Home parenteral nutrition (HPN) in incurable cancer patients: patients’ qualification criteria and treatment outcome

Cel pracy. Żywienie pozajelitowe stanowi podstawową metodę leczenia u chorych z niewydolnością jelit, niezależnieod jej etiologii. O ile wskazania do jego zastosowania w warunkach domowych w przypadku schorzeń nienowotworowychnie budzą zastrzeżeń, o tyle w grupie pacjentów z zaawansowaną chorobą nowotworową ich ustaleniestało się niemalże niemożliwe. Kwestionowana jest także zasadność takiego leczenia. Celem pracy była próba ocenywskazań do domowego żywienia pozajelitowego (HPN) w grupie pacjentów z zaawansowaną chorobą nowotworowąoraz ocena wyników leczenia.Materiał i metoda. Analizie poddano grupę 69 pacjentów (42 kobiety, 27 mężczyzn, średni wiek 58,1 lat) z zaawansowanąchorobą nowotworową w przebiegu raka żołądka, trzustki, jelita grubego, jajnika, szyjki i trzonu macicy,pęcherzyka żółciowego, przełyku oraz nieznanego umiejscowienia pierwotnego, leczonych w okresie od stycznia2009 r. do czerwca 2012 r. Analizie poddano czas przeżycia i jakość życia chorych.Wyniki. Średni czas leczenia (od początku HPN) wyniósł 99,8 dnia. Analiza wykazała, iż średni czas przeżycia chorychz nowotworami wywodzącymi się z układu rozrodczego znamiennie statystycznie przekraczał średni czas przeżyciaoraz czas przeżycia nowotworów górnego odcinka przewodu pokarmowego (231,8 vs 99,8 dni, p < 0,05). Podobniekorzystne wyniki wykazała analiza jakości życia: różnica pomiędzy nowotworami narządów kobiecych a pozostałymibyła znamienna statystycznie (7,8 vs 4,3 punkty, p < 0,05). W przypadku innych schorzeń nowotworowych różnicenie były znamienne statystycznie.Wnioski. Żywienie pozajelitowe w warunkach domowych należy rozważyć w każdym przypadku pacjentek z rakiemjajnika, szyjki lub trzonu macicy. W przypadku innych grup pacjentów wskazania powinno się rozważyć indywidualnie,gdyż wyniki leczenia nie są przekonujące.Aim. Parenteral nutrition (PN) represents a recognized therapeutic modality for intestinal failure patients, independentlyof its etiology. Home parenteral nutrition (HPN) has, however, become controversial in oncological patients,and creation of widely accepted indications for this treatment has become difficult. The aim of the study was toassess treatment outcome in cancer HPN patients as well as to propose recommendations for this kind of treatmentin advanced cancer patients.Material and methods. 69 patients (42 F, 27 M, mean age 58.1 y.) treated between January 2009 and June 2012 wereanalyzed. The study group was formed of gastric, pancreatic, colon, esophagus, gall bladder, ovarian and uterus cancerpatients. The time of treatment and quality of life of the patients were analyzed.Results. The mean overall survival time reached 99.8 days but varied among tumour groups. It was longer in ovarian and uterine cancer than in any other neoplasm (231.8 vs. 99.8 days, p < 0.05). The quality of life was also higher in the ovarian and uterine cancer group (7.8 vs. 4.3 points, p < 0.05) , while it was significantly lower in the others.Conclusions. Home parenteral nutrition should be considered as a therapeutic option in every patient with advanced ovarian and uterine cancer. In other advanced cancer patients its use should be carefully considered as its value is not so convincing

Enteral nutrition in cancer patients

Artykuł przedstawia kolejną część zaleceń dotyczących żywienia do- i pozajelitowego w onkologii. Przedstawione zostały wskazania do leczenia, metody interwencji i monitorowania oraz rodzaje diet. Jako metoda z wyboru, żywienie dojelitowe powinno zawsze być rozważane w pierwszym etapie podejmowania decyzji o leczeniu żywieniowym. Korzystny wpływ tej interwencji został udowodniony w wielu pracach naukowych.The manuscript presents the second part of recommendations on enteral and parenteral nutrition in oncology. It describes indications, methods of intervention, types of diets and techniques for monitoring. The enteral nutrition (EN) is a method of choice for nutritional support, hence it should be always considered as the first step, whenever the latter is necessary. The beneficial effect of EN was demonstrated in many clinical studies

Polish Recommendations on Enteral and Parenteral Nutrition in Oncology — part two: enteral nutrition

Artykuł przedstawia kolejną część zaleceń dotyczących żywienia do- i pozajelitowego w onkologii. Przedstawione zostały wskazania do leczenia, metody interwencji oraz monitorowania oraz rodzaje diet. Jako metoda z wyboru żywienie dojelitowe powinno zawsze być rozważane na pierwszym etapie podejmowania decyzji o leczeniu żywieniowym. Korzystny wpływ tej interwencji został udowodniony w wielu pracach naukowych.The manuscript presents the next part of recommendations on enteral and parenteral nutrition in oncology. It describes indications, methods of intervention, types of diets and techniques for monitoring. The enteral nutrition (EN) is a method of choice for nutritional support, hence it should be always considered as the first step, whenever the latter is necessary. The beneficial effect of EN was demonstrated in many clinical studies

Clinical classification of adult patients with chronic intestinal failure due to benign disease: An international multicenter cross-sectional survey

BACKGROUND & AIMS: The aim of the study was to evaluate the applicability of the ESPEN 16-category clinical classification of chronic intestinal failure, based on patients' intravenous supplementation (IVS) requirements for energy and fluids, and to evaluate factors associated with those requirements. METHODS: ESPEN members were invited to participate through ESPEN Council representatives. Participating centers enrolled adult patients requiring home parenteral nutrition for chronic intestinal failure on March 1st 2015. The following patient data were recorded though a structured database: sex, age, body weight and height, intestinal failure mechanism, underlying disease, IVS volume and energy need. RESULTS: Sixty-five centers from 22 countries enrolled 2919 patients with benign disease. One half of the patients were distributed in 3 categories of the ESPEN clinical classification. 9% of patients required only fluid and electrolyte supplementation. IVS requirement varied considerably according to the pathophysiological mechanism of intestinal failure. Notably, IVS volume requirement represented loss of intestinal function better than IVS energy requirement. A simplified 8 category classification of chronic intestinal failure was devised, based on two types of IVS (either fluid and electrolyte alone or parenteral nutrition admixture containing energy) and four categories of volume. CONCLUSIONS: Patients' IVS requirements varied widely, supporting the need for a tool to homogenize patient categorization. This study has devised a novel, simplified eight category IVS classification for chronic intestinal failure that will prove useful in both the clinical and research setting when applied together with the underlying pathophysiological mechanism of the patient's intestinal failure

Home parenteral nutrition with an omega-3-fatty-acid-enriched MCT/LCT lipid emulsion in patients with chronic intestinal failure (the HOME study):study protocol for a randomized, controlled, multicenter, international clinical trial

BACKGROUND: Home parenteral nutrition (HPN) is a life-preserving therapy for patients with chronic intestinal failure (CIF) indicated for patients who cannot achieve their nutritional requirements by enteral intake. Intravenously administered lipid emulsions (ILEs) are an essential component of HPN, providing energy and essential fatty acids, but can become a risk factor for intestinal-failure-associated liver disease (IFALD). In HPN patients, major effort is taken in the prevention of IFALD. Novel ILEs containing a proportion of omega-3 polyunsaturated fatty acids (n-3 PUFA) could be of benefit, but the data on the use of n-3 PUFA in HPN patients are still limited. METHODS/DESIGN: The HOME study is a prospective, randomized, controlled, double-blind, multicenter, international clinical trial conducted in European hospitals that treat HPN patients. A total of 160 patients (80 per group) will be randomly assigned to receive the n-3 PUFA-enriched medium/long-chain triglyceride (MCT/LCT) ILE (Lipidem/Lipoplus® 200 mg/ml, B. Braun Melsungen AG) or the MCT/LCT ILE (Lipofundin® MCT/LCT/Medialipide® 20%, B. Braun Melsungen AG) for a projected period of 8 weeks. The primary endpoint is the combined change of liver function parameters (total bilirubin, aspartate transaminase and alanine transaminase) from baseline to final visit. Secondary objectives are the further evaluation of the safety and tolerability as well as the efficacy of the ILEs. DISCUSSION: Currently, there are only very few randomized controlled trials (RCTs) investigating the use of ILEs in HPN, and there are very few data at all on the use of n-3 PUFAs. The working hypothesis is that n-3 PUFA-enriched ILE is safe and well-tolerated especially with regard to liver function in patients requiring HPN. The expected outcome is to provide reliable data to support this thesis thanks to a considerable number of CIF patients, consequently to broaden the present evidence on the use of ILEs in HPN. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT03282955. Registered on 14 September 2017

Home parenteral nutrition provision modalities for chronic intestinal failure in adult patients:An international survey

Background & aims: The safety and effectiveness of a home parenteral nutrition (HPN) program depends both on the expertise and the management approach of the HPN center. We aimed to evaluate both the approaches of different international HPN-centers in their provision of HPN and the types of intravenous supplementation (IVS)-admixtures prescribed to patients with chronic intestinal failure (CIF). Methods: In March 2015, 65 centers from 22 countries enrolled 3239 patients (benign disease 90.1%, malignant disease 9.9%), recording the patient, CIF and HPN characteristics in a structured database. The HPN-provider was categorized as health care system local pharmacy (LP) or independent home care company (HCC). The IVS-admixture was categorized as fluids and electrolytes alone (FE) or parenteral nutrition, either commercially premixed (PA) or customized to the individual patient (CA), alone or plus extra FE (PAFE or CAFE). Doctors of HPN centers were responsible for the IVS prescriptions. Results: HCC (66%) was the most common HPN provider, with no difference noted between benign-CIF and malignant-CIF. LP was the main modality in 11 countries; HCC prevailed in 4 European countries: Israel, USA, South America and Oceania (p < 0.001). IVS-admixture comprised: FE 10%, PA 17%, PAFE 17%, CA 38%, CAFE 18%. PA and PAFE prevailed in malignant-CIF while CA and CAFE use was greater in benign-CIF (p < 0.001). PA + PAFE prevailed in those countries where LP was the main HPN-provider and CA + CAFE prevailed where the main HPN-provider was HCC (p < 0.001). Conclusions: This is the first study to demonstrate that HPN provision and the IVS-admixture differ greatly among countries, among HPN centers and between benign-CIF and cancer-CIF. As both HPN provider and IVS-admixture types may play a role in the safety and effectiveness of HPN therapy, criteria to homogenize HPN programs are needed so that patients can have equal access to optimal CIF care