摘要
目的调查国内64家三甲医院胰十二指肠切除围术期营养管理的现状,探讨其营养管理策略。方法采用横断面调查研究方法。2020年3月31日至4月13日,以中华医学会外科学分会胰腺外科学组青年精英俱乐部成员及部分其他国内三甲医院的胰腺外科医师为调查对象,设计《胰十二指肠切除术围术期营养支持调查表》电子问卷进行调查研究。问卷通过网络微信推送方式发放。观察指标:(1)一般信息。(2)术前营养管理。(3)术中营养管理。(4)术后营养管理。(5)不同手术量医学中心营养管理比较。正态分布的计量资料以x±s表示。计数资料以绝对数或百分比表示,组间比较采用χ2检验。结果(1)一般信息:共收回22个省35个城市64家三甲医院的96份有效问卷。96位医师中,男94例,女2例;年龄为(42±7)岁,年龄范围为29~59岁。(2)术前营养管理。①术前营养评价及筛查:96位医师中,62.5%(60/96)医师常规进行术前营养状况评价。术前营养筛查:41.7%(40/96)医师对每位患者进行筛查,54.2%(52/96)医师仅在考虑需要营养支持时进行筛查。筛查工具选择:66.7%(64/96)医师仅采用营养风险筛查2002。非工具性评价指标选择:97.9%(94/96)医师选择≥2种指标综合评价,92.7%(89/96)医师选择白蛋白作为评价指标。②术前营养支持:96位医师中,13.5%(13/96)医师常规进行术前营养支持。术前营养支持方式:94.8%(91/96)医师选择以饮食为基础的营养支持方式。术前营养支持时间:43.8%(42/96)医师选择根据手术时间确定术前营养支持时间。加速康复外科(ERAS):24.0%(23/96)医师常规术前2 h给予清流质饮食或碳水化合物负荷。(3)术中营养管理。①术中空肠造瘘管理:96位医师中,8.3%(8/96)医师常规行空肠造瘘。②术中营养管路管理:30.2%(29/96)医师术中放置鼻空肠管,78.1%(75/96)医师术中放置鼻胃管,38.7%(29/75)医师根据患者胃液量决定鼻胃管拔除时间,32.0%(24/75)医师在患者排气后拔除鼻胃管。(4)术后营养管理。①术后营养支持方式:96位医师中,84.4%(81/96)医师术后常规营养支持,其中56.8%(46/81)医师行肠外营养为主,向饮食过渡。78.1%(75/96)医师选择术后第1天行全肠外营养或补充性肠外营养,86.5%(83/96)医师选择术后7 d经口进食。②术后并发症营养管理:术后发生B级以上胰瘘时,63.5%(61/96)医师选择通过经皮内镜下胃⁃空肠造瘘、鼻胃管或鼻空肠管行肠内营养支持。术后发生胃排空障碍时,72.9%(70/96)医师选择通过经皮内镜下胃⁃空肠造瘘或鼻空肠管行肠内营养支持。(5)不同手术量医学中心营养管理比较:96位医师中,所在医学中心手术量>100例/年的医师术中鼻胃管放置率为66.7%(32/48),所在医学中心手术量≤100例/年的医师术中鼻胃管放置率为89.6%(43/48),两者比较,差异有统计学意义(χ2=7.375,P<0.05)。结论我国三甲医院胰腺外科医师胰十二指肠切除围术期营养支持的指征、途径和时间等尚无统一标准,营养管理及ERAS策略理论与实践差异较大,亟待开展以营养管理策略为干预措施的前瞻性研究,总结形成符合我国临床实际的胰腺外科围术期营养管理专家共识。
Objective To assess the current practice in perioperative nutritional managament of patients undergoing pancreatoduodenectomy from 64 level A tertiary hospitals in China,and investigate nutritional managament strategies.Methods The cross⁃sectional survey was conducted.From March 31 st to April 13 th,electronic questionnaires of perioperative nutritional management of patients undergoing pancreatoduodenectomy were sent to the members of Youth Club of Chinese Pancreatic Surgery Association and some pancreatic surgeons from other level A tertiary hospitals in China.The questionnaires were issued by online Wechat platform.Observation indicators:(1)general data;(2)preoperative nutritional management;(3)intraoperative nutritional management;(4)postoperative nutritional management;(5)comparison of nutritional management among medical centers with different surgical amount.Measurement data with normal distribution were represented as Mean±SD.Count data were described as absolute numbers or percentages,and comparison between groups was analyzed using the chi⁃square test.Results(1)General data:a total of 96 questionnaires from 64 level A tertiary hospitals in 35 cities of 22 provinces were retrieved.There were 94 males and 2 females,aged(42±7)years,with a range from 29 to 59 years.(2)Preoperative nutritional management.①Preoperative nutritional evaluation and screening:62.5%(60/96)of surgeons evaluated preoperative nutritional status for patients.For preoperative screening,41.7%(40/96)of surgeons performed nutritional screening in every patient,and 54.2%(52/96)performed nutritional screening when considering nutritional support.For screening tools,Nutritional Risk Screening 2002 was used in 66.7%(64/96)of surgeons.For selection of non⁃tool evaluation parameters,97.9%(94/96)chose two or more indicators for comprehensive evaluation,92.7%(89/96)chose Albumin as the evaluation parameter.②Preoperative nutritional support:there were 13.5%(13/96)of surgeons conducting nutritional support regularly.For preoperative nutritional support methods,nutritional support based on diet was conducted by 94.8%(91/96)of surgeons.For timing of perioperative nutritional support,43.8%(42/96)of surgeons determined the time according to the surgical time.Based on the theory of enhanced recovery after surgery,24.0%(23/96)of surgeons routinely gave liquid diet or carbohydrate load at the preoperative 2 hours.(3)Intraoperative nutritional management.①Intraoperative jejunostomy management:8.3%(8/96)of surgeons performed routine jejunostomy.②Intraoperative nutrition line management:the nasojejunal tube was placed intraoperatively by 30.2%(29/96),and the nasogastric tube was placed intraoperatively by 78.1%(75/96).Of the above surgeons,38.7%(29/75)determined the time to nasogastric tube removal based on gastric volume,and 32.0%(24/75)removed the nasogastric tube after flatus in patients.(4)Postoperative nutritional management.①Postoperative nutritional support methods:84.4%(81/96)of surgeons gave nutritional support,in which 56.8%(46/81)mainly gave the parenteral nutrition and transition to diet.Total parenteral nutrition at the postoperative first day or complementary parenteral nutrition was the first choice in 78.1%(75/96)of surgeons,oral feeding at postoperative 7 days was the first choice in 86.5%(83/96)of surgeons.②Postoperative nutritional management for complications:63.5%(61/96)of surgeons chose enteral nutritional support through percutaneous endoscopic gastrojejunostomy,nasogastric tube or nasojejunal tube for grade B or C pancreatic fistula,72.9%(70/96)chose enteral nutritional support through percutaneous endoscopic gastrojejunostomy or nasojejunal tube for delayed gastric emptying.(5)Comparison of nutritional management among medical centers with different surgical amount:of the 96 surgeons,surgeons in medical centers with surgical amount>100 cases a year had the nasogastric tube placement rate of 66.7%(32/48),and surgeons in medical centers with surgical amount≤100 cases a year had the nasogastric tube placement rate of 89.6%(43/48),showing a significant difference between the two groups(χ2=7.375,P<0.05).Conclusions There is no uniform standards for indications,routes,or timing of perioperative nutritional management of patients undergoing pancreatoduodenectomy among surgeons from level A tertiary hospitals in China.In patients undergoing pancreatoduodenectomy,the theories and practice of perioperative nutritional management and enhanced recovery after surgery are diverse,which urgently require prospective study with nutritional management strategy as intervention and expert consensus on perioperative nutritional managament in pancreatic surgery accorded with clinical practice in China.
作者
许静涌
卫积书
崔红元
徐强
张献娜
吴文铭
韦军民
Xu Jingyong;Wei Jishu;Cui Hongyuan;Xu Qiang;Zhang Xianna;Wu Wenming;Wei Junmin(Department of General Surgery,Beijing Hospital,National Centerf Gerontology,Institute of Geriatric Medicine,Chinese Academy of Medical Sciences,Beijing 100730,China;Pancreas Center,the First Affiliated Hospital with Nanjing Medical University,Nanjing 210029,China;Department of General Surgery,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences&Peking Union Medical Coll ge,Beijing 100730,China;Department of Pancreatic Surgery,Union Hospital of Tongji Medical College,Huazhong University of Science and Technology,Wuhan 430022,China)
出处
《中华消化外科杂志》
CAS
CSCD
北大核心
2020年第10期1062-1069,共8页
Chinese Journal of Digestive Surgery
基金
北京市科学技术委员会首都临床特色应用研究项目(Z181100001718216)。
关键词
胰腺肿瘤
胰十二指肠切除术
围术期
营养管理
现况调查
Pancreatic neoplasms
Pancreatoduodenectomy
Perioperative period
Nutritional management
Prevalence survey
