Role of Gut after severe surgical stress

严重创伤后脓毒症常导致多系统器官衰竭（MSOF）和死亡。这种临床表现的连续性导致了MSOF发展的“两次发作”或“第二次发作”理论。我们研究了大鼠二次发作模型中的细菌易位（BT）和细胞因子反应，并观察营养供应的时间和途径是否可以调节这些反应。方法：大鼠（n=57）行剖腹切开术，术后以zymosan作为第二次攻击。动物分为S1 （zymozan on POD1）组和S3 （zymozan on POD3）组，每组大鼠又分为TPN（全肠外营养）组、TEN（全肠内营养）组和C （chow）组。开腹后给予TPN和TEN大鼠等热量和等氮营养。C组随机给予标准大鼠饲料。酶生酶激发18小时后，给大鼠灌胃108大肠杆菌和sacr， 4小时后再灌胃。取肝脏、肠系膜淋巴结（MLN）、脾脏和血液。测定各脏器中BT和细胞因子水平。结果<<表>>术后第二次发作早期（S1）较术后第二次发作晚期（S2）细菌易位发生率高，IL-6反应不受调节，肠内营养可减少细菌易位和IL-6产生。结论：在术后早期，肠内营养是最有效的，因为第二次发作会造成严重的后果。实验2在实验1的基础上，对全胃切除术或食管次全切除术患者进行术后早期肠内营养。26例患者术后24小时内开始肠内营养。在最初的12名患者中，在POD 1中给予300千卡/天，在POD 3中给予2600千卡/天，在POD 5后给予41200千卡/天。由于腹胀和/或腹泻，两名服用POD 4的患者停止肠内营养，两名服用POD 5的患者肠内营养量减少。在其余患者中，POD 5后给予900千卡/天，并且耐受性良好。结论：大多数患者术后24小时内早期肠内营养是可能的。少

Experiment ISepsis that follows severe trauma often results in multiple system organ failure (MSOF) and death. The sequential nature of this clinical picture has led to the idea of a "two-hit" or "second attack" theory for the development of MSOF. We investigated bacterial translocation (BT) and cytokine responses in a rat second attack model and see if the timing and route of nutrition supply can modulate these responses.Methods: Rats (n=57) underwent midline laparotomy and were postoperatively challenged I.p. with zymosan as a second attack. Animals were divided into S1 (zymozan on POD1) and S3 (zymozan on POD3) group and each group of rats were further divided into TPN (total parenteral nutrition) group, TEN (total enteral nutrition) group and C (chow) group. After laparotomy TPN and TEN rats received isocaloric and isonitrogenous nutrition. Rats in C group were provided standard rat chow ad libitum. Eighteen hours after zymosan challenge, rats were gavaged with 108 E. coli and sacr … More ificed four hours later. Liver, mesenteric lymphnode (MLN), spleen and blood were harvested. BT and cytokine levels in the organs were determined.Results <<table>>Early occurrence of postoperative second attack (S1) resulted in higher incidence of bacterial translocation and u regulated IL-6 response than in the late occurrence of second attack (S2), Nutrition supply by enteral route decreased translocation of bacterial and IL-6 production.Conclusion: Nutrition supply by enteral route appeared to be most useful in the early postoperative course when the occurrence of second attack may cause serious consequences.Experiment IIOn the basis of experiment I, post operative early enteral nutrition was performed to those underwent total gastrectomy or subtotal esophagectomy. Enteral nutrition was initiated in 26 patients within 24 hours after surgery. In the initial 12 patients, 300 kcal/day was administered on POD 1 and 2, 600 kcal/day on POD 3 and 4, 1200 kcal/day after POD 5. Enteral nutrition was discontinued in two patients on POD 4 and the amount was decreased in two patients on POD 5 because of abdominal distention and/or diarrhea. In the rest of patients, 900 kcal/day was administered after POD 5 and they were well tolerated.It is concluded that early enteral nutrition within 24 hours post gastrointestinal surgery was possible in the majority of patients. Less