JPEN J Parenter Enteral Nutr

Role of nutrition support during induction chemoradiation therapy in esophageal cancer.

Sikora SS. Ribeiro U. Kane JM 3rd. Landreneau RJ. Lembersky B. Posner MC.
Department of Surgery, University of Pittsburgh Medical Center, Pennsylvania, USA.
BACKGROUND: Preoperative chemoradiation therapy (CRT) potentially benefits a subgroup of patients with esophageal cancer. The ability to administer aggressive CRT may depend on the initial nutritional status and the ability to sustain nutrition during therapy. Parenteral nutrition support during CRT may lead to complications that limit its usefulness and negate any potential benefit. METHODS: Data were analyzed to evaluate the role of parenteral nutrition support (PNS) in patients receiving CRT. Forty-five consecutive patients with locoregional esophageal cancer, enrolled in a phase I/II trial of induction CRT, were analyzed. On the basis of the nutrition support received, two groups were defined as follows: group I (with PNS, n = 30) and group II (without PNS, n = 15). Results were compared in terms of chemotherapy (CT) dose tolerated, morbidity of CRT, response rates, and surgical outcome in groups with and without PNS. RESULTS: The two groups were comparable for demographic data, stage and site of disease, and performance status. There was no significant difference between the groups in the nutritional parameters (weight and serum albumin) before and after CRT. Group I patients received significantly more (% of total calculated dose) CT compared with group II (5-fluorouracil [5-FU], 86.4% vs 68.8%, p = .02; cisplatin [CDDP], 90.8% vs 78.2%, p = .05; and interferon alpha-2b [IFN-alpha], 95.4% vs 79.8%, p = .05, in groups I and II, respectively). Major (grade III/IV) adverse effects of CT were hematologic (group I, 93.3% vs group II, 86.6%, p = .59) and gastrointestinal (group I, 56.67% vs group II, 33.3%, p = .2). Postsurgical staging revealed complete response in 10 (22%) and a major response in 23 (51%) patients, although the response rates were similar in the two groups (group I, 76.6% vs group II, 66.6%, p = .8). Surgical morbidity (51.8% vs 61.5%, p = .73), mortality (7.4% vs 7.6%, p = 1.00), and hospital stay (22.5 vs 19.6 days, p = .63) were also similar in the two groups. CONCLUSIONS: PNS can be provided to these patients without an increased risk of CRT or resection-related morbidity. Although early and prolonged PNS facilitates administration of complete CRT doses, no benefit is derived from the administration of more CRT in the present regimen. The utility of PNS in this setting is unclear and, until further clarified, should not be applied routinely to this cohort of patients.

Physiologic response to a protein, carbohydrate, fat meal in patients with human immunodeficiency virus who underwent small intestinal enteropathy as characterized by a kinetic model of D-xylose absorption.

Carlson SJ. Deutsch JC. Craig RM.
Northwestern University Medical School, Chicago, IL, USA.
PURPOSE: Small intestinal human immunodeficiency virus enteropathy is characterized by profound absorptive dysfunction unrelated to histology or pathogens. Frequently an attempt is made to compensate for this intestinal failure by supplementing nutrient intake with nourishing liquid meals. It is not known how the diminished absorptive function in these patients will respond to this intake. With the use of a D-xylose kinetic model of absorption, we determined the absorptive response of patients with small intestinal enteropathy to an isotonic liquid feeding. METHODS: Seven male patients with acquired immunodeficiency syndrome (AIDS), diarrhea, weight loss, and no detectable pathogens (stool studies and duodenal biopsy) were enrolled. After an overnight fast, the patients were studied on three separate days. On day 1, the patients received 15 g oral D-xylose. On day 2, 10 g i.v. D-xylose was given. On day 3, 15 g oral D-xylose was again given along with 250 mL of a liquid polymeric isotonic diet. Serum and urine collections were obtained to calculate the kinetic rate constants and extent of D-xylose absorption. RESULTS: Mean values for the rate constant for absorption of D-xylose, Ka, (0.26/h; N > 0.65) and the rate constant for nonabsorptive loss, K0' (2.47/h; N < 0.353) were very abnormal before the meal. Mean K0 improved (decreased to 0.66), but Ka and bioavailability, F, did not have a statistically significant change after the meal. The improvement in mean K0 with the meal was much more pronounced in the five subjects with high K0 values before the meal (without meal 3.22: with meal 0.67; p < .05). CONCLUSIONS: (1) An isotonic liquid polymeric diet leads to less nonabsorptive loss of D-xylose, but does not affect the extent of D-xylose absorption in this group as a whole. This is probably due to the meal slowing gastric emptying. (2) Improvement in nonabsorptive loss with a meal is most pronounced when there is excessive nonabsorptive loss, K0, without a meal. (3) Improvement in nonabsorptive losses with a meal might predict which patients will benefit from antimotility agents and continued feedings vs those requiring i.v. hyperalimentation.

Is vitamin K1 supplementation necessary in long-term parenteral nutrition?

Year 1998
Chambrier C. Leclercq M. Saudin F. Vignal B. Bryssine S. Guillaumont M. Bouletreau P.
Unite de Nutrition Artificielle, Hotel Dieu, Lyon, France.
BACKGROUND: I.v. lipid emulsions contain vitamin K in substantial quantities and in 1989, we therfore stopped supplying vitamin K1 to patients receiving home parenteral nutrition (HPN). METHODS: Nine patients (group I) receiving HPN before 1989 (10 mg i.v. vitamin K1 supplementation weekly until 1989, which was discontinued thereafter) and six patients with an initial low plasma vitamin K1 concentration (related to their malabsorption) (group II) receiving HPN after 1989 were studied. Prothrombin time (PT), plasma vitamin K1 concentration, and vitamin K1, content in lipid emulsions were measured throughout the period of HPN. RESULTS: All lipid emulsions, except for Eurolip 20% and Clinoleic 20% (Baxter SA, Maurepas, France) contained vitamin K1, with concentration ranges from 179 +/- 39 to 353 +/- 78 ng/L. Group I patients had an initial high plasma vitamin K1 concentration due to the vitamin K1 supplementation. After this supplementation was discontinued, plasma vitamin K1 decreased and remained in normal ranges with a normal PT. Throughout the HPN period after 1989, patients received 255 +/- 104 micrograms of vitamin K1 weekly through lipid emulsions. The PT and plasma vitamin K1 concentrations in group II patients were restored by lipid emulsions, which contained 418 +/- 143 micrograms/wk of vitamin K1. CONCLUSIONS: In patients receiving i.v. lipids (except for Eurolip and Clinoleic), a normal vitamin K1 status can be maintained during long-term HPN without vitamin K1 supplementation. However, vitamin K supplementation cannot be abandoned until the vitamin K content of emulsions is standardized by manufacturers. A weekly supply of 250 to 400 micrograms of vitamin K1 is enough to maintain and even restore a normal vitamin K1 status in HPN.

Fecal short-chain fatty acids predict digestive disorders in premature infants.

Year 1998
Szylit O. Maurage C. Gasqui P. Popot F. Favre A. Gold F. Borderon JC.
Unite d'Ecologie et de Physiologie du Systeme Digestif, Centre de Recherche de Jouy-en-Josas, Institut National de la Recherche Agronomique, France.
BACKGROUND: Excretion of fecal short-chain volatile fatty acids (SCFAs) may indicate changes in colonic or colonocyte metabolism. The aim of this study was to detect the existence of an average fecal SCFA profile and to define which changes were associated with clinical events that occurred during the survey period. METHODS: SCFA profiles of 185 stool samples collected from 46 fed preterm neonates (mean birth weight, 1920 g; mean gestational age, 32.8 weeks) were evaluated and their association with digestive disorders or therapy was explored. RESULTS: Total SCFA concentration increased from 0 to 80 micromol/g feces wet weight over the first 20 days of life. A basic SCFA profile revealed the existence of a highly sensitive period between the second and the third week of life. In the absence of any digestive problem (n = 15), the butyric acid (C4) ratio increased from 7% to 24%. Phototherapy (n = 13) enhanced the SCFA concentration but decreased the ratios of C4 and minor acids. Digestive disorders reported included abdominal distention (n = 6) or bleeding (n = 8). Only in the case of bleeding was the SCFA profile changed by an enhancement of C4 by >50%. Antibiotic therapy (n = 3) suppressed SCFA production. CONCLUSIONS: This study supports a hypothesis that changes in the SCFA profile could offer a noninvasive method to anticipate functional modifications of the gastrointestinal tract before the first clinical signs of pathologic events, including necrotizing enterocolitis.

A valid and reliable tool to quantify stool output in tube-fed patients.

Year 1998
Guenter PA. Sweed MR.
Allegheny University Hospital, Graduate Division, Philadelphia, PA, USA.
A major problem in determining whether diarrhea exists in tube-fed patients is the quantification of stool output. On the basis of this need a stool output assessment tool was developed and tested for validity and reliability. Interrater reliability and construct validity were determined by using staff nurses' and principal investigators' observations. Observers blindly rated the bowel movement (BM) on size and consistency and on whether the BM was thought to represent "diarrhea." Interrater reliability was found to be significant. Stool output scores were determined by using a 24-hour output form that assessed stool size, consistency, and frequency. Content validity was established as well as concurrent and construct validity.