Role of Gut after severe surgical stress

严重创伤后的实验感染常导致多系统器官衰竭(MSOF)和死亡。这种临床图像的顺序性导致了关于MSOF发展的“两击”或“二次攻击”理论的想法。我们研究了大鼠二次攻击模型中细菌易位(BT)和细胞因子的反应，并观察营养供应的时机和途径是否可以调节这些反应。方法：大鼠(n=57)接受正中剖腹手术，术后接受腹腔注射。酵母多糖作为第二次攻击。将动物分为S1组和S3组，每组又分为全肠外营养(TPN)组、全肠内营养(TEN)组和饲料(C)组。手术结束后，TPN组和10只大鼠接受等热量、等氮营养。C组大鼠自由进食标准饲料。酵母多糖攻击18h后，大鼠灌胃108E.Coli和SACR…。四个小时后，情况更加明朗。取肝、肠系膜淋巴结(MLN)、脾、血。结果：术后早期二次发作(S1)导致细菌易位的发生率和对IL-6反应的调节作用明显高于二次发作晚期(S2)，肠内营养支持减少了细菌易位和IL-6的产生。结论：术后早期肠内营养支持在二次发作可能造成严重后果的情况下是最有效的。26例患者术后24小时内开始肠内营养。治疗前12例患者分别于第1天、第3天和第5天分别给予300kcal/d、2600kcal/d和41200kcal/d的肠内营养。2例患者在第4天停止肠内营养，2例在第5天因腹胀和/或腹泻而减少肠内营养。其余患者在术后5天给予900大卡/天，耐受性良好。结论：大多数患者在胃肠道手术后24小时内早期肠内营养是可行的。较少

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