消化道肿瘤患者围手术期营养不良对临床结局的影响研究
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摘要
研究背景
住院患者的营养状态与临床结局的关系一直是研究者和医务人员关注的焦点,由于调查对象和临床实践的不同以及对营养不良的不同定义,文献的研究结果并不一致,而且多数研究是在西方文化背景下进行的。消化道肿瘤患者由于病变累及消化道,直接影响食物消化和营养物质吸收,而且肿瘤本身也会通过多种途径发生或加剧营养不良的发展。同时,接受消化道手术患者需要消化道重建,必然影响患者术后的常规进食,营养不良的发生率更高。但是目前为止,在我国针对该类患者的营养评估和营养支持现状尚缺乏相关的研究报道,营养状态是否会影响临床指标和经济指标尚无定论。
研究目的
1.描述消化道肿瘤患者围手术期营养状态和营养支持的应用情况,并探讨二者之间的关系；
2.比较营养不良患者与营养良好患者并发症发生率和住院时间的差别,探讨营养不良对相关临床指标的影响；
3.比较营养不良患者与营养良好患者营养支持药品费用、相关并发症费用、总药品费用及总住院费用的差别,探讨营养不良对相关经济指标的影响。
研究方法
采用前瞻性队列研究设计,定点连续抽样,于2009年4月-12月北京协和医院基本外科和胸外科接受手术治疗的消化道肿瘤患者336名分别在入院48h和术后7d采用主观全面营养评估法(Subjective Global Assessment, SGA)对其进行营养状态评价(SGA A表示营养良好,SGA B和SGA C表示营养不良),并对住院期间的营养支持应用情况、并发症、住院时间和住院费用进行随访调查,直至出院、死亡或因治疗并发症转科时终止。
结果
1.消化道肿瘤患者入院时营养不良的发生率为28.6%,由于体重丢失、饮食改变、活动能力降低等因素的影响,术后7d增加到53.6%；83.3%的患者住院期间出现体重下降,平均下降2.73±1.64Kg。术后7d与入院48h相比,患者营养状态的变化及体重降低均有统计学意义(P<0.05)。
2.术前有24名患者使用营养支持,其中营养状态为SGA A的患者使用率为2.9%(7/240)；营养状态为SGA B的患者使用率为12.9%(9/70)；营养状态为SGA C的患者使用率为30.8%(8/26)。营养支持方式以EN为主,不同营养状态之间营养支持使用率的差别有统计学意义(P<0.05)。
3.所有消化道肿瘤手术患者术后均常规使用营养支持,营养支持方式以PN为主,仅有5.7%(19/336)的患者使用PN+EN的方式,营养支持的使用与否与患者的营养状态没有相关性；营养状态越差的患者营养支持时间越长,摄入能量越高(P<0.05)。
4.入院48h营养良好组(SGA A)和营养不良组(SGA B+SGA C)感染并发症的发生率分别为16.3%和17.7%,非感染并发症的发生率分别为1.7%和3.1%；术后7d营养良好组(SGA A)和营养不良组(SGA B+SGA C)感染并发症的发生率分别为15.4%和17.8%,非感染并发症的发生率分别为0.6%和3.3%；不同营养状态之间并发症发生率的差别没有统计学意义(P>0.05)。经过Logistic回归分析,控制干扰因素的影响,结果显示入院48h及术后7d营养状态对术后并发症的发生没有影响。
5.入院48h营养良好组(SGA A)和营养不良组(SGA B+SGA C)平均总住院时间分别为18.07±6.74天和18.45±5.73天,平均术后住院时间为11.15±5.63天和10.99±3.99天；术后7d营养良好组(SGA A)和营养不良组(SGA B+SGA C)平均总住院时间分别为17.71±6.38天和18.58±6.52天,平均术后住院时间为10.85±5.19天和11.33±5.22天；不同营养状态之间住院时间的差别没有统计学意义(P>0.05)。经过多元逐步回归分析,控制干扰因素的影响,结果发现营养状态对住院时间没有影响。
6.入院48h营养良好组(SGA A)和营养不良组(SGA B+SGA C)ICU转入率分别为13.3%(32/240)和21.9%(21/96),不同营养状态之间ICU转入率的差别没有统计学意义(P>0.05)。经过Logistic回归分析,控制干扰因素的影响,结果发现营养状态对患者是否转入ICU没有影响。
7.消化道肿瘤患者术后使用的营养支持药品费用占总住院费用的3%-39%,平均占13.2%；占总药品费用的13%-69%,平均占36.8%。入院48h营养良好组(SGA A)和营养不良组(SGA B+SGA C)平均总住院费用分别为33230.77±11941.87元和33720.60±±10448.05元,术后营养支持药品费用分别为4447.87±±2039.26元和4334.66±±1938.25元,治疗并发症费用的中位数分别为1190.21元和642.93元；术后7d营养良好组(SGA A)和营养不良组(SGA B+SGA C)平均总住院费用分别为34120.96±11409.02元和32505.06±11627.53元,术后营养支持制剂费用分别为4485.17±1994.66元和4355.17±2024.39元,治疗并发症费用的中位数分别为977.74元和886.77元。不同营养状态之间各种费用的差别均没有统计学意义(P>0.05)。经过多元逐步回归分析,控制干扰因素的影响,结果发现营养状态对总住院费用没有影响。
结论
1.消化道肿瘤患者入院时约有1/3的患者存在营养不良,住院期间营养不良发生率显著增加。
2.术前不同营养状态患者营养支持的使用率存在差别,随着营养状态下降,营养支持使用率升高；但营养状态为SGA C的患者术前营养支持使用率不够,未达到营养支持指南推荐的标准。
3.所有消化道肿瘤手术患者术后均常规使用营养支持,营养支持的使用与否与患者的营养状态无关,方式以PN为主；营养状态越差的患者营养支持使用时间越长,摄入能量越高。
4.由于调查对象和临床实践的不同,本研究尚未发现营养不良对消化道肿瘤手术患者术后并发症发生率、ICU转入率和住院时间等临床指标产生影响。
5.消化道肿瘤患者术后营养支持药品费用占总住院费用和总药品费用相当的比例；尚未发现营养不良对消化道肿瘤手术患者总住院费用、相关并发症费用及营养支持药品费用等经济指标产生影响。
Background
The impact of malnutrition on clinical outcomes has always been the focus of research attention. However, the results of different studies differed greatly due to absence of standardized definition of malnutrition, variable populations or types of institutions and as most of the studies have been conducted in western cultures. Patients with gastrointestinal cancer may develop malnutrition in more than one way:mechanical obstructions in the gastrointestinal tract, response to tumor factors, normal food intake interrupted by digestive tract reconstruction. As a result, malnutrition is frequently seen in these patients. Few studies have involved the nutritional status and practice of nutrition support and the subsequent impact on clinical outcomes and hospital costs among these patients in China.
Objectives
1. To discribe the prevalence of malnutrition and nutrition support practice in gastrointestinal cancer surgical patients, and to analyze the relationship between nutritional status and nutrition support.
2. To compare the incidence of complications and length of hospital stay between malnourished and well nourished gastrointestinal cancer surgical patients, and to evaluate the impact of malnutrition on related clinical indices.
3. To compare the hospital costs between malnourished and well nourished gastrointestinal cancer surgical patients, and to evaluate the impact of malnutrition on hospital costs.
Methods
In this prospective cohort study, a consecutive series of 336 gastrointestinal cancer patients undergoing elective surgery in Peking Union Medical College Hospital were enrolled from April to December 2009. Nutritional status was evaluated by Subjective Global Assessment within 48h of admission and 7 days post surgery. Nutrition support practice, complications, length of hospital stay and hospital costs were collected during hospitalization. Patients were followed until discharge, hospital death, or transfer to
Results
1. Malnutrition was present in 28.6% and 53.6% on admission and 7 days post surgery, respectively.83.3%(280/336) of patients experienced mean weight loss of 2.73±1.64Kg. There were significant differences in the change of nutritional status and weight loss between admission and 7 days post surgery (P<0.05).
2.24 patients were given nutritional support before surgery and the majority of them were given enteral nutrition. For the patients with nutritional status SGA A, SGA B and SGA C,2.9%(7/240),12.9%(9/70), and 30.8%(8/26) of them were given nutritional support, respectively. There was significant difference in the prescription rate of nutritional support among the three groups (P<0.05).
3. All the patients were given nutritional support after surgery and parenteral nutrition was applied to most of them. Only 5.7%(19/336) were given combined parenteral-enteral nutrition. There was no relationship between the prescription of nutritional support and nutritional status, while patients with worse nutritional status were given longer duration of nutrition support and higher energy intake (P<0.05).
4. Infectious complications occurred in 16.3% versus 17.7% and noninfectious complications occurred 1.7% versus 3.1% of the nourished patients versus malnourished patients according to the nutritional assessment within 48h on admission. Infectious complications occurred in 15.4% versus 17.8% and noninfectious complications occurred 0.6% versus 3.3% of the nourished patients versus malnourished patients according to the nutritional assessment 7 days post surgery. There were no significant differences between the two groups (P>0.05). Logistic regression analysis showed nutrition status was not the predictive parameter for the occurrence of postoperative complications when adjusted for confounders.
5. Mean length of hospital stay were 18.07±6.74 days versus 18.45±5.73 days and postoperative hospital stay were 11.15±5.63 days versus 10.99±3.99 days of the nourished patients versus malnourished patients according to the nutritional assessment within 48h on admission. Mean length of hospital stay were 17.71±6.38 days versus 18.58±6.52 days and postoperative hospital stay were 10.85±5.19 days versus 11.33±5.22 days of the nourished patients versus malnourished patients according to the nutritional assessment 7 days post surgery. There were no significant differences between the two groups (P>0.05). Multiple stepwise regression analysis showed nutrition status was not the predictive parameter for the length of hospital stay when adjusted for confounders.
6. ICU transfer rate was 13.3%(32/240) of nourished patients versus 21.9%(21/96) of the malnourished patients according to the nutritional assessment within 48h on admission, but there was no significant difference between the two groups (P>0.05). Logistic regression analysis showed nutrition status was not the predictive parameter for ICU transfer when adjusted for confounders.
7. The cost of postoperative nutrition solution accounted for 3%-39% of total hospital cost (mean 13.2%),13%-69% of drug cost (mean 36.8%). Mean total hospital cost was (?) 33230.77±11941.87 versus (?) 33720.60±10448.05, nutrition solution cost was (?) 4447.87±2039.26 versus Y 4334.66±1938.25, and median cost of treating complications was Y 1190.21 versus Y 642.93 of the nourished patients versus malnourished patients according to the nutritional assessment within 48h on admission. Mean total hospital cost was Y34120.96±11409.02 versus (?)32505.06±11627.53, nutrition solution cost was (?)4485.17±1994.66 versus Y4355.17±2024.39, and median cost of treating complications was Y977.74 versus Y886.77 of the nourished patients versus malnourished patients according to the nutritional assessment 7 days post surgery. There were no significant differences between the two groups (P>0.05). Multiple regression analysis showed nutrition status was not the predictive parameter for the total hospital cost when adjusted for confounders.
Conclusions
1. One patient in every three admitted to hospital was malnourished and malnutrition rates increased 7 days post surgery.
2. With the decline in nutritional status before surgery, there was a significant increase in the prescription rate of nutritional support. Nutrition support was suboptimal in patients with nutritional status SGA C according to the guidelines on nutritional support.
3. All the patients were given nutritional support after surgery and parenteral nutrition was applied to most of them. There was no relationship between the prescription of nutritional support and nutritional status, while patients with worse nutritional status were given longer duration of nutrition support and higher energy intake.
4. Malnutrition was not the predictive parameter for the postoperative complications, length of hospital stay in gastrointestinal cancer undergoing elective surgery.
5. Nutrition solution costs accounted for considerable proportion of total hospital cost and drug cost. Malnutrition was not the predictive parameter for the hospital cost in gastrointestinal cancer undergoing elective surgery.
住院患者的营养状态与临床结局的关系一直是研究者和医务人员关注的焦点,由于调查对象和临床实践的不同以及对营养不良的不同定义,文献的研究结果并不一致,而且多数研究是在西方文化背景下进行的。消化道肿瘤患者由于病变累及消化道,直接影响食物消化和营养物质吸收,而且肿瘤本身也会通过多种途径发生或加剧营养不良的发展。同时,接受消化道手术患者需要消化道重建,必然影响患者术后的常规进食,营养不良的发生率更高。但是目前为止,在我国针对该类患者的营养评估和营养支持现状尚缺乏相关的研究报道,营养状态是否会影响临床指标和经济指标尚无定论。
研究目的
1.描述消化道肿瘤患者围手术期营养状态和营养支持的应用情况,并探讨二者之间的关系；
2.比较营养不良患者与营养良好患者并发症发生率和住院时间的差别,探讨营养不良对相关临床指标的影响；
3.比较营养不良患者与营养良好患者营养支持药品费用、相关并发症费用、总药品费用及总住院费用的差别,探讨营养不良对相关经济指标的影响。
研究方法
采用前瞻性队列研究设计,定点连续抽样,于2009年4月-12月北京协和医院基本外科和胸外科接受手术治疗的消化道肿瘤患者336名分别在入院48h和术后7d采用主观全面营养评估法(Subjective Global Assessment, SGA)对其进行营养状态评价(SGA A表示营养良好,SGA B和SGA C表示营养不良),并对住院期间的营养支持应用情况、并发症、住院时间和住院费用进行随访调查,直至出院、死亡或因治疗并发症转科时终止。
结果
1.消化道肿瘤患者入院时营养不良的发生率为28.6%,由于体重丢失、饮食改变、活动能力降低等因素的影响,术后7d增加到53.6%；83.3%的患者住院期间出现体重下降,平均下降2.73±1.64Kg。术后7d与入院48h相比,患者营养状态的变化及体重降低均有统计学意义(P<0.05)。
2.术前有24名患者使用营养支持,其中营养状态为SGA A的患者使用率为2.9%(7/240)；营养状态为SGA B的患者使用率为12.9%(9/70)；营养状态为SGA C的患者使用率为30.8%(8/26)。营养支持方式以EN为主,不同营养状态之间营养支持使用率的差别有统计学意义(P<0.05)。
3.所有消化道肿瘤手术患者术后均常规使用营养支持,营养支持方式以PN为主,仅有5.7%(19/336)的患者使用PN+EN的方式,营养支持的使用与否与患者的营养状态没有相关性；营养状态越差的患者营养支持时间越长,摄入能量越高(P<0.05)。
4.入院48h营养良好组(SGA A)和营养不良组(SGA B+SGA C)感染并发症的发生率分别为16.3%和17.7%,非感染并发症的发生率分别为1.7%和3.1%；术后7d营养良好组(SGA A)和营养不良组(SGA B+SGA C)感染并发症的发生率分别为15.4%和17.8%,非感染并发症的发生率分别为0.6%和3.3%；不同营养状态之间并发症发生率的差别没有统计学意义(P>0.05)。经过Logistic回归分析,控制干扰因素的影响,结果显示入院48h及术后7d营养状态对术后并发症的发生没有影响。
5.入院48h营养良好组(SGA A)和营养不良组(SGA B+SGA C)平均总住院时间分别为18.07±6.74天和18.45±5.73天,平均术后住院时间为11.15±5.63天和10.99±3.99天；术后7d营养良好组(SGA A)和营养不良组(SGA B+SGA C)平均总住院时间分别为17.71±6.38天和18.58±6.52天,平均术后住院时间为10.85±5.19天和11.33±5.22天；不同营养状态之间住院时间的差别没有统计学意义(P>0.05)。经过多元逐步回归分析,控制干扰因素的影响,结果发现营养状态对住院时间没有影响。
6.入院48h营养良好组(SGA A)和营养不良组(SGA B+SGA C)ICU转入率分别为13.3%(32/240)和21.9%(21/96),不同营养状态之间ICU转入率的差别没有统计学意义(P>0.05)。经过Logistic回归分析,控制干扰因素的影响,结果发现营养状态对患者是否转入ICU没有影响。
7.消化道肿瘤患者术后使用的营养支持药品费用占总住院费用的3%-39%,平均占13.2%；占总药品费用的13%-69%,平均占36.8%。入院48h营养良好组(SGA A)和营养不良组(SGA B+SGA C)平均总住院费用分别为33230.77±11941.87元和33720.60±±10448.05元,术后营养支持药品费用分别为4447.87±±2039.26元和4334.66±±1938.25元,治疗并发症费用的中位数分别为1190.21元和642.93元；术后7d营养良好组(SGA A)和营养不良组(SGA B+SGA C)平均总住院费用分别为34120.96±11409.02元和32505.06±11627.53元,术后营养支持制剂费用分别为4485.17±1994.66元和4355.17±2024.39元,治疗并发症费用的中位数分别为977.74元和886.77元。不同营养状态之间各种费用的差别均没有统计学意义(P>0.05)。经过多元逐步回归分析,控制干扰因素的影响,结果发现营养状态对总住院费用没有影响。
结论
1.消化道肿瘤患者入院时约有1/3的患者存在营养不良,住院期间营养不良发生率显著增加。
2.术前不同营养状态患者营养支持的使用率存在差别,随着营养状态下降,营养支持使用率升高；但营养状态为SGA C的患者术前营养支持使用率不够,未达到营养支持指南推荐的标准。
3.所有消化道肿瘤手术患者术后均常规使用营养支持,营养支持的使用与否与患者的营养状态无关,方式以PN为主；营养状态越差的患者营养支持使用时间越长,摄入能量越高。
4.由于调查对象和临床实践的不同,本研究尚未发现营养不良对消化道肿瘤手术患者术后并发症发生率、ICU转入率和住院时间等临床指标产生影响。
5.消化道肿瘤患者术后营养支持药品费用占总住院费用和总药品费用相当的比例；尚未发现营养不良对消化道肿瘤手术患者总住院费用、相关并发症费用及营养支持药品费用等经济指标产生影响。
Background
The impact of malnutrition on clinical outcomes has always been the focus of research attention. However, the results of different studies differed greatly due to absence of standardized definition of malnutrition, variable populations or types of institutions and as most of the studies have been conducted in western cultures. Patients with gastrointestinal cancer may develop malnutrition in more than one way:mechanical obstructions in the gastrointestinal tract, response to tumor factors, normal food intake interrupted by digestive tract reconstruction. As a result, malnutrition is frequently seen in these patients. Few studies have involved the nutritional status and practice of nutrition support and the subsequent impact on clinical outcomes and hospital costs among these patients in China.
Objectives
1. To discribe the prevalence of malnutrition and nutrition support practice in gastrointestinal cancer surgical patients, and to analyze the relationship between nutritional status and nutrition support.
2. To compare the incidence of complications and length of hospital stay between malnourished and well nourished gastrointestinal cancer surgical patients, and to evaluate the impact of malnutrition on related clinical indices.
3. To compare the hospital costs between malnourished and well nourished gastrointestinal cancer surgical patients, and to evaluate the impact of malnutrition on hospital costs.
Methods
In this prospective cohort study, a consecutive series of 336 gastrointestinal cancer patients undergoing elective surgery in Peking Union Medical College Hospital were enrolled from April to December 2009. Nutritional status was evaluated by Subjective Global Assessment within 48h of admission and 7 days post surgery. Nutrition support practice, complications, length of hospital stay and hospital costs were collected during hospitalization. Patients were followed until discharge, hospital death, or transfer to
Results
1. Malnutrition was present in 28.6% and 53.6% on admission and 7 days post surgery, respectively.83.3%(280/336) of patients experienced mean weight loss of 2.73±1.64Kg. There were significant differences in the change of nutritional status and weight loss between admission and 7 days post surgery (P<0.05).
2.24 patients were given nutritional support before surgery and the majority of them were given enteral nutrition. For the patients with nutritional status SGA A, SGA B and SGA C,2.9%(7/240),12.9%(9/70), and 30.8%(8/26) of them were given nutritional support, respectively. There was significant difference in the prescription rate of nutritional support among the three groups (P<0.05).
3. All the patients were given nutritional support after surgery and parenteral nutrition was applied to most of them. Only 5.7%(19/336) were given combined parenteral-enteral nutrition. There was no relationship between the prescription of nutritional support and nutritional status, while patients with worse nutritional status were given longer duration of nutrition support and higher energy intake (P<0.05).
4. Infectious complications occurred in 16.3% versus 17.7% and noninfectious complications occurred 1.7% versus 3.1% of the nourished patients versus malnourished patients according to the nutritional assessment within 48h on admission. Infectious complications occurred in 15.4% versus 17.8% and noninfectious complications occurred 0.6% versus 3.3% of the nourished patients versus malnourished patients according to the nutritional assessment 7 days post surgery. There were no significant differences between the two groups (P>0.05). Logistic regression analysis showed nutrition status was not the predictive parameter for the occurrence of postoperative complications when adjusted for confounders.
5. Mean length of hospital stay were 18.07±6.74 days versus 18.45±5.73 days and postoperative hospital stay were 11.15±5.63 days versus 10.99±3.99 days of the nourished patients versus malnourished patients according to the nutritional assessment within 48h on admission. Mean length of hospital stay were 17.71±6.38 days versus 18.58±6.52 days and postoperative hospital stay were 10.85±5.19 days versus 11.33±5.22 days of the nourished patients versus malnourished patients according to the nutritional assessment 7 days post surgery. There were no significant differences between the two groups (P>0.05). Multiple stepwise regression analysis showed nutrition status was not the predictive parameter for the length of hospital stay when adjusted for confounders.
6. ICU transfer rate was 13.3%(32/240) of nourished patients versus 21.9%(21/96) of the malnourished patients according to the nutritional assessment within 48h on admission, but there was no significant difference between the two groups (P>0.05). Logistic regression analysis showed nutrition status was not the predictive parameter for ICU transfer when adjusted for confounders.
7. The cost of postoperative nutrition solution accounted for 3%-39% of total hospital cost (mean 13.2%),13%-69% of drug cost (mean 36.8%). Mean total hospital cost was (?) 33230.77±11941.87 versus (?) 33720.60±10448.05, nutrition solution cost was (?) 4447.87±2039.26 versus Y 4334.66±1938.25, and median cost of treating complications was Y 1190.21 versus Y 642.93 of the nourished patients versus malnourished patients according to the nutritional assessment within 48h on admission. Mean total hospital cost was Y34120.96±11409.02 versus (?)32505.06±11627.53, nutrition solution cost was (?)4485.17±1994.66 versus Y4355.17±2024.39, and median cost of treating complications was Y977.74 versus Y886.77 of the nourished patients versus malnourished patients according to the nutritional assessment 7 days post surgery. There were no significant differences between the two groups (P>0.05). Multiple regression analysis showed nutrition status was not the predictive parameter for the total hospital cost when adjusted for confounders.
Conclusions
1. One patient in every three admitted to hospital was malnourished and malnutrition rates increased 7 days post surgery.
2. With the decline in nutritional status before surgery, there was a significant increase in the prescription rate of nutritional support. Nutrition support was suboptimal in patients with nutritional status SGA C according to the guidelines on nutritional support.
3. All the patients were given nutritional support after surgery and parenteral nutrition was applied to most of them. There was no relationship between the prescription of nutritional support and nutritional status, while patients with worse nutritional status were given longer duration of nutrition support and higher energy intake.
4. Malnutrition was not the predictive parameter for the postoperative complications, length of hospital stay in gastrointestinal cancer undergoing elective surgery.
5. Nutrition solution costs accounted for considerable proportion of total hospital cost and drug cost. Malnutrition was not the predictive parameter for the hospital cost in gastrointestinal cancer undergoing elective surgery.
引文
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