【作者】 王红禄；

【导师】 张道荣； 牛爱国；

【作者基本信息】 河北医科大学 ， 外科学， 2002， 硕士

【摘要】 目的：小儿处于特定的成长阶段，代谢率较高，处于正氮平衡状态，再加上手术及禁食的打击，机体处于高分解代谢状态，免疫功能减退。因而术后给予营养支持是必要的。本研究的目的在于：1、探讨手术及禁食对患儿机体营养及免疫状态的影响；2、分析消化道重建术后分别给予肠外、肠内营养及不予营养支持对患儿营养及免疫状态的转归；3、对肠外、肠内营养及不予营养支持三组间的营养及免疫指标提升情况给予对比；4、确定三组肠道及全身并发症的发生率有无差异。从而确定合适的临床营养支持方案。 方法：选取需行消化道重建手术(如先天性胆总管囊肿、先天性巨结肠、肠梗阻、美克尔憩室、肠重复畸形等，按anand评分均属大中手术)的患儿，术前肝功能为child A级，肾功能正常，年龄在10月以上，按随机原则分为A、B、C三组。A组：术后72小时起给予肠外营养，逐日增至基础能量消耗(BEE)的120％，BEE按Harris-Benedict公式计算出。氮热比为1：200，共7天。B组：术后72小时开始给予肠内营养(果味力摄滴)，每日热量供应与A组相同，共7天。C组：对照组，术后72小时开始给予少量流食，逐渐恢复正常饮食。三组均根据需要给予抗生素及止血药物，营养支持前给予足量液体。三组分别于术前1天、术后3天、10天测量体重、身高、三头肌皮褶厚度、上臂肌围、肝肾功能、前白 中文摘要蛋白、靴蛋白、免疫球蛋白、哪、渺、则，椰察记录肠道及全身并发症的发生靓。硼删酣的差值均数与总蝴数0比较的t跳，比较所有患］林后3天与郴，以潞组患）时垢10天与相3天各营秘一的鳅有无统计学差异。挪成组设计的两样本均数比较的t检验，比溅外营养、肠内营养、对照组各组之间术后10天与术后3天各营养及免疫指标的变化值的差异有无统计学意义。采用四格表扩检验比较肠外、肠内营养组及对照组的枕并发症的发生率有无统计镌异。从而确定合理的营养支持方案。 结果：与郴相比，腿3天患）胳售养及免疫主剖示均明显下降，各营养及免疫指标的差异均有非常显著意义 巾刃01）；对照组枢m 天与术后3预肚b，前白蛋白任叭）与敞蛋白（TFN）的升高服著胜（p＜0．05），其瓣营养及免疫f额的变化均踉著性（仰．05＼gi’Afl’m内营辆组术后10天与术后3天相比，各营养及ai标的升高均有非常显著意义中吻．of人分另取肠外营养组术后10大与术后3大的营翻免疫指标差值均数如与硼组术后10天与棚3踞赦免疫f晰的差值均数dc，比较二者差异，结果显示：转铁蛋白（ITN）与u两指标差值均数的差异有显著意义（叫．05人 其余指标差异均有非常显著意义巾刃．of），分别取肠内营养组术后10天与术后3大的营养及腑跳撇数物 与对照组的dc相比，结果显示，前白蛋白（PA）与赋蛋白（TTN）TIng差值均数的差异有显著献（w．仍），其斜g标的差值均数的差异椭非常显著意义（p＜0．0卜肠外营养组乙与肠内营养屯相比， 2 中文摘要 除 IgA在 EN组比 PN d高差熊踞意义外 中刃。05）， 其斜g标差异均无显著统计学意义巾功．05）；各组患）怵后 肠酚全身并发症发蝉比较，EN组与硼鞭异有显著 绷学意义（p＜0．05＼而 PN组与ZUlt组、PN组与 u组比 较，差异均无显著统计学意义中to．05人 结论：l、手术创伤及禁食导致患儿机体的严重应激反 应，表现为机体B副亢及骨脚孤8，负研衡，内脏蛋白及 免删蛋白合成下降，内分泌獭，免疫功a聊制。如概 予营养支持，上述代谢紊sLI能得到阻止，机体进一步消耗， 营养不良得不到纠正，导致伤口愈合不良，术后并发症增多。 L肠外营养与肠内营养对于枕患／收育吕提供机体所需的营 养物质，减少及阻止机体的懒8，纠正营养不良，促进免疫 功能的恢复，减少脓症的发生率。3、与肠外营养相比，肠 内营养更符合食物消化、吸收的生理过程维持了肠粘膜屏障 功能的完整，减少了内毒素的释放，更好地促进免疫功能的 恢复，就液症更小，不影响肝功能。而且安全、方便、 费用低廉。所以，应啦“当胃肠有功能时，首先利用肠内 营养”的观点。更多还原

【Abstract】 Objective : Qiildren are in a special growth period. Their metabolize rate is higher than adults’. Malnutrition exists among many children who need operatioa Futhermore, after operation, their bodies are in a high catabolism state, and their immune function decrease. So it is necessary to give nutrition support to them.The objectives of this study are :l.To investigate the effects of operation and fasting on the nutrition and immune state of children who took digestive tract reconstruction operation; 2.To analysis the changes of nutrition and immune state of children respectively in ENk PN and control groups ; 3.To compare the differences of increasing level of nutrition and immune parameters among the three groups after nutrition support;4.To study the differences of morbidity and mortality among these groups, and determine which is the best nutrition support way.Methods: Select sixty children needing digestive tract reconstruction operation, whose hepatic functions were rated child A and renal functions were normal before operation, their ages were all above ten months old. they were divided randomized into three groups. Group A: 20 children were given PN since 72 hoursafter operation, nutrition energy increased according to supporting day, gradually added up to 120 percent of BEE.BEE was calculated out by Harris-Benedict formula, supporting time lasted for 7 days. Group B: 20 children were given equal energy of EN at the same time with group A. Group C:20 children were given liquid diet since 72 hours after operation and changed to semiliquid and normal diet gradually. The three Groups were all given anrtbiotic and antibleeding drugs according to needing and enough fluid through vein before nutrition support. Nutrition parameters: weight^ height^ arm circumference (AC) triceps skinfold thickness (TSF)> hepatic function and renal function prealbumin(PA) transferrin(TFN) immune function parameters including immunoglobulin G A M were measured 1 day before operation and 3 10 days after operation Recover of intestine function and morbidity and mortality were observed after operation. Arm muscle circumference (AMC) was Calculated by the formula: AMQcm) =AC(cm>3.14XTSF(cm).Body mass index(BMI) was calculated out by the formula: BMI=W(kg)/HV).Results: The attacks of operation and fasting on patient children deteriorate their nutrition and immune states. There were very significant differences (p<0.01)in weight TSF AMC BMI PA TFN IgG IgA IgM level between preoperation and 3 days after operation. There were very significant differences in all these nutrition parameters between 3 days and 10 days after operation ingroup A and B(p<0.01) But in group C, there were significant differences (pO.05) in PA and TFN, while in other parameters, there were not significant differences between 3 days and 10 days after operation. When comparing dfN and dc, We found all these parameters had significant differences too. In PA and TFN, p<0.05,and others pO.Ol.While comparing dpN and deN, IgA in EN group was higher than it in PN group, with significant difference (p<0.05), but in other parameters there weren’t significant differences(p>0.05). There weren’t any mortality in all these three groups, when comparing morbidity, there were significant differences between group B and C (p<0.05) but there weren’t significant differences between group A and B, or group AandC.Conclusion: The attacks of operation and fasting on children who took digestive tract reconstruction operation degrade their nutrition states and impair their immune functions. If they are not given nutrition support, their bad nutrition state will prolong and be accompanied by negative nitrogen balance Confused endocrine delayed wound healing , and immune function can not recover fast. If given enteral or parenteral nutrition support after operation, their nutrition states and immune functions can recover in relatively short period, and morbidity decreases significantly. Comparing with PN, EN has die advantages of safety Convience cheapment et al. So we c更多还原