Objective To summarize the nutritional management strategies of patients undergoing electively gastrointestinal surgery. Methods This article reviewed the recent researches on perioperative nutritional management in electively gastrointestinal surgery, including four major directions: preoperative nutritional evaluation, glucose level control, nutritional type, and immunonutrition. Results At present, preoperative nutritional evaluation methods included anthropometry, laboratory tests, subjective global assessment (SGA), nutritional risk screening (NRS) 2002, Reilly nutritional risk screening, nutritional risk indicator (NRI), and so on. For preoperative nutritional assessment system, however, current data could not single out superiority for any nutritional assessment methods in the ability to predict surgery-related complications. The usage of enhanced recovery after surgery (ERAS) protocol to reduce surgical stress and preclude postoperative insulin resistance had recently been clearly linked to reductions in postoperative morbidity and adverse outcomes. There were specific criterias for perioperative parenteral and enteral nutrition in undernourished patients, who were defined in clinical guidelines recently, such as the Guidelines for Adult Perioperative Nutrition Support issued by Chinese Society of Parenteral and Enteral Nutrition (CSPEN). Several systematic reviews showed that immunonutrition could reduce both morbidity and length of stay after major electively gastrointestinal surgery. Conclusion Perioperative nutritional management can ensure patients benefit from nutritional support by nutritional assessment, can reduce the nutritional risk and metabolic disorder caused by operation, can achieve the goal of optimal nutrition support in surgical patients, and can ultimately reduce postoperative complications.
目的报告Vacuseal负压引流系统在腹部外科的应用体会。方法1999年5月至2002年3月，作者对47例腹部手术病例实施Vacuseal引流，其中肝切除术6例，急性胰腺炎胰床松解术7例，胰十二指肠切除术5例，门奇断流术4例，腹腔清创术4例，直、结肠癌根治术10例，切口感染11例。并与同期64例（次）普通负压引流结果进行比较。结果Vacuseal组日均腹腔引流量大于普通引流，引流后伤口肉芽组织情况改善，二期缝合时间缩短，无引流不适反应。结论Vacuseal负压引流的效果明显优于普通负压引流，适用于腹部的脏器切除或严重炎症、低位空腔脏器术后、巨大缺损的伤口感染。
Objective To study the MRI diagnosis of sacral fracture with sacral neurological damage and its cl inical appl ication. Methods From October 1999 to October 2007, 20 cases of sacral fracture (Denis classification, Type II)with sacral neurological damage were examined by obl ique coronal MRI of sacrum to show the whole length of sacral nerve. There were 17 males and 3 females, aged 30-55 years. The time from injury to hospital ization varied from 1 day to 23 months. The injury was caused by traffic accident in 10 cases, smash of heavy object in 8 cases and crush in 2 cases. Eight cases were accompanied by pubis fracture and 4 cases by urethral disruption. All patients accepted the examination of X-ray, CT and spiral CT 3D reconstruction. X-ray showed the displacement of fracture fragment was backwards and upwards, and sacral-hole l ine was vague, asymmetric and distorted. CT showed that sacral neural tube was left-right asymmetry, the displacement of fracture fragment was backwards and upwards, combining with the compression and intruding to sacrum center at different section levels. The cl inical manifestations, international standards for Neurological Classification of Spinal Cord Injury recommended by American Spinal Injury Association International Spinal Cord Society, comparison between normal and abnormal MRI and Gierada’s results were the basis for cl inical diagnose and MRI diagnose, which was confirmed by operation. Results Nerve injury diagnosed by cl inical manifestation were S1 (17 cases), S2 (14 cases), S3 (7 cases), and S4 (6 cases). Nerve injury diagnosedby MRI were S1 (17 cases), S2 (14 cases), S3 (3 cases), and S4 (2 cases). Nerve injury confirmed by operation were S1 (17 cases), S2 (14 cases), S3 (7 cases), and S4 (1 case). Obl ique coronal MRI of sacrum showed the whole length of sacral nerve and its adjacent relationship, detecting bone fragment compression and route alteration of never were evident in 5 cases, the fat disappearance around the site of nerve root injury in 19 cases, narrowness of sacral nerve canal in 17 cases and the abnormally enlarged sacral nerve in 11 cases. Conclusion Obl ique coronal MRI of sacrum is of great value in the local ization and the qual itative diagnosis of sacral neurological damage.
Objective To assess the risk factors associated with postoperative infection after elective abdominal operation for elderly in department of general surgery. Methods One hundred and fifty-nine consecutive elderly patients admitted to the department of general surgery in our hospital for elective abdominal operation between May 2010 and February 2012 were considered for inclusion and retrospectively analyzed. Thirty-eight patients （23.90%）with postoperative infection were taken as the infection group and 121 patients without postoperative infection as noninfection group. The differences in the objective physiological indicators， subjective health status indicators， operation status， the incidence of postoperative infective complications， and mortality were compared between the two groups. Results Of enrolled 159 patients in this study， the incidence of postoperative infective complications was 23.90% （38/159）； 2 patients died， and the postoperative mortality rate was 1.26%. Single factor and multivariate logistic regression analysis showed that preoperative malnutrition risk， history of diabetes， and chronic respiratory system disease were the independent risk factors of postoperative infection complications in elective abdominal surgery for elderly patients. Conclusion Improving preoperative respiratory function， diabetes mellitus， and nutritional status would help to reduce incidence of postoperative infection for elderly patients with elective abdominal operation.
ObjectiveTo compare the indirect calorimetry (IC) measured resting energy expenditure (MREE) with adjusted Harris-Benedict formula calculating resting energy expenditure (CREE) in the mechanically ventilated surgical critically ill patients and to evaluate the relationship between the resting energy expenditure (REE) with the severity of illness. MethodsTwenty-one patients undergonging mechanical ventilation for critical illness in the intensive care unit of general surgery between August 2008 and February 2010 were included in this study. Data during the study period of nutrition support were collected for computation of the severity of critical illness by acute physiology and chronic health evaluation Ⅱ scores (APACHE Ⅱ scores) and organ dysfunction scores (Marshall scores). MREE was measured by using IC of the MedGraphics CCM/D System within the first 7 d after nutrition therapy. CREE was calculated by using the HarrisBenedict formula adjusted with correction factors for illness at the same time. According to APACHE Ⅱ scores on admission, the enrolled patients were divided into two groups: APACHEⅡ score ≥20 scores group (n=8) and APACHE Ⅱ score lt;20 scores group (n=13), and the differences between MREE and CREE of patients in two groups were determined. ResultsThe reduction of variation tendency in CREE other than MREE in the enrolled patients within the first week of nutritional support was statistical significance (Plt;0.001). The CREE of patients 〔(1 984.49±461.83) kcal/d〕 was significantly higher than the MREE 〔(1 563.88±496.93) kcal/d〕 during the first week of nutritional support (Plt;0.001). The MREE on the 0, 1, 2, and 4 d after nutrition therapy were statistically significant lower than CREE at the same time interval in these patients (Plt;0.01), and the differences at the other time points were not significant (Pgt;0.05). There was a trend towards a reduction in APACHE Ⅱ and Marshall scores within the first week of nutrition therapy that reached statistical significance (Plt;0.001). During the first week of nutrition therapy, APACHEⅡ and Marshall scores of patients in ≥20 scores group were significantly higher than those in lt;20 scores group, respectively (Plt;0.05 or Plt;0.01), and the reductions of APACHE Ⅱ scores and Marshall scores were significant in patients of two groups (Plt;0.001). A significant positive correlation was found between CREE with APACHE Ⅱ scores (r=0.656, Plt;0.001) and Marshall scores (r=0.608，Plt;0.001) in patients within the first week after nutrition support. Although no statistically significant correlation was observed between MREE and APACHEⅡ scores (r=-0.045， P=0.563), a significant positive correlation was observed between MREE and Marshall scores (r=0.263, P=0.001) within the first week after nutrition therapy. There was no correlation between MREE and CREE (r=0.064, P=0.408) in patients at the same time interval. The reduction of MREE of patients in ≥20 scores group other than in lt;20 scores group was statistically significant within the first week after nutrition therapy (P=0.034). In addition, the MREE of patients in ≥20 scores group were not significantly different from those in lt;20 scores group (Pgt;0.05), and the mean CREE was not different in two groups patients within the first week of nutritional therapy 〔(1 999.55±372.73) kcal/d vs. (1 918.39±375.27) kcal/d, P=0.887〕. CREE was significantly higher than MREE of patients in ≥20 scores group within the first week except the 3 d and 5 d after nutrition therapy (Plt;0.05), while in lt;20 scores group CREE was significantly higher than MREE in patients only within the first 3 d after nutrition therapy (Plt;0.05 or Plt;0.01). MREE and CREE of patients in ≥20 scores group were not different from those in lt;20 scores group, respectively (Pgt;0.05).
Objective To summarize the recent progress in pathogenetic, diagnostic and therapeutic researches on the intestinal barrier dysfunction (IBD) of severe acute pancreatitis (SAP). MethodsThe advancement of IBD in SAP, which was published recently at home and abroad, was collected and reviewed. Results The pathogenesis of IBD in patients with SAP was complex. Ischemia-reperfusion injury, endotoxin, inflammatory mediators and gastrointestinal hormone played an important role in the process of IBD. There were many ways to detect IBD, and the ratio of lactulose and mannitol, plasma diamine oxidase were relatively ideal markers. Medical therapies, such as treatment of SAP and maintaining the perfusion of intestines, were essential to cure IBD. On this basis, the propulsives, nutritional support and traditional Chinese drugs should be administered reasonably. Conclusions IBD is a sophisticated process of pathophysiology. In recent years, abundant of animal experiments and clinical researches have provided new clue for prevention and cure of IBD, but further researches are still needed on the mechanism of the cells and molecules implicated.