Influence of perioperative oral nutritional supplementation on short‑term efficacy of laparos-copic sleeve gastrectomy for obesity patients: a prospective study
-
摘要:目的
探讨围手术期口服营养补充对肥胖症患者行腹腔镜袖状胃切除术（LSG）后短期疗效的影响。
方法采用前瞻性研究方法。选取2018年1月至2021年12月宁夏医科大学总医院收治的218例肥胖症行LSG患者的临床资料。患者围手术期行口服营养补充治疗设为试验组,行常规治疗设为对照组。观察指标：（1）入组患者分组情况。（2）术后及随访情况。（3）营养相关指标情况。（4）饮食依从性情况。（5）减重相关指标情况。采用电话、微信和门诊方式进行随访。患者出院后30 d随访1次,随访内容包括白蛋白（Alb）、血红蛋白（Hb）、饮食依从性情况和减重相关指标。随访时间截至2022年2月。正态分布的计量资料以x±s表示,组间比较采用独立样本t检验。偏态分布的计量资料以M（范围）表示,组间比较采用Mann‑Whitney U检验。计数资料以绝对数或百分比表示,组间比较采用χ²检验。重复测量数据采用重复测量方差分析。等级资料比较采用秩和检验。
结果（1）入组患者分组情况。筛选出符合条件的患者218例；男42例,女176例；年龄为（32±9）岁；体质量指数（BMI）为（39±7）kg/m2。218例患者中,试验组和对照组各109例。试验组患者性别（男、女）,年龄,BMI,术前Alb,术前Hb分别为17、92例,（33±9）岁,（39±7）kg/m2,（40.6±4.8）g/L,（141.7±13.9）g/L；对照组患者上述指标分别为25、84例,（31±8）岁,（39±8）kg/m2,（40.9±4.2）g/L,（142.9±9.7）g/L；两组患者上述指标比较,差异均无统计学意义（χ²=1.89,t=-1.52、0.51、0.40、0.71,P>0.05）。（2）术后及随访情况。试验组患者首次住院时间、首次住院费用分别为（9.1±2.9）d、（3.6±0.5）万元；对照组患者上述指标分别为（11.6±3.7）d、（4.9±1.0）万元；两组患者上述指标比较,差异均有统计学意义（t=5.58,12.38,P<0.05）。218例患者中,119例获得随访,其中试验组62例、对照组57例。119例患者随访时间为31.0（25.0~38.0）d。218例患者中,14例发生术后并发症导致再入院治疗,其中试验组2例,分别为恶心呕吐1例、肠梗阻1例；对照组12例,分别为恶心呕吐10例、胃瘘2例；两组患者再入院治疗比较,差异有统计学意义（χ²=7.63,P<0.05）。14例患者再入院与首次出院时间间隔为（22.0±6.7）d。（3）营养相关指标情况。试验组62例获得随访患者术前、首次出院前、术后1个月Alb和Hb分别为（40.4±5.5）g/L、（35.9±3.8）g/L、（45.4±2.9）g/L和（140.8±13.9）g/L、（130.5±16.9）g/L、（147.8±17.2）g/L；对照组57例获得随访患者上述指标分别为（41.2±3.9）g/L、（34.2±3.9）g/L、（42.7±5.3）g/L和（143.0±9.7）g/L、（122.9±12.8）g/L、（139.0±11.4）g/L；两组患者术前至术后1个月Alb和Hb组间变化趋势比较,差异均有统计学意义（F组间=4.27,5.72,P<0.05）；两组患者术前至术后1个月Alb和Hb变化趋势比较,差异均有统计学意义（F时间=187.46,85.13,P<0.05）；两组患者术前至术后1个月Alb和Hb变化趋势之间均有交互效应（F交互=7.25,9.13,P<0.05）。单独效应结果显示：两组患者Alb和Hb术前干预效应比较,差异均无统计学意义（t=-0.90,-0.99,P>0.05）；首次出院前、术后1个月干预效应比较,差异均有统计学意义（t=2.45,3.34,2.75,3.34,P<0.05）。（4）饮食依从性情况。试验组62例获得随访患者饮食依从性完全依从、部分依从、不依从分别为28、19、15例；对照组57例获得随访患者上述指标分别为17、16、24例；两组患者饮食依从性比较,差异有统计学意义（Z=-2.14,P<0.05）。（5）减重相关指标情况。试验组62例获得随访患者术前体质量、体脂肪、骨骼肌、体脂率、腰臀脂肪比、内脏脂肪面积分别为（111.0±23.0）kg、（50.0±15.0）kg、（34.0±7.0）kg、45%±6%、0.99±0.08、（178±53）cm2；对照组57例获得随访患者上述指标分别为（108.0±22.0）kg、（49.0±13.0）kg、（33.0±7.0）kg、45%±5%、0.98±0.09、（174±51）cm2；两组患者上述指标比较,差异均无统计学意义（t=-0.71,-0.48,-1.04,0.70,-0.80,-0.46,P>0.05）。试验组62例获得随访患者术后1个月体质量下降、体脂肪下降、骨骼肌下降、体脂率下降、腰臀脂肪比下降、内脏脂肪面积下降分别为13.8（11.8~16.5）kg、7.5（6.3~10.1）kg、3.4（2.5~4.6）kg、2.05%（1.19%~3.21%）、0.04（0.03~0.06）、31.5（24.4~41.0）cm2；对照组57例获得随访患者上述指标分别为10.8（8.5~13.1）kg、5.9（4.8~8.0）kg、4.0（3.0~5.2）kg、2.0%（0.75%~3.20%）、0.04（0.03~0.05）、29.1（21.8~37.9）cm2；两组患者体质量下降、体脂肪下降比较,差异均有统计学意义（Z=-4.99,-3.54,P<0.05）,骨骼肌下降、体脂率下降、腰臀脂肪比下降、内脏脂肪面积下降比较,差异均无统计学意义（P>0.05）。
结论围手术期口服营养补充可减少肥胖症患者行LSG后并发症发生和再入院治疗情况,改善患者术后短期营养状况和提高减重手术疗效。
Abstract:ObjectiveTo investigate the influence of perioperative oral nutritional supple-mentation on short‑term efficacy of laparoscopic sleeve gastrectomy (LSG) for obesity patients.
MethodsThe prospective study was conducted. The clinical data of 218 obesity patients who underwent LSG in the General Hospital of Ningxia Medical University from January 2018 to December 2021 were selected. Patients receiving perioperative oral nutritional supplementation were allocated into the experiment group, and patients receiving perioperative conventional treatment were allo-cated into the control group, respectively. Observation indicators: (1) grouping situations of the enrolled patients; (2) postoperative situations and follow‑up; (3) nutrition related indicators; (4) dietary compliance; (5) weight loss related indicators. Follow‑up was conducted using telephone interview, WeChat communication and outpatient examination to detect albumin (ALB), hemoglobin (HB), dietary compliance and weight loss related indicators of patients up to February 2022. Patients were followed up once every 30 days after discharge. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was conducted using the indepen-dent sample t test. Measurement data with skewed distribution were represented as M(range), and comparison between groups was conducted using the Mann‑Whitney U test. Count data were described as absolute numbers or percentages, and comparison between groups was performed using the chi‑square test. Repeated measurement data were analyzed using the repeated ANOVA. Comparison of ordinal data was analyzed using the rank sum test.
Results(1) Grouping situations of the enrolled patients. A total of 218 patients were selected for eligibility. There were 42 males and 176 females, aged (32±9)years with body mass index (BMI) as (39±7)kg/m2. Of the 218 patients, there were 109 patients in the experiment group and 109 patients in the control group. Gender(male, female), age, BMI, preoperative albumin (Alb), preoperative hemoglobin (Hb) were 17, 92, (33±9)years, (39±7)kg/m2, (40.6±4.8)g/L, (141.7±13.9)g/L in the experiment group, versus 25, 84, (31±8)years, (39±8)kg/m2, (40.9±4.2)g/L, (142.9±9.7)g/L in the control group, showing no signifi-cant difference in the above indicators between the two groups (χ²=1.89, t=‒1.52, 0.51, 0.40, 0.71, P>0.05). (2) Postoperative situations and follow‑up. The duration of initial hospital stay, the cost of initial hospital stay were (9.1±2.9)days, (3.6±0.5)ten thousand yuan in the experiment group, versus(11.6±3.7)days, (4.9±1.0)ten thousand yuan in the control group,showing significant differences in the above indicators between the two groups (t=5.58, 12.38, P<0.05). Of the 218 patients,119 patients were followed up,including 62 patients in the experiment group and 57 patients in the control group,with the follow up time as 31.0(range, 25.0‒38.0)days. Of the 218 patients, 14 cases were read-mitted for postoperative complications. There were 2 cases in the experiment group including 1 case with nausea and vomiting and 1 case with ileus, and there were 12 cases in the control group including 10 cases with nausea and vomiting and 2 cases with gastric fistula. There was a significant difference in the readmission between the two groups (χ²=7.63,P<0.05). The interval between readmission and initial discharge of the 14 patients was(22.0±6.7)days. (3) Nutrition related indica-tors. The Alb and Hb of the 62 patients being followed up in the experiment group were (40.4±5.5)g/L, (35.9±3.8)g/L, (45.4±2.9)g/L and (140.8±13.9)g/L, (130.5±16.9)g/L, (147.8±17.2)g/L before opera-tion, before the first discharge and one month after operation, respectively. The above indicators of the 57 patients being followed up in the control group were (41.2±3.9)g/L, (34.2±3.9)g/L, (42.7±5.3)g/L and (143.0±9.7)g/L, (122.9±12.8)g/L, (139.0±11.4)g/L before operation, before the first discharge and one month after operation, respectively. There were significant differences in change trends of Alb and Hb before operation to one month after operation between the two groups (Fgroup=4.27, 5.72, P<0.05). There were significant differences in Alb and Hb before operation to one month after operation between the two groups (Ftime=187.46, 85.13, P<0.05). There were interaction effects in change trends of Alb and Hb before operation to one month after operation between the two groups (Finteraction=7.25, 9.13, P<0.05). Results of individual effect shown that there was no significant difference in the intervention effect of Alb and Hb before operation between the two groups (t=‒0.90, ‒0.99, P>0.05), and there were significant differences in the intervention effect of Alb and Hb before the first discharge and one month after operation (t=2.45, 3.34, 2.75, 3.34, P<0.05). (4) Dietary compliance. Cases with dietary complete compliance, partial compliance, non‑compliance of the 62 patients being followed up in the experiment group were 28, 19, 15, respectively. The above indicators of the 57 patients being followed up in the control group were 17, 16, 24, respectively. There was a signifi-cant difference in the dietary compliance between the two groups (Z=‒2.14, P<0.05). (5) Weight loss related indicators. The body mass, body fat mass, skeletal muscle mass, body fat ratio, waist hip fat ratio, visceral fat area of the 62 patients being followed up in the experiment group were (111.0±23.0)kg, (50.0±15.0)kg, (34.0±7.0)kg, 45%±6%, 0.99±0.08, (178±53)cm2, respectively, before opera-tion. The above indicators of the 57 patients being followed up in the control group were (108.0±22.0)kg, (49.0±13.0)kg, (33.0±7.0)kg, 45%±5%, 0.98±0.09, (174±51)cm2, respectively, before opera-tion. There was no significant difference in the above indicators between the two groups (t=‒0.71, ‒0.48, ‒1.04, 0.70, ‒0.80, ‒0.46, P>0.05). The body mass loss, body fat mass loss, skeletal muscle mass loss, body fat ratio loss, waist hip fat ratio loss, visceral fat area loss of the 62 patients being followed up in the experiment group were 13.8(range, 11.8‒16.5)kg, 7.5(range, 6.3‒10.1)kg, 3.4(range, 2.5‒4.6)kg, 2.05%(range, 1.19%‒3.21%), 0.04(range, 0.03‒0.06), 31.5(range, 24.4‒41.0)cm2, respectively, one month after operation. The above indicators of the 57 patients being followed up in the control group were 10.8(range, 8.5‒13.1)kg, 5.9(range, 4.8‒8.0)kg, 4.0(range, 3.0‒5.2)kg, 2.0%(range, 0.75%‒3.20%), 0.04(range, 0.03‒0.05), 29.1(range, 21.8‒37.9)cm2, respectively, one month after operation. There were significant differences in the body mass loss and body fat mass loss between the two groups (Z=‒4.99, ‒3.54, P<0.05), and there was no significant difference in skeletal muscle mass loss, body fat ratio loss, waist hip fat ratio loss, visceral fat area loss between the two groups (P>0.05).
ConclusionPerioperative supplement of oral nutritional can reduce the incidence of post-operative complications and readmission and enhance the postoperative nutritional status and short‑term efficacy of obesity patients undergoing LSG.
-
Keywords:
- Obesity /
- Bariatric surgery /
- Nutritional intervention /
- Readmission /
- Nutri-tional status /
- Laparoscopy
-
减重手术已成为治疗肥胖症及其相关并发症长期有效的治疗方案,其中腹腔镜袖状胃切除术（laparoscopic sleeve gastrectomy,LSG）因操作简便、对消化道结构破坏少、安全性高等特点成为减重代谢外科常用手术方式[1‑3]。虽然LSG后并发症发生率较低,但仍有部分患者因严重并发症再次入院治疗。再入院率已成为医疗质量评价体系重要指标。已有的研究结果显示：虽然术前医护人员已对行减重手术患者进行详细饮食宣传与教育,但患者术后饮食依从性效果不佳[4‑6]。此外,减重手术后由于患者消化道结构改变,易引起营养相关并发症,影响患者正常的生活和工作[7‑9]。本研究前瞻性分析2018年1月至2021年12月宁夏医科大学总医院胃肠外科收治的218例肥胖症行LSG患者的临床资料,探讨围手术期口服营养补充对患者短期疗效的影响。
资料与方法
一、病例选择
采用前瞻性研究方法。选取218例肥胖症行LSG患者的临床资料。
纳入标准：（1）符合《减重手术的营养与多学科管理专家共识》手术适应证[7]。（2）初次行减重手术。（3）年龄为18~60岁。
排除标准：（1）患有严重的心脑血管疾病、甲状腺功能亢进或减退、恶性肿瘤等影响饮食的疾病。（2）患有难以控制的精神疾病。（3）妊娠期或哺乳期。
本研究通过我院医学伦理委员会审批,批号为2019‑392。患者及家属均签署知情同意书。
二、样本量估算与入组及分组
样本量估算：本研究以肥胖症患者行LSG后再入院率作为研究评价指标进行样本量计算。由于无围手术期口服营养补充对肥胖症患者行LSG后再入院的相关研究,所以使用预试验结果数据进行样本量计算。预试验中,试验组（围手术期行口服营养补充治疗）与对照组（围手术期行常规治疗）患者的再入院率分别为2%和14%。取α=0.05（双侧）,检验效能1‑β=80%。采用优效性设计样本量计算公式计算样本量为162例[10]。本研究最终收集218例患者进行分析,每组患者109例。
患者入组和分组：参与本研究的218例患者,根据患者意愿,围手术期行口服营养补充治疗设为试验组,围手术期行常规治疗设为对照组。
三、治疗方法
1.术前评估：所有患者根据术前检查资料由胃肠外科、营养科、内分泌科、心身医学科医师经综合评估后制订手术方案。
2.试验组围手术期治疗方案：术前3~5 d,给予整蛋白型营养液,150~250 mL/次,6次/d,总热量按理想体质量×20 kcal/（kg·d）计算,其中蛋白质占总热量30%,脂肪占总热量27%；术后第1天,给予温开水30~100 mL/次,共6次；术后第2天,给予清流质饮食50~100 mL/次,共6次；术后第3~4天,给予短肽型营养液,50~100 mL/次,6次/d,起始浓度为0.4 kcal/mL,根据患者胃肠道适应情况逐渐升高至正常浓度,总热量按600 kcal/d计量,其中蛋白质占总热量40%,脂肪占总热量28%；术后第5~11天,给予整蛋白型营养液,100 mL/次,6次/d,总热量按600 kcal/d计量,其中蛋白质占总热量40%,脂肪占总热量30%；术后第12~30天,给予流质饮食,100~150 mL/次,6~8次/d,每次进食每口咀嚼>30次,进食期间缓慢饮水,保证饮水量为1 000 mL/d,补充给予分离乳清蛋白粉60 g/d+钙1 500 mg/d+铁58 mg/d+复合维生素10 g/d。
3.对照组围手术期治疗方案：术前3~5 d,正常饮食；术后第1天,给予温开水20~30 mL/次,3~5次,1次/h,小口慢饮；术后第2~3天,给予清流质饮食,30~50 mL/次,1次/h,总量500~600 mL/d,每次进食>30 min后饮水20~30 mL；术后第4~30天,给予流质饮食,100~150 mL/次,2~3 h/次,每次进食每口咀嚼>30次,进食期间缓慢饮水,保证饮水量为1 000 mL/d,补充给予分离乳清蛋白粉60 g/d+钙1 500 mg/d+铁58 mg/d+复合维生素10 g/d。
4.手术治疗：所有患者由同一手术团队行LSG。
四、观察指标和评价标准
观察指标：（1）入组患者分组情况包括性别、年龄、BMI、术前Alb、术前Hb。（2）术后及随访情况：首次住院时间、首次住院费用、获得随访的患者例数、随访时间、并发症发生情况、再入院情况、再入院与首次出院时间间隔。（3）营养相关指标情况：随访患者术前、首次出院前、术后1个月Alb和Hb情况。（4）饮食依从性情况：随访患者饮食依从性。（5）减重相关指标情况：随访患者术前体质量、体脂肪、骨骼肌、体脂率、腰臀脂肪比、内脏脂肪面积,术后1个月体质量下降、体脂肪下降、骨骼肌下降、体脂率下降、腰臀脂肪比下降、内脏脂肪面积下降情况。
评价标准：饮食依从性,严格按照指定的饮食方案进行日常饮食为完全依从,按照>50%指定饮食方案进行日常饮食为部分依从,其他为不依从[11‑12]。
五、随访
采用电话、微信和门诊方式进行随访。患者出院后30 d随访1次,随访内容包括Alb、Hb、饮食依从性情况和减重相关指标。随访时间截至2022年 2月。
六、统计学分析
应用SPSS 23.0统计软件进行分析。正态分布的计量资料以x±s表示,组间比较采用独立样本t检验。偏态分布的计量资料以M（范围）表示,组间比较采用Mann‑Whitney U检验。计数资料以绝对数或百分比表示,组间比较采用χ²检验。重复测量数据采用重复测量方差分析。等级资料比较采用秩和检验。P<0.05为差异有统计学意义。
结果
一、入组患者分组情况
筛选出符合条件的患者218例；男42例,女176例；年龄为（32±9）岁；BMI为（39±7）kg/m2。218例患者中,试验组和对照组各109例。两组患者性别、年龄、BMI、术前Alb、术前Hb比较,差异均无统计学意义（P>0.05）,具有可比性。见表1。
表 1 试验组与对照组肥胖症患者行腹腔镜袖状胃切除术前临床特征比较Table 1. Comparison of preoperative clinical characteristics of obesity patients undergoing laparoscopic sleeve gastrectomy between the experiment group and the control group组别 例数 性别（例） 年龄（x±s,岁） 体质量指数（x±s,kg/m2） 术前白蛋白（x±s,g/L） 术前血红蛋白（x±s,g/L） 男 女 试验组 109 17 92 33±9 39±7 40.6±4.8 141.7±13.9 对照组 109 25 84 31±8 39±8 40.9±4.2 142.9±9.7 统计值 χ²=1.89 t=-1.52 t=0.51 t=0.40 t=0.71 P值 0.169 0.129 0.610 0.689 0.478 注： 试验组患者围手术期行口服营养补充治疗,对照组患者围手术期行常规治疗二、术后及随访情况
试验组患者首次住院时间、首次住院费用分别为（9.1±2.9）d、（3.6±0.5）万元；对照组患者上述指标分别为（11.6±3.7）d、（4.9±1.0）万元；两组患者上述指标比较,差异均有统计学意义（t=5.58,12.38,P<0.001,P<0.001）。
218例患者中,119例获得随访,其中试验组62例、对照组57例。119例患者随访时间为31.0（25.0~38.0）d。218例患者中,14例发生术后并发症导致再入院治疗,其中试验组2例,分别为恶心呕吐1例、肠梗阻1例；对照组12例,分别为恶心呕吐10例、胃瘘2例；两组患者再入院治疗比较,差异有统计学意义（χ²=7.63,P=0.006）。14例患者再入院与首次出院时间间隔为（22.0±6.7）d。
三、营养相关指标情况
试验组62例获得随访患者术前、首次出院前、术后1个月Alb和Hb分别为（40.4±5.5）g/L、（35.9±3.8）g/L、（45.4±2.9）g/L和（140.8±13.9）g/L、（130.5±16.9）g/L、（147.8±17.2）g/L；对照组57例获得随访患者上述指标分别为（41.2±3.9）g/L、（34.2±3.9）g/L、（42.7±5.3）g/L和（143.0±9.7）g/L、（122.9±12.8）g/L、（139.0±11.4）g/L；两组患者术前至术后1个月Alb和Hb组间变化趋势比较,差异均有统计学意义（F组间=4.27,5.72,P=0.041,P=0.018）；两组患者术前至术后1个月Alb和Hb变化趋势比较,差异均有统计学意义（F时间=187.46,85.13,P<0.001,P<0.001）；两组患者术前至术后1个月Alb和Hb变化趋势之间均有交互效应（F交互=7.25,9.13,P=0.001,P<0.001）。单独效应结果显示：两组患者Alb和Hb术前干预效应比较,差异均无统计学意义（t=-0.90,-0.99,P=0.326、0.326）；首次出院前、术后1个月干预效应比较,差异均有统计学意义（t=2.45,3.34,2.75,3.34,P=0.016,0.001,0.007,0.001）。
四、饮食依从性情况
试验组62例获得随访患者饮食依从性完全依从、部分依从、不依从分别为28、19、15例；对照组57例获得随访患者上述指标分别为17、16、24例；两组患者饮食依从性比较,差异有统计学意义（Z=-2.14,P=0.032）。
五、减重相关指标情况
试验组62例获得随访患者术前体质量、体脂肪、骨骼肌、体脂率、腰臀脂肪比、内脏脂肪面积分别为（111.0±23.0）kg、（50.0±15.0）kg、（34.0±7.0）kg、45%±6%、0.99±0.08、（178±53）cm2；对照组57例获得随访患者上述指标分别为（108.0±22.0）kg、（49.0±13.0）kg、（33.0±7.0）kg、45%±5%、0.98±0.09、（174±51）cm2；两组患者上述指标比较,差异均无统计学意义（t=-0.71,-0.48,-1.04,0.70,-0.80,-0.46,P=0.482,0.635,0.302,0.488,0.424,0.649）。
试验组62例获得随访患者术后1个月体质量下降、体脂肪下降、骨骼肌下降、体脂率下降、腰臀脂肪比下降、内脏脂肪面积下降分别为13.8（11.8~16.5）kg、7.5（6.3~10.1）kg、3.4（2.5~4.6）kg、2.05%（1.19%~3.21%）、0.04（0.03~0.06）、31.5（24.4~41.0）cm2；对照组57例获得随访患者上述指标分别为10.8（8.5~13.1）kg、5.9（4.8~8.0）kg、4.0（3.0~5.2）kg、2.0%（0.75%~3.20%）、0.04（0.03~0.05）、29.1（21.8~37.9）cm2；两组患者体质量下降、体脂肪下降比较,差异均有统计学意义（Z=-4.99,-3.54,P<0.001,P<0.001）,骨骼肌下降、体脂率下降、腰臀脂肪比下降、内脏脂肪面积下降比较,差异均无统计学意义（Z=-1.68, -1.03,-1.52,-1.23,P=0.092,0.303,0.130,0.219）。
讨论
一、肥胖症患者饮食习惯对术后并发症和再入院治疗的影响
肥胖症的患病率逐年递增,患者常合并高血压、糖尿病、心血管疾病等各种慢性代谢性疾病,进而严重影响患者生命质量[13‑18]。已有的临床研究结果显示：减重手术是治疗肥胖症及其相关并发症最经济有效的首选治疗方案,其中LSG在所有减重手术中开展数量位居首位[1,19‑21]。目前临床医师更关注减重手术治疗肥胖症及其相关并发症的疗效,对患者术后并发症和短期营养状况关注度不足。
肥胖症患者行手术治疗前常存在不良饮食习惯,而由于术后30 d内的进食模式与平时不同,且患者术后短期内没有饥饿感,部分患者会产生消极态度,进而影响术后饮食依从性[22‑24]。术后不合理饮食易导致恶心呕吐的发生,严重者会引发胃瘘,需再入院治疗[25‑27]。已有的研究结果显示：围手术期采取合理饮食策略,可以降低行减重手术患者术后不良反应发生率,进而促进术后疗效[28‑30]。
二、围手术期饮食指导对肥胖症患者饮食依从性、再入院治疗及减重效果的影响
目前我国临床上现行的饮食指导策略,多数仅进行书面和口头宣传与教育,不能及时跟踪和进行个性化调整,导致患者术后饮食依从性较差[23,31]。本研究根据《减重手术的营养与多学科管理专家共识》,在术前饮食宣传与教育基础上,制订个性化口服营养补充方案,并于患者出院后及时随访,了解和监督其正确饮食及生活方式,保证患者术后饮食依从性。本研究结果显示：两组患者术后1个月饮食依从性、营养相关指标,再入院治疗比较,差异均有统计学意义。
围手术期给予患者合理饮食指导可减少不良反应发生率,并对维持减重效果至关重要[32‑36]。LSG最理想的身体成分变化状态是体质量降低并伴随体脂肪下降[37‑38]。合理饮食指导结合适量蛋白质摄入,可保持肌肉质量,增加体脂肪丢失[39‑40]。本研究结果显示：两组患者术后1个月体质量下降、体脂肪下降比较,差异均有统计学意义。
综上,围手术期口服营养补充可减少肥胖症患者行LSG后并发症发生和再入院治疗情况,改善患者术后短期营养状况和提高减重手术疗效。
张盛军、张娜、陈申思：研究设计；张盛军、张娜、程倩、邓莲：研究实施及随访；张盛军、程倩、王磊、俞永涛：入组患者；张盛军、张娜、邓莲：数据分析；张盛军：论文撰写；王磊、俞永涛、陈启众、陈申思：研究指导,论文修改,经费支持所有作者均声明不存在利益冲突张盛军, 张娜, 程倩, 等. 围手术期口服营养补充对肥胖症患者行腹腔镜袖状胃切除术后短期疗效影响的前瞻性研究[J]. 中华消化外科杂志, 2022, 21(11): 1432-1439. DOI: 10.3760/cma.j.cn115610-20220829-00475.http://journal.yiigle.com/LinkIn.do?linkin_type=cma&DOI=10.3760/cma.j.cn115610-20220829-22475
-
表 1 试验组与对照组肥胖症患者行腹腔镜袖状胃切除术前临床特征比较
Table 1 Comparison of preoperative clinical characteristics of obesity patients undergoing laparoscopic sleeve gastrectomy between the experiment group and the control group
组别 例数 性别（例） 年龄（x±s,岁） 体质量指数（x±s,kg/m2） 术前白蛋白（x±s,g/L） 术前血红蛋白（x±s,g/L） 男 女 试验组 109 17 92 33±9 39±7 40.6±4.8 141.7±13.9 对照组 109 25 84 31±8 39±8 40.9±4.2 142.9±9.7 统计值 χ²=1.89 t=-1.52 t=0.51 t=0.40 t=0.71 P值 0.169 0.129 0.610 0.689 0.478 注： 试验组患者围手术期行口服营养补充治疗,对照组患者围手术期行常规治疗
下载: 导出CSV
-
[1] 肖志立,郑文彬,杨钧,等.腹腔镜袖状胃切除术治疗肥胖症相关非酒精性脂肪性肝病的临床疗效[J].中华消化外科杂志,2021,20(9):988‑993. DOI: 10.3760/cma.j.cn115610-20210823-00411. [2] MadsbadS, HolstJJ. Bariatric surgery‑which procedure is the optimal choice?[J]. Lancet,2019,393(10178):1263-1264. DOI: 10.1016/S0140-6736(19)30489-1.
[3] 陈刚,张贵祥,冷措,等.袖状胃切除术衍生手术与胃旁路术疗效及安全性的比较[J]. 中华消化外科杂志,2021,20(12):1373‑1376. DOI: 10.3760/cma.j.cn115610-20211025-00521. [4] KocherRP, AdashiEY. Hospital readmissions and the affordable care act: paying for coordinated quality care[J]. JAMA,2011,306(16):1794‑1795. DOI:10.1001/jama.2011. 1561.
[5] HoodMM, KellyMC, FeigEH, et al. Measurement of adherence in bariatric surgery: a systematic review[J]. Surg Obes Relat Dis,2018,14(8):1192‑1201. DOI: 10.1016/j.soard.2018.04.013.
[6] 胡安妮,任梦晓,张笑燕,等.2型糖尿病患者低碳水化合物饮食管理依从性影响因素的质性研究[J].中华现代护理杂志,2020,26(9):1182‑1187. DOI:10.3760/cma.j.cn115682-20 190916-03345. [7] 李子建,于健春.减重手术的多学科诊疗与营养管理[J].中国医学科学院学报,2018,40(5):577‑580. DOI: 10.3881/j.issn.1000-503X.10740. [8] 朱信强,黄海龙,蒋学通,等.减重代谢手术及其对全身系统的影响[J].中国普外基础与临床杂志,2018,25(3):276‑282. DOI: 10.7507/1007-9424.201801016. [9] de LuisDA, PachecoD, IzaolaO, et al. Micronutrient status in morbidly obese women before bariatric surgery[J]. Surg Obes Relat Dis,2013,9(2):323‑327. DOI: 10.1016/j.soard.2011.09.015.
[10] 李雪迎.优效性设计样本量估算——计数指标[J].中国介入心脏病学杂志,2016,24(4):190. DOI: 10.3969/j.issn.1004-8812.2016.04.003. [11] 周玲.加强饮食干预对快速康复胃癌术后患者营养状况的影响探讨[J].基层医学论坛,2021,25(6):837‑838. DOI:10. 19435/j.1672-1721.2021.06.050. [12] 郑晖,沈小河.个性化饮食干预对肺结核患者的营养状况及康复情况的影响[J].医学食疗与健康,2021,19(7):22,115. [13] World Health Organization. Obesity and overweight facts[EB/OL]. (2020‑04‑01)[2020‑06‑15]. https://www.who.int/zh/news-room/fact-sheets/detail/obesity-and-overwei ght.
[14] 李媛,靳雅男,田园,等.宁夏地区成年居民超重、肥胖、中心性肥胖流行现状及影响因素[J].中国公共卫生,2019,35(10):1360‑1362. DOI: 10.11847/zgggws1118245. [15] 杨华,陈缘,董志勇,等.中国肥胖代谢外科数据库:2020年度报告[J/CD].中华肥胖与代谢病电子杂志,2021,7(1):1‑7. DOI: 10.3877/cma.j.issn.2095-9605.2021.01.001. [16] 司原成,任晨晨,康朝霞,等.肠道短链脂肪酸与单纯性肥胖症形成的关系及其机制[J].肠外与肠内营养,2022,29(2):121-125. DOI: 10.16151/j.1007-810x.2022.02.012. [17] 童国相,王莎,高国应,等.肥胖患者血清Apelin水平与血糖、血脂和胰岛素抵抗的相关性分析[J].临床误诊误治,2019,32(3):90-93. DOI: 10.3969/j.issn.1002-3429.2019.03.020. [18] 刘向阳,曹宏伟,赖敬波,等.恩格列净联合二甲双胍治疗新诊断超重及肥胖2型糖尿病的临床观察[J].解放军医药杂志,2020,32(9):26-29. DOI:10.3969/j.issn.2095-140X.2020. 09.007. [19] EnglishWJ, DeMariaEJ, HutterMM, et al. American society for metabolic and bariatric surgery 2018 estimate of meta-bolic and bariatric procedures performed in the United States[J]. Surg Obes Relat Dis,2020,16(4):457‑463. DOI: 10.1016/j.soard.2019.12.022.
[20] XiaQ, CampbellJA, AhmadH, et al. Bariatric surgery is a cost‑saving treatment for obesity‑a comprehensive meta-analysis and updated systematic review of health economic evaluations of bariatric surgery[J]. Obes Rev,2020,21(1):e12932. DOI: 10.1111/obr.12932.
[21] PetrickAT, KuhnJE, ParkerDM, et al. Bariatric surgery is safe and effective in Medicare patients regardless of age: an analysis of primary gastric bypass and sleeve gastrectomy outcomes[J]. Surg Obes Relat Dis,2019,15(10):1704-1711. DOI: 10.1016/j.soard.2019.07.010.
[22] 朱涵菲,杨宁琍,任子淇,等.减重代谢术后患者饮食依从性影响因素的质性研究[J].中华护理杂志,2021,56(1):56‑61. DOI: 10.3761/j.issn.0254-1769.2021.01.009. [23] LarjaniS, SpivakI, Hao GuoM, et al. Preoperative predictors of adherence to multidisciplinary follow‑up care post-bariatric surgery[J]. Surg Obes Relat Dis,2016,12(2):350-356. DOI: 10.1016/j.soard.2015.11.007.
[24] ChanJ, KingM, VartanianLR. Patient perspectives on psychological care after bariatric surgery: a qualitative study[J]. Clin Obes,2020,10(6):e12399. DOI: 10.1111/cob.12399.
[25] 丁睿,薛跃进,杨雁灵,等.腹腔镜袖状胃切除术后胃漏的预防与治疗策略[J].中华消化外科杂志,2020,19(11):1154-1158. DOI: 10.3760/cma.j.cn115610-20200929-00639. [26] 王迪,钱湛,王鹏程,等.肥胖患者减重代谢手术后居家康复体验的研究[J].中华现代护理杂志,2020,26(14):1861-1864. DOI: 10.3760/cma.j.cn115682-20200119-00289. [27] TolvanenL, SvenssonÅ, HemmingssonE, et al. Perceived and preferred social support in patients experiencing weight regain after bariatric surgery‒a qualitative study[J]. Obes Surg,2021,31(3):1256‑1264. DOI:10.1007/s11 695-020-05128-5.
[28] 赵敏,徐晓平,周兰殊,等.肥胖症患者袖状胃切除术的围手术期饮食指导[J].中国社区医师,2021,37(8):165‑166. DOI: 10.3969/j.issn.1007-614x.2021.08.080. [29] PapalazarouA, YannakouliaM, KavourasSA, et al. Lifestyle intervention favorably affects weight loss and maintenance following obesity surgery[J]. Obesity (Silver Spring),2010,18(7):1348‑1353. DOI: 10.1038/oby.2009.346.
[30] MehaffeyJH, MehaffeyRL, MullenMG, et al. Nutrient deficiency 10 years following Roux‑en‑Y gastric bypass: who′s responsible?[J]. Obes Surg,2017,27(5):1131‑1136. DOI: 10.1007/s11695-016-2364-0.
[31] 李志文,潘颖丽,秦敬敬,等.减重代谢术后患者饮食与营养康复方案的构建[J].中华护理杂志,2022,57(4):455‑462. DOI: 10.3761/j.issn.0254-1769.2022.04.011. [32] 宋京海,赵刚,韦军民.代谢手术后营养评估与管理的研究进展[J/CD].中华肥胖与代谢病电子杂志,2016,2(2):107-110. DOI: 10.3877//cma.j.issn.2095-9605.2016.02.010. [33] 李志文,王迪,李雪,等.减重代谢手术后患者饮食与营养管理的研究进展[J].中华现代护理杂志,2021,27(20):2796-2800. DOI: 10.3760/cma.j.cn115682-20201204-06533. [34] 孙林丽,谭显瀚,朱晒红,等.减重代谢外科病人综合管理平台的设计与应用[J].护理研究,2020,34(8):1423‑1427. DOI: 10.12102/j.issn.1009-6493.2020.08.024. [35] 李雪,陈思,潘颖丽.减重代谢手术后患者生活质量的研究现状[J].中华现代护理杂志,2020,26(4):553‑557. DOI:10. 3760/cma.j.issn.1674-2907.2020.04.027. [36] 黄亚杰,王超,杨海苓,等.肥胖症患者减重代谢术后自我管理现状调查[J].腹腔镜外科杂志,2021,26(11):814‑819. DOI: 10.13499/j.cnki.fqjwkzz.2021.11.814. [37] 邓莲,程倩,闫璐,等.袖状胃切除术对患者术后早期的身体成分变化及糖脂代谢的影响[J].中华临床营养杂志,2021,29(6):356‑362. DOI: 10.3760/cma.j.cn115822-20210930-00196. [38] 万海林,郑敏华,郭云萍,等.NICE减重管理模式对超重及肥胖人群体重及相关指标的管理效果[J].中华全科医学,2022,20(4):643‑647. DOI: 10.16766/j.cnki.issn.1674-4152.002420. [39] SoenenS, MartensEA, Hochstenbach‑WaelenA, et al. Normal protein intake is required for body weight loss and weight maintenance, and elevated protein intake for additional preservation of resting energy expenditure and fat free mass[J]. J Nutr,2013,143(5):591‑596. DOI:10.3945/jn.112. 167593.
[40] Sherf DaganS, TovimTB, KeidarA, et al. Inadequate protein intake after laparoscopic sleeve gastrectomy surgery is associated with a greater fat free mass loss[J]. Surg Obes Relat Dis,2017,13(1):101‑109. DOI:10.1016/j.soard. 2016.05.026.
计量
- 文章访问数: 1289
- HTML全文浏览量: 0
- PDF下载量: 0
