家庭肠内营养在食管癌患者中有效性和安全性的Meta分析

doi:10.12114/j.issn.1007-9572.2022.0853

摘要/Abstract

摘要： 背景食管癌患者常发生营养不良，国内外研究显示，营养不良严重影响患者的恢复。目前居家期间接受家庭肠内营养（HEN）的患者越来越多，但HEN对食管癌患者的有效性和安全性并不明确。目的通过Meta分析评价HEN对食管癌患者的有效性和安全性。方法计算机检索PubMed、Cochrane Library、Embase、Web of Science、CINAHL、Scopus、万方数据知识服务平台、中国知网、维普网及中国生物医学文献数据库，搜集有关食管癌患者接受HEN的随机对照试验，检索时限从建库至2021年12月。试验组患者接受HEN支持〔肠内管饲（ETF）和口服营养补充（ONS）均可〕，对照组仅接受常规口服饮食。由2名研究者独立筛选文献、提取资料，并采用Cochrane协作网推荐的RoB 2.0工具对文献进行质量评价。采用RevMan 5.4.1软件进行Meta分析。结果共纳入14篇文献，包括1 040例食管癌患者。Meta分析结果显示，试验组患者体质量增长值、BMI增长值、血红蛋白增长值、血清总蛋白增长值、血清前白蛋白增长值、血清转铁蛋白增长值均高于对照组〔SMD=0.63，95%CI（0.40，0.85），P<0.000 01；SMD=0.60，95%CI（0.44，0.76），P<0.000 01；SMD=1.58，95%CI（1.37，1.79），P<0.000 01；SMD=1.19，95%CI（0.79，1.58），P<0.000 01；SMD=0.97，95%CI（0.79，1.14），P<0.000 01；SMD=1.12，95%CI（0.45，1.79），P=0.001〕。在ETF亚组和ONS亚组分析中，试验组血清白蛋白增长值均高于对照组〔SMD=1.25，95%CI（0.82，1.68），P<0.000 01；SMD=0.61，95%CI（0.26，0.97），P<0.000 01〕。试验组营养不良发生率低于对照组〔OR=0.47，95%CI（0.33，0.67），P<0.000 1〕。两组胃肠道并发症发生率比较，差异无统计学意义〔RR=1.33，95%CI（1.00，1.77），P=0.05〕。试验组和对照组生活质量评分比较，差异无统计学意义〔MD=4.97，95%CI（0.06，9.87），P=0.05〕；试验组躯体功能评分高于对照组〔MD=6.67，95%CI（2.86，10.48），P=0.000 6〕，疲劳症状评分低于对照组〔MD=-7.31，95%CI（-11.85，-2.77），P=0.002〕。敏感性分析结果显示，合并结果稳定可靠。结论 HEN能够改善食管癌术后出院患者的营养状况和躯体功能，并减轻患者的疲劳症状，且并未增加胃肠道并发症的发生率，但暂未发现能够改善患者总体生活质量。

关键词: 食管肿瘤, 肠道营养, 家庭肠内营养, 管饲喂养, 口服营养补充, 营养状况, 生活质量, 随机对照试验, Meta分析

Abstract:

Background

Malnutrition is a common complication in patients with esophageal cancer, which has been validated by domestic and international studies to seriously impact the recovery of patients. While the number of patients receiving home enteral nutrition (HEN) is increasing, the effectiveness and safety of HEN for patients with esophageal cancer remains unclear.

Objective

To systematically evaluate the effectiveness and safety of HEN by meta-analysis.

Methods

RCTs on the HEN in patients with esophageal cancer were retrieved in PubMed, Cochrane Library, Embase, Web of Science, CINAHL, Scopus, Wanfang Data, CNKI, VIP and CBM from inception to December 2021. Patients in the experimental group received HEN support〔both enteral tube feeding (ETF) and oral nutritional supplement (ONS) were both acceptable〕, while patients in the control group received conventional oral diet only. Two researchers independently screened the literature and extracted data. The RoB 2.0 recommended by the Cochrane Collaboration was used to evaluate the quality of the included studies, and the RevMan 5.4.1 software was used to perform the meta-analysis.

Results

A total of 14 articles were included, involving 1 040 patients with esophageal cancer. Meta-analysis showed that the increase values of body mass, BMI, hemoglobin, serum total protein, serum prealbumin and serum transferrin in the experimental group were higher than those in the control group〔SMD=0.63, 95%CI (0.40, 0.85), P<0.000 01; SMD=0.60, 95%CI (0.44, 0.76), P<0.000 01; SMD=1.58, 95%CI (1.37, 1.79), P<0.000 01; SMD=1.19, 95%CI (0.79, 1.58), P<0.000 01; SMD=0.97, 95%CI (0.79, 1.14), P<0.000 01; SMD=1.12, 95%CI (0.45, 1.79), P=0.001〕. The increase value of serum albumin in the experimental group was higher than that in the control group in both ETF and ONS subgroups analysis〔SMD=1.25, 95%CI (0.82, 1.68), P<0.000 01; SMD=0.61, 95%CI (0.26, 0.97), P<0.000 01〕. The incidence of malnutrition was lower in the experimental group than in the control group〔OR=0.47, 95%CI (0.33, 0.67), P<0.000 1〕. There was no statistically significant differences in the incidence of gastrointestinal complications〔RR=1.33, 95%CI (1.00, 1.77), P=0.05〕and life quality score〔MD=4.97, 95%CI (0.06, 9.87), P=0.05〕 between the two groups. The physical function score of the experimental group was higher than that of the control group〔MD=6.67, 95%CI (2.86, 10.48), P=0.000 6〕, and the fatigue symptom score was lower than that of the control group〔MD=-7.31, 95%CI (-11.85, -2.77), P=0.002〕. Sensitivity analysis showed that the combined results were stable and reliable.

Conclusion

HEN can significantly improve the nutritional status and physical function, reduce fatigue symptoms of discharged patients after esophageal cancer surgery, and does not increase the incidence of gastrointestinal complications, however, it has not been found to improve the global overall quality of life.

Key words: Esophageal neoplasms, Enteral nutrition, Home enteral nutrition, Enteral tube feeding, Oral nutritional supplements, Nutritional status, Quality of life, Randomized controlled trial, Meta-analysis

薛珊,李来有,梁军利,等. 家庭肠内营养在食管癌患者中有效性和安全性的Meta分析[J]. 中国全科医学, 2023, 26(20): 2540-2547. DOI: 10.12114/j.issn.1007-9572.2022.0853.
XUE Shan,LI Laiyou,LIANG Junli, et al. The Efficacy and Safety of Home Enteral Nutrition in Patients with Esophageal Cancer: a Meta-analysis[J]. Chinese General Practice, 2023, 26(20): 2540-2547. DOI: 10.12114/j.issn.1007-9572.2022.0853.

图/表 16

参考文献 41

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步骤	检索式
#1	"Esophageal Neoplasms" [MeSH] OR "esophageal neoplasm" [Title] OR "esophageal neoplasms" [Title] OR "cancer of esophagus" [Title] OR "cancer of the esophagus" [Title] OR "esophagus cancer" [Title] OR "esophagus cancers" [Title] OR "esophageal cancer" [Title] OR "esophageal cancers" [Title] OR "esophageal carcinoma" [Title] OR "esophagus carcinoma" [Title] OR "esophagectomy" [Title] OR "esophagus resection" [Title] OR "postesophagectomy" [Title]
#2	"Enteral Nutrition" [MeSH] OR "home enteral nutrition" [Title/Abstract] OR "family enteral nutrition" [Title/Abstract] OR "enteral nutrition" [Title/Abstract] OR "enteral nutritional" [Title/Abstract] OR "nasogastric gavage" [Title/Abstract] OR "tube feeding" [Title/Abstract] OR "enteral feeding" [Title/Abstract] OR "enteric feeding" [Title/Abstract] OR "jejunostomy" [Title/Abstract] OR "oral nutritional supplements" [Title/Abstract] OR "ONS" [Title/Abstract]
#3	#1 AND #2
#4	"aftercare" [All Fields] OR "discharge" [All Fields] OR "home" [All Fields] OR "family" [All Fields] OR "community" [All Fields]
#5	#3 AND #4

步骤	检索式
#1	"Esophageal Neoplasms" [MeSH] OR "esophageal neoplasm" [Title] OR "esophageal neoplasms" [Title] OR "cancer of esophagus" [Title] OR "cancer of the esophagus" [Title] OR "esophagus cancer" [Title] OR "esophagus cancers" [Title] OR "esophageal cancer" [Title] OR "esophageal cancers" [Title] OR "esophageal carcinoma" [Title] OR "esophagus carcinoma" [Title] OR "esophagectomy" [Title] OR "esophagus resection" [Title] OR "postesophagectomy" [Title]
#2	"Enteral Nutrition" [MeSH] OR "home enteral nutrition" [Title/Abstract] OR "family enteral nutrition" [Title/Abstract] OR "enteral nutrition" [Title/Abstract] OR "enteral nutritional" [Title/Abstract] OR "nasogastric gavage" [Title/Abstract] OR "tube feeding" [Title/Abstract] OR "enteral feeding" [Title/Abstract] OR "enteric feeding" [Title/Abstract] OR "jejunostomy" [Title/Abstract] OR "oral nutritional supplements" [Title/Abstract] OR "ONS" [Title/Abstract]
#3	#1 AND #2
#4	"aftercare" [All Fields] OR "discharge" [All Fields] OR "home" [All Fields] OR "family" [All Fields] OR "community" [All Fields]
#5	#3 AND #4

第一作者	发表时间（年）	样本量（E/C）	年龄（E/C）	病理分期（Ⅰ/Ⅱ /Ⅲ/Ⅳ）	干预措施及持续时间（E/C）	结局指标
LIU^[11]	2020	26/24	62.04±5.12/64.58±5.87	24/16/10/0	空肠造瘘管饲喂养或ONS 4周/常规口服饮食4周	①②④⑧⑨
BOWREY^[17]	2015	20/21	64.6±8.0/63.1±8.7	6/12/22/1	空肠造瘘管饲喂养6周/常规口服饮食6周	①⑧⑨
XIE^[18]	2021	42/35	61.57±8.45/63.06±5.79		ONS 4周/常规口服饮食4周	⑧⑨
CHEN^[19]	2021	53/53	67.83±7.17/67.79±7.24	49/57/0/0	空肠造瘘管饲喂养4周/常规口服饮食4周	②③④⑤⑥⑦⑨⑩
LI^[20]	2020	30/32	63.25±5.23/63.61±5.64	11/23/21/7	空肠造瘘管饲喂养4周/常规口服饮食4周	①②
CHEN^[21]	2021	30/30	70.37±7.58/69.53±9.4	9/27/24/0	ONS 4周/常规口服饮食4周	②③④⑥⑩
ZENG^[22]	2017	30/30	61.7±8.4/59.3±10.4	1/28/31/0	空肠造瘘管饲喂养4周/常规口服饮食4周	⑧⑨⑩
范富翠^[23]	2020	40/40	62.58±6.64/60.88±6.86	Ⅰ~Ⅲ	空肠造瘘管饲喂养4周/常规口服饮食4周	③④⑤⑥⑦⑩
曹子昂^[24]	2013	40/40	65.8/67.4	1/36/42/0	空肠造瘘管饲喂养2个月/常规口服饮食2个月	④⑤⑥⑦⑨
童雅萍^[25]	2018	44/41	62.07±7.06/60.85±8.08	32/53/0/0	空肠造瘘管饲喂养4周/常规口服饮食4周	②③④⑤⑥⑦⑩
刘秀娟^[26]	2021	46/48	59.03±7.79/57.52±7.88	21/51/22/0	十二指肠营养管喂养2个月/常规口服饮食2个月	②③④⑤⑩
王倩^[27]	2019	48/48	53±6.75/55±7.25	41/55/0/0	空肠造瘘管饲喂养4个月/常规口服饮食4个月	①②③④⑤
谷金玲^[28]	2020	41/40	54±8.0/52±7.9	30/42/9/0	空肠造瘘管饲喂养4周/常规口服饮食4周	②③④⑤⑥⑩
石海燕^[29]	2021	34/34	67.3±8.1/68.4±8.5		ONS 4周/常规口服饮食4周	①④⑤⑥

第一作者	发表时间（年）	样本量（E/C）	年龄（E/C）	病理分期（Ⅰ/Ⅱ /Ⅲ/Ⅳ）	干预措施及持续时间（E/C）	结局指标
LIU^[11]	2020	26/24	62.04±5.12/64.58±5.87	24/16/10/0	空肠造瘘管饲喂养或ONS 4周/常规口服饮食4周	①②④⑧⑨
BOWREY^[17]	2015	20/21	64.6±8.0/63.1±8.7	6/12/22/1	空肠造瘘管饲喂养6周/常规口服饮食6周	①⑧⑨
XIE^[18]	2021	42/35	61.57±8.45/63.06±5.79		ONS 4周/常规口服饮食4周	⑧⑨
CHEN^[19]	2021	53/53	67.83±7.17/67.79±7.24	49/57/0/0	空肠造瘘管饲喂养4周/常规口服饮食4周	②③④⑤⑥⑦⑨⑩
LI^[20]	2020	30/32	63.25±5.23/63.61±5.64	11/23/21/7	空肠造瘘管饲喂养4周/常规口服饮食4周	①②
CHEN^[21]	2021	30/30	70.37±7.58/69.53±9.4	9/27/24/0	ONS 4周/常规口服饮食4周	②③④⑥⑩
ZENG^[22]	2017	30/30	61.7±8.4/59.3±10.4	1/28/31/0	空肠造瘘管饲喂养4周/常规口服饮食4周	⑧⑨⑩
范富翠^[23]	2020	40/40	62.58±6.64/60.88±6.86	Ⅰ~Ⅲ	空肠造瘘管饲喂养4周/常规口服饮食4周	③④⑤⑥⑦⑩
曹子昂^[24]	2013	40/40	65.8/67.4	1/36/42/0	空肠造瘘管饲喂养2个月/常规口服饮食2个月	④⑤⑥⑦⑨
童雅萍^[25]	2018	44/41	62.07±7.06/60.85±8.08	32/53/0/0	空肠造瘘管饲喂养4周/常规口服饮食4周	②③④⑤⑥⑦⑩
刘秀娟^[26]	2021	46/48	59.03±7.79/57.52±7.88	21/51/22/0	十二指肠营养管喂养2个月/常规口服饮食2个月	②③④⑤⑩
王倩^[27]	2019	48/48	53±6.75/55±7.25	41/55/0/0	空肠造瘘管饲喂养4个月/常规口服饮食4个月	①②③④⑤
谷金玲^[28]	2020	41/40	54±8.0/52±7.9	30/42/9/0	空肠造瘘管饲喂养4周/常规口服饮食4周	②③④⑤⑥⑩
石海燕^[29]	2021	34/34	67.3±8.1/68.4±8.5		ONS 4周/常规口服饮食4周	①④⑤⑥