鼻胆管引流联合鼻空肠营养管在老年重症急性胆管炎患者中的临床应用

Clinical application of endoscopic nasobiliary drainage combined with nasojejunal tube feeding in elderly patients with severe acute cholangitis

摘要:

目的评价经内镜鼻胆管引流术（endoscopic naso biliary drainage，ENBD）联合鼻空肠营养管治疗老年重症急性胆管炎的临床价值。方法回顾性收集2016年1月1日—2018 年5月31日在浙江大学医学院附属杭州市第一人民医院消化内科接受ENBD联合鼻空肠营养管治疗的43例老年重症急性胆管炎病例纳入观察组，按照1∶1匹配原则于同期病例中匹配43例采用单独ENBD治疗联合常规保守治疗病例纳入对照组，主要观察术前、术后营养支持3 d、7 d时肝功能指标[丙氨酸氨基转移酶（ALT）、门冬氨酸氨基转移酶（AST）水平]、营养指标[血红蛋白（Hb）、总蛋白（TP）、白蛋白（ALB）含量]和炎症性指标[白细胞（WBC）计数、中性粒细胞百分比（NEU%）、C-反应蛋白（CRP）浓度]的组间差异，同时观察营养支持相关胃肠不良反应指标（腹胀、腹泻发生率）、病死率、住院时间和住院费用的组间差异。结果患者性别构成、平均年龄以及术前APACHE-Ⅱ评分、NRS2002评分、肝功能指标、营养指标和炎症性指标水平组间比较差异均无统计学意义（P＞0.05），2组基线资料具有可比性。术后营养支持3 d时，观察组ALT、AST水平、TP含量分别为21.0（15.0，35.5） U/L、26.0（21.0，36.5） U/L、（64.2±5.2） g/L，对照组分别为47.0（29.5，82.5） U/L（P＜0.05）、47.0（29.0，75.0） U/L（P＜0.05）、（60.5±6.4） g/L（P＜0.05），其他指标水平该时点组间差异均无统计学意义（P＞0.05）；术后营养支持7 d时，观察组ALT、AST水平、TP、ALB含量、CRP浓度分别为22.0（14.0，31.5） U/L、26.0（20.5，38.5） U/L、（67.6±5.4） g/L、（34.6±3.7） g/L、28.0（18.5，35.5） mg/L，对照组分别为43.0（18.0，59.5） U/L（P＜0.01）、34.0（24.0，60.5） U/L（P=0.02）、（64.5±5.7） g/L（P=0.01）、（31.5±7.0） g/L（P=0.02）、34.0（24.0，66.5） mg/L（P＜0.05），其他指标水平该时点组间差异均无统计学意义（P＞0.05）。观察组腹泻、腹胀发生率、病死率、住院时间和住院费用分别为32.6%（14/43）、30.2%（13/43）、9.3%（4/43）、（16.0±7.0） d和（4.0±1.0）万元，对照组分别为4.7%（2/43）（P＜0.05）、7.0%（3/43）（P＜0.05）、11.6%（5/43）（P=0.72）、（19.3±3.7）d（P＜0.05）和（5.3±2.3）万元（P＜0.05）。结论对于老年重症急性胆管炎患者，在ENBD引流的同时，同台置入营养管进行肠内营养，可有效改善患者营养状态、减轻炎症反应、减少对肝功能的影响，能有效缩短住院时间、减少住院费用，适合于临床进一步推广应用。

Abstract:

ObjectiveTo evaluate endoscopic nasobiliary drainage (ENBD) combined with nasojejunal tube feeding for elderly patients with severe acute cholangitis. MethodsData of 43 elderly patients with severe acute cholangitis, who received ENBD combined with nasojejunal tube feeding from January 1, 2016 to May 31, 2018 at Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine were retrospectively analyzed and were included in the observation group, and 43 other patients who received ENBD combined with conventional therapy in the same period were included in the control group with the matching principle of 1∶1. Liver function indices (ALT and AST), nutritional status (Hb, TP and ALB) and inflammation indices (WBC, NEU% and CRP) of the two groups before the operation, 3 days and 7 days of nutritional support after the operation were compared. Adverse reactions (abdominal distention and diarrhea), mortality, hospitalization time and expenses of the two groups were also compared. ResultsThere were no significant differences in gender composition, mean age, preoperative APACHE-Ⅱ score, NRS2002 score, liver function index, nutritional index, or inflammatory index between the observation group and the control group (P＞0.05). The baseline data of the two groups were comparable. After 3 days of nutritional support, ALT, AST, TP were 21.0 (15.0, 35.5) U/L, 26.0 (21.0, 36.5) U/L, and 64.2±5.2 g/L, respectively in the observation group, and 47.0 (29.5, 82.5) U/L (P＜0.05), 47.0 (29.0, 75.0) U/L (P＜0.05), and 60.5±6.4 g/L (P＜0.05), respectively in the control group. The levels of other indicators were not statistically different at this time point (P＞0.05). At 7 days postoperative nutritional support, ALT, AST, TP, ALB and CRP of the observation group were 22.0 (14.0, 31.5) U/L, 26.0 (20.5, 38.5) U/L, 67.6±5.4 g/L, 34.6±3.7 g/L, and 28.0 (18.5, 35.5) mg/L, respectively, and 43.0 (18.0, 59.5) U/L (P＜0.01), 34.0 (24.0, 60.5) U/L (P=0.02), 64.5±5.7 g/L (P=0.01), 31.5±7.0 g/L (P=0.02), and 34.0 (24.0, 66.5) mg/L (P＜0.05) in the control group. There were no significant differences in the levels of other indicators between the two groups at this time point (P＞0.05). In the observation group, the incidence of diarrhea, abdominal distension, mortality, hospitalization time and hospitalization expenses were 32.6% (14/43), 30.2% (13/43), 9.3% (4/43), 16.0±7.0 days and 40±10 thousand yuan, respectively, and in the control group, the above indicators were 4.7% (2/43) (P＜0.05), 7.0% (3/43) (P＜0.05), 11.6% (5/43) (P=0.72), 19.3±3.7 days (P＜0.05)) and 53±23 thousand yuan (P＜0.05), respectively. ConclusionFor elderly patients with severe acute cholangitis, enteral nutrition with ENBD can effectively improve the nutritional status, reduce inflammatory reaction, the impact on liver function, and hospital costs, and shorten the hospitalization time, which is suitable for further clinical application.