O'Keefe Stephen J D
Division of Gastroenterology, University of Pittsburgh School of Medicine, PA 15213, USA.
Nat Rev Gastroenterol Hepatol. 2009 Apr;6(4):207-15. doi: 10.1038/nrgastro.2009.20.
The advent of total parenteral nutrition in the late 1960s meant that no situation remained in which a patient could not be fed. Unfortunately, total parenteral nutrition was complicated by serious infective and metabolic side effects that undermined the beneficial effects of nutrient repletion. Consequently, creative ways of restoring upper gut function were designed, based on semielemental diets and novel feeding tube systems. The employment of specific protocols and acceptance of increased gastric residual volumes has allowed most patients in intensive care to be fed safely and early by nasogastric tube. However, nasogastric feeding is unsuitable for patients with severely compromised gastric emptying owing to partial obstruction or ileus. Such patients require postpyloric tube placement with simultaneous gastric decompression via double-lumen nasogastric decompression and jejunal feeding tubes. These tubes can be placed endoscopically 40-60 cm past the ligament of Treitz to enable feeding without pancreatic stimulation. In patients whose disorders last more than 4 weeks, tubes should be repositioned percutaneously, by endoscopic, open or laparoscopic surgery. Together, the advances in enteral access have improved patients' outcomes and led to a 70-90% reduction in the demand for total parenteral nutrition.
20世纪60年代末全胃肠外营养的出现意味着不存在患者无法进食的情况。不幸的是，全胃肠外营养存在严重的感染性和代谢性副作用，削弱了营养补充的有益效果。因此，基于半要素饮食和新型喂养管系统，设计出了恢复上消化道功能的创新方法。采用特定方案并接受增加的胃残余量，使得大多数重症监护患者能够通过鼻胃管安全、早期地进行喂养。然而，鼻胃管喂养不适用于因部分梗阻或肠梗阻导致胃排空严重受损的患者。此类患者需要放置幽门后管，并通过双腔鼻胃减压管和空肠喂养管同时进行胃减压。这些管子可在内镜下放置于屈氏韧带以远40 - 60厘米处，以便在不刺激胰腺的情况下进行喂养。对于疾病持续超过4周的患者，应通过经皮、内镜、开放或腹腔镜手术重新放置管子。总之，肠内营养通路的进展改善了患者的预后，并使全胃肠外营养的需求减少了70% - 90%。
