Construction of a preoperative nutrition management plan for patients with gastric cancer conversion therapy based on evidence summary
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摘要:
目的 系统整合胃癌转化治疗患者术前营养管理领域循证医学证据，构建科学、规范的术前营养管理实施方案。 方法 通过系统检索国内外权威数据库文献，结合科学的文献质量评价与分析方法，拟定胃癌转化治疗患者术前营养管理方案。2024年10—12月，运用德尔菲法对14名专家进行两轮函询，根据专家反馈对方案条目进行修订与优化，并整合最新循证证据，最终形成完善的术前营养管理方案。 结果 胃癌患者常伴有严重的营养不良和恶病质的状况，实施规范化术前营养支持可显著改善胃癌转化治疗患者的临床预后，不仅提升血清蛋白及血红蛋白水平，加强对化疗、放疗等转化治疗的耐受性，并将恶心、呕吐等不良反应发生率从70%降至40%~50%，减少因不良反应导致的治疗中断，确保治疗的连续性。此外，营养干预可提高肿瘤缓解率，延长患者生存期、减少因营养不良导致的住院时间延长和医疗费用增加。通过两轮专家函询（回收率分别为93.3%和100.0%），构建了包含7项一级条目和36项二级条目的胃癌转化治疗患者术前的营养管理方案，权威系数为0.825，肯德尔和谐系数分别为0.259和0.530（P < 0.001），各条目变异系数为0~0.175。 结论 基于循证证据总结的胃癌转化治疗患者术前营养管理方案具备科学性和临床实用性，可为今后开展胃癌转化治疗患者术前营养管理实践提供借鉴。 Abstract:Objective Systematically integrate evidence-based medical findings in the field of preoperative nutritional management for patients undergoing neoadjuvant therapy for gastric cancer, and to develop a scientific and standardized implementation plan for preoperative nutritional management. Methods By systematically searching domestic and foreign authoritative databases and combining with scientific literature quality evaluation and analysis methods, a preliminary preoperative nutrition management plan for gastric cancer patients undergoing conversion therapy was formulated. From October to December 2024, the Delphi method was used to conduct two rounds of letter consultation with 14 experts. According to expert feedback, the items of the plan were revised and optimized, and the latest evidence-based evidence was integrated to finally form a perfect preoperative nutrition management plan. Results Patients with gastric cancer are often accompanied by severe malnutrition and cachexia. The implementation of standardized preoperative nutritional support can significantly improve the clinical prognosis of patients with gastric cancer conversion therapy, not only improve serum protein and hemoglobin levels, strengthen the tolerance of conversion therapy such as chemotherapy and radiotherapy, but also reduce the incidence of adverse reactions such as nausea and vomiting from 70% to 40%-50%. The interruption of treatment due to adverse reactions was reduced to ensure the continuity of treatment. In addition, nutritional intervention can improve the tumor response rate, prolong the survival of patients, and reduce the prolonged hospitalization and medical costs caused by malnutrition. Through two rounds of expert consultation (the recovery rates were 93.3% and 100.0%, respectively), a preoperative nutrition management plan for patients with gastric cancer conversion therapy was constructed, including 7 first-level items and 36 second-level items. The authority coefficient was 0.825, and the Kendall harmony coefficients were 0.259 and 0.530, respectively (P < 0.001). The coefficient of variation of each item ranged from 0 to 0.175. Conclusion The evidence-based preoperative nutrition management plan for patients with gastric cancer conversion therapy is scientific and clinical practical, which can provide a reference for the practice of preoperative nutrition management for patients with gastric cancer conversion therapy in the future. -
Key words:
- Gastric cancer /
- Conversion therapy /
- Preoperative /
- Nutrition management /
- Delphi method
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表 1 胃癌转化治疗患者术前营养管理方案的构建
Table 1. Construction of preoperative nutritional management program for patients with gastric cancer undergoing conversion therapy
条目 重要性评分(x±s，分) 变异系数 1营养支持团队：胃外科医生、营养师、营养专科护士、康复师等共同负责患者的营养筛查、评估与干预。 5.00±0.00 0.00 2营养筛查评估 2.1时机：首次门诊或住院8 h内。 4.79±0.42 0.09 2.2(一级诊断)营养筛查：NRS 2002营养风险筛查；NRS 2002＜3分，无营养风险，每周评估；NRS 2002≥3分进入二级评估。 5.00±0.00 0.00 2.3(二级诊断)评估：患者主观整体评估量表(PG-SGA)、GLIM共识、膳食回顾调查、人体学测量、肌肉功能[四肢骨骼肌质量指数(ASMI)、握力、6分钟步行试验(6MWT)]、能量需求估算。 5.00±0.00 0.09 2.4(三级诊断)综合评价：炎症水平、代谢改变、人体成分分析、实验室数据(白蛋白、前白蛋白、C反应蛋白等)、心理及家庭支持等。 4.79±0.42 0.08 2.5预防再喂养综合征。 4.14±0.36 0.08 3营养方案制定 3.1营养治疗绝对指征：体重丢失≥20%、PG-SGA评分≥9分；相对指征：体重丢失10%~19%、PG-SGA评分4~8分。如放化疗后出现严重黏膜反应、进食困难等影响进食的情况。 4.79±0.42 0.09 3.2能量需求 3.2.1热量：25~30 kcal/(kg·d)，个体化调整。 4.93±0.26 0.05 3.2.2蛋白质: 1.2~2.0 g/(kg·d)，肾功能不全0.8~1.0 g/(kg·d)。 4.86±0.36 0.07 3.2.3调整供能比：减少碳水化合物，适当提高脂肪比例。 4.79±0.42 0.08 3.3.4预防RFS：限钠限液，避免补铁，监测电解质。 4.21±0.43 0.10 4营养治疗：首选ONS，遵循五阶梯治疗模式。 4.93±0.26 0.05 4.1首选ONS，剂量：400~600 kcal/d，餐间服用，持续3~6个月。 4.21±0.42 0.10 4.2配方：短肽或低脂全营养制剂，必要时增加免疫调节配方(ω-3 PUFAS、谷氨酰胺等)。 4.21±0.42 0.10 4.3糖尿病患者等选择专用型营养制剂。 4.00±0.00 0.00 4.4建议使用特医食品代替家庭肠内营养制剂。 4.71±0.46 0.10 5营养方案实施 5.1个体化营养指导：评估患者及照护者认知水平后，采用图文手册、APP等多元方式开展教育，重点指导营养制剂使用、并发症应对及戒酒戒烟。 4.93±0.26 0.05 5.2根据地域和个人喜好，调整ONS口味，实施“小量多次、由稀到稠、现配现用”渐进式喂养策略，逐步达目标量。 4.93±0.27 0.05 5.3口腔黏膜炎患者, 可在医师指导下含漱, ONS冷却后口服。 4.06±0.37 0.17 5.4症状管理 5.4.1食欲缺乏：少食多餐，补充锌、B族维生素。 4.07±0.26 0.06 5.4.2化疗导致恶心呕吐：预防性止吐，清淡饮食，建设无呕病房。 4.57±0.51 0.11 5.4.3肠内营养并发症：高血糖、鼻咽黏膜损伤、喂养管堵塞、吸入性肺炎等，通过规范操作与专科护理防控。 4.14±0.36 0.08 5.4.4肠内营养不耐受处理：腹泻、腹胀等，口服ONS排查原因，更换配方(如低脂配方)。管饲患者应优化输注速度或更换要素膳(短肽/氨基酸型)，必要时联合药物治疗。 4.86±0.36 0.07 5.4.5吞咽困难：评估吞咽功能、调整食物质地，考虑管饲(鼻胃管或造瘘)。 4.14±0.39 0.08 5.4.6幽门梗阻：胃肠减压+PPI，纠正电解质。 4.86±0.36 0.07 5.4.7消化道出血：禁食+肠外营养，止血后逐步恢复饮食。 4.79±0.42 0.09 5.4.8肠梗阻：禁食+胃肠减压，肠外营养支持。 4.93±0.26 0.05 5.5运动指导：运动前进行风险，开展有氧运动(如太极拳、八段锦)和抗阻运动(如哑铃、弹力带、平板支撑)，循序渐进。 4.86±0.36 0.07 5.6心理护理：加强心理疏导，改善进食环境。 4.86±0.36 0.08 6营养监测 6.1每日检测：食欲、摄入量、估算膳食摄入热卡，胃肠道耐受情况。 4.86±0.36 0.06 6.2每周评估：人体测量(体重、BMI、臂围、皮褶厚度、ASMI)、生活能力(ADL量表评估)、握力、6MWT。 4.07±0.26 0.07 6.3每周实验室指标：血常规、电解质、白蛋白等。 4.79±0.42 0.08 6.4每周评价患者及照顾者营养知识、态度、依从性及技能水平。 4.79±0.42 0.08 6.5方案调整 6.5.1根据患者营养监测数据、胃肠道耐受程度调整剂量或更改ONS配方，不可自行中断。 4.79±0.42 0.08 6.5.2当前一阶梯不能满足患者营养需求(＜60%目标需要量3~5 d时)或无法实施时，应进入下一阶梯。 4.86±0.36 0.06 7随访：至少每月1次门诊营养咨询。 4.07±0.26 0.07 注：营养风险筛查2002(nutritional risk screening 2002，NRS 2002)；ω-3多不饱和脂肪酸(ω-3 polyunsaturatedfatty acids, ω-3 PUFA)；全球领导人营养不良倡议(global leadership initiative on malnutrition，GLIM)；日常生活活动能力量表(activity of daily living，ADL)；再喂养综合征(refeeding syndrome，RFS)；肠内营养(enteral nutrition，EN)；肠外营养(parenteralnutrition，PN)；口服营养补充(oral nutritional supplements，ONS)；质子泵抑制剂(proton pump inhibitor, PPI)；四肢骨骼肌质量指数(appendicular skeletal muscle mass index, ASMI)。 
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