24 patients receiving conventional fluid infusion were allocated to the control group.Patients in the experimental group received the nutritional support therapy using TNA at preoperative day 5 and at postoperative days 1-5,and patients in the control group received the postoperative intravenous rehydration including water,glucose,electrolyte,vitamins and micro elements.The nutritional indexes [albumin (Alb),prealbumin,transferrin and hemoglobin (Hb)],time to anal exsufflation,incidence of complications (wound infection,anastomotic leakage,blooding and intestinal obstruction) and duration of hospital stay were observed before nutritional support therapy and at postoperative day 8.The count data were analyzed using the chi-square test.The chi-square value of correction for continuity was used when 1 ≤ minimum theoretical frequency ≤ 5.The measurement data with normal distribution were presented as (x) ±s and analyzed using the t test or repeated measures ANOVA.The ordinal data were analyzed by the analysis of variance.Results The Alb,prealbumin,transferrin and Hb in the experimental group were (38.6 ± 2.0) g/L,(281 ± 33) mg/L,(2.5 ± 0.9) g/L and (111 ± 20) g/L before nutritional support therapy and (38.2 ± 1.9) g/L,(277 ± 16) mg/L,(2.3 ± 1.1) g/L and (112 ± 37) g/L at postoperative day 8,respectivley.The Alb,prealbumin,transferrin and Hb in the control group were (38.3 ±2.4) g/L,(287 ± 34) mg/L,(2.4 ± 1.1) g/L and (107 ± 21) g/L before nutritional support therapy and (30.3 ±2.3) g/L,(190 ± 41) mg/L,(1.6 ± 0.3) g/L and (93 ± 22) g/L at postoperative day 8,respectivley.There were significant differences in the nutritional indexes at postoperative day 8 between the 2 groups (F =174.042,95.637,9.529,4.919,P ＜ 0.05).The time to anal exsufflation in the experimental group were (52 ± 11) hours,which was significantly different from (70 ± 12) hours in the control group (t =-5.176,P ＜ 0.05).The incidence of complications was 15.4％ (4/26) in the experimental group,which was significantly different from 58.3％ (14/24) in the control group (x2=6.460,P ＜0.05).Patients with complications in the 2 groups were cured by anti-infective or symptomatic treatment.The duration of hospital stay was (9 ± 3) days in the experimental group and (12 ± 4) days in the control group,with a significant difference between the 2 groups (t =-2.912,P ＜ 0.05).Conclusion TNA can improve the nutritional status of patients after radical gastrectomy in a short time.It could help patients to get through the perioperative period smoothly,and enhance the postoperative recovery.

Application of arginine-rich enteral nutritional support therapy after gastrectomy / 中华消化外科杂志

Objective To explore the clinical effects of arginine-rich enteral nutritional support therapy in patients undergoing gastrectomy.Methods The clinical data of 84 patients with gastric carcinoma who were admitted to the Wuhan Central Hospital from January 2013 to December 2014 were retrospectively analyzed.Mter gastrectomy,42 patients undergoing arginine-rich enteral nutritional support therapy were allocated to the argininerich enteral nutrition (AEN) group and 42 patients undergoing standardized enteral nutritional support therapy were allocated to the enteral nutrition (EN) group.The indexes of nutrition [BMI of patients were calculated and serum total protein (TP),albumin (Alb) and prealbumin (PAB) were detected] and immunology [T-lymphocyte subsets,total number of lymphocyte,white blood cell (WBC) and CD4 +/CD8 + were detected by flow cytometry],postoperative complications and indexes of prognosis were analyzed.The measurment data with normal distributionwere presented as (x) ± s.The comparision between groups were evaluated with the t test and repeated measures ANOVA.The count data were analyzed using the chi-square test.Results The value of TP from preoperation to postoperative day 7 was from (64 ± 16)g/L to (55 ± 13)g/L in the AEN group and from (65 ± 21)g/L to (52 ±11) g/L in the EN group,with no significant difference between the 2 groups (F =29.653,P ＞ 0.05).The values of Alb and PAB from pre-operation to postoperative day 7 were from (33 ± 17) g/L to (32 ± 3) g/L and from (0.20 ± 0.01) g/L to (0.26 ± 0.06) g/L in the AEN group and from (32 ± 19) g/L to (27 ± 5) g/L and from (0.20 ±0.03)g/L to (0.22 ±0.03) g/L in the EN group,respectively,with significant differences in the Alb and PAB between the 2 groups (F =21.784,10.653,P ＜ 0.05).The number of WBC,number of lymphocyte and percentage of CD8 + T-cell in the AEN group were (5.3 ± 0.7) × 109/L,(1.39 ± 0.06) × 109/L and 17.3 ％ ±3.5％ before operation and (5.9 ±0.7) × 109/L,(1.33 ± 0.03) × 109/L and 18.4％ ± 3.8％ after operation.The number of WBC,number of lymphocyte and percentage of CD8 + T-cell in the EN group (5.1 ± 0.5) × 109/L,(1.40±0.04) × 109/L and 16.4％±2.8％ before operation and (5.4±0.5) ×109/L,(1.23±0.04) ×109/L and 17.3％ ± 3.1％ after operation.There was no significant difference in the above indexes between the 2 groups (F =17.429,20.461,38.820,P ＞ 0.05).The percentages of CD4 + T-cell and CD4 +/CD8 + before operation and at postoperative day 10 were 34.7％ ± 5.4％,39.5％ ± 3.9％ and 1.80 ± 0.29,2.23 ± 0.32 in the AEN group,and 33.2％±4.6％,34.6％±2.4％ and 1.73 ±0.26,1.82 ±0.42 in the EN group,respectively,with no significant difference in the above indexes between the 2 groups (F =14.398,7.473,P ＜ 0.05).The incidences of postoperative complication in the AEN group and in the EN group were 9.5％ (4/42) and 31.0％ (13/42),showing a significant difference between the 2 groups (x2=4.459,P ＜ 0.05).The duration of postoperative systemic inflammatory response syndrome (SIRS) were (1.3 ± 0.6)days in the AEN group and (2.4 ± 1.0) days in the EN group,with a significant difference between the 2 groups (t =6.360,P ＜ 0.05).The time to anal exsufflation and time of bowel movements were (2.6 ± 0.3) days and (3.6 ± 0.5) days in the AEN group and (2.5 ± 0.3) days and (3.5 ± 0.5) days in the EN group,respectively,with no significant difference between the 2 groups (t =1.570,0.897,P ＞ 0.05) . There was no perioperative death.The hospital expenses were (17 000 ±4 000) yuan in the AEN group and (22 000 ±5 000) yuan in the EN group,with a significant difference between the 2 groups (t =3.860,P ＜ 0.05).Conclusion Arginine-rich enteral nutritional support therapy is superior to standardized enteral nutrition in effectively improving postoperative nutrition status,immune function and prognosis of patients undergoing gastrectomy.

Perioperative nutritional support therapy in patients with gastrointestinal cancer / 中华消化外科杂志

Patients with gastrointestinal cancer usually suffer from malnutrition,which is associated with increased incidence of surgery-related complications and mortality,prolonged duration of hospital stay,reduced quality of life.The feasible and effective perioperative nutritional support therapy could improve nutritional status and immunologic function of patients,meanwhile,reduce incidence of infected complications,duration of hospital stay and mortality.

Hot topics in the perioperative nutritional support therapy in abdominal surgery / 中华消化外科杂志

Malnutrition is common in the abdominal surgery and affects the recovery of patients.Reasonable nutritional support therapy can improve the prognosis of patients.The nutritional risk screening should be apphed to patients within 24 hours of admission.Patients with the nutritional risk and malnutrition should receive the nutritional support by selecting a good timing and way based on the nutritional support planning.Preoperative fasting all night for the majority of patients is not necessary,patients should be allowed to intake low-concentration liquid diet at hour 2 before anesthesia.Patients with preoperative severe malnutrition should be given 7-10 days of nutritional support therapy.The enteral nutritional therapy was preferred to patients needing postoperative nutritional support therapy,while parenteral nutrition therapy should be supplied to patients with infeasible enteral nutrition or expected target of 60％ for enteral nutrition.Individual nutritional support therapy is not necessary for patients without severe concomitant disease.Pharmacological nutrients such as ω-3 polyunsaturated fatty acids and glutamine are beneficial for abdominal surgery and critical patients,which should be used reasonably.

Application value of nutritional support therapy after resection of esophageal cancer / 中华消化外科杂志

Objective To investigate the application value of nutritional support therapy after resection of esophageal cancer.Methods The clinical data of 125 patients with esophageal cancer who were admitted to the Shandong Provincial Hospital Affiliated to Shandong University between May and November 2013 were retrospectively analyzed.According to the Nutritional Risk Screening 2002 (NRS 2002), 58 patients with scores of NRS 2002 ≥3 were allocated to the A group including 43 receiving nutritional support therapy in the A1 group and 15 receiving no nutritional support therapy in the A2 group;67 patients with scores of NRS 2002 ＜ 3 were allocated to the B group including 29 receiving nutritional support therapy in the B1 group and 38 receiving no nutritional support therapy in the B2 group.The NRS 2002 was used as a screening tool of nutritional risk within 48 hours after admission.There was nutritional risk in patients with scores of NRS 2002 ≥ 3 and no nutritional risk in patients with scores of NRS 2002 ＜ 3.Patients and their families would choose whether or not underwent nutritional support therapy after the risks being informed.Parenteral nutritional support therapy used any 2 kinds of intravenously infusions of glucose, fat emulsion and amino acid, and enteral nutritional support therapy included tube feeding enteral nutrition or oral nutriments.The calories ≥ 10 kcal/(kg · d) were offered for more than 5 days.The incidence of malnutrition in patients with nutritional risk was calculated, and the level of serum Alb and prealbumin before operation, at postoperative day 3 and day 7, postoperative recovery time of gastrointestinal function and duration of hospital stay were detected.Count data were analyzed using the chi-square test.Measurement data with normal distribution were presented as-x ± s.Comparison among groups was analyzed using the LSD-t test, and repeated measures data were analyzed by the repeated measures ANOVA.Results Of 58 patients in the A group, 51 patients were complicated with malnutrition with a incidence of 87.9％, and nutritional support therapy in 43 patients was well tolerated without abdominal pain, distension and diarrhea.The level of serum Alb before operation, at postoperative day 3 and day 7 were (29.4 ± 1.7) g/L, (29.8 ± 1.5) g/L, (32.2 ± 2.3) g/L in the A1 group, (28.5±1.9)g/L, (27.0±1.8)g/L, (28.3 ±1.7)g/L in the A2 group, (35.8±1.3)g/L, (36.0± 1.4) g/L, (37.4 ± 2.1) g/L in the B1 group and (34.5 ± 1.3) g/L, (35.3 ± 1.7) g/L, (36.3 ± 1.5) g/L in the B2 group, showing a significant difference in the changing trends between the A1 and A2 groups (F =2.541, P ＜0.05) and no significant difference between the B1 and B2 groups (F =0.734, P ＞ 0.05).The number of patients with level of prealbumin ＜2.5 g/L and ≥2.5 g/L before operation, at postoperative day 3 and day 7 were 17 and 26, 13 and 30, 10 and 33 in the A1 group, 6 and 9, 9 and 6, 10 and 5 in the A2 group, 5 and 24, 6 and 23, 7 and 22 in the B1 group and 7 and 31, 9 and 29, 13 and 25 in the B2 group, with a significant difference between the A1 and A2 groups (x2 =4.183, P ＜ 0.05) and no significant difference between the B1 and B2 groups (x2 =0.795, P ＞ 0.05).The postoperative recovery time of gastrointestinal function and duration of hospital stay were (3.2 ± 0.8) days and (11.6 ± 1.1) days in the A1 group, (3.8 ± 1.0) days and (15.5 ± 2.7) days in the A2 group, (2.7 ± 1.0) days and (10.6 ± 2.6) days in the B1 group and (3.2 ± 0.8) days and (11.3 ±1.5) days in the B2 group, with significant differences between the A1 and A2 groups (t =0.921, 3.005, P ＜0.05) and no significant difference between the B1 and B2 groups (t =0.927, 0.440, P ＞ 0.05).Conclusions Application of NRS 2002 for evaluating nutritional status and guiding nutritional support therapy in patients with esophageal cancer is accurate and trusted.The postoperative nutritional support therapy should be selectively and reasonably applied to patients with nutritional risk, and it can improve the nutritional status of patients with esophageal cancer, enhance postoperative recovery and reduce duration of hospital stay.