胰腺炎胃管课件

NasogastricorNasojejunalAbstractNasojejunaltubefeedingisconsideredthecurrentstandardofcareinpatientswithsevereandcriticalacutepancreatitis.However,itisnotknownwhetherenteralnutritionisbestdeliveredintothejejunum.ThisCommentarydiscussesrecentclinicalstudiesthathaveshownthattubefeedingintothestomachissafeandwelltoleratedinthevastmajorityofpatientswithacutepancreatitis,thusoverthrowingthenotionofputtingthepancreasatrest.Developmentofanewconceptualframeworkiswarrantedtofurtheradvancenutritionalmanagementofpatientswithacutepancreatitis.backThestudybyChangandcolleagues[1]addsanimportantperspectivetothediscussionregardingthe‘pancreaticrest’concept,whichisperhapstheoldestdogmainthemanagementofAP.Thecentraltenetofthisconceptisthatenteralnutritiondeliveredintoanypartoftheuppergastrointestinaltractotherthanthejejunumstimulatespancreaticsecretionand,consequently,exacerbatestheseverityofAP.backThecorollaryisthat‘non-stimulatory’nutritionhadbeenwidelyadvocated,beingtotalparenteralnutritiontwotothreedecadesagoandnasojejunaltubefeedinginthepastdecade.Thatiswhythemajorityofrandomisedcontrolledtrialsinthepaststudied‘non-stimulatory’regimensasbothinterventionandcomparator,thatis,eitherparenteralnutritionversusnilperos,orparenteralnutritionversusjejunaltubefeeding,orjejunaltubefeedingversusnilperos[7,8].DefinitionsofthefourseveritycategoriesTherecentinternationalmultidisciplinaryclassificationofAPhasredefinedthe‘severe’categoryofseverityandintroducedthenew‘critical’categoryofseverity(Table1),thusputtingahighemphasisontheneedtooptimisemanagementofthesemostchallengingpatients.(Peri)pancreaticnecrosisis:1.nonviabletissuelocatedinthepancreasalone,2.orinthepancreasandperipancreatictissues,3.orinperipancreatictissuesalone.Itcanbesolidorsemisolid(partiallyliquefied)andiswithoutaradiologicallydefinedwall.Sterile(peri)pancreaticnecrosisistheabsenceofproveninfectioninnecrosis.DefinitionsofthefourseveritycategoriesInfected(peri)pancreaticnecrosisisdefinedwhenatleastoneofthefollowingispresent:1.gasbubbleswithin(peri)pancreaticnecrosisoncomputedtomography;2.apositivecultureof(peri)pancreaticnecrosisobtainedbyimageguidedfine-needleaspiration;3.apositivecultureof(peri)pancreaticnecrosisobtainedduringthefirstdrainageand/ornecrosectomy.Organfailureisdefinedforthreeorgansystems(cardiovascular,renal,andrespiratory)onthebasisoftheworstmeasurementovera24-hourperiod.Inpatientswithoutpre-existingorgandysfunction,organfailureisdefinedaseitherascoreof2ormoreintheassessedorgansystemusingtheSOFA(Sepsis-relatedOrganFailureAssessment)scoreorwhentherelevantthresholdisbreached,asshown:Cardiovascular,needforinotropicagent;Renal,creatinine≥171μmol/L(≥2.0mg/dl);Respiratory,PaO2/FiO2(partialpressureofoxygen/fractionalinspiredoxygenconcentration)≤300mmHg(≤40kPa).DefinitionsofthefourseveritycategoriesPersistentorganfailureistheevidenceoforganfailureinthesameorgansystemfor48hoursormore.Transientorganfailureistheevidenceoforganfailureinthesameorgansystemforlessthan48hours.DefinitionsofthefourseveritycategoriesThesystematicliteraturereviewhasappraisedthecurrentbestevidenceregardingtheuseofnasogastrictubefeeding(presumedtobe‘stimulatory’)inpatientswithAP.Itdemonstratesthattheevidencebaseis(still)relativelysmallbutdoesshowthatenteralnutritiongivenviathenasogastricrouteiswelltoleratedinmorethan90%ofpatientswithAP[9-11].NewInlinewiththeprevioussystematicreview[2],itshowsnostatisticallysignificantdifferencebetween‘non-stimulatory’and‘stimulatory’regimensintermsofmorbidityandmortality.Thenew,andsomewhatsurprising,findinghereisthatbothroutesofenteralfeedingappeartobeequivalentintermsofdeliveryoftargetcalories.NewTherearetwopossibleexplanationsfortheobservedresults.First,tubefeedingintothestomachmighthavebeen‘non-stimulatory’inpatientswithAP.Unfortunately,littleisknownaboutthesecretoryresponseofthepancreasduringtheacutephaseofclinicalAP,letalonetheeffectoffeedingonit[12].Butastudyinhealthyvolunteersdemonstratedthatbothoralandduodenaltubefeedingstimulatepancreaticenzymesecretionincomparisonwithplacebo[13].Moreover,thedegreeofpancreaticstimulationisverysimilarbetweenoralandduodenaltubefeeding.Second,tubefeedingintothestomachmighthavestimulatedthepancreasinpatientswithAPbutithasnoclinicalramifications,essentiallymeaningthattheconceptof‘pancreaticrest’mighthavebeenfallacious.AlthoughithasbecomedeeplyentrenchedinthemanagementofAP,itisworthnotingthatthe‘pancreaticrest’conceptwasneverproveninrandomisedcontrolledtrials.Moreover,therecentMIMOSA(MIldtoMOderateacutepancreatitis:earlynaSogastrictubefeedingcomparedwithpAncreaticrest)trialcomparedinarandomizedfashionearlynasogastrictubefeeding(commencedwithin24hoursafterhospitaladmission)withnilperosandfoundthatnasogasricfeedingdoesnotexacerbatethecourseofAPandevenreducestheriskoforalfoodintolerance[14].Similarly,anearlierrandomisedcontrolledtrialcomparedearlynasogastrictubefeeding(commencedwithin24hoursafterhospitaladmission)withparenteralnutritionandfoundnodifferencebetween‘non-stimulatory’and‘stimulatory’regimens[15].Inconclusion,accumulatingevidenceindicatesthatthesiteofenteraltubefeedingdoesnotaffectmajorclinicaloutcomesinpatientswithAP.Giventhattubefeedingintothestomachismorepracticalthanintothejejunuminthemajorityofclinicalsettings,itshouldbeconsideredasthefirst-lineapproachforpatientswithsevereandcriticalAP.The‘pancreaticrest’conceptcannowbeputtorest.ThereisaneedandjustificationfordevelopingacontemporaryconceptualframeworkconcerningnutritionalmanagementofAP.AbstractIntroduction:Enteralfeedingcanbegiveneitherthroughthenasogastricorthenasojejunalroute.Studieshaveshownthatnasojejunaltubeplacementiscumbersomeandthatnasogastricfeedingisaneffectivemeansofprovidingenteralnutrition.However,theconcernthatnasogastricfeedingincreasesthechanceofaspirationpneumonitisandexacerbatesacutepancreatitisbystimulatingpancreaticsecretionhaspreventeditbeingestablishedasastandardofcare.Weaimedtoevaluatethedifferencesinsafetyandtolerancebetweennasogastricandnasojejunalfeedingbyassessingtheimpactofthetwoapproachesontheincidenceofmortality,trachealaspiration,diarrhea,exacerbationofpain,andmeetingtheenergybalanceinpatientswithsevereacutepancreatitis.Method:WesearchedtheelectronicdatabasesoftheCochraneCentralRegisterofControlledTrials,PubMed,andEMBASE.Weincludedprospectiverandomizedcontrolledtrialscomparingnasogastricandnasojejunalfeedinginpatientswithpredictedsevereacutepancreatitis.Tworeviewersassessedthequalityofeachstudyandcollecteddataindependently.Disagreementswereresolvedbydiscussionamongthetworeviewersandanyoftheotherauthorsofthepaper.WeperformedametaanalysisandreportedsummaryestimatesofoutcomesasRiskRatio(RR)with95%confidenceintervals(CIs).Results:Weincludedthreerandomizedcontrolledtrialsinvolvingatotalof157patients.Thedemographicsofthepatientsinthenasogastricandnasojejunalfeedinggroupswerecomparable.Nasogastricfeedingwasnotinferiortonasojejunalfeeding.Therewerenosignificantdifferencesintheincidenceofmortality(RR=0.69,95%CI:0.37to1.29,P=0.25);trachealaspiration(RR=0.46,95%CI:0.14to1.53,P=0.20);diarrhea(RR=1.43,95%CI:0.59to3.45,P=0.43);exacerbationofpain(RR=0.94,95%CI:0.32to2.70,P=0.90);andmeetingenergybalance(RR=1.00,95%CI:0.92to1.09,P=0.97)betweenthetwogroupsConclusions:Nasogastricfeedingissafeandwelltoleratedcomparedwithnasojejunalfeeding.Studylimitationsincludedasmalltotalsamplesizeamongothers.Morehigh-qualitylarge-scalerandomizedcontrolledtrialsareneededtovalidatetheuseofnasogastricfeedinginsteadofnasojejunalfeeding.(Pancreas2012;41:153Y159)Objective:Thisstudyaimedtodeterminethenoninferiorityofearlyenteralfeedingthroughnasogastric(NG)comparedtonasojejunal(NJ)routeoninfectiouscomplicationsinpatientswithsevereacutepancreatitis(SAP).Methods:PatientswithSAPwerefedviaNG(candidate)orNJ(comparative)route.Theprimaryoutcomewastheoccurrenceofanyinfectiouscomplicationinblood,pancreatictissue,bile,ortrachealaspirate.Secondaryendpointswerepaininrefeeding,durationofhospitalstay,intestinalpermeability