肝细胞癌肝切除患者的围手术期营养支持

Perioperative nutritional support in patients undergoing hepatectomy for hepatocellular carcinoma.

作者信息

Fan S T, Lo C M, Lai E C, Chu K M, Liu C L, Wong J

机构信息

Department of Surgery, University of Hong Kong, Queen Mary Hospital.

出版信息

N Engl J Med. 1994 Dec 8;331(23):1547-52. doi: 10.1056/NEJM199412083312303.

DOI:10.1056/NEJM199412083312303

PMID:7969324

Abstract

BACKGROUND

Resection of hepatocellular carcinoma is associated with high rates of morbidity and mortality. Since intensive nutritional support can reduce the catabolic response and improve protein synthesis and liver regeneration, we performed a prospective study to investigate whether perioperative nutritional support could improve outcome in patients undergoing hepatectomy for hepatocellular carcinoma.

METHODS

We studied 124 patients undergoing resection of hepatocellular carcinoma. Sixty-four patients (39 with cirrhosis, 18 with chronic active hepatitis, and 7 with no associated liver disease) were randomly assigned to receive perioperative intravenous nutritional support in addition to their oral diet, and 60 patients (33 with cirrhosis, 12 with chronic active hepatitis, and 15 with no associated liver disease) were randomly assigned to a control group. The perioperative nutritional therapy consisted of a solution enriched with 35 percent branched-chain amino acids, dextrose, and lipid emulsion (50 percent medium-chain triglycerides) given intravenously for 14 days perioperatively.

RESULTS

There was a reduction in the overall postoperative morbidity rate in the perioperative-nutrition group as compared with the control group (34 percent vs. 55 percent; relative risk, 0.66; 95 percent confidence interval, 0.45 to 0.96), predominantly because of fewer septic complications (17 percent vs. 37 percent; relative risk, 0.57; 95 percent confidence interval, 0.34 to 0.96). There were also a reduction in the requirement for diuretic agents to control ascites (25 percent vs. 50 percent; relative risk, 0.57; 95 percent confidence interval, 0.37 to 0.87), less weight loss after hepatectomy (median loss, 0 kg vs. 1.4 kg, P = 0.01), and less deterioration of liver function as measured by the change in the rate of clearance of indocyanine green (-2.8 percent vs. -4.8 percent at 20 minutes, P = 0.05). These benefits were seen predominantly in the patients with underlying cirrhosis who underwent major hepatectomy. There were five deaths during hospitalization in the perioperative-nutrition group, and nine in the control group (P not significant).

CONCLUSIONS

Perioperative nutritional support can reduce complications after major hepatectomy for hepatocellular carcinoma associated with cirrhosis.

摘要

背景

肝细胞癌切除术与高发病率和死亡率相关。由于强化营养支持可降低分解代谢反应并改善蛋白质合成及肝脏再生，我们进行了一项前瞻性研究，以调查围手术期营养支持能否改善肝细胞癌肝切除术患者的预后。

方法

我们研究了124例接受肝细胞癌切除术的患者。64例患者（39例肝硬化、18例慢性活动性肝炎和7例无相关肝脏疾病）被随机分配，除口服饮食外，还接受围手术期静脉营养支持；60例患者（33例肝硬化、12例慢性活动性肝炎和15例无相关肝脏疾病）被随机分配至对照组。围手术期营养治疗包括一种富含35%支链氨基酸、葡萄糖和脂质乳剂（50%中链甘油三酯）的溶液，在围手术期静脉输注14天。

结果

与对照组相比，围手术期营养组的总体术后发病率有所降低（34%对55%；相对危险度，0.66；95%置信区间，0.45至0.96），主要是因为感染并发症较少（17%对37%；相对危险度，0.57；95%置信区间，0.34至0.96）。控制腹水所需利尿剂的使用也有所减少（25%对50%；相对危险度，0.57；95%置信区间，0.37至0.87），肝切除术后体重减轻较少（中位数减轻，0 kg对1.4 kg，P = 0.01），以吲哚菁绿清除率变化衡量的肝功能恶化程度较轻（20分钟时为-2.8%对-4.8%，P = 0.05）。这些益处主要见于接受大肝切除术的肝硬化患者。围手术期营养组住院期间有5例死亡，对照组有9例死亡（P无统计学意义）。