早期肠内营养和全胃肠外营养治疗重症急性胰腺炎疗效的Meta分析

发布时间：2018-03-06 07:43

本文选题：早期肠内营养　切入点：全胃肠外营养　出处：《大连医科大学》2013年硕士论文　论文类型：学位论文

【摘要】：背景：重症急性胰腺炎（severe acute pancreatitis，SAP）是一种临床常见的急腹症，病情凶险、病死率高。SAP时患者由于严重的炎症反应，使得机体处于明显的高分解代谢和负氮平衡状态，能量消耗显著增加。同时，SAP还会引起营养物质和电解质的代谢紊乱。因此，营养支持是SAP患者重要的治疗措施。全胃肠外营养（total parenteral nutrition，TPN）和早期肠内营养（early enteral nutrition，EEN）是营养支持治疗的两种方式。TPN作为SAP营养支持治疗的传统模式，能够抑制胰腺分泌、减轻胃肠负担，但患者的肠道屏障功能损伤明显。EEN有助于维护患者肠粘膜结构和功能的完整，减少肠源性感染等并发症的发生，但容易引起患者的胃肠道不适。因此，目前对选择TPN或EEN治疗SAP仍存在争议。目的：评价TPN和EEN治疗SAP患者的疗效及其安全性，为临床实践提供循证医学依据。方法：计算机检索MEDLINE、PubMed、中国生物医学文献数据库（CBM）、中国知网（CNKI）、维普资讯网（VIP）及Google学术搜索引擎(Google Scholar)，检索时间为1966年1月至2013年1月。纳入所有有关EEN和TPN治疗SAP的随机对照试验（randomized control trial，RCT），同时查阅所有检出文献的参考文献作为补充。通过阅读文献题目、摘要或全文，排除不符合纳入标准的RCT。选择病死率、胰腺感染发生率、多器官衰竭发生率、外科手术干预率、腹泻发生率、高血糖发生率作为最后的分析指标。在对纳入研究的RCT进行质量评价和数据提取后，应用RevMan5.2统计软件进行统计学分析。结果：有9项RCT纳入研究，共包括453例患者，其中EEN组221例、TPN组232例。EEN组中所有SAP患者均经空肠远端途径实施肠内营养，并且开始时间为入院72h内。Meta分析结果显示：与TPN相比，，EEN可以显著降低SAP患者的病死率〔RR=0.35、95%CI（0.20,0.61）、P=0.0002〕、胰腺感染发生率〔RR=0.41、95%CI（0.24,0.71）、P=0.001〕、外科手术干预率〔RR=0.50、95%CI（0.35,0.70）、P＜0.0001〕，同时减少多器官衰竭〔RR=0.37、95%CI（0.18,0.77）、P=0.008〕和高血糖〔RR=0.47、95%CI（0.24,0.93）、P=0.03〕的发生。但在腹泻发生率方面，EEN组高于TPN组〔RR=5.54、95%CI（2.44,12.57）、P＜0.0001〕。结论：目前研究提示：经空肠远端途径、入院72h内实施的EEN可以显著降低SAP患者的病死率、外科手术干预率，并明显减少胰腺感染、多器官衰竭和高血糖的发生，有助于患者的预后。因此，SAP患者在无肠内营养禁忌症时，应将EEN作为营养支持治疗的首选方式。
[Abstract]:Background: severe acute patients with severe acute pancreatitis (SAP) is a common clinical acute abdomen. The patient is in a state of high catabolism and negative nitrogen balance due to severe inflammatory reaction. Energy consumption increased significantly. SAP also caused metabolic disorders of nutrients and electrolytes. Total parenteral nutrition (total parenteral nutrition) and early enteral nutrition (early enteral nutrition) are two methods of nutrition support therapy. TPN is the traditional mode of SAP nutrition support therapy and can inhibit pancreatic secretion. Reduce gastrointestinal burden, but the injury of intestinal barrier function is obvious. EEN is helpful to maintain the integrity of intestinal mucosal structure and function, reduce the occurrence of complications such as enterogenic infection, but it is easy to cause gastrointestinal discomfort in patients. At present, the choice of TPN or EEN for SAP is still controversial. Objective: to evaluate the efficacy and safety of TPN and EEN in the treatment of SAP patients. Methods: a computer-based search of MEDLINE PubMed, China Biomedical Literature Database (CBM), Chinese Biomedical Literature Database (CBM), Chinese Biomedical Database (CNKI), and Google academic search engine (Google) was conducted. The search time was from January 1966 to January 2013. All relevant EEN and TPN therapy SAP were included. The randomized control trialator test was supplemented by a review of all the references in the literature. Abstract or full text, exclude RCT.Select mortality, pancreatic infection, multiple organ failure, surgical intervention rate, diarrhea rate. The incidence of hyperglycemia was used as the final analysis index. After the quality evaluation and data extraction of RCT which was included in the study, the statistical analysis was carried out by RevMan5.2 statistical software. Results: nine subjects of RCT were included in the study, including 453 patients, including 221 patients in EEN group, 232 patients in EEN group. All SAP patients in EEN group were treated with enteral nutrition via distal jejunum pathway. Within 72 hours after admission, the results of Meta-analysis showed that compared with TPN, the mortality rate of patients with SAP was significantly lower than that of TPN. The incidence of pancreatic infection was 0.240.71P0.001, and the rate of surgical intervention was 0.350 / 0.70,0.350.700.000, while reducing the RR0.3795CII 0.180.379CII 0.180.771and the RR775CI0.240.2471P0.001, the surgical intervention rate was 0.350.70mg / 0.000, while reducing the RR0.3795CII 0.180.3795 / 0.180.77 / 0.77 / 0. 008). But the incidence of diarrhea in EEN group was higher than that in TPN group (P < 0.0001). Conclusion: the present study suggests that EEN administered through distal jejunum within 72 hours of admission can significantly reduce the mortality, surgical intervention rate, pancreatic infection, multiple organ failure and hyperglycemia in patients with SAP. Therefore, EEN should be the first choice of nutrition support treatment in patients without enteral nutrition contraindication.
【学位授予单位】：大连医科大学
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：R576

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