李 迪,涂永久,陳 戰(zhàn),林 碩
早期腸內(nèi)營(yíng)養(yǎng)對(duì)直腸癌手術(shù)患者炎癥因子及淋巴細(xì)胞的影響
李 迪,涂永久,陳 戰(zhàn),林 碩
目的觀(guān)察早期腸內(nèi)營(yíng)養(yǎng)對(duì)直腸癌手術(shù)患者炎癥因子及淋巴細(xì)胞的影響。方法80例直腸癌術(shù)后患者隨機(jī)分為兩組,每組40例,對(duì)照組術(shù)后給予靜脈營(yíng)養(yǎng),觀(guān)察組術(shù)后給予早期腸內(nèi)營(yíng)養(yǎng),分別在術(shù)前30 min和術(shù)后3、4、7 d采集患者外周血,采用ELISA法測(cè)定TNF-a、IL-6水平,采用流式細(xì)胞儀測(cè)定CD4+T及CD8+T細(xì)胞水平,比較兩組檢測(cè)結(jié)果。結(jié)果在術(shù)后3、4、7 d,觀(guān)察組TNF-α和IL-6水平顯著低于對(duì)照組(均P<0.05),而CD4+T和CD8+T細(xì)胞水平顯著高于對(duì)照組(均P<0.05)。觀(guān)察組術(shù)后出現(xiàn)腹脹4例,均經(jīng)對(duì)癥治愈,無(wú)患者因腹脹而中斷腸內(nèi)營(yíng)養(yǎng);對(duì)照組術(shù)后發(fā)生腹脹5例,兩組不良反應(yīng)發(fā)生率無(wú)統(tǒng)計(jì)學(xué)差異(P>0.05)。結(jié)論早期腸內(nèi)營(yíng)養(yǎng)有助于降低直腸癌手術(shù)患者TNF-α和IL-6水平,對(duì)調(diào)節(jié)機(jī)體炎性反應(yīng)具有重要作用;且可使CD4+T、CD8+T細(xì)胞水平升高,有助于免疫功能恢復(fù),具有重要臨床價(jià)值。
早期;腸內(nèi)營(yíng)養(yǎng);直腸癌;炎癥因子;CD4+;CD8+
目前,直腸癌患者臨床常見(jiàn),手術(shù)治療為直腸癌臨床干預(yù)重要方式。直腸癌術(shù)后營(yíng)養(yǎng)供給是促進(jìn)病情恢復(fù)的重要手段,腸內(nèi)營(yíng)養(yǎng)不僅可提供機(jī)體全部營(yíng)養(yǎng)需要,還可進(jìn)一步補(bǔ)充腸外營(yíng)養(yǎng)所不足[1]。動(dòng)物研究表明[2],早期腸內(nèi)營(yíng)養(yǎng)有助于保護(hù)機(jī)體腸內(nèi)粘膜完整,對(duì)降低腸源性感染具有重要作用。隨著臨床研究深入,早期腸內(nèi)營(yíng)養(yǎng)理念逐步提出,即要求術(shù)后12 h內(nèi)開(kāi)始胃腸道進(jìn)食,其對(duì)促進(jìn)患者康復(fù)及預(yù)后均有重要臨床價(jià)值,但其對(duì)患者炎性反應(yīng)及免疫功能影響如何尚未明確。本研究旨在探討早期腸內(nèi)營(yíng)養(yǎng)對(duì)直腸癌手術(shù)患者術(shù)后TNF-a、IL-6、CD4+T細(xì)胞及CD8+T細(xì)胞水平影響。
1.1 病例資料 選擇本院2015年6月~2016年1月收治的直腸癌術(shù)后患者80例入選本研究,均經(jīng)患者及家屬知情同意,簽署知情同意書(shū),且經(jīng)醫(yī)院倫理委員會(huì)批準(zhǔn)。均行直腸癌根治術(shù),均未合并先天性心臟病及嚴(yán)重肝腎功能不全。根據(jù)患者入院順序編號(hào),采用奇偶數(shù)法隨機(jī)分為兩組,兩組一般資料比較均無(wú)統(tǒng)計(jì)學(xué)差異(P>0.05,表1)。
表1 兩組一般資料比較(n=40)
1.2 營(yíng)養(yǎng)治療 對(duì)照組患者術(shù)后1 d開(kāi)始接受靜脈營(yíng)養(yǎng),按照105 kJ/(kg·d)計(jì)算每日所需熱量供給,給予20%脂肪乳及復(fù)方氨基酸注射液、葡萄糖,直至術(shù)后7 d。觀(guān)察組患者術(shù)后1 d接受早期腸內(nèi)營(yíng)養(yǎng),應(yīng)用腸內(nèi)營(yíng)養(yǎng)乳劑“瑞素”(500 ml/瓶,華瑞制藥有限公司,國(guó)藥準(zhǔn)字H20020588),按照105 kJ/(kg·d)計(jì)算每日患者所需熱量供給。兩組均持續(xù)治療至術(shù)后7 d。
1.3 檢測(cè)指標(biāo) 分別在術(shù)前30 min和術(shù)后3、4、7 d,取患者晨起空腹外周血10 ml,即刻取3 ml行細(xì)胞免疫功能檢測(cè),采用流式細(xì)胞儀(型號(hào)FC500,美國(guó)BeckmanCoulter公司)觀(guān)察CD4+、CD8+的表達(dá)水平;余下7 ml常規(guī)3000 r/min離心,取上層清液并放置于-20℃待檢測(cè),采取ELISA法測(cè)定TNF-a、IL-6水平,試劑盒由南京建成生物有限公司提供,檢測(cè)流程嚴(yán)格按照說(shuō)明書(shū)操作。同時(shí)觀(guān)察記錄患者治療期間的不良反應(yīng)發(fā)生情況。
1.4 統(tǒng)計(jì)學(xué)方法 應(yīng)用SPSS13.0統(tǒng)計(jì)軟件進(jìn)行統(tǒng)計(jì)分析,計(jì)數(shù)資料采用χ2檢驗(yàn),計(jì)量資料以±s表示,組間比較采用t檢驗(yàn),P<0.05為差異具有統(tǒng)計(jì)學(xué)意義。
2.1 兩組不同時(shí)間TNF-α水平和 IL-6水平比較
兩組術(shù)前TNF-α和IL-6水平比較無(wú)統(tǒng)計(jì)學(xué)差異(P>0.05);在術(shù)后3、4、7 d,兩組TNF-α水平和IL-6水平均呈異常升高后逐漸下降的變化趨勢(shì),且觀(guān)察組在各時(shí)點(diǎn)升高的幅度均顯著低于對(duì)照組(P<0.05)。見(jiàn)表2。
表2 兩組不同時(shí)間TNF-α和IL-6水平比較(ng/L,n=40)
2.2 兩組不同時(shí)間CD4+T及CD8+T細(xì)胞水平比較
兩組術(shù)前CD4+T及CD8+T細(xì)胞水平無(wú)統(tǒng)計(jì)學(xué)差異(P>0.05);在術(shù)后3、4、7 d,兩組CD4+T及CD8+T細(xì)胞水平均呈降低后逐漸回升的變化趨勢(shì),且觀(guān)察組在各時(shí)點(diǎn)的水平均顯著高于對(duì)照組(P<0.05)。見(jiàn)表3。
2.3 兩組不良反應(yīng)比較 觀(guān)察組術(shù)后出現(xiàn)腹脹4例,均經(jīng)對(duì)癥治愈,無(wú)患者因腹脹而中斷腸內(nèi)營(yíng)養(yǎng);對(duì)照組術(shù)后發(fā)生腹脹5例,兩組不良反應(yīng)發(fā)生率無(wú)統(tǒng)計(jì)學(xué)差異(P>0.05)。
近年隨著人口老齡化改變、飲食結(jié)構(gòu)調(diào)整,直腸癌發(fā)生率呈現(xiàn)逐年升高趨勢(shì)。手術(shù)干預(yù)為直腸癌重要干預(yù)措施之一,同時(shí),也被認(rèn)為是治療直腸癌療效最佳方式之一。但術(shù)后營(yíng)養(yǎng)如何供給對(duì)患者術(shù)后的康復(fù)具有重要影響。隨著臨床研究深入,營(yíng)養(yǎng)支持作為外科治療重要組成部分,其對(duì)直腸癌患者術(shù)后免疫功能及炎性反應(yīng)影響成為臨床研究熱點(diǎn)[3]。
表3 兩組不同時(shí)間CD4+T及CD8+T細(xì)胞水平比較(%,n=40)
目前臨床有腸外營(yíng)養(yǎng)和腸內(nèi)營(yíng)養(yǎng)支持兩種方式,各有利弊。有文獻(xiàn)報(bào)道[4],腸外營(yíng)養(yǎng)??蓪?dǎo)致腸道消化道活性降低,不利于術(shù)后腸道功能恢復(fù)。劉洪一等[5]認(rèn)為,術(shù)后腸外營(yíng)養(yǎng)患者易發(fā)生腸道廢用、通透性升高、細(xì)菌移位等問(wèn)題,不利于術(shù)后康復(fù)。近些年來(lái)早期腸內(nèi)營(yíng)養(yǎng)支持理念逐步提出,并得到較多醫(yī)師、學(xué)者的認(rèn)可,該理念認(rèn)為手術(shù)后6~12 h小腸功能即開(kāi)始恢復(fù),早期腸內(nèi)營(yíng)養(yǎng)有助于促進(jìn)胃腸黏膜生長(zhǎng)、運(yùn)動(dòng),并清除內(nèi)容物淤積,促進(jìn)機(jī)體康復(fù)[6]。
直腸癌患者多伴有營(yíng)養(yǎng)不良和免疫功能衰退,手術(shù)作為一種應(yīng)激刺激,可刺激炎性介質(zhì)如TNF-α、IL-6等釋放,引起機(jī)體炎性損傷。此外術(shù)后禁食、機(jī)體營(yíng)養(yǎng)補(bǔ)充不足,也進(jìn)一步加劇了免疫抑制狀態(tài)[7]。
本研究結(jié)果顯示,觀(guān)察組術(shù)后1 d給予早期腸內(nèi)營(yíng)養(yǎng)支持取得顯著的臨床效果,術(shù)后外周血TNF-α、IL-6較對(duì)照組有明顯下降,而CD4+T、CD8+T得到較好穩(wěn)定,且未見(jiàn)明顯的胃腸道不良反應(yīng),表明早期腸內(nèi)營(yíng)養(yǎng)支持治療的效果好、安全性高,與王智浩等[8]的結(jié)論一致。
綜上所述,直腸癌患者術(shù)后給予早期腸內(nèi)營(yíng)養(yǎng)支持是有效、安全可行的,相較常規(guī)腸外營(yíng)養(yǎng)支持,能更好地抑制炎性介質(zhì)TNF-a、IL-6的表達(dá),提高CD4+T和CD8+T淋巴細(xì)胞水平,對(duì)減少術(shù)后并發(fā)癥、促進(jìn)患者病情康復(fù)具有重要意義。
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Effects of early enteral nutrition on inflammatory factors and lymphocytes in patients with rectal cancer
Li Di1,TuYongjiu1,Chen Zhan1,Lin Shuo21.Surgical Department,Hospital 174 of PLA,Xiamen,Fujian,361000,China; 2.Department of ENT&HN Surgery,Hospital 174 of PLA,Xiamen,Fujian,361000,China
Objective To observe the effects of early enteral nutrition on inflammatory factors and lymphocytes in patients with rectal cancer.MethodsA total of 80 patients with rectal cancer were selected and randomly divided into two groups(n=40, respectively).The control group was given parenteral nutrition while the observation group was given early enteral nutrition.Peripheral blood of patients was taken 30 minutes before the operation and three,four and seven days after the operation.ELISA method was taken to detect the levels of TNF-a and IL-6 levels and the levels of CD4+T and CD8+T cells were detected by flow cytometry.The detection results in the two groups were compared.ResultsThree,four and seven days after the operation,the levels of TNF-α and IL-6 in the observation group were significantly lower than those in the control group(P<0.05),while the levels of CD4+T and CD8+T cells were much higher than those in the control group(P<0.05).There were four cases of abdominal distension later cured by treatment in the observation group after the treatment;the enteral nutrition was not interrupted in any patient due to abdominal distension.There were five cases of abdominal distension in the control group after the treatment.There was no statistical difference in the incidence of adverse reactions in the two groups(P>0.05).ConclusionEarly enteral nutrition can help reduce the levels of TNF-α and IL-6 of patients in rectal cancer surgery,which is important for the adjustment of inflammatory response of the body;it can improve the levels of CD4+T and CD8+T cells,help the recovery of the inflammatory reaction and has great clinical significance.
early enteral nutrition;rectal cancer;inflammatory factor;CD4+;CD8+
R 735.37/459.3
A
1004-0188(2016)12-1428-03
10.3969/j.issn.1004-0188.2016.12.022
2016-06-25)
361000福建 廈門(mén),解放軍174醫(yī)院外科(李 迪,涂永久,陳 戰(zhàn)),五官外科(林 碩)
涂永久,E-mail:3464377416@qq.com