美国肠外肠内营养学会临床指南：肠外瘘成人患者的营养支持

　　2016年12月2日，美国《肠外肠内营养杂志》在线发表美国（范德堡大学医学中心、波士顿儿童医院、伊利诺伊大学芝加哥分校、克利夫兰医院、凯斯西储大学勒纳医学院、布朗大学阿尔珀特医学院、罗德岛医院、宾夕法尼亚大学）、巴西（大瓦尔泽亚大学医学院）、墨西哥（阿纳瓦克大学安杰利斯·洛马斯医院）、拉丁美洲营养疗法、临床营养与代谢联合会（FELANPE）、美国肠外肠内营养学会（ASPEN）的临床指南：肠外瘘成人患者的营养支持。

　　肠外瘘患者管理需要多学科协作，并对医生、创伤瘘口诊疗专家、营养师、药剂师和其他营养临床医生提出重大挑战。在这些患者中优化营养状态的指南通常不明确、基于有限和过时的临床研究，并且通常依赖于个别机构或临床医生的经验。在肠外瘘患者管理中，特定营养素需求量、适当喂养途径、免疫增强配方作用、生长抑素类似物的使用未被明确。该临床指南的目的是为成人肠外瘘患者的营养诊疗提供建议。

　　该临床指南使用建议、评定、制定与评价（GRADE）工作组的概念，对回答关于肠外瘘成人临床管理系列问题的最佳现有证据进行系统回顾。在ASPEN理事会和FELANPE进行同行评审和批准之前，使用匿名共识过程制定临床指南建议。

　　该临床指南共涉及肠外瘘成人患者的7个主要问题，并针对这些问题提供了循证建议、证据质量和未来研究方向：

　　1、描述营养状况的最佳指标？

　　建议：

  • 通过营养史诊断营养不良，包括非故意体重减轻、能量和营养摄入量的估计、体格检查。

  • 在肠外瘘诊断时进行营养不良评定。如果基线时不存在营养不良，则需要定期进行营养评定，因为肠外瘘患者由于营养素吸收不良、液体和电解质损失、脓毒症而很可能变为营养不良；

  • 在营养疗法之前和期间检测血清蛋白质浓度，因为它们是结局预后指标，但不是敏感的营养指标。

　　证据质量：很低。

　　2、营养疗法（口服饮食、肠内营养或肠外营养）的首选途径？

　　建议：液体和电解质平衡稳定后，对于肠外瘘（建议无远端梗阻）排出量低（＜500mL/d）的患者，建议口服饮食或肠内营养，可能可行并可耐受。然而，对于肠外瘘排出量高（＞500mL/d）的患者，可能需要肠外营养满足液体、电解质和营养素的需求，以支持肠外瘘的自发或手术闭合。

　　证据质量：很低。

　　3、提供最佳临床结局的蛋白质和能量摄入量？

　　建议：基于专家共识，建议根据营养评估结果提供蛋白质1.5～2.0g/kg/d和适合患者能量需求的能量摄入。肠空气瘘和高排出量瘘的患者可能需要更多蛋白质（高达2.5g/kg/d）。

　　证据质量：仅基于共识，因为无最新证据。

　　4、肠瘘喂养与标准治疗相比是否结局更佳？

　　建议：

  • 对于输注部位远端具有完整肠吸收能力的患者，并且当肠外瘘输注部位预计不会自发闭合时，建议使用肠瘘喂养进行营养疗法。

  • 建议最初使用大分子多聚配方，如果发生不耐受，则更换为半要素（小分子寡聚）饮食。

　　证据质量：很低。

　　5、免疫增强配方与标准配方相比是否结局更佳？

　　建议：由于缺乏证据，无法推荐多成分免疫增强配方以改善肠外瘘结局。建议口服谷氨酰胺补充肠外营养可以改善死亡率和瘘闭合率。

　　证据质量：很低。

　　6、使用生长抑素或其类似物是否比标准药物疗法提供更佳结局？

　　建议：我们建议肠外瘘排出量高（＞500mL/d）的成人患者使用生长抑素类似物作为减少排出和增加自发闭合的方法。

　　证据质量：中等。

　　7、家庭肠外营养支持的适合时机？

　　建议：基于专家共识，当患者病情稳定，瘘排出量可控时，以及对于肠外瘘排出量高（＞500mL/d）的患者尚不建议手术闭合时，建议考虑家庭肠外营养。

　　证据质量：仅基于共识，因为无最新证据。

　　未来研究方向：

  • 肠外瘘的解剖/位置如何影响营养素需求量和营养支持的最佳途径？

  • 有效优化肠内营养使用和肠瘘喂养使用的策略？

  • 对于肠外瘘治疗最有效的蛋白质和能量提供量？对于营养不良患者、肥胖患者的需求是否不同？

  • 肠道休息作为控制瘘排出量和促进瘘闭合的方法，有益于哪些患者？

  • 生长抑素与肠外营养混合液配伍时，相容性和有效性如何？

  • 免疫增强营养素能否有效治疗肠外瘘？

JPEN J Parenter Enteral Nutr. 2016 Dec 2. [Epub ahead of print]

ASPEN-FELANPE Clinical Guidelines: Nutrition Support of Adult Patients With Enterocutaneous Fistula.

Kumpf VJ, de Aguilar-Nascimento JE, Diaz-Pizarro Graf JI, Hall AM, McKeever L, Steiger E, Winkler MF, Compher CW; FELANPE; American Society for Parenteral and Enteral Nutrition..

Vanderbilt University Medical Center, Nashville, Tennessee, USA; UNIVAG Medical School, Cuiaba, Brazil; Anáhuac University and Hospital Angeles Lomas, Mexico; Boston Children's Hospital, Boston, Massachusetts, USA; University of Illinois at Chicago, Chicago, Illinois, USA; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University and Cleveland Clinic, Cleveland, Ohio, USA; Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island, USA; University of Pennsylvania, Philadelphia, Pennsylvania, USA.

BACKGROUND: The management of patients with enterocutaneous fistula (ECF) requires an interdisciplinary approach and poses a significant challenge to physicians, wound/stoma care specialists, dietitians, pharmacists, and other nutrition clinicians. Guidelines for optimizing nutrition status in these patients are often vague, based on limited and dated clinical studies, and typically rely on individual institutional or clinician experience. Specific nutrient requirements, appropriate route of feeding, role of immune-enhancing formulas, and use of somatostatin analogues in the management of patients with ECF are not well defined. The purpose of this clinical guideline is to develop recommendations for the nutrition care of adult patients with ECF.

METHODS: A systematic review of the best available evidence to answer a series of questions regarding clinical management of adults with ECF was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group. An anonymous consensus process was used to develop the clinical guideline recommendations prior to peer review and approval by the ASPEN Board of Directors and by FELANPE.

QUESTIONS: In adult patients with enterocutaneous fistula:

(1) What factors best describe nutrition status?

Recommendation: We suggest the following:

  • Malnutrition be diagnosed by nutrition history, including unintentional weight loss and estimation of energy/ nutrient intake, and physical examination.

  • Assessment for malnutrition be conducted at the time of diagnosis of an ECF. If malnutrition is not present at baseline, periodic nutrition assessment is warranted as patients with fistulas have a high likelihood of becoming malnourished due to nutrient malabsorption, fluid and electrolyte losses, and sepsis.

  • Serum protein concentrations be obtained prior to and during nutrition therapy since they are prognostic outcome indicators, yet are not sensitive nutrition markers.

Quality of Evidence: Very low.

(2) What is the preferred route of nutrition therapy (oral diet, enteral nutrition, or parenteral nutrition)?

Recommendation: After stabilization of fluid and electrolyte balance, we suggest that oral diet or EN may be feasible and tolerated in patients with low-output (<500 mL/d) ECF (suggesting no distal obstruction). However, patients with high-output ECF (>500 mL/d) may require PN to meet fluid, electrolyte, and nutrient requirements to support spontaneous or surgical closure of the ECF.

Quality of Evidence: Very low.

(3) What protein and energy intake provide best clinical outcomes?

Recommendation: Based on expert consensus, we suggest the provision of protein at 1.5-2.0 g/kg/d and energy intake appropriate to the patient’s energy requirements based on results of nutrition assessment. More protein may be required (up to 2.5 g/kg/d) in patients with enteroatmospheric fistula and high fistula output.

Quality of Evidence: Based on consensus only, as no recent evidence was available.

(4) Is fistuloclysis associated with better outcomes than standard care?

Recommendation:

  • We suggest the use of fistuloclysis for nutrition therapy for patients with intact intestinal absorptive capability distal to the infusion site and when the infusion ECF site is not expected to close spontaneously.

  • We suggest the use of polymeric formulas initially and change to semi-elemental (oligomeric) diet if intolerance occurs.

Quality of Evidence: Very low.

(5) Are immune-enhancing formulas associated with better outcomes than standard formulas?

Recommendation: We cannot recommend multicomponent immune-enhancing formulas to improve outcomes of ECF due to lack of evidence. We suggest that oral glutamine in addition to PN may improve mortality and fistula closure rates.

Quality of Evidence: Very low.

(6) Does the use of somatostatin or somatostatin analogue provide better outcomes than standard medical therapy?

Recommendation: We recommend use of somatostatin analogue in adult patients with high-output (>500 mL/d) ECF as a method to reduce effluent drainage and enhance spontaneous closure.

Quality of Evidence: Moderate.

(7) When is home parenteral nutrition support indicated?

Recommendation: Based on expert consensus, we suggest consideration of HPN when the patient is medically stable and the fistula output is manageable, as well as in patients with high-output ECF (>500 mL/d) when surgical repair is not yet advised.

Quality of Evidence: Based on consensus only, as no recent evidence was available.

Areas of Future Research:

  • How does the anatomy/location of the ECF influence nutrient requirements and optimal route of nutrition support?

  • What strategies are effective in optimizing use of EN, as well as use of fistuloclysis?

  • What levels of protein and energy provision are most effective in terms of ECF healing? Do these needs vary in patients with malnutrition, in those with obesity?

  • Which patients benefit from bowel rest as a method to control fistula output and promote fistula closure?

  • Is somatostatin compatible and effective when provided as a component of the PN admixture?

  • Is the provision of immune-enhancing nutrients effective in the management of ECF?

KEYWORDS: GI fistula; enterocutaneous fistula; nutrition support

PMID: 27913762

PII: 0148607116680792

DOI: 10.1177/0148607116680792

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