入院48小时内启动肠内营养对重症急性胰腺炎治疗价值的Meta分析
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摘要
目的系统评价入院48小时内给予肠内营养(EN)在治疗重症急性胰腺炎中的安全性与有效性。方法计算机检索PubMed、EMbase、The Cochrane Library、CBM、CNKI和WanFang Data等数据库,搜集关于早期EN对治疗重症急性胰腺炎安全性与有效性的随机对照试验(RCT),检索时限均从建库至2018年10月。由2名研究者独立筛选文献、提取资料并评价纳入研究的偏倚风险后,采用Stata 12.0软件进行Meta分析。结果共纳入9个RCT,包括1 074例患者。Meta分析结果显示:与入院48小时后给予EN或入院后不同时段给与肠外营养相比,入院48小时内给予EN的病死率[RR=0.53,95%CI(0.29,0.96),P=0.036]和多器官功能障碍综合征(MODS)发生率[RR=0.58,95%CI(0.44,0.77),P<0.001]更低。但两组全身炎症反应综合征(SIRS)发生率[RR=1.00,95%CI(0.86,1.16),P=1.00]的差异无统计学意义。结论当前证据显示,入院48小时内给予EN能降低重症急性胰腺炎患者的病死率和MODS发生率。受纳入研究数量和质量限制,上述结论尚待更多高质量研究予以验证。
Objectives To systematically review the efficacy and safety of enteral nutrition(EN) for severe acute pancreatitis(SAP) patients within 48 hours after admission. Methods PubMed, EMbase, The Cochrane Library,CBM, CNKI and WanFang Data databases were electronically searched to collect randomized controlled trials(RCTs) on early EN(starting within 48 hours after admission) in SAP from inception to October, 2018. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies, then, meta-analysis was performed by using Stata 12.0 software. Results A total of 9 RCTs involving 1 074 patients were included. The results of metaanalysis showed that: compared to patients with EN after 48 hours or parental nutrition, the patients given EN within 48 hours after admission had lower mortality(RR=0.53, 95%CI 0.29 to 0.96, P=0.036) and morbidity of multiple organ dysfunction syndrome(MODS)(RR=0.58, 95%CI 0.44 to 0.77, P<0.001). However, no significant differences were found in systemic inflammatory response syndrome(SIRS)(RR=1.00, 95%CI 0.86 to 1.16, P=1.00). Conclusions The current evidence shows that EN within 48 hours after admission can reduce the mortality and morbidity of MODS in SAP patients. Due to limited quality and quantity of the included studies, more high-quality studies are needed to verify above conclusions.
Objectives To systematically review the efficacy and safety of enteral nutrition(EN) for severe acute pancreatitis(SAP) patients within 48 hours after admission. Methods PubMed, EMbase, The Cochrane Library,CBM, CNKI and WanFang Data databases were electronically searched to collect randomized controlled trials(RCTs) on early EN(starting within 48 hours after admission) in SAP from inception to October, 2018. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies, then, meta-analysis was performed by using Stata 12.0 software. Results A total of 9 RCTs involving 1 074 patients were included. The results of metaanalysis showed that: compared to patients with EN after 48 hours or parental nutrition, the patients given EN within 48 hours after admission had lower mortality(RR=0.53, 95%CI 0.29 to 0.96, P=0.036) and morbidity of multiple organ dysfunction syndrome(MODS)(RR=0.58, 95%CI 0.44 to 0.77, P<0.001). However, no significant differences were found in systemic inflammatory response syndrome(SIRS)(RR=1.00, 95%CI 0.86 to 1.16, P=1.00). Conclusions The current evidence shows that EN within 48 hours after admission can reduce the mortality and morbidity of MODS in SAP patients. Due to limited quality and quantity of the included studies, more high-quality studies are needed to verify above conclusions.
引文
1Warren M, Mc Carthy MS, Roberts PR. Practical application of the revised guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient:a case study approach. Nutr Clin Pract, 2016, 31(3):334-341.
2Yang R, Tenhunen J, Tonnessen TI. HMGB1 and histones play a significant role in inducing systemic inflammation and multiple organ dysfunctions in severe acute pancreatitis. Int J Inflam, 2017,2017:1817564.
3Li HC, Fan XJ, Chen YF, et al. Early prediction of intestinal mucosal barrier function impairment by elevated serum procalcitonin in rats with severe acute pancreatitis. Pancreatology,2016, 16(2):211-217.
4 Schietroma M, Pessia B, Carlei F, et al. Intestinal permeability and systemic endotoxemia in patients with acute pancreatitis. Ann Ital Chir, 2016, 87:138-144.
5Qiao SF, Lu TJ, Sun JB, et al. Alterations of intestinal immune function and regulatory effects of L-arginine in experimental severe acute pancreatitis rats. World J Gastroenterol, 2005, 11(39):6216-6218.
6Schwarz M, Thomsen J, Meyer H, et al. Frequency and time course of pancreatic and extrapancreatic bacterial infection in experimental acute pancreatitis in rats. Surgery, 2000, 127(4):427-432.
7Luo XJ, Peng Y. Enteral nutrition in severe acute pancreatitis.World Chinese J Digest, 2014, 22(12):1658-1662.
8Ekelund M, Kristensson E, Ekelund M, et al. Total parenteral nutrition causes circumferential intestinal atrophy, remodeling of the intestinal wall, and redistribution of eosinophils in the rat gastrointestinal tract. Dig Dis Sci, 2007, 52(8):1833-1839.
9Hua Z, Su Y, Huang X, et al. Analysis of risk factors related to gastrointestinal fistula in patients with severe acute pancreatitis:a retrospective study of 344 cases in a single Chinese center. BMC Gastroenterol, 2017, 17(1):29.
10Corcoy R, Sanchez JM, Domingo P, et al. Nutrition in the patient with severe acute-pancreatitis. Nutrition, 1988, 4(4):269-275.
11Feng P, He C, Liao G, et al. Early enteral nutrition versus delayed enteral nutrition in acute pancreatitis:A PRISMA-compliant systematic review and meta-analysis. Medicine(Baltimore), 2017,96 (46):e8648.
12Li JY, Yu T, Chen GC, et al. Enteral nutrition within 48 hours of admission improves clinical outcomes of acute pancreatitis by reducing complications:a meta-analysis. PLo S One, 2013, 8(6):e64926.
13Qi DS, Yu B, Huang J, et al. Meta-analysis of early enteral nutrition provided within 24 hours of admission on clinical outcomes in acute pancreatitis. J Parenter Enter Nutr, 2018, 42(7):1139-1147.
14Reintam Blaser A, Starkopf J, Alhazzani W, et al. Early enteral nutrition in critically ill patients:ESICM clinical practice guidelines. Intensive Care Med, 2017, 43(3):380-398.
15Tenner S, Baillie J, De Witt J, et al. American College of Gastroenterology guideline:management of acute pancreatitis. Am J Gastroenterol, 2013, 108(9):1400-1415.
16Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology, 2013, 13(4 Suppl 2):e1-e15.
17Sun JK, Mu XW, Li WQ, et al. Effects of early enteral nutrition on immune function of severe acute pancreatitis patients. World J Gastroenterol, 2013, 19(6):917-922.
18Wang G, Wen J, Xu L, et al. Effect of enteral nutrition and ecoimmunonutrition on bacterial translocation and cytokine production in patients with severe acute pancreatitis. J Surg Res,2013, 183(2):592-597.
19Bakker OJ, van Brunschot S, van Santvoort HC, et al. Early versus on-demand nasoenteric tube feeding in acute pancreatitis. N Engl J Med, 2014, 371(21):1983-1993.
20Eckerwall GE, Axelsson JB, Andersson RG. Early nasogastric feeding in predicted severe acute pancreatitis:A clinical,randomized study. Ann Surg, 2006, 244(6):959-965.
21王艳,李宝华,李立,等.经鼻肠营养管超早期肠内营养支持治疗重症急性胰腺炎的临床对照研究.中国微创外科杂志, 2014,14(9):786-791.
22 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. Br J Surg, 1997, 84(12):1665-1669.
23Petrov 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 entera nutrition. Dig Surg, 2006, 23(5-6):336-344.
24Wereszczynska-Siemiatkowska U, Swidnicka-Siergiejko A Siemiatkowski A, et al. Early enteral nutrition is superior to delayed enteral nutrition for the prevention of infected necrosis and mortality in acute pancreatitis. Pancreas, 2013, 42(4):640-646.
25 Stimac D, Poropat G, Hauser G, et al. Early nasojejunal tube feeding versus nil-by-mouth in acute pancreatitis:A randomized clinical trial. Pancreatology, 2016, 16(4):523-528.
26Al-Omran M, Albalawi ZH, Tashkandi MF, et al. Enteral versus parenteral nutrition for acute pancreatitis. Cochrane Database Syst Rev, 2010,(1):CD002837.
27Roberts KM, Nahikian-Nelms M, Ukleja A, et al. Nutritional aspects of acute pancreatitis. Gastroenterol Clin North Am, 2018,47(1):77-94.
28陈洁,王兴鹏,刘丕,等.持续性早期肠内营养对急性坏死型胰腺炎犬肠屏障功能的影响.中华医学杂志, 2004, 84(20):1726-1731.
29 Foitzik T. Pancreatitis and nutrition. Significance of the gastrointestinal tract and nutrition for septic complications.Zentralbl Chir, 2001, 126(1):4-9.
2Yang R, Tenhunen J, Tonnessen TI. HMGB1 and histones play a significant role in inducing systemic inflammation and multiple organ dysfunctions in severe acute pancreatitis. Int J Inflam, 2017,2017:1817564.
3Li HC, Fan XJ, Chen YF, et al. Early prediction of intestinal mucosal barrier function impairment by elevated serum procalcitonin in rats with severe acute pancreatitis. Pancreatology,2016, 16(2):211-217.
4 Schietroma M, Pessia B, Carlei F, et al. Intestinal permeability and systemic endotoxemia in patients with acute pancreatitis. Ann Ital Chir, 2016, 87:138-144.
5Qiao SF, Lu TJ, Sun JB, et al. Alterations of intestinal immune function and regulatory effects of L-arginine in experimental severe acute pancreatitis rats. World J Gastroenterol, 2005, 11(39):6216-6218.
6Schwarz M, Thomsen J, Meyer H, et al. Frequency and time course of pancreatic and extrapancreatic bacterial infection in experimental acute pancreatitis in rats. Surgery, 2000, 127(4):427-432.
7Luo XJ, Peng Y. Enteral nutrition in severe acute pancreatitis.World Chinese J Digest, 2014, 22(12):1658-1662.
8Ekelund M, Kristensson E, Ekelund M, et al. Total parenteral nutrition causes circumferential intestinal atrophy, remodeling of the intestinal wall, and redistribution of eosinophils in the rat gastrointestinal tract. Dig Dis Sci, 2007, 52(8):1833-1839.
9Hua Z, Su Y, Huang X, et al. Analysis of risk factors related to gastrointestinal fistula in patients with severe acute pancreatitis:a retrospective study of 344 cases in a single Chinese center. BMC Gastroenterol, 2017, 17(1):29.
10Corcoy R, Sanchez JM, Domingo P, et al. Nutrition in the patient with severe acute-pancreatitis. Nutrition, 1988, 4(4):269-275.
11Feng P, He C, Liao G, et al. Early enteral nutrition versus delayed enteral nutrition in acute pancreatitis:A PRISMA-compliant systematic review and meta-analysis. Medicine(Baltimore), 2017,96 (46):e8648.
12Li JY, Yu T, Chen GC, et al. Enteral nutrition within 48 hours of admission improves clinical outcomes of acute pancreatitis by reducing complications:a meta-analysis. PLo S One, 2013, 8(6):e64926.
13Qi DS, Yu B, Huang J, et al. Meta-analysis of early enteral nutrition provided within 24 hours of admission on clinical outcomes in acute pancreatitis. J Parenter Enter Nutr, 2018, 42(7):1139-1147.
14Reintam Blaser A, Starkopf J, Alhazzani W, et al. Early enteral nutrition in critically ill patients:ESICM clinical practice guidelines. Intensive Care Med, 2017, 43(3):380-398.
15Tenner S, Baillie J, De Witt J, et al. American College of Gastroenterology guideline:management of acute pancreatitis. Am J Gastroenterol, 2013, 108(9):1400-1415.
16Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology, 2013, 13(4 Suppl 2):e1-e15.
17Sun JK, Mu XW, Li WQ, et al. Effects of early enteral nutrition on immune function of severe acute pancreatitis patients. World J Gastroenterol, 2013, 19(6):917-922.
18Wang G, Wen J, Xu L, et al. Effect of enteral nutrition and ecoimmunonutrition on bacterial translocation and cytokine production in patients with severe acute pancreatitis. J Surg Res,2013, 183(2):592-597.
19Bakker OJ, van Brunschot S, van Santvoort HC, et al. Early versus on-demand nasoenteric tube feeding in acute pancreatitis. N Engl J Med, 2014, 371(21):1983-1993.
20Eckerwall GE, Axelsson JB, Andersson RG. Early nasogastric feeding in predicted severe acute pancreatitis:A clinical,randomized study. Ann Surg, 2006, 244(6):959-965.
21王艳,李宝华,李立,等.经鼻肠营养管超早期肠内营养支持治疗重症急性胰腺炎的临床对照研究.中国微创外科杂志, 2014,14(9):786-791.
22 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. Br J Surg, 1997, 84(12):1665-1669.
23Petrov 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 entera nutrition. Dig Surg, 2006, 23(5-6):336-344.
24Wereszczynska-Siemiatkowska U, Swidnicka-Siergiejko A Siemiatkowski A, et al. Early enteral nutrition is superior to delayed enteral nutrition for the prevention of infected necrosis and mortality in acute pancreatitis. Pancreas, 2013, 42(4):640-646.
25 Stimac D, Poropat G, Hauser G, et al. Early nasojejunal tube feeding versus nil-by-mouth in acute pancreatitis:A randomized clinical trial. Pancreatology, 2016, 16(4):523-528.
26Al-Omran M, Albalawi ZH, Tashkandi MF, et al. Enteral versus parenteral nutrition for acute pancreatitis. Cochrane Database Syst Rev, 2010,(1):CD002837.
27Roberts KM, Nahikian-Nelms M, Ukleja A, et al. Nutritional aspects of acute pancreatitis. Gastroenterol Clin North Am, 2018,47(1):77-94.
28陈洁,王兴鹏,刘丕,等.持续性早期肠内营养对急性坏死型胰腺炎犬肠屏障功能的影响.中华医学杂志, 2004, 84(20):1726-1731.
29 Foitzik T. Pancreatitis and nutrition. Significance of the gastrointestinal tract and nutrition for septic complications.Zentralbl Chir, 2001, 126(1):4-9.