Home Parenteral Nutrition Support in Adults: Experience of a Medical Center in Asia  
From the * Department of Surgery, Correspondence: Ming-Tsan Lin, MD, PhD, Department of Surgery, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, Taiwan. Electronic mail may be sent to linmt{at}ha.mc.ntu.edu.tw. Background: Parenteral nutrition (PN) support is mandatory in patients with gut failure. Short bowel syndrome is a term used for symptoms and pathophysiological disorders brought about by the removal or malfunction of a large portion of the small bowel. Inflammatory bowel disease, vascular disease, and malignancy are the most common causes of short bowel syndrome in adults. There are many complications associated with chronic use of PN. Cholestasis, nutrient deficiency, small bowel bacterial overgrowth, and catheter-related infections were noted in these patients. Due to the various etiologies, we tried to find the optimal method to manage these patients. Methods: We reviewed all patients over 16 years old, from 1989 to 2002, who required home PN support for at least 30 days. Charts were reviewed to obtain information regarding demographics, nutrition management, outcome, and complications related to PN. Survival was estimated by using the Kaplan-Meier method. The association of survival with primary disease, length of small bowel, age, and gender was assessed by proportional hazard regression analysis. Results: There were 31 patients who needed home PN support during this period, 14 male and 17 female. The average age was 55 (median age, 53; range, 28–88); the average period of PN administration was 19 months (median, 7; range, 1–115 months). The most common indications for home PN were alimentary tract obstruction and short bowel syndrome. Most deaths were related to their original diseases and catheter-related sepsis. Malignant diseases were a major indication for home PN (HPN). However, 20% of these patients with incurable diseases lived longer than 1 year. The disease patterns were different from those in western societies. Most patients had malignancies and vascular insults in our series. There was much less inflammatory bowel disease in our patients than in western countries; catheter-related infections were frequent and caused 25% of mortality. Conclusions: HPN is very important to patients with intestinal failure or who are waiting for recovery from temporal intestine insufficiency. Even in malignant diseases, a significant number of patients survived for >1 year with treatment of HPN. Most complications related to their underlying diseases and associated infections. Improving patient education and treatment might improve the prognosis of these patients and expand the application of this technique to help more patients with small intestine failure. Since Wilmore and Dudrick published their results about an infant weighing 2.3 kg with almost complete atresia of the small bowel, who was fed intravenously for 44 days and demonstrated normal growth and development in 1968,1,2 total or partial/integrative home parenteral nutrition (HPN) has became an established treatment in patients presenting severe, definitive, or transient gut failure secondary to malignant or nonmalignant diseases. IV nutrition has resulted in the survival of patients with intestinal failure who otherwise would not survive. HPN was introduced in the late 1960s as a means of decreasing the duration of hospital stay for patients requiring parenteral nutrition (PN).3 In Europe, the mean annual incidence of newly enrolled cases is about 3 patients per million.4 The use of HPN is much more common in North America.5 The crucial role of HPN in the treatment of adult patients with intestinal failure, 31%–68% of whom have short bowel syndrome (SBS), has been documented extensively. Takagi et al6 reported that 40% of patients receiving HPN had cancer as their primary diagnosis. However, primary diseases and indications for HPN vary vastly between institutions. This reflected the fact the there were different disease patterns in different areas and ethnicities. We extensively investigated the effect of PN in perioperative period and sepsis status in our previous studies7–10; however, much less had been investigated in the effects of HPN in our country. There was much less literature investigating HPN in Asian populations too. The aim of this study was to evaluate, mostly in clinical terms, the current use of HPN for adult patients in our institute, emphasizing disease patterns and indicators. In this study, we describe the unique features of patients receiving HPN in a typical Asian country from a single institute.
A retrospective review of all patients, from 1989 to 2002, who needed HPN support for at least 30 days in National Taiwan University Hospital, was conducted. Charts were reviewed to obtain information regarding patient demographics, nutrition management, outcome, and complications related to PN. The present study was approved by the institutional review board of National Taiwan University Hospital. Survival was estimated using the Kaplan-Meier method. The association of survival with primary disease, length of small bowel, age, and gender was assessed by using proportional hazard regression analysis and t-testing.
During this study, 31 patients received PN support for >30 days and were discharged from the hospital and returned home. There were 14 male and 17 female patients. The average age was 55 years old (median age, 53; range, 28–88). The average period of PN administration was 19 months (median, 7 months; range, 1–115; Figure 1). Seventeen patients received PN because of alimentary tract obstruction. Cancerous peritonitis caused chronic obstruction in 13 patients. Two patients refrained from surgical intervention for pancreatic cancer and esophageal cancer, which caused GI tract obstruction. The remaining 2 patients had postoperation ileus and refrained from further surgical intervention. Ten patients received PN because of SBS. In these patients, 5 had vascular insufficiency caused by 3 superior mesenteric artery embolisms, 1 by trauma and 1 by internal incarcerated hernia caused by adhesion band. Four patients had extensive bowel resection due to postoperation adhesion ileus and 1 for inflammatory bowel disease. In the remaining 4 patients, 2 had enterocutaneous fistulae, 1 had an enterovaginal fistula, and 1 had malabsorption caused by tropical sprue (Table I).
In those with malignant diseases as their primary disease, 16 had gastric cancer, 2 had colorectal cancer, 2 had pancreatic head cancer, 1 had endometrial cancer, 1 had lung cancer, and 1 had esophageal cancer. In these patients, most received HPN due to gastrointestinal obstruction caused by cancerous peritonitis. Some received it because of chronic emaciation caused by postoperation partial ileus or postoperation complications, such as enterocutaneous fistulas, enterovaginal fistulae, and unexpected extensive resection of the small bowel during operation (Table II).
Ten patients had cholestasis, 8 had gastrointestinal bleeding, 5 had deep vein thrombosis, 5 had urinary tract infections, 4 had renal insufficiency, and 4 had gallstones. There were 51 episodes of catheter-related infection in the 606 patient-months; this equaled 1 episode for every 12 patient-months. Twenty-four patients died during the study. Nineteen patients died from infection, 1 died of tumor bleeding, and another died of liver failure. The causes of death of the remaining 3 were unrelated to their diseases. In the 19 infection mortalities, 6 had catheter-related infections and 4 had chemotherapy-related infections. The remaining 9 patients included 3 biliary tract infections, 2 intra-abdominal abscesses, 2 cases of urosepsis, and 2 cases of pneumonia (Table III).
In the 6 patients who died of catheter-related blood-stream infection (CRBSI), 3 patients received HPN due to cancerous peritonitis, 2 had SBS, and 1 had chronic emaciation due to malabsorption after pancreas head surgery. The average age was 69 years old (median, 74 years old; range, 36–84). There were no significant differences in etiology, genders, duration of HPN administration, and primary disease. Only age was found to be marginally different (p = .04, t-test). In the 20 patients with incurable malignant diseases, the median survival time was 4 months (range, 1–36; Figure 2). The median age at the initiation of PN was 54 (range, 31–88). Four patients survived longer than 1 year (Table IV). In patients receiving HPN because of nonmalignant disease, median survival was 53 months (range, 2–115). The median age at initiation of PN was 43 (range, 30–74; Figure 3).
HPN is usually administered to patients with intestinal failure or who are waiting for recovery from temporal intestine insufficiency. Indications for HPN were very different in different regions. In the Ireton-Jones series, the top 5 diagnoses for patients receiving HPN were cancer, Crohn's disease, ischemic bowel disease, motility disorders, and AIDS.11 Howard and Ashley12 reported that the underlying diagnoses in over 5000 HPN patients, reported to a voluntary registry between 1985 and 1992, were approximately 40% cancer. However, in the Violante et al13 series, only 12% of patients received HPN for nonneoplastic disease. Cancer cases may represent the largest percentage of HPN patients in some countries (57% in Italy or 60% in The Netherlands) and the lowest in other countries (8% in Denmark and 5% in the United Kingdom). In our series, most patients received HPN because of malignant disease (23/31; 74%), with gastric cancer composing the majority (16/23). Japan, an adjacent Asian country, reports that only 40% of their patients receive HPN due to malignant diseases.6 This reflected the fact that there is still much controversy about the application of HPN and different diseases' prevalence among different ethnicities.
In the Hoda et al14 series, carcinoid/islet cell tumors, ovarian cancer, amyloidosis/multiple myelomas, and colon cancer were the leading primary malignant diseases in these patients. In Howard's15 series, colon (20%) and ovarian cancer (14%) were the leading causes. Santarpia et al16 reported that sites of primary cancer were the stomach (31.6%), ovaries (27.6%), and colorectum (19.7%). This may reflect the fact that colon cancer incidence was lower in Taiwan, with gastric cancer prevalence still high. Central venous catheter (CVC)–related infection is the major complication in patients receiving PN, and in our previous study, the majority of organisms cultured from CRBSI were fungi (64%).17 Although we did not explore the issue in this study, the bacteriology should be similar. CVC complications are also a major challenge for patients receiving HPN. In more recent reports, the infection rate was estimated to be 2.89% of the days of treatment13 and 0.84–0.44 per 1000 catheter-days.11 In our series, 51 episodes occurred in 606 patient-months, averaging 1 episode in 12 patient-months, equal to 2.78 per 1000 catheter-days. These differences might be attributed to the fact that patient volume was relatively small and to the different age groups (median age, 55; range, 28–88 in our group vs mean age, 44.2; range, 42–45 in the Ireton-Jones11 series). In the Ireton-Jones11 series, 50% or more of patients completed their therapy (ie, patient was able to meet nutrients enterally or orally). Therapy was discontinued due to death in an average of only 19% of patients. However, in our series, deaths caused by primary diseases were the most common reason of discontinuation of HPN, and only 1 patient could complete therapy and resume adequate oral feeding. These differences reflected the facts that the disease pattern and severity were very different from each reported series and might play an important role in the prognosis of these patients.
CRBSI had been reported to represent 20%–50% of deaths directly
related to HPN.18
In our series, CRBSI represented 25% of the deaths in our patients. These
patients might have difficulties following precise aseptic procedures, and
extension of the nutrition support team function of home nursing in these
patients is necessary to avoid CRBSI and reduce mortality. Furthermore,
long-term use of HPN may alter the immune function in these patients, and
these alterations might contribute to HPN-related
complications.19,20
There are evidences of benefits using immunonutrition in severe-trauma
patients and general-surgery patients with moderate to severe
malnutrition.21 In
our previous studies, specialty nutrients, including glutamine and SBS is the second major indication for HPN. Half of these patients were vascularly compromised by SMA embolism, injuries, and internal incarceration by adhesion band. Four had extensive small bowel resection while receiving enterolysis for postoperation adhesion ileus. Thompson et al23 reported 25% of SBS patients with postoperation complications. The most frequent cause was surgical treatment of postoperative obstruction after common surgical procedures. Five of our SBS patients could be classified into this group. The second most frequent cause was intestinal ischemia. Preventing adhesions, avoiding technical errors, diagnosing a potentially ischemic intestine in a timely manner, and approaching the frozen abdomen cautiously are important strategies for preventing this condition. The role of nutrition support in patients with metastatic malignancy is still controversial. In early reports, PN therapy does not seem to benefit comfort care in patients with terminal disease.24 August et al25 reported short survivals in patients with inoperable malignant bowel obstructions, with median survival at 53 days. Some authors contend that no definite evidence exists showing HPN to be beneficial to these patients.26 In early studies, patients with terminal malignant disease usually had limited survival, such as in the August et al25 series. However, with more and more malignant-disease patients surviving with fewer HPN-related complications, combined with more sophisticated techniques and teamwork, the notion of terminal malignant diseases and incurable diseases should be distinguished. It should be clear that although all terminal cancer patients are "oncologically" incurable, not all incurable cancers are "biologically" terminal.27 Cessation of energy intake is associated with a life expectancy of only a few months.28 In our patients, median survival was 4 months, and 20% of patients survived more than 1 year. If denied HPN, they might die from malnutrition, not from their underlying disease. Orreval et al29 reported that most cancer patients and their families experienced physical, social, and psychological benefits from HPN treatment, further strengthening the role of HPN in incurable cancer patients.
In summary, we describe the unique disease patterns and prognoses in patients needing HPN in an Asian country. Much less inflammatory bowel disease was found in this group than in Western countries, and most patients received HPN because of incurable malignant diseases. Compared with western countries, fewer patients could complete HPN therapy and resume normal oral feeding. This might reflect the fact that, currently, the application of HPN is conservative. HPN is very important to patients with intestinal failure or who are recovering from temporal intestine insufficiency. Even in malignant diseases, a significant number of patients survived for >1 year with treatment of HPN. We could expand the application of this technique to help more patients with small intestine failure and those with incurable malignant disease. Received for publication September 5, 2006. Accepted for publication December 12, 2006.
Journal of Parenteral and Enteral Nutrition, Vol. 31, No. 4,
306-310 (2007)
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MATERIALS AND METHODS
RESULTS
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fatty acid, might have improved
immunity.