一位大腸癌患者雙造口灌食的營養照護個案報告

Case Report of Nutrition Care in a Colon Cancer Patient Who Underwent Double Jejunostomy: A Case Report

陳美吟(Mei-Yin Chen) ； 張敏琪(Min-Chi Chang)

《臺灣膳食營養學雜誌》 10卷2期 (2018/12) Pp. 29-40

https://doi.org/10.6709/TJD.201812_10(2).0004

摘要

大腸直腸癌的個案，手術前體重流失超過10%及在進行癌常見的徵狀—營養不良，都是導致死亡的危險因子。大部分術前的危險因子對於術後併發症的發生是無法被改變的，然而營養不良的風險是可以藉由適當的營養處置被改善。七十八歲的男性因直腸癌曾接受低位前切除，之後又因局部復發，陸續接受右上腹施行橫結腸造口及復發腸段切除與結腸肛門吻合手術；然於5年後，因小腸阻塞、壞死、穿孔至本院急診，經剖腹探查術切除壞死小腸，並行左側空腸造口及右側空腸造口術。在術後禁食期間，先提供了靜脈營養，之後由此二處同時給予造口灌食。我們同時參考了美國靜脈暨腸道營養學會（The American Society for Parenteral and Enteral Nutrition, ASPEN）對於重症病人及歐洲靜脈暨腸道營養學會（The European Society for Clinical Nutrition and Metabolism, ESPEN）對於癌症病人營養需求建議，評估熱量為25～30 kcal/kg body weight（BW）/day，蛋白質為1.2～2.0 g/kg actual body weight（ABW）/day。在營養診斷上，主要問題（problem, P）為非計畫性體重減輕，主因（etiology, E）為腸道營養灌食不足，病徵（sign/symptom, S）為體重減輕。因此在營養介入的措施，一開始先以預解配方供應並採連續灌食，觀察病人之吸收狀況，同時監控生化指數及疾病之進展，適時調整營養策略，更改灌食配方給予並逐步增加熱量與灌食速度，營養介入監測指標為病人的體重變化。此外，每日於2處造口收集24小時引流之消化液並回灌，以避免消化液的流失。病人於住院3個月後，流失的體重回升了4.7 kg，且經由口進食軟質食物情況良好，關閉二處空腸造口，並辦理出院改至門診追蹤。

關鍵字

直腸癌 ； 低位前切除 ； 橫結腸造口 ； 空腸造口 ； 營養診斷 ； 預解配方

並列摘要

In the case of colorectal cancer, loss of ＞ 10% of the body weight prior to surgery and malnutrition have been shown to be frequent manifestations of advanced cancer and mortality risk factors. Most preoperative risk factors of postoperative complications cannot be modified, whereas nutritional risk could potentially be improved by adequate nutritional treatment. The patient was a 78-year-old man who underwent low anterior resection of a rectal cancer but had a local recurrence after surgery. The patient successively underwent proximal T-loop colostomy, segmental resection of the small intestine, and coloanal anastomosis. However, after 5 years, the patient visited the emergency department of Kaohsiung Veterans General Hospital for consultation with complaints of small bowel obstruction, necrosis, and perforation. He then underwent segmental resection of the small intestine by laparotomy, left jejunostomy, and right jejunostomy. During the postoperative period, he did not take food orally, but was provided parenteral nutrition followed by simultaneous double jejunostomy feeding. At the same time, for recommendations on nutritional requirements, we referred to the American Society for Parenteral and Enteral Nutrition guidelines on nutrition for critically ill patients and the European Society for Clinical Nutrition and Metabolism guidelines on nutrition for patients with cancer. Accordingly, we provided the patient with 25-30 kcal/kg body weight (BW)/day and 1.2-2.0 g protein/kg actual body weight (ABW)/ day. In the nutritional diagnosis, unintended weight loss caused by feeding insufficiency was observed. Initially, the patient was given a pre-digested formula via continuous feeding and was observed for absorption status. Subsequently, we monitored biochemical indices and the disease progression and made timely adjustments of the nutritional strategy by changing to a commercial formula and gradually increasing the feeding calories and rate. The monitor index of nutritional intervention was change in body weight. Moreover, the 24-hour digestive fluid drainages from the 2 jejunostomies were collected and reinfused to prevent loss of digestive fluid. After 3 months of hospitalization, the patient's body weight increased by 4.7 kg, and he could eat soft foods; therefore, the 2 jejunostomies were closed. The patient was discharged and directed to outpatient follow-up.

並列關鍵字

rectal adenocarcinoma ； low anterior resection ； proximal T-loop colostomy ； jejunostomy ； nutritional diagnosis ； pre-digested formula