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目的：探讨胃癌围手术期能量及营养物质的代谢特点，研究强化胰岛素治疗对围手术营养代谢的影响。方法：选取胃中、下部癌病理诊断明确并且外科病房ICU 住院时间不少于24 h 的患者64 例，取得知情同意后随机分到强化胰岛素治疗（IIT）组血糖控制在4.4~6.1 mmol/L，和传统治疗（CIT）组血糖控制在10 mmol/L 以下；应用CCM 营养代谢监测系统测定围手术期静息能量消耗（REE），呼吸商（RQ），每公斤体重静息能量消耗（REE/kg）和脂肪氧化比率，应用多频人体生物电阻抗分析仪测定围手术期人体组分的变化及应用稳态模式评估法计算胰岛素抵抗指数（HOMA-IR）。结果：64 例病人入选，每组32 例，手术创伤引起术后第1、3 天REE 水平增加约22 %和12 %，呼吸商降低至0.759 和0.791，REE/kg 增加28 kcal/kg 和26 kcal/kg,脂肪氧化比率增加至78 % 和65 %，Ln-HOMA-IR 明显增加（P<0.05）；IIT 治疗能降低术后第1、3 天Ln-HOMA-IR 和REE/kg 水平；术后人体指标如细胞内液、脂肪组织、蛋白组织、肌肉组织、瘦体组织和体质量较术前水平明显降低（P<0.05）；IIT 能明显减少脂肪组织、蛋白组织和细胞内液的消耗量(P=0.009，t= 0.026)。结论：IIT 能够有效降低胃癌围手术期胰岛素抵抗程度、降低静息能量消耗的水平和减少脂肪及蛋白质的消耗。

英文摘要:

Objective: To investigate perioperative metabolic characteristic of gastric cancer and to assess effect of intensive insulin therapy on the perioperative nutritional substrate metabolism. Methods: Within 24 h of ICU management, patients of gastric cancer were enrolled after written informed consent and randomized to intensive insulin therapy (IIT) group to keep glucose levels from 4.4 to 6.1 mmol/L or conventional insulin therapy (CIT) group to keep levels less than 10mmol/L. resting energy expenditure (REE), respiratory quotient (RQ), resting energy expenditure per kilometer (REE/kg), and lipids oxidation rate were monitored by Indirect calorimeter of CCM nutrition metabolism investigation system. The changes of body composition were analyzed by multi-frequency BIA. Blood fasting glucose and insulin concentration for HOMA-IR were measured. Results: 64 patients were enrolled. Comparing with the preoperative baseline, postoperative REE level increased by 22% and 12%, RQ decreased to 0.759 and 0.791, REE per kilometer went up to 28 kcal/kg and 26 kcal/kg, lipids oxidation rate rose up to 78% and 65%, Ln-HOMA-IR score went up dramatically on postoperative 1st and 3rd day (P<0.05 respectively). IIT reduced the REE/kg level and decreased the Ln-HOMA-IR score on postoperative 1st and 3rd day comparing with CIT (P<0.05 respectively). Postoperative values of internal cell fluid (ICF), fat mass (FM), protein mass (PM), muscle mass (MM), free fat mass (FFM) and body weight (BW) decreased obviously on postoperative 7th day comparing with the preoperative baseline in CIT group (P<0.05, respectively). IIT reduced markedly consumption of FM, PM and ICF comparing with CIT (P=0.009 to 0.026). Conclusions: There were some benefits of IIT in decreasing perioperative insulin resistance state, reducing mean energy expenditure and the consumption of protein and lipids tissue in this small population undergoing the radical distal gastrectomy.

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