ABSTRACT Methods and MaterialsThe historical highlights of the management of fistulas of the gastrointestinal tract during the past century are presented briefly, together with the significant lessons learned from the studies published in the literature. DiscussionThe evolution from predominantly operative or technical approaches to comprehensive multidisciplinary management of metabolic and nutritional support, which are essential to optimal fistula closure, and morbidity and mortality outcomes are discussed. The importance of achieving hemodynamic stability, fluid and electrolyte homeostasis, fistula effluent control, protection of the skin, control of infection and sepsis, and cardiopulmonary and major organ support, preferably by specially trained and motivated teams in critical care units of institutions with the interest, resources, and skills in managing the metabolic consequences of gastrointestinal fistula patients, is emphasized. The current status of the nutritional and metabolic support of patients with gastrointestinal tract fistulas is outlined and discussed briefly. ConclusionsThe optimal metabolic and nutritional management of patients with gastrointestinal tract fistulas is an extraordinary and daunting challenge which has yet to be perfected, demonstrated, and applied universally. Much education, research, motivation, proficiency, and concerted conscientious effort will be required in order to achieve this elusive but noble goal. Some suggestions for achieving success in this endeavor are proffered, consistent with the senior author’s philosophy, which has evolved during a half-century of experience and endeavor in this vital area. KeywordsEnterocutaneous fistula–Gastrointestinal fistula–Enteral nutrition–Parenteral nutrition–Nutritional support–Metabolism

Traumatic brain injury (TBI) is associated with a profound immunological dysfunction manifested by a severe shift from T-helper type 1 (Th1) to T-helper type 2 (Th2) response. This predisposes patients to infections, sepsis, and adverse outcomes. Probiotic bacteria have been shown to balance the Th1/Th2 cytokines in allergic murine models and patients. For the present study, we hypothesized that the enteral administration of probiotics would adjust the Th1/Th2 imbalance and improve clinical outcomes in TBI patients.We designed a prospective, randomized, single-blind study. Patients with severe TBI and Glasgow Coma Scale scores between 5 and 8 were included, resulting in 26 patients in the control group and 26 patients in the probiotic group. All patients received enteral nutrition via a nasogastric tube within 24 to 48 hours following admission. In addition, the probiotic group received 109 bacteria of viable probiotics per day for 21 days. The associated serum levels of Th1/Th2 cytokines, Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores, nosocomial infections, length of ICU stay, and 28-day mortality rate were studied.The patients responded to viable probiotics, and showed a significantly higher increase in serum IL-12p70 and IFN纬 levels while also experiencing a dramatic decrease in IL-4 and IL-10 concentrations. APACHE II and SOFA scores were not significantly affected by probiotic treatment. Patients in the probiotic group experienced a decreased incidence of nosocomial infections towards the end of the study. Shorter ICU stays were also observed among patients treated with probiotic therapy. However, the 28-day mortality rate was unaffected.The present study showed that daily prophylactic administration of probiotics could attenuate the deviated Th1/Th2 response induced by severe TBI, and could result in a decreased nosocomial infection rate, especially in the late period.ChiCTR-TRC-10000835.

目的观察益生菌联合早期肠内营养对重型颅脑损伤患者感染的影响。方法选取重型颅脑损伤患者38例，按随机数字表分为研究组（17例）和对照组（21例）。2组患者均在入院后24—72h内开始经鼻胃管行肠内营养，研究组在肠内营养基础上添加益生菌。于肠内营养开始后1、4、7、15d晨空腹抽血监测白细胞、淋巴细胞、C-反应蛋白等指标，记录患者感染发生时间、严重程度，观察患者预后情况，比较ICU住院天数和GCS、SOFA、APACHEⅡ评分。结果研究组白细胞计数在营养后7d显著低于对照组（P〈0．05），C-反应蛋白在15d显著低于对照组（P〈0．05），而淋巴细胞计数在各时相点两组差异均无统计学意义（P〉0．05）。研究组总感染发生率、肺部感染发生率也显著低于对照组（P〈0．05），其ICU住院天数明显降低（P〈0．05）。在营养第15天，研究组GCS评分显著高于对照组（P〈0．05）。结论与单纯早期肠内营养相比，添加益生菌能更好地降低重型颅脑损伤患者的感染发生率，缩短ICU住院天数，改善患者的预后。

目的探讨益生菌联合早期肠内营养对重型颅脑损伤患者感染的影响，以期提高临床治疗水平。方法随机选取2010年1月-2013年2月70例重型颅脑损伤感染患者为研究对象，将其随机分为对照组和观察组，各35例，对照组予以早期肠内营养，观察组在对照组基础上加用益生菌治疗，观察两组治疗效果。结果对照组与观察组在治疗后的第1天白细胞计数、淋巴细胞计数、C-反应蛋白（CRP）、肿瘤坏死因子-α（TNF-α）、白介素-6（IL-6）比较，差异无统计学意义；而在治疗后的第4、7、15天两组比较，各项指标差异均有统计学意义（P＜0．05）；对照组感染率为48．57％、病死率为14．29％，观察组分别为25．71％和5．71％；两组治疗后在GCS评分、SOFA评分、APACHF-Ⅱ评分上比较，差异有统计学意义（P＜0．05）。结论益生菌联合早期肠内营养对重型颅脑损伤患者感染影响性低，临床效果满意。

目的：探讨早期肠内营养联合益生菌对重型颅脑损伤患者术后感染的 影响，以降低感染率。方法选取重型颅脑损伤手术患者110例，随机分为两组，对照组53例给予早期肠内营养治疗，观察组57例在对照组基础上给予益生菌联 合应用，对两组患者住院期间发生感染进行统计，采用 SPSS13．0软件进行分析。结果患者发生肺部感染率及总感染率观察组分别为19．30％及31．58％、对照组分别为30．19％及47．17％，观 察组均明显低于对照组；治疗7 d 时观察组患者白细胞计数为（9．88 ± 1．05）×109／L ，7、15 d 时 C-反应蛋白分别为（80．47 ± 7．92）、（19．79±2．20）mg／L ，对照组分别为（12．20 ± 1．19）×109／L 及（175．58±20．05）、（77．39 ± 9．30）mg／L ；治疗15 d 时患者 GCS 评分观察组为（12．43 ± 1．97）分、对照组为（9．18 ± 0．63）分；住院时间观察组为（6．40 ± 0．95）d 、对照组为（12．17 ± 1．82）d ；患者病死率观察组为14．04％、对照组为35．85％，两组差异均有统计学意义（P＜ 0．05）。结论对重型颅脑损伤患者在早期肠内营养的基础上给予益生菌联合应用有利于降低感染发生率，改善患者预后。

目的探讨合生元制剂联合早期肠内营养对高龄重型颅脑损伤患者感染的影响。方法在该院接受治疗的82例高龄重型颅脑损伤患者,随机分成两组各41例。对照组接受重型颅脑损伤的常规抢救治疗,同时早期展开肠内营养支持治疗。观察组在对照组治疗方式的基础上,应用合生元制剂治疗。结果治疗3、7、10 d后,观察组患者的白细胞水平低于对照组(P0.01)。治疗3、7、10 d后,观察组患者的分泌型Ig A(SIg A)水平高于对照组(P0.01)。治疗后,观察组患者(格拉斯哥昏迷评分)GCS评分及光纤放大系统(SOFA)评分高于对照组(P0.01)。治疗后,观察组患者急性生理及慢性健康状况(APACHEⅡ)评分及重症监护病房(ICU)住院天数小于对照组(P0.01)。观察组患者的死亡率少于对照组(P0.05)。观察组患者总感染率少于对照组(P0.01)。结论合生元制剂联合早期肠内营养治疗老年重型颅脑损伤疗效显著,具有维持肠道菌群平衡、提高肠道黏膜免疫的作用,能够改善患者病情、降低患者感染风险和死亡率,促进患者的康复预后。

目的探讨不同早期肠内营养方案对严重颅脑外伤患者胃肠功能和营养状况的影响。方法收集我院2010-06—2013-06收治的严重颅脑外伤患者62例为研究对象,随机分为试验组与对照组,每组各31例。2组患者入院24h内开始肠内营养,试验组还同时给予益生菌。然后观察2组患者的呕吐、腹胀、胃潴留、反流、便秘及腹泻等胃肠道反应情况;观察患者的首次排便时间和肠内营养达标时间。于营养开始第0、6、14、21天检测患者的血清白蛋白、血红蛋白、空腹血糖及淋巴细胞计数等营养指标,并比较2组患者住ICU时间。结果 2组呕吐、腹胀、胃潴留、腹泻和住ICU时间比较差异均无统计学意义（P〉0.05）。试验组反流及便秘发生例数和营养支持第6、14天空腹血糖明显低于对照组。试验组营养支持第21天白蛋白及血红蛋白水平显著高于对照组。试验组的首次排便时间及肠内营养达标时间早于对照组。结论在肠内营养同时添加益生菌既可以改善严重颅脑损伤患者的胃肠功能,又可以提高患者机体的营养状况。

目的：观察重型颅脑创伤患者采用生态营养鼻饲肠内营养支持的效果。方法：选择我院62例重型颅脑创伤（GCS评分4～8分）患者作前瞻性研究。生态营养组于早期（伤后12h）开始双歧杆菌四联活菌片3#＋30mL温水胃管注入。每日3次，同时给肠内营养混悬液持续胃管滴注；普通膳食组仅给肠内营养混悬液持续胃管滴注。结果：生态营养组支持后血清白蛋白、血清前白蛋白等营养指标明显优于普通膳食组（P〈0．05）；胃肠道功能障碍症状（上消化道出血、胃内容物返流、症状性腹胀、腹泻和拒食等）明显少于普通膳食组（P〈0．05或P〈0．01），神志恢复快，生存质量有明显改善。结论：重型颅脑创伤患者早期给予生态营养可有效降低胃肠功能障碍的发生率，从而促进神经功能恢复，有效降低病死率和致残率。

Gut under severe insult is considered to have an important role in promoting infection and multiple organ dysfunction syndrome from the viewpoint of altered intestinal epithelium, immune system and commensal bacteria. There are few reports, however, about the relationship between gut flora and septic complications.We analyzed gut flora in patients with systemic inflammatory response syndrome (SIRS) and evaluated key bacteria and their cutoff values for infectious complications and mortality by using classification and regression trees (CART). Eighty-one SIRS patients with a serum C-reactive protein level higher than 10mg/dL treated in the intensive care unit (ICU) for more than 2days were included for the study. We quantitatively evaluated nine types of bacteria in fecal samples by plate or tube technique. Two hundred seventy-one samples were analyzed using CART and logistic regression.The dominant factors for complication of enteritis were the minimum number of total obligate anaerobes and the maximum number of Staphylococcus and Enterococcus. The dominant factors for complication of bacteremia were the minimum numbers of total obligate anaerobes and total facultative anaerobes. The dominant factors for mortality were the numbers of total obligate anaerobes and total facultative anaerobes and age.A decrease in total obligate anaerobes and an increase in pathogenic bacteria in the gut are associated with septic complications and mortality in patients with SIRS. The altered gut flora may be a potential prognostic marker in SIRS patients.

Abstract INTRODUCTION: Ciprofloxacin and meropenem have effects on intestinal bacteria that are responsible for pancreatic infection, and on the basis of recent data it has been argued that probiotics, especially those used in the food industry, could improve efforts to prevent and treat secondary pancreatic infections by inhibiting bacterial translocation. AIMS: To evaluate the effects of probiotic treatment alone or in combination with early administration of two different antibiotics on serum amylase, pancreatic histopathology, bacterial translocation, and oxidative markers. METHODOLOGY: Acute pancreatitis was induced in rats with 3% sodium taurocholate (1 mL/kg intraductally), except in group VI (sham group). After the stabilization period, the rats were divided into seven groups (n = 20) randomly. At hour 6 after injection, group I rats received probiotic Saccharomyces boulardii (25 mg/d orally q.d.), group II received meropenem (60 mg/kg intraperitoneally b.i.d.), group III received ciprofloxacin (40 mg/kg intraperitoneally b.i.d.), group IV received the same dose of probiotic plus meropenem, and group V received probiotic plus ciprofloxacin. Treatment was not given to group VI (sham group) and group VII (pancreatitis group). At hour 48 after induction, specimens were collected. RESULTS AND CONCLUSION: Although histopathologic scores in treatment groups were found to be lower than in group VII, the difference was statistically significant only in group V (p < 0.001). In evaluation of oxidative stress, we found that MDA levels decreased and SOD levels increased in treatment groups in comparison with levels in group VII. Probiotic treatment alone reduced bacterial translocation. Probiotic-antibiotic combination therapy was shown to improve histopathologic scores and oxidative parameters.

This article discusses the role that immunity plays in the risk of diarrhoea and the potential role for probiotics in the management of acute infectious diarrhoea in older people, including antibiotic-associated diarrhoea and Clostridium difficile-associated diarrhoea.

Recent clinical trials, epidemiological studies and animal experiments have suggested that probiotics may help suppress the development of allergic responses.To investigate whether the application of the probiotic Escherichia coli strain Nissle 1917 (EcN) protects mice from developing ovalbumin (OVA)-specific T helper-2 responses in the airways.OVA-specific Th2 responses were induced by 2 intraperitoneal (i.p.) injections with OVA/alum followed by 1 intranasal (i.n.) challenge with OVA. EcN was given orally during the entire sensitization and challenge period, together with OVA/alum during the i.p. sensitizations, or i.n. before or during the airway challenge with OVA.We found that when the bacteria were given together with OVA/alum airway eosinophilia, airway hyper-reactivity, goblet cell metaplasia and IL-5 levels in the bronchoalveolar lavage and mediastinal lymph node cell cultures were reduced. This effect was associated with increased numbers of IFN-gamma producing T helper-1 cells and IFN-gamma levels in the airways and strongly increased OVA-specific IgG(2a) titers in the serum. The suppressive effect on airway eosinophilia was dependent on IFN-gamma but not TLR-4. Applying EcN i.n. or orally did not reduce the development of allergen-specific Th2 responses.Our results suggest that EcN can inhibit the development of allergic responses when the bacteria are present at the site of Th2 cell priming and that this immunomodulatory effect is due to a shift from Th2 to Th1 response. The data support the hypothesis that probiotics may help reduce allergic responses and that EcN may also be used as adjuvant therapy to induce allergen-specific Th1 responses.

<a name="Abs1"></a><div class="AbstractSection"> <div class=""><h3>Background&nbsp;&nbsp;</h3>Since probiotics are considered to exert beneficial health effects by enhancing the host&#8217;s immune response, we investigated the benefits of a synbiotics treatment on the rate of infections, systemic inflammatory response syndrome (SIRS), severe sepsis, and mortality in critically ill, mechanically ventilated, multiple trauma patients. Length of stay in the intensive care unit (ICU) and number of days under mechanical ventilation were also evaluated.