| BackgroundIn recent years,The concept of enhance recovery after surgery(ERAS) proposed by Danish doctors Kehlet is widely used in clinical. The aim of ERAS is to reduce surgical stress response, reduce the incidence of postoperative complications and mortality, speed up the rehabilitation of patients, and prompting the patient discharged early by using a variety of comprehensive and effective measures within perioperative. With the development of clinical nutrition support therapy, nutritional risk screening and to correct malnutrition of surgical patients has become an important part of ERAS.Nutritional support is a dietary method meant to treat or alleviate the symptoms of the disease, and enhance clinical efficacy used in nutrition science mechanism. The important measure that input Amino acids, fat emulsion, glutamine and other nutrients into the patient through a nasogastric, intravenous and other ways can improve and maintain the function and metabolism of organ, tissue and cell,and prevent the occurrence of multiple organ failure. Studies have shown that nutrition therapy for patients with nutritional risk can improve the prognosis of patients, have no nutritional support will affect the rehabilitation of patients; and for non-nutritive risk patients, nutritional support may not improve outcomes, or even aggravate the liver metabolic burden, resulting in nutritional support abuse. With the rise of nutritional support, millions of patients implement nutrition support therapy each year, it is necessary to regulate indications for nutritional support in theory. Therefore we need to determine whether the patient exist "nutritional risk." For patients with nutritional risk, we should formulate and implement nutritional support programs combined with clinical practice. The patients with no nutritional risk should not blindly implement nutritional support, to avoid increasing the financial burden of patients and waste of national limited resources."Nutritional risk screening (NRS2002)" is a nutritional risk screening tool applied to the inpatients made by Professor Kondrup etc. based on 128 RCT studies in 2002, and it is the only one built on the basis of evidence-based medicine. The purpose of building this tool is to select those patients who can be improved the clinical outcome through nutrition support. "NRS2002" have a very good application adaptability at home and abroad because it is relatively simple to use. "NRS2002" have achieved good results in nutritional risk screening of gastrointestinal, respiratory system cancer patients, but it is relatively few reports for hepatobiliary diseases during peri-operative nutrition risk screening and nutritional support guiding. In the clinical situation, nutritional risk or malnourished is not uncommon in Hepatobiliary disease patients. The liver is the center of energy metabolism. Hepatobiliary surgical diseases occur will affect the liver metabolism, and it has a way different from the general gastrointestinal disorders in nutritional support time, dosage,or form, etc. Unreasonable nutritional intake can not only improve patient outcomes, but would adversely affect the patient. Therefore, hepatobiliary disease patients treated with nutritional support in particular should strictly control indications. It is necessary to take the nutritional support treatment for the patients most in need and take reasonable decisions about their different nutritional support programs.Gin involved in immune regulation effect was endorsed by most scholars and it is not uncommon that Gln facilitates surgical patients postoperative rehabilitation. But at the same time, studies have reported that the use of Gln does not improve the patient’s prognosis indicators and Domestic and Nutrition Society guidelines for the use of Gln also hold different views. Glutamine peptide used in the clinical is expensive. Combined with China’s national conditions, its application value is more important from the perspective of pharmacoeconomics consider.In summary, this project will make a research about the nutrition risk screening and the efficacy of nutritional support of the hepatobiliary surgery patients in Guangzhou Military Region, Wuhan General Hospital. We will make comparative analysis about curative effects and the corresponding economic indicators of patients with or without nutritional risk which take different nutritional support program. At the same time, we will make comparative analysis about clinical effects of glutamine and the corresponding economic indicators of hepatobiliary surgery patients using glutamine perioperative. Through this work, we expect to provide a certain basis for liver surgical disease patient in selecting proper perioperative nutrition support treatment.Chapter one Influences of clinical outcome affected by glutamine in hepatobiliary surgery patients with nutritional riskObjectiveTo observe the incidence of patient’s nutritional risk in hepatobiliary surgery.,and analyse the influences of glutamine treatment on these patientsMaterial and Methods1. Object of studyThe patients who treatmented in hepatobiliary surgery of Wuhan General Hospital of Guangzhou Military Region from January 2011 to December 2014 were included in study. Inclusion criteria:(1) diseases:include liver carcinoma, bile duct carcinoma, gallbladder carcinoma, intrahepatic bile duct stones, huge liver cyst or hemangioma need partial hepatectomy, bile duct stones need choledochotomy stone laparotomy, portal hypertension patients need door devascularization. (2) Have surgery treatment after admission. (3) Came complete height and weight measurement. (4) The length of stay≥5d. (5) NRS 2002 score^ 3 points. (6) The preoperative liver function is Child A-B grade. (7) The discharge standards consistent: the patient no pain, wound healing, liver function returned to normal, have normal diet, can get out of bed. Must meet all the above criteria. Exclusion criteria:(1) pregnant and lactating women. (2) There is a serious ascites affect the actual body weight. (3) Nutritional risk screening after admission were not completed within 48h. (4) Liver function is Child C grade. (5) Have surgical complications include intranperative or postoperative bleeding (≥ 800ml), biliary leakage, wound dehiscence. (6) End-stage cancer patients.Exclude the patient who have one criteria above.2. Nutritional risk screeningEvaluate nutritional risk score of patients included in the study according NRS2002 standard. NRS2002 contains three aspects:(1) Impaired nutritional status score (0-3 points). (2) Disease severity score (0-3 points). (3) Age Rating:Add 1 point if the age≥ 70 years based on the above rates; the total score is from 0 to 7 points. According the study of Kondrup professor and the European Research Institute of Nutrition guide, NRS score< 3 points is no nutritional risk, NRS score≥ 3 points means the presence of nutritional risk. The body mass index (BMI)< 18.5 is defined as malnutrition,24.0≤BMI<28.0 as overweight, BMI5≥28.0 as obesity.3. Related treatmentThe patients of Gln group treated with alanyl glutamine 20g/d through intravenous in postoperative (100mL:20g Lukang Chen Xin Pharmaceutical in Shandong), the treatment time is 5～7d.. All patients have a preventive treatment with same level antibiotic before surgery. Adjust antibiotics as needed when the patient have infectious complications in postoperative. All patients have a treatment with parenteral nutrition combine eating early.4. Case grouping and data collectionWhen patients’NRS 2002 score≥ 3 points, according to the clinical treatment of the actual situation, divid them into Gln group and non Gln group, and next, according to the degree of NRS score by 3≤NRS<5 and 5≤NRS<7 divided into two sub group; according to the nature of the disease by benign and malignant divided into two sub groups; according to whether biliary is obstructed divided into two sub groups. Collect data continuous and input it into database by two researcher Establishing Epidata database, and applying the database system to collect data and do statistical analysis. Recording each patient’s clinical data, including age, sex, height, weight, Gln treatment, and outcome measures including cases of infectious complications and postoperative hospital stay. Infectious complications using the American College of Chest Physicians and the Society of Critical Care Medicine criteria, refer to the emergence of pathogens and pathogens by culture results confirmed the original sterile body tissues, and there is a corresponding infection with clinical symptoms and signs, radiological or hematology based aspects, including wound infection, pulmonary infection, urinary tract infection, sepsis,etc.This research project won the Guangzhou Military Region, Wuhan General Hospital Ethics Committee approval (registration number:20090058), and the consent of the patient informed consent.5. Statistical methodsStatistical analyzes were performed using SPSS 19.0 statistical software, measurement data (such as age, BMI, length of stay) with mean ± standard deviation (x±s) and count data (gender, infectious complications, malnutrition, etc.) with percentage (%). The mean compare two sets of measurement data using t test, count data using chi-square test (such as the comparison of gender constituent ratio and complication rates), analysis of risk factors for complications of using binary logistic regression analysis. P<0.05 was considered statistically significant.Results:Infectious complications of Gin group and non Gin group were 3.6%.9.1%(P <0.05); the number of days of hospitalization were (11.28±7.77) d, (12.03 ± 9.02) d (P> 0.05). Gin treatment can significantly reduce the malignant disease, biliary obstruction patient morbidity (P<0.05), patients with benign disease, non biliary obstruction patient hospital stay, and incidence of complications was no significant difference (P> 0.05).NRS score≥5 points patient, Gin group (n= 130) and non Gin group (n= 47) patients with complications were 3.07%、12.77%, hospitalization time was (11.21 ± 7.15) d, (12.73±1.26) d (P<0.05). Multivariate logistic regression analysis showed that, Gin treatment is a protective factor for infectious complications, while the NRS score^5 points, GGT increased, lower preoperative albumin are risk factors, the OR values were 0.76,1.19,1.25,1.39, all P<0.05.ConclusionsGin treatment can significantly reduce the incidence of infectious complications of patients with nutritional risk in hepatobiliary surgery. Gin treatment can significantly reduce the complication rate of patients with malignant disease or biliary obstruction. For patients with NRS score≥5 points, Gln also can shorter hospital stays, and have more benefit from Gin treatment.Chapter two Influences of clinical outcome with different nutritional support in hepatobiliary surgery patients with nutritional riskObjectiveTo observe the incidence of nutritional risk in hepatobiliary surgery, and to explore the effects of different nutritional support program for clinical outcomes in patients with nutritional risk.Material and Methods1. Object of studyThe patients who treatmented in hepatobiliary surgery of Wuhan General Hospital of Guangzhou Military Region from January 2011 to December 2014 were included in study. Inclusion criteria:(1) diseases:include liver carcinoma, bile duct carcinoma, gallbladder carcinoma, intrahepatic bile duct stones, huge liver cyst or hemangioma need partial hepatectomy, bile duct stones need choledochotomy stone laparotomy, portal hypertension patients need door devascularization. (2) Have surgery treatment after admission. (3) Came complete height and weight measurement. (4) The length of stay≥5d. (5) NRS 2002 score ≥ 3 points. (6) The preoperative liver function is Child A-B grade. (7) The discharge standards consistent: the patient no pain, wound healing, liver function returned to normal, have normal diet, can get out of bed. Must meet all the above criteria. Exclusion criteria:(1) pregnant and lactating women. (2) There is a serious ascites affect the actual body weight. (3) Nutritional risk screening after admission were not completed within 48h. (4) Liver function is Child C grade. (5) Have surgical complications include intranperative or postoperative bleeding(≥ 800ml), biliary leakage, wound dehiscence. (6) End-stage cancer patients.Exclude the patient who have one criteria above.2. Nutritional risk screeningEvaluate nutritional risk score of patients included in the study according NRS2002 standard. NRS2002 contains three aspects:(1) Impaired nutritional status score (0-3 points). (2) Disease severity score (0-3 points). (3) Age Rating:Add 1 point if the age≥70 years based on the above rates; the total score is from 0 to 7 points. According the study of Kondrup professor and the European Research Institute of Nutrition guide, NRS score< 3 points is no nutritional risk, NRS score≥ 3 points means the presence of nutritional risk. The body mass index (BMI)< 18.5 is defined as malnutrition,24.0≤BMI<28.0 as overweight, BMI≥28.0 as obesity.3. Nutritional support programProgram ①:Input artificial nutrients including amino acids, glucose and lipid emulsion from intravenous infusion,also called parenteral nutrition (PN); or supplement nutrients by oral, nasogastric tube, nasal intestine, percutaneous administration of gastrointestinal fistula channel, also called enteral nutrition (EN). The non-protein calories of PN or EN accounted for 15-30 kcal/kg/day, and the amino acid accounted for 0.8-1.6g/kg/day, continuous≥5d. Program ②:Energy and protein intake meet the above PN or EN standard, but the application time is only 2-4d; or the energy and protein intake non-compliance (below or above) the above PN or EN range, but the application time≥2d. Program ②:Only use amino acid or fat emulsion; or use nutritional support only one day. The patients receiving nutritional support program ①,②,③ all use parenteral nutrition combined with early eating. The fat emulsion used is structural fat emulsion injection (C6-24) 20% (250ml:50g Huarui pharmaceutical companies), the amino acid used is compound amino acid injection 18AA-V (250ml,Lukang Chen Xin Pharmaceutical in Shandong). Program ④:Only add glucose and saline, unused amino acids and fat emulsion, start eating after intestinal peristalsis recovery. All patients begun early to eat after restore bowel function.4. Case grouping and data collectionThe NRS 2002 score≥3 points of the patients, according to four different nutritional support program is divided into ①, ②, ③,④ group, respectively, according to the nature of the disease by benign and malignant divided into two sub groups; according to whether biliary is obstructed divided into two sub groups; according to the degree of NRS score by 3≤NRS<5and5≤NRS≤ 7 divided into two sub group. Establishing Epidata database, and applying the database system to collect data and do statistical analysis. Record clinical data for each patient, including age, sex, height, weight, nutrition therapy, clinical outcome measures and the incidence of postoperative infectious complications, length of stay (d) and hospital costs.5. Statistical methodsStatistical analyzes were performed using SPSS 19.0 statistical software, measurement data (such as age, BMI, length of stay) with mean ± standard deviation (x±s) and count data (gender, infectious complications, malnutrition, etc.) with percentage (%). The mean compare two sets of measurement data using t test, count data using chi-square test (such as the comparison of gender constituent ratio and infectious complication rates), analysis of risk factors for infectious complications of using binary logistic regression analysis. P<0.05 was considered statistically significant.Results936 patients have successful surgery in hepatobiliary surgery by continuously screening from January 2011 to December 2014, a total of 402 cases have nutritional risk and included in cohort studies. Cohort ①,②,③,④accounted for 90 cases (22.39%),106 cases (26.37%),100 cases (24.88%),106 cases (26.37%),respectively. A total of 23 cases have infectious complications within 402 cases with nutritional risk.The overall complication rate of infection of benign and malignant disease patients was 4.93%(14/284),7.63% (9/118), respectively;and the average length of stay time was (12.39 ± 4.70) d, (12.53 ± 6.37) d, respectively (all P>0.05). The overall complication rate of infection of non-biliary obstruction and biliary obstruction disease patients was 4.04%(12/297),10.48%(11/105), respectively(P< 0.05);and the average length of stay time was (12.36 ± 5.90) d, (12.76 ± 3.74) d, respectively (P>0.05).The infectious complications of Queue ①,②,③,④ accounted for 4 cases (4.4%),3 cases (2.8%),6 cases (6%) and10 cases (9.4%), respectively(P>0.05).The hospital stay of four groups were (11.27 ± 7.25) d, (10.76 ± 6.48) d, (11.97 ± 8.77) d and (12.26 ± 10.04) d, respectively(P>0.05).The hospital costs of four groups were (53170.60 ± 23470.50) yuan, (39853.09 ± 22713.07) yuan, (22933.51 ± 13542.79) yuan and (24216.98 ± 15930.63) yuan, respectively (P<0.05). The subgroup analysis according to whether the patient with benign or malignant disease, biliary obstruction or non-biliary obstruction.The study result showed that the hospital stay, incidence of infectious complications was no significant difference (P>0.05) between four different treatment groups with benign disease or non-biliary obstruction. The incidence of infectious complications in program ① group’s patients with malignant diseases or biliary obstruction is minimum, and significantly lower than other groups (P<0.05). The incidence of infectious complications in patients with NRS score≥5 points and receiving nutritional support program ①,②,③,④were 4.3% (2/47),2.0%(1/51),5.4%(2 /37),16.7%(7/42), respectively (P<0.05). Multivariable logistic regression analysis of complications rate for patients with nutritional risk showed that no nutritional support, NRS score^5 points, preoperative GGT increased, lower preoperative albumin are risk factors,, the OR values were 1.13,1.19,1.25,1.39, respectively,all P <0.05.ConclusionsFor patients with NRS>3 points in hepatobiliary surgical, we should pay attention to nutritional support therapy to reduce the incidence of postoperative infectious complications, and promote the rehabilitation of patients. Especially for patients with NRS>5 points,more attention should be given for appropriate nutritional support to improve the patient’s immune function and the body’s resistance to disease endurance, reduce postoperative infectious complications and other adverse clinical outcome occurrence... |
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