Nutritional support in oncologic patients: where we are and where we are going.

The use of nutritional support in cancer patients has evolved since its introduction in the clinical practice 40 years ago. Both parenteral and enteral nutrition are now increasingly integrated within the main oncologic strategy with the aim of making surgery, chemotherapy and radiation therapy more safe and effective. This requires a better awareness of the inherent risk of starvation and undernutrition by the surgeons, medical oncologists and radiologists, the ability to implement a policy of nutritional screening of cancer patients and to propose them the nutritional support in a single bundle together with the oncologic drugs. Four different areas of nutritional intervention are now recognized which parallel the evolutionary trajectory of patients with tumour: the perioperative nutrition in surgical patients, the permissive nutrition in patients receiving chemotherapy and/or radiation therapy and the home parenteral nutrition which may be total (in aphagic-obstructed-incurable patients) or supplemental (in advanced weight-losing anorectic patients). Since cancer is a common disease and the continuous progress in medical therapy is changing its natural history, with more and more patients entering in a chronic and finally incurable phase where nutrition is determinant for survival, we can expect an increased demand for nutritional support in the next future.

The advent of home parenteral nutrition support.

I review here some key developments of personal and professional interest, with special reference to total parenteral nutrition (TPN), an area in which I have been involved from 1937 until recently. As a result of basic and biomedical science advances achieved in university and industrial laboratories in numerous countries, many essential nutrients were identified, synthesized, produced, and provided to patients in safe and effective forms both enterally and parenterally. This period also saw important developments in analytic instrumentation. I have had the privilege of seeing major advances in nutrition during my lifetime, and it is my belief and my hope for the future that with the advent of bowel transplants and tissue growth from cells, TPN will be a temporary measure rather than a lifetime regimen.

Suporte nutricional após ressecções intestinais extensas / Nutritional support after massive intestinal resection

Os pacientes submetidos à ressecção intestinal extensa apresentam sintomatologia decorrente da insuficiência intestinal. Desenvolvem complicações nutricionais e infecciosas, apresentam síndrome de má absorção e distúrbios do equilíbrio hidrossalino e ácido-basico e muitas vezes desnutrição. O suporte nutricinal apresenta-se como terapêutica fundamental para uma boa evolução. Com o advento do transplante de intestino delgado, um maior número de portadores de síndrome do intestino curto poderá ser beneficiado.

Short bowel syndrome (SBS) is the clinical entity that results from an effective reduction in the functioning intestinal absorptive surface, with leads to malabsorption and an inability to maintain an adequate nutritional status. Before the introduction of parenteral nutrition, survival of patients with SBS was exceptional. The article reviews the pathophysiology of intestinal resection and the metabolic derangements and nutritional deficits that occur in SBS. Nutrition support for SBS is also discussed.

Home infusion for the 1990s: a patient's perspective.

Home infusion therapy gives patients a great degree of control over their lives. Although adjustments are needed to follow the prescribed infusion therapy, these changes are minimal when compared to hospitalization. With social and technical support, patients will choose home infusion therapy.

[A decade of experience with home total parenteral nutrition].

Between August 1980 and October 1990 we treated 36 patients with home total parenteral nutrition (HTPN) with a cumulative treatment duration of 92 years. They included 14 females and 22 males ranging in age from newborn to 75 years, with a mean of 38 +/- 21. The 4 commonest indications for HTPN were short bowel syndrome (mainly due to mesenteric occlusion (50%), inflammatory bowel disease 14%), motility disorders (14%) and malabsorption (11%). All-in-one nutritional mixtures utilizing the big-bag technique were used for all patients. Broviac or Hickman catheters were implanted in 35 patients and an infusion port in 2. Infusions were administered during the night for 8-12 hours with a volumetric pump. 14 patients are still receiving HTPN (39%) while in 8 it was discontinued as they can maintain their nutritional status by the gastrointestinal route (22%). 14 patients have died (39%), 3 from HTPN-related causes (2 of sepsis and 1 of liver failure). Catheter-related sepsis was 0.42/year of HTPN. Other common complications were metabolic bone disease, deranged liver function and cholecystolithiasis. 80% were able to return to work, school, or housekeeping activities, or at least to take care of themselves and cope with HTPN unaided. Social rehabilitation was full or partial in 72% and only 29% were house-bound and needed major assistance. Patients with a poor life quality tended to be older and suffer from intestinal diseases as a manifestation of a systemic disorder, such as atherosclerosis or malignancy.(ABSTRACT TRUNCATED AT 250 WORDS)

Roundtable discussion on metabolic support of the cancer patient. Regional centers of excellence.

Home TPN has undergone a dramatic evolution over a relatively short period. It is unfortunate that the current system is barely realizing the potential to enhance patient care while keeping costs reasonable. Although industry has made the mistake of not demonstrating how important quality is for outcome, third-party reimbursement policy is making a more critical mistake of encouraging the implementation of poor-quality care through reimbursement levels so low that factors that ensure high quality must be cut if the provider is to survive. We must recognize that the provision of product is only part of the large system needed to deliver this expensive therapy. The institution of centers of excellence will allow consumers to make intelligent choices in the future application of health care dollars.