,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,胃肠道和头颈部癌症,患者的营养问题,Choy Tak Kong,CSCO 2021,目 录,研究的意义,营养不良的影响,营养研究中存在的问题,外科营养支持研究的结果,化疗,/,放疗时营养支持的研究结果,肿瘤辅助治疗时营养支持的研究结果,结论,研究的意义,美国头颈部癌症占所有恶性肿瘤的6香港更高,美国胃肠道癌症占所有恶性肿瘤的24,美国癌症协会，2007,癌症患者营养缺乏的原因,癌症相关因素,恶性肿瘤相关性食欲下降和恶病质,恶性肠梗阻,恶性吞咽障碍,腹部癌扩散,胃肠道瘘,治疗相关因素,化疗引起的恶心呕吐,化疗和,/,或放疗继发的粘膜炎,术后肠梗阻,感染,/,败血症,合并症,充血性心力衰竭,急性呼吸衰竭,急性肾衰,抑郁,营养研究中存在的问题,存在的问题与期临床试验相比,营养不良的定义多种多样,缺乏统一实用的标准,缺乏大规模研究,入选患者多种多样,日常肿瘤实践中，营养属于最次要的问题,Spiro A,Baldwin C,Patterson A,Thomas J,Andreyev HJ.The views and practice of oncologists towards nutritional support in patients receiving chemotherapy.Br J Cancer 2006;95:4314.,营养不良定义,美国肠外肠内营养协会指南,6个月内体重不自主下降超过平常体重的10 或者1个月内体重不自主下降超过平常体重的5,Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients.,JPEN J Parenter Enteral Nutr 2002;26:1SA138SA,欧洲指南,重度营养不良：6个月内体重下降 10-15，BMI 18.5，主观整体评估SGAC级或血清白蛋白浓度 30 g/L,Weimann A,Braga M,Harsanyi L,et al.ESPEN guidelines on enteral nutrition:,surgery including organ transplantation.Clin Nutr 2006;25:22444.,除了这些标准，还有营养比率指数,血清白蛋白g/dL+41.7 目前体重/平常体重,Buzby GP,Knox LS,Crosby LO,et al.Study protocol:a randomized clinical trial of,total parenteral nutrition in malnourished surgical patients.Am J Clin Nutr 1988;47:36681.,营养不良的影响,一项多中心协作研究包含3047例直肠癌患者，结果显示化疗前体重下降与生存中值下降相关体重下降者与无体重下降者比较，p 0.01。,Dewys WD,Begg C,Lavin PT,et al.Prognostic effect of weight loss prior to chemotherapy in cancer patients.Eastern Cooperative Oncology Group.Am J Med 1980;69:4917.,Andreyev和他的同事们进行的一项1555例化疗患者回忆分析显示体重下降是严重剂量限制毒性反响p 0.0001，应答率下降p=0.006和总体生存时间缩短胃癌和结直肠癌，p 0.0001的一个独立预测因子。,Andreyev HJ,Norman AR,Oates J,Cunningham D.Why do patients with weight loss have a worse outcome when undergoing chemotherapy for gastrointestinal malignancies?Eur JCancer 1998;34:5039.,350例晚期食管癌患者研究显示体重下降与预后不良相关9个月 vs 12个月，p=0.006,Polee MB,Hop WC,Kok TC,et al.Prognostic factors for survival in patients with advanced oesophageal cancer treated with cisplatin-based combination chemotherapy.,Br J Cancer2003;89:204550.,重度营养不良的其他影响,发病率上升,术前感染风险上升,12.3 vs 7.1%,Malone DL,Genuit T,Tracy JK,Gannon C,Napolitano LM.Surical site infections:reanalysis of risk factors.,J Surg Res 2002;103:89-95,死亡率上升,Kelsen DP,Ginsberg R,Pajak TF,et al.,Chemotherapy followed by surgery compared with surgery alone for localized esophageal cancer.N Engl J Med 1998;339:197984,Alves A,Panis Y,Mathieu P,Mantion G,Kwiatkowski F,Slim K.Postoperative mortality and morbidity in French patients undergoing colorectal surgery:results of a prospective multicenter study.Arch Surg 2005;140:278-83,住院时间延长,治疗费用增加,体力状态下降,生活质量下降,术前,TPN,4项前瞻性随机试验荟萃分析评估,3项明显获益术后发病率降低，主要并发症降低18,尚无数据证实围手术期营养支持能够改善术后死亡率,可能的原因,方法学不同导致明显的差异,患者样本量少,术前营养支持时间短,有些研究热量摄入不适合,Torosian MH.Perioperative nutrition support for patients undergoing gastrointestinal surgery:,critical analysis and recommendations.World J Surg 1999;23:5659.,Heyland DK,Montalvo M,MacDonald S,Keefe L,Su XY,Drover JW.,Total parenteral nutrition in the surgical patient:a metaanalysis.Can J Surg 2001;44:10211.,Klein S,Kinney J,Jeejeebhoy K,et al.Nutrition support in clinical practice:review of published data and recommendations for future research directions.Summary of a conference sponsored by the National Institutes of Health,American Society for Parenteral and Enteral Nutrition,and American Society for Clinical Nutrition.Am J Clin Nutr 1997;66:683706.,术前肠外营养,1982年，Muller和他的同事们报道胃肠道肿瘤患者术前使用肠外营养可能有益，主要并发症减少，死亡率明显下降4.5%vs 18.6%。,Muller JM,Brenner U,Dienst C,Pichlmaier H.Preoperative parenteral feeding in patients with gastrointestinal carcinoma.Lancet 1982;1:6871,围手术期,TPN,退伍军人效劳部协作研究对照研究观察了395例营养不良中度和重度患者51为胃肠道癌症，分为围手术期TPN组术前7-15天和术后3天和非TPN组。,仅有重度营养不良患者NRI 83.5接受TPN后较对照组非感染性并发症明显减少5.3%vs 42.9%，p=0.03。,The Veterans Affairs Total Parenteral Nutrition Cooperative Study Group.,Perioperative total parenteral nutrition in surgical patients.N Engl J Med 1991;325:52532,Bozzetti和他的同事们发现围手术期TPN能够降低营养不良癌症患者体重下降超过10的手术风险。,90例胃癌或结直肠癌患者随机分为围手术期肠外营养组和非TPN组对照组。接受TPN患者术后发病率下降20%p=0.03。,Bozzetti F,Gavazzi C,Miceli R,et al.Perioperative total parenteral nutrition in malnourished,gastrointestinal cancer patients:a randomized,clinical trial.J Parenter Enteral Nutr 2000;24:714.,肠内营养,v,s,肠外营养,Braunschweig,和他的同事们进行荟萃分析，观察了肠内或肠外营养对成人胃肠道癌症手术患者的影响。,肠内管饲能够显著缩短住院时间并降低感染发生率,死亡率无差异,Braunschweig CL,Levy P,Sheean PM,Wang X.Enteral compared with parenteral nutrition:a meta-analysis.,Am J Clin Nutr 2001;74:53442.574 P.Senesse et al,Elia M,van Bokhorst-de van der Schueren MA,Garvey J,et al.,Enteral(oral or tube administration)nutritional support and eicosapentaenoic acid in patients with cancer:a systematic review.,Int J Oncol 2006;28:523,Elia M,van Bokhorst-de van der Schueren MA,Garvey J,et al.,Enteral(oral or tube administration)nutritional support and eicosapentaenoic acid in patients with cancer:a systematic review.