Total parenteral nutrition (TPN) with complete nutritive mixtures: An artificial gut in cancer patients

Solassol, C; Joyeux, H; Dubois, Jean‐Bernard

doi:10.1080/01635587909513622

Cited by 55 publications

(19 citation statements)

References 11 publications

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“…Some authors have reported long survival with PN [67,73], while others have observed a rapid deterioration in terminally ill patients [31,51,74]. The effects of PN depend strictly on the extent of the preexisting malnutrition, type and stage of tumour, and previous oncologic treatment.…”

Section: Chemotherapymentioning

confidence: 97%

Parenteral versus enteral nutrition in cancer patients: indications and practice

Mercadante

1998

Support Care Cancer

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Prospective randomly controlled trials have failed to demonstrate the clinical efficacy of providing nutritional support to most cancer patients in terms of morbidity, mortality, and duration of hospitalization. Serious shortcomings in study design have limited the possibility of drawing definitive conclusions from the data. Thus, nutritional intervention needs to be seen as a method of support, with the aim of maintaining nutritional and functional status during the stress of the oncology treatment to prevent or attenuate cachexia. There is no disease during which the patient benefits from prolonged wasting. Pretreatment weight loss is quoted as a major indicator of poor survival and response to therapy of cancer patients. As a consequence, an early and serial assessment of nutritional status, perhaps followed by an immediate intervention with nutritional support is strongly recommended. There are other specific reasons for using the gut rather than the intravenous route for nutrient administration besides the often reported disadvantage of significant cost. Local intestinal stimulation prevents the mucosal atrophy and bacterial translocation that can be triggered by several precipitating factors, as frequently seen in oncologic patients. These include endotoxin, radiation therapy, cytotoxic and immunosuppressive drugs, cytokines, bowel and biliary obstruction, broad-spectrum antibiotics, and the tumour itself, as well as parenteral nutrition (PN). As the enteral route of nutritional support has been found to be as good as or preferable to PN in terms of maintenance of nutritional status or immune function, prevention of bacterial translocation, maintenance of normal gut flora, transit and histology, and prevention of hypercatabolic responses to stressful events, it is always preferable in terms of physiological response, local and systemic competence, quality of life and cost, and should be the method of choice for the nutritional support of cancer patients. Although retrospective studies of PN suggest a benefit for patients with cancer who are undergoing surgery, radiation, or chemotherapy, carefully designed, prospective studies report less conclusive findings. The failure of conventional PN to improve clinical outcomes in patients with cancer may be related to the fact that standard formulations do not address or reverse abnormalities of intermediate metabolism that result in cancer cachexia. Supplemental substances have been proposed in an attempt to improve the efficacy of PN, including insulin, growth hormone and branched chain amino acids. The difficult task is to identify those patients who are at risk for malnutrition and at the same time identify the subset of patients who will benefit clinically from parenteral nutritional repletion. Severe malnutrition in patients requiring surgery, bone marrow transplantation in patients unable to tolerate enteral supplementation and postoperative complications necessitating nutritional support are specific indications. Routine use of PN should be discouraged.

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Section: Chemotherapymentioning

confidence: 97%

Parenteral versus enteral nutrition in cancer patients: indications and practice

Mercadante

1998

Support Care Cancer

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“…It can induce positive nitrogen balance and weight gain in such situations, although no benefit has been observed in other studies of patients supported with PN [8,25]. Some authors have reported long survival [59,66], while others have observed a rapid deterioration in terminally ill patients [32,47,67].…”

Section: Parenteral Nutritionmentioning

confidence: 97%

“…The AMA Council on Ethical and Judicial Affairs in 1986 specified that "it is not unethical to discontinue all means of life-prolonging treatment, including nutrition and hydration" for the incompetent patients [60]. Medical procedures used to provide nutrition are similar to other medical procedures and their benefits and burdens should to be evaluated in the same manner as other medical procedures [59]. In the case of incompetent adults, caretakers and family should first try to ascertain the patient's wishes.…”

Section: Ethical Issues With Terminally Ill Patientsmentioning

confidence: 99%

Nutrition in cancer patients

Mercadante

1996

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Many factors can modify nutritional status in cancer patients, including cachexia, nausea and vomiting, decreased caloric intake or oncologic treatments capable of determining malabsorption. Cachexia is a complex disease characterized not only by a poor intake of nutrients or starvation, but also by metabolic derangement. Nausea and vomiting may limit the nutrient intake and are most often the consequences of oncologic treatments or opioid chronic therapy. Decreased caloric intake is considered to be one of the major causes of malnutrition, although the causes of anorexia remain unclear. Malabsorption is generally attributed to the consequences of oncologic treatments reducing the gastrointestinal absorption. Biochemical measurements and immunological tests may be not reliable indicators of nutritional status in cancer patients. Therefore, medical history, physical examination, estimates of daily oral intake, weight changes and an appropriate consideration of the nutritional requirements according to the stage of disease must still be assessed. The therapeutic approaches should be individualized and realistic. Whenever possible, oral nutrition is the method of choice, with due consideration for specific dietary needs. Nausea and anorexia can be reduced by different kinds of drugs. A careful decision based on good clinical judgement is necessary before deciding to start either enteral or parenteral nutrition, to avoid a useless, costly and difficult treatment. In choosing the route for administration of nutrients, availability of and access to a functioning gastrointestinal tract, compliance and comfort of the patient, gastrointestinal toxicity due to chemotherapy or radiotherapy fields, different costs, duration and place of treatment should be considered rather than the different capacity of parenteral versus enteral nutrition. However, postoperative periods after massive intestinal resection often require prolonged parenteral nutrition. The benefits of parenteral nutrition are not often demonstrable in patients with bowel obstruction. Different ethical aspects are presented. Flexibility in attempting to meet the nutrition needs of each patient is probably the most useful guide.

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“…The use of pharmacologic agents that decrease bile and pancreatic secretion, such as octreotide, makes intuitive sense, but no specific trials of their use in preventing radiation enteritis have been performed. • Prophylactic dietary modifications have included trials of an elemental diet [13] and the use of TPN [14,15] during radiation to lessen the severity of treatment-related diarrhea [16,17]. • Salminen and colleagues [9] have demonstrated a significant decrease in the incidence of diarrhea (P <0.01) with the controlled use of live lactobacillus acidophilus cultures in 24 female patients undergoing internal and external pelvic irradiation for gynecologic malignancy.…”

Section: Diet and Lifestylementioning

confidence: 99%