Clinical trial comparing enteral nutrition and parenteral nutrition following pylorus-preserving pancreatoduodenectomy

对于保留幽门的胰腺切除术（PPPD）术后早期的营养管理，主要采用肠外营养（TPN）。然而，目前，肠内饮食（艾德）作为一种有效的措施，以防止细菌移位引起了人们的广泛关注。本随机对照研究旨在评价艾德和TPN作为术后营养管理的方法，我们比较了PPPD术后期间接受艾德或TPN支持的患者，特别是观察了术后并发症的发生率和血液中细胞因子的水平，并获得了有趣的结果。[受试者]受试者包括1999年4月至2001年3月接受PPPD的42例患者。[方法]（1）采用信封投票法，将受试者随机分为艾德组和TPN组。 ...更多信息 方法(2)通过以下途径给予营养：对于艾德组（22例患者），将一根8 Fr的营养管从重建期间抬高的空肠闭合端插入抬高的空肠体;对于TPN组（20例患者），将一根FVH导管插入锁骨下静脉，并在手术完成后缝合腹部后立即留在那里。(3)术后营养管理进行如下。对于艾德组，患者在术后第1天服用50 ml茶，分两次服用，第2天服用200 ml易消化营养补充剂（1 kcal/ml），第3天服用400 ml，第4天服用600 ml，第5天服用800 ml，第6天服用1200 ml，第7天服用1600 ml。从第8天开始，肠内喂养与正常经口喂养相结合。就每日卡路里摄入量的增加而言，TPN组以类似的方式进食。(4)在手术前和手术后第1天、第8天、第15天和第22天测量血液中细胞因子（IL-6）的水平。术后并发症的发生率也被跟踪。比较了艾德和TPN组血液中细胞因子水平随时间的变化和术后并发症的发生率，以评价哪种喂养方法是接受PPPD患者术后早期营养管理的更好方法。[结果]（1）并发症发生率：艾德组4例（淋巴漏1例，胰肠吻合口轻度漏1例，胃排空延迟2例），TPN组6例（肺炎1例，胰肠吻合口轻度漏1例，胃排空延迟2例，IVH导管感染2例）。两组并发症发生率无显著差异。(2)对于艾德组，术前血液中细胞因子（IL-6）的平均水平为5.8（pg/ml），术后第1天为107.0，第8天为34.4，第15天为21.1，第22天为12.0。TPN组的相应值分别为5.9（pg/ml）、106.0、46.9、80.1、32.8和12.8。TPN组血清细胞因子水平显著高于艾德组（p <0.05）。[结论]从术后并发症发生率和术后血中细胞因子水平变化来看，肠内营养是PPPD患者术后早期营养管理的一种较好的方法。少

For nutritional management during the early phase of the post operative period for pylorus-preserving pancreatoduodenectomy (PPPD), parenteral nutrition (TPN) has been mainly employed. Currently, however, enteral dieting (ED) has attracted much attention as an effective measure to prevent the translocation of bacteria. In this randomized, controlled study to evaluate ED and TPN as means for post-operative nutritional management, we compared patients supported by either ED or TPN during the postoperative period following PPPD, especially looking at the incidence of post operative complications and the level of cytokines in the blood, and obtained interesting results.[Subjects]The subjects included forty-two patients who had received PPPD from April 1999 to March 2001.[Methods](1) The type of feeding to be employed during the post operative period was determined as follows : the subject was assigned randomly to either the ED or TPN group immediately after PPPD by the ballot-in-envelop me … More thod.(2) Nutrition was given through the following routes: for the ED group22 patients), a nutritional tube with a size of 8 Fr. was inserted from the closed end of the jejunum that was elevated during reconstruction into the elevated jejunum body; and for the TPN group(20 patients), an FVH catheter was inserted into the subclavian vein to remain there immediately after the abdomen was sutured upon completion of the surgery.(3) post-operative nutritional management proceeded as follows. For the ED group, the patient was administered 50 ml of tea two times on postoperative Day 1, 200 ml of easily digestible nutritional supplement (1 kcal/ml) on Day 2, 400 ml on Day 3, 600 ml on Day 4,800 ml on Day 5, 1200 ml on Day 6, and 1600 ml on Day 7. From Day 8 onward, the enteral feeding proceeded in combination with normal oral feeding. Feeding proceeded in a similar manner for the TPN group in terms of the daily increase in calorie intake.(4) The level of cytokine (IL-6) in the blood was measured before surgery, and on post-surgery Day 1, Day 8, Day 15 and Day 22. The incidence of post operative complications was also followed. The ED and TPN groups were compared for their change in cytokine levels in the blood over time and for the incidence of post operative complications, to evaluate which feeding method is a better means of nutritional management during the early phase of the post operative period for patients receiving PPPD.[Results](l) With regard to the incidence of complications, there were 4 cases in the ED group (one with lymphorrhea, one with minor leakage through the pancreatojejunal anastomosis and two with delayed gastric empty) and six in the TPN group (one with pneumonia, one with minor leakage through the pancreatojejunal anastomosis, two with delayed gastric empty and two with infection through the IVH catheter). There was no significant difference in the incidence of complications between the two groups.(2) For the ED group, the average level of cytokine (IL-6) in the blood was 5.8 (pg/ml) before surgery, and 107.0 on postoperative Day 1, 34.4 on Day 8, 21.1 on Day 15 and 12.0 on Day 22. For the TPN group, the corresponding values were 5.9 (pg/ml), 106.0, 46.9 80.1, 32.8 and 12.8, respectively. The average level of cytokine in the blood was significantly higher m the TPN group as compared with the ED group (p < 0 05).[Conclusion]It was concluded that, based on the incidence of post operative complications and on the postoperative change in cytokine levels in the blood, enteral feeding is better than parenteral feeding as a means for nutritional management of PPPD patients during their early postoperative period. Less