State of the Science: Cancer Complementary and Alternative Medicine Therapeutics Research-NCI Strategic Workshop Highlights of Discussion Report.

In May 2016, the Office of Cancer Complementary and Alternative Medicine, Division of Cancer Diagnosis and Treatment, of the National Cancer Institute convened a special workshop focused on the State of the Science: Cancer Complementary and Alternative Medicine Therapeutics Research. The current state of the science, gaps, and future opportunities were reviewed and discussed by a distinguished panel of experts in this field of research, and the highlights of this meeting are reported herein.

Small bowel transplantation.

Until very recently, outcomes from small bowel transplantation (SBTx) lagged behind those in liver, heart, and kidney transplantation because of the magnitude of the immunologic burden; the strong expression of histocompatibility antigens; and the contamination in grafts by bacterial organisms. With novel techniques of immune-induction therapies, such as recipient "preconditioning" with lymphocyte reduction, followed by the more subtle use of immunosuppression-based single-agent tacrolimus, graft and host 1-year survival is now over 90% in the most active US centers, a finding that parallels the outcomes in liver and kidney transplantation. In contrast to the alternative therapy for permanent intestinal failure, home total parenteral nutrition (TPN), SBTx improves quality of life and restores digestive and absorptive function, making patients nutritionally autonomous. With survival beyond 1 to 3 years, the procedure is cost-effective. Current results support expansion of the indications for SBTx from use as salvage therapy for patients with TPN failure to preemptive therapy for patients at risk of developing TPN failure.

Nutrition support during acute pancreatitis.

Studies have shown that protein catabolism increases by 80% and energy expenditure by 20% in acute pancreatitis, indicating that nutritional requirements are elevated. Other studies have associated the resolution of negative nitrogen balance by nutrition support with improved outcome. Consequently, the need for effective nutrition is one cornerstone of management of acute pancreatitis. Concerns that feeding may exacerbate the disease process by stimulating the synthesis of proteolytic enzymes in the acinar cell and perpetuating autolysis has led to the widespread use of total parenteral nutrition (TPN) and bowel rest. Unfortunately, the use of TPN in clinical practice has been associated with major metabolic and infective complications, possibly because 1). patients with acute pancreatitis are intolerant of glucose due to coexistent pancreatic endocrine dysfunction and 2). the disease causes immune suppression. This has led to the search for alternatives. Based on physiologic studies, infusion of nutrients into the distal jejunum bypasses the stimulatory effect of feeding on pancreatic secretion. Many controlled trials have compared TPN with jejunal feeding. No study has shown that jejunal feeding exacerbates the disease. Further, jejunal feeding is associated with fewer infectious and metabolic complications. These observations and the fact that enteral feeding is one-tenth the cost of TPN has resulted in the general acceptance of jejunal feeding as the preferred mode for maintaining nutrition in patients with acute pancreatitis.

Hypocaloric jejunal feeding is better than total parenteral nutrition in acute pancreatitis: results of a randomized comparative study.

OBJECTIVES: The aims of this study were to define the indications for, and to evaluate the cost-effectiveness of, nutritional support in patients with acute pancreatitis. METHODS: All admissions during the 12-month period from January through December 2000, were entered into a common management protocol consisting of an initial 48-h fast with i.v. fluids and analgesics. After 48 h, those patients who were improving were restarted on oral feeding (group O). The remaining patients were randomized to receive nasojejunal (group EN) or parenteral feeding (group TPN). The randomization study was continued until 50 patients had been accrued. Outcomes in the three groups were compared with respect to length of hospital stay, duration of feeding, complications, and hospital costs. RESULTS: A total of 156 admissions were evaluated in the first 12 months. Of these, 87% patients had mild disease, 10% moderate, and 3% severe; 62% were related to alcohol abuse, 18% gallstones, and 8% idiosyncratic drug reactions. Of the patients, 75% improved on 48 h bowel rest and i.v. fluids, and were discharged within 4 days. The remainder were randomized to jejunal elemental (n = 26) or parenteral (n = 27) feeding. Duration of feeding was shorter with EN (6.7 vs 10.8 days, p < 0.05) and nutrition costs were lower, representing an average cost saving of $2362.00 per patient fed. EN was less effective in meeting estimated nutritional requirements (54 vs 88%, p < 0.0001), but metabolic (p < 0.003) and septic complications (p = 0.01) were lower. Subgroup analysis of patients with severe disease showed similar findings. CONCLUSION: Despite concerns that metabolic expenditure is increased and that food-stimulated pancreatic secretion might exacerbate the disease process, hypocaloric enteral feeding seems to be safer and less expensive than parenteral feeding and bowel rest in patients with acute pancreatitis.