Probst Pascal, Keller Daniel, Steimer Johannes, Gmür Emanuel, Haller Alois, Imoberdorf Reinhard, Rühlin Maya, Gelpke Hans, Breitenstein Stefan
Department of Surgery, Cantonal Hospital Winterthur, Brauerstrasse 15, 8400 Winterthur, Switzerland; Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany.
Department of Surgery, Cantonal Hospital Winterthur, Brauerstrasse 15, 8400 Winterthur, Switzerland.
Ann Med Surg (Lond). 2016 Feb 4;6:68-73. doi: 10.1016/j.amsu.2016.02.002. eCollection 2016 Mar.
Suggested guidelines for nutritional support after pancreaticoduodenectomy are still controversial. Recent evidence suggests that combining enteral nutrition (EN) with parenteral nutrition (PN) improves outcome. For ten years, patients have been treated with Early Combined Parenteral and Enteral Nutrition (ECPEN) after PD. The aim of this study was to report on rationale, safety, effectiveness and outcome associated with this method.
Consecutive PD performed between 2003 and 2012 were analyzed retrospectively. Early EN and PN was standardized and started immediately after surgery. EN was increased to 40 ml/h (1 kcal/ml) over 24 h, while PN was supplemented based on a daily energy target of 25 kcal/kg. Standard enteral and parenteral products were used.
Sixty-nine patients were nutritionally supplemented according to ECPEN. The median coverage of kcal per patients related to the total caloric requirements during the entire hospitalization (nutrition balance) was 93.4% (range: 100%-69.3%). The nutritional balance in patients with needle catheter jejunostomy (NCJ) was significantly higher than in the group with nasojejunal tube (97.1% vs. 91.6%; p < 0.0001). Mortality rate was 5.8%, while major complications (Clavien-Dindo 3-5) occurred in 21.7% of patients. Neither the presence of preoperative malnutrition nor the application of preoperative immunonutrition was associated with postoperative clinical outcome.
This is the first European study of ECPEN after PD. ECPEN is safe and, especially in combination with NCJ, provides comprehensive coverage of caloric requirements during the postoperative phase. Clinical controlled trials are needed to investigate potential benefits of complete energy supplementation during the early postoperative phase after PD.
胰十二指肠切除术后营养支持的推荐指南仍存在争议。近期证据表明，肠内营养（EN）与肠外营养（PN）联合应用可改善预后。十年来，患者在胰十二指肠切除术后接受早期肠内与肠外联合营养（ECPEN）治疗。本研究的目的是报告该方法的理论依据、安全性、有效性及预后情况。
回顾性分析2003年至2012年间连续进行的胰十二指肠切除术。早期EN和PN进行了标准化，并在术后立即开始。EN在24小时内增加至40毫升/小时（1千卡/毫升），而PN则根据每日25千卡/千克的能量目标进行补充。使用标准的肠内和肠外产品。
69例患者按照ECPEN进行了营养补充。每位患者在整个住院期间与总热量需求相关的千卡覆盖中位数（营养平衡）为93.4%（范围：100% - 69.3%）。采用空肠穿刺导管（NCJ）的患者营养平衡显著高于鼻空肠管组（97.1%对91.6%；p < 0.0001）。死亡率为5.8%，而21.7%的患者发生了严重并发症（Clavien-Dindo 3 - 5级）。术前营养不良的存在及术前免疫营养的应用均与术后临床结局无关。
这是欧洲第一项关于胰十二指肠切除术后ECPEN的研究。ECPEN是安全的，尤其是与NCJ联合应用时，可在术后阶段全面满足热量需求。需要进行临床对照试验来研究胰十二指肠切除术后早期阶段完全能量补充的潜在益处。
