Department of General Surgery, Qingdao University Medical College Hospital, Qingdao 266003, Shandong Province, China.
World J Gastroenterol. 2012 Jun 7;18(21):2695-703. doi: 10.3748/wjg.v18.i21.2695.
To investigate the effect of intensive vs conventional insulin therapy on perioperative nutritional substrates metabolism in patients undergoing radical distal gastrectomy.
Within 24 h of intensive care unit management, patients with gastric cancer were enrolled after written informed consent and randomized to the intensive insulin therapy (IIT) group to keep glucose levels from 4.4 to 6.1 mmol/L or the conventional insulin therapy (CIT) group to keep levels less than 10 mmol/L. Resting energy expenditure (REE), respiratory quotient (RQ), resting energy expenditure per kilogram (REE/kg), and the lipid oxidation rate were monitored by the indirect calorimeter of calcium citrate malate nutrition metabolism investigation system. The changes in body composition were analyzed by multi-frequency bioimpedance analysis. Blood fasting glucose and insulin concentration were measured for assessment of Homeostasis model assessment of insulin resistance.
Sixty patients were enrolled. Compared with preoperative baseline, postoperative REE increased by over 22.15% and 11.07%; REE/kg rose up to 27.22 ± 1.33 kcal/kg and 24.72 ± 1.43 kcal/kg; RQ decreased to 0.759 ± 0.034 and 0.791 ± 0.037; the lipid oxidation ratio was up to 78.25% ± 17.74% and 67.13% ± 12.76% supported by parenteral nutrition solutions from 37.56% ± 11.64% at the baseline; the level of Ln-HOMA-IR went up dramatically (P < 0.05, respectively) on postoperative days 1 and 3 in the IIT group. Meanwhile the concentration of total protein, albumin and triglyceride declined significantly on postoperative days 1 and 3 compared with pre-operative levels (P < 0.05, respectively). Compared with the CIT group, IIT reduced the REE/kg level (27.22 ± 1.33 kcal/kg vs 29.97 ± 1.47 kcal/kg, P = 0.008; 24.72 ± 1.43 kcal/kg vs 25.66 ± 1.63 kcal/kg, P = 0.013); and decreased the Ln-HOMA-IR score (P = 0.019, 0.028) on postoperative days 1 and 3; IIT decreased the level of CRP on postoperative days 1 and 3 (P = 0.017, 0.006); the total protein and albumin concentrations in the IIT group were greater than those in the CIT group (P = 0.023, 0.009). Postoperative values of internal cell fluid (ICF), fat mass, protein mass (PM), muscle mass, free fat mass and body weight decreased obviously on postoperative 7th day compared with the preoperative baseline in the CIT group (P < 0.05, respectively). IIT reduced markedly consumption of fat mass, PM and ICF compared with CIT (P = 0.009 to 0.026).
There were some benefits of IIT in decreasing the perioperative insulin resistance state, reducing energy expenditure and consumption of proteins and lipids tissue in patients undergoing gastrectomy.
研究强化胰岛素治疗与常规胰岛素治疗对接受根治性远端胃切除术的患者围手术期营养底物代谢的影响。
在重症监护病房管理后 24 小时内，经书面知情同意并随机分组后，胃癌患者被纳入研究，分为强化胰岛素治疗（IIT）组，以将血糖水平维持在 4.4 至 6.1mmol/L，或常规胰岛素治疗（CIT）组，以将血糖水平维持在低于 10mmol/L。通过柠檬酸钙苹果酸营养代谢调查系统的间接热量计监测静息能量消耗（REE）、呼吸商（RQ）、每公斤静息能量消耗（REE/kg）和脂质氧化率。通过多频生物阻抗分析来分析身体成分的变化。测定空腹血糖和胰岛素浓度以评估稳态模型评估的胰岛素抵抗。
共纳入 60 例患者。与术前基线相比，术后 REE 增加超过 22.15%和 11.07%；REE/kg 上升至 27.22±1.33kcal/kg 和 24.72±1.43kcal/kg；RQ 下降至 0.759±0.034 和 0.791±0.037；由肠外营养溶液提供的脂质氧化比例增加至 78.25%±17.74%和 67.13%±12.76%，基线水平为 37.56%±11.64%；IIT 组术后第 1 天和第 3 天 Ln-HOMA-IR 水平显著升高（P<0.05）。同时，与术前水平相比，IIT 组术后第 1 天和第 3 天总蛋白、白蛋白和甘油三酯浓度明显下降（P<0.05）。与 CIT 组相比，IIT 降低了 REE/kg 水平（27.22±1.33kcal/kg 比 29.97±1.47kcal/kg，P=0.008；24.72±1.43kcal/kg 比 25.66±1.63kcal/kg，P=0.013）；并降低了术后第 1 天和第 3 天的 Ln-HOMA-IR 评分（P=0.019，0.028）；IIT 降低了术后第 1 天和第 3 天的 CRP 水平（P=0.017，0.006）；IIT 组的总蛋白和白蛋白浓度大于 CIT 组（P=0.023，0.009）。与术前基线相比，CIT 组术后第 7 天细胞内液（ICF）、脂肪量、蛋白质质量（PM）、肌肉量、游离脂肪量和体重明显减少（P<0.05）。与 CIT 相比，IIT 显著减少了脂肪量、PM 和 ICF 的消耗（P=0.009 至 0.026）。
强化胰岛素治疗可降低胃癌患者围手术期胰岛素抵抗状态，降低能量消耗和蛋白质及脂质组织消耗。
