Vantini I, Benini L, Bonfante F, Talamini G, Sembenini C, Chiarioni G, Maragnolli O, Benini F, Capra F
Department of Medical and Surgical Sciences, Internal Medicine A and Rehabilitation Gastroenterology, University of Verona, Policlinico G.B. Rossi, Piazz. le L.A. Scuro, 37134 Verona, Italy.
Dig Liver Dis. 2004 Jan;36(1):46-55. doi: 10.1016/j.dld.2003.09.015.
Intestinal failure impairs nutritional status and survival expectance. Though intestinal adaptation and enteral independence may be achieved, artificial nutrition is needed in about half of the patients.
This study is aimed at assessing the causes of death, survival rate, enteral independence in time, and factors affecting the clinical outcome in a group of patients with intestinal insufficiency.
Sixty-eight patients with intestinal insufficiency, due to major intestinal resection in 60 cases (short bowel syndrome) (remnant intestine length 101-150 cm in 31 cases, 50-100 cm in 23 cases, <50 cm in 6 cases), and due to chronic idiopathic pseudo-obstruction in 8 cases, were enrolled and followed-up for (median) 36 months (25th and 75th percentile in 12 and 60 months, respectively). In 60 short bowel syndrome patients, the main conditions that led to intestinal failure were ischemic bowel (28), major surgery complications or severe adhesions (17), radiation enteritis (10), Chron's disease, intestinal tuberculosis, small bowel lymphoma and trauma (others).
Seventeen variables age, underlying disorders, length of remnant bowel, type of surgery, hospital stay, type of nutrition (hospital and home) and its variations in time, causes of death, survival rate and time were considered. Statistical analysis was carried out by Mann-Whitney U-test, Pearson chi2, Spearman correlation test, Kaplan-Meyer method and Cox's proportion hazards regression model.
At the time of admission to the hospital, none of the patients had nutritional independence, 54 (79.4%) were on parenteral nutrition and 14 (20.6%) were on enteral nutrition. At the time of discharge, 23 (33.8%) patients showed enteral independence, 39 were on home parenteral nutrition, 3 on enteral nutrition + i.v. feeding, 1 on enteral nutrition, and 2 needed oral supplementation with hydroelectrolyte solutions only. After a median value of 36 months, 30 and 2 patients were on home parenteral nutrition and enteral nutrition + i.v. feeding, respectively, 2 on enteral nutrition, 2 on oral supplementation with hydroelectrolyte solutions, and 26 cases reached enteral independence. A significant relationship was detected between the length of remnant bowel and types of nutrition at both admission (r = 0.38; P = 0.001) and discharge (r = 0.48; P = 0.001), parenteral nutrition being more frequent in patients with very short bowel. Twenty-two patients (32.4%) died (4 from newly occurring malignancies), 40 (58.8%) survived, and 6 (8.8%) were lost to the follow-up. Eleven of 22 patients died from conditions related to intestinal failure (8 cases) and/or home parenteral nutrition complications (3 cases). At 12, 24, 36, 48, 60 and 72 months, survival rates were 95.4, 93.3, 88.1, 78.6, 78.6 and 65.5%, respectively, but it was significantly lower for patients with <50 cm of remnant bowel than those with longer residual intestine (P < 0.05), and in patients who started home parenteral nutrition above the age of 45 years (P < 0.02). Survival rate was higher in patients with enteral independence than those with enteral dependence (P < 0.05). Better survival rates were registered in patients with chronic obstructive intestinal pseudo-obstruction and major surgery complications, whereas ischemic bowel and even more radiation enteritis were associated with a lower survival expectance.
Actuarial survival rate of patients with intestinal failure quotes 88 and 78% at 3 and 5 years, respectively. It is influenced by the length of remnant intestine, age at the start of home parenteral nutrition, enteral independence and, to some extent at least, by the primary disorder. Enteral independence can be achieved in time by about 40% of the patients with intestinal insufficiency, but for home parenteral nutrition-dependent cases, intravenous feeding can be stopped in less than one out of five patients during a median 3-year period.
肠衰竭会损害营养状况和预期寿命。尽管可实现肠道适应和肠内营养自主，但约半数患者仍需人工营养支持。
本研究旨在评估一组肠功能不全患者的死亡原因、生存率、肠内营养自主时间以及影响临床结局的因素。
68例肠功能不全患者纳入研究并随访（中位时间）36个月（第25和第75百分位数分别为12个月和60个月），其中60例因肠道大部切除（短肠综合征）（31例残余肠管长度为101 - 150 cm，23例为50 - 100 cm，6例<50 cm），8例因慢性特发性假性肠梗阻。在60例短肠综合征患者中，导致肠衰竭的主要病因包括缺血性肠病（28例）、重大手术并发症或严重粘连（17例）、放射性肠炎（10例）、克罗恩病、肠结核、小肠淋巴瘤及外伤（其他）。
考虑17个变量，包括年龄、基础疾病、残余肠管长度、手术类型、住院时间、营养类型（住院及居家）及其随时间的变化、死亡原因、生存率及生存时间。采用Mann - Whitney U检验、Pearson卡方检验、Spearman相关检验、Kaplan - Meyer法及Cox比例风险回归模型进行统计分析。
入院时，所有患者均无肠内营养自主，54例（79.4%）接受肠外营养，14例（20.6%）接受肠内营养。出院时，23例（33.8%）患者实现肠内营养自主，39例接受家庭肠外营养，3例接受肠内营养 + 静脉营养，1例仅接受肠内营养，2例仅需口服补充水电解质溶液。中位36个月后，分别有30例和2例患者接受家庭肠外营养及肠内营养 + 静脉营养，2例接受肠内营养，2例接受口服补充水电解质溶液，26例实现肠内营养自主。残余肠管长度与入院时（r = 0.38；P = 0.001）及出院时（r = 0.48；P = 0.001）的营养类型均存在显著相关性，肠管极短的患者肠外营养更为常见。22例患者（32.4%）死亡（4例死于新发恶性肿瘤），40例（58.8%）存活，6例（8.8%）失访。22例死亡患者中，11例死于与肠衰竭相关的疾病（8例）和/或家庭肠外营养并发症（3例）。在12个月、24个月、36个月、48个月、60个月和72个月时，生存率分别为95.4%、93.3%、88.1%、78.6%、78.6%和65.5%，但残余肠管<50 cm的患者生存率显著低于残余肠管较长者（P < 0.05），且45岁以上开始接受家庭肠外营养的患者生存率也较低（P < 0.02）。肠内营养自主患者的生存率高于肠内营养依赖患者（P < 0.05）。慢性阻塞性肠假性梗阻和重大手术并发症患者的生存率较高，而缺血性肠病尤其是放射性肠炎患者的预期生存率较低。
肠衰竭患者的精算生存率在3年和5年时分别为88%和78%。其受残余肠管长度、开始家庭肠外营养的年龄、肠内营养自主情况影响，至少在一定程度上还受原发疾病影响。约40%的肠功能不全患者可及时实现肠内营养自主，但对于依赖家庭肠外营养的患者，在中位3年期间每5例患者中不到1例可停止静脉营养。
