• 四川大學(xué)華西醫(yī)院加強(qiáng)醫(yī)療科（成都610041）;

目的 　探討早期腸內(nèi)營養(yǎng)（EN）在重癥急性胰腺炎（SAP）治療中的可行性、安全性及對(duì)預(yù)后的影響。
方法 　復(fù)習(xí)近年早期EN在SAP治療中應(yīng)用的研究成果并進(jìn)行綜述。
結(jié)果  對(duì)SAP患者空腸置管行早期EN能維護(hù)腸黏膜屏障的完整性，減少感染并發(fā)癥，但對(duì)于EN的開始時(shí)機(jī)、配方、輸注方式等仍然存在爭(zhēng)議。
結(jié)論 　早期EN在SAP的治療中有積極的作用，但仍有待深入的研究。

引用本文： 董亮,康焰. 早期腸內(nèi)營養(yǎng)在重癥急性胰腺炎治療中的應(yīng)用. 中國普外基礎(chǔ)與臨床雜志, 2008, 15(8): 567-571. doi: 復(fù)制

1. 　Kotani J, Usami M, Nomura H, et al. Enteral nutrition prevents bacterial translocation but does not improve survival during acute pancreatitis [J]. Arch Surg， 1999; 134(3)∶287.
2. 　Windsor AC, Kanwar S, Li AG, et al. Compared with parenteral nutrition, enteral feeding attenuates the acute phase response and improves disease severity in acute pancreatitis [J]. Gut, 1998; 42(3)∶431.
3. 　Powell JJ, Murchison JT, Fearon KC, et al. Randomized controlled trial of the effect of early enteral nutrition on markers of the inflammatory response in predicted severe acute pancreatitis [J]. Br J Surg, 2000; 87(10)∶1375.
4. 　Eckerwall GE, Axelsson JB, Andersson RG. Early nasogastric feeding in predicted severe acute pancreatitis: A clinical, randomized study [J]. Ann Surg, 2006; 244(6)∶959.
5. 　Kumar A, Singh N, Prakash S, et al. Early enteral nutrition in severe acute pancreatitis: a prospective randomized controlled trial comparing nasojejunal and nasogastric routes [J]. J Clin Gastroenterol, 2006; 40(5)∶431.
6. 　李維勤， 黎介壽. 重癥急性胰腺炎患者的階段性營養(yǎng)支持策略 [J]. 江蘇臨床醫(yī)學(xué)雜志， 2002; 6（2）∶96.
7. 　Heinrich S, Schfer M, Rousson V, et al. Evidence-based treatment of acute pancreatitis: a look at established paradigms [J]. Ann Surg, 2006; 243(2)∶154.
8. 　Tellado JM. Prevention of infection following severe acute pancreatitis [J]. Curr Opin Crit Care, 2007; 13(4)∶416.
9. 　李寧， 黎介壽. 外科營養(yǎng)近20年的進(jìn)展與展望 [J]. 中國實(shí)用外科雜志， 2002； 22（1）∶6.
10. 　秦環(huán)龍， 蘇振東， 胡雷光， 等. 早期腸內(nèi)營養(yǎng)對(duì)犬重癥急性胰腺炎自然病程和腸道屏障功能的影響 [J]. 中國普外基礎(chǔ)與臨床雜志， 2002； 9（5）∶325.
11. 　Casas M, Mora J, Fort E, et al. Total enteral nutrition vs. total parenteral nutrition in patients with severe acute pancreatitis [J]. Rev Esp Enferm Dig, 2007; 99(5)∶264.
12. 　 Jiang K, Chen XZ, Xia Q, et al. Early nasogastric enteral nutrition for severe acute pancreatitis: a systematic review [J]. World J Gastroenterol, 2007; 13(39)∶5253.
13. 　秦環(huán)龍. 腸外與腸內(nèi)營養(yǎng)對(duì)胰腺外分泌和急性重癥胰腺炎的影響 [J]. 腸外與腸內(nèi)營養(yǎng), 2001; 8(4)∶240.
14. 　Kalfarentzos F, Kehagias J, Mead N, et al. Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: results of a randomized prospective trial [J]. Br J Surg, 1997; 84(12)∶1665.
15. 　Wittmann T, Róka R, Palágyi P, et al. Continuous enteral feeding has an attenuating effect on the exocrine pancreas in rats [J]. Pancreas, 2001; 23(3)∶329.
16. 　Hamvas J, Schwab R, Pap A. Jejunal feeding in necrotising acute pancreatitis—a retrospective study [J]. Acta Chir Hung, 1999; 38(2)∶177.
17. 　王興鵬. 重癥急性胰腺炎患者實(shí)施早期腸內(nèi)營養(yǎng)的可能性及其理論基礎(chǔ) [J]. 胰腺病學(xué)， 2002； 2（3）∶171.
18. 　劉曉臣, 彭燕. 腸屏障功能障礙與重癥急性胰腺炎 [J]. 世界華人消化雜志, 2006; 14(32)∶3131.
19. 　Gupta R, Patel K, Calder PC, et al. A randomised clinical trial to assess the effect of total enteral and total parenteral nutritional support on metabolic, inflammatory and oxidative markers in patients with predicted severe acute pancreatitis (APACHE Ⅱ ＞or=6) [J]. Pancreatology, 2003; 3(5)∶406.
20. 　Kudsk KA, Li J, Renegar KB. Loss of upper respiratory tract immunity with parenteral feeding [J]. Ann Surg, 1996; 223(6)∶629.
21. 　Janu P, Li J, Renegar KB, et al. Recovery of gut-associated lymphoid tissue and upper respiratory tract immunity after parenteral nutrition [J]. Ann Surg， 1997; 225(6)∶707.
22. 　King BK, Li J, Kudsk KA. A temporal study of TPN-induced changes in gut-associated lymphoid tissue and mucosal immunity [J]. Arch Surg， 1997; 132(12)∶1303.
23. 　Li J, Kudsk KA, Gocinski B, et al. Effets of parenteral and enteral nutrition on gut-associated lymphoid tissue [J]. J Trauma， 1995; 39(1)∶44.
24. 　Qin HL, Su ZD, Hu LG, et al. Effect of early intrajejunal nutrition on pancreatic pathological features and gut barrier function in dogs with acute pancreatitis [J]. Clin Nutr, 2002; 21(6)∶469.
25. 　O’Dwyer ST, Michie HR, Ziegler TR, et al. A single dose of endotoxin increases intestinal permeability in healthy humans [J]. Arch Surg, 1988; 123(12)∶1459.
26. 　萬獻(xiàn)堯, 于凱江, 馬曉春, 等. 中國重癥加強(qiáng)治療病房危重患者營養(yǎng)支持指導(dǎo)意見(2006) [J]. 中華外科雜志, 2006; 44(17)∶1167.
27. 　Cassim MM, Allardyce DB. Pancreatic secretion in response to jejunal feeding of elemental diet [J]. Ann Surg, 1974; 180(2)∶228.
28. 　Vu MK, van der Veek PP, Frlich M, et al. Does jejunal feeding activate exocrine pancreatic secretion? [J]. Eur J Clin Invest, 1999; 29(12)∶1053.
29. 　Abou-Assi S, Craig K, OKeefe SJ. Hypocaloric jejunal feeding is better than total parenteral nutrition in acute pancreatitis: results of a randomized comparative study [J]. Am J Gastroenterol, 2002; 97(9)∶2255.
30. 　Ragins H, Levenson SM, Signer R, et al. Intrajejunal administration of an elemental diet at neutral pH avoids pancreatic stimulation. Studies in dog and man [J]. Am J Surg, 1973; 126(5)∶606.
31. 　Marik PE, Zaloga GP. Meta-analysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis [J]. BMJ, 2004; 328(7453)∶1407.
32. 　Erstad BL. Enteral nutrition support in acute pancreatitis [J]. Ann Pharmacother, 2000; 34(4)∶514.
33. 　Kale-Pradhan PB, Elnabtity MH, Park NJ, et al. Enteral nutrition in patients with pancreatitis [J]. Pharmacotherapy, 1999; 19(9)∶1036.
34. 　Karakan T, Ergun M, Dogan I, et al. Comparison of early enteral nutrition in severe acute pancreatitis with prebiotic fiber supplementation versus standard enteral solution: a prospective randomized double-blind study [J]. World J Gastroenterol, 2007; 13(19)∶2733.
35. 　van Berge Henegouwen MI, Akkermans LM, van Gulik TM, et al. Prospective, randomized trial on the effect of cyclic versus continuous enteral nutrition on postoperative gastric function after pylorus-preserving pancreatoduodenectomy [J]. Ann Surg, 1997; 226(6)∶677.
36. 　Dickerson RN, Vehe KL, Mullen JL, et al. Resting energy expenditure in patients with pancreatitis [J]. Crit Care Med, 1991; 19(4)∶484.
37. 　Lobo DN, Memon MA, Allison SP, et al. Evolution of nutritional support in acute pancreatitis [J]. Br J Surg, 2000; 87(6)∶695.
38. 　Petrov MS, Kukosh MV, Emelyanov NV. A randomized controlled trial of enteral versus parenteral feeding in patients with predicted severe acute pancreatitis shows a significant reduction in mortality and in infected pancreatic complications with total enteral nutrition [J]. Dig Surg, 2006; 23(5-6)∶336.
39. 　Oláh A, Belágyi T, Issekutz A, et al. Combination of early nasojejunal feeding with modern synbiotic therapy in the treatment of severe acute pancreatitis (prospective, randomized, double-blind study) [J]. Magy Seb, 2005; 58(3)∶173.
40. 　吳在德, 吳肇漢主編. 外科學(xué) [M]. 第6版. 北京: 人民衛(wèi)生出版社， 2004∶148～150.
41. 　吳丹， 婁健穎， 林漢庭. 急性胰腺炎的腸內(nèi)營養(yǎng) [J]. 中國實(shí)用外科雜志， 2003; 2（23）∶70.
42. 　Nakad A, Piessevaux H, Marot JC, et al. Is early enteral nutrition in acute pancreatitis dangerous? About 20 patients fed by an endoscopically placed nasogastrojejunal tube [J]. Pancreas, 1998; 17(2)∶187.
43. 　劉俊， 夏強(qiáng). 急性重癥胰腺炎早期腸內(nèi)營養(yǎng)反復(fù)失敗1例 [J]. 腸內(nèi)與腸外營養(yǎng)， 2002； 9（2）∶118.
44. 　伍曉汀， 張肇達(dá)， 趙小菲. 重癥急性胰腺炎的營養(yǎng)支持 [J]. 中國普外基礎(chǔ)與臨床雜志， 2004； 11（3）∶273.
45. 　Whitcomb DC. Clinical practice. Acute pancreatitis [J]. N Engl J Med, 2006; 354(20)∶2142.
  1. 1. 　Kotani J, Usami M, Nomura H, et al. Enteral nutrition prevents bacterial translocation but does not improve survival during acute pancreatitis [J]. Arch Surg， 1999; 134(3)∶287.
  2. 2. 　Windsor AC, Kanwar S, Li AG, et al. Compared with parenteral nutrition, enteral feeding attenuates the acute phase response and improves disease severity in acute pancreatitis [J]. Gut, 1998; 42(3)∶431.
  3. 3. 　Powell JJ, Murchison JT, Fearon KC, et al. Randomized controlled trial of the effect of early enteral nutrition on markers of the inflammatory response in predicted severe acute pancreatitis [J]. Br J Surg, 2000; 87(10)∶1375.
  4. 4. 　Eckerwall GE, Axelsson JB, Andersson RG. Early nasogastric feeding in predicted severe acute pancreatitis: A clinical, randomized study [J]. Ann Surg, 2006; 244(6)∶959.
  5. 5. 　Kumar A, Singh N, Prakash S, et al. Early enteral nutrition in severe acute pancreatitis: a prospective randomized controlled trial comparing nasojejunal and nasogastric routes [J]. J Clin Gastroenterol, 2006; 40(5)∶431.
  6. 6. 　李維勤， 黎介壽. 重癥急性胰腺炎患者的階段性營養(yǎng)支持策略 [J]. 江蘇臨床醫(yī)學(xué)雜志， 2002; 6（2）∶96.
  7. 7. 　Heinrich S, Schfer M, Rousson V, et al. Evidence-based treatment of acute pancreatitis: a look at established paradigms [J]. Ann Surg, 2006; 243(2)∶154.
  8. 8. 　Tellado JM. Prevention of infection following severe acute pancreatitis [J]. Curr Opin Crit Care, 2007; 13(4)∶416.
  9. 9. 　李寧， 黎介壽. 外科營養(yǎng)近20年的進(jìn)展與展望 [J]. 中國實(shí)用外科雜志， 2002； 22（1）∶6.
  10. 10. 　秦環(huán)龍， 蘇振東， 胡雷光， 等. 早期腸內(nèi)營養(yǎng)對(duì)犬重癥急性胰腺炎自然病程和腸道屏障功能的影響 [J]. 中國普外基礎(chǔ)與臨床雜志， 2002； 9（5）∶325.
  11. 11. 　Casas M, Mora J, Fort E, et al. Total enteral nutrition vs. total parenteral nutrition in patients with severe acute pancreatitis [J]. Rev Esp Enferm Dig, 2007; 99(5)∶264.
  12. 12. 　 Jiang K, Chen XZ, Xia Q, et al. Early nasogastric enteral nutrition for severe acute pancreatitis: a systematic review [J]. World J Gastroenterol, 2007; 13(39)∶5253.
  13. 13. 　秦環(huán)龍. 腸外與腸內(nèi)營養(yǎng)對(duì)胰腺外分泌和急性重癥胰腺炎的影響 [J]. 腸外與腸內(nèi)營養(yǎng), 2001; 8(4)∶240.
  14. 14. 　Kalfarentzos F, Kehagias J, Mead N, et al. Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: results of a randomized prospective trial [J]. Br J Surg, 1997; 84(12)∶1665.
  15. 15. 　Wittmann T, Róka R, Palágyi P, et al. Continuous enteral feeding has an attenuating effect on the exocrine pancreas in rats [J]. Pancreas, 2001; 23(3)∶329.
  16. 16. 　Hamvas J, Schwab R, Pap A. Jejunal feeding in necrotising acute pancreatitis—a retrospective study [J]. Acta Chir Hung, 1999; 38(2)∶177.
  17. 17. 　王興鵬. 重癥急性胰腺炎患者實(shí)施早期腸內(nèi)營養(yǎng)的可能性及其理論基礎(chǔ) [J]. 胰腺病學(xué)， 2002； 2（3）∶171.
  18. 18. 　劉曉臣, 彭燕. 腸屏障功能障礙與重癥急性胰腺炎 [J]. 世界華人消化雜志, 2006; 14(32)∶3131.
  19. 19. 　Gupta R, Patel K, Calder PC, et al. A randomised clinical trial to assess the effect of total enteral and total parenteral nutritional support on metabolic, inflammatory and oxidative markers in patients with predicted severe acute pancreatitis (APACHE Ⅱ ＞or=6) [J]. Pancreatology, 2003; 3(5)∶406.
  20. 20. 　Kudsk KA, Li J, Renegar KB. Loss of upper respiratory tract immunity with parenteral feeding [J]. Ann Surg, 1996; 223(6)∶629.
  21. 21. 　Janu P, Li J, Renegar KB, et al. Recovery of gut-associated lymphoid tissue and upper respiratory tract immunity after parenteral nutrition [J]. Ann Surg， 1997; 225(6)∶707.
  22. 22. 　King BK, Li J, Kudsk KA. A temporal study of TPN-induced changes in gut-associated lymphoid tissue and mucosal immunity [J]. Arch Surg， 1997; 132(12)∶1303.
  23. 23. 　Li J, Kudsk KA, Gocinski B, et al. Effets of parenteral and enteral nutrition on gut-associated lymphoid tissue [J]. J Trauma， 1995; 39(1)∶44.
  24. 24. 　Qin HL, Su ZD, Hu LG, et al. Effect of early intrajejunal nutrition on pancreatic pathological features and gut barrier function in dogs with acute pancreatitis [J]. Clin Nutr, 2002; 21(6)∶469.
  25. 25. 　O’Dwyer ST, Michie HR, Ziegler TR, et al. A single dose of endotoxin increases intestinal permeability in healthy humans [J]. Arch Surg, 1988; 123(12)∶1459.
  26. 26. 　萬獻(xiàn)堯, 于凱江, 馬曉春, 等. 中國重癥加強(qiáng)治療病房危重患者營養(yǎng)支持指導(dǎo)意見(2006) [J]. 中華外科雜志, 2006; 44(17)∶1167.
  27. 27. 　Cassim MM, Allardyce DB. Pancreatic secretion in response to jejunal feeding of elemental diet [J]. Ann Surg, 1974; 180(2)∶228.
  28. 28. 　Vu MK, van der Veek PP, Frlich M, et al. Does jejunal feeding activate exocrine pancreatic secretion? [J]. Eur J Clin Invest, 1999; 29(12)∶1053.
  29. 29. 　Abou-Assi S, Craig K, OKeefe SJ. Hypocaloric jejunal feeding is better than total parenteral nutrition in acute pancreatitis: results of a randomized comparative study [J]. Am J Gastroenterol, 2002; 97(9)∶2255.
  30. 30. 　Ragins H, Levenson SM, Signer R, et al. Intrajejunal administration of an elemental diet at neutral pH avoids pancreatic stimulation. Studies in dog and man [J]. Am J Surg, 1973; 126(5)∶606.
  31. 31. 　Marik PE, Zaloga GP. Meta-analysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis [J]. BMJ, 2004; 328(7453)∶1407.
  32. 32. 　Erstad BL. Enteral nutrition support in acute pancreatitis [J]. Ann Pharmacother, 2000; 34(4)∶514.
  33. 33. 　Kale-Pradhan PB, Elnabtity MH, Park NJ, et al. Enteral nutrition in patients with pancreatitis [J]. Pharmacotherapy, 1999; 19(9)∶1036.
  34. 34. 　Karakan T, Ergun M, Dogan I, et al. Comparison of early enteral nutrition in severe acute pancreatitis with prebiotic fiber supplementation versus standard enteral solution: a prospective randomized double-blind study [J]. World J Gastroenterol, 2007; 13(19)∶2733.
  35. 35. 　van Berge Henegouwen MI, Akkermans LM, van Gulik TM, et al. Prospective, randomized trial on the effect of cyclic versus continuous enteral nutrition on postoperative gastric function after pylorus-preserving pancreatoduodenectomy [J]. Ann Surg, 1997; 226(6)∶677.
  36. 36. 　Dickerson RN, Vehe KL, Mullen JL, et al. Resting energy expenditure in patients with pancreatitis [J]. Crit Care Med, 1991; 19(4)∶484.
  37. 37. 　Lobo DN, Memon MA, Allison SP, et al. Evolution of nutritional support in acute pancreatitis [J]. Br J Surg, 2000; 87(6)∶695.
  38. 38. 　Petrov MS, Kukosh MV, Emelyanov NV. A randomized controlled trial of enteral versus parenteral feeding in patients with predicted severe acute pancreatitis shows a significant reduction in mortality and in infected pancreatic complications with total enteral nutrition [J]. Dig Surg, 2006; 23(5-6)∶336.
  39. 39. 　Oláh A, Belágyi T, Issekutz A, et al. Combination of early nasojejunal feeding with modern synbiotic therapy in the treatment of severe acute pancreatitis (prospective, randomized, double-blind study) [J]. Magy Seb, 2005; 58(3)∶173.
  40. 40. 　吳在德, 吳肇漢主編. 外科學(xué) [M]. 第6版. 北京: 人民衛(wèi)生出版社， 2004∶148～150.
  41. 41. 　吳丹， 婁健穎， 林漢庭. 急性胰腺炎的腸內(nèi)營養(yǎng) [J]. 中國實(shí)用外科雜志， 2003; 2（23）∶70.
  42. 42. 　Nakad A, Piessevaux H, Marot JC, et al. Is early enteral nutrition in acute pancreatitis dangerous? About 20 patients fed by an endoscopically placed nasogastrojejunal tube [J]. Pancreas, 1998; 17(2)∶187.
  43. 43. 　劉俊， 夏強(qiáng). 急性重癥胰腺炎早期腸內(nèi)營養(yǎng)反復(fù)失敗1例 [J]. 腸內(nèi)與腸外營養(yǎng)， 2002； 9（2）∶118.
  44. 44. 　伍曉汀， 張肇達(dá)， 趙小菲. 重癥急性胰腺炎的營養(yǎng)支持 [J]. 中國普外基礎(chǔ)與臨床雜志， 2004； 11（3）∶273.
  45. 45. 　Whitcomb DC. Clinical practice. Acute pancreatitis [J]. N Engl J Med, 2006; 354(20)∶2142.