本文发表在 rolia.net 枫下论坛Patients undergoing massive small bowel resections frequently experience large fluid shifts and difficulties with volume and electrolyte homeostasis in the early postoperative period. The first priority is to ensure that the patient is adequately resuscitated and hemodynamically stable. Fluid and electrolyte disorders comprise the most important group of complications in the early postoperative period in this group of patients, according to Cosnes and associates (1985).
Scolapio and Fleming (1998) have described therapeutic guidelines for the fluid and electrolyte management of these patients. These include replacement of fluid and electrolytes lost through nasogastric suctioning and in stool. They recommended that 300-500 mL be added to the total volume administered to replace insensible losses. These replacement volumes are added to the patient's calculated daily maintenance volume. Daily urine output should be at least 1 L.
Parenteral nutrition is an important therapy in the care of the patient with short-bowel syndrome. Parenteral nutrition provides adequate protein, calories, other macronutrients, and micronutrients until the bowel has had time to adapt. The time required for optimal bowel adaptation is a source of controversy. Booth (1994) states that bowel adaptation may not be complete until a year or more after resection. Carbonnel (1996) and others have written that little bowel compensation occurs after 3 months. Data from animal studies conducted by Wilmore and colleagues (1971) suggest that supplementing enteral intake with parenteral nutrition early in the postoperative course results in better overall bowel adaptation. This is most likely because it facilitates provision of adequate calorie and nitrogen sources.
According to Nightingale and colleagues (1990), when enteral nutrient absorption falls to below one third of premorbid capacity, some amount of parenteral nutrition is needed. Parenteral nutrition can be started with standard formulations and administered over the course of 24 hours daily on an inpatient basis. Make efforts to infuse daily requirements in shorter time periods before the patient is discharged. This is called cycling and it allows liberation from the solution pump for at least some time each day. In addition, laboratory studies, including serum chemistries and mineral and trace element levels, are monitored frequently and provision of these nutrients adjusted accordingly in the parenteral nutrition formula.
Gradually, most patients are able to resume and increase oral food intake. This is begun by providing small frequent feedings and slowly advancing the diet as tolerated. According to Scolapio and Fleming (1998), the process of weaning the patient off parenteral nutrition can begin once oral calorie intake exceeds 1000 kcal/d. Further reductions in parenteral nutrition are predicated on increased oral intake. Woolf and associated (1987) have described that nutrient absorption is not complete in patients with loss of half or more of the small bowel. Therefore, they usually require 30-40 kcal/kg/d to meet daily energy requirements.
A subset of patients who have lost significant amounts of ileum and colon may have massive fluid losses. Stomal outputs may exceed 2.5 L/d. Many of these patients are likely to be dependent on prolonged intravenous fluid therapy. Some may do well with oral sources of water, glucose, and sodium. Wilmore's group (1997) has reported good success with the use of Gatorade. Scolapio and Fleming (1998) state that the solution should contain at least 90 mmol/L of sodium. This may require supplementation with salt in some of the commercially available solutions.
Despite bowel adaptation and meticulous nutritional therapy, some patients are unable to be liberated from parenteral nutrition. These patients usually are those with less than 60 cm of small bowel remaining, loss of the ileum and ileocecal valve, and loss of the colon. Wilmore, Byrne, and colleagues (1997) have been leaders in the concept of pharmacologic bowel compensation, which includes measures aimed at further enhancing bowel adaptation and increasing the chances that even these patients with difficult cases can be liberated from parenteral nutrition. This includes provision of growth hormone 0.03-0.14 mg/kg/d subcutaneously for 4 weeks, parenteral (0.16 g/kg/d) or enteral (30 g/d) glutamine supplementation, and a high-carbohydrate (55-60% calories from carbohydrate versus 20-25% from fat and 20% from protein) diet.
Somatropin (Zorbtive) is a recombinant human growth hormone that elicits anabolic and anticatabolic influence on various cells, including myocytes, hepatocytes, adipocytes, lymphocytes, and hematopoietic cells. It exerts activity on specific cell receptors, including insulinlike growth factor-1 (IGF-1). Actions on the gut may be direct or mediated via IGF-1. Somatropin is indicated to treat short-bowel syndrome in conjunction with nutritional support. The adult dose is 0.1 mg/kg SC qd for up to 4 weeks (not to exceed 8 mg/d). Pediatric dosing has not been established.
Wilmore, Byrne, and colleagues published their results on 87 patients treated with this regimen in Current Problems in Surgery in 1997. After 4 weeks, 52% were completely off parenteral nutrition and an additional 38% had significantly reduced parenteral nutrition requirements. The same group of investigators published results with this regimen, also in 1997, in 45 patients with a jejunoileal remnant less than 50 cm and with a segment of colon remaining in continuity. After 4 weeks on the regimen, 58% were liberated from parenteral nutrition. After a mean follow-up of 1.8 years, this had fallen to 40%.
Specific drug therapies in short-bowel syndrome are mainly aimed at decreasing gastric hypersecretion or decreasing diarrhea. Gastric hypersecretion may be treated by proton pump inhibitors or histamine-2 (H2) blockers in the early postoperative period. In most patients, gastric hypersecretion severe enough to cause clinical problems is self-limited.
Diarrhea is a more vexing problem. When the patient is on nothing by mouth (NPO), codeine 60 mg IM q4h may be helpful. When enteral intake is resumed, Imodium (4-5 mg q6h) or Lomotil (2.5-5 mg qid) is useful. In refractory cases, tincture of opium in doses of 5-10 mL q4h may be tried. Cases involving patients who have lost all of their colon and ileum, with less than 100 cm of jejunum and an end jejunostomy, are the most difficult to manage. In these patients, the somatostatin analogue octreotide can be administered in doses of 100 mcg subcutaneously 3 times a day. This can reduce stool output by as much as 50% according to Farthing (1993).更多精彩文章及讨论，请光临枫下论坛 rolia.net
Scolapio and Fleming (1998) have described therapeutic guidelines for the fluid and electrolyte management of these patients. These include replacement of fluid and electrolytes lost through nasogastric suctioning and in stool. They recommended that 300-500 mL be added to the total volume administered to replace insensible losses. These replacement volumes are added to the patient's calculated daily maintenance volume. Daily urine output should be at least 1 L.
Parenteral nutrition is an important therapy in the care of the patient with short-bowel syndrome. Parenteral nutrition provides adequate protein, calories, other macronutrients, and micronutrients until the bowel has had time to adapt. The time required for optimal bowel adaptation is a source of controversy. Booth (1994) states that bowel adaptation may not be complete until a year or more after resection. Carbonnel (1996) and others have written that little bowel compensation occurs after 3 months. Data from animal studies conducted by Wilmore and colleagues (1971) suggest that supplementing enteral intake with parenteral nutrition early in the postoperative course results in better overall bowel adaptation. This is most likely because it facilitates provision of adequate calorie and nitrogen sources.
According to Nightingale and colleagues (1990), when enteral nutrient absorption falls to below one third of premorbid capacity, some amount of parenteral nutrition is needed. Parenteral nutrition can be started with standard formulations and administered over the course of 24 hours daily on an inpatient basis. Make efforts to infuse daily requirements in shorter time periods before the patient is discharged. This is called cycling and it allows liberation from the solution pump for at least some time each day. In addition, laboratory studies, including serum chemistries and mineral and trace element levels, are monitored frequently and provision of these nutrients adjusted accordingly in the parenteral nutrition formula.
Gradually, most patients are able to resume and increase oral food intake. This is begun by providing small frequent feedings and slowly advancing the diet as tolerated. According to Scolapio and Fleming (1998), the process of weaning the patient off parenteral nutrition can begin once oral calorie intake exceeds 1000 kcal/d. Further reductions in parenteral nutrition are predicated on increased oral intake. Woolf and associated (1987) have described that nutrient absorption is not complete in patients with loss of half or more of the small bowel. Therefore, they usually require 30-40 kcal/kg/d to meet daily energy requirements.
A subset of patients who have lost significant amounts of ileum and colon may have massive fluid losses. Stomal outputs may exceed 2.5 L/d. Many of these patients are likely to be dependent on prolonged intravenous fluid therapy. Some may do well with oral sources of water, glucose, and sodium. Wilmore's group (1997) has reported good success with the use of Gatorade. Scolapio and Fleming (1998) state that the solution should contain at least 90 mmol/L of sodium. This may require supplementation with salt in some of the commercially available solutions.
Despite bowel adaptation and meticulous nutritional therapy, some patients are unable to be liberated from parenteral nutrition. These patients usually are those with less than 60 cm of small bowel remaining, loss of the ileum and ileocecal valve, and loss of the colon. Wilmore, Byrne, and colleagues (1997) have been leaders in the concept of pharmacologic bowel compensation, which includes measures aimed at further enhancing bowel adaptation and increasing the chances that even these patients with difficult cases can be liberated from parenteral nutrition. This includes provision of growth hormone 0.03-0.14 mg/kg/d subcutaneously for 4 weeks, parenteral (0.16 g/kg/d) or enteral (30 g/d) glutamine supplementation, and a high-carbohydrate (55-60% calories from carbohydrate versus 20-25% from fat and 20% from protein) diet.
Somatropin (Zorbtive) is a recombinant human growth hormone that elicits anabolic and anticatabolic influence on various cells, including myocytes, hepatocytes, adipocytes, lymphocytes, and hematopoietic cells. It exerts activity on specific cell receptors, including insulinlike growth factor-1 (IGF-1). Actions on the gut may be direct or mediated via IGF-1. Somatropin is indicated to treat short-bowel syndrome in conjunction with nutritional support. The adult dose is 0.1 mg/kg SC qd for up to 4 weeks (not to exceed 8 mg/d). Pediatric dosing has not been established.
Wilmore, Byrne, and colleagues published their results on 87 patients treated with this regimen in Current Problems in Surgery in 1997. After 4 weeks, 52% were completely off parenteral nutrition and an additional 38% had significantly reduced parenteral nutrition requirements. The same group of investigators published results with this regimen, also in 1997, in 45 patients with a jejunoileal remnant less than 50 cm and with a segment of colon remaining in continuity. After 4 weeks on the regimen, 58% were liberated from parenteral nutrition. After a mean follow-up of 1.8 years, this had fallen to 40%.
Specific drug therapies in short-bowel syndrome are mainly aimed at decreasing gastric hypersecretion or decreasing diarrhea. Gastric hypersecretion may be treated by proton pump inhibitors or histamine-2 (H2) blockers in the early postoperative period. In most patients, gastric hypersecretion severe enough to cause clinical problems is self-limited.
Diarrhea is a more vexing problem. When the patient is on nothing by mouth (NPO), codeine 60 mg IM q4h may be helpful. When enteral intake is resumed, Imodium (4-5 mg q6h) or Lomotil (2.5-5 mg qid) is useful. In refractory cases, tincture of opium in doses of 5-10 mL q4h may be tried. Cases involving patients who have lost all of their colon and ileum, with less than 100 cm of jejunum and an end jejunostomy, are the most difficult to manage. In these patients, the somatostatin analogue octreotide can be administered in doses of 100 mcg subcutaneously 3 times a day. This can reduce stool output by as much as 50% according to Farthing (1993).更多精彩文章及讨论，请光临枫下论坛 rolia.net