The prognosis of incurable cachectic cancer patients on home parenteral nutrition: a multi-centre observational study with prospective follow-up of 414 patients.

BACKGROUND: The role of home parenteral nutrition (HPN) in incurable cachectic cancer patients unable to eat is extremely controversial. The aim of this study is to analyse which factors can influence the outcome. PATIENTS AND METHODS: We studied prospectively 414 incurable cachectic (sub)obstructed cancer patients receiving HPN and analysed the association between patient or clinical characteristics and surviving status. RESULTS: Median weight loss, versus pre-disease and last 6-month period, was 24% and 16%, respectively. Median body mass index was 19.5, median KPS was 60, median life expectancy was 3 months. Mean/median survival was 4.7/3.0 months; 50.0% and 22.9% of patients survived 3 and 6 months, respectively. At the multivariable analysis, the variables significantly associated with 3- and 6-month survival were Glasgow Prognostic Score (GPS) and KPS, and GPS, KPS and tumour spread, respectively. By the aggregation of the significant variables, it was possible to dissect several classes of patients with different survival probabilities. CONCLUSIONS: The outcome of cachectic incurable cancer patients on HPN is not homogeneous. It is possible to identify groups of patients with a ≥6-month survival (possibly longer than that allowed in starvation). The indications for HPN can be modulated on these clinical/biochemical indices.

Organisation, regulations, preparation and logistics of parenteral nutrition in hospitals and homes; the role of the nutrition support team - Guidelines on Parenteral Nutrition, Chapter 8.

PN (parenteral nutrition) should be standardised to ensure quality and to reduce complications, and it should be carried out in consultation with a specialised nutrition support team whenever possible. Interdisciplinary nutrition support teams should be established in all hospitals because effectiveness and efficiency in the implementation of PN are increased. The tasks of the team include improvements of quality of care as well as enhancing the benefit to cost ratio. Therapeutic decisions must be taken by attending physicians, who should collaborate with the nutrition support team. "All-in-One" bags are generally preferred for PN in hospitals and may be industrially manufactured, industrially manufactured with the necessity to add micronutrients, or be prepared "on-demand" within or outside the hospital according to a standardised or individual composition and under consideration of sterile and aseptic conditions. A standardised procedure should be established for introduction and advancement of enteral or oral nutrition. Home PN may be indicated if the expected duration of when PN exceeds 4 weeks. Home PN is a well established method for providing long-term PN, which should be indicated by the attending physician and be reviewed by the nutrition support team. The care of home PN patients should be standardised whenever possible. The indication for home PN should be regularly reviewed during the course of PN.

Access technique and its problems in parenteral nutrition - Guidelines on Parenteral Nutrition, Chapter 9.

Catheter type, access technique, and the catheter position should be selected considering to the anticipated duration of PN aiming at the lowest complication risks (infectious and non-infectious). Long-term (>7-10 days) parenteral nutrition (PN) requires central venous access whereas for PN <3 weeks percutaneously inserted catheters and for PN >3 weeks subcutaneous tunnelled catheters or port systems are appropriate. CVC (central venous catheter) should be flushed with isotonic NaCl solution before and after PN application and during CVC occlusions. Strict indications are required for central venous access placement and the catheter should be removed as soon as possible if not required any more. Blood samples should not to be taken from the CVC. If catheter infection is suspected, peripheral blood-culture samples and culture samples from each catheter lumen should be taken simultaneously. Removal of the CVC should be carried out immediately if there are pronounced signs of local infection at the insertion site and/or clinical suspicion of catheter-induced sepsis. In case PN is indicated for a short period (max. 7-10 days), a peripheral venous access can be used if no hyperosmolar solutions (>800 mosm/L) or solutions with a high titration acidity or alkalinity are used. A peripheral venous catheter (PVC) can remain in situ for as long as it is clinically required unless there are signs of inflammation at the insertion site.

ESPEN Guidelines on Enteral Nutrition: Gastroenterology.

Undernutrition as well as specific nutrient deficiencies have been described in patients with Crohn's disease (CD), ulcerative colitis (UC) and short bowel syndrome (SBS). The present guideline gives evidence-based recommendations for the indication, application and type of formula of enteral nutrition (EN) (oral nutritional supplements (ONS) or tube feeding (TF)) in these patients. It was developed in an interdisciplinary consensus-based process in accordance with officially accepted standards and is based on all relevant publications since 1985. ONS and/or TF in addition to normal food is indicated in undernourished patients with CD or CU to improve nutritional status. In active CD EN is the first line therapy in children and should be used as sole therapy in adults mainly when treatment with corticosteroids is not feasible. No significant differences have been shown in the effects of free amino acid, peptide-based and whole protein formulae for TF. In remission ONS is recommended only in steroid dependent patients in CD. In patients with SBS TF should be introduced in the adaptation phase and should be changed with progressing adaptation to ONS in addition to normal food.

Home enteral nutrition in adults: a European multicentre survey.

AIMS: This study was undertaken to report indications and practice of home enteral nutrition (HEN) in Europe. METHODS: A questionnaire on HEN practice was sent to 23 centres from Belgium (B), Denmark (D), France (F), Germany (G), Italy (I), Poland (P), Spain (S) and the United Kingdom (UK). This involved adult patients newly registered in HEN programme from 1 January 1998 to 31 December 1998. RESULTS: A total of 1397 patients (532 women, 865 men) were registered. The median incidence of HEN was 163 patients/million inhabitants/year (range: 62-457). Age distribution was 7.5%, 16-40 years; 37.1%, 41-65 years; 34.5%, 66-80 years and 20.9% >80 years. The chief underlying diseases were a neurological disorder (49.1%), or head and neck cancer (26.5%); the main reason for HEN was dysphagia (84.6%). A percutaneous endoscopic gastrostomy (58.2%) or a naso-gastric tube (29.3%) were used to infuse commercial standard or high energy diets (65.3%), or fibre diets (24.5%); infusion was cyclical (61.5%) or bolus (34.1%). Indications and feeds were quite similar throughout the different centres but some differences exist concerning the underlying disease. There was greater variation in the choice of tubes and mode of infusion. In F, G, I, S, and UK, costs of HEN are fully funded. In B, D, and P patients have to pay part or all of the charges. CONCLUSIONS: In Europe, HEN was utilised mainly in dysphagic patients with neurological disorders or cancer, using a standard feed via a PEG. However, there were important differences among the countries in the underlying diseases treated, the routes used, the mode of administration and the funding.

Central venous catheter complications in 447 patients on home parenteral nutrition: an analysis of over 100.000 catheter days.

RATIONALE: The purpose of this study is to report the frequency of central venous catheter (CVC) complications and to analyze the potential risk factors for complications requiring CVC removal in home parenteral nutrition (HPN) patients. METHODS: A questionnaire developed by the ESPEN HAN WORKING GROUP was distributed to 12 European centers to investigate the complications occurring during the period between January 1995 and December 2000 when HPN patients used their first CVC. The questionnaire collected informations related to the Home Parenteral Nutrition technique and the underlying disease. Factors affecting the time of CVC removal were jointly investigated using Cox's multivariable regression models. RESULTS: The study was performed on 447 patients for a total of 110869 CVC-days. Complications occurred in about 1/4 of patients, approximately half were infections and about half required Central Venous Catheter removal. The Cox analysis showed that using the CVC 7 times/week and implanted ports were associated with a hazard ratio of 3 and 2.8, respectively. A reduced risk of removal (of about 40%) was associated with using CVC also for non-nutritional purposes (P = 0.0016). CONCLUSIONS: Within the limits of this retrospective investigation, the type of CVC, the type of administration of HPN and the type of training are important factors associated with occurrence of complications or with CVC removal. However, in our opinion, proper care of the CVC, of preparation and administration of the nutritive admixture seem to be paramount for a safe management of HPN.

Home parenteral nutrition in adults: a european multicentre survey in 1997. ESPEN-Home Artificial Nutrition Working Group.

A retrospective survey on home parenteral nutrition (HPN) in Europe was performed from January to December 1997. Data were compared to a similar study performed in 1993. A questionnaire of HPN practice was designed by the members of the ESPEN-HAN group. This involved adult patients (older than 16 years) newly registered in an HPN program between 1 January and 31 December 1997 and included: number of patients, underlying diseases and a 6-12 month outcome. Incidence and prevalence (at 1.1.1998) of adult HPN were calculated according to the estimated total population in 1997 for the countries in which more than 80% of HPN patients were reported.A total of 494 patients were registered in 73 centres from nine countries (Belgium (B), Denmark (D), France (F), Poland (P), Spain (S), Sweden (Sw), United Kingdom (UK), The Netherlands (N) and Germany (G). The underlying diseases for HPN in 494 patients were cancer (39%), Crohn's (19%), vascular diseases (15%), radiation enteritis (7%), AIDS (2%), other diseases with intestinal failure (18%). Incidence (patients/million inhabitants/year) were in N (3), F. (2.9), D. (2.8), B. (2.6), UK (1. 2), S (0.7) and P (0.36), respectively. Prevalence were in D. (12.7). U.K. (3.7), N. (3.7), F (3.6), B (3.0), P (1.1), S (0.65). After this 6-12 months follow-up (n=284), the mortality was respectively 4% in Crohn's disease, 13% in vascular diseases, 16% in others, 21% in radiaton enteritis, 34% in AIDS, 74% in cancer. Incidences and prevalences modestly increased in these seven European countries in 1997 in comparison to 1993. The percentages of underlying diseases in these countries remained similar except for AIDS that significantly decreased (from 7% to 2%). Outcomes did not significantly differ in the 4-year period except for AIDS (34% instead of 88% mortality) and could have been related to newer, more efficacious therapy.

Intravascular disruption of central venous ports.

Intravasal catheter disruption is a rare complication of central venous ports. Main causes are chronic trauma due to compression of the catheter between clavicle and first rib, or primary damage by sharp instruments during insertion. Utilizing the subclavian route, a more lateral insertion can minimize the risk of catheter compression. Regular postoperative X-ray controls can help to recognize progressive catheter compression. In the case of significant compression, early replacement is advisable to avoid disruption. Percutaneous transvenous snare technique is the therapy of choice to retrieve dislocated fragments.

[Perioperative nutritional therapy and its relevance for postoperative outcome]. / Perioperative Ernährungstherapie und ihre Relevanz für postoperative Ergebnisse.

The clinical effect of perioperative nutrition was analyzed from 28 controlled clinical trials. Preoperative nutritional support is indicated only in patients with high-grade malnutrition and can reduce the postoperative morbidity and mortality in these patients. If the nutritional status is normal preoperatively, artificial nutrition may influence the postoperative outcome negatively. A clinical benefit from postoperative nutritional support has been proven only in patients not able to eat an adequate oral diet within 1 week. In 20% of these case a cardiopulmonary complication was observed during total parenteral nutrition. The infusion of D5W is sufficient in the majority of surgical patients even after major procedures.

Home parenteral nutrition in adults: a multicentre survey in Europe in 1993.

A retrospective survey was performed in 1994, involving 496 adult home parenteral nutrition (HPN) cases, newly enrolled in the year 1993 from 13 European countries from 75 centres. From the 8 countries having registered more than 80% of cases (423 patients), incidence and prevalence ranged from 0.2 to 4.6 and 0.3 to 12.2 patients/10(6) population/year. In the patients studied, the diagnosis was cancer (42%), Crohn's disease (15%), vascular diseases (13%), radiation enteritis (8%), AIDS (4%) and other nonmalignant non-AIDS diseases (18%). Short bowel syndrome and intestinal obstruction were the two major indications for HPN in 31% and 22%, respectively. Seventy-three percent of the centres had a nutrition team. HPN was administered through a tunnelled venous central catheter in 73%, cyclical nocturnal infusions were used in 90% of patients, and intravenous feeding was the sole source of nutrition in 33%. Only 44% undertook HPN unaided. The present report indicates that cancer has now become the main indication for HPN in Europe; there was, however, a heterogeneous distribution of diseases amongst the reporting countries. The observed 9 (6-12)-month probability of survival was poor in AIDS (n = 8; 12%) and cancer patients (n = 78; 29%) but better for the other HPN indications (n = 115; 92%).

[Ambulatory artificial nutrition: 15 years experiences at the Cologne University Surgical Clinic]. / Ambulante künstliche Ernährung: Erfahrungen an der Chirurgischen Universitätsklinik Köln über 15 Jahre.

Beetween 1979 and 1994 629 respectively 223 patients were treated by home enteral and parenteral nutrition. The duration of the treatment on average was 361 days in case of enteral and 346 days for home parenteral nutrition, in special cases however up to 15 years. In enteral nutrition there were no metabolic complications and only minor technical problems. Catheter related problems represented the most challenging complications in parenteral feeding. 12 out of 14 patients treated more than 1 year with home parenteral nutrition because of non-cancerous disease died from recurrent pulmonary embolism or catheter-related septicemia.

[Symptomatic stenoses following stapler anastomosis of the large intestine]. / Symptomatische Stenosen nach maschinellen Dickdarmanastomosen.

Since 1978 the stapled colonic anastomosis belongs to the technical standard in surgery of the rectosigmoid. It is followed by an extension of indications for sphincter-preserving excisional treatment. The main advantages of the mechanical suturing are the shortening of operation time as well as the practical and easy management, especially when the anastomosis is located low in the pelvis. Early respectively late postoperative strictures represent the most frequent complications of stapled anastomosis. From 1989 to 1991, the stapling technique was used for colorectal anastomosis in 196 cases in our hospital. Clinical stenosis occurred in 5 cases, an incidence of 2.5%. Causative the size of the cartridge, the healing by second intention because of the metallic staples, a disturbed microcirculation depending on the tension around the anastomosis, missing normal fecal dilation because of protective colostomy and an incongruity of the combined lumina are discussed. Independent of localisation and grade of the stricture, repeated dilation was a successful therapy in all 5 cases.

[Effect of errors (particularly one's own!) on making surgical decisions]. / Einfluss von Fehlern (besonders eigenen!) auf die chirurgische Entscheidungsfindung.

Looking for medical errors in clinical practice we reviewed several cases from our daily indication and case conference, 6 cases discussed in the lethality conference and 9 which were treated by legal institutions. The points of criticism were analysed. We discriminated between diagnostic, therapeutic failures and those of organisation. The basis were 4045 patients with 4583 operations during the year 1989. The overall lethality was 1.2%. The instruments of avoiding medical errors in individual and general sense were shown.

[Monitoring and management of the central nervous system in treatment of tumor cachexia]. / Uberwachung und Handhabung von zentralnervösen und intestinalen System zur Behandlung der Tumorkachexie.

After palliative surgery artificial nutrition is indicated primarily in patients receiving postoperative chemotherapy or radiotherapy. The techniques of ambulatory enteral or parenteral nutrition have been standardized during the past decade. They can be used with minimal risk even in patients with advanced cancer. An improvement of the nutritional status can be expected in most of the patients. Further clinical trials are needed to determine whether the patients' quality of life improves.

[Does parenteral fat administration modify immunocompetence?]. / Führt die parenterale Fettgabe zu einer Beeinflussung der Immunkompetenz?

Evidence from studies in carcinoma patients who received intravenous glucose or glucose-lipid solutions preoperatively indicates that fibrinogen, alpha-II-macroglobulin, and coeruloplasmin serum levels remain unchanged. On the other hand, parenteral administration of lipids or glucose induces an increase of IgM, IgG, IgA and complement C3 serum concentrations. Cutaneous allergy testing shows no significant difference whether only glucose was used or half of the calories were replaced by 2.4 g lipids/kg BW x day.

[Continued education at a university clinic with integrated specialties]. / Weiterbildung in einer Universitätsklinik mit integrierten Spezialgebieten.

During a 14 year period 145 medial doctors were employed at the Chirurgische Universitätsklinik Köln 45 became certified general surgeons after a mean of 7.2 years. 18 received a PhD. 4800 operations year permitted the training and qualification of 0.7 doctors for the subspeciality vascular surgery and 0.8 doctors for traumatology per year. Despite extended selection 53 did not accomplish board certification for surgery in the hospital of their initial training.

[Comparison of prognostic nutrition indices in preoperative detection of risk patients. A prospective trial]. / Der Vergleich prognostischer Ernährungsindizes zur präoperativen Erfassung von Risikopatienten. Eine prospektive Prüfung.

Malnutrition must be considered as a factor of risk in surgery and therefore it has to be taken into account in surgical planning. Many authors aggregated several measurements into an index or another mathematical model by stepwise regression or discriminant analysis. Hitherto none of these approaches has been subjected to a critical analysis designed to determine whether the information gained differentiates patients with increased operative risk from those without, to a degree that is clinically relevant. In a prospective study the predictive values of nutritional assessment techniques of various authors were examined in 246 surgical patients undergoing a major surgical procedure. The specificity, sensitivity, and validity of each assessment technique were determined. The statistical analysis showed that none of the assessment techniques separated patients who were at high risk from those who were at low risk in a statistically significant predictive power. Serum albumin level was a quite accurate prognostic indicator of postoperative morbidity and mortality. The mean complication rate in this study was 26.8%. Concerning the specificity, sensitivity, and validity the single measurement of the serum albumin had a predictive value as high as all other determined assessment techniques in this study. We contend that combining measurements into a statistically derived index is time-consuming and expensive and does not produce an assessment technique with sufficient predictive power to identity high risk patients in a clinically relevant fashion.